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Male Factor Infertility in the Era of Assisted Reproduction
It is predicted that about 15% of couples will have difficulty achieving their first pregnancy. A common misconception about infertility is that it is a woman’s problem. Despite the fact that a fertility evaluation is often initiated by the female partner, infertility affects men and women equally. In fact, roughly one third of the causes of infertility are due to male factors, one third due to female factors and one third is due to combined male and female factor or unexplained.
Historically, the approach to the infertile couple has started with an evaluation of the female with a limited evaluation of the male partner by a reproductive endocrinologist. A recent study showed that only 41% of Ob/Gyn physicians considered a urological evaluation of men necessary and only 24% routinely refer men to the urologist before ordering a semen analysis. Indeed, is it really necessary to evaluate the male patient given the availability of IVF with Intra-cytoplasmic sperm injection (ICSI)?
The Importance of Evaluating the Male Partner
Yes! Evaluation of the male partner is essential for the diagnosis and timely treatment of specific causes of male factor infertility. Even men with proven fertility in the past may develop new problems. In many cases such treatment alone may result in a successful natural pregnancy. Another compelling reason is the patient’s overall health.
Male infertility sometimes is the only initial symptom of significant medical problems such as brain tumors, thyroid gland disease, diabetes, multiple sclerosis, and genetic diseases. There has been a growing concern that infertility may actually be a forerunner to the testicular cancer since it is more common in infertile men than in the general population. Integration of testicular cancer screenings into the routine evaluation of infertile men has been strongly suggested.
Screening semen analysis alone is not diagnostic for these medical problems. Therefore, abnormal semen analysis should not be the only indication for the evaluation of male patients. For the most comprehensive results, men should receive a complete evaluation by a physician specializing in male infertility.
The Importance of Diagnostic Testing
The identification of genetic conditions has important implications not only for the infertile couple, but also for their offspring. As an example, if both male and female partners are carriers of the cystic fibrosis gene, they must be counseled regarding the possibility of having a cystic fibrosis–affected child. However, genetic testing of infertile couples is not performed routinely. Alternatively, a simple physical examination of the male partner may reveal the absence of the vas deferens, which is linked to the mutation of the cystic fibrosis gene. This finding requires prompt genetic testing of both partners.
Detection of the problem causing male infertility and its specific treatment is possible in many cases. It can help a couple to get pregnant through normal sexual intercourse. Future pregnancy can also be achieved naturally without any additional treatment. New data indicate that the treatment of male factor, even if unsuccessful by itself, may improve the outcome of assisted reproduction in select couples.
However, most couples have a limited understanding of the abnormalities associated with male factor infertility. While it is difficult to establish the superiority of one treatment choice over another, it is important to educate patients about their reproductive treatment choices.
Evaluation of infertile men must be performed by a urologist with a special interest in male infertility. The reason for this is that new diagnostic and treatment methods including technically challenging sperm retrieval procedures require special training and expertise in this rapidly evolving field.
Presently, only 6.2-13.2% of fertility clinics have a male infertility specialist as a part of their team. Ask your doctor for a referral to a urologist/ male infertility specialist so both partners will have a necessary and timely diagnostic work-up before beginning any treatment for infertility.