Why Men Should Be Evaluated Sooner in Infertility Cases

Infertility is not a woman’s problem. It’s a couple’s problem.

According to a historic World Health Organization study, 38 percent of infertility cases were due to female causes, yet 47 percent were due to either male or combined male and female causes. (The remaining 15 percent was undetermined.)

So why does infertility testing often involve only the female?

“Because females are usually the first to see their PCP or gynecologist when they can’t get pregnant,” says male infertility specialist Sarah Vij, MD. “In their 20s, women start building relationships with their physicians and having regular exams. Men often don’t.”

That’s cause for concern, says Dr. Vij. Not only can many male infertility conditions be diagnosed and treated, they can be a window to a man’s overall health.

Here Dr. Vij provides key points to guide primary care practitioners in their care of men facing fertility problems.

Q: When should a man be evaluated for infertility?

Dr. Vij: Couples — both the man and the woman — should be evaluated for infertility if they have not had a successful pregnancy after 12 months of timed intercourse. They should be evaluated sooner if there are infertility risk factors (see list below), if the female is over age 35, or if the couple desires.

For some couples, evaluating the male first makes sense. Male evaluation is relatively simple. Sometimes we see couples go through costly reproductive techniques, like in vitro fertilization, only to discover that the male had an easily treated condition.

Q: How should men be tested?

Dr. Vij: A PCP (or gynecologist) can order a semen analysis and then refer the patient to a urologist if results are abnormal. The urologist will do a detailed history and physical, which are the most critical parts of male infertility evaluation. Based on the history, physical and semen testing, the urologist may order endocrine or genetic testing as well, and possibly imaging of the testicles.

Q: What are possible causes of male infertility?

Dr. Vij: Up to 40 percent of men seeking evaluation for infertility have a varicocele, a disorder in which dilated veins in the scrotum affect the quantity and quality of sperm produced by the testes.

But a multitude of other environmental and medical factors can contribute, including:

• Diabetes and other endocrine disorders.
• High temperature. (A febrile illness can cause low sperm counts for up to three months. Regularly sitting in a hot tub or holding a warm laptop computer on your lap can have a similar effect.)
• Obesity.
• Sexually transmitted diseases.
• Epididymitis and prostatitis.
• Certain types of cancer and their treatments.
• Prolactinoma, a benign pituitary tumor that can suppress gonadotropins.
• Genetic or chromosomal abnormalities, such as Klinefelter syndrome.
• Congenital conditions, such as absence of the vas deferens.
• Undescended testicle in childhood.
• Cigarette smoking.
• Taking testosterone supplementation.

The list goes on. That’s why taking a man’s history — and involving a urologist — is so important.

Q: What treatments are available?

Dr. Vij: First are the lifestyle adjustments, such as smoking cessation if the patient is a smoker or weight loss if the patient is obese. I also counsel my patients on reproduction basics, such as strategic timing and not using lubricant.

Medical treatment can help some men with low sperm counts. We may try to manipulate the hormonal axis and stimulate the testicles to produce more sperm. Taking antioxidants may improve sperm health as well.

Finally, there are surgical approaches such as varicocele repair, testis biopsy and reconstructive procedures.

Q: How is infertility indicative of a man’s overall health?

Dr. Vij: Sometimes infertility is the first sign of a health condition, or the first reason that a man seeks medical care. Our evaluation may lead to a diagnosis of diabetes, hypogonadism or other endocrinopathies that can impact overall health.

Infertile men also have a higher risk of autoimmune disorders, such as rheumatoid arthritis, psoriasis, multiple sclerosis and Graves’ disease. Risk of testicular and prostate cancers is doubled in men with infertility.