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Male infertilityBy Mayo Clinic staff
Original Article: http://www.mayoclinic.com/health/male-infertility/DS01038
Approximately 15 percent of couples are infertile. This means they aren't able to conceive a child even though they've had frequent, unprotected sexual intercourse for a year or longer. In about half of these couples, male infertility plays a role.
Male infertility is due to low sperm production, misshapen or immobile sperm, or blockages that prevent the delivery of sperm. Illnesses, injuries, chronic health problems, lifestyle choices and other factors can play a role in causing male infertility.
Not being able to conceive a child can be stressful and frustrating, but a number of male infertility treatments are available.
The main sign of male infertility is the inability to conceive a child. There may be no other obvious signs or symptoms. In some cases, however, an underlying problem such as an inherited disorder, hormonal imbalance or a condition that blocks the passage of sperm may cause signs and symptoms. Male infertility signs and symptoms may include:
- The inability to conceive a child
- Problems with sexual function — for example, difficulty with ejaculation or difficulty maintaining an erection (erectile dysfunction)
- Pain, swelling or a lump in the testicle area
- Decreased facial or body hair or other signs of a chromosomal or hormonal abnormality
- Having a lower than normal sperm count (fewer than 15 million sperm per milliliter of semen or a total sperm count of less than 39 million per ejaculate)
When to see a doctor
See a doctor if you:
- Are unable to conceive a child after a year of regular, unprotected sexual intercourse
- Have erection or ejaculation problems, low sex drive, or other problems with sexual function
- Have pain, discomfort, a lump or swelling in the testicle area
- Have a history of testicle, prostate or sexual problems
- Have had groin, testicle, penis or scrotum surgery
Male fertility is a complex process. To get your partner pregnant, the following must occur:
- You must produce healthy sperm. Initially, this involves the growth and formation of the male reproductive organs during puberty. At least one of your testicles must be functioning correctly, and your body must produce testosterone and other hormones to trigger and maintain sperm production.
- Sperm have to be carried into the semen. Once sperm are produced in the testicles, delicate tubes transport them until they mix with semen and are ejaculated out of the penis.
- There needs to be enough sperm in the semen. If the number of sperm in your semen (sperm count) is low, it decreases the odds that one of your sperm will fertilize your partner's egg. A low sperm count is fewer than 15 million sperm per milliliter of semen or fewer than 39 million per ejaculate.
- Sperm must be shaped correctly and able to move. If the movement (motility) or shape (morphology) of your sperm is abnormal, the sperm may not be able to reach or penetrate your partner's egg.
Problems with male fertility can be caused by a number of health issues and medical treatments. Some of these include:
- Varicocele. A varicocele is a swelling of the veins that drain the testicle. It's a common cause of male infertility. This may prevent normal cooling of the testicle, leading to reduced sperm count and fewer moving sperm.
- Infection. Some infections can interfere with sperm production or sperm health, or can cause scarring that blocks the passage of sperm. These include some sexually transmitted infections, including chlamydia and gonorrhea; inflammation of the prostate (prostatitis); and inflamed testicles due to mumps (mumps orchitis).
- Ejaculation issues. Retrograde ejaculation occurs when semen enters the bladder during orgasm instead of emerging out the tip of the penis. Various health conditions can cause retrograde ejaculation, including diabetes, spinal injuries, medications, and surgery of the bladder, prostate or urethra. Some men with spinal cord injuries or certain diseases can't ejaculate semen, even though they still produce sperm.
- Antibodies that attack sperm. Anti-sperm antibodies are immune system cells that mistakenly identify sperm as harmful invaders and attempt to eliminate them.
- Tumors. Cancers and nonmalignant tumors can affect the male reproductive organs directly or can affect the glands that release hormones related to reproduction, such as the pituitary gland. In some cases, surgery, radiation or chemotherapy to treat tumors can affect male fertility.
- Undescended testicles. In some males, during fetal development one or both testicles fail to descend from the abdomen into the sac that normally contains the testicles (scrotum). Decreased fertility is more likely in men who have had this condition.
- Hormone imbalances. Infertility can result from disorders of the testicles themselves or an abnormality affecting other hormonal systems including the hypothalamus, pituitary, thyroid and adrenal glands. Low testosterone (male hypogonadism) and other hormonal problems have a number of possible underlying causes.
- Sperm duct defects. The tubes that carry sperm (sperm ducts) can be damaged by illness or injury. Some men experience blockage in the part of the testicle that stores sperm (epididymis) or a blockage of one or both of the tubes that carry sperm out of the testicles. Men with cystic fibrosis and some other inherited conditions may be born without sperm ducts altogether.
