If you and your partner have been having unprotected sex for a year without conceiving, you might want to consider scheduling a consultation with us to explore the causes of your potential infertility and the medical options available to address them. (If your partner is age 35 or older, the time frame is six months.) Infertility affects about 15% of couples in our country.

Conception is a complex biological process. That can be hard to remember when other couples seem to conceive so easily. But successful conception depends on many factors including glands, hormones, sex cell development, and one’s overall health. A thorough fertility examination will explore all the relevant factors.

Causes of Male Infertility

Sperm cells are essential for fertilization. During ejaculation, the average man releases about 100 million sperm. Shaped like tadpoles, sperm cells swim to their egg.

But in some cases, men’s bodies produce too little sperm (oligospermia) or no sperm at all (azoospermia). Sperm cells also need to be well formed, with a proper head and tail, to be healthy. And they need to swim well to reach an egg cell.

Many factors can affect your sperm production and quality:

• Your overall lifestyle habits like diet, exercise, alcohol consumption, and drug use.
• Medications like drugs for arthritis, cancer, high blood pressure, and depression
• Cancer treatments like chemotherapy, surgery, and radiation
• Illness and infections, such as diabetes, multiple sclerosis, diabetes, sexually transmitted infections, and sickle cell anemia.
• Congenital conditions present at birth, such as Klinefelter syndrome or congenital adrenal hyperplasia (CAH)
• Obstructions. Sometimes, a man’s body can make sperm, but the cells can’t reach their destination because the path is blocked. Obstructions can be caused by infections, surgery, or developmental defects. And if a man has had a vasectomy, of course the path will be blocked.
• Retrograde ejaculation. In this case, sperm cells can leave the testes, but they go backward into a man’s bladder instead of forward out of the penis during ejaculation. The sperm cells pass with a man’s urine. On its own, retrograde ejaculation isn’t harmful, but it makes it challenging to father a child.
• Varicoceles. These swollen veins in the scrotum interfere with blood flow and drainage. The scrotum needs to be cooler for good sperm production, but varicoceles make the environment too warm.
• Genetic problems. Sperm cells might not contain the correct amount and types of genetic material necessary to fertilize an egg cell.
• Immunologic infertility. In this rare situation, antibodies produced by a man’s own immune system attack sperm cells and interfere with their movement.

Testosterone Deficiency (Hypogonadism)

The hormone testosterone is an integral part of sperm production. If a man has low levels of testosterone, he might not produce enough viable sperm to create a pregnancy.

Hypogonadism can be caused by problems in testes (the glands that make sperm, also called testicles), such as from testicular injury or cancer treatment.

Problems in the hypothalamus and the pituitary gland – two areas of the brain that trigger testosterone production – can also lead to low testosterone levels.

Diagnosis

Your Medical History

At this stage, we will gather information about your overall health. It’s important to be candid and honest in your answers. Doing so gives us a clear picture of what factors may be contributing to your difficulties conceiving.

While taking your medical history, we will likely cover these topics:

• Your health during childhood
• Your experiences with puberty and sexual development
• Your sexual history
• Past illnesses or infections, including sexually-transmitted infections
• Any surgeries you’ve had in the past
• Any accidents or pelvic traumas you’ve experienced
• Your lifestyle – drinking, smoking, use of recreational drugs or street drugs
• Exposures to chemicals, like pesticides or heavy metals, that might impair fertility
• Your family medical history

A Physical Exam

During a physical exam, we will assess your testicles (also called the testes), epididymis, vas deferens, and penis.

Your testes are the glands that produce sperm cells.

Testicles are connected to the epididymis. This coiled area is where sperm cells mature. They are also stored there until you ejaculate. Usually, there are enough sperm cells for two or three ejaculations. (Experts estimate that men aged 21 to 55 have can have up to 200 million sperm cells in each epididymis.) Sperm cells that are not ejaculated are absorbed by the body.

When a man is sexually stimulated, the sperm make their way to the vas deferens – a tube that connects the epididymis to the urethra in the penis. And from there, they are expelled out during orgasm. Sperm can be stored in the vas deferens, too.

We will also check your body fat, skin, hair, and breasts. Sometimes, a testicular or transrectal ultrasound is done to give another perspective. Together, these results may provide clues about testosterone deficiency or other conditions that can affect fertility.

Semen Analysis

You’ll probably have a semen analysis (sperm count), too. During this test, we look for several things:

• How much semen you ejaculate (volume)
• Semen characteristics (such as thickness, color, and acidity)
• How many sperm cells your semen contains
• Sperm cell morphology – the shape and structure of the cells and whether their heads and tails are well-formed
• Sperm cell motility – the percentage of sperm that “swim” in a forward direction and how well they move, especially through cervical mucus
• Total motile count (total number of moving sperm)

Typically, a semen analysis will be done in a specialized dedicated lab where you’ll be asked to masturbate in private, directing your ejaculate into a cup.

Producing a sample “on demand” can be a challenge for some men, so you might be able to do it at home in a sterile cup or condom we provide. Once you have your sample, it’s critical that you deliver it to the lab within an hour. Whenever possible, it is preferable to provide the specimen in the lab to avoid the transportation and delay challenges of home collection.

For best results, you should avoid ejaculating 3 days before giving your sample. You might have to give several semen samples over a period of weeks for us to provide a thorough analysis.

