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Infertility – Taseer Dawakhana
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Male infertility

Approximately 15% of couples attempting their first pregnancy meet with failure. Most authorities define these patients as primarily infertile if they have been unable to achieve a pregnancy after one year of unprotected intercourse. Conception normally is achieved within twelve months in 80-85% of couples who use no contraceptive measures, and persons presenting after this time should therefore be regarded as possibly infertile and should be evaluated. Data available over the past twenty years reveal that in approximately 30% of cases pathology is found in the man alone, and in another 20% both the man and woman are abnormal. Therefore, the male factor is at least partly responsible in about 50% of infertile couples.


Important issues related to the evaluation of the male factor include the most appropriate time for the male evaluation, the most efficient format for a comprehensive male exam, and definition of rationale and effective medical and surgical regimens in the treatment of these disorders. It is extremely important in the evaluation of infertility to consider the couple as a unit in evaluation and treatment and to proceed in a parallel investigative manner until a problem is uncovered. It has been shown that the longer a couple remains sub fertile, the worse their chance for an effective cure. Many couples experience significant apprehension and anxiety after only a few months of failure to conceive. Unduly prolonged unprotected intercourse should not be advocated before a workup of the man is instituted. Initial screening of the man should be considered whenever the patient presents with the chief complaint of infertility. This initial evaluation should be rapid, non-invasive and cost effective. Of interest is the fact that pregnancy rates of up to 50% have been reported when only the woman has been investigated and treated even when the man was found to have moderately severe abnormalities of semen quality.



Causes generally can be divided into pretesticular, testicular, and posttesticular.

Pretesticular Causes of Infertility

Pretesticular causes of infertility include congenital or acquired diseases of the hypothalamus, pituitary, or peripheral organs that alter the hypothalamic-pituitary axis.


Disorders of the hypothalamus lead to hypogonadotropic hypogonadism. If GnRH is not secreted, the pituitary does not release LH and FSH. Ideally, patients respond to replacement with exogenous GnRH or HCG, an LH analogue, although this does not always occur.

  • Idiopathic hypogonaotropic hypogonadism
  • A failure of GnRH secretion without any discernible underlying cause may be observed alone (isolated) or as part of Kallmann syndrome, which is associated with midline defects such as anosmia, cleft lip and cleft palate, deafness, cryptorchidism, and color blindness. Kallmann syndrome has been described in both familial (X-linked and autosomal) and sporadic forms, and its incidence is estimated as 1 case per 10,000-60,000 births.
  • A failure of GnRH neurons to migrate to the proper location in the hypothalamus has been implicated. Patients generally have long arms and legs due to a delayed closure of the epiphyseal plates, delayed puberty, and atrophic testis. Testosterone therapy may allow patients to achieve normal height but does not improve spermatogenesis. Exogenous testosterone should never be administered in an attempt to boost sperm production because it actually decreases intratesticular testosterone levels owing to feedback inhibition of GnRH release.
  • Pulsatile GnRH and HCG have been used but result in only 20% achieving complete spermatogenesis.
  • Adding recombinant human FSH to HCG has been shown to be effective in achieving spermatogenesis in most patients.
  • Select patients with adult-onset idiopathic hypogonadotropic hypogonadism may respond to clomiphene citrate therapy.
  • Prader-Willi syndrome: Patients have characteristic obesity, mental retardation, small hands and feet, and hypogonadotropic hypogonadism due to a GnRH deficiency. Prader-Willi syndrome is caused by a disorder of genomic imprinting with deletions of paternally derived chromosome arm 15q11-13.
  • Laurence-Moon-Biedl syndrome: Patients with this syndrome have retinitis pigmentosa and polydactyly. Infertility is due to hypogonadotropic hypogonadism.
  • Other conditions: Various other lesions and diseases, such as CNS tumors, temporal lobe seizures, and many drugs (eg, dopamine antagonists) may interrupt the hypothalamic-pituitary axis at the hypothalamus.



Both pituitary insufficiency and pituitary excess cause infertility. Pituitary failure may be congenital or acquired. Acquired causes include tumor, infarction, radiation, infection, or granulomatous disease. Nonfunctional pituitary tumors may compress the pituitary stalk or the gonadotropic cells, interrupting the proper chain of signals leading to pituitary failure. In contrast, functional pituitary tumors may lead to unregulated gonadotropin release or prolactin excess, interrupting the proper signaling.


  • A prolactin-secreting adenoma is the most common functional pituitary tumor. Prolactin stimulates breast development and lactation; therefore, patients with infertility due to a prolactinoma may have gynecomastia and galactorrhea. In addition, loss of peripheral visual fields bilaterally may be due to compression of the optic chiasm by the growing pituitary tumor.
  • A prolactin level of more than 150 mcg/L suggests a pituitary adenoma, while levels greater than 300 mcg/L are nearly diagnostic. Patients should undergo an MRI or CT scan of the sella turcica for diagnostic purposes to determine whether a microprolactinoma or a macroprolactinoma is present.
  • Bromocriptine, a dopamine agonist, is used to suppress prolactin levels and is the therapy of choice for microprolactinomas. Cabergoline is also a treatment option. Some men respond with an increase in testosterone levels; many also recover normal sperm counts. Transsphenoidal resection of a microprolactinoma is 80-90% successful, but as many as 17% recur. Surgical therapy of a macroprolactinoma is rarely curative, although this should be considered in patients with visual-field defects or those who do not tolerate bromocriptine.
  • Isolated LH deficiency (fertile eunuch): In these patients, LH levels are decreased while FSH levels are within the reference range. Patients have eunuchoidal body habitus, large testis, and a low ejaculatory volume. The treatment of choice is exogenous HCG.
  • Isolated FSH deficiency: This is a very rare cause of infertility. Patients present with oligospermia but have LH levels within the reference range. Treatment is with human menopausal gonadotropin (HMG) or exogenous FSH.
  • Thalassemia: Patients with thalassemia have ineffective erythropoiesis and undergo multiple blood transfusions. Excess iron from multiple transfusions may get deposited in the pituitary gland and the testis, causing parenchymal damage and both pituitary and testicular insufficiency. Treatment is with exogenous gonadotropins and iron-chelating therapy.
  • Cushing disease: Increased cortisol levels cause a negative feedback on the hypothalamus, decreasing GnRH release.

Peripheral Organs


The hypothalamus-pituitary axis may be interrupted by hormonally active peripheral tumors or other exogenous factors, due to cortical excess, cortical deficiency, or estrogen excess.

  • Excess cortisol may be produced by adrenal hyperplasia, adenomas, carcinoma, or lung tumors. High cortisol levels may also be seen with exogenous steroid use, such as that administered to patients with ulcerative colitis, asthma, arthritis, or organ transplant. For example, high cortisol levels are seen in patients with Cushing syndrome, which causes negative feedback on the pituitary to decrease LH release.
  • Cortical deficiency may be seen in patients with adrenal failure due to infection, infarction, or congenital adrenal hyperplasia (CAH). CAH may be due to the congenital deficiency of one of several adrenal enzymes, the most common of which is 21-hydroxylase deficiency. Because cortisol is not secreted, a lack of feedback inhibition on the pituitary gland occurs, leading to adrenocorticotropic hormone (ACTH) hypersecretion. This leads to increased androgen secretion from the adrenal gland, causing feedback inhibition of GnRH release from the hypothalamus. Patients present with short stature, precocious puberty, small testis, and occasional bilateral testicular rests. Screening tests include increased plasma 17-hydroxylase and urine 17-ketosteroids.
  • Estrogen excess may be seen in patients with Sertoli cell tumors, Leydig tumors, liver failure, or severe obesity. Estrogen causes negative feedback on the pituitary gland, inhibiting LH and FSH release.

Primary Testicular Causes of Infertility

Primary testicular problems may be chromosomal or non chromosomal in nature. While chromosomal failure is usually caused by abnormalities of the sex chromosomes, autosomal disorders are also observed.

Chromosomal Abnormalities 


An estimated 6-13% of infertile men have chromosomal abnormalities (compared with 0.6% of the general population). Patients with azoospermia or severe oligospermia are more likely to have a chromosomal abnormality (10-15%) than infertile men with sperm density within the reference range (1%). A karyotype test and a Y chromosome test for microdeletions are indicated in patients with nonobstructive azoospermia or severe oligospermia (<5 million sperm/mL), although indications are expanding.

  • Klinefelter syndrome is the most common chromosomal cause of male infertility, estimated to be present in 1 per 500-1000 male births. Classic Klinefelter syndrome has a 47, XXY karyotype and is caused by a nondisjunction during the first meiotic division, more commonly of maternal origin; mosaic forms are due to nondisjunction following fertilization. The only known risk factor for Klinefelter syndrome is advanced maternal age. Infertility is caused by primary testicular failure, and most patients are azoospermic. Hormonal analysis reveals increased gonadotropin levels, while 60% have decreased testosterone levels. Surprisingly, most patients have normal libido, erections, and orgasms, so testosterone therapy has only a limited role; exogenous testosterone may also suppress any underlying sperm production.
  • Physical examination reveals gynecomastia, small testis, and eunuchoid body habitus due to delayed puberty. In some patients, secondary sex characteristics develop normally, but they are usually completed late. These men are at a higher risk for breast cancer, leukemia, diabetes, empty sella syndrome, and pituitary tumors. Testicular histology reveals hyalinization of seminiferous tubules. Some men with Klinefelter syndrome may be able to conceive with the help of assisted reproductive techniques. Of azoospermic patients with Klinefelter syndrome, 20% show the presence of residual foci of spermatogenesis. Although the XXY pattern is observed in the spermatogonia and primary spermatocytes, many of the secondary spermatocytes and spermatids have normal patterns. The chromosomal pattern of the resultant embryos can be assessed with preimplantation genetic diagnosis.
  • XX male (sex reversal syndrome): An XX karyotype is due to a crossover of the sex-determining region (SRY) of the Y chromosome (with the testis determining factor) to either the X chromosome or an autosome. Patients are often short, with small firm testis and gynecomastia, but they have a normal-sized penis. Seminiferous tubules show sclerosis.
  • XYY male: An XYY karyotype is observed in 0.1-0.4% of newborn males. These patients are often tall and severely oligospermic or azoospermic. This pattern has been linked with aggressive behavior. Biopsy reveals maturation arrest or germ cell aplasia. Functional sperm that are present may have a normal karyotype.


  • Noonan syndrome (46, XY): Patients with Noonan syndrome, also known as male Turner syndrome, have physical characteristics similar to that of women with Turner syndrome (45, X). Features include a webbed neck, short stature, low-set ears, ptosis, shield-like chest, lymphedema of hands and feet, cardiovascular abnormalities, and cubitus valgus. Leydig cell function is impaired, and most patients are infertile due to primary testicular failure.
  • Mixed gonadal dysgenesis (45, X/46, XY): Patients have ambiguous genitalia, a testis on one side, and a streaked gonad on the other.
  • Y chromosome microdeletion syndrome: The long arm of the Y chromosome (Yq) is considered critical for fertility, especially Yq11.23 (interval 6). Macroscopic deletions of Yq11 are often observed in patients with azoospermia, although many new microdeletions have been implicated as a significant cause of infertility. These microdeletions are not observed on regular karyotype; rather, their identification requires polymerase chain reaction (PCR)–based sequence-tagged site mapping or Southern blot analysis. Three regions have been described, called azoospermic factors a, b, and c (AZFa, AZFb, AZFc). These deletions are observed in 3-19% of patients with idiopathic infertility and 6-14% of patients with oligospermia, although up to 7% of patients with other known causes of infertility may also be found to have a deletion. Patients with azoospermia or severe oligospermia seeking assisted reproductive techniques should be screened.
  • Bilateral anorchia (vanishing testis syndrome): Patients have a normal male karyotype (46, XY) but are born without testis bilaterally. The male phenotype proves that androgen was present in utero. Potential causes are unknown, but it may be related to infection, vascular disease, or bilateral testicular torsion. Karyotype shows a normal SRY gene. Patients may achieve normal virilization and adult phenotype by the administration of exogenous testosterone, but they are infertile.
  • Down syndrome: These patients have mild testicular dysfunction with varying degrees of reduction in germ cell number. LH and FSH levels are usually elevated.
  • Myotonic dystrophy: This is an autosomal dominant defect in the dystrophin gene that causes a delay in muscle relaxation after contraction. Seventy-five percent of patients have testicular atrophy and primary testicular failure due to degeneration of the seminiferous tubules. Leydig cells are normal. Histology reveals severe tubular sclerosis. No effective therapy exists.

Nonchromosomal Testicular Failure

Testicular failure that is nonchromosomal in origin may be idiopathic or acquired by gonadotoxic drugs, radiation, orchitis, trauma, or torsion.



  • A varicocele is a dilation of the veins of the pampiniform plexus of the scrotum. Although varicoceles are present in 15% of the male population, a varicocele is considered the most common correctable cause of infertility (30-35%) and the most common cause of secondary (acquired) infertility (75-85%). Varicoceles are observed more commonly on the left side than the right. Those with isolated right-sided varicoceles should be evaluated for retroperitoneal pathology.
  • Varicoceles are generally asymptomatic, and most men with varicoceles do not have infertility or testicular atrophy. However, varicoceles may lead to impaired testicular spermatogenesis and steroidogenesis, potentially due to an increased intratesticular temperature, reflux of toxic metabolites, and/or germ cell hypoxia as potential causes of these changes, and this appears to be progressive over time.
  • Varicoceles lead to an increased incidence of sperm immaturity, apoptosis, and necrosis with severe disturbances in meiotic segregation compared to fertile men without varicoceles, and these parameters generally improve after repair.


  • Patients with a grade 2-3 varicocele (visible or palpable) associated with infertility should have the varicocele repaired. After repair, 40-70% of patients have improved semen parameters, while 40% are able to achieve a pregnancy without other interventions. Those with a varicocele diagnosable only on scrotal ultrasonography will likely not benefit from repair. Adolescents with a varicocele and testicular atrophy or lack of growth should similarly undergo repair. Controversy exists regarding whether to routinely repair an adolescent varicocele not associated with testicular atrophy.
  • In those with azoospermia and a varicocele, sperm may appear after repair in up to one third, but most of these men return to an azoospermic state within a few months. If sperm appears, these men should be offered cryopreservation.


  • An estimated 3% of full-term males are born with an undescended testicle, but fewer than 1% remain undescended by age 1 year. Undescended testicle may be isolated or may be observed as part of a syndrome such as prune belly syndrome. Patients are at increased risk of infertility, even if the testicle is brought down into the scrotum, as the testicle itself may be inherently abnormal. The farther from the scrotum, and the longer duration that the testicle resides outside the scrotum, the greater the likelihood of infertility. Testicular histology typically reveals a decreased number of Leydig cells and decreased spermatogenesis. Cryptorchidism may be due to inherent defects in both testes because even men with unilateral cryptorchidism have lower than expected sperm counts.
  • Trauma: Testicular trauma is the second most common acquired cause of infertility. The testes are at risk for both thermal and physical trauma because of their exposed position.
  • Sertoli cells-only syndrome (germinal cell aplasia): Patients with germinal cell aplasia have LH and testosterone levels within the reference range but have an increased FSH level. The etiology is unknown but is probably multifactorial. Patients have with small- to normal-sized testes and azoospermia, but normal secondary sex characteristics. Histology reveals seminiferous tubules lined by Sertoli cells and a normal interstitium, although no germ cells are present.
  • Chemotherapy: Chemotherapy is toxic to actively dividing cells. In the testicle, germ cells (especially up to the preleptotene stage) are especially at risk. The agents most often associated with infertility are the alkylating agents such as cyclophosphamide. For example, treatment for Hodgkin disease has been estimated to lead to infertility in as many as 80-100% of patients.
  • Radiation therapy: While Leydig cells are relatively radioresistant because of their low rate of cell division, the Sertoli and germ cells are extremely radiosensitive. If stem cells remain viable after radiation therapy, patients may regain fertility within several years. However, some have suggested that patients should avoid conception for 6 months to 2 years after completion of radiation therapy because of the possibility of chromosomal aberrations in their sperm caused by the mutagenic properties of radiation therapy. Even with the testis shielded, radiation therapy below the diaphragm may lead to infertility due to the release of reactive oxygen free radicals.



  • The most common cause of acquired testicular failure in adults is viral orchitis, such as that caused by the mumps virus, echovirus, or group B arbovirus. Of adults with who are infected with mumps, 25% develop orchitis; two thirds of cases are unilateral, and one third are bilateral. While orchitis develops a few days after the onset of parotid gland inflammation, it may also precede it. The virus may either directly damage the seminiferous tubules or indirectly cause ischemic damage as the intense swelling leads to compression against the tough tunica albuginea. After recovery, the testicle may return to normal or may atrophy. Atrophy is observed within 1-6 months, and the degree of atrophy does not correlate with the severity of orchitis or infertility. Normal fertility is observed in three fourths of patients with unilateral mumps orchitis and in one third of patients in bilateral orchitis.
  • Granulomatous disease: Leprosy and sarcoidosis may infiltrate the testicle and lead to testicular failure.
  • Sickle cell disease: Sickling of cells within the testis leads to microinfarcts and secondary testicular failure.


  • Excessive use of alcohol, cigarettes, caffeine, and marijuana may lead to testicular failure.
  • Idiopathic causes: Despite a thorough workup, nearly 25% of men have no discernible cause for their infertility.

Posttesticular Causes of Infertility

Posttesticular causes of infertility include problems with sperm transportation through the ductal system, either congenital or acquired. Genital duct obstruction is a potentially curable cause of infertility and is observed in 7% of infertile patients. Additionally, the sperm may be unable to cross the cervical mucus or may have ultrastructural abnormalities.

Congenital blockage of the ductal system: An increased rate of duct obstruction is observed in children of mothers who were exposed to DES during pregnancy. Segmental dysplasia is defined as a vas deferens with at least 2 distinct sites of vasal obstruction.

  • Cystic fibrosis: CF is the most common genetic disorder in whites. Patients with CF nearly uniformly have CBAVD. The cystic fibrosis transmembrane regulator (CFTR) protein plays a role in mesonephric duct development during early fetal life, so these patients may also have urinary tract abnormalities. Patients may be candidates for assisted reproduction techniques after appropriate genetic screening in the partner.
  • Acquired blockage of the ductal system: Genital ducts may become obstructed secondary to infections, such as chlamydia, gonorrhea, tuberculosis, and smallpox. Young syndrome is a condition that leads to inspissation of material and subsequent blockage of the epididymis. Trauma, previous attempts at sperm aspiration, and inguinal surgery may also result in ductal blockage. Small calculi may block the ejaculatory ducts, or prostatic cysts may extrinsically block the ducts. Scrotal surgery, including vasectomy, hydrocelectomy (5-6%), and spermatocelectomy (up to 17%), may lead to epididymal injury and subsequent obstruction.


  • Antisperm antibodies: Antisperm antibodies bind to sperm, impair motility, and lead to clumping, impairing movement through the female reproductive tract and interaction with the oocyte.
  • Immotile cilia syndrome may be isolated or part of Kartagener syndrome with situs inversus. Because of a defect in the dynein arms, spokes, or microtubule doublet, cilia in the respiratory tract and in sperm do not function properly. In addition to sperm immobility, patients experience sinusitis, bronchiectasis, and respiratory infections.
  • Ejaculatory duct obstruction: Complete and partial ejaculatory duct obstruction has been implicated as a cause of 1-5% of patients with male infertility. Patients may have a normal palpable vas deferens bilaterally but show decreased ejaculate volume and hemospermia and may experience pain upon ejaculation. Etiologies include cysts (midline and eccentric), ductal calcification and stones, postinfectious, and postoperative. Transrectal ultrasonography (TRUS) may reveal enlarged seminal vesicles, but this is not universal. Seminal vesicle aspiration revealing numerous sperm or a dynamic test such as injection of indigo carmine into the seminal vesicle or ejaculatory duct may be necessary for diagnosis.
  • Anejaculation/retrograde ejaculation may be due to an open bladder neck or a lack of rhythmic contractions during ejaculation. Etiologies include diabetic neuropathy, bladder neck surgery, RPLND, transurethral prostatectomy, colon or rectal surgery, multiple sclerosis, spinal cord injury, or the use of medicines such as alpha-antagonists. Diagnosis is suggested by history, a low ejaculate volume, and the observance of 10-15 sperm per high-power field (HPF) in the postejaculatory urine.

Physical Symptoms of Male Infertility


For men, the most typical symptom of male infertility that may signal an underlying fertility problem is six months of unprotected intercourse without successful conception. Unlike many cases of female infertility, most men do not show any physical symptoms of infertility problems, but continue to have trouble getting pregnant with their partner. Nonetheless, there are some infertility symptoms that may be experienced along with difficulty getting pregnant as a result of a specific, underlying cause of infertility.

