Male Infertility

When it comes to infertility, men are not nearly so well organized as women. Their reproductive closets are cluttered with a multitude of large and small problems. When the door to the closet is opened, the problems tumble out all over one another and pile up in a confused heap. Each little piece in the jumble is different. One has a funny shape or a peculiar color, another is chipped on the surface, and another rocks aimlessly from side to side. They look nothing like the well defined pieces in the intricate reproductive closet of a woman.

It's strange that this should be so, because men and women start off with the same components. Their reproductive organs arise from similar fetal tissue (for every female organ there is a comparable male organ). Further, both sets of reproductive hormones are controlled by identical brain hormones. All that distinguishes the two systems is the final layout of the anatomy.

Apparently that is enough. Because when things go wrong, all comparisons between the two systems come to an end.

It is still news that men share half the burden of infertility in America. Thirty years ago, if a man produced an erection, along with some sperm, he was presumed to be fertile. If a couple was childless, neighbors and scientists alike shook their heads and said wasn't it too bad about poor Mrs. Jones. That Mr. Jones needed to make a certain number of sperm to get his wife pregnant was only a vaguely recognized concept.

Three major discoveries over the past thirty years have made the study of male infertility one of the hottest investigative fields in science. The first came when a researcher named J. MacLeod thought about quantifying sperm. The second was the discovery that a varicose vein in the testicle could affect sperm production. Perhaps the most important discovery was that infertility is relative, that a man with a borderline sperm count would be infertile if his wife ovulated irregularly.

Multiple Causes

The bad news about male infertility is that it's usually impossible to distinguish one single disorder. An infertility problem in a man is usually a mixture of several disorders that overlap, or one disorder that affects several different parts of the reproductive system. Dozens of small problems can arise almost anywhere in the system. In themselves, the problems are not especially destructive, but when they cluster they can reduce sperm count to a point where pregnancy is no longer viable.

The majority of problems fall into the category of sperm production; that is, for a multitude of reasons some simple and others complex. The testicles do not make adequate quantities of sperm. About 10 percent of infertility problems turn up in the transport system, that long series of passageways through which sperm must swim to get from the testicles into the penis. Sometimes a passageway gets clogged up; in a few instances the spermatic duct is missing. A few more problems take shape in the final ejaculation of sperm into the vagina. These deposit problems are very rare, but every once in a while a man simply uses the wrong entry point during sexual intercourse.

Because of the clustering of problems, treatment is often difficult and much less precise than it is in women, although the same fertility drugs are used to drive both systems. In men, the fertility specialist usually works with the overall system to improve general conditions in the hope that even a slightly elevated sperm count might be enough for pregnancy.

So what's the good news? The good news is that what some experts consider the most common cause of male infertility occurring in 50 to 60 percent of infertile men is also the most successfully treated.

Varicocele

The swollen, hot veins that spell varicocele were the second major discovery that propelled male infertility into the realm of twenty first century medicine. In 1952, soon after MacLeod and Gold did their sperm counts, a scientist named W. S. Tulloch tied off a varicose vein in the testicle of a man who had no sperm. Within a few months, the man was producing good quality sperm and went on to impregnate his wife. This bit of surgical experimentation awakened a new idea. If a man was infertile, something could be done about it. Like MacLeod's earlier surveys, Tulloch's work launched a wave of investigative research.

Today, we know that Tulloch was lucky. When a varicocele causes a complete absence of sperm, as was the case with his first patient, the damage is usually profound; surgery almost never fully improves sperm production.

A varicocele is a small flaw in the anatomy of a vein. One artery and a network of veins carry blood to and from the testicles. The artery pumps blood in, and the little bundle of veins carry it back to the heart. These veins are flaccid. Blood climbs back up to the heart on a ladder of oneway valves. For unknown reasons, these valves may be missing, or existing valves may break down. The blood pools in the veins of the testicle. The question is: Why does a varicocele cause infertility'?

