If you or your partner are struggling with an infertility diagnosis, please refer to this page, how to cope with infertility for some gentle tips for coping with this trying condition.
What Is Infertility?
Infertility is a disease of the reproductive system that impairs the ability to conceive a child. Infertility may be diagnosed after a couple has been having well-timed, unprotected sexual intercourse for a full year.
If the woman is over thirty-five, infertility may be diagnosed after six months of well-timed, unprotected sexual intercourse.
Infertility may also be diagnosed if a woman is under age thirty-five and has suffered multiple miscarriages (also called "recurrent pregnancy loss" or RPL).
Read more about recurrent pregnancy losses.
While infertility can be one of the most isolating challenges a couple can face, being infertile is not uncommon. In fact, 10-15 percent of couples in the US are infertile.
Infertility can be caused by one single problem in either partner, or a combination of factors that lead to a couple being unable to conceive or carry a pregnancy to term.
There are many safe treatments that can help a couple overcome infertility and successfully carry a child to term.
What Is Male Factor Infertility?
Infertility is wildly considered a "woman's problem," although studies firmly contradict that. 35% of infertility is related to problems with the male reproductive system.
Regardless of where the infertility originates, infertility is a problem for both members of a relationship and something that must be faced as a team.
Facing infertility is a difficult and very emotional journey for a man, as men often associate feelings of masculinity with the ability to sire a child. A man facing male factor IF may feel like he's less of a man if he is not easily able to produce a child.
The emotional journey of a man facing male factor infertility can start with guilt and anger, leading to low self-esteem and poor self image - things that can greatly affect family life.
A couple who has been diagnosed with male factor infertility must communicate their feelings to one another as they face the challenge of infertility together.
The Male Reproductive System:
The male reproductive system, unlike the female reproductive system, is located primarily outside of the body and is the part of the body that is designed for procreation. A problem in any of the areas of the male reproductive system can lead to male factor infertility.
Let's explore the parts of the male reproductive system:
Penis: a sexual organ full of nerve endings, composed of three parts: the root, the shaft, and the glans.
The shaft, or the body of the penis, is shaped like a cylinder and composed of specialized tissues that contains large spaces that become engorged with blood when the man is aroused. When the penis is erect, or aroused, urine is blocked from the urethra so that semen is the only substance released upon ejaculation.
The glans, or the tip of the penis, may or may not be covered with foreskin, but also contains the opening of the urethra, a slender tube that transports seminal fluid (and urine, although not at the same time) into a woman's vagina.
Seminal fluid (semen): the fluid filled with reproductive cells called "sperm" that is ejaculated by a man upon orgasm.
Scrotum: The scrotum refers to the loose sac of skin that dangles behind and below the penis. The scrotum contain the testicles (testes) and a plethora of nerves and blood vessels. The scrotum is a climate-control system for the testes; a system of special muscles in the walls of the scrotum allow the skin to relax and contract in response to temperature. In cold temperatures, the scrotum move the testes closer to the body, and in hot temperatures, farther away from the body. Normal sperm development occurs at temperatures slightly below body temperature.
Structures Within The Male Reproductive System:
Epididymis: a long tube that rests on the back of each testicle that is responsible for storing and transporting sperm cells that have been formed inside the testes. The epididymis is responsible for making the sperm mature after they leave the testes. During arousal, contractions move the sperm into the vas deferens.
Vas Deferens: a long tube that travels from the epididymis to just behind the bladder in the pelvic cavity. The vas deferens are responsible for transporting mature sperm into the urethra, in preparation for ejaculation.
Ejaculatory Ducts: the ejaculatory ducts are special ducts formed by the fusion of the vas deferens and seminal vesicles. These ducts empty into the urethra.
Urethra: the urethra is a tube that carries urine from the bladder to the outside of the body where it is excreted as waste. In men, the urethra is also responsible for ejaculation of semen.
Seminal Vesicles: these sac-like pouches attach to the vas deferens near the base of the bladder and produce a fructose-rich fluid that provides the sperm cells with energy to make them move. The fluid produced by the seminal vesicles is what makes up most of a man's ejaculate.