Risk Factors

A number of risk factors are linked to male infertility. They include:

  • Age. Men older than 35 may have a gradual decline in fertility.
  • Tobacco smoking. Fertility may improve when you quit smoking.
  • Alcohol use. Heavy alcohol use can lower testosterone levels, cause erectile dysfunction and decrease sperm production.
  • Being overweight — or too thin. Being at an unhealthy weight can reduce sperm count.
  • Celiac disease. A digestive disorder caused by a sensitivity to gluten, untreated celiac disease can cause male infertility. Fertility may improve after adopting a gluten-free diet.
  • Prostate infections. Past prostate or other genital infections such as mumps or a sexually transmitted disease can affect fertility.
  • Exposure to toxins. Examples include heavy metals, industrial chemicals and radioactivity.
  • Exposure to certain drugs and medications. Examples include cancer medications and anabolic steroids.
  • High temperatures. Exposing the testicles to high temperatures — such as a hot tub or sauna — can temporarily reduce fertility.
  • Previous vasectomy. Some men who’ve had a vasectomy reversed remain infertile.


Many types of male infertility aren’t preventable. However, there are a few things that you can avoid that are known causes of male infertility:


  • Don’t have a vasectomy. If there’s any possibility you’ll want to father a child in the future, opt for other forms of birth control. Even if reversed, a vasectomy may still affect fertility.
  • Avoid illicit drugs. Use of anabolic steroids, marijuana and cocaine can impair sperm production.
  • Don’t drink too much alcohol. Heavy drinking can impair fertility and sexual function. Drink no more than two drinks a day.
  • If you smoke tobacco, quit. Smoking is linked to impaired fertility.
  • Avoid exposure to heat. Steer clear of extended or regular use of hot tubs, saunas and steam baths. High temperatures are thought to temporarily impair sperm production.

Tests and Diagnosis

If you and your partner are unable to become pregnant within a reasonable time, see your doctor. Some infertile couples have more than one cause of their infertility. Your doctor will usually begin a comprehensive infertility examination on both you and your partner.

In some cases, the cause of your infertility may be unclear, or it may take a number of tests to determine the cause. Infertility tests can be expensive and may not be covered by insurance — find out what your medical plan covers ahead of time.

For a man to be fertile, the testicles must produce enough healthy sperm, and the sperm must be ejaculated effectively into the woman’s vagina. Tests for male infertility attempt to determine whether any of these processes are impaired.

General Physical Examination and Medical History

This includes examination of your genitals and questions about illnesses, disabilities and surgeries that could affect fertility. Your doctor will want to know what medications you take and your sexual habits. Your doctor may also ask about your sexual development as a boy and whether you’ve had any signs of low testosterone, such as decreased body or facial hair.

Semen Analysis

This is the most important test for the male partner. Semen is generally obtained by masturbating or by interrupting intercourse and ejaculating your semen into a clean container. A laboratory analyzes the physical characteristics of your semen, the number of sperm present and looks for any abnormalities in the shape and structure (morphology) and movement (motility) of the sperm. The lab will also check your semen for signs of problems, such as infections or blood. Often sperm counts fluctuate from one specimen to the next, so your doctor may want to evaluate a few different samples. If your sperm analysis is normal, your doctor will likely recommend thorough testing of your female partner before conducting further male infertility tests.

Depending on initial findings, your doctor may recommend additional, more specialized tests that can help identify the cause of your infertility. These can include:

Scrotal Ultrasound

Ultrasound, which uses high-frequency sound waves to produce images of structures within your body, can help your doctor look for evidence of a varicocele or obstruction of the epididymis.

Hormone Testing

Hormones produced by the pituitary and hypothalamus glands and the testicles play a key role in sexual development and sperm production. Your doctor may recommend a blood test to determine the level of testosterone and other male hormones that affect fertility. A number of infertility problems can be caused by an underlying condition that affects hormone levels.

Genetic Tests

These tests are used if your doctor suspects your fertility problems could be caused by an inherited sex chromosome abnormality. When sperm concentration is extremely low, genetic causes could be involved. A blood test can reveal whether there are subtle changes in the Y chromosome.

Testicular Biopsy

This test involves removing samples from the testicle with a needle. It may be used if your semen analysis shows no sperm at all. The results of the testicular biopsy will tell if sperm production is normal. If it is, your problem is likely caused by blockage or another problem with sperm transport.

Anti-Sperm Antibody Tests

These tests are used to check for immune cells (antibodies) that attack sperm and can affect their ability to function. You are especially likely to have anti-sperm antibodies if you’ve had vasectomy reversal.


In some cases, contrast dye is injected into each vas deferens to see whether they are blocked.

Specialized Sperm Function Tets

A number of different tests can be used to evaluate how well your sperm survive after ejaculation, how well they can penetrate the egg membrane, and whether there’s any problem attaching to the egg.


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Female Infertility

Infertility is the failure of a couple to become pregnant after one year of regular, unprotected intercourse. In both men and women the fertility process is complex.

About 10% of couples who wish to have a baby are still unable to after a year of unprotected sex. About half of these couples can achieve pregnancy within 2 years after appropriate treatment of the woman, the man, or both. Even under ideal circumstances, the probability that a woman will get pregnant during a single menstrual cycle is only about 30%. And, when conception does occur, only 50 – 60% of pregnancies advance beyond the 20th week. (The inability of a woman to produce a live birth because of abnormalities that cause miscarriages is called infecundity and is not discussed in detail in this report.)


Males and females each account for 40% of infertility. In the remaining 20%, either both partners are responsible or the cause is unclear. Although this report specifically addresses infertility in women, it is equally important for the male partner to be tested at the same time.

Causes of Female Infertility

Causes of infertility can be found in about 90% of infertility cases but, despite extensive tests, about 10% of couples will never know why they cannot conceive. Between 10 – 30% of cases of infertility have more than one cause. Male or female infertility each account for about 30 – 40% of cases. In men, sperm defects (their quality and quantity) are usually responsible. Female infertility is more complex.

Pelvic Inflammatory Disease


Pelvic inflammatory disease (PID) is the major cause of female infertility worldwide. PID comprises a variety of infections caused by different bacteria that affect the reproductive organs, appendix, and parts of the intestine that lie in the pelvic area. The sites of infection most often implicated in infertility are in the fallopian tubes, a specific condition referred to as salpingitis.

Causes of PID.

PID may result from many different conditions that cause infections. Among them are:

  • Sexually transmitted diseases (cause of most PIDs). Chlamydia trachomatis is an infectious organism that causes 75% of infertility in the fallopian tubes. Gonorrhea is responsible for most of the remaining cases.


  • Pelvic tuberculosis (a growing global problem as tuberculosis cases increase)
  • Nonsterile abortions
  • Ruptured appendix
  • Herpesvirus (suggested for some cases, but not confirmed as a cause)

Symptoms of PID. The infection may be subclinical (occurring without any symptoms), or there may be fever, chills, or pelvic pain indicating inflammation of the entire pelvic area.

Effects of PID. Severe or frequent attacks of PID can eventually cause scarring, abscess formation, and tubal damage that result in infertility. About 20% of women who develop symptomatic PID become infertile. PID also significantly increases the risk of ectopic pregnancy (fertilization in the fallopian tubes). The severity of the infection, not the number of the infections, appears to pose the greater risk for infertility.


Endometriosis may account for as many as 30% of infertility cases. Some evidence suggests that between 30 – 50% of women with endometriosis are infertile. Often, however, it is difficult to determine if endometriosis is the primary cause of infertility, particularly in women who have mild endometriosis. Endometriosis rarely causes an absolute inability to conceive, but, nevertheless, it can contribute to it both directly and indirectly.

Endometriosis is the condition in which the tissue that normally lines the uterus (endometrium) grows on other areas of the body causing pain and irregular bleeding.

Direct Effect of Endometrial Cysts. Endometrial cysts may directly cause infertility in several ways:

  • If implants occur in the fallopian tubes, they may block the egg’s passage.
  • Implants that occur in the ovaries prevent the release of the egg.
  • Severe endometriosis can eventually form rigid webs of scar tissue (adhesions) between the uterus, ovaries, and fallopian tubes, thereby preventing the transfer of the egg to the tube.


Immune Factors and the Inflammatory Response. Researchers are focusing on defects in the immune system that not only may be responsible for endometriosis in the first place but may also cause the infertility associated with endometriosis. Even in early stage endometriosis, investigators have observed increased immune system activity.

Other Conditions Linking Endometriosis and Infertility. Researchers have sometimes noted unusually low levels of specific substances that enable a fertilized egg to adhere to the uterine lining. (Such abnormalities are more often a factor in infertility in women with mild to moderate endometriosis than in those with severe cases.)

One study found that the eggs in women with endometriosis appeared to have more genetic abnormalities than those in women without the disorder.

Polycystic Ovarian Syndrome

Polycystic ovarian syndrome (PCOS) is a condition in which the ovaries produce high amounts of androgens (male hormones), particularly testosterone. PCOS occurs in about 6% of women, and amenorrhea or oligomenorrhea (infrequent menses) is quite common. According to a 2002 study, nearly 30% of obese women with PCOS had amenorrhea. (The rate was lower — 4.7% — in women with normal weight.)

In PCOS, increased androgen production produces high LH levels and low FSH levels, so that follicles are prevented from producing a mature egg. Without egg production, the follicles swell with fluid and form into cysts. Every time an egg is trapped within the follicle, another cyst forms, so the ovary swells, sometimes reaching the size of a grapefruit. Without ovulation, progesterone is no longer produced, whereas estrogen levels remain normal.

The elevated levels of androgens (hyperandrogenism) can cause obesity, facial hair, and acne, although not all women with PCOS have such symptoms. Other male characteristics, such as deepening voice and clitoral enlargement, are rare.

PCOS also poses a high risk for insulin resistance, particularly in women who are also obese. Insulin resistance is associated with diabetes type 2, in which insulin levels are normal or high but the body cannot use this hormone efficiently. About half of PCOS patients, in fact, also have diabetes.

Premature Ovarian Failure (Early Menopause)

Premature ovarian failure (POF) is the early depletion of follicles before age 40, which, in most cases, leads to premature menopause. It affects about 1% of women and is typically preceded by irregular periods, which might continue for years. In this condition, follicle-stimulating hormone (FSH) levels are elevated, as they are during per menopause. Premature ovarian failure is a significant cause of infertility,


and women who have this condition have only a 5 – 10% chance to conceive without fertility treatments.

Causes of Premature Ovarian Failure. There are numerous causes of POF. Often the cause of this disorder or other causes of POF is unknown. In some cases, POF may represent an acceleration of the aging process.

The following conditions may produce POF:

  • Adrenal, pituitary, or thyroid gland deficiencies.
  • Genetic factors related to the X chromosome. A woman needs two functioning X chromosomes for normal reproduction. When one is abnormal, ovarian function fails. The most severe example is Turner’s syndrome, a genetic condition, in which one of the two X-chromosomes is missing or malfunctioning. Milder cases of ovarian failure can occur in fragile X syndrome and other rare inherited conditions that cause partial X-chromosome abnormalities.
  • Cancer treatments (radiation, chemotherapy, or both). Women who are undergoing cancer treatments and who want to become pregnant should see a reproductive specialist to discuss their options. According to the American Society of Clinical Oncology’s 2006 guidelines, the fertility preservation method with the best chance of success is embryo cryopreservation. This procedure involves harvesting a woman’s eggs (oocytes), followed by in vitro fertilization and freezing of embryos for later use. Other treatments under investigation include egg preservation, collecting and freezing unfertilized eggs, removing and freezing a part of the ovary for later reimplantation, and using hormone therapy to protect the ovaries during chemotherapy. Women may be able to access these investigational approaches through enrolling in clinical trials.
  • Autoimmunity. Autoimmune diseases, including diabetes type 1, systemic lupus erythematosus, autoimmune hypothyroidism, and autoimmune Addison’s disease, are associated with a higher risk for early menopause. Autoimmunity, however, may also play a role in some cases of POF without the presence of specific autoimmune diseases. In such cases, antibodies specifically attack the cells that secrete reproductive hormones thus causing ovarian failure.
  • Other causes of POF include sarcoidosis, mumps, some sexually transmitted diseases, and tuberculosis. Women with epilepsy are at higher risk for POF.

Idiopathic Hypogonadotropic Hypogonadism

Idiopathic hypogonadotropic hypogonadism is a rare condition in which follicle-stimulating hormone (FSH) and luteinizing hormone (LH) are underproduced and prevent the development of functional ovaries. There are no other abnormalities in the hypothalamus-pituitary axis (such as tumors or abnormal stress hormones or prolactin). In most cases, the causes of hypergonadotropic hypogonadism are unknown. Genetic factors, including Kallman’s syndrome, have been identified in about 20% of these cases.

Functional Hypothalamic Amenorrhea (FHA) and Eating Disorders

Functional hypothalamic amenorrhea (FHA) is the absence of menstruation due to disturbances in the thyroid gland and hypothalamus-pituitary-adrenal (HPA) system, which regulates reproduction and other important functions. The eating disorders anorexia and bulimia are most often associated with FHA. FHA may be due to other different factors, most unknown.


Luteal Phase Defect (Implantation Failure)

Luteal phase defect is a general term referring to problems in the corpus luteum that result in inadequate production of progesterone. Because progesterone is necessary for thickening and preparing the uterine lining, the ovum fails to successfully implant in the endometrium. Between 25 – 60% of women who experience recurrent miscarriages may have a luteal phase defect. A luteal phase defect, however, can also occur in fertile women, so other factors may be responsible for implantation failure.

Benign Uterine Fibroids

Benign fibroid tumors in the uterus are extremely common in women in their 30s. The effect of fibroids on fertility is controversial. A 2002 analysis suggested that they may account for infertility in only 1 – 2.4% of women who are having trouble conceiving.

Large fibroids may cause infertility impairing the uterine lining, by blocking the fallopian tube, or by distorting the shape of the uterine cavity or altering the position of the cervix.

Some evidence suggests that even small fibroids may reduce the chances of pregnancy in women who are undergoing assisted reproductive techniques. Treatments to reduce fibroids may be helpful in such women, although there has been little research on this subject.

Elevated Prolactin Levels (Hyperprolactinemia)

Prolactin is a hormone produced in the pituitary gland that stimulates breast development and milk production in association with pregnancy. High levels of prolactin (hyperprolactinemia) reduce gonadotropin hormones and inhibit ovulation. Hyperprolactinemia in women who are not pregnant or nursing can be caused by hypothyroidism or pituitary adenomas. (These are benign tumors that secrete prolactin. They can cause headache and visual problems as well as breast secretions.) Some drugs, including oral contraceptives and some antipsychotic drugs, can also elevate levels of prolactin.

Secretions from the breast not related to pregnancy or nursing (called galactorrhea ) is a telltale symptom of high prolactin levels and should be investigated.

Structural Problems Causing Obstruction

Inborn Abnormalities. Inborn genital tract abnormalities may cause infertility. Mullerian agenesis is a specific malformation in which no vagina or uterus develops. Even in these cases, some women can become mothers by undergoing in vitro fertilization and having the fertilized egg implanted in another woman who is willing and able to carry the pregnancy (a surrogate mother).

Uterine or Abdominal Scarring. Bands of scar tissue that bind together after abdominal or pelvic surgery or infection (called adhesions) can restrict the movement of ovaries and fallopian tubes and may cause infertility. Asherman’s syndrome, for example, is scarring in the uterus that can cause obstructions and secondary amenorrhea. It may be caused by surgery, repeated injury, or unknown factors. Laparoscopic surgery is less likely to cause adhesions than standard open surgery.

In some of these cases, surgery may be helpful. One technique, called pressure lavage under ultrasound guidance (PLUG), may prove to be useful for treating some cases of mild scarring in the uterus (intrauterine adhesions). This technique is based on transvaginal sonohysterography, which uses ultrasound along with saline infused into the uterus to enhance visualization. Continuous accumulation of saline in the procedure is used to break up the scars.

Other Causes of Infertility

Ectopic Pregnancies. Ectopic pregnancies increase the risk for infertility, although subsequent pregnancy rates are quite variable. Ectopic pregnancies that terminate without treatment appear to pose a lower risk for future infertility. Even a ruptured tube does not appear to reduce the chance for a future pregnancy in most women. Such an event however can be dangerous and even life threatening for the woman. Laparoscopic surgery to remove a fallopian tube affected by an ectopic pregnancy may preserve fertility better than traditional abdominal surgery.

Medications. Among the medications that can cause temporary infertility are those used to treat chronic disorders, as well as antidepressants, hormones, pain killers, and antipsychotic drugs.

Inflammatory Bowel Disease. Inflammatory bowel disease (particularly Crohn’s disease or surgery for ulcerative colitis) can affect fertility.

Celiac Sprue. Celiac sprue is a disease in which the patient cannot tolerate gluten, a common food chemical. The disorder is also highly associated with infertility in men and women, possibly through multiple effects on nutrition, immune factors, and hormones. The mechanisms are not altogether clear, but infertility is usually reversible with strict dietary control.

Epilepsy. In one study of women with epilepsy, fertility rates were 33% lower than among women in the general population, perhaps due to certain antiepileptic drugs that increase the risk for birth defects. The social effects of epilepsy may also lead to marriage at an older age, which can be associated with delayed attempts to get pregnant and thereby affect fertility.

Thyroid Problems. Thyroid problems, either too much thyroid hormone (hyperthyroidism) or too little (hypothyroidism), can interrupt cycles.

Metabolic Syndrome (also Called Syndrome X). Doctors diagnose this condition when at least three of the the following abnormalities are present:

  • Abdominal obesity
  • Low HDL (good) cholesterol levels
  • High triglyceride levels
  • High blood pressure
  • Insulin resistance


Metabolic syndrome is a pre-diabetic condition that is significantly associated with heart disease. A 2002 study reported that, as with PCOS, women with metabolic syndrome have higher levels of male hormones and are therefore at risk for infertility. A 2002 study estimated that 24% of the population now has this condition.

Other Medical Conditions. Medical conditions associated with delayed puberty and amenorrhea (absence of periods) include Cushing’s disease, sickle cell disease, HIV, kidney disease, and diabetes. Genetic mutations that affect luteinizing hormone may also be responsible for some cases of light or absent menstruation. Other rare genetic disorders, such as Kallman syndrome, cause abnormalities in the hypothalamus of the brain.

Risk Factors

In the U.S., an estimated 10.2% of women between the ages of 15 – 44, or about 6.1 million women, have impaired fertility, and the incidence is increasing. About 25% of women experience some period of infertility during their reproductive years.


As a woman ages, her chances for fertility decline. Infertility in older women appears to be mostly due to a higher risk for chromosomal abnormalities that occur in her eggs as they age. Older women are also more likely to have health problems that may interfere with fertility. If fertilization occurs, older, healthy women can usually successfully bear a fetus to term, although they have a higher risk for miscarriage. Using population studies, experts have come up with estimated odds for pregnancy at different ages, given no fertility intervention. A 2002 analysis of pregnancy rates based on conception on the day of ovulation suggested that women between ages 19 – 26 have twice the pregnancy rates as those between 35 – 39.

Chances for Pregnancy by Age
Age Fertility %
Up until age 34 90%
By age 40 Declining to 67%
By age 45 Declining to 15%

Weight Factors and Excessive Exercise


Although most of a woman’s estrogen is manufactured in her ovaries, 30% is produced in fat cells by a process that transforms circulating adrenal male hormones into estrogen. Because a normal hormonal balance is essential for the process of conception, it is not surprising that extreme weight levels, either high or low, can contribute to infertility.

Being Overweight. Being overweight or obese (fat levels that are 10 – 15% above normal) can contribute to infertility in various ways. Obesity is highly associated with polycystic ovarian syndrome (PCOS), which is the cause of infertility in some cases. In one 2003 study, overweight women without PCOS were classified in one of five grades, depending on the severity of the obesity. The risk for irregular or absent periods increased two-fold by each increase in grade. In this group, amenorrhea (absent periods) was also highly associated with type 2 diabetes and blood sugar abnormalities.

Being Underweight. Body fat levels 10 – 15% below normal can completely shut down the reproductive process. Women at risk include:

Women with eating disorders, such as anorexia or bulimia.

Women on very low-calorie or restrictive diets are at risk, especially if their periods are irregular.

Strict vegetarians might have difficulties if they lack important nutrients, such as vitamin B12, zinc, iron, and folic acid.

