Male Infertility: Symptoms, Diagnosis & Treatment – Urology Care Foundation

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Many male fertility problems can be treated without surgery.

Anejaculation (dry ejaculate)

Anejaculation is when there’s no semen fluid released with a man’s sexual climax. It’s not common, but can be caused by:

• spinal cord injury
• prior surgery
• diabetes
• multiple sclerosis
• abnormalities present at birth
• other mental, emotional or unknown problems

Drugs are often tried first to treat this condition. If they fail, there are several option. Penile vibratory stimulation (PVS)  or Rectal probe electroejaculation (RPE, better known as electroejaculation or EEJ) may induce ejaculation.  Sperm may also be retrieved directly from the testicle with a needle (Testicular Sperm Aspiration)

Rectal probe electroejaculation is most often done under anesthesia. This is true except in men with a damaged spinal cord. RPE retrieves sperm in 90 out of 100 men who have it done. Many sperm are collected with this method. But sperm movement and shape may still lower fertility.

Penile vibratory stimulation vibrates the tip and shaft of the penis to help get a natural climax. While non-invasive, it doesn’t work as well as RPE. This is especially true in severe cases.

Assisted reproductive techniques like in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) are of great value to men with anejaculation because sperm may be weak in men with impaired sperm (cells) and semen (fluid) transport out of the body, the underlying problem with anejaculation.

Genital Tract Infection

Genital tract infection is rarely linked to infertility. It’s only found in about 2 out of 100 men with fertility problems. In those cases, the problem is often diagnosed from a semen test. In the test, white blood cells are found. White blood cells make too much “reactive oxygen species” (ROS). This can damage sperm, lowering the chances of sperm being able to fertilize an egg. For example, a severe infection of the epididymis and testes may cause testicular shrinking and epididymal duct blockage. The infection doesn’t have to be sudden to cause problems.

Antibiotics are often given for full-blown infections. But they’re not used for lesser inflammations. Some antibiotics can occasionally harm sperm production or function. Non-steroidal anti-inflammatories (such as ibuprofen) are often used instead.

Inflammation from causes other than infection can also affect fertility. For example, chronic prostatitis, in rare cases, can also block the ejaculatory ducts.

Hyperprolactinemia

Hyperprolactinemia is when the pituitary gland makes too much of the hormone prolactin. It’s a factor in infertility and erectile dysfunction. Treatment depends on what’s causing the increase. Drugs or less commonly surgery may be used to treat tumors in the pituitary if present.

Hypogonadotropic Hypogonadism

Hypogonadotropic hypogonadism is when the testicles don’t make sperm due to poor stimulation by the pituitary hormones. This is due to a problem in the pituitary or hypothalamus. It’s the cause of a small percentage of infertility in men. It can exist from birth,typically being apparent when the young man is supposed to go through puberty (“congenital”). Or it can show up later (“acquired”).

The congenital form, known also as Kallmann’s syndrome, is caused by lower amounts of gonadotropin-releasing hormone (GnRH). GnRH is a hormone made by the hypothalamus. The acquired form can be triggered by other health issues such as:

• pituitary tumors
• head trauma
• anabolic steroid use.

If hypogonadotropic hypogonadism is suspected, your health care provider may want you to have an MRI. This will show a picture of your pituitary gland. You will also have a blood test to check prolactin levels. Together, an MRI and blood test can evaluate for pituitary tumors. If there are high levels of prolactin but no tumor on the pituitary gland, your provider may try to lower your prolactin first. Gonadotropin replacement therapy would be the next step. During treatment, blood testosterone levels and semen will be checked. Chances for pregnancy are very good. The sperm resulting from this treatment are normal.

Genetic Conditions

Some men are born with a genetic condition that may be new (not present in other family members) or hereditary (passed from mother and/or father), showing up first in the affected patient.  The known causes of genetic abnormalities are most commonly detected in men with no sperm in the ejaculate (azoospermia), where the condition affects sperm production (e.g., Klinefelter syndrome – where an extra chromosome is present in the man, or Y chromosome microdeletions – where a small segment of genetic tissue is missing.). Genetic conditions can also affect the development of the male tract that carries sperm, resulting in failure of formation of the tubes that are supposed to carry sperm.

Retrograde Ejaculation

Retrograde ejaculation, semen flowing back instead of going out the penis, has many causes. It can be caused by:

• prostate or bladder surgeries
• diabetes
• spinal cord injury
• anti-depressants
• certain anti-hypertensives
• medications used to treat prostate enlargement (BPH)

Retrograde ejaculation is found by checking your urine for sperm. This is done under a microscope right after ejaculation. Drugs can be used to correct retrograde ejaculation.

It is often treated first with over-the-counter medications like Sudafed®. If medications don’t work and you need assisted reproductive techniques (ARTs), your health care provider may try to collect sperm from your bladder after ejaculation.

