Male Infertility – Treatment
Protocols · Male infertility · Treatment
Male infertility treatment: treat the cause first, operate when it helps, and keep assisted reproduction for when it is really needed
Male infertility is treated by treating what causes it. For the men we see that most often means clearing a chronic infection of the prostate, seminal vesicles and epididymis, correcting a varicocele, or restoring the hormones that drive the testicle, and the semen improves when that is done. Surgery can bypass an obstruction, and when sperm production is too low for a natural pregnancy, sperm can be retrieved from the epididymis or testicle for ICSI. This page sets out the options in the order we use them, what each achieves, and how long it takes, so that you can see where IVF belongs: at the end of the list, not the beginning.
Treatment at a glance
What decides the treatment
Three things: the cause we found in the work-up, how long the man has had the problem, and his age and his partner’s. A 28-year-old with white cells in his semen and an inflamed prostate on ultrasound needs the infection treated and nothing else. A 42-year-old with a 38-year-old partner, a large varicocele and a count of two million needs the varicocele corrected and, in parallel, a plan for ICSI, because time matters. The partner is examined at the same time, because infertility belongs to the couple: a chronic, almost silent urogenital infection in the woman, a cystitis, vaginitis or endometritis that nobody cultured, often has to be treated before a weakened semen can fertilise at all.
Most of the men who come to us have already been offered IVF. We ask them to wait three to six months, while we treat what we have found. In the large majority of men whose problem is an infection or a varicocele, the semen improves enough to try naturally, and many of those couples conceive without any assisted reproduction. Where IVF or ICSI is still needed, it works better with healthy sperm. Nothing is lost by treating first; a great deal is lost by skipping it.
A. Treating the cause
A1. Chronic prostatitis and genital tract infection
This is the commonest cause of infertility in the men we see and the one with the clearest reward. The prostate is the reservoir; the seminal vesicles and the epididymis are infected from it. We treat it with the Georgiadis protocol: cultures to identify every organism, antibiotics delivered into the gland where oral treatment cannot reach, drainage of the infected ducts and the seminal vesicles, and the partner treated at the same time so the couple do not pass the infection back and forth. As the inflammation clears, the white cells disappear from the semen, the volume and liquefaction return to normal, and the count, motility and morphology recover over the following months. Even a man with very few sperm often reaches a count that allows a natural pregnancy.
A2. Hormonal disorders
A small minority of men have a hormonal cause, and they do very well. When the pituitary is not driving the testicles (low FSH, LH and testosterone), injections of hCG, with FSH if needed, restart sperm production within months. High prolactin from a pituitary adenoma is treated with tablets that shrink it. Thyroid disorders are corrected. Men who have taken testosterone or anabolic steroids stop them, and their own production is restarted with hCG and clomiphene. What a man who wants children must never be given is testosterone itself, which switches the testicles off.
A3. Metabolic and general health
Poorly controlled diabetes, high cholesterol and triglycerides, high uric acid, obesity and thyroid disease all lower sperm quality, through heat, oxidative stress and hormonal imbalance. Bringing them under control, with the man’s physician, often improves the semen analysis on its own and always improves the response to the other treatments. Medicines that damage sperm, from some antidepressants and antihypertensives to anti-ulcer drugs, are reviewed and replaced where possible.
B. Treating sexual problems
A couple cannot conceive naturally if intercourse is infrequent, incomplete or impossible. Erectile dysfunction, premature ejaculation, low libido and pain during intercourse are all treatable, and in the men we see they very often share a cause with the poor semen: an inflamed prostate pressing on the nerves and vessels beside it, or low testosterone. Treating the prostate improves erections and ejaculatory control as well as the semen; the remaining problems are treated on their own terms, as described on our sexual dysfunction pages. Timing intercourse to the fertile window, every one to two days around ovulation, costs nothing and is often neglected.
C. Surgery
C1. Varicocele repair
A varicocele is the second commonest cause of infertility in young men, after chronic prostatitis, and the two often coexist, so we culture and treat any infection first. When the varicocele is palpable, the semen analysis abnormal and no other cause remains, microsurgical varicocelectomy improves the count and motility in about two thirds of men and roughly doubles the chance of a natural pregnancy. It is a short operation through a 3 cm incision in the groin, under the microscope, with a day or two off work.
