An Introduction to Male Factor Infertility

Male factor infertility is an issue for many couples wishing to conceive. With 2 percent of all men exhibiting sperm parameters beyond the ideal, male factor infertility is a subject which deserves serious discussion. Charles from Dreaming of Baby discusses with Dr. Nidhee Sachdev the causes behind such issues and the solutions for dealing with suboptimal sperm.

Charles: Today we have with us Dr. Nidhee Sachdev with CCRM OC Fertility to discuss male factor infertility solutions. If you would be so kind as to introduce yourself to our readers so they may know you a little better before we dive into this important subject.

Nidhee Sachdev MD, FACOG: Hi Charles, thanks for the invitation. I am a Reproductive Endocrinologist and Infertility specialist. I specialize in helping patients who are having trouble getting pregnant, are thinking about getting pregnant, or are interested in preserving their fertility for when they are ready to start a family.

Male Infertility Due To Obstruction

Charles: It is my understanding that when it comes to male factor infertility our problem can be productive or obstructive resulting in either low motility, low sperm count or no sperm at all. Can you give us a brief overview of the main causes and the outlined issues?

Nidhee Sachdev MD, FACOG: Nearly 15% of all couples that are seeking treatment for fertility issues will have some sort of male factor involved.

Nidhee Sachdev MD, FACOG: The causes of these “male factor” issues causing a lower or absent amount of motile sperm could be either because of a blockage in the male reproductive tract or because the testicles are not producing any or enough sperm. An obstructive or “blocked” reproductive tract could be for several reasons. Some men are born with an absence of a portion of the male reproductive tract called the vas deferens, which is important for allowing the sperm to pass through the proper channels to make its way out when ejaculation occurs. Many men are not aware of this because they are able to ejaculate and engage in sexual intercourse without any obvious signs.

Nidhee Sachdev MD, FACOG: Another reason, could be that a male has had a vasectomy in which they have a procedure blocking the vas deferens intentionally to prevent sperm from coming out during ejaculation.

Dr. Nidhee Sachdev: “Nearly 15% of all couples that are seeking treatment for fertility issues will have some sort of male factor involved.”

Charles: It is my understanding that for vasectomies the procedure is reversible within a certain timeframe, is this understanding correct?

Nidhee Sachdev MD, FACOG: Yes, the procedure can often be reversed, however the amount of time it takes to resume a normal sperm count can vary. The success of vasectomy reversal often depends on the length of time it has been since the vasectomy was performed.

Nidhee Sachdev MD, FACOG: Other causes of obstructive causes of low sperm count could be the result of prior groin surgery or infection. The latter two aren’t as common but could lead to scarring in the reproductive tract.

Fixing an Obstruction Issue

Charles: So to focus on one of the issues at a time as I believe it ties in with vasectomies as well, with obstructive issues what is the most common form of treatment? Using an analogy we can probably understand, can the pipes be fixed or re-routed or are other methods employed? In the case of fixing the pipes (if this is possible) what type of surgery is involved and what can one expect? If the pipes cannot be fixed what is the alternative route to parenthood?

Nidhee Sachdev MD, FACOG: In the case of a congenital absence of the vas deferens, there is no surgery to correct it or “join the pipes together”.

Nidhee Sachdev MD, FACOG: However, there are procedures that can be performed by a Urologist, typically ones trained to treat male infertility, in which the sperm can be removed from the epididymis (another part of the male reproductive tract) and can be used to fertilize eggs from the female.

Nidhee Sachdev MD, FACOG: So, in other words, there are ways to “bypass” the blockage and obtain the sperm.

Charles: Excellent, and in terms of fixing the pipes, is this ever done? I understand one of the most common ones would be vasectomy reversal, are there any others?

Nidhee Sachdev MD, FACOG: Vasectomy reversals are the most common procedure that I’m familiar with. However, removing sperm from the Epididymis is a very good option for many patients, including those who have undergone vasectomies. Since the time to pregnancy with a vasectomy reversal is variable, depending on the age of the female partner, many patients opt to have the sperm removed from the epididymis instead. The only disadvantage to this over the reversal is that the treatment course would need to be IVF instead of allowing the patients to try to conceive on their own.

