Patient education: Treatment of male infertility (Beyond the Basics)

INFERTILITY OVERVIEW — Infertility is defined as a couple's inability to become pregnant after one year of regular, unprotected sex (if the female partner is less than 35 years old) or six months of unprotected sex (if the female partner is 35 or older). Studies suggest that infertility affects about 10 to 20 percent of couples who are trying to get pregnant. Approximately 10 percent of men may be infertile or have trouble getting their partner pregnant.

When a couple has trouble getting pregnant, it can be due to factors with the male partner, the female partner, or both. Sometimes, doctors cannot find a clear cause for infertility with either partner.

If you and your partner have been trying to get pregnant without success, talk to a health care provider. They can talk with you and run tests to try to determine the cause and whether treatment may be helpful.

This article is about infertility in the male partner. More information about infertility in the female partner, as well as in vitro fertilization (IVF), is available separately. (See "Patient education: Ovulation induction with clomiphene or letrozole (Beyond the Basics)" and "Patient education: Infertility treatment with gonadotropins (Beyond the Basics)" and "Patient education: In vitro fertilization (IVF) (Beyond the Basics)".)

CAUSES — In men, the ability to get a partner pregnant requires several different processes and hormones. The hypothalamus and the pituitary gland are both hormone-producing glands in the brain. The hypothalamus secretes a hormone called "gonadotropin-releasing hormone" (GnRH), which stimulates the pituitary gland to secrete "luteinizing hormone" (LH) and "follicle-stimulating hormone" (FSH). These hormones are involved in the production of testosterone and sperm in the testicles.

Infertility can be due to:

●A problem with the hypothalamus or pituitary gland that leads to low production of LH and FSH (and low stimulation of the testicles to make testosterone and sperm)

●A problem in the testicles that leads to decreased sperm production (this is the most common cause of male infertility)

●Problems with sperm from the testicles getting into the seminal fluid and exiting the body through ejaculation

In some cases, doctors are unable to find a specific cause for infertility.

EVALUATION — The evaluation of infertility in couples is discussed in more detail separately. The most important test for men is a semen analysis or seminal fluid analysis (a test to evaluate the number of sperm as well as their shape and motility, or movement). (See "Patient education: Evaluation of infertility in couples (Beyond the Basics)".)

TREATMENT — The treatment options for male infertility depends upon the underlying cause. The decision to pursue treatment depends on other factors as well, including personal preferences and cost.

While there are some situations in which male infertility can be reversed with medication or surgery, in many cases, assisted reproductive technology (ART; for example, in vitro fertilization [IVF] or IVF with intracytoplasmic injection [ICSI]) is the recommended approach. (See 'Assisted reproductive technologies' below.)

Lifestyle changes — Although there is limited evidence that specific lifestyle changes improve fertility, it is reasonable to take steps like avoiding smoking, limiting alcohol intake (to less than 24 ounces of beer, 10 ounces of wine, or 2 ounces of hard alcohol daily), avoiding any marijuana or recreational drugs, eating a healthy diet that contains fresh fruit and vegetables, and maintaining a healthy weight. These healthy habits may improve your chances of conceiving a child and certainly will help improve your overall health. (See "Patient education: Quitting smoking (Beyond the Basics)" and "Patient education: Risks and benefits of alcohol (Beyond the Basics)" and "Patient education: Diet and health (Beyond the Basics)".)

Vitamin and mineral supplements are sometimes recommended for their "antioxidant" properties (which can prevent damage to the sperm-making process). These supplements might be helpful, but there is too little evidence to recommend taking them. These supplements are often expensive, and a healthy diet will supply these same vitamins and minerals. Because sperm production is decreased by high heat around the testicles, there are myths about how to improve fertility by keeping the testicles cool. There is no evidence that wearing loose fitting underwear is helpful. Sitting in a very hot sauna or hot tub (>39°C or 102.5°F) for 20 minutes or longer might temporarily lower sperm concentrations and should be minimized.

Hypothalamic or pituitary deficiency — In a small percentage of cases (2 to 5 percent), male infertility is due to problems in the hypothalamus and pituitary gland. In this situation, treatment with human chorionic gonadotropin (hCG) that acts like LH, often in combination with recombinant human follicle-stimulating hormone (rhFSH), is given. The goal is to achieve normal blood hormone levels so the body can produce sperm.