C2. Reconnecting a blocked epididymis or vas
When sperm are being made but cannot get out because the epididymis or the vas deferens is blocked, by scarring after infection, by a childhood hernia operation or by a vasectomy, the block can be bypassed microsurgically: vasovasostomy joins the two ends of the vas, vasoepididymostomy joins the vas directly to the epididymis above the block. Sperm return to the semen in most men, and a natural pregnancy becomes possible again.
C3. Opening the ejaculatory ducts
Stones, cysts or scarring at the ejaculatory ducts, where the seminal vesicles and vas empty into the urethra, cause a low-volume semen with few or no sperm. The ducts can be opened through the urethra (transurethral resection of the ejaculatory ducts), restoring the flow of semen. Infection of the seminal vesicles behind the obstruction must be treated at the same time or the ducts block again.
D. Supporting the semen
Antioxidants, vitamins and lifestyle
Once the cause is being treated, the recovering seminiferous epithelium can be helped: antioxidants such as vitamins C and E, coenzyme Q10, L-carnitine, zinc, selenium and folate for three to six months reduce oxidative damage and DNA fragmentation. Stopping smoking, cutting alcohol, losing weight, avoiding saunas, hot baths and long hours of sitting, and loose underwear all raise the count measurably. None of these replaces treating the cause; all of them improve the result.
Retrograde ejaculation and absent emission
When semen flows backwards into the bladder, medicines that tighten the bladder neck restore forward ejaculation in some men; in the rest, sperm are recovered from urine passed after orgasm, after the urine has been made alkaline, and used for insemination or ICSI. When emission is absent after spinal injury or nerve damage, vibratory stimulation or electroejaculation produce semen, or sperm are retrieved from the testicle.
E. Assisted reproduction
Intrauterine insemination (IUI)
Washed, concentrated sperm are placed in the uterus at ovulation. Useful with a mildly reduced count or motility, or sexual problems, once the semen is free of infection.
In vitro fertilisation (IVF)
Eggs are collected and mixed with the sperm in the laboratory; the resulting embryo is placed in the uterus. Needs a reasonable number of motile sperm.
ICSI
A single sperm is injected directly into each egg. Makes a pregnancy possible with very few sperm, with immotile sperm, or with sperm retrieved surgically from the epididymis or testicle.
These are powerful tools and we refer couples for them when they are needed: when the cause cannot be corrected, when the count stays very low after treatment, when the woman’s age makes waiting unwise, or when there is a female factor as well. What they are not is a substitute for treatment. A urogenital infection in either partner lowers the success of every cycle, and the sperm that goes into the laboratory should be the best the man can produce. In the right order, treatment first, assisted reproduction second, many couples never reach the second step, and those who do have a better chance.
F. Surgical sperm retrieval for azoospermia
When there are no sperm in the ejaculate, either because the ducts are blocked (obstructive azoospermia) or because the testicle produces very few (non-obstructive azoospermia), sperm can usually still be found in the epididymis or the testicle and used for ICSI. The aims are to retrieve sperm of the best possible quality, in sufficient numbers for the immediate attempt and for freezing for later ones, with the least possible damage to the testicle, so that future retrievals or a later reconstruction remain possible. The technique is chosen accordingly.
TESA: fine-needle aspiration of the testicle
A fine 21 to 23 gauge needle on a 20 ml syringe draws tissue and sperm from the testicle through the skin, under local anaesthesia. No incision, no microsurgical equipment, no significant discomfort afterwards. Suitable for obstructive azoospermia, where sperm production is normal.
PESA: percutaneous epididymal sperm aspiration
A fine butterfly needle is passed through the skin into the head of the epididymis and fluid rich in sperm is aspirated, repeatedly if needed, under local or general anaesthesia. Quick and painless, with no microsurgical equipment, and successful in about four men in five with obstructive azoospermia; the sample usually contains some red cells.
Percutaneous testicular biopsy
A spring-loaded 14 to 16 gauge biopsy needle takes cores of testicular tissue about 1 cm long, under local anaesthesia, for both diagnosis and sperm retrieval. More tissue than TESA, still without an incision.
MESA: microsurgical epididymal sperm aspiration
Under the operating microscope the head of the epididymis is opened and its tubules isolated one by one; each is punctured with a very fine glass pipette and its contents aspirated. It retrieves large numbers of sperm from the epididymis, free of red cells, which gives better fertilisation in ICSI than PESA and plenty of sperm to freeze. Our method of choice when the obstruction cannot be repaired.
