Male Factor Infertility

Evaluation will assess the status of male sperm as well as the male reproductive history and lifestyle. An evaluation for habits such as hot tub use, medications being taken or exposures to organic chemicals are examples of the information we gather in the male fertility evaluation.

Evaluating male sperm

A sperm analysis can provide a lot of answers to a couple experiencing fertility struggles. This test measures four properties of a sperm sample, each of which is important to egg fertilization and conception.

  • Semen Volume : The amount of the ejaculate produced. Low semen volume could also be due to retrograde ejaculation, where the ejaculated sperm is entering the bladder rather than exiting the urethra.

  • Sperm Count : A normal sperm count ranges from 15 million sperm to more than 200 million sperm per milliliter (mL) of semen. Anything less than 15 million sperm per milliliter, or 39 million sperm per ejaculate, is considered low. A lower than normal sperm count can indicate blockage of the seminal vesicles, where seminal fluid is produced.

  • Motility : This is the percentage of sperm in the sample that is alive and exhibiting healthy, forward movement. This quality is vital to enabling the sperm to unite with the egg in the fallopian tube.

  • Morphology : This refers to the percentage of normally shaped sperm – an aspect that can indicate whether the sperm has developed or 'matured' properly in the testicle. Poorly developed sperm may be unable to fertilize the female egg.

Urologic Examination

If necessary, the male partner may be advised to receive a urological exam, as well as more specific sperm testing and evaluation of hormone levels. If a male partner is thought to have a sperm abnormality, we will recommend that he receive an exam from a urologist – a physician who focuses on the male urinary tract and reproductive organs. A urologist who specializes in andrology will have further expertise with the male reproductive system.

A urology exam will include:

  • Assessment of kidney and bladder function to rule out infection or other problems

  • Examination of testicles. Small size may be associated low hormone levels, which impact sperm development.

  • Examination for a varicocele. A varicocele or dilated vein in the scrotum can overheat the testes, negatively impacting sperm production and quality.

A problematic semen analysis is often the result of defects in the male reproductive anatomy, which can sometimes be successfully addressed through surgery, medications or laboratory procedures. A genetic evaluation for chromosomes or DNA deletions in a specific area of the Y chromosome are sometimes recommended, especially for men with very low sperm counts or no sperm in the ejaculate (azoospermia).

Diagnosis and Treatment of Male Factor Infertility


A variety of conditions may block potentially normal sperm from traveling from the testes to the ejaculate:

  • Obstruction in the vas deferens, or any of the other 'collecting tubes' that gather sperm from the testes may be a congenital condition, existing from birth

  • Congenital Absence of the Vas Deferens (Obstructive Azoospermia) in which there is normal testicular sperm production, but no sperm in the ejaculate

  • Vasectomy, an intentional contraceptive 'surgical obstruction' in which the vas deferens from each testicle is clamped shut, preventing sperm from reaching semen

  • Obstruction may be caused by infection of the epididymis, the part of the anatomy that stores, matures and transports sperm between the vas deferens and the testes

Treating obstructions

Surgical treatment such as vasectomy reversal or cytoscopy, using a thin lighted instrument to clear a blocked ejaculatory duct, may clear a pathway for sperm.

Other successful treatments for male factor infertility involve a simple needle aspiration procedure (percutaneous epididymal sperm aspiration or PESA) that will often yield enough sperm to achieve fertilization with IVF, although usually just enough for one IVF cycle. Alternatively, a MESA (microsurgical epididymal sperm aspiration) surgery may be performed, yielding many vials of usable sperm.

When working with low sperm numbers, whether in the ejaculate or obtained by needle aspiration or biopsy, we consider the ideal treatment to be in vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI), a laboratory procedure in which individual sperm are injected into an egg, optimizing the opportunity for fertilization. [Learn more) about IVF with ICSI.


A varicocele is a version of a varicose vein in the scrotum. Due to an otherwise harmless, anatomical flaw in the veins which circulate blood to and from the testicles, blood flow becomes backed up and veins become enlarged and elongated. The blood carried in these veins may elevate the scrotal temperature negatively affecting sperm production.

Treating varicocele

Varicocele may be treated by tying off or ligating the abnormally dilated veins. This surgery seems to be most effective in men whose varicocele is of significant size. In this surgery, about two thirds of patients will see some improvement in the sperm quality. IVF may also be recommended in this situation.

Non-obstructive Azoospermia

Men with very poor sperm production in the testicles and no sperm in the ejaculate often demonstrate high blood FSH levels and, at times, low testosterone levels. Small testicles and testicular failure are also common. Testicular biopsy or testicular mapping are diagnostic procedures that evaluate the extent of male factor infertility by determining if any sperm are being produced at all in the testicles.