Marathon runners, dancers, and others who exercise very intensely. (Lower body fat contributes to menstrual irregularities in competitive athletes, but other mechanisms are also involved.)

Environmental Risks

Exposure to environmental hazards (herbicides, pesticides, industrial solvents) may affect fertility. Estrogen-like hormone-disrupting chemicals are of particular concern for infertility in men and for effects on offspring of women.

Phthalates, chemicals used to soften plastics, are under particular scrutiny for their ability to disrupt hormones. Specific phthalates of special concern include dibutyl phthalate (DBP) and others found in many products, including cosmetics and clay products sold to children (Fimo, Sculpey). Animals exposed to phthalates have significantly impaired sperm count and abnormalities in reproductive structures, such as the testes. In addition, there is some concern that exposure in pregnant women may affect the offspring.

Stress and Fertility

Neurotransmitters (chemical messengers) act in the hypothalamus gland, which controls both reproductive and stress hormones. Severely elevated levels of stress hormone can, in fact, shut down menstruation. Whether stress has any significant effect on fertility or fertility treatments is unclear. One 2005 study found that psychological stress does not affect the success or failure of in vitro fertilization.


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The Causes of Male Infertility

Male infertility has many causes–from hormonal imbalances, to physical problems, to psychological and/or behavioral problems.  Moreover, fertility reflects a man’s “overall” health.  Men who live a healthy lifestyle are more likely to produce healthy sperm.  The following list highlights some lifestyle choices that negatively impact male fertility–it is not all-inclusive:



  • Smoking–significantly decreases both sperm count and sperm cell motility.
  • Prolonged use of marijuana and other recreational drugs.
  • Chronic alcohol abuse.
  • Anabolic steroid use–causes testicular shrinkage and infertility.
  • Overly intense exercise–produces high levels of adrenal steroid hormones which cause a testosterone deficiency resulting in infertility.
  • Inadequate vitamin C and Zinc in the diet.
  • Tight underwear–increases scrotal temperature which results in decreased sperm production.
  • Exposure to environmental hazards and toxins such as pesticides, lead, paint, radiation, radioactive
  • substances, mercury,  benzene, boron, and heavy metals
  • Malnutrition and anemia.
  • Excessive stress!
  • Modifying these behaviors can improve a man’s fertility and should be considered when a couple is trying to achieve pregnancy.

Hormonal Problems

  • A small percentage of male infertility is caused by hormonal problems.  The hypothalamus-pituitary endocrine system regulates the chain of hormonal events that enables testes to produce and effectively disseminate sperm.  Several things can go wrong with the hypothalamus-pituitary endocrine system:


  • The brain can fail to release gonadotrophic-releasing hormone (GnRH) properly.  GnRH stimulates the hormonal pathway that causes testosterone synthesis and sperm production.  A disruption in
  • GnRH release leads to a lack of testosterone and a cessation in sperm production.
  • The pituitary can fail to produce enough lutenizing hormone (LH) and follicle stimulating hormone
  • (FSH) to stimulate the testes and testosterone/sperm production.  LH and FSH are intermediates in the hormonal pathway responsible for testosterone and sperm production.


  • The testes’ Leydig cells may not produce testosterone in response to LH stimulation.
  • A male may produce other hormones and chemical compounds which interfere with the sex-hormone balance.

The following is a list of hormonal disorders which can disrupt male infertility:


Elevated prolactin–a hormone associated with nursing mothers, is found in 10 to 40 percent of infertile males.  Mild elevation of prolactin levels produces no symptoms, but greater elevations of the hormone reduces sperm production, reduces libido and may cause impotence.  This condition responds well to the drug Parlodel (bromocriptine).


Low thyroid hormone levels–can cause poor semen quality, poor testicular function and may disturb libido.  May be caused by a diet high in iodine.  Reducing iodine intake or beginning thyroid hormone replacement therapy can elevate sperm count.  This condition is found in only 1 percent of infertile men.

Congenital Adrenal Hyperplasia

Occurs when the pituitary is suppressed by increased levels of adrenal androgens.  Symptoms include low sperm count, an increased number of immature sperm cells, and low sperm cell motility.  Is treated with cortisone replacement therapy.  This condition is found in only 1 percent of infertile men.

Hypogonadotropic Hypopituitarism

Low pituitary gland output of LH and FSH.  This condition arrests sperm development and causes the progressive loss of germ cells from the testes and causes the seminiferous tubules and Leydig (testosterone producing) cells to deteriorate.  May be treated with the drug Serophene.  However, if all germ cells are destroyed before treatment commences, the male may be permanently infertile.


Complete pituitary gland failure–lowers growth hormone, thyroid-stimulating hormone, and LH and FSH levels.  Symptoms include:  lethargy, impotence, decreased libido, loss of secondary sex characteristics,


and normal or undersized testicles.  Supplementing the missing pituitary hormones may restore vigor and a hormone called hCG may stimulate testosterone and sperm production.

Physical Problems

A variety of physical problems can cause male infertility.  These problems either interfere with the sperm production process or disrupt the pathway down which sperm travel from the testes to the tip of the penis.  These problems are usually characterized by a low sperm count and/or abnormal sperm morphology.  The following is a list of the most common physical problems that cause male infertility.


Azoospermia is the complete absence of sperm in the semen and as such means that a man will be completely infertile. The diagnosis of azoospermia is sometimes still made even though as many as 500,000 sperm per ml of semen may have been seen because it is extremely unlikely that the man will be able to father a child naturally with this number of sperm. Its incredible to realise that millions are needed for any chance of natural conception!

However, modern techniques such as ICSI (intra cytoplasmic sperm injection) mean that a man can still father his own biological child with expert medical help – This means that you must ask your doctor whether you have either (i) a very low sperm count so that you know you do at least make some sperm or (ii) absolutely no sperm at all which is the worst case scenario for any man to face.

In fact it is rare that a man has absolutely no sperm at all and as long as some sperm are produced it is possible nowadays to help couples have children via the ICSI procedure. So, if the doctor says you have azoospermia make sure you ask for a copy of the semen analysis results so that you can understand the situation.

Azoospermia occurs in about 2% of men in the general population. So whilst not common there are plenty of infertile men around – in the UK alone we would expect to find at least 300,000 men with azoospermia and many of these would appear extremely healthy and have no indication that any problem might exist !

Around 10-20% of men attending infertility centers will probably have azoospermia as well. This means that if you and your partner have been trying for a year or more to have a baby there is an increased risk that you may have a problem.


Oligospermia is the leading cause of male fertility problems. A normal sperm count is 20 million or more per millimetre of semen. In order for conception to occur, a minimum of 60% of these sperm should have a normal shape (morphology) and normal forward movement (motility).


However, the above sperm count figure represents a general guideline, as some men with a higher sperm count have had difficulty conceiving while men with a sperm count lower than this number have been able to successfully get their partners pregnant.


Necrospermia is a condition in which sperm are produced and found in the semen but are not alive and are unable to fertilize eggs. That over 40% sperms are dead in the semen analysis indicates necrospermia.

Necrospermia is a condition in which sperm are produced and found in the semen but are not alive and are unable to fertilize eggs. That over 40% sperms are dead in the semen analysis indicates necrospermia.

Necrospermia is still a poorly documented cause of male infertility. Among infertile subjects, the incidence reported in the literature is 0.2 to 0.48 per cent. We undertook a retrospective study to contribute to the comprehension of this abnormality. Histories, physical examination, analysis of the semen and hormonal dosages performed in necrozoospermic subjects were reviewed. We observed that in patients with necrospermia in at least three semen samples, infections represent 40 per cent of aetiologies. In 20% of the whole population, no aetiology was observed, but abnormalities of the epididymis function were suggested. Through this study, we suggest an aetiological classification and practical guidance in case of necrozoospermia.

Antisperm Antibodies

Necrospermia is still a poorly documented cause of male infertility. Among infertile subjects, the incidence reported in the literature is 0.2 to 0.48 per cent. We undertook a retrospective study to contribute to the comprehension of this abnormality. Histories, physical examination, analysis of the semen and hormonal dosages performed in necrozoospermic subjects were reviewed. We observed that in patients with necrospermia in at least three semen samples, infections represent 40 per cent of aetiologies. In 20% of the whole population, no aetiology was observed, but abnormalities of the epididymis function were suggested. Through this study, we suggest an aetiological classification and practical guidance in case of necrozoospermia.


This condition may be treated by several methods such as cortisone, sperm washing which increases sperm concentration, intrauterine insemination, or in vitro fertilization. Semen volume – the amount of fluid that makes up the semen


  • Sperm count – the number of sperm present in a standard volume. A normal sample contains more than 20 million sperm per milliliter.
  • Motility – the percent of sperm moving when the semen is examined under the microscope. Normal is defined as >50% motile.
  • Progression – the forward movement of sperm cells
  • Viability – the percent of live sperm
  • Sperm morphology or shape

Additional semen contents, such as white blood cells, are an indication of infection. Less than five white blood cells per high power field is considered normal.

Average volume of ejaculate    0.5 to 1 teaspoon
Chief ingredient    Fructose sugar
Caloric content 5 calories per teaspoon
Protein content 6 milligrams per teaspoon
Average number of ejaculatory spurts 3 to 10
Average interval of ejaculatory contractions 0.8 seconds
Farthest medically recorded ejaculation 11.7 inches



A varicocele is an enlargement of the internal spermatic veins that drain blood from the testicle to the abdomen (back to the heart) and are present in 15% of the general male population and 40% of infertile men.  These images show what a variocoele looks like externally and internally.

A varicocele develops when the one way valves in these spermatic veins are damaged causing an abnormal back flow of blood from the abdomen into the scrotum creating a hostile environment for sperm development.  Varicocoeles may cause reduced sperm count and abnormal sperm morphology which cause infertility.  Variococles can usually be diagnosed by a physical examination of the scrotum which can be aided by the Doppler stethoscope and scrotal ultrasound.  Varicocoele can be treated in many ways (see treatment section), but the most successful treatments involve corrective surgery.

Damaged Sperm Ducts

Seven percent of infertile men cannot transport sperm from their testicles to out of their penis.  This pathway may be blocked by a number of conditions:

  • A genetic or developmental mistake may block or cause the absence of one or both tubes (which transport the sperm from the testes to the penis).
  • Scarring from tuberculosis or some STDs may block the epididymis or tubes.
  • An elective or accidental vasectomy may interrupt tube continuity.


Is a common problem affecting fertility that is caused by a supportive tissue abnormality which allows the testes to twist inside the scrotum which is characterized by extreme swelling.  Torsion pinches the blood vessels that feed the testes shut which causes testicular damage.  If emergency surgery is not performed to untwist the testes, torsion can seriously impair fertility and cause permanent infertility if both testes twist.

Infection and Disease

Mumps, tuberculosis, brucellosis, gonorrhea, typhoid, influenza, smallpox, and syphilis can cause testicular atrophy.  A low sperm count and low sperm motility are indicators of this condition.  Also, elevated FSH levels and other hormonal problems are indicative of testicular damage.  Some STDs like gonorrhea and chlamydia can cause infertility by blocking the epididimis or tubes.  These conditions are usually treated by hormonal replacement therapy and surgery in the case of tubular blockage.

Testicular Failure

This generally refers to the inability of the sperm-producing part of the testicles (the seminiferous elithelium) to make adequate numbers of mature sperm. This failure may occur at any stage in sperm production for a number of reasons. The testicle may completely lack the cells that divide to become sperm (Sertoli Cell-Only Syndrome). There may be an inability of the sperm to complete their development (maturation arrest). Sperm may be made in such low numbers that few, if any, successfully travel through the ducts and into the ejaculated fluid (hypospermatogeneses). This situation may be caused by genetic abnormalities, hormonal factors, or varicoceles.


Even in the case where the testes are only producing low numbers of sperm, the sperm may be harvested and used in conjunction with advanced reproductive techniques to attempt a pregnancy.


Cryptochiridism may be a cause of testicular failure. When a baby boy is born without the testes having fully descended into the scrotum, the condition is known as cryptorchidism.

Since the testes are very sensitive to temperature, if they do not descend into the scrotum prior to adolescence, they will stop producing sperm altogether. In fact, they have a higher rate of malignancy. The current recommendation is that at approximately one year of age, if the testes have not descended by themselves, they be brought down surgically.

Cryptorchidism is often associated with male factor infertility. Eight-one percent of men who have a single testis that is cryptorchid have normal fertility. However, approximately, 50% of men who have bilateral cryptorchidism have normal fertility. This may be due both to something inherent in the testes, to the surgery, or to damage done by not having the testes brought down in time.


Mumps is the best-known cause, but is not the only one. Mumps will only affect fertility if it causes orchitis and, even then, only rarely. Undescended testicles (cryptorchidism) are another common cause of failure of sperm production. Male infants and children are routinely examined to identify this problem, as future fertility can only be preserved if surgical treatment to fix the testicles in the scrotum is performed in early childhood. Even surgery in infancy does not guarantee future fertility.


Orchitis is an inflammation of testicle tissue. Mumps orchitis, a complication of the childhood viral disease, is the most typical example of complication in childhood; however, some men who get mumps with swelling of the parotid gland (the saliva-producing glands in the cheeks) will experience an inflammation in one or sometimes both testicles.

Klinefelter’s Syndrome

Is a genetic condition in which each cell in the human body has an additional X chromosome–men with Klinefelter’s Syndrome have one Y and two X chromosomes.  Physical symptoms include peanut-sized testicles and enlarged breasts.  A chromosome analysis is used to confirm this analysis.  If this condition is treated in its early stages (with the drug hCG), sperm production may commence and/or improve.  However, Klinefelter’s Syndrome eventually causes all active testicular structures to atrophy.  Once testicular failure has occurred, improving fertility is impossible.

Retrograde Ejaculation

Is a condition in which semen is ejaculated into the bladder rather than out through the urethra because the bladder sphincter does not close during ejaculation.  If this disorder is present, ejaculate volume is small and urine may be cloudy after ejaculation.  This condition affects 1.5 percent of infertile men and may be controlled by medications like decongestants which contract the bladder sphincter or surgical reconstruction of the bladder neck can restore normal ejaculation.


Psychological/Physical/Behavioral Problems

Several sexual problems exist that can affect male fertility.  These problems are most often both psychological and physical in nature:  it is difficult to separate the physiological and physical components.

Erectile Disfunction (ED)

Also known as impotence, this condition is common and affects 20 million American men.  ED is the result of a single, or more commonly a combination of multiple factors.  In the past, ED was thought to be the result of psychological problems, but new research indicates that 90 percent of cases are organic in nature.  However, most men who suffer from ED have a secondary psychological problem that can worsen the situation like performance anxiety, guilt, and low self-esteem.  Many of the common causes of impotence include:  diabetes, high blood pressure, heart and vascular disease, stress, hormone problems, pelvic surgery, trauma, venous leak, and the side effects of frequently prescribed medications (i.e. Prozac and other SSRIs, Propecia).  Luckily, many treatment options exist for ED depending on the cause–these will be discussed in the treatment section.

Premature Ejaculation

Is defined as an inability to control the ejaculatory response for at least thirty seconds following penetration.  Premature ejaculation becomes a fertility problem when ejaculation occurs before a man is able to fully insert his penis into his partner’s vagina.  Premature ejaculation can be overcome by artificial insemination or by using a behavioral modification technique called the “squeeze technique” which desensitizes the penis.


Ejaculatory Incompetence

This rare psychological condition prevents men from ejaculating during sexual intercourse even though they can ejaculate normally through masturbation.  This condition sometimes responds well to behavioral therapy; if this technique does not work, artificial insemination can be employed using an ejaculate from masturbation.

General Medical Disorders that Reduce Fertility

There are several conditions that may reduce fertility

  • Fever

    Influenza (flu), pneumonia, or even a severe cold can cause a high fever, which will adversely affect sperm production and quality. These changes usually recover over a few weeks.

  • Diabetes

    In the longer term, diabetes can cause problems with erection and ejaculation through causing damage to the function of the ‘automatic nervous system’.

  • High Blood Pressure

    Hypertension (high blood pressure) can cause problems with erection, either directly or as a side effect of medication.

  • Coronary Artery Disease

    Coronary artery disease can cause problems with erection. This could be due to generalised hardening of the arteries, in the penis as well as the heart, or to drugs used in the treatment of heart problems.

  • Neurological Disorders

    Multiple sclerosis, stroke, and spinal cord injury and disease can all cause problems with erection and ejaculation.

  • Kidney Disease

    Chronic renal failure, which results in a build up of waste products in the body, can adversely affect sperm quality and fertility. It can also cause erection problems.

  • Cancers

    That affect the genital tract or endocrine (hormone-producing) systems may directly reduce fertility. Otherwise, drugs and radiation used to treat cancer may severely reduce sperm production or even stop it altogether. Stress (see below) may also have an effect.

  • Alcoholism

    Alcohol is toxic to sperm and overuse of alcohol can reduce sperm quality and fertility.

  • Stress

    Stress causes several hormonal changes in the body that can affect fertility. Stress can have many causes, including anxiety over fertility problems.


  • General Health and Lifestyle

    A man’s general health and lifestyle may affect fertility. Some common causes of infertility related to health and lifestyle include:

  • Emotional Stress

    Stress may interfere with certain hormones needed to produce sperm. Your sperm count may be affected if you experience excessive or prolonged emotional stress. A problem with fertility itself can sometimes become long term and discouraging, producing more stress. Infertility can affect social relationships and sexual functioning.

  • Malnutrition

    Deficiencies in nutrients such as vitamin C, selenium, zinc and folate may contribute to infertility.

  • Obesity

    Increased body mass may be associated with fertility problems in men.

  • Cancer and its Treatment

    Both radiation and chemotherapy treatment for cancer can impair sperm production, sometimes severely. The closer radiation treatment is to the testicles, the higher the risk of infertility. Removal of one or both testicles due to cancer also may affect male fertility.

  • Pesticides and other Chemicals

    Herbicides and insecticides may cause female hormone-like effects in the male body and may be associated with reduced sperm production and testicular cancer. Lead exposure may also cause infertility.

  • Substance Abuse

    Use of cocaine or marijuana may temporarily reduce the number and quality of your sperm.

  • Other Medical Conditions

    A severe injury or major surgery can affect male fertility. Certain diseases or conditions, such as diabetes, thyroid disease, Cushing’s syndrome, or anemia may be associated with infertility.

  • Age

    A gradual decline in fertility is common in men older than 35.

Possible Causes

General Health

Even in the absence of systemic illness, poor general health will impair fertility.


  • Aim for an ideal BMI.
  • In those who are overweight (BMI 25 to 30) and obese (BMI>30) there is a relationship between the degree of excessive weight and poor quality and quantity of sperm.11
  • The adverse effects of smoking on male fertility are inadequately appreciated.12,13


  • Excessive alcohol consumption also impairs fertility.14
  • The effect of lower levels of consumption does not seem to have been adequately researched.
  • Male exposure to recreational drugs, toxic substances in the workplace and ionising radiation do not seem to have a significant effect on fertility, but may cause an increase in congenital malformations, spontaneous abortions, fetal resorption, low birth weight infants, increase in childhood cancers, developmental and behavioural abnormalities.15
  • Past abuse of anabolic steroids may cause infertility.16
  • It is reasonable to suggest that anyone intent on embarking on the rigours of fatherhood should show responsibility with regard to alcohol, drugs and other aspects of lifestyle.

Disorders of the Testis and Spermatogenesis

These may be structural or hormonal.

  • Persistent azoospermia is incompatible with fertility.
  • Whilst a low sperm count is a poor prognostic feature, and the lower the count the worse the prognosis, it is not totally incompatible with fertility.
  • Klinefelter’s syndrome with karyotype XXY is associated with hypogonadism and disorders of spermatogenesis.
  • Failure of descent of the testes has already been mentioned.
  • Early orchidopexy is required to permit normal development.
  • Testicular feminisation is when there is resistance to the virilising effects of androgens and a child with an XY karyotype appears as a girl.
  • This can be much less complete and more limited resistance to androgens can lead to poor development of the testes.17
  • Testicular tumours are usually treated by orchidectomy, possibly followed by radiotherapy.
  • In men presenting with infertility and abnormal semen analysis there is a 20-fold increase in the risk of testicular cancer.18
  • Treatment of testicular cancer reduces fertility by 30%, but this is most marked in those who have received radiotherapy.19
  • Traditional teaching has been that varicocele results in a warmer environment for the testis and that this impairs spermatogenesis and fertility.
  • There has been much dispute over the years about the significance of varicocele, but an interesting recent observation is that varicocele is more associated with secondary than primary infertility and so it may be responsible for a premature decline in sperm count.20
  • Trauma can cause testicular damage.
  • Pituitary tumours will displace or destroy normal tissue and the production of FSH and LH is often the first to be affected.
  • Panhypopituitarism is also called Simmond’s disease.
  • Hyperprolactinaemia rarely present with galactorrhoea in men.
  • In one study it caused gynaecomastia in 8% of men but impotence in 30%.21
  • The control of prolactin is unlike the other releasing factors in that it is controlled by an inhibiting rather than a releasing factor from the hypothalamus into the hypothalamic-pituitary portal circulation.
  • It is also released in response to thyrotrophin releasing factor, as is TSH, and so it is elevated if thyroxine is low.
  • The pituitary gland may be responsible for other disorders such as Cushing’s syndrome.
  • Low levels of testosterone are found in 20 to 30% of infertile men, but giving testosterone does not improve fertility.16

Disorders of the Genital Tract

  • Failure of adequate differentiation of the embryonic testis can cause failure of proper development of the spermatic ducts.
  • In vasectomy the objective is to interrupt the vas deferens and it may be possible to reunite this in an attempt to reverse the procedure but the success rate as measured by successful pregnancy is poor.