Treatment with hCG with or without rhFSH is often called "gonadotropin treatment." It involves getting injections of hCG three times per week under the skin for at least six months and usually one to two years. Blood tests are used to monitor blood testosterone levels and to adjust the dose if necessary. If sperm cells do not appear in semen after six months of treatment, rhFSH injections may be added. While the success rate for this therapy is high, it can take one to two years of treatment (and sometimes even longer) to achieve normal fertility.

Varicocele — A varicocele is a dilation of a vein in the scrotum. Many men with varicocele have a low sperm count or abnormal sperm morphology (shape). However, many men with varicoceles are able to get their partner pregnant. The reason a varicocele affects sperm production and shape might be related to a higher-than-normal temperature in the testicles.

Varicocele can be treated with surgery to cut the veins connected to the varicocele. However, surgery does not always improve fertility and is not recommended in most cases, unless there is a large varicocele that can be easily felt. A varicocele that has been present for a long time can cause irreversible damage that cannot be surgically treated.

An alternative to varicocele repair is ART, such as ICSI. With ICSI, only a small number of sperm are needed. (See 'Intracytoplasmic sperm injection (ICSI)' below.)

Blockage or abnormality of the reproductive tract — Sometimes, infertility is related to a blockage in the ducts that allow sperm to mix with the semen before ejaculation; this can happen as a result of certain infections. In some cases, surgery can fix the blockage. If it is not possible to correct the blockage or the attempt is unsuccessful, another option is ART using sperm removed directly from the testes. This may also be an option for people who were born without a vas deferens (the tube that sperm travel through before leaving the body during ejaculation). (See 'Testicular extraction of sperm' below.)

Vasectomy is a form of permanent birth control; it involves deliberately blocking the path of sperm in order to prevent any future pregnancy. Vasectomies can be reversed in up to 85 percent of cases; over 50 percent of couples can achieve pregnancy following vasectomy reversal. However, the more time that has passed since the vasectomy, the less likely vasectomy reversal is to restore fertility. (See "Patient education: Vasectomy (Beyond the Basics)", section on 'Vasectomy reversal'.)

Other causes of male infertility — In most situations, medical therapies to fix the underlying cause of abnormal sperm production are not currently available. Treatment depends upon the results of blood testing and whether or not sperm are present (which can be determined by testing the fluid that is ejaculated or with a testicular biopsy). If any sperm are present, even a small number, IVF or ICSI may be an option. (See 'In vitro fertilization (IVF)' below and 'Intracytoplasmic sperm injection (ICSI)' below.)

Men who are found to not produce sperm at all may choose to pursue artificial insemination with donor sperm, or they might make other decisions regarding family planning. (See 'When infertility cannot be treated' below.)

If the male partner is having difficulty getting or maintaining an erection, or having trouble ejaculating, there are often treatments that can help. (See "Patient education: Sexual problems in males (Beyond the Basics)".)

ASSISTED REPRODUCTIVE TECHNOLOGIES — If tests show that the male partner's semen contains no or few normal sperm, assisted reproductive technologies (ART) can often help. These techniques offer hope to many couples who could not achieve pregnancy without them.

However, the techniques are expensive, require a considerable commitment of time and energy, and may come with certain health risks. The likelihood of success declines after several cycles (attempts) of ART. If you and your partner are considering ART, it's important to talk with a fertility specialist in order to understand the risks, benefits, and efficacy of the available options.

In vitro fertilization (IVF) — IVF is a commonly used technique for a variety of infertility problems, including female tubal blockages and unexplained infertility. IVF is usually recommended with intracytoplasmic sperm injection (ICSI) for men with infertility. (See 'Intracytoplasmic sperm injection (ICSI)' below.)

In general, IVF involves collecting eggs from the ovaries, fertilizing them with sperm in a lab, and transplanting the resulting embryo(s) into the uterus to try to achieve pregnancy. (See "Patient education: In vitro fertilization (IVF) (Beyond the Basics)".)

IVF success rates depend upon a number of variables, including the age and health of the female partner, the health of the egg and sperm, and, to some extent, the experience of the infertility center.

Intracytoplasmic sperm injection (ICSI) — With ICSI, a single sperm from the male partner is injected directly into an egg in the lab. This is similar to IVF, but may be more successful if there is there a known issue with the male partner's sperm production.