- Chromosome defects. Inherited disorders such as Klinefelter's syndrome — in which a male is born with two X chromosomes and one Y chromosome (instead of one X and one Y) — cause abnormal development of the male reproductive organs. Other genetic syndromes associated with infertility include cystic fibrosis, Kallmann's syndrome, Young's syndrome and Kartagener syndrome.
- Problems with sexual intercourse. These can include trouble keeping or maintaining an erection sufficient for sex (erectile dysfunction), premature ejaculation, painful intercourse, anatomical abnormalities such as having a urethral opening beneath the penis (hypospadias), or psychological or relationship problems that interfere with sex.
- Celiac disease. A digestive disorder caused by sensitivity to gluten, celiac disease can cause male infertility. Fertility may improve after adopting a gluten-free diet.
- Certain medications. Testosterone replacement therapy, long-term anabolic steroid use, cancer medications (chemotherapy), certain antifungal medications, some ulcer drugs and certain other medications can impair sperm production and decrease male fertility.
Overexposure to certain environmental elements such as heat, toxins and chemicals can reduce sperm production or sperm function. Specific causes include:
- Industrial chemicals. Extended exposure to benzenes, toluene, xylene, pesticides, herbicides, organic solvents, painting materials and lead may contribute to low sperm counts.
- Heavy metal exposure. Exposure to lead or other heavy metals also may cause infertility.
- Radiation or X-rays. Exposure to radiation can reduce sperm production, though it will often eventually return to normal. With high doses of radiation, sperm production can be permanently reduced.
- Overheating the testicles. Frequent use of saunas or hot tubs may temporarily lower your sperm count. Sitting for long periods, wearing tight clothing or working on a laptop computer for long stretches of time also may increase the temperature in your scrotum and slightly reduce sperm production. The type of underwear you wear is unlikely to make a significant difference in male fertility.
Health, lifestyle and other causes
Some other causes of male infertility include:
- Illegal drug use. Anabolic steroids taken to stimulate muscle strength and growth can cause the testicles to shrink and sperm production to decrease. Use of cocaine or marijuana may temporarily reduce the number and quality of your sperm as well.
- Alcohol use. Drinking alcohol can lower testosterone levels, cause erectile dysfunction and decrease sperm production. Liver disease caused by excessive drinking also may lead to fertility problems.
- Occupation. Certain occupations can increase your risk of infertility, including those associated with extended use of computers or video display monitors, shift work, and work-related stress.
- Tobacco smoking. Men who smoke may have a lower sperm count than do those who don't smoke. Secondhand smoke also may affect male fertility.
- Emotional stress. Stress can interfere with certain hormones needed to produce sperm. Severe or prolonged emotional stress, including problems with fertility, can affect your sperm count.
- Weight. Obesity can cause hormone changes that reduce male fertility.
- Prolonged bicycling. Prolonged bicycling is another possible cause of reduced fertility due to overheating the testicles. In some cases, bicycle seat pressure on the area behind the testicles (perineum) can cause numbness in the penis and erectile dysfunction.
A number of risk factors are linked to male infertility. They include:
- Smoking tobacco
- Using alcohol
- Using certain illegal drugs
- Being overweight
- Having certain past or present infections
- Being exposed to toxins
- Overheating the testicles
- Having a prior vasectomy or vasectomy reversal
- Being born with a fertility disorder or having a blood relative with a fertility disorder
- Having certain medical conditions, including tumors and chronic illnesses
- Taking certain medications or undergoing medical treatments, such surgery or radiation used for treating cancer
- Performing certain prolonged activities such as bicycling or horseback riding, especially on a hard seat or poorly adjusted bicycle
Infertility can be stressful for both you and your partner. Complications can include:
- Surgery or other procedures to treat an underlying cause of low sperm count or other reproductive problems
- Expensive and involved reproductive techniques such as in vitro fertilization
- Stress and relationship difficulties related to the inability to have a child
- An increased risk of cancer, particularly prostate cancer
Preparing for your appointment
You're likely to start by seeing your family doctor or a general practitioner. However, when you call to set up an appointment, you may be referred to a specialist.
Here's some information to help you get ready for your appointment, and what to expect from your doctor.
What you can do
- Be aware of any pre-appointment restrictions. At the time you make the appointment, be sure to ask if there's anything you need to do in advance, such as refraining from ejaculating for a certain period of time or stopping certain medications.
- Write down any symptoms you're experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.