  • Congenital urogenital abnormalities such as hypospadias can cause problems. It tends to deposit the semen in the acid environment of the vagina rather than near the friendlier environment of the cervix.
  • Does the possession of just one testis impair fertility?
  • In theory it should reduce the sperm count by 50% that would have no significant effect on fertility.
  • However, the loss of the testis may have been associated with other problems that may have had an adverse effect on the other one such as chemotherapy or radiotherapy for cancer.
  • Where a single testis has been lost or failed to develop in the absence of other problems, the presence of just one testis does not have an adverse effect on fertility.

Signs and Symptoms

Statistically, a couple’s failure to achieve conception is equally as likely to result from a problem with the man as with the woman.


Over the last several decades, concern has risen about the impact of industrialization on reproductive health. This concern stems largely from reports showing that semen quality of men in Europe and the United States has decreased over the latter half of the 20th century. The environmental toxins most often cited as potential contributors to infertility can be organized into physical, chemical, occupational and lifestyle factors. Hyperthermia (increased temperature), radiation and electromagnetic fields, for example, are several physical factors that have been linked to infertility in men. Cigarette smoking, excessive alcohol consumption, marijuana and cocaine use as well as caffeine intake may contribute to chemical causes of infertility. Occupational hazards such as some pesticides, industrial toxins like dioxin and polychlorinated biphenyls (PCBs), and exposure to heavy metals also may be linked to infertility. Finally, stress, nutrition and other lifestyle factors also can play a role.

Any fertility treatment may be expected to have an effect on semen quality roughly three months after it is started, as this is the length of time required for a single cycle of spermatogenesis, or sperm production. If neither surgical nor medical therapy is appropriate, assisted reproductive technologies are possible.

In choosing a treatment plan, consideration should be given to each couple’s long-term goals and financial constraints and the results of the female partner’s evaluation in addition to male factor findings.

Male Symptoms

Some men experience physical symptoms that indicate a cause of infertility and assist the healthcare provider to make a diagnosis, while others have none.


A change in the size of a man’s testes and weight gain or loss can be relevant. Reporting symptoms in a timely fashion can help your physician make a diagnosis and bring you and your partner one step closer to your goal.

Here you will find descriptions of symptoms that can be linked to male infertility. They have been categorized according to how they manifest themselves, such as through infection or physical indicators.

They are categorized into 2 groups:

  • Infections
  • Physical signs/symptoms


Certain infections have been known to affect a man’s fertility. In most instances the impact is minimal, but in the case of sexually transmitted diseases (STDs), the effects can be severe.

  • Mumps

If a man has had mumps as an adult or a child, it should be mentioned to the healthcare provider or specialist. Commonly the virus affects only the glands below the jaw, which does not usually compromise fertility. If, however, the virus affects the testicles, it can cause a condition called mumps orchitis. Approximately one-third of these men will experience reduced testicular function that can lead to abnormal sperm count or motility.

  • Sexually Transmitted Diseases (STDs)

Chlamydia can do permanent damage if not treated and can eventually cause infertility. Even if a man had chlamydia in the past and was treated for it, the residual effects can be destructive. If a man has been treated for STDs in the past (especially chlamydia), one of the following infertility diagnoses may apply:

  • Azoospermia
  • Epididymitis
  • Sperm Problems
  • Urinary Tract Infections (UTIs)

Recurrent UTIs are not necessarily a sign of an infertility problem, but may be indicative of other problems. If a man has them regularly, it should be mentioned to the healthcare provider since it may suggest an immunological problem.

Physical symptoms

Some men may be symptomatic while others may need a healthcare provider to detect the problem. Some physical symptoms can indicate an underlying infertility problem.

  • Swollen Testes

The man himself is the best judge of whether or not his testicles are swollen.


If the testes appear to be swollen, this may suggest epididymitis — a condition in which the epididymis (the site of sperm storage) becomes inflamed.

  • Undescended Testes

Undescended testes are usually surgically corrected at a very young age, however it is still important to inform the healthcare provider since the correction may have caused a hernia. If the condition wasn’t corrected, the scrotal sac will still be present, but will feel empty. This may indicate an infertility condition called cryptorchidism.

  • Vasectomy and Vasectomy Reversals

If a man has had a vasectomy reversal, his healthcare provider should be informed. Vasectomy reversals are not always successful and can cause a man to develop problems later on such as blockages, sperm problems and azoospermia.

Preventing Male Infertility

Often preventing infertility is much easier and better than treating it! What can you do to reduce the risk of being infertile ? The biggest preventable danger to male fertility is due to uncontrolled sexually transmitted diseases (STDs) such as syphilis, gonorrhea and chlamydia which can cause irreparable damage to the reproductive tract .

Another important preventable cause of testicular damage in men is uncorrected undescended testes. Undescended testes should be surgically treated at an early age to prevent damage – preferably before the age of 2 years. This requires educating mothers of young boys; and doctors as well. It may also be a good idea to immunise boys against mumps in childhood, thus preventing the ravage which mumps can cause to the testes in later life.

Drugs – including alcohol, cocaine and marijuana – are all poisons. They can reduce sex drive; damage sperm production; and interfere with ovulation – and sometimes this damage is irreparable. Smoking tobacco also affects reproductive function – by depleting egg production; increasing the risk of PID; and lowering sperm counts. Often, the adverse effect is temporary, so that when these are stopped, the harmful effects on reproductive function are likely to be reversed. However, since abstinence is easier than moderation, the best option is not to smoke, drink or use drugs

Occupational hazards can also decrease sperm counts. Many toxic drugs – including radiation, radioactive materials, anesthetic gases, and industrial chemicals such as lead, the pesticide DBCP and the pharmaceutical solvent ethylene oxide can reduce fertility by imparing sperm production. Intense exposure to heat in the workplace (for example, long-distance truck drivers exposed to engine heat; and men working in furnaces or in bakeries) can cause long-term and even permanent impairment of sperm production. You should be aware of these hazards and may need to control your exposure if fertility is a concern.

Interestingly, many researchers have observed that sperm counts the world over are declining. Whether this is due to exposure to toxic chemicals such as dioxins ( formed as a result of environmental pollution) , which cause disruption of the endocrine system; or to the stresses of modern day life remains unclear.

What can you do to improve your sperm count ? Stop smoking, drinking or abusing drugs. Most doctors will advise that you take vitamins ( such as Vitamin E, Vitamin C); and others prescribe antioxidants and selenium, though the effect of these on male fertility is still a contentious issue. Traditional advise included taking cold water showers and wearing loose underwear, to help keep the testicular temperature low and “ sperm friendly “, but the results can be unpredictable. Certain drugs ( for example, salazopyrine which is used for treating ulcerative colitis) can suppress sperm counts, so if you are taking prescription medicines, ask your doctor about what their effect on sperm counts it. One simple way of increasing your chances of getting your wife pregnant is to have sex frequently – the more the sperm you deposit, the better your chances of hitting the jackpot!


Does cigarette smoking affect male fertility?

Research on the effect of smoking on semen quality is unclear.  However, it is generally recommended that men quit smoking if they are trying to have children.  A greater number of birth defects have been found in the children of men who smoke heavily.

Does alcohol affect fertility?

What sexually transmitted infections can affect fertility?

Sexually transmitted infections (STIs), such as gonorrhoea, can damage the epididymis, preventing sperm from passing from the testes into the ejaculate.  Genital herpes, while not affecting sperm production or transport, is a problem when spread to a female partner, particularly if a couple is trying to get pregnant.

It is important for men who think they may have a STI to get immediate treatment from a doctor.  This can stop the spread of the disease to a partner and also reduce the chance of blockages developing in the male reproductive tract.  Safe sex practices involving the use of condoms are generally recommended when not attempting to have a family.

Both partners may want to be tested for STIs before trying to have a family.  This may stop any disease being passed on to partners or children.

Do underwear styles really affect fertility?

There is ongoing debate about the effect of underwear styles on sperm production.

Whether looser (cooler) boxer shorts are better than tighter (warmer) briefs is unclear.  Some research has suggested that wearing tight underwear can decrease sperm counts, although other studies have not found this to be the case.

Doctors usually suggest that patients reduce the chances of heat stress on sperm production by avoiding tight-fitting clothing.

How do spas and saunas affect fertility?

It is generally recommended that men avoid spas, saunas and hot baths if trying to father a child.  Raising the body temperature, and particularly the temperature around the testes, can reduce sperm production.  Sperm need a cooler environment to develop.

What work environments affect fertility?


Although there is no clear evidence that certain work environments affect fertility, it is generally recommended that couples trying to become pregnant avoid exposure to any possible harmful chemicals.  Pesticides, heavy metals, toxic chemicals and radiation may affect the quality and quantity of sperm produced.

Do recreational drugs affect fertility?

Androgens (anabolic steroids) taken for body building or sporting purposes, reduce sperm production by stopping the hormones made by the pituitary gland.  Androgens can also be harmful to general health if men who have normal testosterone levels take them.  These drugs should be stopped immediately, particularly if a couple is trying to have a baby.

Other illegal use of drugs, such as marijuana, may also affect fertility.  There is some proof of a harmful effect on testicular function in some men, therefore it is suggested that men avoid using these drugs.

How do vaginal lubricants affect the chances of becoming pregnant?

Many vaginal lubricants are toxic to (kill) sperm.  If couples are trying to become pregnant, the use of vaginal lubricants should not be used during the fertile time in the female partner’s menstrual cycle.

Is age important when trying to have a family?

It is well known that the chances of becoming pregnant drop as a woman becomes older.  This is particularly true for women using IVF procedures.  After a woman is over 35 years, the chance of assisted reproduction being successful are reduced, even if the infertility problem is mainly due to the man.

New research has shown that men’s fertility slightly drops with age. It can take longer for couples to become pregnant once the man is over 45 years of age4.  The amount of semen ejaculated (semen volume) and the movement of the sperm (sperm motility) also seems to decrease as men get older 5.

Why is sperm storage recommended before some treatments?


Sperm storage is the collection (through masturbation) and freezing of semen.  Men about to start treatment that could make them infertile, may want to consider storing sperm before starting treatment.  If and when a couple want to have a family this semen can be thawed and used in fertility treatments such as vaginal insemination at the time of ovulation or, in some cases, through IVF (in vitro fertilisation).

All men and teenage boys, who have started or passed puberty, and who are about to receive chemotherapy or radiotherapy should consider sperm storage before their cancer treatment starts.

Men who need to take medicines for other health reasons when they are also trying to start a family, should check with their doctor to make sure that the medicine does not cause infertility.  If medicines cause infertility, such as Salazopyrin (used to treat inflammatory bowel disease), men can also store sperm before starting treatment.

Men who have taken hormone treatments in order to improve sperm production, but wish to stop this therapy after their first child has been born, may wish to store some sperm for later possible pregnancies.

Men planning a vasectomy should think about storing sperm before having this procedure.  This may remove the possible need for vasectomy reversals or IVF at a later stage.


If you and your partner are finding it difficult to get pregnant, it may be a good idea to visit your local fertility clinic for a physical workup. Here, your reproductive endocrinologist will analyze both male and female factors in order to find out exactly what is going on with your fertility. Sometimes, male factor infertility can play a large role in pregnancy difficulties. Azoospermia can cause serious problems with sperm production and transfer, preventing a man’s sperm from entering his ejaculate. This can make pregnancy very difficult, if not impossible. However, new techniques are now being performed to help men with azoospermia father biological children.


What is Azoospermia?

Azoospermia is one of the most severe forms of male factor infertility. It is a condition in which a man has no sperm in his ejaculate. In order to transport sperm outside of the body, it mixes with ejaculate (semen) at certain places throughout the male reproductive system. Sometimes, due to blockages or sperm production problems, sperm does not mix with ejaculate, and therefore cannot leave the body. This is why so many men with azoospermia find it difficult to have children.

There are actually two types of Azoospermia

Obstructive Azoospermia: Obstructive Azoospermia – The result of obstruction in either the upper or lower male reproductive tract (epididymis, vas deferens, seminal vesicles or ejaculatory ducts). Sperm production may be normal (which may be verified through testicular biopsy or aspiration), but the obstruction is preventing the sperm from being ejaculated. Some causes of obstructive azoospermia are vasectomy, congenital absence of vas deferens, scarring from past infections, and hernia operations, or some genetic conditions such as Cystic Fibrosis. Some sperm may be found and extracted directly from the testicles.

Non-obstructive Azoospermia: Severely impaired or non-existent sperm production in the testicle.  The function of the testicle is twofold.  One is production of male hormones, and the other is production of sperm.  Insufficiency of one or the other is frequently congenital, but in some situations can be acquired during one’s life.  If the system of the testicle which produces hormones is impaired, the hormones could be substituted by numerous preparations readily available.  Unfortunately, if the system producing sperm is impaired or missing, the only substitute is donor/surrogate semen.  Many couples in similar situations prefer using semen form a properly screened donor under a physician’s supervision, compared to adoption.  Sometimes the genetic and biological information about the adopted child are not available; sometimes care of the child after birth has been deficient and improper, leading to the acquisition of various diseases, for example HIV/AIDS and many others.

How Common is Azoospermia?


Azoospermia affects only about 2% of the general male population; however, it does account for a large percentage of those men actively seeking fertility treatments. It is thought that between 10% and 20% of men undergoing fertility treatments suffer from azoospermia. Most of these men have little or no sperm present in their ejaculate.

Symptoms of Azoospermia

Unfortunately, it is very difficult to recognize azoospermia without undergoing fertility testing. This is because there are no symptoms that occur along with the condition. You will likely have semen of a normal color and texture, and will encounter few difficulties with ejaculation. Only a sperm count can diagnose the condition.


Causes of Azoospermia

The are typically two main causes of azoospermia: a problem with sperm production or a problem with sperm transport. There are a variety of factors that may contribute to either of these causes.

Sperm Production Problems

Sometimes, azoospermia is the result of a dysfunction within the testes themselves, making it impossible for your body to produce enough viable sperm. In order to produce sperm, the proper cells need to be present in the testes and the proper hormones need to trigger sperm production. Failed sperm production is often the result of:

Hormonal Abnormalities

Sometimes your body may not produce enough of certain hormones involved in the sperm-making process, causing azoospermia. Hormonal imbalances caused by anabolic steroid use or particular disorders, like Cushing’s Syndrome, can contribute to azoospermia.


Cryptorchidism, or undescended testicles, is a condition in which your testes have not descended properly. It is generally corrected in childhood, however, if it isn’t corrected, your testicles will be unable to produce sperm properly.

Vascular Trauma

Trauma to the testes or to the blood vessels within the testes can also prevent your body from producing sperm. Varicocele causes veins in the testes to enlarge and become swollen. As a result, blood pools in the testes, impairing sperm production.

Sperm Transport Problems

In order for sperm to leave your body, it must be transported from your testes to your urethra. Sperm travels through a series of ducts inside of your reproductive system, until it eventually mixes with your ejaculate and exits your body. Sometimes, blockages can occur inside of these ducts preventing sperm from mixing with your ejaculate. Sperm transport problems are often caused by:

  • Vasectomy: The vasectomy procedure introduces a cut or blockage into your vas deferens, preventing sperm from mixing with your ejaculate.
  • Congenital Absence of Vans Deferens: Some men are born without the vas deferens, which are tiny tubes that carry sperm to the urethra for ejaculation.
  • Infection: Certain infections, including STDS, can cause blockages in the epididymis or vas deferens, preventing sperm from mixing with your semen.

Causes of Obstructive Azoospermia


You may have been born with genes that may cause infertility. A gene is a piece of DNA that tells your body what to do or what to make. Genes may affect sperm transport, such as in congenital bilateral absence of the vas deferens.


Infections of the male reproductive system, such as in the testicles or prostate, may affect male fertility.



Previous injury or surgery to the spine, pelvis, lower abdomen (stomach), or male sex organs may cause damage to the male reproductive system. This may include surgery on an inguinal (groin) hernia. Trauma may affect sperm production or cause an obstruction in the flow or transport of sperm.


A varicocele is a condition where the veins (blood vessels) in the scrotum are enlarged and dilated (widened). Ask your caregiver for information about varicocele.


A vasectomy is a surgical procedure that is done on males as a method of birth control. The vas deferens (tubes that carry sperm from the testicles to the seminal vesicles) are cut, tied, or burned. The semen that is ejaculated no longer contains sperm.

Nonobstructive Azoospermia


Certain drugs, such as steroids, antibiotics, and drugs to treat inflammation or cancer may affect male fertility. Smoking, drinking alcohol, and using illegal drugs may also cause problems with sperm production.



You may have been born with genes that may affect sperm production, such as Klinefelter’s syndrome. These genes may also affect the formation of your reproductive (sex) organs, such as Kallmann’s syndrome.


Disorders of the testicles may produce abnormal levels of hormones that may affect the production of sperm.


Radiation, such as that used to treat cancer, may affect sperm production.

Retrograde Ejaculation

Retrograde ejaculation is when semen travels into the bladder instead of outside the body. It is usually caused by a problem with the neck of the bladder and may be due to spinal cord injuries, medicines, or diabetes.

Other Factors

Pesticides, heavy metals, heat, and undescended testes (testicles that did move from the abdomen into the scrotum) may affect sperm production.


What are the signs and symptoms of Azoospermia?

You may have any of the following:

  • Inability to get your partner pregnant.
  • Increased body fat, body hair, and breast tissue.
  • Clear, watery, or whitish discharge from the penis.
  • Presence of a mass or swelling on the scrotum that feels like a bag of worms (varicocele).
  • Stress or emotional pressure from not being able to conceive a child.
  • Testicles that are small, soft, or non-palpable (cannot be felt).
  • Veins that are enlarged, twisted, and may be seen in the scrotum (varicocele).

How is Azoospermia diagnosed?

Your caregiver will take a complete medical, reproductive, and sexual health history from you. He may need to know how long you have been trying to have a baby. The timing and frequency of your sexual activities, and problems with sexual urges and functions are also important. You will also be asked about your lifestyle, including alcohol intake and smoking, medications taken, and past diseases. You may need any of the following:

Physical Examination

Your caregiver will look for signs of any imbalance in your hormones, such as increased body fat, body hair, and breast tissue. The size and shape of your testicles will also be examined. Your caregiver may also do a digital rectal exam (DRE) to check your prostate and other parts of your reproductive system.


A sample of your testicle is taken by a needle or through a small incision (cut) in the scrotum. The sample is sent to a lab for tests. This will help determine the ability of the testicles to produce normal sperm.

Blood Tests

You may need blood taken for tests. The blood can be taken from a blood vessel in your hand, arm, or the bend in your elbow. It is tested to see how your body is doing. It can give your caregivers more information about your health condition. You may need to have blood drawn more than once.


Genetic Screening

Genetic testing may be done to look for abnormal genes. Abnormal genes may cause problems with sperm production, sperm transport, or formation of the male reproductive organs.

Imaging Tests

Dye may be used in certain tests to make pictures show up better. Tell your caregiver if you are allergic to shellfish (lobster, crab, or shrimp), as you may also be allergic to this dye. Imaging tests may include the following:

Magnetic Resonance Imaging Scan

This test is also called an MRI. An MRI uses magnetic waves to take pictures of your pituitary gland to check for other causes of your infertility. You will need to lie still during an MRI. Never enter the MRI room with an oxygen tank, watch, or any other metal objects. This may cause serious injury.

Spermatic Venography

This test will examine and show the position of the veins in the scrotum. It may be used to check for a varicocele.


A scrotal or transrectal ultrasound uses sound waves to find lumps and other changes in your testicles and scrotum. These tests may be used to check for a varicocele or any missing parts of the reproductive system.

