Male Fertility: Maximizing Your Fertility Potential

Varicocoele
When I examined Steven S., I could see his varicocoele as I crossed the room:

"Steven, see these veins crisscrossing over the left side of your scrotum?"

He leaned over for a better view. "Oh, those. I've had those for years. They never give me any trouble." "They're called a varicocoele—a varicose vein that allows blood to pool in your scrotum. It's thought that poor circulation may lead to a buildup of blood toxins or increase your scrotal temperature. Either of these conditions may result in what's called a testicular stress pattern.

"The typical stress pattern shows depressed sperm production, poor sperm motility, and poor sperm morphology—which is exactly what your semen analysis showed. I also noticed that your left testicle is a bit small. That's another frequent finding with varicocoeles."

"Is that why I'm infertile?"

"It could be," I answered. "Forty percent of infertile men have varicocoeles." "What can you do about it?" "With some men I'd try artificial insemination with their sperm. If that didn't work, I d get a second opinion from a urologic surgeon. There is some evidence that repairing the vein may improve your chances of having a baby to at least fifty-fifty. However, with your 15 million count and 20 percent motility and few normal sperm, it's my guess your chances for AIH working aren't very good.

"I'd like you to see a urologic surgeon. You should know, however, that 10 percent of normally fertile men have varicocoeles. So there are no guarantees that the varicocoele is causing your marginal count or that repairing it will improve your fertility."

A varicocoele is a dilation of the veins that carry blood out of your scrotum. The bulging veins cannot support the column of blood returning to your circulatory system, so your blood pools in the swollen vessels surrounding your testicles. Because of the venous structure, varicocoeles usually occur on your left side. How they cause infertility is unknown, but it is speculated that poor circulation (toxic buildup) and/or higher scrotal heat from pooling blood may be factors.

Two-thirds of the infertile men who have a varicocoele also have reduced sperm motility and abnormal sperm morphology. The semen will contain large numbers of sperm with tapered heads and many immature spermatids. If these findings are coupled with smaller than normal testicular size, you probably have a varicocoele.

A pronounced varicocoele feels like a "bag of worms" in the scrotum. Your doctor may find a less obvious varicocoele by having you bend over and exert a downward pressure as though you are forcing a bowel movement. The pressure will force the veins to bulge out. Other tests used to diagnose varicocoele include the Doppler stethoscope (ultrasound) and thermography (thermal detection methods). If the temperature difference between one side of your scrotum and the other is significant, you probably have a varicocoele. Unfortunately the instruments and techniques used to measure this small temperature difference have not been perfected. These diagnostic procedures are not painful and are relatively inexpensive.

Varicocoele treatment
Corrective surgery is not always necessary because laboratory techniques for improving semen quality may provide an adequate sample for intrauterine insemination. For example, your semen can be collected, concentrated, and washed for artificial insemination (AIH).

Varicocoele repair is one of the primary methods used to improve sperm motility and concentration. Surgical correction of the varicocoele will improve semen quality in 70 percent of infertile men, and 50 percent of their wives become pregnant. When the surgery works, as it did for Steven, improved sperm motility seems to be the most significant result. If you rate varicocoele surgery by improvement in semen quality, Steven's results were nominal. His count improved to 20 million and his motility to 40 percent. However, if you ask Steven and Kathy to rate his improvement by the final results—a delightful baby girl—they would say the surgery was 100 percent successful.

Undescended Testicles (Cryptorchidism)
Undescended testicles occur in 8 out of 1,000 boys. Since some testicles descend during the first year, making a diagnosis before one year of age is difficult. If only one testicle is affected, fertility will not be compromised. However, there's a 20 percent increased incidence of cancer in the normal testicle. (Normal risk for testicular cancer is 8 in 100,000 men.)

If the undescended testicles are surgically lowered before age six, normal fertility will be preserved. If the repair is done after age six, however, irreversible damage to the seminiferous tubules will cause infertility. These men will appear virile, but they have a forty to fifty times greater risk of developing testicular cancer.

Infection
Mumps, tuberculosis, brucellosis, gonorrhea, typhoid, influenza, smallpox, and syphilis can cause your testes to atrophy. With some of these infections your LH and testosterone (virility) levels may remain normal. However, if your FSH is high, as in Pete B.'s case, the prognosis for testicular recovery is poor.