TESE: testicular sperm extraction
Through a small incision in the scrotum, the tunica of the testicle is opened and sizeable samples of tissue are taken to maximise the chance of finding sperm in non-obstructive azoospermia. The larger the samples, the more vessels are injured, so care is needed to take enough tissue without damaging the testicle.
Micro-TESE: microsurgical testicular sperm extraction
TESE under the microscope, at 20 to 25 times magnification. The vessels on the surface of the testicle are seen and avoided, and the tubules that contain sperm, which are wider and more opaque, can be distinguished from the thin, sclerosed ones that do not, so that far more sperm are found in far less tissue. In men with non-obstructive azoospermia sperm are found in roughly six out of ten, with fertilisation rates above 60% in ICSI. It is the method of choice for non-obstructive azoospermia.
How long it takes, and what to expect
Sperm take about 74 days to be made and another two weeks to mature in the epididymis, so no treatment changes the semen analysis in less than three months. We repeat the analysis three months after treatment begins and again at six, and we look for the right things in the right order: first the white cells and the volume and liquefaction normalise, then the motility improves, then the count rises, and the morphology last. Where a varicocele has been corrected, the improvement continues for a year. Where hormones are being restarted, it can take six to twelve months. Couples are encouraged to keep trying throughout; many conceive before the “final” result is in.
Male infertility is today a major factor in the failure to conceive, and in the large majority of men it has a cause that can be found and treated. Chronic urogenital infection, above all chronic prostatitis, and varicocele account for most of the men with poor semen quality, and even a very low count often recovers enough after proper treatment to allow a natural pregnancy. The chronic urogenital infections of the partner have at least as much impact on conception and on the course of the pregnancy, and treating them gives consistently good results. Finding and treating the causes in both partners gives the best chance of restoring normal fertility, and makes assisted reproduction, when it is still needed, far more likely to succeed.
Ready to treat the cause rather than work around it?
Bring your semen analyses, your partner’s results and any treatment you have had, including failed IVF cycles. We will tell you honestly what we have found, what we can treat, how long it will take, and whether and when assisted reproduction should be part of the plan.
Frequently asked questions
Can a low sperm count be treated?
In most men, yes, because the usual causes, a chronic infection of the prostate and its neighbours, a varicocele, or a hormonal disorder, respond to treatment and the count rises over three to six months. A count that stays very low after treatment, or no sperm at all, is managed with sperm retrieval and ICSI.
Does treating prostatitis improve sperm?
Yes, and it is the commonest improvement we see. As the infection clears, the white cells disappear from the semen, volume and liquefaction normalise, and motility, count and morphology recover over the following months. Many couples who had been told they needed IVF conceive naturally after the prostate is treated.
How is weak sperm (low motility) treated?
Poor motility is nearly always a sign of a hostile seminal fluid, from an inflamed prostate and seminal vesicles, or of a varicocele. Treating the infection, correcting the varicocele and adding antioxidants restores motility in most men. Motility that stays poor is bypassed with ICSI, which needs only a single living sperm per egg.
Do I need IVF if my sperm count is low?
Not usually as a first step. A count that is low because of an infection or a varicocele often rises enough after treatment for a natural pregnancy. IVF or ICSI is the right choice when the cause cannot be corrected, when the count stays very low after treatment, or when the partner’s age makes waiting unwise.
What can be done if there are no sperm at all?
First, find out why: blocked ducts with a normal testicle, or a testicle producing very little. In the first case the block can often be bypassed surgically, or sperm retrieved easily from the epididymis (PESA, MESA). In the second, micro-TESE finds sperm in roughly six men out of ten, and ICSI makes a pregnancy possible with them.
How long before the semen improves after treatment?
Sperm take about three months to be produced, so the first meaningful change is at three months and the full effect at six to twelve. Signs of inflammation clear first, then motility, then count, then morphology.
Does my partner need to be treated too?
Usually examined, often treated. The organisms that cause chronic prostatitis pass between partners, and a silent chronic cystitis, vaginitis or endometritis in the woman lowers the chance of conception and of a healthy pregnancy even with excellent sperm. Treating both partners at the same time is part of the protocol.