Semen Analysis

A semen analysis is a test to check a man’s fertility. It is done by taking a semen sample. You may need to talk with your caregiver about the method of sample collection.


Post-ejaculatory urinalysis is a test that is done on your urine after you have ejaculated. This test looks for the presence of sperm in the urine, which may suggest an obstruction or problems with ejaculation.


Treatment for Azoospermia by Dr. &  Hakeem Tariq Mehmood Taseer

This treatment by Dr. Tariq Mehmood Taseer is especially for males with no sperms/ very less negligible sperms. A highly effective herbal and natural treatment to cure Azoospermia.


Low sperm count (oligospermia) is one cause of male infertility. Although it takes only a single sperm to fertilize an egg (ovum), the odds of a single sperm reaching the egg are very low. For this reason, having a low sperm count decreases your chance of getting your partner pregnant.


The lower your sperm count, the more likely you’ll have trouble fathering a child. But treatments for male infertility related to low sperm count can help. Urologists are skilled in evaluating men with fertility problems and can recommend treatment.

In addition to evaluating and treating male fertility problems such as low sperm count, your doctor may also suggest treating your female partner to increase her fertility. This can help compensate for male infertility. If other treatments aren’t effective, artificial insemination or in vitro fertilization can be used to produce a pregnancy when low sperm count is a factor



For most men, the only sign of low sperm count men is the inability to conceive a child (infertility. A couple is considered infertile if they’re unable to conceive after one year of regular intercourse. If sperm production is impaired by an underlying hormonal problem, you may have other signs such as decreased facial or body hair or problems with sexual function.

Although in many cases the exact cause isn’t always clear, possible reasons for low sperm count include:

  • Varicocele. This is a swollen vein inside the scrotum that can affect sperm production. This common cause of male infertility can be repaired with minor surgery.
  • Damaged sperm ducts. Inherited conditions, infections, surgeries or injuries can damage the delicate duct system that carries sperm from the testicles into the penis.
  • Anti-sperm antibodies. Men who have anti-sperm antibodies have an immune system response that attacks their own sperm. Common in men who have had a vasectomy reversal, this condition can also be caused by other problems such as an injury or infection.

Problems with Sperm Production

These issues can be caused by a genetic (inherited) condition such as Klinefelter’s syndrome or a hormonal disorder such as a health problem that affects the pituitary gland in your brain. If you have an inherited condition, you’re more likely to have complete lack of sperm in your semen (azoospermia).


Risk Factors

Factors that increase your risk of low sperm count include:

  • Genetic or hormonal problems. Certain health conditions affect sperm production, such as Klinefelter’s syndrome or a problem with hormone production.
  • Substance abuse. Sperm count can be reduced by use of illegal drugs such as cocaine or marijuana.
  •  Smoking. Smoking cigarettes affects sperm production. Secondhand smoke may also lower sperm count.
  • Being overweight. Being obese has been shown to cause hormonal changes that affect sperm production.
  • Exposure to environmental toxins. Exposure to radiation therapy, certain chemicals, heat and some medications can temporarily reduce sperm production.
  • Cancer treatment. Radiation treatment and chemotherapy can hamper sperm production.
  • Certain surgeries or injuries. Surgeries or injuries that affect the testicles or glands that produce hormones can affect sperm production.


A number of factors can help you maintain higher numbers of healthy sperm — and increase your chances of conceiving a child. Here are a few lifestyle decisions that may help:



  • Avoid excessive drinking. Excessive alcohol consumption (more than two drinks a day for men) has been shown to reduce sperm production and affect libido.
  • Steer clear of illegal drugs. Drugs including anabolic steroids, marijuana and cocaine can all affect sperm production and libido.
  • Keep the weight off. Obesity is linked to decreased sperm production.
  • Don’t get a vasectomy. If there’s any possibility you may want to father a child in the future, use other methods of birth control. Even though vasectomies can sometimes be reversed, you may have a reduced sperm count.
  • Keep cool. Avoid hot tubs, saunas and other sources of sustained heat, which can temporarily reduce sperm count. Tight underwear and sitting for long periods or using a laptop computer also may increase scrotal temperature.
  • Don’t smoke. Smoking can damage sperm and interfere with sperm production and libido. Secondhand smoke also may cause low sperm count.

Abnormalities in Sperm


This is reduced levels of normally shaped sperm less than 15% sperm of normal morphology.

  • Mild teratozospermia – 10-15% of sperm of normal morphology – probably of limited clinical significance
  • Severe teratozoopermia – less than 5% of sperm of normal morphology

Sperm Volume

A very low volume i.e. less than 0.5 ml may indicate a problem in producing the specimen (including missing the container), a dysfunction with the accessory glands or retrograde ejaculation.

High semen volume but low sperm numbers no need of semen concentration our medicine will take care of this problem.

Abnormal pH

An abnormally low pH i.e. less than 7.0 may indicate retrograde ejaculation when combined with a very low ejaculate volume. A pH of below 7.0, normal volume and azoospermia may indicate an obstruction of the ejaculatory ducts or congenital bilateral absence of the vas in this case result is poor.

An abnormally high pH i.e. greater than 8.5 may indicate an infection or dysfunction of one of the accessory glands result is good.

Abnormal Sperm Density

A sperm count below 20 x 10^6 / ml should be considered clinically relevant, a count nearby 5 x 10^6 / ml count will increase with treatment.

Reduced sperm count is generally idiopathic. However it may be due to defective spermatogenesis or an incomplete obstruction.

Abnormal Sperm Motility

If less than 50% of the sperm are moving progressively (asthenozospermia) a problem with motility or an increased level of sperm degradation may be indicated.

Decreased motility may be secondary to sperm dysfunction, prolonged periods of sexual abstinence, partial blockage or infection.

If greater than 50% of sperm are immotile then the analysis will determine whether the sperm are immotile or dead. This will determine whether the sperm immotility is due to cell death or a motility defect.

Increased cell death may be treatable if the cause is identifiable e.g. partial blockage, increased abstinence periods, infection. Immotile sperm can be used for assisted conception purposes as long as they are alive.

Lifestyle and Home Remedies


Taking care of yourself can help increase the number of healthy sperm in your semen.

  • Frequency of ejaculation. It’s important to have sex on a regular basis around the time of ovulation, when your partner can get pregnant. But ejaculating more than a few times a week can reduce the number of sperm present in your semen.
  • Avoid the heat. High body temperatures have been shown to decrease sperm production. Avoid hot tubs, saunas and exposure to hot weather. Tight fitting shorts or prolonged laptop computer use also may increase the temperature of your testicles, decreasing sperm production.
  • Make healthy lifestyle choices. Staying at a healthy weight and avoiding tobacco, excessive drinking and illegal drugs can all help reduce the risk of low sperm count.

Tests and diagnosis

When you see a doctor because you’re having trouble getting your partner pregnant, your doctor will try to determine the underlying cause. Sperm production is complex and requires normal functioning of the testicles (testes) as well as the hypothalamus and pituitary glands — organs in your brain that produce hormones that trigger sperm production. Problems with any of these systems can affect sperm production.

Initial Examination

Expect to answer detailed questions about your medical history and any sexual issues. Your doctor will do a careful physical examination of your reproductive organs to look for signs of a problem such as a varicocele — a varicose vein of the testicle.

Semen Analysis

Low sperm counts are diagnosed as part of a semen analysis test. Sperm count is generally determined by examining semen under a microscope to see how many sperm appear within squares on a grid pattern. In some cases, a computer may be used to measure sperm count. If you have no visible sperm in your semen sample, your doctor may use a more involved test to try to isolate any sperm present in your semen for examination.

To collect a semen sample, your doctor will have you masturbate and ejaculate into a special container. It’s also possible to collect sperm for examination during intercourse, using a special condom. Because measurements from sample to sample can vary widely, you’ll need to present a few samples for your doctor to get a clear picture of the quantity — and health — of your sperm.

Normal sperm densities range from 20 to greater than 100 million sperm per milliliter of semen. While men can reproduce with much lower numbers of sperm, your chance of getting your partner pregnant decreases along with decreasing sperm counts:

Less than half the men with sperm counts between 12.5 and 25 million sperm per milliliter are able to get their partner pregnant.

Less than one-quarter of men with sperm counts less than 12.5 million sperm per milliliter are able to get their partner pregnant.

There are many factors involved in reproduction, and some men with low sperm counts have fathered children. Likewise, some men with normal sperm counts have been unable to father children. The number of sperm in your semen is only one factor. Even if you have enough sperm, you’re much more likely to achieve pregnancy if at least half of your sperm have a normal shape and show normal forward movement (motility).

Your doctor may conduct further tests if he or she suspects your low sperm count is caused by an underlying condition. Your doctor will also want to make sure your female partner has been tested for any fertility problems.



If your doctor suspects your reproductive tract is blocked, he or she may order an ultrasound test. Scrotal ultrasound is used to detect a varicocele or blocked epididymis.

Testicular Biopsy

This procedure uses a fine needle to take a small tissue sample of the testicle to look for any abnormalities and to determine if sperm are present. The doctor will numb the area where the samples will be taken (generally one from either testicle). The procedure isn’t painful, but you may feel sore for a few weeks afterward.

Blood Tests and Genetic Tests

If your doctor suspects your low sperm count may be caused by an underlying hormonal condition, your doctor may test your blood for hormone levels. In some cases, problems with sperm production are linked to a genetic (chromosomal) abnormality. If your doctor suspects this is the case, genetic testing can be used to check for absent or abnormal regions of the male chromosomes (Y chromosomes).

Advantage of Treatment

  • The treatment is completely free of any side effects.
  • Medicine is effective in 95% in sperm abnormalities i.e. Low Sperm count, Low Motility, Low Semen Quantity and Abnormal Sperm Cell.
  • It is the fastest among all treatment. It raises sperm count fourfold with every month’s treatment till optimum count. So with low sperm count like 3 million per ml. to normal count of 40 million per ml. can be achieved within two months of treatment.
  • The lowest count which can be helped is 1 lac per ml or 0.1 million per ml. Below, this the result may be variable.
  • It does not support azoospermia or zero count at all.
  • It improves not only sperm count but also it’s quality. It raises low sperm motility to high sperm motility. It also improves grades of sperm motility simultaneously.
  • The success rate of system is very high. In about 3000 patients, it succeeded in 95% of the patients.
  • The Medicine provide by us are free from hormone.
  • The duration of the treatment is very short. It clears the case in one month to four months.
  • It has no restrictions during the treatment. No food restrictions. The only restriction is to avoid taking male hormones, as male hormone testosterone can block the good affect of this treatment. So, the patient should avoid taking any male hormones at least from one month prior to taking this treatment.
  • The greatest advantage is that even after stopping the treatment the higher count remains longer, where as in male hormones, it falls as soon as the treatment is stopped.
  • It is quite comfortable to take it, as it has sweet pills and drops only, to take with few doses per day.
  • So, this treatment being simpler avoids complicated procedures in case of male infertility.

Precaution Before and During Treatment

  • No oral or Hormonal treatment is allowed at least one month prior to this treatment and during the course of treatment.
  • Semen analysis report is must before starting treatment, so one can know the effect of treatment at middle and end of treatment.
  • Extra food supplements, Vitamins and other sexual tonic should be avoided during treatment.


Herbal Treatment for  Oligospermia by Dr. &  Hakeem Tariq Mehmood Taseer

Pure herbal treatment by Dr. Tariq Mehmood Taseer to cure infertility/low sperm count in males with well proven results. Has a very high success rate in treating different causes of infertility in males. Dosage and duration of the treatment may vary as per the patient profile. Treatment is without any side effects.

What is Necrospermia?

When semen has less of mature normal sperms & more of dead sperms this condition is abnormal. When ever there is less of normal sperm then chances of spontaneous pregnancy decreases (i.e. difficulty in conceiving i.e. wife does not becomes pregnant). This is one of the common causes of male factor infertility. This is also one of the most common semen abnormalities in men.

How sperms develop: When boy becomes of 14 years of age then L.H. & F.S.H. hormone secretion from pituitary increases. The rise in these hormones leads to proliferation of sperm forming cells (Germ Cells) in the testis. These germ cells start multiplying under the effect of above-mentioned pituitary  hormones along with assistance of other hormones as testosterones, Growth hormones, Androstenidione, insulin like growth factor-I, Thyroids hormone, paracrine hormone & growth factors. Under the control of above-mentioned hormones germs cells divide & transformed into primary spermatocytes. Then further maturation of primary spermatocytes to spermatids & then finally into mature spermatozoa (i.e. normal sperms) occurs under the control of above-mentioned hormones. After few weeks of progressive maturation inside the testis these sperms become normally motile & develop the capacity to fertilize the ovum. This total sperm cycle from first stage to final stage of normal mature sperms is of three months. Any hindrance in the development of these spermatozoa will lead to dead sperms, less count of sperm & decreased motility, immotile or even dead sperms.

Causes of Dead Sperm

The various causes of dead sperms are as follows:

  1. Deficiency of central sperm producing hormones

Hypothalamic: pituitary deficiency: Idiopathic GnRH deficiency, Kallman syndrome, Prader-Willi syndrome, Laurence-Moon-Biedl syndrome, Hypothalamic deficiency, pituitary hypoplasia, Trauma, post surgical, postiradiation, Tumour (Adenoma, craniopharyngioma, other), Vascular (pituitary infraction, carotid aneurysm), Infiltrative (Sarcoidosis, histiocytosis, hemochromatosis) Autoimmune hypophysitis, Drugs (drug-induced hyperprolactinemia,  steroids use)

Untreated endocrinopathies, Glucocorticoid excess, Hypopituitarism, Isolated gonadotropin deficiency (non acquired): Pituitary, Hypothalamic, Associated with multiple pituitary hormone deficiencies: Idiopathic pan hypo pituitarism (hypothalamic defects), Pituitary dysgenesis, Space-occupying lesions(craniopharyngioma, Rathke pouch cysts, hypothalamic tumors, pituitary adenomas), , Laurence-Moon-Beidl syndrome Prader-Willi syndrome , Frohlich syndrome, Hypergonadotropic hypogonadism : Klinefelter syndrome,  Noonan syndrome,  Viral orchitis, Cytotxic drugs, Testicular irradiation.

  1. Testicular disorders (primary leydig cell dysfunction i.e. Hypoganadism), Chromosomal (Klinefelter syndrome and variants, XX male gonadal dysgenesis), Defects in androgen biosynthesis, Orchitis (mumps, HIV, other viral, ),Myotonia dystrophica, Toxins (alcohol, opiates, fungicides, insecticides, heavy metals, cotton seed oil), Drugs (cytotoxic drugs, ketoconazole, cimetidine, spironolactone)
  2. Varicocelevaricocele is dilatation of scrotal vein in the scrotum that leads to rise in temperature of testis and raise testicular temperature, resulting in less sperm production & death of whatever sperms are produced.
  3. Drugs(e.g. spironolactone, ketoconazole, cyclophosphamide, estrogen administration, sulfasalazine)
  4. Autoimmunity i.e. presence of Antisperm antibody. These Antisperm antibodies bind with sperms & either make them less motile, totally immotile or even dead which is called necrospermia.
  5. Undescended Testicle(cryptorchidism). Undescended testis is a condition when one or both testicles fail to descend from the abdomen into the lower part of scrotum during fetal development. Undescended testicles can lead to less sperm production. Because the testicles temperature increase due to the higher internal body temperature compared to the temperature in the scrotum, sperm production may be affected.
  6. Mosaic Klinefelter’s syndrome In this disorder of the  chromosomes, of the man is abnormal. This causes abnormal development of the testicles, resulting in low sperm production. Testosterone production may be low or normal.
  7. Viral Orchits as mumps or other viral infections.
  8. Infections as tuberculosis, sarcoidosis involving testis or surrounding structures as epididymis.
  9. Chronic systemic diseases as Liver diseases, Renal failure, Sickle cell disease, Celiac disease
  10. Neurological disease as myotonic dystrophy
  11. Development and structural defects as mild degree of Germinal cell hypo-plasia
  12. Partial Androgen resistance
  13. Mycoplasmal infection
  14. Partial Immotile cilia syndrome
  15. Partial Spermatogenic arrest due to interruption of the complex process of germ cell  differentiation from spermatid level to the formation of mature spermatozoa results in decreased sperm count i.e. oligospermia. Its diagnosis is made by testicular biopsy. This is found in upto 30% of all cases of dead sperm patients.
  16. Heat Exposure to testis: as febrile illness or exposure to hot ambience induces a abnormality in spermatogenesis.
  17. Infection – as bacterial epididimo-orchitis, even in prostatis spermatogenic defect have been noted
  18. Hyper-thermia due to cryptorchidism
  19. Chromosomal abnormality: has been found in many cases of low sperm count
  20. Alcohol use, Cocaine or heavy marijuana use or Tobacco smoking may lower sperm count
  21. Anti-sperm antibodies.  In some people there occurs development of some abnormal blood proteins called anti-sperm antibodies, which binds with sperm and make them either immotile or dead or decrease their count.
  22. Infections. Infection of uro-genital tract may affect sperm production. Repeated bouts of infections are one of the common causes associated with male infertility.
  23. Klinefelter’s syndrome. In this disorder of the  chromosomes, a man has two X chromosomes and one Y chromosome instead of one X and one Y. This causes abnormal development of the testicles, resulting in low or absent sperm production. Testosterone production also may be lower.
  24. Trauma to testis
  25. Environmental toxins: as Pesticides and other chemicals in food  or as ayurvedic medicines.
  26. Genetic Factors: as idiopathic partial hypo-gonadotropic hypogonadism

Diagnosis of Cause of Dead Sperms


For correct diagnosis of cause of more of Dead sperm, we need detail history & physical examinations then certain relevant investigations are required.

History & Physical Examinations: First step in proper treatment is accurate diagnosis of cause of dead sperms. So we first try to find out cause. We take detailed history, thorough drug history and general physical examination, examination of testis, epididymis, testicular veins & sperm carrying duct examinations. These examinations give idea about whether testis is normally developed or not & how is its function. After that depending on likelihood of particular, cause relevant tests are done. All testing facilities are available at our centre. Thus you may consult us at our centre & at same time you may get all tests done. The time taken in getting all the reports ready is 36 hours.

Investigation & Diagnosis: For completes diagnosis of causes of dead sperms one or more of the following tests may be required as

1) Complete male hormone profile: This profile includes all the male hormone tests which control testicular development, functions including normal sperm Productions. The tests include L.H., F.S.H., Testosterones, prolactins, thyroids test, & other relevant hormone tests depending on history & examinations.

2) Antisperm antibody

3) USG or Doppler study of scrotum & testis

4) Semen culture sensitivity

5) Semen fructose

6) Immunobead test

7) Sperm Function Tests

8) Human Sperm-Zona Pellucida Binding Ratio

9) Human Sperm-Zona Pellucida Pentration test

10) Genetic Studies

11) FNAC Testis

12) Egg penetration test

13) Molecular genetic studies done in some special cases

14) Chromosome analysis i.e. Karyotype

15) Assessment of androgen receptor

16) Combined Pituitary hormone tests is performed when needed

17) MRI head if pituitary hormone defect suspected

18) Hemogram test for systemic diseases.

19) Sperm Function Tests

The hamster egg penetration assay (HEPA) and the hemizona assay (HZA) are sperm function tests which can help assess the ability of sperm to penetrate the egg. These tests will not definitively tell whether a pregnancy will occur, but an abnormal test result helps predict reduced fertilizing capability. These tests are performed only rarely today.

20) Semen Fructose

21) Sperm Coiling Test to find out whether the particular sperm is live or dead



Once the cause of low sperm count are found then with in three months of treatment sperm count & motility becomes normal in more than 90% cases.

The various treatments are as follows:

Correction of the Cause: First of all we try to find out the primary cause of infertility by above mentioned investigations. Then we correct the basic defect i.e. correction of hormone disorder & other defects. We also give following treatment for permanent cure of low sperm count & motility disorder.

1) Correction of Hormone deficiencies: Once the hormone disorder is found then it is corrected by any of the below medicines. Usually dead sperms problem is cured in three month time with proper hormone treatment.

2) Gonadotropin Therapy: Gonadotropins are most potent natural stimulators of sperm production in the testis. Once we start gonadotropin therapy, these gonadotropins stimulates the sperm producing cells in testis. Under the stimulating influence of gonadotropins dormant sperm forming cells which were not producing normal sperms, they start dividing & producing normal sperms. Thus in more than 90% cases sperm production can be normalized in three to four months time if it is started in properlyselected cases of low sperm count. Gonadotropin therapy is most successful of all the available treatment for dead sperms till now. In many cases of dead sperms, when all other treatment has failed even in those cases gonadotropin therapy is effective. Thus treatment of dead sperms with gonadotropin therapy results in pregnancy soon.

