Infertility affects 15% of couples attempting pregnancy in the United States. Roughly speaking, about half of these couples will have a male factor involved, and a male factor will be the sole cause of infertility in about 25% of cases. Thus, all men should have at least a basic evaluation by a urologist early in the course of the female's evaluation to avoid expensive and unnecessary female treatments. Infertility is defined as the inability to achieve pregnancy after 1 year of unprotected intercourse. Many couples seek medical attention prior to waiting a year, especially if the female partner is over 35 years old. Most couples who seek medical assistance for fertility do not require high technology, expensive treatments.
The male reproductive system consists of internal and external sex organs (Fig. 1A) that are under sensitive hormonal control from structures in the brain such as the pituitary gland and hypothalamus.
(Fig 1B). Normally, the hypothalamus secretes molecules that then stimulate the pituitary gland to produce hormones that are necessary for testis function. Testis function can be most simply divided into endocrine and exocrine function. The endocrine function of the testis includes production of testosterone, a critical steroid hormone that helps form and maintain the function of the male sex organs, stimulates sperm production, and regulates secretion of pituitary hormones to prevent their overproduction. The exocrine function of the testis consists of a remarkably high output of sperm, the cells necessary to carry the male's genetic material to the female egg to produce an embryo. From start to finish, sperm take roughly 74 days to form. From the testis, sperm are secreted into the epididymis, a highly convoluted single tubular organ residing behind each testicle. It is in the epididymis that sperm gain their ability to swim as well as other important maturational qualities.
Normally, mature and some immature sperm are expelled from the urethra during ejaculation. Orgasm is a complex neurological event in which sperm are deposited from the paired vas deferens tubes (emission) where they join important secretions from other glands situated behind the urinary bladder (prostate gland and seminal vesicles) before being forcefully emitted from the penis (ejaculation). The sperm and seminal fluids normally enter the urethra within the prostate gland and are prevented from flowing into the bladder (retrograde ejaculation) by tight closure of the bladder neck at the time of orgasm.
While there is no one strict definition for a "normal" semen analysis, the World Health Organization (WHO) has determined minimal standards of what can be considered adequate semen quality for conception to occur. It is important to realize that these represent minimum standards and not necessarily "normal" values found in fertile men.
The first visit is geared to understanding each individual couples' problems, goals and timeline for treatment. I spend a lot of time educating patients on fertility issues that may pertain specifically to them as there are a lot of terms and phrases used and understanding these is critical.
| Volume | > 2.0 cc |
| pH | > 7.2 |
| Sperm Concentration | > 20 million/cc |
| Total Sperm Count | > 40 million/ejaculate |
| Motility | > 50% or ³ 25% with progressive motility |
| Morphology | > 15% normal forms (strict criteria) |
| Vitality | > 50% alive (vital staining) |
(Adapted from WHO laboratory manual for the examination of human semen and sperm-cervical mucus interaction. Fourth edition, 1998).
Male factor abnormalities are diverse, but generally include hormonal problems (pre- testicular), intrinsic testicular problems (testicular), and problems with ducts leading from the testes (post-testicular).
Sperm production is dependent on the careful balance of pituitary gland and testicular hormones. The main pituitary hormones involved in reproduction are follicle stimulating hormone (FSH) and leutinizing hormone (LH). These are the same hormones that are often tested in the female partner. Prolactin (PRL) is another pituitary hormone that, if elevated, drastically inhibits sperm production and function. A complete hormonal evaluation should be done in all men presenting with infertility. This is done with a simple blood test. While hormone problems account for only 10% of male fertility problems, most are easily treatable.
Testis problems result in a decline in sperm production and/or function. The causes of these problems are very diverse and require a complete evaluation done by a urologist specializing in fertility. Many of these can be detected on a simple physical examination.
A very common cause of testicular problems is a varicocele, or set of dilated veins surrounding the testes. These are simply an abundance of the normally found veins in the spermatic cord, or cable leading through the groin area to the testis on each side. These veins are no different the varicose veins seen in the legs of some people and are caused by gravity's effect (see section on evaluation and treatment).
In some men, impaired fertility is caused by a failure of normally produced sperm in the testes to get to the outside world. The following represents the normal course of sperm once it is produced in the testis:
Testis --> epididymis --> vas deferens --> ejaculatory ducts --> urethra
The epididymis is a gland sitting on the back of each testis that consists of a single, fine tube where sperm mature and gain their ability to swim (become motile). The epididymis can become obstructed from acquired or congenital problems. Acquired causes of epididymal obstruction include mumps infection, epididymitis, and trauma. Occasionally, the epididymis can be obstructed at birth for unknown reasons (congenital).
The vas deferens are paired tubes that carry sperm from the epididymis to the ejaculatory ducts of the prostate gland. They are the tubes that are divided during a vasectomy. Acquired causes of vassal blockage are rare. The most common is vassal injury at the time of inguinal hernia repair, especially during childhood hernia repair. Congenital causes of vassal blockages are also rare. The most common of these is a complete absence of the vas tubes on each side called congenital bilateral absence of the vas deferens (CBAVD). This produces a complete absence of sperm in the ejaculation and can only be diagnosed by a careful physical examination. CBAVD is also linked to being a carrier for the lung disease cystic fibrosis. Careful genetic testing is necessary in all patients with this condition.
