Johns Hopkins Division of Infectious Diseases
M E N S  H E A L T H  G U I D E
search:



Men's Health Sponsors About this site Site Map
Expert Questions & AnswersFeature Articles
HOME DISEASES
  Infertility
 
Author: Jonathan Jarow Last modified: March 19, 2002
DIAGNOSTIC CRITERIA

  EPIDEMIOLOGY

  • Approximately 15% of couples have difficulty initiating conception.
  • Approximately 20% of infertile couples have a solitary male factor as the cause of their infertility.
  • Approximately 40% of infertile couples have combined male factor and female factor infertility.
  • Approximately 15% of infertile couples have unexplained infertility.

  RISK FACTORS

  • Varicoceles, enlarged scrotal veins, are present in 30 - 40% of infertile men.
  • Men with a history of undescended testes are at increased risk of infertility, particularly if they were not brought down before puberty.
  • Viral orchitis (ie. mumps) is a risk factor for infertility.
  • Gonadal toxins - exposure to chemicals, heat or radiation at home or in the work place.
  • Medications - various medications affect sperm production and function (ie. calcium channel blockers used to treat hypertension).
  • Surgery: scrotal surgery may result in inadvertent obstruction and retroperitoneal surgery can affect ejaculation.
  • Heat: Testes function best at 2-3 degrees below body temperature. Hot tub use can lower sperm counts. Tight underwear does not have an adverse effect.
  • Endocrine disruptors: Anabolic steroids act as contraceptive agents and their effect may be prolonged despite discontinuation.
  • Recreational drugs: A variety of drugs have an adverse effect upon male fertility including cocaine and marijuana.
  • Family history: There are many genetic causes of male infertility. Many of these genes are located on the X chromosome, so maternal uncles are an important source of information.
  • Infections: Sexually transmitted diseases and epididymitis are associated with male infertility.
  • Cancer: There is an increased risk of testicular cancer in infertile men and men with testicular cancer are often subfertile.
  • Diabetes mellitus: Diabetes can adversely affect sexual function and ejaculation.
  • Impotence: Erectile dysfunction prevents normal deposition of sperm in the vagina.
  • Hypospadias: Normal placement of the urethral meatus is necessary for normal sperm deposition at the cervical os.

  SIGNS AND SYMPTOMS

  • The vast majority of infertile men do not have any outward signs or symptoms.
  • Testicular atrophy: The majority of the testicular volume is involved in producing sperm.
  • Erectile dysfunction
  • Gynecomastia
  • Reduced ejaculate volume
  • Scrotal mass
  • Absent vasa deferentia.

  DIFFERENTIAL DIAGNOSIS

  • Endocrine disorders: hypothalamic and pituitary disorders or anabolic steroid abuse.
  • Disorders of sperm production: Gonadal toxins, Klinefelter syndrome, Y chromosome microdeletion, varicocele, cryptorchidism, etc.
  • Disorders of sperm delivery: Vasal or epididymal obstruction, vasal agenesis, ejaculatory duct obstruction, ejaculatory dysfunction.
  • Disorders of sperm function: Varicocele, idiopathic, immunoinfertility, medications, genetic, etc.

  LABORATORY FINDINGS

  • Semen analysis: cornerstone of male fertility evaluation
  • Endocrine testing: Serum testosterone and FSH are obtained to identify endocrine disorder or testicular failure.
  • Postejaculatory urinalysis is performed in men with low ejaculate volume.
  • Antisperm antibodies: obtained in men with sperm agglutination or history of obstruction.
  • Karyotype and Y chromosome analysis: Performed in men with testicular failure or non-obstructive azoospermia.
  • Testis biopsy: Performed to diagnose obstructive azoospermia.
  • Abdominal Ultrasound: Obtained to rule out renal abnormalities in patients with vasal agenesis.
  • Pituitary imaging: MRI or CT scan are obtained in men with elevated prolactin levels or aquired hypogonadotropic hypogonadotropic hypogondaism.
  • Abdominal Ultrasound: Indicated in patients with vasal agenesis because of its association with renal agenesis.
  • Prolactin is obtained in patients with low testosterone levels.
  • Genetic testing: Indicated in patients with extermely low sperm counts and includes karyotype and Y chromosome microdeletion analysis.
  • asdf
 