3) Repronex.

4) Bravelle

5) Ovidrel

6) Gonadotropin-releasing hormone (Gn-RH) analogs

7) Growth hormone therapy in many cases where somatotropin deficiency is found

8) Growth Factor, Mineral & Micronutrient Therapy

9) Free Radial Scavangers: These are drug to reduce the free damaging oxidative radical in the testis. For your information every minute lot of oxidant radicals are generated inside the testis which damages sperm forming cells. These special antioxidant drugs scavange these damaging oxidative free radicals thus leading to production of normal sperms by the testis. In many study these free radical scavengers have been found to be very-very effective in curing dead sperms.

10) Coenzyme ubique: These drugs improve the nutritional status of the testis. Thus testis as well as sperm forming cells get enough nutrient which helps in fast generation of normal sperms in good number with good motility & fertilizing capacity.

11)  Carnititine supplementation increases the production of sperm, with normalization of normal sperms in semen in three months.

12) Fertyl: This drug is taken orally and it causes the pituitary gland to release more FSH and LH, which then stimulates the testis to produce more normal sperms.

13) Bromocriptine. This medication is for men who have elevated levels of prolactin.

14) Correction of thyroid hormone

15) Correction of congenital adrenal hyperplasia

16) Vitamins

17) Zinc

18) Methy-Predinisolone

19) Antibiotics

20) Antiestrogens

21) Tamoxifen

22) Clomiphene

23) Hgh

24) Antimicrobials

25) Anti-inflammatory

26) AIH

27) ART

  • Correction of Hormone deficiencies: Once the hormone disorder is found then it is corrected by any of the below medicines. Usually dead sperms problem is cured in three month time with proper hormone treatment.
  • Gonadotropin Therapy: Gonadotropins are most potent natural stimulators of sperm production in the testis. Once we start gonadotropin therapy, these gonadotropins stimulates the sperm producing cells in testis. Under the stimulating influence of gonadotropins dormant sperm forming cells which were not producing normal sperms, they start dividing & producing normal sperms. Thus in more than 90% cases sperm production can be normalized in three to four months time if it is started in properlyselected cases of low sperm count. Gonadotropin therapy is most successful of all the available treatment for dead sperms till now. In many cases of dead sperms, when all other treatment has failed even in those cases gonadotropin therapy is effective. Thus treatment of dead sperms with gonadotropin therapy results in pregnancy soon

28) Certain Newer Drugs has been found very effective

30) Surgery:  Surgery is also the treatment of choice for significant varicocele. Similarly surgery may be one of the treatment options for many endocrine tumours.

32)  Test tube baby is also delivered with our efforts by use of intra-cytoplasmic sperm injection (ICSI) after separating out live sperms out of dead ones then transfer of embryo to uterus of mother.

33) Semen Bank: Facility for good quality sperm is semen bank in also available. At our center we have facility for all the testing & treatment facility required for low sperm count to achieve pregnancy.

The most common forms of ART include:

  • In Vitro Fertilization (IVF). This is the very effective ART technique. IVF involves retrieving mature eggs from a woman, fertilizing them with a man’s sperm in a dish in a laboratory and implanting the embryos in the uterus three to five days after fertilization. IVF often is recommended as a first-line therapy. It’s also widely used for unexplained infertility, male factor infertility.

  • Electroejaculation

    Electric stimulus brings about ejaculation to obtain semen.

  • Surgical Sperm Aspiration


  • This technique involves removing sperm from part of the male reproductive tract such as the epididymis, vas deferens or testicle. This allows retrieval of sperm if blockage is present.

  • Intracytoplasmic

    sperm injection (ICSI). This technique consists of a microscopic technique (micromanipulation) in which a single sperm is injected directly into an egg to achieve fertilization in conjunction with the standard IVF procedure. ICSI has been especially helpful in couples who have previously failed to achieve conception with standard techniques. For men with low sperm concentrations, ICSI dramatically improves the likelihood of fertilization.

34) Varicocele ligation: A varicocele is an abnormal tortuosity and dilation of veins of within the scrotum. It can be surgically treated – which might help fertility in some cases.

Response Of Treatment

When we start treatment, maturation of spermatocyte to mature spermatozoa start occurring in three to 4 weeks time and achievement of normal sperm count with normal sperms is achieved in three months. Thus cure rate is achieved in more than 95% of patients in three months time.

Side Effects

This treatment is harmless because we prescribe well proven drugs which are prescribed in scientific literature. These medicines have to be purchased from medical store by patient himself.

Antisperm Antibodies

Normally, our bodies develop antibodies to help protect our immune system against illnesses. However, sometimes our bodies develop antibodies to the wrong thing, which can cause negative repercussions. Among infertile men, about 10% will be diagnosed with having antisperm antibodies, a condition that can significantly decrease your chances of pregnancy.


Immune Overdrive

Normally, the testes contain a natural barrier, known as the blood-testes barrier. This barrier acts a protective layer that prevents immune cells from being able to access sperm within the male reproductive tract. Yet, this barrier can be broken, through injury to the reproductive tract, thereby allowing the immune cells to come into contact with the sperm.

Once the barrier is broken, immune cells are able to detect the presence of sperm due to their unique antigen surface. This triggers a response by the immune system to treat sperm as an “invader” and attack it. Antibodies then attach themselves to different parts of the sperm and interfere with male fertility in a number of ways.

Antibodies that are located on the tail of sperm can cause the sperm to become immobilized or clump together. When antibodies are found on the head of sperm, they can prevent the sperm from being able to efficiently make its way through a woman’s cervical mucus to the egg. However, it is also possible for a woman to develop antisperm antibodies in her cervical mucus, which will only serve to hinder attempts at conception even more. It is thought that antisperm antibodies in cervical mucus could account for as much as 40% unexplained infertility cases.

Sperm that does manage to make it to the egg can have a difficult time properly binding and fertilizing the egg due to antibodies attached to its head.

Reason for Antisperm Antibodies

There are numerous reasons why the natural barrier between sperm and the immune system can be broken causing antisperm antibodies to form. Some of these factors include:

  • Injury to the testicles
  • Undescended testicles
  • Twisting of the testicles
  • Infection
  • Testicular cancer
  • Testicular biopsy
  • CAVD
  • Varicocele

Additionally, men who have undergone a vasectomy reversal are particularly prone to developing this fertility problem. Close to 70% of men who have had their vasectomy reversed will develop antisperm antibodies.

Treating Antisperm Antibodies


Detecting antisperm antibodies is usually fairly simple as a semen analysis should be able to identify whether the antibodies are present. It is also possible to do an individual test that looks specifically for antisperm antibodies on sperm or, in women, in cervical mucus. However, getting rid of the antibodies may not be as easy.

While the use of corticosteroids can decrease the number of antibodies, temporarily restoring fertility, it is necessary to use very high doses. These high doses often cause serious side effects, thereby making this solution less desirable. Women who have antisperm antibodies may be prescribed medications to suppress their immune system.

Assisted reproductive techniques have been found to be the most helpful for couples suffering from this problem. Some couples have found success with IUI as this involves depositing sperm directly into the uterus. This technique appears to work best in couples whose difficulties stem from the cervical mucus. Washing sperm before the procedure can also rid the sperm of most antibodies.

Overall, though,IVF has proven to be the most helpful method in helping couples with antisperm antibodies conceive. Again, washing sperm beforehand is often helpful. HOwever, in some cases, it may be necessary to incorporate ICSI into the treatment as well.

Antisperm Antibodies: How common are they?


Sperm are relatively protected from the immune system by a natural protective mechanism called the blood-testes barrier. Tight connections between the cells lining the male reproductive tract keep immune cells from gaining entry to the sperm within. If an injury breaches this barrier, then the immune system has access to sperm and antibodies are formed.

Antisperm antibodies have been reported in approximately 10% of infertile men, compared to less than 1% of fertile men. The prevalence of antibodies jumps dramatically in men who have had surgery on their reproductive tract: nearly 70% of men who have undergone a vasectomy reversal will have antibodies present on their sperm. Women have a much lower chance for developing antibodies to sperm: less than 5% of infertile women can be shown to have antisperm antibodies, and it is unclear who is at risk for their formation.

Who is at risk for Antisperm Antibodies?


Anything that disrupts the normal blood-testes barrier can result in the formation of antisperm antibodies. This may include any of the following conditions:

  • Vasectomy reversal
  • Varicocele (dilation of the veins surrounding the spermatic cord)
  • Testicular torsion (twisting of the testicle)
  • Congenital absence of the vas deferens
  • Testicular biopsy
  • Cryptorchidism (failure of testicular descent)
  • Testicular cancer
  • Infection (orchitis, prostatitis)
  • Inguinal hernia repair prior to puberty


Fortunately, intrauterine insemination (the placement of washed sperm into the uterine cavity – a common fertility treatment) has not been shown to cause antisperm antibody formation.

Despite the long list of risk factors, most men with antisperm antibodies have not had any of the conditions listed above. Therefore all infertile men are potentially at risk, and consideration should be given to testing infertile men for antisperm antibodies, especially if no other reasons for the infertility have been detected by the diagnostic workup.

How do antisperm antibodies cause infertility?

Antibodies that attach to the sperm may impair motility and make it harder for them to penetrate the cervical mucus and gain entrance to the egg; they may also cause the sperm to clump together, which is occasionally noted on a routine semen analysis. Antibodies may also interfere with the ability of the sperm to fertilize the egg.

What is the best way to detect antisperm antibodies?

Over the years, many tests have been developed to detect antisperm antibodies. In women, blood tests for antisperm antibodies in women may be more practical than trying to measure antibodies in the cervical mucus, which is the primary site where her immune system interacts with sperm. The postcoital test, which has been a standard part of the infertility evaluation, may suggest the presence of antisperm antibodies. By examining the cervical mucus following intercourse near the time of ovulation, antisperm antibodies may result in either a lack of sperm or in the presence of sperm, which are shaking in place rather than actively swimming through the mucus.

In men, a direct examination of their sperm for attached antibodies is more reliable than testing blood for the presence of antibodies. Two commonly used tests are the immunobead assay and the mixed agglutination reaction (MAR). Both tests use antibodies bound to a small marker, such as plastic beads or red blood cells, which will attach to sperm that have antibodies on their surface. The results are read as a percentage of sperm bound by antibodies.

What treatments are available for Antisperm Antibodies?

Suppressing the immune system with corticosteroids may decrease the production of antibodies but can result in serious side effects, including severe damage to the hipbone. Intrauterine insemination, with or without the use of fertility medications, has been used for the treatment of antisperm antibodies. It is believed to work by delivering the sperm directly into the uterus and fallopian tubes, thus bypassing the cervical mucus.

In vitro fertilization appears to be the most effective treatment for antisperm antibodies, especially when there are very high levels of antibodies (near 100% of sperm are bound by antibodies). There is no clear guidance on whether intracytoplasmic sperm injection (ICSI), the direct fertilization of an egg with a single sperm, is required for the treatment of antisperm antibodies, unless there had been a complete absence of fertilization on a prior attempt at in vitro fertilization.

Are there other antibodies that affect fertility?


For women with recurrent miscarriage, there are a group of antibodies that appear to attack an early developing pregnancy, resulting in either a miscarriage or severe preeclampsia with risk of intrauterine growth retardation or even fetal death. Collectively these belong to a class of antibodies known as antiphospholipid antibodies, which include the lupus anticoagulant and the anticardiolipin antibody. Testing for these antibodies are an integral part of the workup for recurrent pregnancy loss. However, it is unclear whether these antibodies play any role in the ability to conceive. Some physicians believe that the presence of antiphospholipid antibodies may decrease the chance for pregnancy through in vitro fertilization. Although this is a controversial subject, one of the largest studies that looked for these antibodies in women undergoing in vitro fertilization found that these antibodies were no more likely to be detected in those who did not become pregnant as in women who did conceive.

Anti-sperm Antibody Testing

What are Antisperm Antibodies?

Anti sperm antibodies are antibodies directed against the sperm.  Under normal conditions the immune system develop antibodies to help protect our immune system against illnesses. However, in the case of anti sperm antibodies the body develops and directs specific antibodies against the sperm which is the wrong approach and can cause negative side effects upon the health status of the sperm and can cause infertility in a man. In general, among infertile men, about 10% will be diagnosed with having antisperm antibodies, a condition that can significantly decrease their chances of pregnancy.

Normally, the testes contain a natural barrier, known as the blood-testes barrier. This barrier acts as a protective layer that prevents immune cells from being able to access sperm within the male reproductive tract. Yet, this barrier can be broken, through injury to the reproductive tract, thereby allowing the immune cells to come into contact with the sperm and recognize them as foreign bodies, which they are.

Once the barrier is broken, immune cells are able to detect the presence of sperm due to their unique antigen surface. This triggers a response by the immune system to treat sperm as an “invader” and attack it. Antibodies then attach themselves to different parts of the sperm and interfere with male fertility in a number of ways.

Normally there are three different types of antibodies produced by the body that can influence the well being of the sperm.  Antibodies that are located on the tail of sperm can cause the sperm to become immobilized or clump together. When antibodies are found on the head of sperm, they can prevent the sperm from being able to efficiently make its way through a woman’s cervical mucus to the egg. Interestingly enough, it is also possible for a woman to develop antisperm antibodies in her cervical mucus, which will only serve to hinder attempts at conception even more. It is thought that antisperm antibodies in cervical mucus could account for as much as 40% in unexplained infertility cases.

Under normal conditions, sperm that does manage to make it to the egg encounter a great deal of difficulty properly binding and fertilizing the egg due to antibodies attached to its head. The etiology for the production of antisperm antibodies are several.

Some of these factors include:

  • Injury to the testicles
  • Undescended testicles
  • Twisting of the testicles
  • Infection such as testiculitis
  • Testicular cancer
  • Testicular biopsy
  • Varicocele associated with hestasis to the testes

It has been documented very clearly that men who have undergone a vasectomy reversal are particularly prone to developing this fertility problem. Publish reports put to 70% of men who have had their vasectomy reversed will develop antisperm antibodies.


Treatment for Antisperm Antibodies by Dr. &  Hakeem Tariq Mehmood Taseer

Pure herbal treatment by Dr & Hakeem Tariq Mehmood Taseer to cure Antisperm antibodies problem in males with well proven results. Has a very high success rate in treating different causes of this problem. Dosage and duration of the treatment may vary as per the patient profile. Treatment is without any side effects.

Premature Ejaculation

Important Facts

  • In premature ejaculation, a man ejaculates quickly after sexual arousal
  • Premature ejaculation, or rapid ejaculation, is a common type of sexual dysfunction
  • Causes for this condition usually are unknown, but it often is related to anxiety
  • Premature ejaculation that prevents sexual intercourse results in infertility

Premature ejaculation (PE) is a term used to describe a condition in which a man regularly ejects semen (i.e., ejaculates) very soon after the onset of sexual arousal, or sooner than he or his partner wishes. This condition, which is also called rapid ejaculation, is the most common type of sexual dysfunction in men under the age of 40.

Premature ejaculation can be primary (in men who have had the condition since puberty), or secondary (acquired; in men who previously had control of ejaculation). It may develop in men who have erectile dysfunction (impotence) and are anxious about maintaining an erection during sexual intercourse.

Premature ejaculation often causes distress for the man and for his partner. When the condition regularly occurs before penetration, it may prevent pregnancy.


Many men occasionally ejaculate sooner during sexual intercourse than they or their partner would like. As long as it happens infrequently, it’s probably not cause for concern. However, if you regularly ejaculate sooner than you and your partner wish — such as before intercourse begins or shortly afterward — you may have a condition known as premature ejaculation.

Premature ejaculation is a common sexual disorder. Estimates vary, but some experts think it affects as many as one out of three men. Even though it’s a common problem that can be treated, many men feel embarrassed to talk to their doctors about it or seek treatment.

Once thought to be purely psychological, experts now know that biological factors also play an important role in premature ejaculation. In some men, premature ejaculation is related to erectile dysfunction.

You don’t have to live with premature ejaculation — treatments including medications, psychological counseling and learning sexual techniques to delay ejaculation can improve sex for you and your partner. For many men, a combination of treatments works best.


There’s no medical standard for how long it should take a man to ejaculate. The primary sign of premature ejaculation is ejaculation that occurs before both partners wish in the majority of sexual encounters, causing concern or distress. The problem may occur in all sexual situations, including during masturbation — or it may only occur during sexual encounters with another person.

Doctors often classify premature ejaculation as either primary or secondary:

  • You have primary premature ejaculation if you’ve had the problem for as long as you’ve been sexually active.
  • You have secondary premature ejaculation if you developed the condition after having had previous, satisfying sexual relationships without ejaculatory problems.

Incidence and Prevalence

Premature ejaculation affects males only and can occur at any age of adulthood. The condition is most common between the ages of 18 and 30. It is estimated that premature ejaculation affects from 30–70% of men during their lifetime.

The cause for premature ejaculation is unknown, although, in most cases, it is thought to be the result of psychological factors (e.g., anxiety, guilt). Rarely, the condition is caused by a physical problem, such as over sensitivity of the genitals or abnormal hormone (e.g., testosterone) levels. Certain medications (e.g., psychiatric drugs) may cause premature ejaculation.

Risk factors for the condition include erectile dysfunction (impotence), stress, and health conditions that cause anxiety during sex (e.g., angina, previous heart attack).


Experts are still trying to determine exactly what causes premature ejaculation. While it was once thought to be only psychological, we now know premature ejaculation is more complicated and involves a complex interaction of both psychological and biological factors.

Psychological Causes

Some doctors believe that early sexual experiences may establish a pattern that can be difficult to change later in life such as:

  • Situations in which you may have hurried to reach climax in order to avoid being discovered
  • Guilty feelings that increase your tendency to rush through sexual encounters

Other factors that can play a role in causing premature ejaculation include:

  • Erectile dysfunction. Men who are anxious about obtaining or maintaining their erection during sexual intercourse may form a pattern of rushing to ejaculate which can be difficult to change.
  • Anxiety. Many men with premature ejaculation also have problems with anxiety — either specifically about sexual performance, or caused by other issues.

Biological Causes

Experts believe a number of biological factors may contribute to premature ejaculation, including:

  • Abnormal hormone levels
  • Abnormal levels of brain chemicals called neurotransmitters
  • Abnormal reflex activity of the ejaculatory system
  • Certain thyroid problems
  • Inflammation and infection of the prostate or urethra
  • Inherited traits

Rarely, premature ejaculation is caused by:

  • Nervous system damage resulting from surgery or trauma
  • Withdrawal from narcotics or a drug called trifluoperazine (Stelazine), used to treat anxiety and other mental health problems

Although both biological and psychological factors likely play a role in most cases of premature ejaculation, experts think a primarily biological cause is more likely if it has been a lifelong problem (primary premature ejaculation).

Risk Factors

Various factors can increase your risk of premature ejaculation, including:

  • Impotence. You may be at increased risk of premature ejaculation if you occasionally or consistently have trouble getting or maintaining an erection. Fear of losing your erection may cause you to rush through sexual encounters. As many as one in three men with premature ejaculation also have trouble maintaining an erection.
  • Health problems. If you have a medical concern that causes you to feel anxious during sex, such as a heart problem, you may have an increased likelihood of hurrying to ejaculate.
  • Stress. Emotional or mental strain in any area of your life can play a role in premature ejaculation, often limiting your ability to relax and focus during sexual encounters.
  • Certain medications. Rarely, drugs that influence the action of chemical messengers in the brain (psychotropics) may cause premature ejaculation.

Tests and Diagnosis

Doctors diagnose premature ejaculation based on a detailed interview about your sexual history. Your doctor may ask a number of very personal questions and may want to include your partner in the interview. While it may be uncomfortable for both of you to talk frankly about sex, the details you provide will help your doctor determine the cause of your problem and the best course of treatment. A mental health professional may help make the diagnosis.

Your doctor will want to know about your health history, and may perform a general physical exam. You doctor may ask you questions about:

  • How often you have premature ejaculation
  • Whether you have premature ejaculation only with a specific partner or partners
  • Whether you have premature ejaculation every time you have sex
  • How often you have sex
  • How you feel premature ejaculation affects your enjoyment of sex and your quality of life
  • Whether you also have trouble getting and maintaining an erection (erectile dysfunction)
  • Your use of prescription medications and recreational drugs

To evaluate whether psychological factors may influence your premature ejaculation, your doctor or mental health professional may also want to know about:

  • Your religious upbringing
  • Your early sexual experiences
  • Your sexual relationships, past and present
  • Any conflicts or concerns within your current relationship

If you have both premature ejaculation and trouble getting or maintaining an erection, your doctor may order blood tests to check your male hormone (testosterone) levels or other tests.