The ejaculatory ducts are paired ducts that traverse the prostate gland to carry sperm from the terminal portion of the vas tubes to the urethra. In some cases, these ducts can be blocked. This usually leads to low ejaculate volume and poor sperm counts. The cause is usually congenital, consisting of a benign cyst in the prostate that blocks flow through these very fine ducts. Treatment is curative, but requires the correct diagnosis.
Once the sperm is deposited in the urethral tube, expulsion of the semen through the penis requires a complex set of neurological events to occur in which the bladder opening is closed off so that semen cannot travel backwards into the bladder. This condition is called retrograde ejaculation. It is not dangerous, but inhibits fertility profoundly. Causes include medications, diabetes, previous bladder surgeries and unknown causes. Patients with this condition are almost universally fertile and high pregnancy rates can be obtained with treatment.
There are several conditions affecting male fertility that can be treated with medicines or supplements. Having said this, it is important for patients to realize that there are numerous supplements available that advertise fertility benefits. Many of these have no proven benefit, however. Conditions that may be reversed with medical therapy include infection or inflammation of the genital tract, the presence of oxidants in the semen, hormonal imbalances, and many others. Supplements that do have some proven benefit can also be discussed.
In some specific cases, men can be treated with Clomid, a medication used much more frequently in women. This is safe and may, in the right cases, significantly improve sperm production and function.
Surgical treatment for male infertility consists of a few highly specialized, out-patient operative procedures. Some of these are listed here:
Varicocele, or varicose veins around the testicles, occur in 15% of the general male population, but 40-50% of the infertile male population. These dilated veins are thought to exert their effects by "heating" the testis with warm blood that pools in the veins. Varicoceles are easily detected on physical exam of the testicles by an experienced urologist used to evaluating fertility issues. There are some specific semen analysis findings that are commonly seen with varicoceles such as a decrease in sperm motility and morphology.
There are multiple surgical approaches to varicocele repair. Broadly speaking, these can be divided into microsurgical and non-microsurgical techniques. Non-microsurgical techniques can be safely performed through a small abdominal incision. However, if one plans the incision in the groin or upper scrotal area (smaller incision, faster recovery time), a surgical microscope should be used as this has clearly been shown to facilitate accurate differentiation of the veins (which need to be "tied off") from other important structures such as the artery supplying blood to the testis and lymph channels carrying lymph fluid away from the testis. It is critical to eliminate all of the veins contributing to a varicocele to prevent recurrence and to achieve the full benefit to fertility. Likewise, it is critical to avoid injury to the artery as this is the only blood supply of the testis in this anatomic location. Inadvertent ligation of the artery will result in testicular atrophy (shrinkage) and worsening sperm counts. Ligation of the lymph channels predisposes to hydrocele formation in the future (fluid surrounding the testis). Thus, the operating microscope is essential to perform an accurate, effective and safe varicocele ligation for fertility purposes.
Varicocele repair surgeries using the operating microscope. This surgery is done through a one to two- inch incision below the "underwear line" in the groin area. Surgery can be done in 1 hour and is done as an outpatient. Recovery time is minimal and most men are back at work a few days later. Heavy activity may resume in 1 - 2 weeks.
Sperm may be harvested surgically from the epididymis without attempted vasectomy reversal reconstruction. This is usually performed in men who have had an extreme time interval between vasectomy and reversal (> 25 years) or in the rare instance when there is a congenital blockage in the male genital system. This can be done either percutaneously (through the skin with a needle) or open (surgically with the operating microscope). In general, the open technique allows for a much greater harvest of sperm to be frozen, but requires a minor surgery with a small scrotal incision. Enough sperm can usually be aspirated from one side precluding the need for a second incision. Surgery takes about 1 hour and is done as an out-patient. Once sperm is cryopreserved, it can be used at any fertility center around the country.
In some cases, sperm must be taken directly from the testicle for in vitro fertilization. This occurs in men with very low sperm production who have no sperm in the ejaculate in which the cause is not from a blockage of sperm flow (called nonobstructive azoospermia). It also occurs in some men with epididymal scarring, previous failed vasectomy reversal and in some men with congenital blockages of the sperm ducts. TESE can be done in either the office (local anesthesia) or in the surgery center (many anesthesia options). It does not require an operating microscope. Essentially, it entails making a very small scrotal incision over the testis and removing a small piece (biopsy) of testis tissue. That tissue is immediately examined and an embryologist to determine the presence or absence of sperm. In some instances, multiple areas of the testis will need to by sampled (all through the same skin incision) in order to find adequate numbers of healthy sperm.
(may be done in the office or day surgery center)
Microscopic varicocele ligation
Los Gatos Surgery Center fees (includes anesthesia time)
Los Gatos Surgical Center would be happy to give you a confidential price quotation in writing prior to your surgery. They can be reached at (408) 356-0454.
*An additional fee will be charged by the sperm bank chosen
**These fees are for 4 hours surgery time they may increase incrementally for more involved surgeries.
Contact Dr. Gholami at 408-358-2030 or via online below:
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