Comprehensive evaluation of the MALE

With 50% of difficulty with conception being related to the male and up to 35% of couples having more than one problem, the male work-up is equally as important as the female. Prior to any evaluation, a complete medical history and review of any pertinent medical records is essential. Unfortunately, in the case of male infertility, only 10% of the time, a cause can be identified and most of the time the only indication of a problem is an abnormal semen analysis. In most cases, you are dealing with a normal healthy male whose only problem is poor "sperm parameters". Besides a complete semen analysis, a thorough medical history is essential. About 10% of the time an abnormal semen analysis (SA) can result from:

1. Previous history of an undescended testicle(s).
2. Family history of cystic fibrosis
3. Any bladder surgery as a child
4. Hernia surgery as a child
5. Certain infections like mumps, epididymitis, urethritis and/or prostatitis
6. Severe trauma to the testicles
7. Alcohol use
8. Marijuana use
9. Certain medications
10. High fever 3 months prior to the SA
11. Varicocele
12. Congenital absence of the vas deferens
13. Exposure to certain chemicals and toxins
14. Anabolic steroid (testosterone) and/or human growth hormone (hGH) use

Besides doing a complete semen analysis using Krueger's strict morphology testing and a thorough medical history, hormone testing and urologic examination may be beneficial. It is important to ask the man if he is using alcohol or marijuana, taking any medications, including steroids and/or hGH, has had any surgery, infection in the testicles (mumps), undescended testicle(s), significant trauma to the genital area and whether or not he has normal sex drive (decreased sex drive may be a sign of elevated prolactin or TSH levels.

Hormone testing would initially include FSH, LH, testosterone, estrogen and prolactin. Urologic examination can identify a varicocele (dilated veins in the scrotum), hydrocele (fluid filled sac in the testicles), smaller an average testicles or the absence of the vas deferens (the tube connecting the testicles to the penis).

An abnormal semen analysis either show oligospermia - decreased numbers of sperm; a zoospermia - the absence of sperm but the presence of semen; aspermia - the absence of sperm and semen; asthenospermia - increase amount of non motile sperm; or teratospermia-increase amount of morphological abnormal sperm. If no sperm are found on the SA,and the FSH level is normal or only slightly elevated, 40+% of the time, enough spermare found on a testicular to use for IVF (ICSI, MESA/TESA) and donor sperm does not have to be used.

It has been the experience at ACFS, that even if a varicocele is diagnosed on a physical examination and surgery recommended, contrary to some opinions, we have seen little to no improvement in pregnancy rates, although there can be some change in sperm parameters. Therefore, ACFS does not recommend varicocele repairs.

Some clinics will recommend the use of fertility medication, mainly Clomid, in men with poor sperm counts. Again, it has been the experience at ACFS, that these medications show little to no improvement in sperm parameters and statistically do not improve pregnancy rates. However, there will be a small percentage of men that may respond to drug treatment and should be given the option of whether or not they want to try the medication. It takes about 75 days to make new sperm and about 15-26 days for those sperm to gain motility and fertilizing ability; therefore, treatment has to be continued for at least 3 months to see if there is any improvement and then continued if there is. Most men do not want to wait this long for a very small chance that there will be a significant improvement in their sperm parameters that could result in a successful pregnancy.

If the man drinks alcohol and/or uses marijuana, there is direct evidence that either can effect spermatogenesis or the production, motility and morphology of the sperm. Although there is no guarantee that completely stopping alcohol and/or marijuana will improve spermatogenesis, there is clear evidence that it "could" be beneficial and the strong recommendation at ACFS is to stop completely, not cut down. It is impossible in any individual to determine "how much is too much or how little is okay". There is no question that anabolic steroids (testosterone) and/or human growth hormone (hGH) use severely effect sperm parameters, and in many cases, sperm counts fall close to zero or zero.

Let's put to rest, once and for all some popular myths - that tight underwear, as opposed to boxer shorts, hot tubs and too much sex cause male infertility. THEY DO NOT.

"Bottom line in male infertility, except in a few isolated situations, that the worse the sperm parameters, the closer you need to get the sperm to the egg. Sorry guys, but it is all about the egg".

It is an established fact that you need a certain of amount of total motile normal sperm (TMNS) to get the job done. The thinking that it only takes one is only partially true. Sure, it takes one to fertilize an egg, but it takes millions to get the job done. The following is meant to be a guide to the amount of TMNS needed to be have a successful pregnancy:

Intercourse	100's of million of TMNS
IUI	Greater than or equal to 5 million TMNS
IVF	250-300,000 TMNS if fertilizing in the dish
ICSI	1 sperm per egg
Donor sperm	None

Anything less than these numbers for each category of treatment will most likely result in that treatment option being unsuccessful.

To calculate this number use the following formula - multiple the total volume of sperm in cc by the total number of sperm reported; than multiply that by the percentage of the normal motility (a report of 50% motility would be by .50); than multiply that number by the percentage of the normal morphology (a report of 9% morphology would be by .09); and divide the resulting number by 1/2 for the amount of sperm that are lost in the vagina/cervix or after sperm washing for insemination. The resulting total will be the total motile normal sperm (TMNS) count.

Here is an example of how to figure out your partner's TMNS count from this sample SA:

Volume	2.4 cc
Numbers	34 million/cc
Motility	47%
Normal	6%

To calculate TMNS count: 2.4 x 34 = 81.6 x .47 = 38.352 x .06 = 2.30 divided by 1/2= 1.15

The TMNS count is 1.15 million total motile normal sperm.