While premature ejaculation doesn’t increase your risk of serious health problems, it can cause distress in your personal life, including:

  • Relationship strains. The most common complication of premature ejaculation is relationship stress. If premature ejaculation is straining your relationship, ask your doctor about including couple’s therapy in your treatment program.
  • Fertility problems. Premature ejaculation can occasionally make fertilization difficult or impossible for couples who are trying to become pregnant. If premature ejaculation isn’t effectively treated, you and your partner may need to consider infertility treatment.


In some cases, premature ejaculation may be caused by poor communication between partners or a lack of understanding of the differences between male and female sexual functioning. Women typically require more prolonged stimulation than men do to reach orgasm, and this difference can cause sexual resentment between partners and add pressure to sexual encounters. For many men, feeling pressure during sexual intercourse increases the risk of premature ejaculation.

Open communication between sexual partners, as well as a willingness to try a variety of approaches to help both partners achieve satisfaction, can help reduce conflict and performance anxiety. If you’re not satisfied with your sexual relationship, talk with your partner about your concerns. Try to approach the topic in a loving way and to avoid blaming your partner for your dissatisfaction.

If you’re not able to resolve sexual problems on your own, talk with your doctor. He or she may recommend seeing a therapist who can help you and your partner achieve a fulfilling sexual relationship

To Learn Ejaculatory Control

  • Don’t use drugs or alcohol. They’re distracting and they interfere with the self-awareness crucial to learning ejaculatory control.
  • Appreciate whole-body sensuality. Men often think sex happens only in the penis and only during intercourse. That view is a one-way ticket to premature ejaculation (not to mention erection problems, and women with those proverbial headaches). The best sex involves head-to-toe arousal. Men learning how to approach — but not arrive at — their point of no return, need to appreciate whole-body sensuality, the pleasure potential in every square inch of the body. Whole-body sensuality releases tension. Tense bodies that have no other outlet often find release through involuntary ejaculation. But as you learn to appreciate sensual pleasure from head to toe, whole-body arousal takes the pressure off your penis, and you last longer.
  • Whole-body sensuality means relaxation, but the “relaxation” involved in great sex is not the kind that includes an easy chair, a six pack, and Monday Night Football. It’s the kind you feel after a hot bath or a good massage. In fact, bathing or showering together before lovemaking can help men relax and appreciate whole-body sensuality — and last longer.
  • Breathe deeply. One very easy way to stay relaxed while making love is to breathe deeply. The body has a natural tendency to breathe deeply during sex. But many men fight it. They think they should stay in control by not breathing deeply and making the little love-moan sounds that go along with it. But when men work to control their breathing, they often sacrifice ejaculatory control. Try breathing deeply. Let your breath go. Many men are amazed how much this one little change improves their premature ejaculation.
  • Start with masturbation with a dry hand. By varying how you caress your penis, you can learn to stay highly aroused for quite a while without coming. When you feel yourself approaching your point of no return, simply back off a bit, stroke yourself more gently or not at all, and stay aroused without ejaculating. Then as you feel yourself getting a little distance from your point of no return, return to more vigorous self-stimulation. Repeat this several times over several sessions. Approach your point of no return, then back off. For most men, it doesn’t take long to develop good ejaculatory control while alone.
  • Then move on to masturbation with a lubricated hand. Use saliva, vegetable oil, or a commercial sexual lubricant. For most people, lubricants increase the sensual intensity of erotic fondling. Follow the same program: Masturbate until you approach your point of no return, then back off. Repeat this several times over several sessions.
  • Once you have good control during masturbation, and appreciate whole-body sensuality, and feel comfortable breathing deeply during lovemaking, then you’re ready for the couples program — if you’re in a couple. The couple approach is called the “Stop-Start Technique.” First, arrange “stop” and “start” signals with your lover, for example, a light pinch or tap, or a tug on an ear.
  • Then, your lover strokes your penis by hand as you lie still. When you approach your point of no return, give the “stop” signal. Your lover immediately stops stroking you and simply holds your penis gently, as you continue to breathe deeply and pays close attention to the sensations you’re feeling. When you no longer feels close to ejaculation, gives the “start” signal, and your lover begins stroking you again. How many stops and starts should you do? A half-dozen over a 15-minute period works well for most couples. Do what feels comfortable for you.
  • With stop-start, the focus is on the man. He’s the one learning the new skill. But don’t forget the woman’s sensual needs. As part of each practice session, she might guide your hand over her to show you what she likes.
  • Once you’ve gained good ejaculatory control with your lover’s hand, try the same stop-start procedure with oral caresses. Again, you begin by lying still.
  • Once you’ve gained good control orally, feel free to start moving. You’re making love again — but now you have ejaculatory control. Congratulations.

Here are some other suggestions for lasting longer:

  • The man-on-top (missionary) position can be fun, but it’s harder for most men to control their ejaculatory timing, because they have to hold themselves up. Try making love with the woman on top. This position is more relaxing for men, and it often helps ejaculatory control.
  • Make some noise. Love moans help men (and women) relax, and they often help men last longer.
  • It’s important to understand that learning ejaculatory control takes time and practice. You may feel a little awkward along the way. Try to maintain a sense of humor about any accidental spills.
  • Some penile skin creams advertise that they help a man last longer. These products contain topical anesthetics that dull sensation in the penis. If you like to play with penile sensation, there’s no harm in using them. But they’re not a good idea for learning to last longer. They dull sensation. But the key to lasting longer is for the man to become more familiar with what he feels so he can back off from his point of no return while still remaining highly aroused.
  • Finally, the program we recommend for learning ejaculatory control is very likely to provide your lover with greater sexual enjoyment — but not just because you last longer. Women generally prefer leisurely, playful, whole-body, massage-oriented sensuality that includes the genitals but is not limited to them. Women’s main complaints about men’s sexual style are that it’s too rushed, too mechanical, too eager for intercourse, and that it focuses only on the breasts and genitals. Women generally feel that the whole body is a sensual playground and can’t understand why so many men explore only a few corners of it. Like women, penises generally prefer leisurely, playful, whole-body, massage-oriented lovemaking. The rushed, penis-centered, intercourse-fixated sex style puts a lot of pressure on the penis, and leads to premature ejaculation. But when men make love the way women prefer, whole-body arousal takes the pressure off your penis and you last longer. Basically, if men would make love the way women prefer, women would have fewer complaints, and men would have fewer sex problems.


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Erectile Dysfunction

Erectile dysfunction, sometimes called “impotence,” is the repeated inability to get or keep an erection firm enough for sexual intercourse. The word “impotence” may also be used to describe other problems that interfere with sexual intercourse and reproduction, such as lack of sexual desire and problems with ejaculation or orgasm. Using the term erectile dysfunction makes it clear that those other problems are not involved.

Erectile dysfunction, or ED, can be a total inability to achieve erection, an inconsistent ability to do so, or a tendency to sustain only brief erections. These variations make defining ED and estimating its incidence difficult. Estimates range from 15 million to 30 million, depending on the definition used. According to the National Ambulatory Medical Care Survey (NAMCS), for every 1,000 men in the United States, 7.7 physician office visits were made for ED in 1985. By 1999, that rate had nearly tripled to 22.3. The increase happened gradually, presumably as treatments such as vacuum devices and inject able drugs became more widely available and discussing erectile function became accepted. Perhaps the most publicized advance was the introduction of the oral drug sildenafil citrate (Viagra) in March 1998. NAMCS data on new drugs show an estimated 2.6 million mentions of Viagra at physician office visits in 1999, and one-third of those mentions occurred during visits for a diagnosis other than ED.

In older men, ED usually has a physical cause, such as disease, injury, or side effects of drugs. Any disorder that causes injury to the nerves or impairs blood flow in the penis has the potential to cause ED. Incidence increases with age: About 5 percent of 40-year-old men and between 15 and 25 percent of 65-year-old men experience ED. But it is not an inevitable part of aging.


Erectile dysfunction (ED) is the inability of a man to maintain a firm erection long enough to have sex. Although erectile dysfunction is more common in older men, this common problem can occur at any age. Having trouble maintaining an erection from time to time isn’t necessarily a cause for concern. But if the problem is ongoing, it can cause stress and relationship problems and affect self-esteem.

Formerly called impotence, erectile dysfunction was once a taboo subject. It was considered a psychological issue or a natural consequence of growing older. These attitudes have changed in recent years. It’s now known that erectile dysfunction is more often caused by physical problems than by psychological ones, and that many men have normal erections into their 80s.

Although it can be embarrassing to talk with your doctor about sexual issues, seeking help for erectile dysfunction can be worth the effort. Erectile dysfunction treatments ranging from medications to surgery can help restore sexual function for most men. Sometimes erectile dysfunction is caused by an underlying condition such as heart disease. So it’s important to take erectile trouble seriously because it can be a sign of a more serious health problem.

How Does an Erection Occur?

The penis contains two chambers called the corpora cavernosa, which run the length of the organ (see figure 1). A spongy tissue fills the chambers. The corpora cavernosa are surrounded by a membrane, called the tunica albuginea. The spongy tissue contains smooth muscles, fibrous tissues, spaces, veins, and arteries. The urethra, which is the channel for urine and ejaculate, runs along the underside of the corpora cavernosa and is surrounded by the corpus spongiosum.

Erection begins with sensory or mental stimulation, or both. Impulses from the brain and local nerves cause the muscles of the corpora cavernosa to relax, allowing blood to flow in and fill the spaces. The blood creates pressure in the corpora cavernosa, making the penis expand. The tunica albuginea helps trap the blood in the corpora cavernosa, thereby sustaining erection. When muscles in the penis contract to stop the inflow of blood and open outflow channels, erection is reversed.


Male sexual arousal is a complex process involving the brain, hormones, emotions, nerves, muscles and blood vessels. If something affects any of these systems or the delicate balance among them erectile dysfunction can result.

Anatomy of an Erection

The penis contains two cylindrical, sponge-like structures (corpus cavernosum) that run along its length, parallel to the tube that carries semen and urine (urethra).

When a man becomes sexually aroused, nerve impulses cause the blood flow to the cylinders to increase several times the normal amount. This sudden influx of blood expands the sponge-like structures and produces an erection by straightening and stiffening the penis.

Continued sexual arousal maintains the higher rate of blood flow into the penis and limits the blood flow out of the penis, keeping the penis firm. After ejaculation or when the sexual excitement passes, the excess blood drains out of the spongy tissue, and the penis returns to its non erect size and shape.

Physical Causes of Erectile Dysfunction

At one time, doctors thought erectile dysfunction was primarily caused by psychological issues. But this isn’t true. While thoughts and emotions always play a role in getting an erection, erectile dysfunction is usually caused by something physical, such as a chronic health problem or the side effects of a medication. Sometimes a combination of things causes erectile dysfunction.

Common Causes of Erectile Dysfunction Include:

  • Heart disease
  • Clogged blood vessels (atherosclerosis)
  • High blood pressure
  • Diabetes
  • Obesity
  • Metabolic syndrome

Other causes of erectile dysfunction include:

  • Certain prescription medications
  • Tobacco use
  • Alcoholism and other forms of drug abuse
  • Treatments for prostate cancer
  • Parkinson’s disease
  • Multiple sclerosis
  • Hormonal disorders such as low testosterone (hypogonadism)
  • Peyronie’s disease
  • Surgeries or injuries that affect the pelvic area or spinal cord

In some cases, erectile dysfunction is one of the first signs of an underlying medical problem.

Psychological Causes of Erectile Dysfunction

The brain plays a key role in triggering the series of physical events that cause an erection, beginning with feelings of sexual excitement. A number of things can interfere with sexual feelings and lead to or worsen erectile dysfunction. These can include:

  • Depression
  • Anxiety
  • Stress
  • Fatigue
  • Poor communication or conflict with your partner

The physical and psychological causes of erectile dysfunction interact. For instance, a minor physical problem that slows sexual response may cause anxiety about maintaining an erection. The resulting anxiety can worsen erectile dysfunction.

Risk Factors

A variety of risk factors can contribute to erectile dysfunction. They include:

  • Getting older.

    As many as 80 percent of men 75 and older have erectile dysfunction. Many men begin to notice changes in sexual function as they get older. Erections may take longer to develop, may not be as rigid or may take more direct touch to the penis to occur. But erectile dysfunction isn’t an inevitable consequence of normal aging. Erectile dysfunction often occurs in older men mainly because they’re more likely to have underlying health conditions or take medications that interfere with erectile function.

  • Having a chronic health condition

    . Diseases of the lungs, liver, kidneys, heart, nerves, arteries or veins can lead to erectile dysfunction. So can endocrine system disorders, particularly diabetes. The accumulation of deposits (plaques) in your arteries (atherosclerosis) also can prevent adequate blood from entering your penis. And in some men, erectile dysfunction may be caused by low levels of testosterone (male hypogonadism)

  • Taking certain medications.

    A wide range of drugs — including antidepressants, antihistamines and medications to treat high blood pressure, pain and prostate cancer — can cause erectile dysfunction by interfering with nerve impulses or blood flow to the penis. Tranquilizers and sleeping aids also can pose a problem.

  • Certain surgeries or injuries.

    Damage to the nerves that control erections can cause erectile dysfunction. This damage can occur if you injure your pelvic area or spinal cord. Surgery to treat bladder, rectal or prostate cancer can increase your risk of erectile dysfunction.

  • Substance abuse.

    Chronic use of alcohol, marijuana or other drugs often causes erectile dysfunction and decreased sexual drive.

  • Stress, anxiety or depression.

    Other psychological conditions also contribute to some cases of erectile dysfunction.

  • Smoking.

    Smoking can cause erectile dysfunction because it restricts blood flow to veins and arteries. Men who smoke cigarettes are much more likely to develop erectile dysfunction.

  • Obesity.

    Men who are obese are much more likely to have erectile dysfunction than are men at a normal weight.

  • Metabolic syndrome.

    This syndrome is characterized by belly fat, unhealthy cholesterol and triglyceride levels, high blood pressure, and insulin resistance.

  • Prolonged bicycling.

    Over an extended period, pressure from a bicycle seat has been shown to compress nerves and blood flow to the penis, leading to temporary erectile dysfunction and penile numbness.


Erectile dysfunction is the inability to maintain an erection sufficient for sexual intercourse at least 25 percent of the time.

An occasional inability to maintain an erection happens to most men and is normal. But ongoing erection problems are a sign of erectile dysfunction and should be evaluated. In some cases, erectile dysfunction is the first sign of another underlying health condition that needs treatment.


Although most men experience episodes of erectile dysfunction from time to time, you can take these steps to decrease the likelihood of occurrences:

  • Work with your doctor to manage conditions that can lead to erectile dysfunction, such as diabetes and heart disease.
  • Limit or avoid the use of alcohol.
  • Avoid illegal drugs such as marijuana.
  • Stop smoking.
  • Exercise regularly.
  • Reduce stress.
  • Get enough sleep.
  • Get help for anxiety or depression.
  • See your doctor for regular checkups and medical screening tests.


A medical examination may indicate neurological, vascular, or hormonal disease, or Peyronie’s disease. History of illness, smoking, drug use, and hypertension can be ascertained with a thorough examination of health history.

Laboratory tests are performed to identify the underlying cause.

Blood Tests and Urinalysis

Blood tests can indicate conditions that may interfere with normal erectile function. These tests measure hormone levels, cholesterol, blood sugar, liver and kidney function, and thyroid function. Excess prolactin (hyperprolactinemea) can lower testosterone levels, which can diminish libido. Both of these levels are measured, as well as levels of other sex hormones. If they are persistently low, an endocrinologist (hormone specialist) should be consulted.

CBC. Complete blood count (CBC) of red cells and white cells is used to evaluate the presence of anemia. A low level of red cells limits the body’s utilization of oxygen and can lead to fatigue and general malaise. The level of blood lipids (fats) such as cholesterol and triglycerides may indicate arteriosclerosis, which can reduce blood flow to the penis.

Liver and kidney function testsLiver and kidney disease can create horomonal imbalances. Blood tests for liver function involves analysis of enzyme and serum creatinine levels, which are indicators of kidney efficiency.

Thyroid function tests. Thyroid hormones regulate metabolism and the production of sex hormones; a deficiency may contribute to impotence.

Urinalysis. Urine is analyzed for protein (albumin), sugar (glucose), and hormone (testosterone) levels that may indicate diabetes mellitus, kidney dysfunction, and testosterone deficiency.

Erectile Function Tests

Tests that assess erectile function examine the blood vessels, nerves, muscles, and other tissues of the penis and pelvic region.

Duplex ultrasound. Duplex ultrasound is used to evaluate blood flow, venous leak, signs of artherosclerosis, and scarring or calcification of erectile tissue. Erection is induced by injecting prostaglandin, a hormone-like stimulator produced in the body. Ultrasound is then used to see vascular dilation and measure penile blood pressure (which may also be measured with a special cuff). Measurements are compared to those taken when the penis is flaccid.

Prostate examination. An enlarged prostate, which can be detected with a digital rectal examination (DRE), can interfere with blood flow and nerve impulses in the penis.

Penile nerve function. Tests such as the bulbocavernosus reflex test are used to determine if there is sufficient nerve sensation in the penis. The physician squeezes the glans (head) of the penis, which immediately causes the anus to contract if nerve function is normal. A physician measures the latency between squeeze and contraction by observing the anal sphincter or by feeling it with a gloved finger inserted past the anus. Specific nerve tests are used in patients with suspected nerve damage as a result of diabetes or nerve disease.

 Nocturnal penile tumescence (NPT). It is normal for a man to have five to six erections during sleep, especially during rapid eye movement (REM). These erections occur about every 90 minutes and last for about 30 minutes. Their absence may indicate a problem with nerve function or blood supply in the penis. There are two methods for measuring changes in penile rigidity and circumference during nocturnal erection: snap gauge and strain gauge.

Snap gauge. Involves wrapping three plastic bands of varying strength around the penis. Erectile function is assessed according to which bands break. Strain gauge involves placing special elastic bands at the base and tip of the penis. These bands stretch during erection and register changes in circumference.

Penile biothesiometryThis test uses electromagnetic vibration to evaluate sensitivity and nerve function in the glands and shaft of the penis. A decreased perception of vibration may indicate nerve damage in the pelvic area, which can lead to impotence.

Vasoactive injectionWhen injected into the penis, certain solutions cause erection by dilating blood vessels in erectile tissue. Normally, these injections produce an erection lasting about 20 minutes. During this procedure, penile pressure is measured and x-rays may be taken of the penile blood vessels using a special dye (contrast agent).


Whether the cause of impotence is physiological or psychological, both the patient and his partner often experience a range of intense feelings and emotions. Any of these feelings can lead to a sense of hopelessness and lower self-esteem.

Of course, feelings of sexual insecurity can reinforce any performance anxiety a man experiences and create a vicious cycle of repeated failures and increasingly negative feelings.

The first step to overcoming these feelings is to acknowledge the problem and communicate honestly and openly with each other.

Self Esteem

Because sexual performance is often a big part of a man’s self-esteem, experiencing erectile dysfunction (ED) can be devastating not only to a man’s sex life, but to his entire sense of being. Men with ED can become uncertain of themselves and avoid intimate situations with their partners; this only increases the pressure and anxiety associated with a condition which is often treatable.

In addition, erectile dysfunction can cause men to feel inadequate in their roles. Men who are suffering from ED tend to isolate themselves from their relationships and withdraw from their partners.

The psychological effects of ED can invade every aspect of a man’s life, from his relationship with his partner, to his interactions on a social level, to his job performance. Therefore, it is important for a man who is suffering from ED to feel as comfortable as possible discussing his condition with his partner, and with his physician, in order to discover the treatment strategy which can best help overcome this condition.


Erectile dysfunction can be embarrassing to discuss not only with a health care provider but with also with a partner. It often causes men to withdraw from those who care about them, which puts a serious strain on relationships.

Partners of men with ED feel that initiating a discussion regarding the situation will cause embarrassment and humiliation. They also may develop a sense of inadequacy, thinking the cause of ED is their fault and that they are no longer physically attractive to their partner.

In most cases, ED is a result of physical causes (although it can easily be made worse by psychological factors), and can often be treated. However, silence, embarrassment, and feelings of inadequacy and humiliation only lead to further withdrawal on the part of both partners, increasing the distance and tension within the relationship. The anxiety which results can easily make a case of ED worse, leading to a vicious circle of failure and anxiety about failure.

