About Male Infertility

Dr. Philip Werthman, FACS
Director, Center for Male Reproductive Medicine
Summary: Dr. Philip Werthman is the most recognized vasectomy reversal surgeon and male fertility specialist in the world. After serving as the chief of urology at Century City Hospital, Dr. Werthman founded the Center for Male Reproductive Medicine and Vasectomy Reversal. Dr. Werthman has lectured around the globe, written numerous books and articles and is a clinical assistant professor of Urology at USC School of Medicine.


What is "male infertility"?

The definition of infertility is a couple who have been trying to conceive for a year and has not met with success. Male infertility relates to any problem on the male side of things which includes anything that has to do with sperm numbers or function, anything that has to do with male hormones as it applies to testicular function. What's interesting about male infertility and what's really not known by many people is that the male contributes almost 40 to 50 percent of the cases of infertility. When you look at a break down of contributing factors to infertility, the male is there almost 40 percent of the time as a problem. Almost everybody thinks that fertility is a female issue and that's really not true.

How common is male infertility?

Male infertility is actually quite common. Of all the people trying to conceive that have been unable to do so, approximatley 40% of the cases are responsible in some way to the man. One out of every 8-10 couples experiences difficulties trying to conceive, so if half of those cases are related to the man, then you're talking to 5-10% of the male population may have trouble conceiving with his wife, which is exceptionally common.

What causes infertility in men?

There's a large number of causes or reasons for a man to experience fertility problems. One of the most common things is something called a varicocele, which are varicose veins around the testicle. Other issues could be obstruction or blockages in the reproductive tract. There could be hormonal issues. It could be issues with age, it could be issues with environmental toxin exposure, with heat exposure, with chemicals, with drugs, with prior surgeries. There are a numerous variety of things that can cause damage to the sperm. We are still learning every day about all the different things that can cause fertility problems for men.

What causes blockage of sperm?

There are numerous things that can cause blockage of sperm or blockage of the reproductive track. You can be born with a blockage, a condition called congenital absence of the vas deferens, meaning being born without the spermduct or tube called a “vas,” that a doctor cuts when he performs a vasectomy. The testicles make sperm as normal but the sperm can't be released because there is no tube or no "plumbing" so to speak. Another issue that can cause blockage of the sperm tube is a vasectomy; which is designed to cause a blockage so that a man can't impregnate a woman. He might later change his mind and decide he wants to conceive again. There are issues such as infection, chlamydia and gonorrhea for example, that can cause blockages to the reproductive tract. There can be cysts or disorders of the prostate that also can cause blockages for sperm, so there are numerous things that may cause an obstruction.

What is "varicocele"?

A varicocele is very simple. It is varicose veins around the testicle. Just as many people as they get older get varicose veins around their legs, many can get varicose veins around the testicle. They are normally a series of several veins that take the blood from the testicle and return it to the body. These veins have one way valves in them so that when you sit up or stand up the blood does not run down with gravity toward the lowest area of the body.If these one way valves don't work then what you have essentially is a vein that is supposed to be a one way street that becomes a two way street. The blood then is allowed to pool around the testicle and can cause damage to the testicle and damage to the sperm production.

How is varicocele treated?

Vericocele is usually treated with surgery. It's a very tiny surgery, outpatient, where a doctor can go in microsurgically and block the veins, stop the abnormal flow of blood back down to the testicle. There are also a variety of other treatments. This can be done laparoscopically. It can also be done radiologically, through a procedure called embolization, where a doctor would go in with a little catheter through one of the big veins in the leg, and snake this catheter into the vein of the testicle and then block the vein from the inside. As opposed to doing it surgically, where you block it from the outside by putting a tie around it, here you put little balloons or coils in that cause the vein to clot off and stop the abnormal blood flow. What's been clear over the last few years is the best way to do this is microsurgically, because it offers the best results, the best chances of success, with the least amount of complications.

What is "oligospermia"?

Oligospermia is a term we use to describe low sperm count. So the World Health Organization came up with parameters for semen analysis that they call normal and it's a big range. For men, the range is anywhere from 2 million sperm per cc, up to over 12 million sperm per cc. So you can see that's a very large range. Any time the sperm count is consistently under 2 million we call that Oligospermia.

What is "azoospermia"?

PhAzoospermia is the term we use to describe the condition where there is no sperm present in the semen and this can be for a variety of different reasons. Number one, someone could be making sperm normally in his testicles but has a blockage so the sperm can't get out into the semen or number two, there can be a problem with sperm production in the testicles such that the man is making no sperm whatoever or very, very small amounts of sperm so small in fact that you don't see any sperm in the semen even though they are present in the testicle. The good thing about azoospermia is that the majority of men can now become fathers through in vitro fertilization or through correction of blockages whereas ten or fifteen years ago this was an impossibility. So reproductive technology has advanced so much in the last ten years that very few men can no longer be genetic fathers.

What therapies are available to improve male fertility?

There are a variety of different things that someone can do to improve their fertility, but before you start with improving your fertility we need to test fertility by doing several semen analyses, and if those are abnormal there are a variety of other tests that could or should be done to try to diagnose the problem. So, number one diagnosis, number two treatment for the specific problem, and number three general therapy, which includes modification of lifestyle: staying out of hot tubs and jacuzzis, it means eating healthy, it means taking certain supplements that can help improve the sperm, so it's a variety of different things. It means stopping smoking, it means limiting alcohol intake; all these things are potentially bad for sperm.