Prostate Gland: the prostate gland is a small structure located below the bladder and in front of the rectum, and contributes additional fluids designed to nourish the sperm in ejaculate.
Bulbourethral Glands (Cowper's Glands): small structures on either side of the urethra below the prostate gland. These glands are responsible for the production of the preseminal fluid, which lubricates the urethra and neutralizes any acidity left over from urine in the urethra.
Problems with any of these structures of the male anatomy can lead to male factor infertility.
What Are Some Causes For Male Factor Infertility?
There are a number of causes for male factor infertility. These are differentiated by part of the male reproductive tract affected.
Pre-Testicular Causes for Male Factor Infertility: The following conditions do not allow sufficient support for the testicles and can include poor hormonal support and/or poor overall health:
Male Hypogonadotropic Hypogonadism: a problem with the pituitary gland or hypothalamus that causes the testes to produce little to no hormones.
- Obesity can increase the risk for Hypogonadotropic Hypogonadism in men.
- Kallman Syndrome - a genetic condition that causes Hypogonadotropic Hypogonadism, as well as a loss of smell.
Usage of recreational drugs and alcohol.
Tobacco smoking - men who smoke have about a 30% higher chance at having problems with fertility.
Robertsonioan Translocation - a chromosomal rearrangement of several pairs of chromosomes.
Riding: Sperm production can be negatively impacted by strenuous cycling or horseback riding.
Medications that affect sperm creation (spermotogenesis), such as chemotherapy or anabolic steroids.
Medications that decrease FSH levels, such as phenytonin (an antiepileptic medication used to prevent seizures).
Testicular Factors that lead to male factor infertility are conditions in which the testicles produce poor quality or lowered amounts of semen, despite proper hormonal functioning.
Testicular factors include:
Acrosome: An acrosome is an organelle that covers the head of the sperm cells which contains digestive enzymes that break down the outer membrane of an ova. In some cases of misshapen sperm, there exists no acrosome, which leads to male infertility.
Cryptorchidism - the absence of one or both testicles from the scrotum, most frequently caused by a birth defect.
Hydrocele Testis - accumulation of fluids around a testicle, caused by cancer, trauma, hernia.
Klinefelter Syndrome - a genetic condition in which a man is born with an additional X chromosome, which leads to no - or very low - production of sperm cells.
Malaria - a mosquito-borne infectious disease that can physically create blockages in the reproductive system of a man.
Mumps - in rare cases of mumps, the testicles may be infected; about half of those with a testicular mumps infection result in testicular atrophy and subsequent infertility.
Paternal age over 40 - over age 40, the quality of sperm may decrease.
Seminoma and other Testicular Cancers - a seminoma is a cancerous germ cell tumor of a testicle that can cause infertility.
Trauma to the testicles from an accident, car crash, or other trauma that impacts the testicles can lead to male factor infertility.
Varicocele - abnormal enlargement of the vein of the scrotum that drains the testicles.
Sperm Disorders: the most common causes for male factor infertility include production and/or maturation of the sperm cells. For men with sperm disorders causing male factor infertility, sperm may be immature, abnormally shaped, or unable to move properly. In other cases, sperm may be produced in abnormally low numbers (a condition called oligospermia) or not at all (azoospermia).
Sperm disorders may also be caused by certain genetic conditions.
Read more about genetic disorders.
These genetic conditions may include:
- Androgen Receptor Gene Mutations - a genetic condition in which a man is genetically male, but has a defect in testosterone receptors.
- Cystic Fibrosis - a genetic condition that has both lung and pancreatic problems. However, those with CF may also have been born without vas deferens, which leads to azoospermia.
- Hemochromatosis - a genetic condition that affects the body's storage of iron, which can lead to testicular dysfunction.
- Immotile Cillia Syndrome: For a man with immotile cillia syndrome (possible cause may include Kartagener's Syndrome - a genetic condition), sperm count is normal, but the sperm are non-motile (meaning they cannot move).
- Myotonic Dystrophy - a genetic condition that involves many systems, including underdeveloped testes and abnormal sperm production.
- Noonan Syndrome - a genetic condition that can cause abnormal function of the testes.
