Infertility

Overview

Couples are said to be infertile if they have had at least one year of unprotected intercourse without successfully initiating a pregnancy. It has been estimated that approximately 15 percent of couples are infertile according to this definition. Furthermore, a male factor is found to play a significant role in approximately 50 percent of cases.

Evaluation

Most patients seen in the urologist’s office with fertility-related concerns have been referred by the female partner’s gynecologist. One of the most important considerations in the evaluation of infertile couples is to evaluate both partners simultaneously. This will hopefully minimize the risk of one partner undergoing an extensive evaluation only to find the other partner has a significant problem.

The gynecologist will typically evaluate the woman with either basal body temperatures or ovulation testing kits to assure she is ovulating. Also, a study called a hysterosalpingogram (HSG) is commonly done to make sure the fallopian tubes are not obstructed. Blood tests may also be done to ensure a hormone imbalance is not responsible for a female factor.

While the female partner’s evaluation is in progress, the man should be seen by the urologist to rule out a male factor. The initial male evaluation will consist of at least one and perhaps as many as three semen analyses. These tests are commonly referred to as sperm counts but it is important to keep in mind that much more is checked than just the number of sperm. A complete semen analysis will also evaluate the volume of the ejaculate and the time it takes the semen to liquefy. Also, the percentage of sperm that are moving is evaluated as well as the morphology (the microscopic features of the sperm or the percent that appear normal).

In addition to semen analyses, blood testing may be recommended to check the level of the male hormone testosterone, and possibly two additional substances called FSH and LH will be checked. These tests will provide information about other aspects of testicular function such as hormone production.

In addition to the tests described above, a detailed medical and surgical history is obtained and a careful physical examination performed. The history will identify factors known to be linked to infertility such as exposure to toxins, trauma, and a history of undescended testes, hernia surgery or adolescent mumps. Cigarette smoking is known to adversely affect semen quality and men are therefore encouraged to quit.

The physical exam will of course include a detailed examination of the penis and testicles. One of the most common findings is a complex of scrotal varicose veins called a varicocele. These are typically found on the left side of the scrotum, although they may be bilateral, and are felt to be responsible for as many as 40 percent of cases of potentially correctable male factor infertility.

Treatment

Once the blood test and semen analysis results are available, treatment recommendations can be made. If a varicocele is found and semen quality seems to be adversely affected, an outpatient surgical procedure to ligate the veins is typically recommended. It must be kept in mind that the process of manufacturing a mature sperm cell from a so-called stem cell is a process that takes 74 to 75 days in humans. It takes another 14 to 16 days for that cell to make its way from the testis to the ejaculatory ducts and into the semen. Because of this "delay" period, intervention to improve the man’s semen quality may not be evident for up to 90 days.

Men who have low sperm density but no clinical evidence of a varicocele may be candidates for treatment with a medication called Clomid® (clomiphene citrate). This drug increases the production of sperm cells but is not uniformly effective.

Other forms of therapy are available for male factor infertility if less common causes are identified. A great deal of research in the area of assisted reproduction is underway. This new technology offers great promise for men who are infertile and have not responded to more conventional treatments. This technique uses a microscope to dissect the female ovum or egg, following which spermatozoa can literally be injected into the ovum one at a time. This is followed by placement of the fertilized ovum into the uterus or fallopian tube. Utilizing these new techniques, even men with severely decreased sperm production may be able to father children.

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