Infertility effects one in every six couples
Many couples experiencing difficulty having a child are referred to our practice for help. It is recommended that a fertility evaluation is performed after one year of unprotected intercourse fails to result in a successful pregnancy. In approximately half of couples that have fertility issues, there is an identifiable contributing factor found in the male partner. This can be true even for men who have fathered children in the past and these fertility concerns are usually investigated by an urologist.
Early identification of fertility problems can be important because these can get worse with age and, as couples wait longer to have children, fertility problems can be harder to repair. The goal of the evaluation and treatment in male fertility issues is to identify life-threatening conditions and to help couples achieve pregnancy with less invasive and less expensive means.
Lifestyle Factors can certainly play a role in fertility.
The initial evaluation will always involve a semen analysis. Semen analysis will provide information on the concentration of sperm in the ejaculate as well as motility, or how many of the sperm are moving. Successful natural conception depends on motile sperm that are healthy. Sperm must travel from where they deposited in the vagina through the cervix into the uterus and up into the fallopian tube where an egg should be present to be fertilized.
A semen analysis is performed after a two to three day period of abstinence. Either a too short or too long of delay can result in semen abnormalities that may not otherwise be truly reflective of actual problems. Men with a single semen analysis that is abnormal will usually have a second one performed to confirm any abnormal findings.
A part of the standard male fertility evaluation includes a hormone panel. Hormone signals from the brain and testicle are very important in normal male function and sperm production. Commonly measures levels include total testosterone and free testosterone, follicle stimulating hormone (FSH), luteinizing hormone (LH), prolactin, thyroid stimulating hormone (TSH), and estradiol.
Abnormalities in testosterone levels are frequently found and can contribute to low sperm count as well as abnormal appearance of sperm. Increasing a low testosterone level may result in improvements in semen parameters, however supplementation with testosterone either through a topical gel or an injection can result in reductions in sperm quality and number as the testicles start producing both testosterone and sperm.
For these reasons standard supplementation technique are not appropriate and often will require use of medications that will enhance the body’s production of testosterone. A commonly used medication is clomiphene citrate which will increase the’ production of testosterone and can improve semen parameters. Additional hormonal compounds, such as human chorionic gonadotropin (HCG), are often used but must be carefully administered and the effects monitored by specially trained urologist.
It is vitally important that men with low testosterone levels not be given routine testosterone replacement if they hope to have children. Although many effects of testosterone are reversible, some men have lifelong impairment of sperm production.
Azoospermia refers to a condition in which no sperm is seen in the ejaculate. This diagnosis requires that two semen analyses be performed separated by at least one or two weeks and that the specimens be centrifuged so that it can be confirmed under microscope that no sperm are seen in the ejaculate. Such a finding should prompt immediate referral to urologist for evaluation.
Azoospermia can be an alarming cause of infertility and will require advanced diagnostic procedures. Azoospermia is classified as either obstructive or nonobstructive.
Obstructive azoospermia refers to a finding of blockage of the travel of sperm from the testicles to where they are deposited in the prostatic urethra. Blockage may occur in both sides. Obstructive azoospermia can be due to congenital anomalies, prior vasectomy, prior hernia surgery or trauma.
One condition associated with obstructive azoospermia is congenital bilateral absence of the vas deferens (CBAVD). Then this is condition that results from a chromosomal mutation that is also commonly seen in patients with cystic fibrosis. With this condition, the vas deferens cannot be felt in the scrotum, because they did not form, and some patients may present with abnormalities of the epididymis or other areas of the genital tract. A family history of cystic fibrosis and a finding of azoospermia should prompt an evaluation for CBAVD.
It is also possible that a cyst of the prostate can block the passage of sperm into the urinary tract for ejaculation. Finding such a blockage can often be repaired.
Although, not technically classified as obstructive azoospermia, some patients will not experience significant amount of ejaculate but will rather have sperm and semen travel into the bladder during orgasm. This condition called retrograde ejaculation is experienced by some man with diabetes or nerve injury and is diagnosed when the urine from such a patient is examined after ejaculation and is found to have sperm. The patients with retrograde ejaculation are still able to have children but oftentimes the sperm needs to be harvested and cleaned and inserted directly into uterus of the partner, called intrauterine insemination (IUI).
Nonobstructive azoospermia is often more complicated condition and suggests that the testicles are not able to produce mature sperm. This condition can be associated with genetic mutation. By definition, nonobstructive azoospermia does not involve the blockage of the ejaculatory duct system. This condition can be caused by genetic factors, hormonal factors, and oftentimes the underlying cause is not known.
