Fertility Men’s Health

Male Infertility: Symptoms, Causes & Diagnosis

Article Summary

Dive into the fascinating world of male infertility with this eye-opening article, shedding light on a condition impacting millions of couples in the US. Unravel the mysteries behind symptoms, causes, and lifestyle influences that shape male fertility, while uncovering the diagnostic journey and exciting treatment possibilities. From medical breakthroughs to environmental influences, this article offers a compelling journey through the complexities of male infertility, empowering individuals with the knowledge to take charge of their reproductive health and embark on the path to parenthood with confidence.

The inability to conceive a child can be stressful and frustrating, and although infertility affects almost 6.7 million couples in the United States (a staggering 10-11% of reproductive-aged couples in the United States), it is highly treatable in many cases.[1][2]

The highly specialized field of male fertility involves a wide range of medical, environmental, and lifestyle causes which also includes many very specific risk factors. However, now that the genetic causes of male infertility are more commonly diagnosed, and several male infertility treatments are readily available, couples having difficulty conceiving or carrying to term, can often have success with the use of fertility medications.[3]

Male Infertility Symptoms

As would be expected the main symptom of infertility (male or female) is the inability to conceive. Although there may be no other obvious symptoms, underlying problems such as hormonal imbalances, inherited disorders, or certain medical conditions in which the passage of sperm may result in telltale signs which include:[4][5]

  • Ejaculation difficulty
  • Difficulty maintaining an erection (erectile dysfunction)
  • Pain, swelling, or a lump in the testicle area
  • Decreased facial or body hair or other signs of a chromosomal or hormonal abnormality
  • A lower-than-normal sperm count
  • A history of testicle, prostate, or sexual problems
  • Groin, testicle, penis, or scrotum surgery
  • Specific, and/or repeated trauma to the groin area

Understanding Male Infertility

Prior to discussing the causes of infertility, let’s examine the complex process of fertility from the male perspective. This process begins with properly functioning testicles, and the ability to produce testosterone as well as the supporting hormones which trigger and maintain sperm production.[6][7] Once produced, delicate tubes transport sperm cells until they mix with semen and are ejaculated out of the penis.[8] If the number of sperm in your semen (sperm count) is low, it decreases fertilization odds.[9] Most authorities consider low sperm count to be fewer than 15 million sperm per milliliter of semen, or fewer than 39 million per ejaculate.[10] In addition to production and volume, sperm cells must be shaped correctly and able to move freely.[9][11] If the movement (motility) and shape (morphology) of your sperm is abnormal, it will experience difficulty reaching and penetrating the egg to complete fertilization.[9]

Male Infertility Causes

Male infertility is most often due to three factors: 1) blockages that prevent the delivery of sperm; 2) low sperm count; and 3) misshapen or immobile sperm cells. However, because the process is so delicate, many related factors can also contribute to the overall problem including injuries, poor lifestyle habits, illnesses, and chronic health problems. More specifically, infertility causes are traditionally grouped into medical, environmental, and lifestyle categories among which are:[12][13][14][15][16][17][18][19][20][21][22][23]

Medical Causes:

  • Hormone imbalances can result from disorders of the testicles or an abnormality affecting the hypothalamus, pituitary, thyroid and adrenal glands causing a deficiency in testosterone production.[24]
  • Sperm duct defects – tubes that carry sperm can be damaged by illness or injury. Other transport problems include a blockage near the epididymis, cystic fibrosis, and genetic conditions which cause males to be born without sperm ducts.[25]
  • Bacterial and viral infections can cause scarring that blocks the passage of sperm, and may result from STDs including chlamydia and gonorrhea, or from inflammation prostatitis and mumps orchitis.[26]
  • Chromosome defects can cause abnormal development of the male reproductive organs and infertility. They include Klinefelter’s, Kallmann’s, Young’s, and Kartagener syndromes.[27]
  • Antibodies that attack sperm are immune system cells that mistake sperm for harmful invaders and attempt to eliminate them.[28]
  • Tumors can affect the male reproductive organs or the glands that release hormones related to reproduction.[25][26][29]
  • Undescended testicles[25]
  • Problems with sexual intercourse such as painful intercourse, anatomical abnormalities like hypospadias, difficulty maintaining an erection (erectile dysfunction), premature ejaculation, and psychological or relationship problems.[30]
  • Certain medications which include anabolic steroids, testosterone replacement therapy, chemotherapy, and certain antifungal medications.[31]
  • Varicocele – a swelling of the veins that drain the testicle, and may prevent normal testicular cooling, resulting in sperm abnormalities and lowered sperm count.[32]
  • Ejaculation issues – retrograde ejaculation occurs when semen enters the bladder during orgasm instead of emerging out the tip of the penis. Various health conditions can cause retrograde ejaculation including diabetes, spinal injuries, medications, and surgery of the bladder, prostate or urethra. Some men with spinal cord injuries or certain diseases can’t ejaculate semen, even though they still produce sperm.[25]

Environmental Causes:[31]

  • Radiation or X-ray exposure can permanently reduce sperm production.
  • Excessive heat from continuous hot tub, sauna, or laptop computer usage.
  • Industrial chemical exposure to pesticides, herbicides, toluene, xylene, paint and varnish products, organic solvents, and benzenes.
  • Heavy metal exposure to lead or other heavy metals.

