About 15% of couples are unable to get pregnant during the first year of unprotected intercourse. In one-third of couples, the man and woman contribute equally to the difficulty conceiving, and in another third of couples, only the man contributes to the infertility. Men who contribute to the difficulty conceiving usually have some abnormality in sperm production or delivery that can be identified on a male fertility evaluation.
When Is a Couple Considered Infertile and When Should an Evaluation Be Performed?
A couple is considered to have fertility problems after 1 year of unprotected intercourse without getting pregnant. After a year of trying to conceive, the couple may consider seeking an evaluation of the male and female partners. There are several reasons the couple may undergo an evaluation sooner, including a history of male anatomy variations such as undescended testis, advanced maternal age (female partner is more than 35 years old) or if the couple’s fertility is under question for any reason.
Why Is It Important for the Man to be Evaluated?
One of the most common misconceptions is that the man in the couple does not contribute to the infertility equation. As stated above, the man can contribute to infertility in the couple about 25-75% of the time. It is necessary in most situations that the man be fully evaluated unless a semen analysis is completely normal.
Part of the reason most non-specialists may not consider this important is because most men will not have symptoms of having fertility issues. Sometimes erectile/sexual dysfunction, prostate problems and trouble urinating or hormonal issues will hint at fertility issues. However, most men will not be identified as having fertility issues until fully evaluated by a specialist.
More recently we have come to realize that during the evaluation of male infertility many other more sinister things can be found. It is not uncommon to find testicular cancers, genetic disorders that may be passed onto offspring, anatomic abnormalities such as missing kidneys, and hormonal imbalances. Often the male fertility evaluation will be the first evaluation of the fully matured man by a physician since adolescence. This visit may refocus the individual towards improvements in general health, and lifestyle even if no male fertility issue is identified.
What Is Involved in a Fertility Evaluation of the Male?
A comprehensive medical, fertility, and sexual history will be requested prior to your visit via a questionnaire. Your replies will be reviewed at your visit. This evaluation will involve your partner and assess her fertility status as well. You will receive a focused physical exam. Two semen analyses should be performed prior to your evaluation to maximize the counseling at the end of the evaluation. The semen analysis will determine your sperm quality and sperm count. Two semen analyses are required to establish a baseline since semen counts can vary greatly even in normal individuals without fertility issues.
Hormonal testing will determine whether the proper environment to make and mature sperm exists. Other genetic testing, or semen retrieval methods may be needed depending on your initial evaluation.
Which Partner Should Be Evaluated First?
Most male reproductive experts agree the male should be evaluated first. This may seem self-serving but the reasons behind it make sense.
- Invasiveness - Usually two ejaculated semen analyses and hormonal analysis are obtained during the evaluation of the male. The female partner will receive blood work, a transvaginal ultrasound, and hysteriosalpingogram (HSG) –a test where dye is placed within the uterus. The male’s workup is less invasive. And, the initial male evaluation costs less.
- Time - Significant improvement and changes in the fertility status of males take at least 3 months, compared to less time for women. Given the increased interval of time required in the man to notice improvement, it may be beneficial to start the male work-up first or simultaneously in couples with a partner >35 years of age.
One caveat to this if the couple wants to conceive as quickly as possible via in-vitro fertilization. IVF does not require improving the man’s fertility in 9 out 10 cases. Furthermore, there is minimal invasiveness for the man and minimal time spent achieving pregnancy, if successful. Nevertheless, this does not minimize the importance of a male factor evaluation as a way to promote general men’s health and to identify more morbid diseases that could be causing sperm dysfunction.
Is Male Infertility Treatable?
Yes. More than 50% of cases of male infertility can be corrected. Treatment depends on the cause.
Anand Shridharani, MD, is a board-certified, fellowship-trained specialist in male reproductive and prosthetic urology with Erlanger Urology in Chattanooga, TN. His practice offers comprehensive men’s reproductive and sexual health services including comprehensive management of the infertile male, reproductive microsurgery including vasectomy reversal, urologic cancer survivorship, and penile/urethral reconstruction.