Male Infertility Testing and Treatment
Any man with impaired semen quality needs to have a full evaluation of his endocrine status. Although it is an uncommon cause of male infertility, various hormone problems do occur in men that can sometimes impair their ability to father a child. These problems must be looked for because when they are found, they constitute one of the few successful ways I have of treating the infertile man.
Poly-Cystic Ovary Syndrome, the most common endocrine problem in women of reproductive age, can affect men as well. PCOS is inherited as an autosomal dominant and therefore, a man can acquire the gene. If a man has a sister with PCOS and he is infertile, he should be evaluated as well. Early balding (younger than age 30) is also an indicator that the man has “PCOS”. Because of the endocrine abnormalities associated with PCOS, the man’s fertility could also be impaired.
Any man who is producing subfertile semen should undergo a complete physical examination just as his wife is doing. Particular attention should be paid to the anatomy of the penis and testicles to make sure that no other problems exist.
Particular attention should be made to the detection of a varicocele - a varicose vein in the scrotum. Varicoceles are most commonly found on the left side but they can be bilateral and, much less commonly, are found only on the right side.
When the cause of a given disease or illness is known, the treatment is usually is straightforward. Even when treatment is not available, I know enough to be able to give a prognosis. When the cause is unknown, often numerous therapies are tried in the hopes that one will be successful. Male fertility falls into this latter category.
In the vast majority of instances, as I have already said, I simply to not know what it is that causes impaired sperm production. Since I do not know why men are infertile, I cannot treat them specifically.
Occasionally, I am lucky and I can uncover a specific endocrine problem or some unusual circumstance that does lend itself to specific therapy. Unfortunately, this is the exception, not the rule.
Studies have been done looking at men requesting vasectomy, i.e. men who have (usually) proven they are fertile by fathering children. Twenty-five to thirty percent of these men have semen quality that is officially “subfertile” - yet these men have been able to father children without difficulty. The difference is their partner.
Given the fact that many “subfertile” men can father children, the implication is that if a man is subfertile and his partner is not becoming pregnant, then she too has a problem. This is why I firmly believe there is not such thing as an infertile man or an infertile women - there are only infertile couples. Just because a male factor has been identified does not mean that the wife can be ignored. She too deserves a full evaluation.
What I have also learned is that in many instances, the successful treatment of the infertile man is really the treatment of his wife. Therapies that were originally designed to treat infertile women have emerged in the last five to ten years as the main stay therapies for male infertility as well. I am referring to in vitro fertilization and the various therapies derived from it such as Pergonal stimulation with Intrauterine Insemination. If male subfertility is one of the factors in a couple’s fertility problem, then going to either IVF or intrauterine insemination is often the best therapy available, depending upon what is wrong with the wife as well.
This philosophy is based on the fact that while there is usually little you can do to improve the quality of semen a man produces, there is a lot you can do to improve the quality of the semen after it has been produced. This is the underlying principle behind intrauterine insemination with sperm wash and sperm enhancement procedures.
Various types of hormone therapies have been tried to stimulate better sperm production in the men. Men have been given Clomiphene, Tamoxifen (the anti-breast cancer drug which is really very similar to Clomiphene), Pergonal, Metrodin and HCG.
The medical literature is full of “anecdotal” reports as to the success of these therapies but most properly conducted scientific studies do not demonstrate any significant improvement. None-the-less, there are men who will improve. Unfortunately it is impossible to select these men from the overall larger group who will not respond. Therefore many men are treated with the hope that a few will be helped.
There have been several reports that using large doses of FSH for six months may improve sperm counts. This requires the man to receive an injection of FSH three times a week. Given the expense of this therapy and the unwillingness of many insurance companies to pay for it, it is not something that most couples will choose.
As I have already pointed out, if significant numbers of white blood cells are found in the semen, antibiotic therapy is often prescribed although again, the evidence for its effectiveness is still not that strong.