Health, Lifestyle, and Other Risk Factors:[31]

  • Prolonged bicycle seat pressure
  • Excessive amounts of body fat and obesity (a BMI of 30 or greater).
  • Tobacco smoking and secondhand smoke exposure.[31][33]
  • Emotional stress can interfere with sperm producing hormone production.[31]
  • Recreational drug use including anabolic steroids, cocaine, and marijuana can have temporarily adverse effects on sperm production.[31][33]
  • Alcohol use and liver disease caused by excessive drinking can lower testosterone levels, cause erectile dysfunction, and decrease sperm production.[31][33]
  • Certain occupations can increase your risk of infertility, including those associated with toxins, extended use of computers or video display monitors, shift work, and work-related stress.[31]

Proper Diagnosis of Male Infertility

The first step in addressing suspected infertility is to visit your family doctor or a general practitioner, after which you will likely be referred to a fertility specialist who will perform an extensive evaluation, which includes a lot of routine present and past medical information.[34] Although the scheduling receptionist may or may not request that you to do so, you can gather much of the necessary data prior to your visit, such as:[34]

Any atypical symptoms you’re experiencing, including any that may seem unrelated to infertility.
All surgeries and dates, whether unrelated or directly related, e.g., a vasectomy or vasectomy reversal.
Key personal information, including all recent major life changing events, and stressors.
Investigate your family history for fertility problems, especially male relatives (grandfather, father, and brothers).
A list of all medications, vitamins and supplements including herbs, remedies, and topicals (specialty shampoos, lotions, etc.) that you currently take.

In most cases, both partners are tested and may undergo a number of varied and gender specific tests to determine the cause of infertility. Such infertility tests can be expensive and may not be covered by insurance, so find out what your medical plan covers ahead of time. Testing usually involves a general physical examination of your genitals, followed by questions that could affect fertility about: surgeries and injuries; chronic health problems and illnesses; sexual habits; sexual development during puberty; and possibly inherited conditions.[35]

Also standard during testing is the semen analysis wherein you’ll submit semen at the doctor’s office, which is sent to a laboratory to measure the number of sperm present, look for abnormalities in the morphology and motility, and signs of infections.[36] Since sperm counts fluctuate from one specimen to the next, several semen analysis tests are done over a period of time to ensure accurate results.[10] If your sperm analysis is normal, your doctor will likely recommend thorough testing of your female partner before conducting any more male infertility tests.[37]

If deemed appropriate, your doctor may recommend additional tests to help identify the cause of your infertility which may include: testicular biopsy; anti-sperm antibody tests; specialized sperm function tests; scrotal or transrectal ultrasounds; hormone testing; post-ejaculation urinalysis; and/or genetic tests.[10][38][39][40][41][42]

The Clinical Rational for Treating Male Infertility

Fertility is improved by either correcting an underlying problem, though sometimes an exact cause of infertility can’t be identified, or by trying treatments that may be helpful which may include:[43][44][45][46]