Evaluation of this condition can include a testicular biopsy or testicular mapping procedure and often will include a laboratory panel to include hormone levels. In certain cases, genetic testing for abnormalities of the chromosomes is performed. The diagnosis of nonobstructive azoospermia is suggested when the patient’s follicle-stimulating hormone and luteinizing hormone levels are elevated. Although often a more advanced cause of infertility, many men with nonobstructive azoospermia are still able to father children.
The blood supply of the testicle is composed of one or more arteries that travel within the spermatic cord to deliver blood to the testicles and a plexus of veins that drain blood from the testicle. The anatomy of the testicle is maximized to allow a lower temperature than body temperature for sperm development.
To accomplish this feat, the testicles are present in a scrotum to help it keep it out of the body. Also, the blood supply is designed so that heat from the arteries to the testicles can be cooled by the complex of veins that run in the opposite direction.
The veins of the testicle, as in the veins of many of the parts of the body, are equipped with valves that prevent the blood from traveling downward with gravity. When these valves become incompetent, the veins can become enlarged and this phenomenon is commonly seen as varicose veins in the legs. When this occurs in the testicle, it is believed to potentially lead to temperature as well as hormonal abnormalities which can influence sperm quality.
Most commonly, varicoceles will create abnormalities in the number of sperm moving, or motility, but can also manifest as changes in the shape of the sperm or lower sperm overall concentration. Some men will be advised to have these varicoceles repaired in an effort to improve their semen parameters. Not all men, however, are considered good candidates and this approach is not appropriate for all couples trying to conceive.
In our practice we perform a subinguinal microscopic or robotic varicocelectomy. In either approach, incisions are made in the lower groin to access the spermatic cord(s) which is then closely evaluated either under microscope or under a high-definition robotic camera to identify the enlarged veins.
Care is taken to avoid damage to the arteries or to the lymph channels of the spermatic cord as well the vas deferens while the enlarged veins are carefully tied up. This is an outpatient procedure that generally takes about 2 hours. It is frequently performed on both sides when varicoceles are detected. Semen analysis improvement is generally expected within three to six months and this treatment can be done in conjunction with hormone treatment, if indicated.
Some patients are chosen to be good candidates for a microscopic approach while other may be deemed appropriate for a robotic assisted approach. The anatomy of the patient will dictate which treatment option is best.
Vasectomy Reversal (Vasovasostomy)
Vasectomy reversal refers to a surgical procedure designed to restore fertility to men who have undergone a prior vasectomy sterilization procedure. Different techniques for vasectomy are performed, however, virtually all involve blockage of the vas defense tubes in the scrotum to prevent flow of sperm from the testicle into the urethra. Vasectomy reversal is a commonly inquired about procedure but is not appropriate for all men. Special considerations include the time since the vasectomy, the age of the man’s partner and other medical conditions that may interfere with the repair.
For men who are considered appropriate of the procedure, it is performed on an outpatient basis, can take anywhere from two to three hours and often requires the use of specialized instruments, including a microscope and in some cases a robotic surgical system. Incisions are made in the scrotum to gain access to the vas deferens. The two ends of the previously divided vas deferens are identified and the two ends are connected using stitches that are very thinner than human hair. A successful vasectomy reversal is defined as moving sperm in the ejaculate.
Factors that can negatively impact a successful vasectomy reversal include: a long time since the vasectomy (generally considered greater than seven years) and older age of the man. Reblockage of the vas deferens is a common complication of the procedure and in some studies is as high as 50% after one year. For this reason, it is important that sperm be collected and frozen at the time of the vasectomy reversal and we offer that service at no additional charge from a surgical standpoint although additional fees for sperm storage will be incurred.
Sperm Retrieval For in-vitro Fertilization (IVF)
Modern reproductive technology has evolved tremendously to help men who were previously considered to be incapable of fathering children. The ability to fertilize eggs by directly injecting sperm into an egg (intra-cytoplasmic sperm injection) means that very few sperm are needed to achieve a successful pregnancy. Sperm are produced in the testicle and transported to the penis where fluid from the prostate combines with the sperm to produce semen.
Sperm retrieval procedures are necessary in situations where there are no sperm in a man’s ejaculate. This condition can result from blockage of the ejaculatory system (obstructive azospermia) or from failure of sperm production in the testicle (non-obstructive azospermia). The most common cause of obstructive azospermia is a prior vasectomy but other causes include: prior infection, prior hernia repair with mesh or other prior surgery on the testicles. Non-obstructive azospermia can be due to genetic conditions, prior testicle infections or hormone abnormalities. These conditions can interrupt the production of normal sperm within the testicle. Fortunately, even in these instances there are often areas of normal sperm production.
