Infertility is the inability to conceive after at least one
year of unprotected intercourse. Since most people are able to
conceive within this time, physicians recommend that couples
unable to do so be assessed for fertility problems. In men,
hormone disorders, illness, reproductive anatomy trauma and
obstruction, and sexual dysfunction can temporarily or
permanently affect sperm and prevent conception. Some
disorders become more difficult to treat the longer they
persist without treatment.
Sperm development (spermatogenesis) takes place in the ducts (seminiferous
tubules) of the testes. Cell division produces mature sperm
cells (spermatozoa) that contain one-half of a man's genetic
code. Each spermatogenesis cycle consists of six stages and
takes about 16 days to complete. Approximately five cycles, or
2 ½ months, are needed to produce one mature sperm.
Energy-generating organelles (mitochondria) inside each sperm
power its tail (flagellum) so that it can swim to the female
egg once inside the vagina. Sperm development is ultimately
controlled by the endocrine (hormonal) system that comprises
the hypothalamic-pituitary-gonadal axis.
Because sperm development takes over 2 months, illness that
was present during the first cycle may affect mature sperm,
regardless of a man's health at the time of examination.
Incidence and Prevalence
According to the National Institutes of Health, male
infertility is involved in approximately 40% of the 2.6
million infertile married couples in the United States.
One-half of these men experience irreversible infertility and
cannot father children, and a small number of these cases are
caused by a treatable medical condition.
Causes and Risk Factors
The primary causes of male infertility are impaired sperm
production, impaired sperm delivery, and testosterone
deficiency (hypogonadism).
Infertility can result from a condition that is present at
birth (congenital) or that develops later (acquired). Causes
of infertility include the following:
Chemotherapy
Defect or
obstruction in the reproductive system such as failure of
testes to descend into the scrotum (cryptorchidism) or
absence of one or both testicles (anorchism)
Varicocele
Retrograde ejaculation occurs when impairment of the muscles
or nerves in the bladder neck prohibit it from closing during
ejaculation, allowing semen to flow backward into the bladder
and causing infertility. It may result from bladder surgery, a
congenital defect in the urethra or bladder, or disease that
affects the nervous system. Diminished or "dry" ejaculation
and cloudy urine after ejaculation are signs of this
condition.
Testicular trauma, resulting from injury, surgery, or
infection can trigger an immune response in the testes that
may damage sperm. Though their effects are not fully
understood, antibodies can impair the ability of sperm cells
to swim through cervical mucus or to penetrate a female egg.
Diagnosis
The search for the cause of infertility usually begins with
the male, because male examination and testing is less
complicated. A thorough examination and a review of the man's
medical and surgical history are necessary, because chronic
disease, pelvic injury, childhood illness, abdominal or
reproductive organ surgery, recreational drug use, and
medications can affect fertility. Physical examination may
detect testicular irregularities (e.g., vericocele, absence of
vas deferens, tumor), evidence of hormonal disorders (e.g.,
underdeveloped reproductive organs, enlarged breast tissue),
or evidence of testosterone deficiency.
Assessing reproductive-fertility history is important;
specialists typically inquire about the following:
Early puberty
(may result from hormonal disorder)
Late puberty
(may result from Kallmann's syndrome)
Previous
pregnancy
Sexual
intercourse timing (understanding ovulation)
STDs (can
cause scarring, obstruction)
Use of
lubricants (may kill sperm)
A semen analysis, usually performed by a
fertility specialist, is used to examine the entire ejaculate,
because seminal fluid can affect sperm function and movement.
Generally, three semen samples are taken at different times to
account for variables such as temperature and error. Most
specialists prefer three samples that differ no more than 20%
from one another before proceeding with diagnosis.
Six sperm factors are analyzed in semen analysis:
Concentration
(sperm/milliliter; cc)
Morphology
(sperm shape; normal structure associated with sperm
health)
Motility (or
mobility; % sperm movement)
Standard
semen fluid test (thickness, color)
Total motile
count (total number of moving sperm)
Volume (total
volume of ejaculate)
Azoospermia is the absence of sperm in the
semen. Men with normal reproductive tracts and hormone systems
can have azoospermia due to a lack of sperm-producing tissue
in the testes or an obstruction. Obstructions can be viewed
with x-ray. The World Health Organization has established
criteria for normal sperm concentration, morphology, and
motility. Total motile sperm count, which should be about 40
million, is calculated by multiplying volume by concentration
by motility.
The semen fluid test looks at factors that
may impede sperm performance. Abnormally thick semen may cause
sperm to swim more slowly through cervical mucus, obstructing
fertilization. Abnormal sperm shape (i.e., disfigured or
multiple heads or tails) usually indicates poor sperm health.
Infertility is likely if 60% or more of sperm in semen is
abnormally shaped.
Other tests are concerned specifically with sperm's ability to
swim through cervical mucus and bind to and penetrate an egg.