What is "assisted reproduction"?

Assisted reproduction is any technique or technology that we use short of natural conception, and it includes intrauterine insemination or sperm washing or IUI, or the turkey baster as it's commonly known. Other assisted reproductive technologies include in vitro fertilization, which means the fertilization is not done in the woman's body, it's done in the lab in a Petri dish.

What is "electroejaculation"?

Electroejaculation is a technique that's used to treat men with a condition called anejaculation, where they're unable to have an orgasm and an ejaculation. This is usually due to a few different types of conditions. Number one, it could be due to a spinal cord injury, where a man had, his spinal cord is severed so the signal from the brain to get to the testicles and the penis to tell them to ejaculate does not go through. It, it's also seen in some men with diabetes, or men who've had different types of surgery and, and the retroperineum, the area behind the abdomen, where the nerves that control ejaculation are, some surgeries can damage those nerves. So in men who can't ejaculate, what happens is, there is a device that is an electrostimulator that is applied to the back of the prostate and by passing current to those muscles it actually causees those muscles to contract in an ejaculation to ensue.

What is "sperm retrieval"?

Sperm retrieval describes a series of techniques used to obtain sperm from the testicle in men who are azoaspermic, or don't have sperm in the ejaculate.

What is "sperm washing"?

Sperm washing is a technique that we use in the laboratory, where a man provides a semen sample and we go ahead and let that liquefy because semen comes out as a gel like substance and over a half an hour to 45 minutes, enzymes that are derived from the prostate, actually cause that gel to liquefy. We let the sperm swim out and we're able to separate the moving sperm from the non moving sperm. We then put it in a centrifuge. To do that we decant off the dead sperm, we take the live moving sperm and we suspend it in a very small amount, a half a cc or a half a milliliter of culture media that supports the sperm with nutritional fluids. That half a cc is then loaded up into a little catheter and is placed inside a womans uterus.

What is "Intracytoplasmic sperm injection"?

Intracytoplasmic sperm injection or ICSI as it is known, is a technique of advanced reproductive technology, and it's a technique of in vitro fertilization. The sperm are taken into the lab, the eggs are retrieved from a woman's ovaries after she goes to a series of fertility treatments, and under a microscope a single sperm is picked up in a very, very tiny needle and is then directly injected directly into the cytoplasm inside of the egg, allowing it to fertilize.

What types of drugs are used to treat male infertility?

Most of the drugs are hormonal based therapies. Meaning if a man has a hormone problem those hormones can be supplemented or replaced to try and improve their sperm counts and the quality of their sperm. In some men we try a medicine called clomid which women frequently use for fertility problems and sometimes that helps improve the numbers of sperm they produce many times it does not. There are a variety of other medications that can be used but they are also situational specific if a man has a prostate infection or a urinary tract infection that can be causing damage to the sperm then treating that person with the appropriate antibiotics can help.

What surgeries are performed to treat male infertility?

There are a variety of different surgeries designed to treat male infertility, but they're based on, and broken down into, three different categories. Number one is the treatment of varicocele or varicose veins around the testicle, and there are several different procedures to block those veins; to block the abnormal blood flow and stop damage to the testicle, so that the testicle can make sperm that are in bigger quantities. The other type of surgery that is done for male infertility is microsurgery to relieve a blockage in either a man who has had a vasectomy and wants it reversed, or in someone who has a blockage either in their epididymis, or in their vas, from either an infection or other types of surgery. The last types of surgery that we do to treat male infertility are sperm retrieval techniques for men who have a condition called azoospermia, where we're able to go into the testicle or the epididymis and get the sperm directly out from there by doing a small, outpatient, microsurgical procedure. Those sperm are then used in combination with in vitro fertilisation and ICSI, where we take the sperm, and then we inject the sperm directly into an egg

Is male fertility affected by stress?
I believe male infertility can be impacted by stress. We see that sperm counts can fluctuate over time, and fluctuate with the environment the man is in, with what he ingests, with the condition of his sleep cycle, so certainly stress can affect sperm production in some way. What it is not is consistent among different men, because different men handle stressors differently, and their bodies handle sperm production differently.

Does stress actually reduce sperm counts?

Depends on what the actual stress is as to whether it reduces sperm count. Is there only the stress of an infection, or the stress of surgery, or is the body mounting it's resources to try to heal some other area or to fight off an infection? If it is any of those things, the body will not be paying its greatest attention to making sperm at that point. This is part of the fight or fight response, where the body, smart enough to know when it is in danger, needs to go into protective mode. So all non-essential functions are reduced in their efficiency. I think that can happen with sperm production as well.

What are the emotional consequences associated with infertility and impotence?

There are a variety of emotional responses that men can have to either being diagnosed as infertile or being impotent or having inability to perform when needed. Those go from anywhere of denial to feelings of low self worth to feelings of not being what we consider a man. Or not being able to satisfy or please his partner or not being able to give his partner a child. It can lead to depression; it can lead to problems with relationships, a strain on a marriage, a strain on a sexual relationship. So, all these things really affect a man's sense of well-being, a man's sense of worth, the happiness of a relationship, they can have profound effects. But the good thing about this is that many of these problems are easily treated and men don't have to suffer silently with any of these conditions.