Male infertility

Male infertility factor accounts for 30% or more of all causes encountered in the evaluation of couples. Therefore evaluation of the male partner should begin at the same time as the female partner. Invasive or expensive diagnostic procedures or therapies for female infertility should not be pursued until the male has been evaluated. It is common for couples to have both male and female factors contributing to their subfertility.  

A. Semen analysis (SA) is absolutely necessary for the evaluation of all couples. If the SA is normal then testing for male factor infertility is usually considered complete. The ejaculate should be collected via masturbation into a sterile specimen cup after 2 to 5 days of abstinence, kept near body temperature, and examined by an experienced andrologist within an hour after collection. Normal parameters for the SA are as follows:

Volume: >2.0 mL.

Sperm concentration: >20 million/mL.

Motility: >50% with forward progression.

Morphology: >30% normal forms.

White blood cells: = 14% normal forms (Tygerberg/Kruger strict criteria) <1 million/mL.

Other semen parameters are often evaluated such as viscosity and sperm agglutination, which if consistently abnormal are an indication for further evaluation or treatment. Every man is permitted a bad sperm day.

If the initial SA has abnormal parameters, it should be repeated. Since sperm production requires approximately 74 days, events negatively impacting the SA such as fever or trauma may not be evident until weeks later. Consequently, the repeat semen analysis should be postponed for 2½ months. Male factor subinfertility is seldom diagnosed on the basis of one SA, whereas values for sperm concentration, motility and morphology can be used to classify men as subfertile. None of these parameters are diagnostic of absolute infertility. 

B.Antisperm antibodies (ASAb) bound to sperm in a man's ejaculate can prevent sperm from migrating up the female genital tract or penetrating an oocyte. ASAb are suggested when there is a significant amount of sperm agglutination seen on SA. ASAb are common after vasectomy reversal. The treatments range from attempting to suppress the male immune system prior to the female partner's ovulation usually combined with IUI, to in vitro fertilization and intracytoplasmic sperm injection (IVF/ICSI). 

C.Urologic evaluation by a urologist that specializes in male infertility is warranted when two, or ideally three, SA results are abnormal. Although most causes of male factor infertility are idiopathic, there are several known conditions that are worth ruling out. 

1.A varicocele (varicose vein in the scrotum) will often produce SA parameters that are all somewhat low. Diagnosis of a varicocele is usually made by genital examination. A small varicocele discovered only by ultrasound is of doubtful significance. Surgical ligation of a large varicocele improves male factor infertility in about 40% of cases and probably improves pregnancy rates. 

2.Other known causes of male infertility less commonly seen include:

Congenital bilateral absence of the vas deferens, usually with cystic fibrosis, presenting as azospermia (no sperm in the ejaculate).  

a. Klinefelter's, Kartagener's, or Kallman's syndrome. 
b.Secondary hypothalamic-pituitary insufficiency from surgery or brain tumors. 
c.Infections such as mumps orchitis or prostatitis. 
d.Testicular failure. 
e.Damage from previous genital surgery. 
f. Chemotherapy. 
g. Excessive alcohol, tobacco, or drug use. 
h.Exposure to some environmental toxins. 
i.Mechanical trauma from long-distance cycling can decrease sperm motility, however, other forms of endurance exercise do not seem to impair SA parameters.

Although there is a widely held belief that boxer shorts can improve fertility, wearing polyester briefs, which increase scrotal temperature, seem to have little impact on SA parameters.