What is infertility?

A couple is considered infertile when they are unable to conceive (get pregnant) after at least one year of unprotected (no birth control) intercourse. This does not mean that pregnancy is not possible. Therefore, "infertile" does not mean the same as "sterile".

Infertility: a common problem

Infertility is a common problem. About 15% of couples are "infertile."

Male infertility: a common problem

Male factors are involved in about one half of cases of infertility and about one third of cases are due to male factors alone.

Causes of male infertility

More than one half of men with infertility have a correctable problem such as a varicocele or obstruction (see below). Many men with infertility, therefore, can be treated.

• Sexual habits, lifestyle
  In some cases infertility can be caused by a medication or improper timing of intercourse. Lifestyle factors, such as smoking, may cause fertility problems. Therefore, it is important to quit smoking both for one's overall health and to improve the chance for fertility. The relationship between diet and fertility is not clear. Antioxidants, such as vitamins C and E may be beneficial.

• Varicocele
  The most common abnormality identified in a male infertility evaluation is a varicocele, or dilated veins of the scrotum. This condition is seen in as many as 40% of men evaluated in an infertility clinic. A varicocele can be corrected surgically or non-surgically.

• Obstruction
  Another common cause is obstruction, such as after a vasectomy, noted in about 10-15% of men seen for infertility. In most cases obstruction can be corrected.

• Other causes of infertility
  In some cases the cause of male factor infertility cannot be identified. In these cases, there may be an underlying genetic abnormality. Specific testing is available to identify some underlying genetic problems. Hormonal problems are rare causes of male infertility.

Timing of the infertility evaluation

In general, the couple should be evaluated after they have been trying to get pregnant for 12 months. There is nothing wrong with seeking an evaluation sooner, though, if the couple desires to do so. If the woman's age may be a factor, beginning the evaluation sooner, is advised.

Both partners should be evaluated

Approximately one third of cases are due to male factors alone, one third are due to female factors alone, and the remaining third are caused by both male and female factors. Therefore, both partners should be evaluated.

The purpose of the male infertility evaluation

The main reason to have the man evaluated is to identify and treat any correctable problems. Correcting these factors can allow a couple to get pregnant naturally or with simpler, less invasive, less expensive treatments. Also, in some cases, a serious underlying medical problem is found during the evaluation.

The male infertility evaluation

The evaluation consists of a medical history, physical examination, and at least two semen analyses. Additional testing may be necessary depending on the results of the initial evaluation.

Male infertility treatment

In more than one half of cases of male infertility, the man has a correctable problem. Treating these correctable problems can allow a couple to conceive naturally or with less expensive or less invasive treatments. In general, if surgery is required to correct the problem it can be done as an outpatient.

• Vasectomy reversal
  Approximately 500,000 vasectomies are performed annually in the United States. Between 4 and 10% of men request a vasectomy reversal. The factors that determine the chance for patency (sperm returning to the semen) are
  1. the time since the vasectomy
  2. the quality of the fluid seen from the vas deferens during the procedure
  3. whether an obstruction is present in the epididymis
  4. the experience of the surgeon and surgical technique

  The chance for pregnancy depends on the above factors plus any female fertility factors that may be present. The procedure can be performed as an outpatient with either local or general anesthesia, depending on the preference of the patient and surgeon.

• Varicocele correction
  A varicocele is a collection of dilated veins in the scrotum. It occurs most commonly on the left side but can occur bilaterally (on both sides). The correction can be performed either surgically or nonsurgically as an outpatient with equivalent chance for success.
  
  In general, treating correctable conditions and allowing a couple to get pregnant naturally is more effective, less invasive and less expensive than alternative fertility treatments.
  

Treatment for uncorrectable conditions and alternatives to specific corrective treatment.

• Medical treatment
  Patients frequently ask if there is a medicine that is effective in treating male infertility. Except for very rare cases, medical treatment of male infertility is generally not effective. There are new medications and supplements that are available or are being developed that may be beneficial. More studies are needed, however, to determine if these are truly effective or not.

• Intrauterine insemination(IUI)
  In cases where the couple has been unable to get pregnant and no corrective treatment exists IUI's can be performed. This procedure is performed by a specialist in female infertility. It involves placing the washed sperm of the man into the woman's uterus. The woman may or may not be placed on fertility drugs for this treatment. IUI's can be performed if the man has a low sperm count but men with severely reduced sperm counts probably have a lower chance for success with this type of treatment and may require in vitro fertilization (IVF). Any sperm that are obtained surgically (see below) are usually used with IVF with intracytoplasmic sperm injection (ICSI).

• In vitro fertilization (IVF)
  For men with very low sperm counts or zero sperm in the semen, IVF with ICSI (see below) can be used. In vitro fertilization means that the sperm fertilizes the egg outside the woman's body. Intracytoplasmic sperm injection involves injection of a single sperm into the egg. This procedure can bypass the problems of a severely reduced sperm count or impaired sperm function. This powerful technique has allowed couples to have their own biological children where in the past their chances were extremely remote. Sperm from the semen, epididymis, or testis can be used with ICSI. Men with uncorrectable conditions or those who do not desire correction of these conditions can have their own biological children with ICSI if sperm can be obtained.

• Other alternatives
  If no sperm are available or if the couple does not want to use these advanced techniques, then they may wish to pursue donor insemination or adoption.

• Other places to learn about male infertility
  In addition to a consultation with a urologist, there are several web sites which provide useful information. See the list below.

Resolve (www.resolve.org)
Male Infertility MD's.com (www.maleinfertilitymds.com)
The American Urological Association (http://www.auanet.org)
The American Society for Reproductive Medicine (www.asrm.org)