Treating non-obstructive Azoospermia

Assuming that the biopsy or mapping have determined that testicular sperm are present, this condition is treated with TESE, or testicular biopsy. Infertility treatment, in which a small sample of tissue from one or both testicles is taken to harvest the sperm for IVF with ICSI treatment. Depending on the amount of sperm obtained, this treatment can be successful.

Unexplained low sperm count

If there is a mild decrease in the male partner's sperm count or motility, a urologist may prescribe Clomid, an infertility pill commonly used to treat women who fail to ovulate. Clomid can stimulate the hormones responsible for sperm production. Sperm counts are re-analyzed 3-6 months after medication is started to evaluate any improvement in sperm production.

Sertoli Cell Only Syndrome

In this rare male factor infertility condition, there is a complete absence of the cells that create sperm. For those seeking pregnancy, sperm donation is the only recommended option.

Surgical Sperm Retrieval

Sperm retrieval is done when pregnancy is the goal but not possible without help. It is for men who don’t have sperms in the semen, or men who aren't able to ejaculate. In these cases, sperm can be collected from other parts of the reproductive tract.

Sperm harvesting is entirely different from a diagnostic testicular biopsy because, in this setting, the goal is not to identify what is happening in the testis but instead it is to find sperm. Only men with no sperm in their ejaculate (azoospermia) need to have sperm retrieved directly from the testis or epididymis.

Surgical-Sperm Retrival

This may involve a simple aspiration for men who have a blockage or require much more extensive sampling of the testis for men who have a sperm production problem. As a result, there is a significant difference in the amount of time it takes, the need for anaesthesia and the equipment utilized.

Simple sperm retrievals are usually performed on the day of egg retrieval. Simple sperm retrievals are procedures performed in men with a known obstruction who make sperm without a problem.

There are many ways to get sperm from the reproductive tract. The goal is to get the best quality and number of sperm. Care is taken not to harm the reproductive tract. This will allow future sperm retrieval or reconstruction, if needed.

Some of these procedures are :

Percutaneous Epididymal Sperm Aspiration (PESA)

It is a short, relatively painless procedure and requires no surgical incision. It is the least invasive method and involves inserting a fine needle into the epididymis, from which fluid is aspirated. This fluid is then inspected immediately by embryologists under a microscope for sperm content and motility. The procedure takes about 20-30 minutes.

Testicular Sperm Aspiration (TESA)

A fine needle is used with a biopsy gun to remove small lengths of seminiferous tubule (sperm producing tubules). These are then carefully dissected under a microscope by embryologists.

Micro-epididymal Sperm Aspiration (MESA)

Instead of using a needle in PESA, a small cut is made through the scrotum and into the epididymis. Fluid is collected under microscope and taken for microscopic examination by embryologists to see if there is any viable sperm.

Testicular Sperm Extraction (Open conventional TESE)

If no sperm is found in PESA, TESA or MESA, TESE will be performed. There are two ways of performing TESE procedure

Single biopsy

If the hormone level and testicular size is normal then a small incision is made into the testis itself. A small sample of testicular tissue is taken which is then examined for sperm. Stitches are applied that are dissolvable and so will not need to be removed. Pain relief is given in the form of local anaesthetic and nerve block to the genital region.

Open scrotal exploration and multifocal testicular biopsies

This involves performing a midline or horizontal incision on the scrotal skin. Three to four biopsies are taken from each testicle in different areas. Stitches are applied that are dissolvable and so will not need to be removed. Pain relief is given in the form of local anaesthetic and nerve block to the genital region. This provides pain relief for 15-16 hours. This procedure will cause some pain and tenderness afterwards, however full recovery is expected within a few days. Samples are passed to the laboratories where an embryologist checks it for sperm suitable for use in further treatment.

Recovery after testicular or epididymal sperm retrieval depends on the method used. Recovery time can range from a few days to a week.

Most men will be told to avoid strenuous activity. Ice packs help right after the surgery. Your Andrologist will prescribe medicine to help with pain. You may also be given antibiotics to take before and/or after sperm retrieval to lower the risk of infection. If you have stitches, you will need more time to heal. Most men can return to office work in 24 to 48 hours. It may take 5 to 10 days to return to heavy work.

Possible problems can include :

  • Bleeding
  • Infection
  • Pain
  • The chance of not finding sperm
  • The need for future procedures
  • Testicular injury or loss (these are rare)

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