Blood tests

Sometimes, hormone levels interfere with a man’s fertility. Blood tests measure the levels of several hormones, such as the following:

• Total testosterone
• Follicle-stimulating hormone (FSH) – a hormone that triggers sperm production
• Luteinizing hormone (LH) – a hormone that triggers testosterone production
• Prolactin

Urinalysis

We might have you give a urine sample to check for health conditions that can affect fertility, like diabetes, kidney disease, and urinary tract infections (UTIs).

We might also check for the presence of sperm cells in your urine. This can happen if you have retrograde ejaculation.

Testicular Biopsy

If there is no sperm present in your semen, we might discuss performing a testicular biopsy combined with testicular sperm extraction (TESE). This procedure can reveal whether there are sperm cells in your testicular tissue. If there are, a section of your reproductive tract might be blocked, preventing sperm cells from leaving the testes (testicles). In other cases, there aren’t enough sperm cells to make it out to the ejaculate, but we can still find them in the testis in many instances.

If sperm cells are found, they will be removed during the extraction procedure, then safely preserved by the embryologist and stored for possible egg fertilization later. (An embryologist is a specialist who helps create and preserve embryos.)

Treatment Options

Your treatment for male infertility will depend on what’s causing it. Here are some examples:

• Gonadtropin treatment. This hormonal approach is used when there are problems in the hypothalamus or pituitary gland – two areas of the brain that trigger testosterone production. Injections of gonadotropin (sometimes combined with follicle-stimulating hormone) are given about three times a week for six months or until sperm are produced.
• Surgery. Some problems, like varicoceles and blockages, can be treated with surgery.
• Medications (or medication adjustments) might be necessary as well.

Patience is key when you’re undergoing fertility treatment. Some approaches, such as gonadotropin treatment, can take up to two years.

Sperm Retrieval Methods

If you and your partner are having trouble conceiving through intercourse, you might consider assisted reproductive technologies (ART), such as in vitro fertilization (IVF). ART allows sperm cells to fertilize egg cells in a laboratory. We work with female reproductive endocrinologists and embryologists as a team to get the best results for couples.

For these paths, specialists can retrieve sperm in a few ways:

• Testicular extraction. While a man is under local anesthesia, a needle is used to remove sperm cells directly from the testes.
• Penile vibratory stimulation. A special vibrator is placed at the base of the penis to induce ejaculation for men who are unable to ejaculate on their own. Sperm cells are then retrieved from the semen. No anesthesia is required.
• Rectal probe electroejaculation. This method triggers ejaculation with an electric probe (electroejaculator) placed into the rectum. Anesthesia is provided if necessary. Patients with certain types of spinal cord injury will need this procedure.

Coping With Infertility Testing and Treatment

Infertility testing, along with the uncertainty of whether you and your partner can conceive, is an emotional experience. Anxiety and depression are common for both men and women. Many people feel responsible or guilty, wondering whether it’s “their fault” there has been no pregnancy. Others feel especially sad when they see their peers having children or posting pictures of their families online.

Stress associated with infertility can actually make it more difficult to conceive. If you think this is an issue for you and your partner, know that you are not alone. It’s okay to seek emotional support. We can refer you to a mental health professional, such as a therapist or counselor, who works specifically with couples in your situation. You might also find a support group of peers – people who have been through what you’re going through now – to be beneficial.

These other tips may help, too:

• Take care of your relationship. You and your partner are a team. Check in with each other and be open about how you’re feeling. Don’t bottle things up.
• Try to still have fun. Make time to do things you enjoy together, whether it’s biking, traveling, watching movies, and yes – having sex, too. While you might feel pressured to have sex for baby-making, don’t forget that intimacy and pleasure are important, too.
• Decide together how much you will tell other people about your fertility issues. Infertility is intensely personal. Depending on what you disclose, you might find friends and family offering advice you didn’t ask for or sharing stories that just don’t help. These people may be well-meaning, but sometimes their contributions cause more stress. There’s nothing wrong with keeping your private life private if that is what you need.
• Take care of your overall health. Stick with healthy habits like good nutrition, proper exercise, and adequate sleep.

---

Resources

Johns Hopkins Medicine

“Overview of the Male Anatomy”
https://www.hopkinsmedicine.org/health/wellness-and-prevention/overview-of-the-male-anatomy

“Penile Vibratory Stimulation and Electroejaculation”
https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/penile-vibratory-stimulation-and-electroejaculation

UpToDate.com

Anawalt, Bradley D., MD and Stephanie T. Page, MD, PhD
“Patient education: Treatment of male infertility (Beyond the Basics)”
(Topic last updated: Jun 27, 2017)
https://www.uptodate.com/contents/treatment-of-male-infertility-beyond-the-basics

Kuohung, Wendy, MD and Mark D. Hornstein, MD
“Patient education: Evaluation of the infertile couple (Beyond the Basics)”
(Topic last updated: Jan 24, 2019)
https://www.uptodate.com/contents/evaluation-of-the-infertile-couple-beyond-the-basics

UrologyHealth.org (American Urological Association)

“What is Male Infertility?”
(No date provided)
https://www.urologyhealth.org/urologic-conditions/male-infertility

Verywellhealth.com

Boskey, Elizabeth, PhD
“The Anatomy of the Epididymis”
(Reviewed: September 1, 2020)
https://www.verywellhealth.com/epididymis-anatomy-4774615

Hayes, Kristin, RN
“The Anatomy of the Vas Deferens”
(Reviewed: July 9, 2020)
https://www.verywellhealth.com/vas-deferens-4846228

WebMD

“Sperm FAQ”
(Reviewed: October 30, 2018)
https://www.webmd.com/infertility-and-reproduction/guide/sperm-and-semen-faq#1