Researchers theorize that the warm blood settling around the sperm production plant overheats the system. Yet every man who has a varicocele is not infertile. In fact, about 10 percent of all men have a varicocele, and no one knows how many ultimately become infertile. We do know, however, that 30 percent of men who are infertile have a varicocele.

The size of the varicocele seems to have no bearing on sperm count. A damaging varicocele may be so big that it bulges when a man stands up, or it may be so small that only highly sophisticated sound and heat measurements can find it. The latest thinking is that even a very small varicocele can severely damage sperm production. Fortunately, surgery can be performed to tie off the vein. Indeed, this is the most successful of all infertility treatments for men. After surgery, sperm counts improve in about 70 percent of all infertile men with varicocele. About half of them go on to become fathers.

As we have said, there are a multitude of other possible causes of male infertility. A few of the most prominent are described below.

Venereal Disease

With venereal disease on the increase, a key issue arises: How does infection affect infertility'? Will the man who has several bouts of gonorrhea wind up sterile?

Venereal disease and other infections are not nearly as dangerous to men as they are to women. The urethra, the only outside entrance into the male reproductive system, is extremely long in men. As the bacteria work their way along the tract, they are flushed back by intermittent streams of urine coursing down the urethra. Therefore, men are usually spared the devastating pelvic infections that destroy the reproductive organs of women.

Gonorrhea is so easily recognized that men usually seek treatment when they notice any unusual discharge from the penis. The discharge is an early warning sign from the urethra, and early treatment stops the infection from attacking the testicles. However, gonorrhea can sometimes clog up the tiny passageway of the epididymis and create an obstruction.

Another recognized source of infection in both men and women is an organism called chlamydia, which today surpasses gonorrhea as the leading cause of sexually transmitted disease in the United States. In men, chlamydia can infect the urinary tract and potentially reach the testicles. Typical symptoms of chlarnydia in men are easily confused with those of gonorrhea, but unfortunately the organism, which is difficult to culture, does not respond to the penicillin type treatment that so easily eradicates gonorrhea. Chlamydia can be eradicated only with a tetracycline class of antibiotic.

The true role of infection is still a broad area of research in the field of infertility. Infection does not usually hurt the sperm producing centers; the real threat is that it can be transmitted to women, in whom it may cause sterility. Many men unwittingly transfer symptomless diseases such as chlamydia to women during sexual intercourse. To prevent such transfers, even mild, innocuous infections of the male reproductive tract should be vigorously treated with antibiotics.

We are also learning that genital infections in men have other, more subtle effects. Many "unknown" causes of infertility may be the result of infectious by products. The so called antibody problem, for example, in which a man is mysteriously allergic to his own sperm, may be caused by a virus or by bacteria that lurk in the prostate gland or seminal vesicles.

Mumps

If mumps occurs during or after puberty, when reproductive cells are rapidly dividing, there is a substantial danger that the virus will attack the testicles. (Tuberculosis too can invade the testicles, but with the advent of modem antibiotics tuberculosis is rare today.) The mumps virus likes to invade lively cells. Once the virus reaches the testicles it has a devastating effect on the sperm production centers, invading the nucleus of the reproductive cells and multiplying until the cells burst.

If the virus is relatively mild, the testicles eventually recover. If the illness is severe, there is a good chance that the reproductive cells will be completely destroyed. If only one testicle is affected, however, the other one can take over the work load, and the man's sperm count will be normal.

Scrotal Injuries

The same kind of damage done by mumps can be caused by a kick in the scrotum. Men who play rough sports or ride motorcycles are extremely prone to scrotal injuries. Sometimes, for no particular reason, one testicle will twist on its own blood supply. This is called torsion. The testicle swells alarmingly and causes excruciating pain. The one thing not to do is put an ice pack on the testicle and wait for the swelling to subside. Any torsion or injury that causes pain and swelling in the scrotum needs emergency care by a urologist. Blood vessels that rupture inside the testicles must be quickly cauterized before internal bleeding scars the delicate microscopic tubules that make sperm. Scar tissue cuts off the blood supply, and the testicle shrivels up and dies.

