Male Infertility | Symptoms, Diagnosis & Treatments

Azoospermia is when no sperm is found in a man’s ejaculate. This rare condition is sometimes symptomatic of testicular disease or blockage. Often, the cause of testicular disease is unknown but it may be related to mumps or to genetic disorders such as Y-chromosome deletions. Azoospermia is also symptomatic of Klinefelter’s syndrome..

Symptoms

• Determining whether your semen is lacking sperm cannot be determined by viewing the semen with the naked eye. A semen analysis by an experienced laboratory is required to check the sperm quality.

Treatment

• The cause of the azoospermia needs to be determined before a treatment plan is agreed upon. Surgical correction may be undertaken to correct a blockage if that’s the cause.
• Sperm are produced in the testes, so a testicular biopsy can be used to retrieve sperm for In Vitro Fertilisation (IVF) with Intracytoplasmic Sperm Injection (ICSI) in situations where there is azoospermia but the man is still producing sperm. Donor sperm may be an option if it is discovered that no sperm is being produced.

The vas deferens is a long, tube-like structure that connects the epididymis (the site of sperm storage) to the urethra (the tube that expels sperm). During ejaculation, the sperm flows out of the testicles, through the vas deferens and into the urethra, which leads outside the body through the penis. Congenital bilateral absence of the vas deferens (CBAVD) is a condition, present from birth, in which the vas deferens is missing. This greatly affects a man’s fertility, since the sperm are in essence stuck in the testicles with no way of reaching the urethra and leaving the body.

This condition exists at birth. Up to 65% of the men with CBAVD are cystic fibrosis (CF) carriers. Forty per cent of men with CBAVD may have a mild form that only presents itself as CBAVD. At least one partner must be screened for cystic fibrosis to be sure that he or she is not passing it on to their offspring. Genetic counselling can help interpret the results.

Symptoms

• Azoospermia is the most significant symptom of this condition. The inability to conceive is another indication that a man may have a fertility issue.

Treatment

• If the vas deferens is absent, surgery cannot correct the problem; however, there are surgical options to retrieve sperm. A testicular biopsy can retrieve sperm for use with an In Vitro Fertilisation (IVF) cycle. Intracytoplasmic Sperm Injection (ICSI) is the preferred treatment because of the immature nature of testicular sperm.
• Couples may instead opt to use donor sperm.

The scrotum is a muscular structure that houses the testes. For normal sperm production to occur, the testes must be a few degrees cooler than the rest of the body. For this reason, the scrotum is outside the body.

Fertility problems can develop if the testes do not descend into the scrotum within the first month or so after birth. Surgery can repair undescended testes, but permanent damage is possible if the testes do not descend early enough.

Symptoms

• Cryptorchidism is a likely diagnosis when a man’s testes have not descended into the scrotum.

Treatment

• Surgery to correct this is usually performed in childhood; however, the results of the procedure can impact a male’s fertility as he matures.

Sperm is stored in the epididymis, where it undergoes final maturation. If infected, the epididymis can malfunction and become a hostile environment for the sperm. Many pathogens can cause epididymitis, including those that cause sexually transmitted diseases.

Symptoms

• The most obvious signs of epididymitis are swollen, painful testicles.

Treatment

• The treatment for acute epididymitis is effective. It includes antibiotic therapy, bed rest, scrotal support (“supporter”) and oral anti-inflammatory drugs (such as Ibuprofen). Each of the treatment modes are important. Chronic epididymitis is more of a problem (though less severe) because its symptoms seem to persist even after the initial treatment.

Hyperprolactinemia is the excessive production of the hormone prolactin (which produces milk in pregnancy and suppresses ovulation). In men, abnormal prolactin levels can lead to sexual dysfunction. It can be symptomatic of hypothyroidism (a condition in which the body lacks thyroid hormone). Hyperprolactinemia can be triggered by:

• Tumours on the pituitary gland or prolactinomas.
• Thyroid gland disorder.
• Surgical scars on the chest wall, and other irritations like shingles.
• Medications including some tranquilisers, high blood pressure medications and antinausea drugs.
• Oral contraceptives and recreational drugs like marijuana.

Symptoms

• In men, hyperprolactinemia may be associated with impotence, visual disturbances, sudden weight loss or gain, fatigue or depression.

Treatment

Both drug and surgical methods are used to treat hyperprolactinemia:

• Bromocriptine is used to reduce excessive prolactin levels.
• Surgery is used to remove tumours (a riskier procedure).

Immunological infertility occurs most often in men. An infection, cancer or a vasectomy can cause the male immune system to react to its sperm as if they were invading cells. The immune system will attack the sperm and render them useless.

If the cause of immunological infertility is female-related, the current theories are that cervical mucus can kill sperm, or the uterus can reject the embryo. The exact cause of immunological infertility is unproven, but may be triggered by past or present infection, cancer or vasectomy (with or without reversal).

Symptoms

• Although there may not be obvious signs, a previous infection that was not successfully treated could still be present in the body.

Treatment

• Treatment for this disorder ranges from drug therapy to assisted reproduction:

• Steroids: Cortisone, prednisone and dexamethasone can reduce the body’s immune system response.
• Antibiotics: Antibiotics are used when it is believed the condition is a result of a bacterial infection (theorised by only some healthcare providers).
• Assisted Reproductive Technology (ART): Intra-Uterine Insemination (IUI), In Vitro Fertilisation (IVF) with Intracytoplasmic Sperm Injection (ICSI) or gamete intra-fallopian transfer (GIFT) are also options.