- Write down key personal information, including any major stresses or recent life changes.
- Find out whether you have a family history of fertility problems. Having a male blood relative, such as your brother or father, with fertility problems or other reproductive issues may give clues to the cause of fertility problems.
- Make a list of all medications, vitamins and supplements that you're taking.
- Take your partner along. For infertility, your partner may also need tests to see whether she has any fertility problems that could be preventing pregnancy. It's also good to have your partner along to help keep track of any instructions your doctor gives you or to ask questions you may not think of.
- Write down questions to ask your doctor.
Questions to ask your doctor
- What do you suspect may be interfering with my ability to father a child?
- Other than the most likely cause, what are other possible reasons my partner and I haven't been able to conceive a child?
- What kinds of tests do I need?
- Will my partner also need tests?
- What's the best treatment for my condition?
- What are the alternatives to the primary approach that you're suggesting?
- Are there any restrictions that I need to follow?
- Should I see a specialist?
- Is there a generic alternative to the medicine you're prescribing me?
- Are there any brochures or other printed material that I can take home with me? What websites do you recommend visiting?
Don't hesitate to ask questions at any time during your appointment.
What to expect from your doctor
Be ready to answer questions your doctor is likely to ask:
- At what age did you start puberty?
- Have you had any sexual problems in this relationship, including difficulty maintaining an erection, ejaculating too soon or not being able to ejaculate?
- Have you ever fathered a child?
- Have you had a vasectomy or a vasectomy reversal?
- Do you use illegal drugs, such as marijuana, cocaine or anabolic steroids?
- Have you been exposed to toxins such as chemicals, pesticides, radiation or lead, especially on a regular basis?
- Are you currently taking any medications, including dietary supplements?
- Do you regularly take hot baths or steam baths?
Tests and diagnosis
Many infertile couples have more than one cause of infertility, so it's likely you will both need to see a doctor. It may take a number of tests to determine the cause of infertility. In some cases, a cause is never identified. Infertility tests can be expensive and may not be covered by insurance — find out what your medical plan covers ahead of time.
Diagnosing male infertility problems usually involves:
- General physical examination and medical history. This includes examining your genitals and questions about any inherited conditions, chronic health problems, illnesses, injuries or surgeries that could affect fertility. Your doctor may also ask about your sexual habits and about your sexual development during puberty.
- Semen analysis. Semen is generally obtained by masturbating and ejaculating into a special container at the doctor's office. Your semen is then sent to a laboratory to measure the number of sperm present and look for any abnormalities in the shape (morphology) and movement (motility) of the sperm. The lab will also check your semen for signs of problems such as infections. Often sperm counts fluctuate from one specimen to the next. In most cases, several semen analysis tests are done over a period of time to ensure accurate results. If your sperm analysis is normal, your doctor will likely recommend thorough testing of your female partner before conducting any more male infertility tests.
Your doctor may recommend additional tests to help identify the cause of your infertility. These can include:
- Scrotal ultrasound. This test uses high-frequency sound waves to produce images inside your body. A scrotal ultrasound can help your doctor see obstructions or other problems in the testicles and supporting structures.
- Transrectal ultrasound. A small, lubricated wand is inserted into your rectum. It allows your doctor to check your prostate, and look for blockages of the tubes that carry semen (ejaculatory ducts and seminal vesicles).
- Hormone testing. Hormones produced by the pituitary, hypothalamus and testicles play a key role in sexual development and sperm production. Abnormalities in other hormonal or organ systems may also contribute to infertility. A blood test measures the level of testosterone and other hormones.
- Post-ejaculation urinalysis. Sperm in your urine can indicate your sperm are traveling backward into the bladder instead of out your penis during ejaculation (retrograde ejaculation).
- Genetic tests. When sperm concentration is extremely low, genetic causes could be involved. A blood test can reveal whether there are subtle changes in the Y chromosome — signs of a genetic abnormality. Genetic testing may also be ordered to diagnose various congenital or inherited syndromes.
- Testicular biopsy. This test involves removing samples from the testicle with a needle. The results of the testicular biopsy will tell if sperm production is normal. If it is, your problem is likely caused by a blockage or another problem with sperm transport.
- Anti-sperm antibody tests. These tests are used to check for immune cells (antibodies) that attack sperm. You are especially likely to have anti-sperm antibodies if you've had a vasectomy reversal.
- Specialized sperm function tests. A number of tests can be used to check how well your sperm survive after ejaculation, how well they can penetrate an egg, and whether there's any problem attaching to the egg. If you do have a low sperm count, having healthy sperm can be an important factor in male fertility.
