The World Health Organization identifies infertility as "a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular, unprotected sexual intercourse." The global health advocate also notes "infertility is often perceived as a predominantly female disorder, even though male-factor infertility is equally prevalent."
Peter N. Kolettis, MD, a professor of Urology at the University of Alabama at Birmingham and director of the Urology Residency Program, has dedicated much of his career to the topic of male infertility as a provider, educator and researcher. He said approximately 10-15 percent of couples meet the WHO definition for infertility and noted that when an underlying cause can be identified, roughly one-third of cases trace back to the female, one-third to the male, and one-third to a combination of issues with both partners.
The first steps to seeking help for infertility often begin in an OB/GYN practice. Kolettis, who completed his residency in urology and a fellowship in male infertility at the Cleveland Clinic Foundation following medical school at the University of Chicago, said there is a perception that men are more reluctant to go to their doctor about infertility issues. Another contributing factor is that a number of men of reproductive age don't have a primary care physician they see with any regularity.
"A lot of times, men just get a semen analysis and not an evaluation," Kolettis said once the infertility process is underway. "That may be sufficient for knowing strictly what their fertility potential is, but it's not the same as having him be a patient," he added of the benefits of taking a history, doing a thorough exam and talking to a patient one-on-one.
There are a variety of factors that could impact the testes' ability to produce healthy sperm and effectively disseminate it. "The most common abnormality leading to infertility is varicocele, or dilated veins, of the scrotum," said Kolettis. Other causes include obstructions and defects of the tubules that transport sperm, some medications, certain genetic disorders, prior cancer treatment, hormonal imbalances and undescended testicles or testicular torsion as a child. "Then there are men where we cannot identify a definite cause," he added.
While a primary care provider could conduct an evaluation, he said many refer to a urologist or other reproductive specialist for a more in-depth investigation into causes and potential solutions. However, he added, going ahead and ordering the semen analysis is quite helpful so the specialist has that piece of information in hand when meeting with the patient. After doing a thorough workup, the specialist might also order hormone and genetic testing.
"In general, there's not a medicine to improve sperm production except for some rare endocrine problems," explained Kolettis.
However, he continued, there are some medicines that could be harmful to sperm production, such as testosterone. Chemotherapy is a medically necessary agent that often has long-term impact on fertility. "The key there is to have men freeze sperm before they get the chemotherapy because in some cases, the damage to the testes is irreversible," Kolettis said of planning ahead for children later.
Microsurgery is another viable option for a number of issues, including reversing vasectomy, correcting varicocele or addressing some obstructions. Lifestyle changes, particularly smoking cessation, is also important. Kolettis said he often suggests increasing exercise and limiting alcohol, as well. "I tell men anything that is good for their health could be good for their fertility ... and it certainly wouldn't be harmful."
While high sperm counts increase the probability of pregnancy, Kolettis said improved technologies offer hope for those with lower numbers, as well. "Even men with low sperm count or no sperm in the semen can achieve a pregnancy," he pointed out of today's assisted reproductive technologies (ART).
Although there hasn't been any significant movement in research to improve sperm production, ART continue to evolve. For example, in vitro fertilization refinements have made it possible to implant fewer embryos, reducing the chances of giving birth to multiples.
For men with non-obstructive azoospermia, a condition where there is a lack of sperm in the seminal fluid due to decreased sperm production, testicular microdissection - devised by Peter Schlegel, MD, FACS of Weill Cornell Medicine - is now considered the gold standard for surgical sperm retrieval. Kolettis said intracytoplasmic sperm injection, or ICSI, was a game-changer for male infertility when it debuted in the 1990s. ICSI features the injection of a single retrieved sperm into a mature egg, allowing couples to conceive.
As with most disorders that have multifactorial causes, there isn't a 'one-size-fits-all' solution to address male infertility. However, reproductive specialists have an arsenal of options to help men achieve the ultimate outcome of becoming a father.