ICSI can be useful in many cases of low sperm count. The success rate depends on many factors, including the female partner's fertility, the quality of the sperm retrieved from the male partner, and the number of times IVF with ICSI is attempted.

Testicular extraction of sperm — If a man's semen contains no sperm or very few sperm, sperm can sometimes be directly removed from the testicles. This is done with a minor surgery or using a needle under local anesthesia. If sperm can be found and extracted from the testis, the sperm can be used for ICSI. (See 'Intracytoplasmic sperm injection (ICSI)' above.)

Risks of ART — Most patients who undergo assisted reproductive technologies (ART) have no major complications. There are few to no risks for men, depending upon the procedure used to obtain sperm. Men who must undergo a procedure to retrieve sperm have a small risk of bleeding, damage to the testes, and infection.

Risks of ART for the female partner include infection and damage to blood vessels and reproductive or surrounding organs. Ovarian hyperstimulation syndrome (OHSS) is a potentially serious complication, but the risk is now very low. (See "Patient education: In vitro fertilization (IVF) (Beyond the Basics)".)

There is some evidence that children of couples who become pregnant with ART with ICSI have a slightly higher rate of chromosomal or congenital (birth) abnormalities and may have a higher rate of lower birth weight. This potential risk should be discussed with a fertility specialist.

WHEN INFERTILITY CANNOT BE TREATED — Sometimes, infertility treatments are not successful, or treatment is not an option. If this is the case, there may be other ways to start a family. This is a very personal decision based on a couple's values and preferences.

Artificial insemination with donor sperm — Some couples may choose artificial insemination of the female partner with donor sperm. Donor sperm may be obtained from a known donor or from a sperm bank, which screens men for infections and certain genetic problems and provides a complete personal and family history. Most sperm banks keep the identity of their donors confidential; some banks give donors the option to be contacted by the children conceived with their sperm.

The decision to use donor sperm can be complicated and difficult for a couple. Counseling may be helpful to help both partners discuss their feelings and the potential implications of using donor sperm, including the question of when to talk to a child about their genetic origins. Expert guidelines recommend telling children if they were conceived with the help of donated sperm. Your health care provider can direct you to resources that can help guide you in this conversation when the time comes.

The use of donor sperm (if the woman is producing eggs) results in overall pregnancy rates that are approximately 50 percent after six cycles of insemination. Insemination may be done without the use of infertility medications or monitoring in women who have no infertility. Women who have difficulty conceiving may require intrauterine insemination or in vitro fertilization (IVF). (See "Patient education: Infertility treatment with gonadotropins (Beyond the Basics)".)

Adoption — Some couples consider adopting a child. A health care provider or social worker can suggest resources if you and your partner wish to pursue this option.

Childlessness — Some couples affected by infertility decide to remain childless. Couples who decide to remain childless often face questions from friends or family regarding their decision. These questions can be hurtful for couples who have struggled with infertility. Couples often benefit from counseling after they decide to stop infertility treatments; communicating openly is important to maintain a healthy relationship.

WHERE TO GET MORE INFORMATION — Your health care provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Female infertility (The Basics)
Patient education: Infertility in couples (The Basics)
Patient education: Testicular cancer (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Ovulation induction with clomiphene or letrozole (Beyond the Basics)
Patient education: Infertility treatment with gonadotropins (Beyond the Basics)
Patient education: In vitro fertilization (IVF) (Beyond the Basics)
Patient education: Evaluation of infertility in couples (Beyond the Basics)
Patient education: Sexual problems in males (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Causes of male infertility
Causes of primary hypogonadism in males
Causes of secondary hypogonadism in males
Clinical features and diagnosis of male hypogonadism
Effects of cytotoxic agents on gonadal function in adult men
Female infertility: Evaluation
Approach to the male with infertility
Induction of fertility in males with secondary hypogonadism
Intracytoplasmic sperm injection
Treatments for male infertility
Unexplained infertility

The following organizations also provide reliable health information.

●National Library of Medicine

(www.nlm.nih.gov/medlineplus/healthtopics.html)

●American Society for Reproductive Medicine

(www.asrm.com)

●Resolve: The National Infertility Association

(www.resolve.org)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Stephanie Page, MD, who contributed to earlier versions of this topic review.