Treatments and drugs
Your doctor will try to improve your fertility by either correcting an underlying problem (if one is found) or trying treatments that seem like they may be helpful. Often, an exact cause of infertility can't be identified. Even if an exact cause isn't clear, your doctor may be able to recommend treatments that work. In all cases of infertility, the female partner also will need to be checked and may need treatment. In some cases, treatment of the female partner may help compensate for male fertility problems.
Treatments for male infertility include:
- Surgery. For example, a varicocele can often be surgically corrected or an obstructed vas deferens repaired.
- Treating infections. Antibiotic treatment may cure an infection of the reproductive tract, but doesn't always restore fertility.
- Treatments for sexual intercourse problems. Medication or counseling can help improve fertility in conditions such as erectile dysfunction or premature ejaculation.
- Hormone treatments and medications. Your doctor may recommend hormone replacement or medications in cases where infertility is caused by high or low levels of certain hormones or problems with the way the body uses hormones.
- Assisted reproductive technology (ART). ART treatments involve obtaining sperm through normal ejaculation, surgical extraction or from donor individuals, depending on your specific case and wishes. The sperm is then inserted into the female genital tract, or used to perform in vitro fertilization or intracytoplasmic sperm injection.
When treatment doesn't work
Sometimes male fertility problems can't be treated, and it's impossible for a man to father a child. Your doctor may suggest that you and your partner consider either using sperm from a donor or adopting a child.
Lifestyle and home remedies
There are a few steps you can take at home to increase your chances of achieving pregnancy:
- Increase frequency of sex. Having sexual intercourse every other day around the time of ovulation increases your chances of getting your partner pregnant. However, ejaculating more often than that may reduce your sperm count.
- Have sex when fertilization is possible. A woman is likely to become pregnant during ovulation — which occurs in the middle of the menstrual cycle, between periods. Experts generally recommend having intercourse every two days near the time of ovulation. This will ensure that sperm, which can live several days, are present when conception is possible.
- Avoid the use of lubricants. Some products such as Astroglide or K-Y jelly, lotions, and saliva have been shown to reduce sperm movement. Ask your doctor about sperm-safe lubricants.
Evidence is still limited on whether — or how much — herbs or supplements might help increase male fertility. Some supplements may help only if you have a deficiency.
Supplements that show some promise for improving sperm count or sperm quality include:
- Vitamin C
- Vitamin E
- Vitamin B-12
- Folic acid
- Vitamin C
- Beta carotene
Talk with your doctor before taking dietary supplements to review the risks and benefits of this therapy, as some supplements taken in high doses (megadoses) or for extended periods of time may be harmful.
Coping and support
Coping with infertility can be difficult. It's an issue of the unknown — you can't predict how long it will last or what the outcome will be. Infertility isn't necessarily solved with hard work. The emotional burden on a couple is considerable, and plans for coping can help.
Planning for emotional turmoil
- Set limits. Decide in advance how many and what kind of procedures are emotionally and financially acceptable for you and your partner and determine a final limit. Fertility treatments can be expensive and often aren't covered by insurance. A successful pregnancy often depends on repeated attempts. Some couples become so focused on treatment that they continue with fertility procedures until they are emotionally and financially drained.
- Consider other options. Determine alternatives — adoption or donor sperm or egg — as early as possible in the fertility process. This can reduce anxiety during treatments and feelings of hopelessness if conception doesn't occur.
- Talk about your feelings. Locate support groups or counseling services for help before and after treatment to help endure the process and ease the grief should treatment fail.
Managing emotional stress during treatment
- Practice stress-reduction techniques. Examples include yoga, meditation and massage therapy.
- Consider going to counseling. Counseling such as cognitive behavioral therapy, which uses methods that include relaxation training and stress management, may help improve semen quality.
- Express yourself. Reach out to others rather than holding in feelings such as guilt or anger.
- Stay in touch with loved ones. Talking to your partner, family and friends can be very beneficial. The best support often comes from loved ones and those closest to you.
Many types of male infertility aren't preventable. However, you can avoid some known causes of male infertility:
- Don't smoke.
- Limit or abstain from alcohol.
- Steer clear of illegal drugs.
- Keep the weight off.
- Don't get a vasectomy.
- Avoid the heat.
- Reduce stress.
- Avoid exposure to pesticides, heavy metals and other toxins.
Though the risk isn't conclusive, if you're an avid cyclist, consider using a gel saddle and a full-suspension bicycle. It may also help to avoid wearing very tightfitting clothing for long periods of time.
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