  • Varicocele surgery to correct an obstructed vas deferens.
  • Antibiotic treatments that may cure an infection of the reproductive tract.
  • Assisted reproductive technology (ART) treatments involve obtaining sperm through normal ejaculation, surgical extraction or from donor individuals, then inserted into the female genital tract, or using sperm to perform in vitro fertilization or intracytoplasmic sperm injection.
  • Hormone treatments and medications
  1. “Quick Facts About Infertility”. American Society for Reproductive Medicine. Web.
  2. “Infertility fact sheet”. ePublicatoins. Office on Women’s Health, U.S. Department of health and Human Services. Web. 1 Jul 2009.
  3. Int Braz J Urol. 2006 Jul-Aug;32(4):385-97. Definition and current evaluation of subfertile men. Shefi S1, Turek PJ.
  4. J Urol. 2005 Nov;174(5):1932-4; discussion 1934. Erectile dysfunction and andropause symptoms in infertile men. O’Brien JH1, Lazarou S, Deane L, Jarvi K, Zini A.
  5. J Endocrinol Invest. 2003;26(3 Suppl):72-6. Stress, sexual dysfunctions, and male infertility. Lenzi A1, Lombardo F, Salacone P, Gandini L, Jannini EA.
  6. Lipshultz L, Howards S, Niederberger C. Infertility in the Male. “Chapter 3: Leydig cell development and function”. (Zirkin B et al.). pp. 29-47. 4th Edition. Cambridge University Press: New York. 2009.
  7. Lipshultz L, Howards S, Niederberger C. Infertility in the Male. “Chapter 2: Male hypothalamic-pituitary-gonadal axis”. (Caroppo E). pp. 14-28. 4th Edition. Cambridge University Press: New York. 2009.
  8. Lipshultz L, Howards S, Niederberger C. Infertility in the Male. “Chapter 6: The epididymis and accessory sex organs”. (Turner T). pp.90-103. 4th Edition. Cambridge University Press: New York. 2009.
  9. Lipshultz L, Howards S, Niederberger C. Infertility in the Male. “Chapter 7: An overview of the molecular mechanisms involved in human fertilization”. (Vazquez-Levin M, Marin-Briggiler C). pp. 104-121. 4th Edition. Cambridge University Press: New York. 2009.
  10. Lipshultz L, Howards S, Niederberger C. Infertility in the Male. “Chapter 11: Evaluation of sperm function”. (Zini A, Sigman M). pp 177-198. 4th Edition. Cambridge University Press: New York. 2009.
  11. Lipshultz L, Howards S, Niederberger C. Infertility in the Male. “Chapter 5: Spermatogenesis in the adult”. (Alukal J et al.). pp. 74-89. 4th Edition. Cambridge University Press: New York. 2009.
  12. Clinics (Sao Paulo). 2013;68 Suppl 1:61-73. Obstructive azoospermia: reconstructive techniques and results. Baker K1, Sabanegh Jr E.
  13. Andrology. 2014 Feb 19. Genetic susceptibility to male infertility: news from genome-wide association studies. Aston KI.
  14. Fertil Steril. 2013 Nov;100(5):1180-6. Effects of chemotherapy and radiotherapy on spermatogenesis in humans. Meistrich ML.
  15. Urol Clin North Am. 2014 Feb;41(1):67-81. Infectious, inflammatory, and immunologic conditions resulting in male infertility. Bachir BG1, Jarvi K.
  16. Reprod Biol Endocrinol. 2013 Jul 16;11:66. Lifestyle factors and reproductive health: taking control of your fertility. Sharma R1, Biedenharn KR, Fedor JM, Agarwal A.
  17. Dtsch Arztebl Int. 2013 May;110(20):347-53. Klinefelter syndrome: the commonest form of hypogonadism, but often overlooked or untreated. Nieschlag E.
  18. Hum Fertil (Camb). 2014 Mar;17(1):60-6. Semen quality in middle-aged males: associations with prostate-specific antigen and age-related prostate conditions. Ausmees K1, Korrovits P, Timberg G, Erm T, Punab M, Mändar R.
  19. J Endocrinol Invest. 2014 Jan 24. Relevance of genetic investigation in male infertility. Asero P1, Calogero AE, Condorelli RA, Mongioi’ L, Vicari E, Lanzafame F, Crisci R, La Vignera S.
  20. Curr Genet Med Rep. 2013 Dec 1;1(4). The Genetics of Infertility: Current Status of the Field. Zorrilla M, Yatsenko AN.
  21. J Assoc Physicians India. 2013 May;61(5):340-3. Aromatase deficiency: an unusual cause for primary amenorrhea with virilization. Sudeep K1, Abraham J1, Seshadri L2, Seshadri MS1.
  22. Cent European J Urol. 2013;66(1):60-67. The role of oxidative stress and antioxidants in male fertility. Walczak-Jedrzejowska R1, Wolski JK2, Slowikowska-Hilczer J1.
  23. Hum Reprod Update. 2007 May-Jun;13(3):209-23. The impact of lifestyle factors on reproductive performance in the general population and those undergoing infertility treatment: a review. Homan GF1, Davies M, Norman R.
  24. Lipshultz L, Howards S, Niederberger C. Infertility in the Male. “Chapter 2: Male hypothalamic-pituitary-gonadal axis”. (Caroppo E). pp. 14-28. 4th Edition. Cambridge University Press: New York. 2009.