The postcoital Sims-Huhmer, or sperm-mucus interaction test,
examines whether the sperm are able to swim through the female
reproductive tract. This ability is referred to as forward
progression. In the middle of the menstrual cycle, the
cervical mucus becomes watery. Intercourse is recommended
during this time, followed, the next day, with an inspection
of the mucus to determine if
enough semen
was delivered to the cervix;
sperm are
healthy and do not show large numbers of clumped,
motionless, or
dead cells;
and
sperm are
swimming energetically through the cervical mucus.
The sperm penetration assay (SPA), or sperm-oocyte
interaction test, examines the ability of sperm to penetrate
the egg by combining it with a hamster egg. The immunobead
test looks at semen for the presence of antibodies that damage
sperm.
Post-ejaculation urinalysis may identify diseases that affect
fertility, such as kidney disease, diabetes, and repeated
urinary tract infection (UTI). Blood tests identify disorders
that impair testosterone and sperm production.
Treatment
At least one-half of male fertility problems can be treated so
that conception is possible. There are three categories of
treatment:
Assisted
reproduction
Drug therapy
Surgery
Therapy includes methods to improve erectile
dysfunction, induce ejaculation, obtain sperm, and inseminate
an egg:
Electroejaculation
Sperm
retrieval and washing
In vitro
fertilization (IVF)
Intracytoplasmic sperm injection (ICSI)
Gamete
intrafallopian transfer (GIFT)
Electroejaculation
This procedure can be used to produce ejaculation when
neurological dysfunction prevents it. An electrical rectal
probe generates a current that stimulates nerves and induces
ejaculation; semen dribbles out through the urethra and is
collected. Retrograde ejaculation is associated with the
procedure and sodium bicarbonate is usually taken the day
before to make the urine alkaline (nonacidic) and
nondetrimental to sperm. Candidates for electroejaculation
include men who have undergone testis removal (orchiectomy),
retroperitoneal lymph node dissection (RPLND), and those with
spinal cord injuries.
Sperm retrieval
This technique is used to obtain sperm from the testes or
epididymis when obstruction, congenital absence of the vas
deferens, failed vasectomy reversal, or inadequate sperm
production causes azoospermia. Using a technique called micro
epididymal sperm aspiration (MESA), a surgeon makes an
incision in the scrotum and gathers sperm from the epididymis,
the elongated, coiled duct that provides for the maturation,
storage, and passage of sperm from the testes. Percutaneous
epididymal sperm aspiration (PESA, or fine needle aspiration)
is similar to MESA but does not involve microsurgery. A
physician uses a needle to penetrate the scrotum and
epididymis and draws sperm into a syringe. Testicular sperm
extraction (TESE), the removal of a small amount of testicular
tissue, is used to retrieve sperm from men with impaired sperm
production, or when MESA fails. (see also Testis Biopsy)
These procedures are done under local anesthesia, usually take
about 30 minutes, and may cause pain and swelling.
Sperm washing
This procedure isolates and prepares the healthiest sperm for
insemination. Sperm and washing medium are combined and spun
rigorously (centrifuged) and the process is repeated if
necessary. The process separates sperm from white blood cells
and fatty acids (prostaglandins) in the semen that may hinder
sperm motility. It also concentrates sperm, which increases
the chance for conception.
Sperm retrieved by MESA, PESA, or TESE may be used in in vitro
fertilization (IVF) and intracytoplasmic sperm injection (ICSI).
IVF involves combining eggs with sperm in a laboratory,
providing proper fertilization conditions, and transferring
the resulting embryos to the uterus. To retrieve an egg, a
specialist uses ultrasound to guide a fine needle through the
vaginal wall and into the ovary or makes an incision in the
abdomen to get to the ovary (laparoscopy). Once the eggs are
retrieved, they are combined with prepared sperm in a sterile
dish for 2 to 4 days. After fertilization, the embryos are
transferred to the uterus. IVF is used most commonly for
infertility caused by female reproductive abnormalities.
Intracytoplasmic sperm injection (ICSI) may be used
with immotile sperm during in vitro fertilization. Using a
tiny glass needle, one sperm is injected directly into a
retrieved mature egg. The egg is incubated and transferred to
the uterus.
Fertilization occurs in 50% to 80% of cases and approximately
30% result in a live birth. The egg may fail to divide or the
embryo may arrest at an early stage of development. Younger
patients achieve more favorable results and poor egg quality
and advanced maternal age result in lower success rates.
ICSI does not increase the incidence of multiple pregnancies.
Long-term information about the health and fertility of
children conceived through this procedure is not available
because it was first performed in 1992.
While excess sperm from MESA or PESA can usually be frozen for
future use, most TESE-derived sperm are not of sufficient
quality or quantity for frozen storage (cryopreservation).
Multiple MESA or PESA procedures are not recommended, since
repetition can lead to scarring.
Gamete intrafallopian transfer (GIFT)
This procedure is recommended for couples with unexplained
fertility problems and normal reproductive anatomy. Mature
eggs and prepared sperm are combined in a syringe and injected
into the fallopian tube using laparascopy. Embryos that result
from this procedure naturally descend into the uterus for
implantation.
Average conception rate for these procedures is about 30%.