- Sickle Cell Disease - a genetic condition that leads to abnormal production of hemoglobin. These abnormally shaped hemoglobin molecules can get caught in the penis, causing intense pain and cell death.
- Sex Reversal Syndrome - a man who has the genetic chromosomes of a female (XY), which can lead to azoospermia.
- Y-Cell Microdeletions - a man is born with the proper amount of chromosomes; however, a small part of the Y chromosome has been deleted or missing. Men who have Y-cell deletions may have low - or no - sperm count.
Post Testicular Causes of Male Factor Infertility are due to conditions and/or health problems that affect the male reproductive system after sperm production. These can be related to defects in the genital tract, as well as problems with ejaculation.
Ejaculatory Duct Obstruction (also known as EDO) - is a congenital or acquired condition in which there is obstruction to one or both of the ejaculatory ducts. This means that the ejaculate is unable to leave the penis; thus causing male factor infertility.
Hypospadias - a birth defect of the male urethra that involves an abnormally placed male urethral orifice. Instead of opening on the tip of the penis, the placement of the urethra varies. If the severity of the hypospadias is high enough, there may be impairment of the ability to deliver semen into the vagina.
Impotence (also known as Erectile Dysfunction) - is the ability to maintain or achieve an erection. Impotence can be caused by disease progression, neurological damage (such as the case with diabetes mellitus), or psychological factors. This can understandably affect male fertility.
Retrograde Ejaculation - retrograde ejaculation is a condition in which semen, normally ejaculated through the urethra, is instead deposited into the urinary bladder. Normally, the urinary bladder contracts prior to ejaculation, which forces the semen to exit via the urethra. If this sphincter does not properly work, retrograde ejaculation may occur.
Structural Problems with the Vas Deferens - The vas deferens are used to transport sperm in preparation for ejaculation. For some men, the Vas Deferens may be missing (a marker for Cystic Fibrosis) or occluded. This means that a male will be unable to transport sperm properly into the penis in preparation for ejaculation.
Diagnosis of Male Factor Infertility:
The diagnosis of infertility begins with a thorough medical history and physical exam by a doctor who specializes in fertility issues.
A thorough medical history is incredibly important for a diagnosis of male factor infertility and should involve the following:
- Length of time the couple has been trying to get pregnant
- Past history of pregnancies with any partners.
- Previous difficulties with conception.
- Discussion of previous problems with the testicles (trauma, cryptorchidism, torsion), penile problems (hypospadis), previous infections (mumps, malaria), environmental factors (heat, radiation, medications, drug use and smoking history).
- Discussion of sexual habits, frequency of intercourse, use of lubricants, timing of intercourse.
- Discussion of past problems with thyroid or liver disease, diabetic neuropathy, pelvic surgeries or hernia repairs.
- Familial history of genetic problems.
Physical Examination: a physical examination will look at the following:
- Amount of hair on the body
- Examination of the penis, scrotum, testicles, anus, and rectum.
- Scrotal palpation while man is standing.
Laboratory Blood Tests: samples of blood will be taken to determine:
- Hormone Assays: FSH levels - high levels of FSH indicates poor testicular response. Testosterone levels may also be measured.
- Karotyping - testing for genetic diseases that may contribute to male factor infertility.
Standard Semen Analysis: A man will be asked to deposit his ejaculate into a sterile examination cup to be examined by a laboratory technician. The contents will be examined for:
- Approximate number of sperm
- Sperm motility
- Percentage of sperm with normal morphology
- Presence of white blood cells that may indicate infection
Post-Wash Semen Analysis - certain reproductive endocrinologists like to examine a semen sample after it's been washed, as is done for an IUI procedure.
Semen Antibody Tests - semen sample will be analyzed for antibodies, including the immunobead assay and mixed agglutination reaction.
Semen deficiencies(which may exist in several categories) include:
- Oligospermia - decreased number of sperm cells
- Aspermia - complete lack of sperm cells
- Hypospermia - reduced volume of seminal fluid
- Azoospermia - absence of sperm cells in semen
- Teratospermia - increased amounts of sperm with abnormal morphology
- Asthenozoospermia - reduced sperm cell motility
TESA/MESA/Testicular Biopsy - if a semen sample is found to contain no sperm, an aspiration or biopsy of the testicles may be performed to ascertain if there are sperm cells in the testicles or epididymus.