The ideal technique for harvesting sperm depends on a variety of factors. Sperm can be retrieved using an open surgical approach, or through the skin using a needle. Each approach has certain risks and benefits and each may not be appropriate for everyone. Although it is sometimes possible to harvest enough sperm for intrauterine insemination (IUI), where the sperm are inserted directly into the woman’s uterus, it is more common to use harvested sperm for in-vitro fertilization (IVF). The sperm that are retrieved can be used immediately to fertilize an egg or can be frozen for use at a later time.
PESA (Percutaneous Epididymal Sperm Extraction) / TESA (Testicular Sperm Aspiration)
PESA and TESA are similar procedures where a needle is used to extract sperm from the testicle or epididymis. The epididymis is an organ that lives behind the testicle and is the location where sperm mature and develop the ability to move. The epididymis can be enlarged after a vasectomy or in other conditions where there is blockage. Both of these procedures can often be performed with only mild sedation and local anesthetic. A needle is inserted into the testicle or epididymis and an attempt is made to collect sperm. The sample collected is immediately examined under a microscope to look for healthy appearing sperm. These sperm can be used immediately to fertilize an egg or can be frozen for use at a later time.
These techniques can be used as a first line approach for sperm collection. Both PESA and TESA and most effective when trying to collect sperm in a man who has undergone a vasectomy and the epididymis is enlarged. The benefits of this approach are that they are relatively painless and do not require an incision in the scrotum or a general anesthetic. The risks of the procedure include bleeding, damage to the epididymis and not being able to obtain sufficient sperm. If these techniques fail, sperm may be found using more advanced methods.
MESA (Microscopic Epididymal Sperm Extraction)
MESA is a technique for collecting sperm that involves using a surgical microscope to open the small tubes within the epididymis to look for sperm. This technique works well in conditions where sperm are being produced in adequate numbers but are blocked from traveling from the testicle to the ejaculate. Examples of such conditions include: a prior vasectomy, prior hernia repair with mesh, blockage of the seminal vesicles, cystic fibrosis, and immotile cilia syndrome. This is the favored approach when harvesting sperm after a vasectomy.
An operating microscope and special skills are necessary to identify the tubes most likely to contain sperm and the samples are immediately examined to look for sperm. Sperm harvested from the epididymis is generally considered better quality than sperm harvested directly from the testicle because they have had more time to mature.
This procedure requires a general or spinal anesthetic and involves an incision in the scrotum to gain access to one or both testicles. The sperm harvested can be used immediately or frozen for use at a later time. In cases where no sperm are found, it is necessary to look in the testicle for viable sperm, a procedure called TESE or testicular sperm extraction.
TESE (Testicular Sperm Extraction)
TESE is very similar to the MESA procedure. In a TESE, tissue is taken directly from the testicle and examined for the presence of sperm. This technique is very successful in cases of obstructive azospermia where there is blockage of the tubes responsible for transporting sperm from the testicle to the ejaculate. However, TESE can also be very useful in patients with non-obstructive azospermia as well. There are several genetic, infection related and hormonal conditions that lead to low levels of sperm production that can be uncovered through surgery.
TESE or micro-TESE (performed with a microscope) requires general or spinal anesthesia and an incision on the scrotum to gain access to the testicles. Depending on the underlying medical condition, the testicle is either incised in several locations to harvest sperm or completely opened to reveal all of the sperm producing cells. Several samples are taken and immediately examined for the presence of sperm. Any sperm found can be used immediately to fertilize an egg of they can be frozen for later use. The testicle is then repaired and placed back into the scrotum. The testicle is generally able to function normally after the procedure and continue to produce testosterone. This procedure has been successful in finding sperm is many conditions thought to result in infertility such as Klinefelter’s syndrome and congenital absence of the vas deferens.
If there is a high degree of uncertainty about whether sperm will be found, a couple undergoing TESE will often be counseled to have the procedure performed before eggs are harvested or to have a donor sperm sample as a back-up.
Bent or Curved Penis
Men who have a bent or curved penis can be suffering from a condition called Peyronie’s disease.
This condition can be associated with painful erections but often is not. In the case of male fertility, a severely bent penis can result in the pain for the male or female partner, can result in ejaculatory difficulties, or can result in some abnormalities in way sperm is deposited into the vagina the sperms are deposited. This is rare cause or contributory of male fertility and should be evaluated by urologist.