Definition of Infertility
No one expects problems when a couple wants to have a baby. However, when pregnancy doesn’t happen on their timetable, there may be a problem. Then, the couple may pursue evaluation for the ability to get pregnant, especially if there is a concern about fertility.
Infertility is a couple’s problem. In general, infertility is the failure to get pregnant within 12 months of intercourse without contraception. It is estimated that 15% of couples may experience infertility. Of course, since there are two people involved, there can be problems with either the female (“female factor” in about 50% of cases) or the male (“male factor” in about 30% of cases) that contribute to the difficulty getting pregnant. The remaining 20% of infertility involves problems with both the female and male.
Fertility evaluation is appropriate for women under the age of 35 years who have tried to conceive for 12 months without pregnancy. Women older than 35 years may seek this evaluation after 6 months without pregnancy. For women older than 40 years, it is reasonable to seek the assistance of subspecialists as reproductive endocrinologists.
In most cases of infertility, no single cause can be identified. Over 40% will have a combination of factors contributing to the infertility. When both partners are evaluated, approximately one third of all cases can be resolved with appropriate treatment.
Infertility Evaluation: Male
1. History
A medical history provides important information to evaluate causes of infertility. The electronic medical record is an amazing tool. However, the computer record is not necessarily comprehensive. Some of these questions touch upon intimate details of your life. You want to be honest and specific so that you can get the help that you have requested. You might need to talk with family to get more details of their health history, especially if they have experienced infertility.
Should you need further evaluation for male infertility, please be aware that some of these questions, tests, or procedures may not apply to your situation. Be sure to check with your insurance company and the provider’s office for information concerning evaluation costs and consider your out-of-pocket costs. It is important to have a qualified physician that you trust to guide you during this season of life.
Here are some general categories of information that could be helpful:
- Symptoms - The most common fertility problem for men is with the number or function of sperm that is available for the woman’s egg. Problems with sexual function may interfere with conception. Pain or swelling in the genital area is important.
- Recent pursuit of pregnancy – How long have you tried to conceive? Have there been previous evaluations and/or surgery in the pursuit of pregnancy? Have you been trying with the same partner? How often do you have intercourse? Do you have any problems with intercourse?
- Medical history – All medical diagnoses are important to share with your provider. Diabetes, high blood pressure, cancer, digestive disorders as celiac disease, or infections may impact conception through the condition itself or the treatment of the condition.
- Surgery history – Provide a list of any surgery that you have had, especially related to the abdomen and urologic system (testicle, penis, etc.). Vasectomy is a critical piece of history to share! Your provider may ask for operative notes or pathology reports if they are available. What were the reasons for the urologic surgery?
- Trauma history - Have you been injured in the past whether by motor vehicle accidents, sports injury, assault, etc.
- Medications and over-the-counter supplements- Any prescriptions and supplements are vital to include with your history. Some medications may affect sperm production as antibacterial agents (nitrofurantoin), antidepressants (paroxetine, fluvoxamine, etc.), arthritis medications (steroids, colchicine, etc.), chemotherapy drugs, antiviral medication, anabolic steroids (for body building), and even testosterone supplementation.
- Family history – Is there a history of fertility problems? Are there any genetic problems or birth defects in the family?
- Social history – Do you use tobacco or vape? Men who smoke in any way are known to have a lower sperm count than men who do not smoke. Do you drink alcohol? Excessive alcohol consumption may affect a man in several ways (decreased sperm production and testosterone levels). Sometimes, erectile dysfunction is also a result of alcohol abuse. Do you use marijuana or other illegal substances? How much of any of these substances do you use and with what frequency? Marijuana and cocaine are reported to negatively affect sperm production and function.
- Occupational history – Does your work involve any materials or environment that could affect male fertility? If so, what kind of work? Do you have any potential exposures to radiation or toxic materials (e.g., pesticides, herbicides, organic chemicals, etc.), lead or other heavy metals? Chronic and unprotected exposure may lead to decreased sperm production. Environments or circumstances that lead to high temperatures have been reported to affect the testicular production of sperm.
- Parenting history – Have you fathered pregnancy with your current or other partners in the past?