When he was seventeen, Pete B., the son of one of my patients, caught the mumps from his little brother. Both testes were affected, one side more than the other. When I saw him in his early twenties, Pete had scanty pubic hair and complained about having no sex drive. His semen analysis showed a sperm count of 10 million, with 30 percent motility, and his FSH was elevated. Together this evidence told me that Pete had suffered extensive testicular damage.

To relieve his immediate concerns about his manliness I prescribed testosterone replacement to restore his virility. Bolstered by his newfound sexual abilities, he married and soon returned for fertility counseling. Since Pete's count was so low I suggested they first try AIH. "If AIH doesn't work within four or five cycles, in vitro fertilization will give you a good chance for a baby." I have to give them credit. They stuck with the AIH regimen for five tries. It was worth it: Pete has a cute red-haired, green-eyed baby girl who's got him wrapped around her little finger. And Grandmother shows me her pictures every time she comes in for an appointment.

Torsion
Torsion of the testis and/or blood vessels supplying the testis (spermatic cord) is a common problem that threatens fertility. Torsion is caused by a supportive tissue abnormality which allows the testis to twist inside your scrotum, causing extreme pain and swelling. When your gonad rotates, the attached blood vessels entwine like the ropes on a swing and pinch shut the blood supply. Within a few hours cellular degeneration from impaired blood flow begins to take its toll. The amount of cellular damage varies with the degree of torsion; however, emergency surgery must be performed to prevent further damage.

Due to rapid growth of the body during puberty, torsion seems to occur most frequently at that age. If you have torsion on one side, you have a 40 percent chance of having torsion on the other side, too. Consequently the surgeon should secure the unaffected testis to prevent subsequent trauma.

When the deteriorated testis is left in place, damage is often induced in the unaffected testis. Studies suggest that removing the damaged testis may help preserve full function and fertility of the remaining one.

Trauma
Severe injury to your testicles requires prompt intervention to avoid tissue loss. If you have marked swelling and pain, a surgeon should explore your scrotum and make needed repairs. When required, a surgeon can drain a clot o f blood from the scrotum (scrotal hematoma) or repair a testicular rupture.

Klinefelter's Syndrome
Each cell in a normal man's body has only one Y. (male) and ones (female) Chromosome People with Klinefelter's syndrome, however, having Y and two X chromosomes in each cell. On examination I will find peanut-sized testes and enlarged breasts. A chromosome analysis (karyotypinx will confirm this diagnosis. In the beginning stages of this rare disorder your FSH is oly slightly e elevated, indicating minimal testicular failure. Administration of hCG at this Stage may improve sperm production. However, eventually all other active testicular structures will atrophy, including germ cells, tubules, Lydig cells, and Sertoli cells; the testes themselves actually shrink. After testicular failure Occurs (causing FSH levels to rise dramatically), improving fertility is impossible. However, these people can still have children by using artificial insemination with donor sperm.

Cushing's Syndrome
Cushing's syndrome occurs when the adrenal gland excreets excessive amounts of cortisol. People with this rare disorder will have a moon-shaped face and will suffer from water retention, obesity, impotence, feminized characteristics, loss of sex drive, and infertility. The condition me be due to an adrenal tumor or to excessive stimulation of the adrenal gland by ACTH (adrenocorticotropic hormone) from the pituitary. If ACTH is high either the pituitary is overactive or an ACTH-secreting pituitary tumor is ris present (called Cushing's disease). Elevated adrenal androgens suppress LH and FSH production ad spermattogenesis. Cortisone replacement therapy will reduce cortisol levels and restore natural LH, FSH, and sperm production. If a tumor s present, surgery and/or radiation therapy is required.

Germ Cell Aplasia (Sertoli Cell Only)
Germ cell aplasia (Sertoli cell only) is an inherited condition. The testicular biopsy will show that the slightly small testes have normal Leydg cells, no germ cells, and narrow tubules. Because their Leydig cells continue to produce testosterone, these men remain virile, but they can't produce sperm.

Germ cell aplasia can also be caused by exposure to large doses of radiation and prolonged exposure to toxic substances. Once the damage is complete, no therapy is available. To couples facing this diagnosis, I usually suggest artificial insemination with donor sperm or adoption.