  25. Lipshultz L, Howards S, Niederberger C. Infertility in the Male. “Chapter 26: Abnormalities of ejaculation”. (Brackett N et al.). pp. 454-473. 4th Edition. Cambridge University Press: New York. 2009.
  26. Lipshultz L, Howards S, Niederberger C. Infertility in the Male. “Chapter 17: The effects of genital tract infection and inflammation on male infertility”. (Kasturi SS et al). pp. 295-330. 4th Edition. Cambridge University Press: New York. 2009.
  27. Lipshultz L, Howards S, Niederberger C. Infertility in the Male. “Chapter 15: Genetic aspects of infertility”. (Oates R, Lamb D.). pp 251-276. 4th Edition. Cambridge University Press: New York. 2009.
  28. Lipshultz L, Howards S, Niederberger C. Infertility in the Male. “Chapter 16: Immunologic Infertility”. (Walsh J, Turek P.). pp 277-295. 4th Edition. Cambridge University Press: New York. 2009.
  29. Lipshultz L, Howards S, Niederberger C. Infertility in the Male. “Chapter 12: Endocrine evaluation”. (Sokol R). pp. 199-214. 4th Edition. Cambridge University Press: New York. 2009.
  30. Lipshultz L, Howards S, Niederberger C. Infertility in the Male. “Chapter 10: Office evaluation of the subfertile male”. (Sigman M, Lipshultz L, Howards S). pp. 153-172. 4th Edition. Cambridge University Press: New York. 2009.
  31. Lipshultz L, Howards S, Niederberger C. Infertility in the Male. “Chapter 14: Adverse effects of environmental chemicals and drugs on the male reproductive system”. (Bruckner J, Fenig D, Lipshultz L.). 4th Edition. Cambridge University Press: New York. 2009.
  32. Lipshultz L, Howards S, Niederberger C. Infertility in the Male. “Chapter 18: Varicocele”. (nagler H, Grotas A.). pp. 331-361. 4th Edition. Cambridge University Press: New York. 2009.
  33. “Optimizing Male Fertility. Fact Sheets. American Society for Reproductive Medicine. 2012
  34. Lipshultz L, Howards S, Niederberger C. Infertility in the Male. “Chapter 10: Office evaluation of the subfertile male”. (Howards S). pp. 152-176. 4th Edition. Cambridge University Press: New York. 2009.
  35. Lipshultz L, Howards S, Niederberger C. Infertility in the Male. “Chapter 10: Office evaluation of the subfertile male”. (Howards S). pp. 152-176. 4th Edition. Cambridge University Press: New York. 2009.
  36. Urol Clin North Am. 2014 Feb;41(1):163-7. Semen assessment. Centola GM.
  37. Lipshultz L, Howards S, Niederberger C. Infertility in the Male. “Chapter 19: Evaluation of female infertility for the non-gynecologiest”. (McClure R, Klein N). pp. 362-374. 4th Edition. Cambridge University Press: New York. 2009.
  38. Lipshultz L, Howards S, Niederberger C. Infertility in the Male. “Chapter 13: Testicular Biopsy”. (Alukal J et al.). pp. 215-225. 4th Edition. Cambridge University Press: New York. 2009.
  39. Lipshultz L, Howards S, Niederberger C. Infertility in the Male. “Chapter 16: Immunologic Infertility”. (Walsh J, Turek P.). pp 277-295. 4th Edition. Cambridge University Press: New York. 2009.
  40. Lipshultz L, Howards S, Niederberger C. Infertility in the Male. “Chapter 20: The use of ultrasound and radiologic imaging in the diagnosis of male infertility”. (Binsaleh S et al.). pp.375-391. 4th Edition. Cambridge University Press: New York. 2009.
  41. Lipshultz L, Howards S, Niederberger C. Infertility in the Male. “Chapter 12: Endocrine evaluation”. (Sokol R). pp. 199-214. 4th Edition. Cambridge University Press: New York. 2009.
  42. Lipshultz L, Howards S, Niederberger C. Infertility in the Male. “Chapter 15: Genetic aspects of infertility”. (Oates R, Lamb D.). pp 251-276. 4th Edition. Cambridge University Press: New York. 2009.
  43. Endocr Pract. 2010 Jul-Aug;16(4):669-72. Achievement of fertility in an infertile man with resistant macroprolactinoma using high-dose bromocriptine and a combination of human chorionic gonadotropin and an aromatase inhibitor. Heidari Z1, Hosseinpanah F, Shirazian N.
  44. J Endocrinol Invest. 2010 Oct;33(9):618-23. Efficacy of recombinant human follicle stimulating hormone at low doses in inducing spermatogenesis and fertility in hypogonadotropic hypogonadism. Sinisi AA1, Esposito D, Bellastella G, Maione L, Palumbo V, Gandini L, Lombardo F, De Bellis A, Lenzi A, Bellastella A.
  45. Pituitary. 2010 Jun;13(2):105-10. Outcome of gonadotropin therapy for male infertility due to hypogonadotrophic hypogonadism. Farhat R1, Al-zidjali F, Alzahrani AS.
  46. Eur J Endocrinol. 2014 Jan 6. [Epub ahead of print] Restoration of fertility by gonadotropin replacement in a man with hypogonadotropic azoospermia and testicular adrenal rest tumours due to untreated simple virilising congenital adrenal hyperplasia. Rohayem J1, Tüttelmann F, Mallidis C, Nieschlag E, Kliesch S, Zitzmann M.

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