Dr. Nidhee Sachdev: “Removing sperm from the Epididymis is a very good option for many patients, including those who have undergone vasectomies.”

Charles: IVF is of course a costly option, so I have to ask when sperm is withdrawn from the epididymis can intra-uterine-insemination be used or is this impossible?

Nidhee Sachdev MD, FACOG: Unfortunately, sperm removed from the epididymis doesn’t have the same ability to fertilize eggs that sperm in the ejaculate do so an intra-uterine-insemination is not an option.

Nidhee Sachdev MD, FACOG: When a patient has a very low or absent concentration of sperm in the semen analysis, we refer them to see a Urologist, particularly ones that specialize in male infertility.

Charles: Now that we know a bit more about obstructive issues and how they are resolved, can you give us a brief overview on how obstructive conditions are diagnosed?

Nidhee Sachdev MD, FACOG: Based on physical exam and ultrasound, they are able to diagnose whether an obstruction is present.

Charles: So, step 1 is providing an ejaculate? Step 2 a physical & ultrasound?

Nidhee Sachdev MD, FACOG: Yes, a routine part of the evaluation for infertility is a semen analysis. If there are abnormalities in the semen analysis, then a referral to a Urologist is made.

Low Motility, Low Sperm Count, and No Sperm

Charles: Excellent, that clears that up so getting diagnosed is quite straightforward. To gain a better understanding of the three main issues with the ejaculate can you explain; low motility, low sperm count & no sperm count?

Nidhee Sachdev MD, FACOG: A low sperm count means the overall concentration of sperm in the ejaculate is less than 15 million sperm. No sperm essentially means that there is very little sperm and essentially 0 sperm.

Nidhee Sachdev MD, FACOG: Motility indicates the percent of sperm in the ejaculate that are moving. Ideally, 40% or greater of the ejaculate will be moving.

Charles: Would it be safe to assume that zero sperm is normally due to an obstructive condition or would that be a dangerous generalization?

Nidhee Sachdev MD, FACOG: It could be due to either an obstruction and in some cases a non-obstructive cause.

Dr. Nidhee Sachdev: “Motility indicates the percent of sperm in the ejaculate that are moving. Ideally, 40% or greater of the ejaculate will be moving.”

Non-Obstructive Causes of Male Infertility

Charles: With that in mind, with regards to productive issues what are the most common possible causes?

Nidhee Sachdev MD, FACOG: Non-obstructive (Productive) causes could be cases where the cells responsible for making the sperm in the testicles aren’t producing them. This could be genetic or sometimes due to prior cancer treatment.

Nidhee Sachdev MD, FACOG: Those are cases in which you might see no sperm or very little. Other cases of seeing a lower sperm count can be the reasons above or due to hormonal imbalances, a varicocele (dilation of blood vessels in the reproductive tract) or cases in which patients are taking testosterone.

Charles: Interesting, any other main causes? Branching out into low motility?

Nidhee Sachdev MD, FACOG: Occasionally, having too long of a period of abstinence can affect the motility. But in general, the causes I discussed previously affect both count and motility.

Charles: You mentioned cancer treatment as a potential cause of male factor infertility; is there any way to safeguard against this impact prior to starting cancer treatment?

Nidhee Sachdev MD, FACOG: Depending on the age of the patient, the best course of action would be to freeze sperm prior to cancer treatment.

Charles: For the other causes listed above what type of solutions are available for someone wishing to use their own sperm?

Nidhee Sachdev MD, FACOG: The majority of the time, with low sperm counts and IVF, patients are still often able to use their own sperm to have a family. Its only in those cases where no sperm is found, most often due to genetic causes, where patients are unable to use their own sperm. Thanks to IVF, male factor infertility often can be treatable.

Charles: So what can we expect? Are there any medications or do we generally resort straight to IVF?

Nidhee Sachdev MD, FACOG: In cases where there are hormonal causes of the low sperm count, then medications such as Clomid can be used to increase the sperm count to the point where an intrauterine insemination can be performed.

Nidhee Sachdev MD, FACOG: Additionally, in cases where there is a varicocele (dilation of the blood vessels), a Urologist may be able to surgically correct it. And over the course of several months (typically at least 3 because the life cycle of spermatogenesis [the process of making sperm] is about 90 days).

