EVALUATION
AND TREATMENT OF MALE INFERTILITY
Infertility
is currently a problem for one out of five couples presently trying
to have children. If after a year of trying to conceive a couple is
not successful, a basic infertility evaluation may be started. However,
if the female partner in the couple is over thirty or has a significant
past medical history of irregular periods or previous pelvic infections,
the infertility evaluation and tests can be started earlier.
Any
couple embarking on an infertility work-up does so with some fear and
reluctance. Some of the common concerns are: What is ahead? How painful
is it? How expensive is it? And, What will the doctor find out? The
whole world of doctors offices, x-ray departments and hospitals is stressful
for many people. It often helps to know what is ahead, to be informed
and aware of how it will feel and what the doctor is hoping to find.
The
infertility work-up itself follows a fairly specific sequence. A complete
work-up or evaluation of the woman usually takes three or four cycles
to complete. This is because certain tests have to be done at specific
times in the menstrual cycle. Insurance coverage varies. Some insurance
plans do cover various tests relating to infertility; others do not.
This work up is performed by a reproductive endocrinologist or a gynecologist.
The
nature of the infertility work-up necessitates that it become a priority
in your daily life. Suddenly, there are specific days that you must
have intercourse. In certain tests you even have to report to the doctor's
office a specific number of hours after intercourse. As a result, spontaneous
lovemaking becomes difficult. Vacations and business trips become low
priority. Schedules have to be made to fit the demands of the testing
cycle. Many women find it hard to take time off from work, especially
if they don't want it known that they are undergoing an infertility
evaluation. It is a stressful time. Both husband and wife are being
tested and scored. There is a feeling of "pass or fail" and
a real sense of despair if a test comes back showing questionable or
negative results. Women often feel frightened and violated by the infertility
tests. Men often feel helpless. For the husband, testing is over if
the semen analysis is normal. In contrast, he may see his wife having
to go through various tests which can be painful and frightening. This
understandably can upset both members of the couple. Added to this worry
and uncertainty is the lingering fear of what the doctor will find.
What if they indeed find an answer, but a discouraging one? Suffice
it to say that deciding to start an infertility workup is a big decision.
The
following is an overview of the tests involved. You may want to use
it to understand what may be required medically or as a tool to double-check
that you have had all the tests.
Initial
Appointment
We
like to see the couple together for the first appointment. This provides
a opportunity for the couple to establish good communication. . It also
is an opportunity to evaluate what, if anything, has been done and what
will be needed in the future. We will be able to explain tests to the
couple and will give them a time frame in which he or she hopes to complete
the evaluation.
A
very careful medical history from the male is obtained. Attention will
be paid to details concerning previous surgery, infections, chronic
illnesses, and hospitalizations. Background information on smoking,
alcohol intakes and medications and exposure to environmental or occupational
toxins will be requested. Of course, a reproductive history from both
partners will be needed. Details about the types of birth control practiced
will be obtained. In addition, any history of previous pregnancies should
be discussed. Information about frequency and nature sexual intercourse
and previous venereal disease is crucial in the evaluation.
Physical
Examination
A
physical examination of the male is usually done on the first visit.
The physical exam will include an examination of the genital organs,
with the doctor noting size, position and condition of the penis and
testes. A rectal exam is done to determine the size and consistency
of the prostate gland and seminal vesicles. The doctor will also note
the development of secondary sex characteristics. Again, routine blood
and urine tests will be done.
Medical
Evaluation of the Male
Semen Analysis - This is the first and most informative test
done on the male. An analysis can be done any time because a man is
not cyclic as women are. Abstinence from intercourse for 48 hours before
the analysis is suggested. Abstinence for a longer period than two days
is not necessary.
Specimen
collection
For the semen analysis, the semen sample should be collected at
the laboratory with masturbation in a special sterile container
after a 2-3 day period of abstinence from ejaculation. Alternatively,
the sample may be brought in from home within 1 hour of ejaculation.
The sample should be maintained at body temperature which can easily
be done by placing the container in a shirt pocket. No lubrication
should be used while obtaining the sample. If specimen can not be
collected due to religious reasons, the sample may have to be obtained
during intercourse in a special condom designed for this purpose.
The laboratory will examine the specimen under a microscope with
in one hour of specimen collection looking for the number of sperm
present, how fast the sperm are swimming (motility) and the shape
of the sperm (morphology). The doctor will also check the total
volume of the specimen and its viscosity (thickness).
The
normal semen parameters
(World Health Organization):
Volume 1.5-5.0
ml
Sperm Density >20 million sperm/ml
Motility >60%
Morphology >60% normal forms
Forward Progression (scale 1-4) 2+
Viscosity No Hyperviscosity
White blood cells 0-5 per high power field
A
semen analysis should be repeated at least once, because all of these
levels fluctuate. It is also a good idea to repeat a semen analysis
periodically if the infertility investigation of the couple is lengthy,
as these levels can change over a long period of time. Other strict
criteria (Krueger's strict morphology) may also be performed.
If
the semen analysis indicates that there may be an infertility problem,
other tests on the semen will be done. The semen will be checked for
the presence of fructose, a special kind of sugar produced in the epididymis.
If it is absent this may mean there is a blockage in the ductal system
but that sperm production may be normal. In addition, the semen may
be checked for unusual clumping or agglutination that could indicate
an immunologic response, or a so-called sperm antibody condition. Some
physicians also order a new test called the "zona free hamster
egg test" to check that the sperm are, in fact, able to penetrate
the outer layer of the hamster egg which is very similar in structure
to a human egg.
1.
Several additional tests may be done on the male
if the semen analysis is not normal includinghormonal
evaluations.
2.
Evaluation for a varicocele is done by palpating
the scrotum while the man is bearing down or coughing. The link between
the presence of a varicocele and infertility is not clearly understood.
The most common theory is that the presence of a varicocele causes
poor circulation which ultimately inhibits normal sperm production.
3.
In the event of a subfertile semen analysis, a small biopsy
of both testicles may be done. This procedure is done in a hospital
under local or general anesthesia. The testicular tissue is examined
in the laboratory. This test can tell the doctor if there is an absolute
infertile state with no sperm-producing tissue present, or blockage
in the vas deferens indicated by the presence of normal testicular
tissue yet little or no sperm in the ejaculate.
4.
Finally, if a blockage in the vas deferens is suspected during a testicular
biopsy, a vasography can be done to pinpoint the
area of the blockage although this procedure
is very rarely performed. This is an x-ray study in
which dye is injected into the vas deferens and a series of x-rays
are taken.
5.
Genetic and chromosomal testing
A
variety of genetic testing are available to evaluate certain conditions
including cystic fibrosis gene, microdeletions of Y chromosomes and
DNA fragmentation.
Once
an infertility work-up is underway it is important that the couple get
the results of each test as they are done. Couples should ask their
doctors for explanations if need be. It is your body and you have a
right to know what is being discovered. Sometimes it is wise to make
a consultation appointment with your doctor if you feel confused or
upset about the tests end results. This is especially important if the
work-up has been going on for a long time or if there is a male factor
problem as well as a female one, which is being treated by another doctor.
It is easy to feel helpless and powerless during an infertility work-up.
Good communication with your doctor can help alleviate some of these
feelings.