Surgical Therapy for Male Infertility

Varicocele Treatments

Varicoceles can be fixed with minor outpatient surgery called varicocelectomy. Fixing these swollen veins helps sperm movement, numbers, and structure. For more information on varicocele treatments please refer to our Varicoceles page.

Azoospermia Treatments

If your semen lacks sperm (azoospermia) because of a blockage, there are many surgical choices.

Even men who have low sperm production as a cause of no sperm in the ejaculate can be treated with surgery to find sperm, together with assisted reproduction, since several million sperm have to be made in the testicles before sperm survive to make it into the semen.

Microsurgical Vasovasostomy

Vasovasostomy is used to undo a vasectomy. It uses microsurgery to join the 2 cut parts of the vas deferens in each testicle. For more information on this treatment please refer to our Vasectomy Reversal page.

Vasoepididymostomy

Vasoepididymostomy joins the upper end of the vas deferens to the epididymis. It’s the most common microsurgical method to treat epididymal blocks. For more information on this treatment please refer to our Vasectomy Reversal Page.

Transurethral Resection of the Ejaculatory Duct (TURED)

Ejaculatory duct blockage can be treated surgically. A cystoscope is passed into the urethra (the tube inside the penis) and a small incision is made in the ejaculatory duct. This gets sperm into the semen in about 65 out of 100 men. But there can be problems. Blockages could come back. Incontinence and retrograde ejaculation from bladder damage are other possible but rare problems. Also, only 1 in 4 couples get pregnant naturally after this treatment.

Treatment for Unknown Causes of Male Infertility

Sometimes it’s hard to tell the cause of male infertility. This is called “idiopathic” male infertility. Your health care provider may uses experience to help figure out what works. This is called “empiric therapy.” Because infertility problems are often due to hormones, empiric therapy might balance hormone levels. It’s not easy to tell how well empiric treatments will work. Each case is different.

Assisted Reproductive Techniques

If infertility treatment fails or isn’t available, there are ways to get pregnant without sex. These methods are called assisted reproductive techniques (ARTs). Based on the specific type of infertility and the cause, your health care provider may suggest:

Intrauterine Insemination (IUI). For IUI, your health care provider places the sperm into the female partner’s uterus through a tube. IUI is often good for low sperm count and movement problems, retrograde ejaculation, and other causes of infertility.

In Vitro Fertilization (IVF). IVF is when the egg of a female partner or donor is joined with sperm in a lab Petri dish. For IVF, the ovaries must be  stimulated to produce multiple eggs (ova). This is often done with drugs given as daily injections.  It allows many mature eggs to be retrieved. After 3 to 5 days of growth, the fertilized egg (embryo) is put back into the uterus. IVF can be used to treat many hormone conditions in women,  for women with blocked tubes, or idiopathic infertility (where there is no cause that explains the fertility problem). But it’s being used more and more in cases where the man has very severe and untreatable oligospermia (low sperm count).

Intracytoplasmic Sperm Injection (ICSI). ICSI is a variation of IVF. It has revolutionized treatment of severe male infertility. It lets couples thought infertile get pregnant. A single sperm is injected into the egg with a tiny needle. Once the egg is fertilized, it’s put in the female partner’s uterus. Your health care provider may use ICSI if you have very poor semen quality. It is also used if you have no sperm in the semen caused by a block or testicular failure that can’t be fixed. Sperm may also be taken from the testicles or epididymis by surgery for this method.

Sperm Retrieval for ART. Many microsurgical methods can remove sperm blocked by obstructive azoospermia (no sperm). The goal is to get the best quality and number of cells. This is done while trying not to harm the reproductive tract. These methods include:

• Testicular Sperm Extraction (TESE). This is a common technique used to diagnose the cause of azoospermia. It also gets enough tissue for sperm extraction. The sperm taken from the testicle can be used fresh or frozen (“cryopreserved”). One or many small biopsies are done, often in the office. A more refined form of this procedure is microTESE, where an operating microscope is used to identify small areas of sperm production in the testicles of men who have such low sperm production that no sperm survive to make it into semen.
• Testicular Fine Needle Aspiration (TFNA). TFNA was first used to diagnose azoospermia. It is now sometimes used to collect sperm from the testicles. A needle and syringe puncture the scrotal skin to pull sperm from the testicle.
• Percutaneous Epididymal Sperm Aspiration (PESA).. PESA may be performed under local or general anesthesia. The urologist sticks a needle attached to a syringe into the epididymis. Then he or she gently withdraws fluid. Sperm may not always be gotten this way. You may still need open surgery.
• Microsurgical Epididymal Sperm Aspiration (MESA). With MESA, sperm are also retrieved from the epididymal tubes. This method uses a surgical microscope. MESA yields high amounts of motile sperm. They can be frozen and thawed later for IVF treatments. This method limits harm to the epididymis.