Drug therapy includes medications to improve sperm
production, treat hormonal dysfunction, cure infections that
compromise sperm, and fight sperm antibodies. The
administration of testosterone is similar to that used to
treat testosterone deficiency. Tamoxifen (Nolvadex®), an
antiestrogen agent, may be used to stimulate gonadotropin (a
male hormone) release, which leads to testosterone production.
Antibiotics, like levofloxacin (Levaquin®) and doxycycline (Periostat®),
are used to treat fertility-impairing infections of the
urinary tract, testes, and prostate, and STDs.
Surgery is performed to treat reproductive tract
obstruction and varicocele. Vasoepididymostomy is a
microsurgical procedure that corrects obstruction in the
coiled tube that connects the testes with the vas deferens (epididymis).
Obstructions commonly result from STDs and also include cysts
and tubal closure (atresia), which is usually genetic.
Vericocelectomy, the removal of a varicocele from the testes,
often results in increased sperm count.
Naturopathic Treatment
Naturopathic treatment for male infertility focuses on
improving sperm quantity, sperm quality, and overall male
reproductive health. Researchers reported that sperm counts
have fallen almost 50% since the 1930s. Although some dispute
these findings, it is generally accepted that sperm counts are
declining. The cause may be environmental and dietary and
lifestyle changes may interfere with men’s sperm production.
If this is so, improving diet and making healthy lifestyle
choices should positively impact male reproductive health.
Nutrition
The importance of a healthy diet cannot be overstated. To
function properly, the reproductive system requires the proper
vitamins and minerals. Nutritional deficiencies can impair
hormone function, inhibit sperm production, and contribute to
the production of abnormal sperm.
Eat a natural foods diet that focuses on fresh vegetables,
fruits, whole grains, fish, poultry, legumes, nuts, and seeds.
Drink ½ of body weight in ounces of water daily (e.g., a 150
lb man would drink 75 oz of water).
Eliminate processed and refined foods (e.g., white flour),
junk food, sugars, alcohol, and caffeine.
Avoid saturated fats and hydrogenated oils (e.g., margarine);
use olive oil.
Pumpkin seeds are naturally high in zinc and essential fatty
acids which are vital to healthy functioning of the male
reproductive system. Eat ¼ to ½ cup a day of pumpkin seeds to
help maintain a healthy reproductive system.
Supplements
The following supplements may increase sperm count and/or
motility. Allow 3-4 months for the supplements to work.
Arginine—Take 4 gr daily. Needed to produce sperm. If the
sperm count is below 10 million per ml, arginine probably will
not provide any benefit.
Coenzyme Q10—Take 10 mg daily. Increases sperm count and
motility.
Flaxseed oil—Take 1 tbsp daily. Is a source of essential fatty
acids.
L-carnitine—Take 3-4 grams daily. Required for normal sperm
function.
Multivitamin-mineral—Buy a high-quality product and take one
serving size (differs from brand to brand).
Selenium—Take 200 mcg daily. Improves sperm motility.
Vitamin B-12—Take 1000 mcg daily. A B-12 deficiency reduces
sperm motility and sperm count. Even if no deficiency exists,
B-12 supplementation may help men with a sperm count of less
than 20 million per milliliter or a motility rate of less than
50%
Vitamin C—Take 500 mg 2 times daily. Is an antioxidant.
Vitamin E—Take 400 IUs 2 times daily. Is an antioxidant and
improves sperms’ ability to impregnate.
Zinc—Take 30 mg 2 times daily. Required for a healthy male
reproductive system and sperm production.
Herbal Medicine
Herbal medicines usually do not have side effects when used
appropriately and at suggested doses. Occasionally, an herb at
the prescribed dose causes stomach upset or headache. This may
reflect the purity of the preparation or added ingredients,
such as synthetic binders or fillers. For this reason, it is
recommended that only high-quality products be used. As with
all medications, more is not better and overdosing can lead to
serious illness and death.
The following herbs may be used to treat male infertility:
Ginseng (Panax
ginseng)—Known as a male tonic (an agent that improves
general health) and used to increase testosterone levels
and sperm count.
Siberian
ginseng (Eleutherococcus senticosus) may also be used.
Sarsaparilla
(Smilax spp.)—Known as a male (and female) tonic.
Saw palmetto
(Serenoa repens)—Used for overall male reproductive
health.
Other Recommendations
Avoid
alcohol. Alcohol consumption is associated with an
increased number of defective sperm.
Consider
acupuncture.
Do not smoke.
There is an association between smoking and low sperm
count, poor sperm motility, and abnormal sperm.
Proxeed® is a
new nutritional supplement that may improve sperm health
and fertility rates. The ingredients include L-carnitine
and acetylcarnitine, two vitamin-like substances
synthesized naturally by the body. These chemicals are
involved in cellular metabolism and are found in semen at
a rate that is proportionate to the amount of healthy
sperm. Proxeed® improves sperm count, concentration, and
motility when taken orally for about 2 months.
Approximately 30% of couples using it experience
pregnancy. It is available without a prescription,
although couples considering it should consult their
physician.
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Multi-Specialty Medical Clinic
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