Hormonal Disturbance

Sperm production, like ovulation in women, is governed by the hormonal system. The hypothalamus/pituitary control center drives the other gland systems in the body, including the testicles. Therefore, any disturbance of hormones produced in the control center or the testicles can cause problems. Because the male hormonal axis is a simpler mechanism than the female axis, problems occur less frequently. Only about 15 percent of all men seen in infertility clinics show a hormonal disturbance.

Chromosomal and Genetic Disorder

Men do occasionally inherit infertility, through either the genes or the chromosomes. A chromosomal abnormality is a defect in a whole chromosome, usually the X or Y sex chromosome. These abnormalities can be discovered only by performing a chromosomal analysis of the blood.

Chromosomal defects may occur spontaneously as the male fetus grows inside the mother's womb. Klinefelter's syndrome is an example of a spontaneous chromosomal flaw. In this syndrome a man is born with at least one extra X chromosome in each cell. Most often a man born with Klinefelter's will have very small and immature testicles, although occasionally all his physical characteristics will appear normal. But he will never produce offspring.

Genetic disorders are flaws in a small section of a chromosome, called a gene. These disorders are difficult to detect and sometimes can be identified only when they repeatedly appear in families.

Genetic and chromosomal disorders that affect sperm production, although rare, are extremely difficult to treat. Usually, sperm production is absent because sexual organs do not develop in puberty. Sometimes sex drive and other male sex characteristics can be stimulated with hormones, but usually there is no way to activate sperm production.

Tubal Blockage

Blockage in the ducts that carry sperm out of the testicles, through the prostate, and out the tip of the penis occurs in less than 10 percent of infertile men, thanks primarily to the difficulty infection has in penetrating the male reproductive tract, (Tubal blockage is a major cause of infertility in women.) When blockage does occur, it is almost always lodged in the tiny channel of the epididymis. High powered magnification has made possible surgical removal of obstructions in this tightly coiled, nearly invisible strand of tissue.

Sometimes a baby is born with his ductal system blocked. Such birth defects in men are becoming more common. A newly discovered chromosomal birth defect may be another cause of blocked tubes. In this disorder, as yet unnamed, cell linings of the tubes produce excessively thick secretions, plugging up the channels and blocking the pathway of sperm. Men who have this mucus disorder also suffer from blocked sinuses and bronchial tubes.

Sexual Problems

Even when a man makes good quality sperm and has a smooth and clear transport system, he still may have some trouble laying the sperm up against the mouth of the cervix. Most problems concerning sperm deposit fall into the realm of sexual technique.

Impotence is rarely more than a transient problem in young men. When a young man is impotent over a prolonged period of time, the problem is usually psychological. Real impotence can begin to occur after age fifty, and it may be either psychological or biological.

For a while, in response to the early stiffing of the women's movement, some sociologists and many drugstore philosophers argued that impotence would be the ailment of the 1980s. In other words, if women persisted in their quest for equal rights, all the penises in America would go limp en masse. Fortunately, in spite of the warnings, the women's movement went forward. And the incidence of impotence does not seem to be increasing.

One sexual problem occasionally seen in young men is premature ejaculation. A man's genitals are extremely sensitive to tactile sensations, and some men ejaculate the instant their penises touch the surface of a woman's vagina. Not only is this not gratifying to either partner, it fails to deposit sperm near the cervix.

Treatment, which includes both partners, involves behavior modification training. The idea is to reduce the heightened sensation little by little by touching other parts of the body. The couple begins touching outside of the bedroom, away from the conjugal bed. Eventually the exercises progress to genital touching and fondling, without intercourse. By using a squeeze technique (squeezing the penis when he feels he's about to ejaculate), the man learns to prolong the sexual plateau. Finally, when he is able to sustain an erection, the couple begins to have sexual intercourse.

There is one other deposit problem that we seldom associate with infertility. It occurs when a couple simply fails to have sex at the right time. Some couples misunderstand the ovulation cycle and actually avoid sex on the days the woman is ovulating. Finally, every once in a while we see a couple who has never consummated marriage in the usual way. When the woman is examined, her hymen is unbroken. Explaining the anatomical facts usually results in pregnancy.