Testicular Enzyme Defects
Testicular enzyme defects prevent the testes from responding normally to hormonal stimulation. These rare genetic defects can cause multiple genital abnormalities, incomplete virilization, small testes, and low o no sperm production. LH and FSH will both be high, since the brain is doing its best to stimulate the unresponsive testicles. Providing some sperm production still exists, AIH or in vitro fertilization may lead to pregnancy.

Seven percent of infertile men cannot transport sperm from their testicles out of their penis. The path from each of your testicles to your penis may be interrupted by a number of conditions:

	A genetic or developmental mistake may cause blockage and/or the absence of one or both tubes (vasa).
	Scarring from tuberculosis or sexually transmitted diseases such as gonorrhea and chlamydia may block your epididymis or tubes.
	An elective or accidental vasectomy (severing of the vasa) may interrupt tube continuity.

I usually suspect an obstruction when you have normal-sized testes and normal hormone levels but fewer than I million sperm per milliliter of ejaculate. If you have a partial obstruction, your sperm count and motility will be low and you will have an increased percentage of abnormal sperm morphology. Complete obstruction results in the total absence of sperm and, depending on the location of the obstruction, possibly the absence of semen. Twenty-five percent of azospermic men have duct obstructions. Unfortunately, if you're missing large sections of the vas, surgical repair is impossible.

If I suspect an obstruction, I will order an ultrasound or X ray of your tubes to locate the exact position of the obstruction or missing section. If the ultrasound is normal, testicular biopsy, X ray and repair may be necessary. Surgical repair is usually performed at the same time as the X ray, since both require general anesthesia. I'd like to describe each type of transport problem and tell you how they are diagnosed and corrected.

Advanced reproductive techniques such as epidermal sperm aspiration (removing sperm from the epididymis) and ICSI (direct injection into eggs retrieved by IVF) results in pregnancy rates between 25 and 30%.

Voluntary or Accidental Vasectomy
Voluntary vasectomy (surgical dissection of both vasa deferentia for birth control) is the most common posttesticular cause of fertility loss. A vasectomy may also occur accidentally as a complication of traumatic injury, scrotal surgery, and lower abdominal surgery such as a hernia repair.

Infection and Disease
Chronic active prostatitis and gonococcal or tuberculosis infections can cause scarring and tubal blockage. I suspect these diseases if you have difficulty voiding, show a urethral discharge, or have a painful and enlarged prostate gland on rectal examination. The tail of the epididymis at its junction with the vas deferens is the usual site of this type of obstruction. The seminal vesicles, prostate, and ejaculatory ducts may also be involved. Azospermic men with acquired obstruction usually have fructose in their seminal fluid and normal FSH levels, indicating that the seminal vesicles and testes are intact and functional. If I have any doubts about my diagnosis, I'll order a testicular biopsy to confirm normal sperm production.

Performing microsurgery to repair the epididymis is tedious, but the 50 to 70 percent success rate approaches that of vasectomy reversals.

Cystic fibrosis, an inherited disease occurring in I out of 2,500 live births, may also cause low sperm counts, diminished semen volume, or the congenital absence of the vas deferens.

Congenital Obstruction
Congenital abnormalities account for approximately 2 percent of male fertility problems. Frequently the blockage will be located at the anatomical junction between your vas and your epididymis. If fructose is absent from your seminal fluid, I suspect congenital absence of both the vasa and seminal vesicles or a rare obstruction of the ejaculatory ducts. Congenital malformations are frequently difficult to overcome, since many times long sections of both vasa may be absent. These require microsurgical retrieval of sperm from the epididymis or testicle and direct injection into the egg.

I remember one unusual situation involving a couple in their mid-twenties. Jess H.'s semen analysis showed no sperm at all. On his history form he indicated that his mother had taken DES to prevent miscarriage. Because I suspected blockage from the usage of this drug while he was in utero, I referred him to a urologic microsurgeon for X rays and a biopsy. In the meantime I completed a fertility workup on his wife and confirmed that she was fertile. (It wouldn't make much sense for them to pay for expensive microsurgery on him if she had a serious fertility problem.) Jess's X ray showed blockage at the epididymis on both sides, so the surgeon repaired the tubes. After several months Jess's semen analysis showed marked improvement.

Vasectomy Reversal and Surgical Repair for Obstruction
Today more and more men want vasectomy reversals. Often they find themselves divorcing and remarrying in mid-life and then wanting to begin a Wg new family. Fortunately, if your reversal is performed within ten years of the original vasectomy, you have a 70 to 90 percent chance of restoring your fertility.