2. Physical exam
After a man’s history is obtained in the detail noted above, a physical exam is needed. Much can be gained from an examination. In the case of an infertility evaluation, the man’s exam may be completely normal. But a normal exam does not mean that there is no male cause (male factor) of infertility. The physical exam attempts to identify any anatomic or functional cause of infertility.
The physical exam should include:
- vital signs (e.g., blood pressure)
- weight and height (Obesity can negatively affect sperm production by suppression of testosterone in the body.)
- general skin assessment – Reduced facial and body hair may be due to lack of male hormone.
- thyroid gland exam (for enlargement as a goiter or tenderness as with thyroiditis)
- breast exam - Breast enlargement in a male is known as gynecomastia. This physical finding may suggest decreased testosterone levels in the body.
- abdominal exam (to document that there is no tenderness, signs of previous surgery or injury)
- urogenital exam A urologist or trained urologic provider performs a physical exam to establish normal or abnormal anatomy. Some abnormal exam findings for the male include testicular abnormalities, varicocele (dilated veins in the scrotum), and signs of tenderness or infection (including possible sexually transmitted diseases).
3. Laboratory studies
Some studies may be requested for general medical health assessment, and some may be ordered for specific infertility issues.
- Semen analysis – Again, the most common reason for male infertility relates to the number or function of the available sperm. A semen analysis (“sperm count”) is obtained in various ways. The specimen should be promptly evaluated by trained lab staff. The evaluation looks for the total number of sperm (between 20-200 million in normal), the number of sperm with normal shape (over 50% should be normal), motility (at least 50% of the sperm should be moving an hour after collection), signs of infection (leukocytes), the pH level (should be between 7.2-7.8), the volume (around 2 ml is considered normal), the liquefication time (15-30 minutes is typical) and the color (white, cloudy).
- Urinalysis – A urine sample can be checked for signs of infection. If it is collected soon after ejaculation, the sample can be evaluated for the uncommon problem of sperm going inside the bladder instead of the normal direction outside through the penis (retrograde ejaculation).
- Hormone testing – Male sexual function and normal sperm production depend upon the normal levels of various hormones as testosterone. These levels are measured with a blood test.
- Genetic testing – This test is not often needed unless there is a concern about a genetic cause of a very low sperm count.
4. Imaging tests
Imaging for infertility evaluation of men is often requested. This kind of evaluation is a non-invasive assessment of the crucial urogenital anatomy for pregnancy. Non-invasive evaluations do not involve the risks of surgical procedures which may include anesthesia and incisions. Non-invasive imaging should be performed by experienced physicians or skilled technicians. These tests are informative about the appearance of the male urogenital anatomy, but it is not a direct picture of the inside of any organ. Actual tissue samples are not collected, so some diagnoses cannot be made with this test alone.
There are two different ultrasound evaluations that may be performed for male infertility exams:
- Scrotal ultrasound – An ultrasound probe is externally placed on the scrotum to provide an image of the anatomy. Normal anatomy will appear different from problems that may affect fertility such as dilated veins (varicocele).
- Transrectal ultrasound – The narrow ultrasound probe is guided into the rectum to provide an image of the prostate area. This test may locate signs of a potential blockage of the usual path of sperm.
5. Surgical procedures
A surgical procedure may be recommended based upon the compiled information that has been accumulated from the extensive medical history, physical examination, laboratory studies and imaging. There are minimally invasive surgical procedures that may be suggested:
- Testicular biopsy – A low sperm count may be evaluated in this manner. A needle biopsy of the testicle is obtained. If a normal amount of sperm is noted within this organ, there must be a problem with the course of the sperm from the inside to the outside. Local anesthesia is usually enough.
- Reversal of vasectomy – If a vasectomy has been performed, a surgical reversal is possible with reconnection of the vas deferens. This procedure is not guaranteed, but could be a means to conceive in the traditional way.
Summary
No couple wants to experience unplanned infertility when their dream is to grow their family with the precious life of a newborn. If infertility is a concern, the couple should be prepared for the appropriate evaluation with the appropriate professionals and pursue the next steps to achieve their dream.