Nidhee Sachdev MD, FACOG: Additionally, those patients who are taking testosterone or other medications that may lower their sperm count, often stopping those meds will show an improvement in their sperm count over the course of the next several months.

The Effect of Testosterone on Sperm Production

Charles: Wait! Testosterone negatively affects sperm production?

Nidhee Sachdev MD, FACOG: Yes! Many men who are taking testosterone (for strength or muscle building) can have a negative impact on their body’s ability to produce sperm.

Nidhee Sachdev MD, FACOG: When the body detects the high level of testosterone from the exogenous source that is being taken, the body produces less of its own testosterone. The testes need a high amount of local testosterone in order to properly produce sperm.

Dr. Nidhee Sachdev: “Many men who are taking testosterone (for strength or muscle building) can have a negative impact on their body’s ability to produce sperm.”

Charles: How invasive are these surgeries, what can be expected?

Nidhee Sachdev MD, FACOG: To get more specifics of the surgery, I would need to refer you to a Urologist. But in general, the patients do pretty well with minimal recovery time.

How Sperm are Extracted for an IVF Procedure

Charles: This has been an enlightening conversation, I do have one last major curiosity. Can you give us a brief overview of the extraction procedure for using sperm in IVF and a basic walkthrough of how it is then used in IVF?

Nidhee Sachdev MD, FACOG: Typically, the sperm extraction procedure would be done in the IVF lab by a Urologist with the help of an Embryologist or Andrologist. Sperm is carefully removed from either the Epididymis or the Testes and given to the embryologist who carefully examines the sample to assess that there are indeed sperm and that they are motile.

Nidhee Sachdev MD, FACOG: The sperm can then be frozen and saved for later use or if the female partner’s eggs have already been removed, they can then be put together with the egg to be fertilized using a process called Intracytoplasmic Sperm Injection (ICSI).

Nidhee Sachdev MD, FACOG: So, the female partner takes hormone injections to grow the eggs. Once the eggs are ready, the eggs are removed from her, and via ICSI the eggs are then fertilized from the sperm that was removed/extracted from the male partner.

Charles: So, in IVF the egg is fertilized directly?

Nidhee Sachdev MD, FACOG: Yes, in the setting of a laboratory, the egg is fertilized directly and then grown to become embryos which are then implanted into the female.

Charles: So the egg is also outside the body?

Nidhee Sachdev MD, FACOG: Yes, the eggs are grown inside the female patient and then they are removed/extracted in a procedure, and the eggs then in the IVF lab are introduced to the sperm via ICSI and fertilized.

How to Help Keep Sperm Healthy

Charles: That clears a few things up. To the big question – how often is fertility a male issue and what can men do to keep our swimmers healthy?

Nidhee Sachdev MD, FACOG: On average, about 15% of couples will have some sort of male factor involved in their infertility.

Charles: Is that of all infertility or of all couples trying to conceive?

Nidhee Sachdev MD, FACOG: That’s all infertile couples.

Nidhee Sachdev MD, FACOG: Eating a well-balanced diet, avoiding smoking, drugs and excessive alcohol use is important. Prolonged periods of time with increased heat to the scrotal area is also not recommended, so activities such as cycling should be limited to under 5 hours a week.

Dr. Nidhee Sachdev: “Obesity, tobacco and excessive alcohol use are important factors that could limit a male’s fertility.”

Charles: Ok, so approximately 1 in 7?

Nidhee Sachdev MD, FACOG: 1/7 couples seeking infertility evaluation will have some male infertility involved.

Charles: On a closing note; do you have any advice or information you would like to share with our readers about Male Factor Infertility that we did not cover yet?

Nidhee Sachdev MD, FACOG: I think the key is to try to live a healthy lifestyle. Obesity, tobacco and excessive alcohol use are important factors that could limit a male’s fertility.

Charles: It has been great having you with us to provide this information, on behalf of our readers, I would like to thank you for your time and valuable information you have provided us.

Nidhee Sachdev MD, FACOG: Thank you, Charles, for the opportunity to speak with you and educate your readers on matters that affect their reproductive health.

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