After ten years the prolonged pressure buildup from sperm in your epididymis may "blow out" holes in the epididymis wall. These ruptures can be difficult to correct. In addition, you may begin to form antibodies against your own sperm. Later I'll discuss the adverse affects of sperm antibodies in greater detail.

Vasectomy reversal and tubal repairs are complicated by the fact that the vas has a thick, tough muscular wall with a pencil-lead-sized opening (lumen) | inside the tube. Pressure from sperm production tends to swell or enlarge the | portion of the tube attached to the epididymis. Thus the lumen will be larger in diameter than the detached tube leading to the penis. Fitting the two ends together can be tedious, but gentle dilation of the smaller tube and microsurgical techniques seem to work well.

Fertility Factor #4: How We Correct Ejaculatory Disturbances

Impotence
You are impotent if you are unable to maintain an erection and ejaculate during sex. Organic impotence differs from psychological impotence in that with organic impotence your body cannot respond because of insufficient hormone stimulation, incomplete nerve paths, and/or insufficient reproductive organ development. Some people have always been impotent (primary impotence) and others may develop impotence later in life as a result of surgery, injury, or an illness. Determining the cause of impotence is not as straightforward as one would like because many men who suffer from organic impotence may also have a number of psychological problems stemming from their inability to perform sexually.

Impotence can be caused by diseases such as prostatitis, diabetes, and kidney failure and by neurological disorders such as multiple sclerosis and spinal injuries. Impotence may also be caused by pelvic surgery, including kidney transplant, prostate, and bladder surgery. Hormone imbalances such as elevated prolactin and low testosterone levels can also decrease sex drive and cause impotence. Many drugs and medications such as antihypertensives, antidepressants, alcohol, and narcotics have been linked with impotence.

Men with organic impotence have few if any erections during their sleep. You can confirm if you have organic impotence by monitoring your nocturnal erections for several nights. You can do this with an expensive overnight at home more simply with my "trading stamp procedure." Just before going to bed moisten a short strip of trading stamps and stick them in a circle around the center of your penis. Make sure the ends of the strip overlap and the stamps glue together securely. If the strip breaks during the night, you probably had a nocturnal erection. Repeat the procedure several nights in a row to make sure.

If your impotence is due to a hormone imbalance and/or systemic disease, appropriate treatment may alleviate your problem. Or supplementing your testosterone to normal levels may improve your sexual desires and performance.

You can overcome irreversible organic impotence with a surgical penile implant or by the use of an injection to stimulate and maintain an erection. Thousands of men use penile implants, and many of their wives report that during intercourse they cannot sense any difference from a normal erection. Nearly half of the penile implants have been used with men having diabetes, spinal cord injury, pelvic fracture, chronic renal disease, ethanolism, multiple sclerosis, or genital trauma. The implant can be bent down easily and worn in a normal position under your clothing. It is a safe and successful cure for organic impotence. However, as the injectible medications are so effective and easy to use, most men now choose this option instead of surgical implants. While a penile implant or injectible medication can improve your sex life, it will not necessarily make you fertile. If you want to father a child, you should request a complete fertility workup.

Premature Ejaculation
If you cannot control your ejaculatory responses for at least thirty seconds after penetrating your wife's vagina, you may suffer from premature ejaculation. Some prefer to broaden this clinical definition: if you cannot control your ejaculatory responses for a sufficient length of time to satisfy your partner at least half of the time, you have premature ejaculation.

Premature ejaculation becomes a fertility problem when you ejaculate prior to inserting your penis fully into your wife's vagina. Of course you can always consider artificial insemination with your sperm. However, given a choice, most couples prefer using "natural" techniques. You can open control this condition by changing coital position and by using a behavior modification procedure called the "squeeze technique."

The squeeze technique helps desensitize your penis so you can participate in sex without experiencing premature ejaculation. When using this procedure, your wife places her thumb on the frenulum on the underside of your penis. (See figure 8-2.) She places her first and second fingers on either side of the coronal ridge on the top of your penis. Squeezing her fingers together for three to four seconds in this manner will make you lose your urge to ejaculate. You may also lose some of your erection. After fifteen to thirty seconds your wife can stimulate your penis again and just before you ejaculate repeat the squeeze technique. If your wife is concerned about how much pressure to use, you can place your fingers over hers and press with her. This demonstration of ejaculatory control improves your self-confidence and will be a major step toward reestablishing communication and improving your marital relations. Once you've practiced this technique, you can try it with her in the female-superior coital position (wife on top). After using the squeeze technique several times, she can insert your penis into her vagina without thrusting her pelvis to stimulate you. With counseling many couples are able to establish "normal" coital patterns and pregnancy.

