The Physicians at Pacific Urology are specialists in the evaluation, treatment and management of all aspects of male infertility. If a couple is having difficulty in achieving a pregnancy, we can evaluate the male partner, while the female partner is evaluated by her gynecologist.
Male infertility issues generally centers around several issues: low sperm counts, abnormal semen parameters (such as sperm motility issues or abnormally shaped sperm), abnormal male hormones, and “zero sperm counts” (azoospermia). When you are seen by a Pacific Urology Infertility Specialist, you will be given a very extensive questionnaire to fill out, which will help to determine the cause of the infertility. Below is a list of some of the more common causes of male infertility:
- Varicocele (varicose veins in the scrotum)
- Infection (prostatitis, epididimitis, orchitis, TB)
- Injury (trauma, torsion)
- Chemotherapy or exposure to high doses of Radiation
- Undescended testicle (cryptorchidism)
- Obstructed sperm transport system (Vasectomy, epididimitis, congenital, TB)
- Chromosomal abnormalities (Cystic Fibrosis, Sickle Cell Disease)
- Hormonal imbalance (disorder of the hypothalamic-pituitary-testicular axis)
- Exposure to toxins (pesticides, certain medications)
- High fever
- Testicular Cancer
A physical exam will be performed and semen analyses reviewed. Usually a battery of blood tests will be obtained to assess general health, male hormone levels, and Pituitary hormone levels. In some situations, a biopsy of the testicles will be recommended. Specific treatment recommendations will then be discussed.
Low Sperm Counts (Oligospermia)
There can be many causes for a low sperm count. Causes include Varicocele (see below), environmental factors, hormonal factors, drug related factors, and use of dietary supplements, just to name a few. The Infertility Questionnaire that you fill out will help to determine if there are any reversible causes for the low sperm count. A physical exam, blood tests and sometimes other tests are required to find the cause. Once the cause is identified, treatment can be directed specifically to your particular problem. Treatment success rates certainly vary depending on the underlying cause.
If there is no identifiable cause, the problem may be congenital. Biopsy of the testicles is sometimes indicated to determine the cause. If there is no medical treatment which can be offered, then couples are referred for Assisted Reproductive Techniques, such as in vitro fertilization (IVF) or Intracytoplasmic Sperm Injection (ICSI).
Varicocele Repair (Varicocelectomy)
The most common cause of male infertility is a Varicocele, or dilated veins in the scrotum next to the testicle. When males with infertility are examined, 40% are found to have a Varicocele as the cause of their infertility. Patients with Varicocele, often have low sperm counts, low sperm mobility, and abnormally formed sperm. Fortunately, fixing the Varicocele (Varicocelectomy) is associated with an improvement in semen parameters and improved pregnancy rates in many patients. Our urologist can advise you if you are a good candidate for Varicocelectomy.
Varicocelectomy is an outpatient procedure, usually performed in a surgery center. It involves a small incision in the groin area, were the enlarged veins are tied. Optical magnification or the operating microscope are often utilized in order to achieve optimum results. Whenever an incision is made, there will be some discomfort, and there will be a period of recuperation lasting up to one month.
Another method of Varicocele repair involves fixing the enlarged veins laparoscopically. This method involves placing a small camera through the belly button and placing small instruments through small openings in the abdomen in order to tie the offending veins. Laparoscopic Varicocelectomy is more invasive than the groin incision approach, but there is less pain and quicker return to normal activity, usually a few days. Laparoscopic Varicocelectomy is more expensive than the groin approach, and is usually performed in the hospital under general anesthesia, rather than in a Surgery Center. It can involve an overnight stay in the hospital. The laparoscopic approach is best suited for patients who need bilateral (right and left side) varicocele repair. Lastly, a varicocele can be treated in the Radiology Suite of the hospital, under local anesthesia. The Interventional Radiologist places a wire up the main leg vein, all the way into the enlarged varicocele, and places an occluding coil in the vein to stop the flow. This is an outpatient procedure, with minimal discomfort, and patients can return to normal activity the next day. However, it is the most expensive approach and has a 10% failure rate. Many insurance plans have limited or no infertility coverage, so cost often becomes a factor for patients to consider when they select a particular treatment. Your urologist will help you to make this decision.
Zero Sperm Count (Azoospermia)
Some men are found to have a zero sperm count (azoospermia). Men with azoospermia are divided into two separate categories: Obstructive Azoospermia and non-Obstructive Azoospermia. Appropriate tests will be determined to determine which group each patient falls into, so they can be treated appropriately. Blood tests are very helpful in determining if the cause is Obstructive or Non-Obstructive Azoospermia. A testicle biopsy is needed to make a definitive diagnosis.
In men with Obstructive Azoospermia, the testicle is making sperm normally, but there is a blockage in the sperm transport system, so that no sperm appear in the semen. A vasectomy is an example of obstructive azoospermia, but there are many other causes. For many cases of obstructive azoospermia, the cause of the obstruction can be identified and repaired, using microsurgical techniques or endoscopic techniques. If it cannot be repaired, sperm can be removed directly form the testicle and used for Intracytoplasmic Sperm Injection (ICSI). The methods to obtain sperm include Microepididimal Sperm Aspiration (MESA), Percutaneous Epididimal Sperm Aspiration (PESA), Testicular Sperm Aspiration (TESA), Testes Biopsy, and Extended Testes Biopsy.
ICSI is an advanced reproductive technique where sperm are obtained from the man and injected directly into the women’s egg (one sperm injected into each egg) to achieve fertilization. The fertilized egg is then placed directly into the women’s uterus in order to achieve a pregnancy. Currently the success rate for ICSI is about 45% per attempt. The fertility specialists at Pacific Urology can give you a lot more information about your situation and discuss all the treatment options.
For patients with non-obstructive azoospermia, the task of the urologist is to determine the cause and find out is there are treatment options. Sometimes the testicle is not making sperm, and there is nothing that can be done. Sometimes there is a hormonal imbalance which can be treated. Sometimes, even when the sperm count is zero, we can still find a few sperm for Intracytoplasmic Sperm Injection (ICSI).
The urologist can determine the cause and advise you of your options. Contact us to schedule an appointment with one of our board certified urologists.