Urology: Male Infertility
About 15 percent of couples are infertile. Gregory Bernstein, MD, FACS
of Washington Urology
, part of the Virginia Hospital Center Physician Group, has a special interest in treating male infertility. HealthReach spoke to him about the causes, diagnosis and treatment options for male infertility.
How do you define infertility?
The traditional definition of infertility is failure to achieve conception after 12 months of frequent, unprotected sexual intercourse. If the woman is 35 years of age or older, we tend to shorten that time frame to about six months.
How common is male infertility?
When couples undergo fertility evaluation, there is a male factor about 40 percent of the time and, equally, a female factor about 40 percent of the time. In another 10 percent of couples, infertility is due to a combination of both male and female factors; in the final 10 percent, the cause is unknown. My recommendation to couples is that if they’ve been trying unsuccessfully to conceive, both the man and the woman should undergo fertility testing.
What causes male infertility?
There can be many causes, but a common cause of male infertility is a varicocele, a dilation (enlargement) of veins on the left side of the scrotum. A varicocele may cause an increased temperature in the scrotum, which can lead to impaired sperm production. During a male evaluation for infertility, I will sometimes identify other risk factors such as hormonal deficiencies that can impact sperm production; cigarette smoking, which can lead to decreased motility of the sperm from the nicotine; or genetic irregularities that can alter sperm production.
How is it diagnosed?
The initial workup for male infertility involves a comprehensive medical history, a general physical exam, and a semen analysis. The semen analysis is critical to the evaluation and, to be accurate, the semen analysis should be provided after a period of abstinence from ejaculation for 48-72 hours. If the semen analysis and physical exam are normal, then we typically do not do any further testing. If there are abnormalities in the semen analysis, I will request a second semen analysis as well as initiate a hormonal evaluation. If those results are abnormal, we look for a medical cause. For example, an abnormal hormonal evaluation could indicate that the body is not producing enough testosterone or the pituitary is underfunctioning, thus failing to stimulate sperm production.
What are the treatments?
They vary depending on the cause. For a varicocele, the treatment is an outpatient surgical procedure to fix the varicocele. If decreased sperm production is due to a hormonal cause, we can give medication to stimulate more sperm production. Some patients have had a previous vasectomy, which obstructs the flow of sperm, and now they want to have additional children. I perform an outpatient surgery to reconnect the vas deferens, the tube through which the sperm flow, in order to restore fertility.
A diagnosis of infertility can be very emotional for a couple. How do you counsel your patients?
I encourage couples to go through fertility evaluation as a team and avoid placing blame or fingerpointing. It is important for each individual to have a thorough medical evaluation. As fertility can sometimes be very stressful, in some situations I may suggest that my patients see a therapist or counselor who works with couples going through fertility evaluation.
When should a man go see a urologist to be tested?
That’s a personal decision, really. Some of my patients come see me before even trying to conceive. They’ll say, “We’re starting to think about having kids and I want to come in and get checked out beforehand.” Others have been trying to get pregnant and want to undergo evaluation to rule out male-factor infertility.