Treatment of Male Factor Infertility:
Treatment for male factor infertility has a lot to do with what is causing MFI. A reproductive endocrinologist should be able to best help determine and execute a treatment plan for male factor infertility. Factors involving male factor infertility may include:
- Age, health, medical history
- Extent of the problem leading to infertility
- Tolerance for certain therapies, medications, or procedures
- Expected course of treatment
- Opinion and preference of the couple
Today, in the age of assisted reproductive technology (ART), there are many treatment options available for those who struggle with male factor infertility.
Hormone Treatment - some men who have male factor infertility have a hormonal condition that can be managed with hormone and drug therapies.
Surgery - surgical correction of structural or anatomical barriers that impede ejaculation, sperm production, or sperm maturation may be utilized. Removing varicoceles may improve the quality of the sperm produced.
Assisted Reproductive Technologies (ART) used in male factor infertility may include:
- Artificial Insemination (IUI or AI): a procedure in which large amounts of healthy sperm are deposited at the entrance of a woman's cervix or directly into the uterus, allowing the sperm direct access to the fallopian tubes that release the mature ova.
- IVF, GIFT - the sperm is prepared in a manner so that the ova are exposed to the highest amount of motile, high-quality sperm.
- Microsurgical Fertilization (Intracytoplasmic Sperm Injection) - a single sperm is injected into the ova, so fertilization may take place under the microscope.
Preventing Male Factor Infertility:
While many of the problems associated with male factor infertility cannot be prevented, some methods that may increase male fertility can include:
- Avoiding cigarette smoke, which damages the DNA of sperm cells
- Avoid heavy use of alcohol
- Avoid marijuana
- Avoid situations that cause extreme heat around the testicles (saunas, hot tubs)
- Appropriate timing of sexual intercourse - too frequent and sperm counts drop, too infrequent may reduce sperm motility.
- Wear a cup while engaged in competitive sports that may cause damage to the testes.
How To Cope With Male Factor Infertility:
Infertility can be a devastating experience for a couple. Male factor infertility can be even more challenging for a couple as men are not as apt to discuss their feelings about male factor infertility. Partially this is due to a bit of removal from the trying to conceive process - charting ovulation and dealing with monthly menstruation mean that women are more involved with the procreation process.
Our culture encourages men to be strong, to not express his emotions, and to be stalwart in the face of adversity. A man who is experiencing male factor infertility should find someone - his partner, or a trained therapist - to talk to about his feelings.
A man may feel emasculated, as virility is often associated with the sexuality, by being diagnosed as infertile.
Sexual problems (erectile dysfunction and a lack of desire) may occur after a man has been diagnosed with infertility - the pressure to perform can be too much for a man. This can be further exacerbated by the pressure to perform sexually on a schedule while trying to conceive.
Marriages, if a couple does not communicate, can suffer. A man may feel his wife is "better off" without him, as he's "not enough of a man" to get his wife pregnant. As with most emotionally charged situations, his feelings of inadequacy can lead to a number of petty disagreements.
Often, a man who has been diagnosed with male factor infertility may try to overcompensate for his "short-comings" by outperforming himself in other areas that can net him positive feedback - such as doing home improvements or playing competitive sports.
It is important that a couple facing infertility do so together as a team. Communication is vital to the relationship, as is an honest approach about the feelings of each partner.
Additional Male Factor Infertility Resources:
Resolve provides timely, compassionate support and information to people who are experiencing infertility and to increase awareness of infertility issues through public education and advocacy.
The InterNational Council on Infertility Information Dissemination, INC. (INCIID – pronounced "inside") is a nonprofit organization that helps individuals and couples explore their family-building options. INCIID provides current information and immediate support regarding the diagnosis, treatment, and prevention of infertility and pregnancy loss, and offers guidance to those considering adoption or child-free lifestyles.
March of Dimes - Guidance and information for couples who are trying to get pregnant.