Ejaculatory Incompetence
Men with this disorder rarely have difficulty achieving or maintaining an erection; however, they cannot ejaculate during sex. Often the wife is unaware of her husband's condition because he simulates orgasm. I can detect this problem by comparing the semen analysis with the postcoital test. If your semen test is normal but there are no sperm in the cervical mucus after sex, ejaculation did not occur. This rare psychological condition sometimes responds well to behavior therapy. Ejaculation may be stimulated by combining masturbation and manual stimulation with eventual insertion into the wife's vagina. If the condition persists, you can overcome the fertility problem by using AIH with a masturbated ejaculate.

Retrograde Ejaculation
Retrograde ejaculation is a condition in which semen is ejaculated into the bladder rather than out through the urethra, because the bladder sphincter does not close at the moment of ejaculation. It is found in 1.5 percent of infertile men and is the most common cause of absent ejaculate. If you have this disorder, you may notice that your ejaculate volume is small (below one milliliter) and that sometimes after intercourse your urine looks turbid or cloudy. The diagnosis can be confirmed by examining a urine specimen taken soon after intercourse. If large quantities of sperm are found in your urine, retrograde ejaculation is the fertility problem.

Retrograde ejaculation often occurs in diabetics, paraplegics, and men taking blood pressure medication (antihypertensives). The disorder may also occur in men with urethral stricture or men who have undergone surgical repair of their bladder, prostate, or other abdominal structures.

Many times medications such as decongestants, which contract the bladder sphincter, will control retrograde ejaculation. In certain circumstances, surgical reconstruction of the bladder neck can restore normal ejaculation. Consult with your doctor to see if you are a candidate for surgical intervention.

The most common fertility treatment method involves retrieving the sperm from the man's bladder and artificially inseminating his wife. This is the technique I tried with Michael and Shelley T. Since sperm cannot survive in an acid urine, I asked Michael to take one teaspoon of bicarbonate of soda in a glass of water four times a day for two days prior to Shelley's most fertile time of the month. About twenty minutes prior to collecting his semen, I asked Michael to empty his bladder. After he ejaculated into a jar, I catheterized Michael to collect his semen together with a small amount of urine. I then washed the sperm and using a syringe placed the sperm into Shelley's cervix.

The success rates are quite good, provided the couple can stick to the regimen. However, Shelley still did not conceive. We had some more work to do with Shelley's endometriosis. I'll discuss the procedures I used in a later chapter.

Although Michael wished to avoid catheterization, this frequently provides the best specimen for AIH. I can obtain a semen sample by first asking you to void. Then I will insert a catheter through the penis into the bladder and drain any excess urine before placing a small amount of sperm nutrient media into the bladder. The man is asked to ejaculate and then voids the nutrient media into a specimen cup. The sperm are separated from this liquid, concentrated and placed into the uterus.

Obtaining Semen Artificially
"Normal" ejaculation may not be possible for many men who are physically impaired; for example, if they are quadriplegic. However, semen can often be obtained by artificially stimulating the man to ejaculate. Using a vibrator to stimulate his penis is a simple and often effective technique. (Some of you may not even consider this to be "artificial.") When this fails, electrical stimulation will make half of these men ejaculate, and an additional 15 percent will have retrograde ejaculation. Thirty-five to 40 percent will not ejaculate because of the pain experienced from the procedure. It's possible, however, that many of these men could ejaculate under general anesthesia. Decisions about using these options should involve the couple and their physician.

Because male fertility has been shrouded in mystery, I've covered male fertility problems in much greater detail than most fertility books do. I hope that with the understanding you've gained in these chapters, you will be able to ensure that your physician is giving you the best opportunity to reach your fertility potential. When you and your wife both maximize your fertility, you have the best chance for getting your miracle baby.

For more information on your initial visit to your physician read the
INCIID Routine Fertility Workup or IVF.com Homepage.

Miracle Babies and Other Happy Endings
for Couples with Fertility Problems
Copyright © 1986 Mark Perloe M.D., and Linda Gail Christie.