Klinefelter’s syndrome, a chromosomal disorder in men, is a genetic condition in which there is no sperm in the ejaculate or the count is low. In many cases, sperm is produced in the testes and can be retrieved with a testicular biopsy. As it’s inherited, if you have this condition, it’s best to consult a genetic counsellor before attempting conception.

Chromosomal testing of the embryos is one option. An extra X chromosome (XXY instead of XY) causes Klinefelter’s syndrome. Advanced maternal age can increase the risk.

Symptoms

• Several physical symptoms, such as small testes and a small penis, can be indicators of the syndrome. Excess hormones that in men stimulate testicular function is another symptom. Children with Klinefelter’s syndrome may be slow learners and are often tall and thin.

Treatment

• Men with this syndrome usually require infertility treatment. The focus of treatments is not to correct the syndrome but to harvest any sperm the man has for use in assisted reproductive procedures such as intracytoplasmic sperm injection (ICSI) – a specialised form of In Vitro Fertilisation (IVF). If this is not possible, donor sperm is another option.
• Seven per cent of infertile men have some form of chromosomal abnormality. Ten to 15% of men with an absence of sperm will have an abnormality, compared with 5% of men with oligospermia (low sperm count) and only 1% of men with normal sperm counts. Two-thirds of these chromosomal abnormalities are Klinefelter’s syndrome.
• Chromosomal abnormalities can be inherited, which is why genetic counselling is a good idea to understand the risk of passing this on and about the increased risk of miscarriages.

Occlusion is the medical term for any blockage in the reproductive systems of women or men. A blockage in the male duct system may prevent sperm from reaching the ejaculate. Causes include:

• Scar tissue from abdominal surgery.
• Congenital conditions.
• Sexually transmitted diseases.
• Hernias.
• Vasectomies (most common).

Symptoms

• This condition can only be diagnosed by transrectal ultrasound, vasography or seminal vesiculography.

Treatment

• The option for this is a vasovasostomy – a procedure in which the doctor stitches the inner and outer layers of the vas deferens back together.
• A testicular biopsy can done to retrieve sperm; however, since the sperm is less mature than ejaculated sperm, the couple will need IVF with ICSI. The cost of vasovasostomy is high compared with IVF and ICSI, and it does not attract a Medicare rebate.

Retrograde ejaculation is where is ejaculated into the bladder instead of exiting the body through the penis. Anatomically, the spermatic duct joins the path of the urethra for semen to exit the body. This rare condition is sometimes the result of diabetes or the removal of the prostate gland.

For men diagnosed with retrograde ejaculation, sperm may be retrieved from collected urine processed by the andrology laboratory. Because the acidity of urine can damage sperm, a man may take neutralising sodium bicarbonate to allow the collection of more viable sperm from the urine. Otherwise, a man can empty his bladder and have a catheter inserted to fill the bladder with laboratory solution. After ejaculation, the fluid is collected, the liquid removed, and the sperm harvested.

The most common reason for retrograde ejaculation is previous prostate surgery. Other possible causes are cancer, diabetes, multiple sclerosis and surgeries involving the abdomen or pelvic or genital areas.

Symptoms

• Lack of ejaculate indicates retrograde ejaculation.

Treatment

• Healthcare providers commonly approach this condition in one of two ways: through the use of drugs or assisted reproductive technology.
• Antihistamine drugs are used to tighten the bladder opening to prevent the sperm from flowing backwards. Various assisted reproductive procedures, such as testicular biopsy, (ICSI)and (IVF), can bypass the normal way sperm is deposited into the vagina.

The chances of conception are reduced when sperm concentrations are lower than normal, a condition known as oligospermia. If sperm have poor swimming ability or are misshapen (relating to morphology), the sperm’s ability to fertilise an egg is compromised.

Sperm problems can be caused by hormonal imbalances and genetic abnormalities. Physical causes such as a blockage can prohibit sperm transportation. Diabetes, which in some cases leads to retrograde ejaculation, can also cause sperm problems. Environmental conditions may play a role as well. Smoking, alcohol and the use of prescription and recreational drugs may all be contributing factors. Also, frequent exposure to high temperatures can cause these abnormalities.

Symptoms

• Semen analysis is the only way to detect these abnormalities.

Treatment
Depending on the cause, treatment options are:

• Lifestyle modifications.
• IVF with or without Intracytoplasmic Sperm Injection (ICSI).
• Donor sperm.

Varicoceles are enlarged veins inside the testicle. The prevailing theory on the effects of varicoceles on fertility is that these enlarged veins may increase the temperature of the testicles, resulting in impaired sperm production. Currently, there is no known cause of varicocele.

Symptoms

• One testicle significantly larger than the other may be a sign of varicocele. An ultrasound can determine whether a vein is enlarged.

Treatment

• Varicocele can be surgically repaired through balloon surgery and microsurgery. ICSIcan circumvent any of the problems varicocele might create.
• There is no evidence that correction of varicocele improves fertility.

Vasectomy reversals are not always successful and depend on when the vasectomy was performed, the amount of vas removed and circulating antibody levels. The procedure can cause a man to develop other problems, such as blockages, immunological issues and an infertility condition named azoospermia. Some men who have had a vasectomy change their minds and want the condition reversed.

Symptoms

• None.

Treatment

• The treatment option is a vasovasostomy or reversal of vasectomy, a procedure in which the doctor stitches together the inner and outer layers of the vas deferens. The procedure brings back continuity to the vas deferens to restore sperm in the ejaculate. It is expensive, takes time and has a lower level of success compared with IVF. In Australia, there is no Medicare support for reversal of vasectomy. There are, however, Medicare rebates for IVF and testicular sperm retrieval.
• If a man has had a vasectomy for more than 10 years, it’s possible his body will not produce viable sperm.