TREATMENT
IN VITRO FERTILIZATION
  • Most patients previously labeled sterile can now potentially father children through the advent of intracytoplasmic sperm injection (ICSI), which is a form of IVF.
  • Ejaculated spermatozoa or sperm retrieved from the male reproductive tract (testis, epididymis, etc.) can successfully fertilize eggs using ICSI.
  • The main risks of IVF using ICSI are ovarian hyperstimulation, multiples gestation and a slightly increased risk of chromosomal abnormalities.
VARICOCELE REPAIR
  • Varicoceles may be repaired by either open surgery, laparoscopic surgery or percutaneous embolization.
  • Depending upon the method chosen the success rate of varicocele repair is up to 98%.
  • The chance of significant improvement in semen parameters following varicocele repair is about 60%.
  • Approximately 35% of couples conceive on their own following varicocele repair with an average time to conception of 10 months.
  • Risks of varicocele repair include persistent varicocele, hydrocele, bleeding, infection, and an extremely small risk of loss of the testis.
RECONSTRUCTIVE SURGERY
  • Indicated for obstructive azoospermia.
  • Vasovasostomy is performed with microsurgical equipment for vasal obstruction with an average patency rate of 90% and pregnancy rate of 65%.
  • Epididymovasostomy is performed with microsurgical technique for epididymal obstruction with an average patency rate of 70% and pregnancy rate of 30%.
  • Transurethral resection of the ejaculatory ducts is indicated in patients with ejaculatory duct obstruction.
HORMONAL THERAPY
  • hCG (2,000 IU IM 3x weekly) and hMG (150 IU IM 3x weekly) are indicated for patients with hypogonadotropic hypogonadism.
  • GnRH (subcutaneous pulsatile pump) is an alternative therapy for hypogonadotropic hypogonadism.
  • Cabergoline (0.25 mg 2x weekly) or bromocryptine (2.5 mg/day) are used to treat hyperprolactinemia
  • Testosterone replacement therapy may be necessary long term for patients with all forms of hypogonadism but does not enhance fertility.
EMPIRIC MEDICAL THERAPY
  • None of the forms of empiric medical therapy have proven efficacy.
  • Clomiphene citrate (25 mg/day) as well as other anti-estrogens are used to treat idiopathic oligospermia. Contraindicated if basal FSH is elevated.
  • Carnitine is a nutritional supplement that has been used to improve sperm quality and quantity without proven efficacy.
 
IMPORTANT POINTS/RECOMMENDATIONS
  • Male infertility is not a disease but a symptom of an underlying disease process that may have medical significance beyond the infertility, such as a testicular cancer.
  • Testosterone is a male contraceptive agent when administered exogenously and should never be used as a treatment for male infertility.
  • Chromosomal and genetic abnormalities may be the cause of or associated with male infertility. Appropriate screening and counseling should be performed not only because of their effects on the patien
 
REFERENCES
  1. S. C. Honig, L. I. Lipshultz, and J. Jarow ;  Significant medical pathology uncovered by a comprehensive male infertility evaluation. ;  Fertility & Sterility 62 (5):1028-1034, 1994.

  2. J. A. Collins, W. Wrixon, L. B. Janes, and E. H. Wilson. ;  Treatment - independent pregnancy among infertile couples. ;  New England Journal of Medicine 309 (20):1201-1206, 1983.

  3. J. P. Jarow and L. I. Lipshultz. ;  Anabolic steroid-induced hypogonadotropic hypogonadism. ;  American Journal of Sports Medicine 18 (4):429-431, 1990.

  4. L. Dubin and R. D. Amelar. ;  Etiologic factors in 1294 consecutive cases of male infertility. ;  Fertility & Sterility 22 (8):469-474, 1971.

  5. P. Thonneau, S. Marchand, A. Tallec, M. L. Ferial, B. Ducot, J. Lansac, P. Lopes, J. M. Tabaste, and ;  Incidence and main causes of infertility in a resident population (1,850,000) of three French regions (1988-1989). ;  Hum.Reprod. 6 (6):811-816, 1991.

  6. P. N. Schlegel and S. K. Girardi. ;  Clinical review 87: In vitro fertilization for male factor infertility. ;  Journal of Clinical Endocrinology & Metabolism 82 (3):709-716, 1997.

Copyright © 2002 The Johns Hopkins University School of Medicine. All rights reserved.