Male infertility is the sole cause of about 20 percent of infertile couples, but is a contributing factor in another 30 percent of couples.

Male infertility is usually diagnosed by finding abnormal semen during testing. But, other issues can cause infertility, even when the man has normal semen.

Infertility should be evaluated by a urologist who specializes in male reproductive health. Some causes of male infertility can be diagnosed and reversed (or improved) with surgery or medicines. Other causes can be diagnosed but not reversed. Rarely, the cause of infertility or an abnormal semen analysis is unknown.

A male infertility evaluation can identify:

• Reversible causes of male infertility and possible treatment. The goal of treatment will be to allow the couple to conceive through intercourse, or using as little technology as possible.
• Irreversible causes that may respond to treatment with assisted reproductive technology using the man’s sperm in combination with a women’s specialist.
• Treatable diseases that may be causing infertility.
• Genetic causes of infertility. Irreversible conditions where the man’s sperm cannot be retrieved. These couples may want to think about using donated sperm or adopting a child.

What to expect during a male infertility evaluation

An infertility evaluation will start with a complete reproductive, medical and surgical history. The doctor will ask about your sexual health and history, past illnesses, fertility treatments, surgeries or testicular exposure to heat, radiation and chemicals.

During the physical exam, a doctor will assess the build, hair distribution, breast development and external genitalia of the patient. The doctor will pay special attention to the size and consistency of testicles and the structures inside the spermatic cord (the series of long tubes that connect the testicles to the body).

Semen Analysis

A semen analysis test is the most important way to evaluate a man’s infertility. For this test, the patient will collect a sample of his semen to be analyzed at a laboratory. Semen samples can vary greatly, so most doctors will want at least two semen analyses before making a diagnosis.

The semen analysis will include:

• Ejaculate volume - how much fluid is in the sample
• Sperm concentration - how many sperm are in the sample
• Sperm motility - how well the sperm can move
• Sperm morphology - the shape of the sperm

Ideal Results for a Semen Analysis

According to standards set by the World Health Organization (WHO), the ideal semen analysis results include:

• Ejaculate volume: 1.5 to 5.0 mL
• Sperm Concentration: More than 15 million/mL
• Sperm Motility: More than 45% motile
• Total Motile Sperm Count: More than 20 million
• Sperm Morphology: More than 5% normal (using the Kruger Strict system, which rates how likely it is that sperm can fertilize an egg)
• Leukocytes (white blood cells) to look for infection or inflammation
• Anti-sperm antibodies, which the body’s immune system may create in response to sperm
• Reactive oxygen species (free radicals that damage sperm)
• Sperm DNA integrity to see if there is damage to the sperm’s genetic material

The doctor may also conduct other special tests to assess possible issues with the endocrine system, genetic concerns, and even surgical intervention.

Endocrine Evaluation

When the hormones controlled by the endocrine system are out of balance, sperm production can be low. Endocrine tests will measure hormones such as testosterone, follicle stimulating hormone, luteinizing hormone and prolactin. A doctor may advise these tests if ejaculate volume is low, sperm concentration is less than 10 million/mL, or a patient shows symptoms of endocrine gland disease.

Medical therapy can help restore the function of the testes if the pituitary gland in the brain is not sending correct hormone signals.

Genetic Testing: Male Infertility

Abnormal genes may cause infertility by affecting sperm production or mobility. Some genetic abnormalities can be passed on to a man’s children and affect their health.

The most common genetic factors that cause male infertility are:

• Y-chromosomal microdeletions that reduce or eliminate sperm count.
• Klinefelter’s Syndrome that impairs functioning of the testes.
• Cystic fibrosis gene mutations that result in an absence of the vas deferens.

Surgical Intervention

After the cause of male infertility is diagnosed, medical therapy may help with hormone regulation, while surgery is often the answer for any physical impediment to sperm production.

The most easily corrected condition includes varicoceles, which are large veins that allow blood to flow backward. This condition is linked to a variety of sperm problems and can be treated either with a small incision in the groin or with a venous embolization wherein a small catheter is fed through the veins. Semen quality improves in about two thirds of men who have surgery to repair varicoceles.

Surgery can also reverse a vasectomy, which is the most common cause of blockage of the male reproductive tract. About six percent of men who have a vasectomy also have a vasectomy reversal. Approximately 85 percent to 99 percent of men can expect a return of sperm after a reversal.

Sperm extraction can also be done with assisted reproductive technologies. Sperm found in the vas deferens, testes or epididymis may be retrieved using minimally invasive techniques and can be used in conjunction with in-vitro fertilization to assist in pregnancy.

With new technology, only a small number of healthy sperm are needed to achieve pregnancy through in-vitro fertilization. This means doctors are often able to obtain healthy sperm for egg fertilization even from men who have a very low sperm count.