In later chapters we will describe these and other causes of male infertility in detail, as if they occurred singularly and affected only one aspect of sperm production. But it's important to remember that most men with low sperm counts have several problems clustered together.

Stress

Stress has become the scapegoat for many illnesses. It is an ideal candidate for the job, since it's virtually impossible to list its components stress is different for everyone. How stressful a situation is depends on the perception of the individual. Driving a car at a high speed may be stressful for one person and stimulating for another. Because stress varies from person to person, it is extremely difficult to trace its effects in illness.

We do know how the body responds when the mind perceives stress: It shuts down the oxygen and blood supply to peripheral systems and gathers all its resources to vital organs, primarily the heart and brain. When such stress is constant, the deprived parts of the body begin to suffer. If we could take sperm counts of men on a battlefield we would probably find them to be extremely low. Modem battlefields can be almost anywhere behind the corporate desk or in the nuclear power plant, in the classroom or on the superhighway, sitting in the courtroom or traveling through outer space. And if the stress doesn't kill you, the air will.

Closely related to stress and population overload is an increasingly toxic environment. Even those remote places where we seek solitude and nature, the great desert basins of Utah and Nevada, are now reeking with invisible pollutants. We are routinely exposed to chemicals unheard of even twenty years ago. This is particularly true in certain occupations. It has been proved that halogenated hydrocarbons, used in the chemical and petroleum industries, carry a high risk of damage to the reproductive organs.

This life threatening trio population density, stress, and pollution could account for the ebb in sperm concentration. If the concentration continues to fall, population may be significantly reduced.

However, most researchers don't believe the dip in sperm concentration is responsible for the present infertility epidemic. They consider the dip a normal fluctuation. Technically speaking, a man is considered probably fertile today if his sperm count exceeds 60 million sperm per ejaculate, about half the original number established in the 1950s. This brings us to the third major discovery in infertility in this decade: The reduced levels of sperm could easily be a part of what researchers call " subfertility. "

In men infertility is a relative condition. At what point below 60 million sperm is a man infertile? Is a man ever truly infertile? Urologists will tell you that as long as a man produces some sperm, and as long as his wife is fertile, there is a chance they can conceive.

But what if a man's sperm count is 60 million per ejaculate or less, and his wife also has a problem that lessens her chances of pregnancy? Perhaps only one fallopian tube is open. Or perhaps she ovulates only six or seven times a year. She is not infertile, but neither is she completely fertile. There may be no such thing as "a little bit pregnant," but there definitely is such a thing as a little bit infertile. With other, more fertile partners, each person might easily achieve pregnancy. Together, they will have a great deal of trouble.

This recognition of a couple's combined subfertility has changed the face of both research and treatment in America. It also explains why minor problems, such as the dip in sperm concentration, can be crucial. As the sperm count slips a little lower, a man becomes a little bit more infertile. If his wife is spectacularly fertile, producing one or more eggs each month like clockwork, the lowered count may have absolutely no effect. But if she has even a slight dysfunction, they will have a serious fertility problem. In other words, any small problem can be very important in the context of the complete evaluation.

A fertility workup begins with all these thoughts in mind. The major idea today is that the couple must be treated as one. Although each partner requires separate evaluation by a specialist a gynecologist for the woman and an andrologist for the man the fertility team views them as one patient. The specialists try to improve overall physical conditions so that pregnancy has the optimum chance. When a couple is borderline infertile, even small things can make a difference.

Clearly, we still have many things to learn about infertility in men. Above all, we need the cooperation of the male partner, which is not always easy to come by, given the known resistance of men to seek medical help in general and to openly discuss infertility in particular. Infertility is perceived as a threat to masculinity. The recognition that infertility is, in most cases, unrelated to sexuality will hopefully encourage the male partner to participate in a complete medical evaluation when a couple is infertile. Only with such information can infertility clinics across the country accumulate enough data to one day neatly arrange what now seems to be a tangle of ailments called male infertility.