Both partners and men with ED need to try to remember that ED is most often a treatable physical condition. The first step to treatment, however, is trust and a willingness on the part of both partners to discuss the situation with each other, and with a physician.


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Testicular Problems and Infertility

Testicular failure is one condition that may affect sperm health and lead to male infertility. There are different forms of testicular failure that may affect the male reproductive system and a variety of causes that may contribute to testicular failure. All of these factors may result in different conditions affecting sperm health. However, there are several infertility treatment options available to help relieve the symptoms of testicular failure and increase a couple’s odds of getting pregnant.

What is Testicular Failure?

Testicular failure is a general term describing a condition in which the testicles do not properly produce sperm or hormones. However, there are a number of underlying male fertility problems that may be diagnosed as the cause of testicular failure. The following are some conditions that may be affecting male fertility and contributing to testicular failure:

  • Chromosomal abnormalities
  • Testicular trauma
  • Testicular torsion (twisting)
  • Diseases or infections such as mumps, orchitis or testicular cancer
  • Undescended testicles at birth
  • Problems involving sexual maturation
  • Certain drugs or medications such as steroids or marijuana
  • Lifestyle factors

Lifestyle factors may affect testicular functioning and prevent the testicles from maintaining normal functions. Activities such as riding a motorcycle, for example, can increase the risk of testicular or scrotum injury.

When testicular failure results in the inability to produce proper levels of male hormones, the condition will likely lead to a diagnosis of hypogonadism.

Testicular Failure Symptoms

Signs and symptoms of testicular failure may include the following:

  • Low or lack of sex drive
  • Infertility
  • Delayed puberty
  • Decrease in height
  • Enlarged breasts (gynecomastia)
  • Lack of muscle mass
  • Hair loss (usually in the underarms or pubic areas)
  • Infrequent need to shave
  • Small testicles
  • Presence of a tumor or mass near the testes

In addition, during examination, decreases in bone density or the presence of bone fractures may be noted as well as low levels of testosterone hormones accompanied by high levels of FSH and LH.

Testicular Failure and Sperm Health

Testicular failure is associated with three main fertility problems that may affect sperm health. These male fertility problems include the following:

  • Azoospermia: this condition results from an absence of the cells necessary to help sperm divide and is also known as sertoli cell-only syndrome
  • Maturation Problems: this refers to a condition in which sperm production begins normally, but is interrupted at some point during development. The resulting sperm that is present in the ejaculate will thus not be fully developed
  • Hypospermatogeneses: this refers to a condition in which few or no sperm are present in the ejaculate as a result of low sperm production

Testicular Failure Diagnosis

Diagnosing testicular failure may involve a variety of male fertility testing procedures. Congenital testicular failure will typically be indicated by the presence of “ambiguous” genitalia at birth.

  • Fertility tests for the diagnosis of testicular failure may include the following:
  • Bood tests to evaluate levels of testosterone hormones, gonadotrophine, FSH and LH
  • Physical exam for signs of testicular atrophy or tumors
  • Semen analysis

Testicle Problems

  • Epididymitis
  • Hydrocele
  • Testicular Cancer
  • Torsion
  • Varicocele


What is it?

An inflammation of the epididymis, the tube that transports sperm from the testicle towards the penis. If the swelling affects the testicle as well as the epididymis, the condition is known as epididymo-orchitis.

What are the main symptoms?

  • Severe pain in the scrotum
  • A swollen area that may feel hot to the touch
  • Fever

What’s the risk?

It’s unusual, although it’s more common in childhood and has a peak occurrence in adolescence.

What causes it?

In adults the condition may follow a viral or bacterial infection. Bacteria can sometimes find their way to the epididymis as a consequence of infection with the common bacteria that cause urinary infections or by other organisms such as those of chlamydia or gonorrhoea. Epididymitis can sometimes follow a vasectomy.

How can I prevent it?

The risk of epididymitis being caused as a result of a sexually transmitted infection (STI) can be reduced by always practising safer sex (i.e. using a condom during intercourse) and having regular check-ups for STIs at a GUM (genito-urinary medicine) clinic.

Should I see a doctor?

Yes. A urine test can diagnose the condition. Your doctor will make the diagnosis and exclude other potentially important conditions.

How can I help myself?

Follow your doctor’s orders and be patient – epididymitis can take several months to clear up completely.

What’s the outlook?

Good, although sometimes the scrotum remains somewhat enlarged.


What is it?

A swelling in the scrotum, caused by a harmless build-up of fluid within the sacs surrounding the testicles.


What are the main symptoms?

A soft and usually painless swelling of the scrotum. Sometimes the swelling can be as large as a grapefruit.

What’s the risk?


What causes it?

A build-up of fluid in the scrotum, sometimes caused by an injury to the testicles or following infection or inflammation.

How can I prevent it? 

It’s not easy to prevent, except by protecting the testicles during sport or potentially risky work.

Should I see a doctor?

Yes. It’s important to rule out any more serious conditions.

The doctor will examine the testicles. He or she may also shine a light through the scrotum – if the light passes through, it’s probably a hydrocele.

How can I help myself?

There’s not much you can do.

What’s the outlook?

Most serious cases can be permanently treated.

Testicular Cancer

What is it?

A relatively rare cancer that usually affects one testicle.

What are the main symptoms?

The key symptoms to look out for are:

  • A lump in either testicle
  • Any enlargement of the testicle
  • A feeling of heaviness in the scrotum
  • A dull ache in the abdomen or groin
  • A sudden collection of fluid in the scrotum
  • Enlargement or tenderness of the breasts

It’s important to remember that testicular cancer may not cause any discomfort or pain, especially in the early stages. The most common symptom is a small painless lump.

Any of these symptoms can also have benign (i.e. non-cancerous) causes, but they should always be checked by a doctor.

As some of these symptoms aren’t always obvious, it’s important to check your testicles regularly.

What’s the risk?

Testicular cancer is the most common cancer affecting men aged 20–35 but the lifetime risk of developing the disease is still only 1 in 400. That compares with 1 in 12 for lung cancer and for prostate cancer. However, the incidence of testicular cancer is increasing – in fact, it’s doubled in the past 20 years.

The risks are greater (1 in 44) for men who were born with undescended testicles. Men with a brother or father who had a testicular tumour have a 6–10 times higher risk of developing this cancer.

What causes it?

The causes aren’t yet fully understood. However, the fact that men who develop testicular cancer are more likely to have had undescended testicles, and to be affected by fertility problems, suggests some sort of common cause.

One plausible theory, not yet fully proven, is that testicular tissues are damaged while male foetuses are still developing, possibly as a result of their mothers’ exposure to environmental pollutants which are chemically similar to the female hormone oestrogen. It may be that male foetuses are being over-exposed to oestrogen and that, as a result, some develop a range of problems with their reproductive systems.

Some studies have also linked testicular cancer to a sedentary lifestyle in boys, although further research is needed to confirm this.

How can I prevent it?

You can’t.

Should I see a doctor?

If you have any of the symptoms listed above you should see your doctor as soon as possible.

Your doctor will examine your testicles and, if he or she suspects a problem, you’ll probably be referred to a specialist doctor (normally a urologist). Your testicles will be examined again and you may be asked to have an ultrasound (a painless procedure) and a blood test.

How can I help myself?

  • Inform yourself about your condition and its treatment. Talk to your doctor; contact cancer organisations; read material on the Internet (although with care – not all of it is accurate).
  • Accept that it’s inevitable that you’ll feel anxious and scared. However, it’s also important to remember that testicular cancer is one of the easiest cancers to treat successfully.
  • Consider ways in which you can reduce your stress, such as counselling, meditation, yoga and relaxation exercises.
  • If it feels right, join a cancer support group. Your hospital or a cancer organisation can give you details of groups that might be suitable for you.

What’s the outlook?

Generally very good indeed. If diagnosed early, 96% of patients can be cured completely. Even when the cancer has spread, up to 80% of men can still be cured.


What is it?

Each testicle is suspended within the scrotum by the spermatic cord. This can become twisted, cutting off the blood supply to a testicle.

What are the main symptoms?

  • Sudden, very severe pain in a testicle
  • Swelling
  • Nausea and vomiting
  • Fever

What’s the risk?

Low. It’s most common in teenage boys.

What causes it?

Many cases have no known or obvious cause, although it can be linked to physical activity. Some men, who have naturally more mobile testicles, are at higher risk.

How can I prevent it?

You can’t.

Should I see a doctor?

Definitely. In fact, torsion is a medical emergency – aside from the pain, if the spermatic cord is twisted for more than a few hours a testicle can die due a lack of blood supply, and will then have to be removed.

How can I help myself?

There’s not much you can do.

What’s the outlook?

Good, if treatment is carried out promptly.


What is it?

Essentially a varicose vein within the testicle.

What are the main symptoms?

  • Varicoceles are often painless and almost always located on the left testicle.
  • There can be a swelling that is often described as feeling like a warm tangle of worms. This is usually more noticeable when you stand up.
  • There may be a “dragging feeling” in the testicle.
  • Fertility problems. It’s thought that the accumulation of blood overheats the testicle and affects sperm production, although not all men with a varicocele are infertile.

What’s the risk?

Approximately 10–15% of men develop a varicocele.

What causes it?

A damaged valve in the vein draining blood from the testicle.

How can I prevent it?

You can’t.

Should I see a doctor?

Yes. It’s important to rule out any more serious conditions.

Varicoceles can usually be diagnosed through manual examination. A doctor may also shine a light through the testicle – a varicocele will block out the light. Small varicoceles can sometimes be diagnosed by ultrasound.

How can I help myself?

There’s not much you can do.

What’s the outlook?

Good, but varicoceles can sometimes recur. The treatment of varicoceles can result in a significant increase in fertility: improvements in semen quality occur in 50–90% of men.


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Low Testosterone

Male Hypogonadism

All men undergoing fertility testing will be checked for hormonal imbalances that could be contributing to their infertility. One important hormone necessary for proper sexual functioning in men is testosterone. When a man is found to have a testosterone deficiency, it can signal a common disorder known as hypogonadism.


Male hypogonadism is a condition in which the body doesn’t produce enough of the sex hormone testosterone. As many as 5 million men in the United Sates may not produce enough testosterone — the hormone that plays a key role in masculine growth and development during puberty.

Testosterone’s effects begin after conception, stimulating the formation of male sex organs. The hormone continues to play an important role through puberty and adulthood by triggering male characteristics and maintaining sex drive.

You may be born with hypogonadism, or it can develop later in life from injury or infection. The effects — and what you can do about them — depend on the cause and at what point in your life hypogonadism occurs.

During fetal development, low testosterone can cause incomplete formation of sex organs. Low testosterone levels before puberty can permanently affect growth and development. After puberty, the development of hypogonadism is more likely to cause temporary problems that may improve with treatment. Some types of hypogonadism can be treated with testosterone replacement therapy.

What Does Testosterone Do?

Testosterone, often referred to as the male hormone although females do produce small amounts of the hormone as well, is a hormone that is produced in the testicles. It is responsible for the growth and development of the sex and reproductive organs in men. Additionally, testosterone contributes to the deepening of a man’s voice during puberty, fat distribution, and bone mass. Testosterone also helps to keep a man’s energy levels up as well as encourage his sex drive and fertility.

Much like women, whose production of estrogen and progesterone taper off as they age, testosterone levels begin to decline as a man gets older. These naturally-occurring low testosterone levels can contribute to a decreased sex drive in older men. Yet, low testosterone levels earlier in life are not natural and can produce many unwanted physical changes, including infertility. A common culprit for these falling testosterone levels: hypogonadism.


Hypogonadism can occur during fetal development, puberty or adulthood. Depending on when it develops, the signs and symptoms differ.

Fetal Development

If the body doesn’t produce enough testosterone during fetal development, growth of external sex organs may be impaired. Depending at when it develops, and how much testosterone is present, a child that is genetically male may be born with:

  • Female genitals
  • Ambiguous genitals (genitals that are neither clearly male or female)
  • Underdeveloped male genitals


During puberty, male hypogonadism may slow growth and affect development. It can cause:

  • Decreased development of muscle mass
  • Lack of deepening of the voice
  • Impaired growth of body hair
  • Impaired growth of the penis and testicles
  • Excessive growth of the arms and legs in relation to the trunk of the body
  • Development of breast tissue (gynecomastia)


In adult males, hypogonadism may alter certain masculine physical characteristics and impair normal reproductive function. Signs and symptoms may include:

  • Erectile dysfunction
  • Infertility
  • Decrease in beard and body hair growth
  • Increase in body fat
  • Decrease in size or firmness of testicles
  • Decrease in muscle mass
  • Development of breast tissue (gynecomastia)
  • Loss of bone mass (osteoporosis)

Hypogonadism can also cause mental and emotional changes. As testosterone decreases, some men may experience symptoms similar to those of menopause in women. These may include:

  • Fatigue
  • Decreased sex drive
  • Difficulty concentrating
  • Hot flashes
  • Irritability
  • Depression


Testosterone Binding [T = testosterone; SHBG = sex-hormone-binding globulin. Source: Braunstein GD. Testes. In: Basic & Clinical Endocrinology. 5th ed. Stamford, CT: Appleton & Lange; 1997:403-433.]

Male hypogonadism means the testicles don’t produce enough of the male sex hormone testosterone. There are two basic types of hypogonadism:

  • Primary. This type of hypogonadism — also known as primary testicular failure — originates from a problem in the testicles.
  • Secondary. This type of hypogonadism indicates a problem in the hypothalamus or the pituitary gland — parts of the brain that signal the testicles to produce testosterone. The hypothalamus produces gonadotropin-releasing hormone, which signals the pituitary gland to make follicle-stimulating hormone (FSH) and luteinizing hormone. Luteinizing hormone then signals the testes to produce testosterone.

Either type of hypogonadism may be caused by an inherited (congenital) trait or something that happens later in life, such as an injury or an infection (acquired).

Primary Hypogonadism

Common causes of primary hypogonadism include:

  • Klinefelter ‘s Syndrome This condition results from a congenital abnormality of the sex chromosomes, X and Y. A male normally has only one X and one Y chromosome. In Klinefelter’s syndrome, two or more X chromosomes are present in addition to one Y chromosome. The Y chromosome contains the genetic material that determines the sex of a child and related development. The extra X chromosome that occurs in Klinefelter’s syndrome causes abnormal development of the testicles, which in turn results in underproduction of testosterone.
  • Undescended Testicles Before birth, the testicles develop inside the abdomen and normally move down into their permanent place in the scrotum two months before birth. One or both of the testicles may not be descended at birth. This condition often corrects itself within the first few years of life without treatment. If not corrected in early childhood, it may lead to malfunction of the testicles and reduced production of testosterone.
  • Mumps Orchitis If a mumps infection involving the testicles in addition to the salivary glands (mumps orchitis) occurs during adolescence or adulthood, long-term testicular damage may occur. This may affect normal testicular function and testosterone production.
  • Hemochromatosis Too much iron in the blood can cause testicular failure or pituitary gland dysfunction affecting testosterone production.
  • Injury to the testicles. Because of their location outside the abdomen, the testicles are prone to injury. Damage to normally developed testicles can cause hypogonadism. Damage to one testicle may not impair testosterone production.
  • Cancer Treatment Chemotherapy or radiation therapy for the treatment of cancer can interfere with testosterone and sperm production. The effects of both treatments often are temporary, but permanent infertility may occur. Although many men regain their fertility within a few months after treatment ends, preserving sperm before starting cancer therapy is an option that many men consider.
  • Normal Aging Older men generally have lower testosterone levels than younger men do. As men age, there’s a slow and continuous decrease in testosterone production. The rate that testosterone declines varies greatly among men. As many as 30 percent of men older than 75 have a testosterone level that’s below normal.

Secondary Hypogonadism

  • In Secondary Hypogonadism the testicles are normal but function improperly due to a problem with the pituitary or hypothalamus. A number of conditions can cause secondary hypogonadism, including:
  • Kallmann Syndrome Abnormal development of the hypothalamus — the area of the brain that controls the secretion of pituitary hormones — can cause hypogonadism. This abnormality is also associated with impaired development of the ability to smell anosmia.
  • Pituitary Disorders An abnormality in the pituitary gland can impair the release of hormones from the pituitary gland to the testicles, affecting normal testosterone production. A pituitary tumor or other type of brain tumor located near the pituitary gland may cause testosterone or other hormone deficiencies. Also, the treatment for a brain tumor such as surgery or radiation therapy may impair pituitary function and cause hypogonadism.
  • Inflammatory Disease Certain inflammatory diseases such as sarcoidosis, histiocytosis, tuberculosis and some fungal infections involve the hypothalmus and pituitary gland and can affect testosterone production, causing hypogonadism.
  • HIV/AIDS This virus can cause low levels of testosterone by affecting the hypothalamus, the pituitary and the testes.
  • Medications The use of certain drugs, such as opiate pain medications and some hormones, can affect testosterone production.
  • Obesity Being significantly overweight at any age may be linked to hypogonadism

Risk Factors

Risk factors for hypogonadism include:

  • Kallmann syndrome
  • Undescended testicles as an infant
  • Mumps infection affecting your testicles
  • Injury to your testicles
  • Testicular or pituitary tumors
  • Klinefelter’s syndrome
  • Hemochromatosis
  • Previous chemotherapy or radiation therapy

Hypogonadism can be inherited. If any of these risk factors are in your family health history, inform your doctor. Be aware of and watch for signs and symptoms of hypogonadism.


The complications of untreated hypogonadism differ depending on what age it first develops — during fetal development, puberty, or as an adult.

Fetal development. If hypogonadism begins during fetal development, a baby may be born with ambiguous or abnormal genitalia.

Puberty. If hypogonadism develops before puberty, a lack of body hair and impaired penis and testicle growth may occur.

Adult. Infertility, erectile dysfunction, decreased sex drive, fatigue, muscle loss or weakness, enlarged male breasts, decreased beard and body hair growth, and osteoporosis are possible complications of hypogonadism in adults.

Tests And Diagnosis

Your doctor may test your blood level of testosterone if you have any of the signs or symptoms of hypogonadism. Early detection in boys can help prevent problems from delayed puberty. Early diagnosis and treatment in men offers better protection against osteoporosis and other related conditions.

Doctors base a diagnosis of hypogonadism on symptoms and results of blood tests that measure testosterone levels. Because testosterone levels vary and are generally highest in the morning, blood testing is usually done early in the day.

If tests confirm you have low testosterone, further testing can determine if a testicular disorder or a pituitary abnormality is the cause. Based on specific signs and symptoms, additional studies can pinpoint the cause. These studies may include:

  • Hormone testing
  • Semen analysis
  • Pituitary imaging
  • Genetic studies
  • Testicular biopsy

Testosterone testing also plays an important role in managing hypogonadism. This helps your doctor determine the right dosage of medication, both initially and over time.


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A fairly common infertility problem resulting in male fertility problems, varicocele refers to the presence of varicose veins in the testicles. This condition is thought to affect 15% of the general male population but as much as 40% of all infertile males. Varicoceles tends to occur more often in men experiencing secondary infertility.



A varicocele is an enlargement of the veins within the scrotum, the loose bag of skin that holds your testicles. A varicocele is similar to a varicose vein that can occur in your leg.

About one in six men have a varicocele. For males who are infertile, the figure is higher — about 40 percent. Varicoceles are the most common cause of low sperm production and decreased sperm quality, although not all varicoceles affect sperm production.

Most varicoceles develop over time. Fortunately, most varicoceles are easy to diagnose and, if they cause symptoms, can be repaired surgically.

A varicocele is a dilation of the pampiniform plexus – the veins that drain blood from the testicle. Due to anatomical differences, varicoceles are more common on the left side although they may also occur on both sides simultaneously. As the varicose veins dilate, the valves within the veins become incompetent and no longer function. This allows blood flow to reverse within the veins which causes abnormal blood flow around the testicle. It is this change in blood flow which leads to poor testicular function by causing overheating of the testicle.

How Does Varicocele Affect Fertility?

As with most other varicose veins, varicoceles occurs when blood in the testicles does not circulate out properly. As a result, this excess blood causes the temperature in the testicles to rise leading to abnormal testosterone levels. This increased temperature in the scrotum then prevents the proper production and maturation of sperm thereby lowering a man’s fertility.

Although it is possible for varicocele to affect both testicles, about 90% of the time it is just the left side that is affected. While experts aren’t exactly sure why it is almost always the left testicle that develops the varicose veins, the fact that there are 40% fewer valves in the left spermatic vein, which is also as much as 8 to 10 centimeters longer than the spermatic cord in the right testicle, is one possible reason. Additionally, the left spermatic vein has more pressure placed on it than the right, which may cause it to be more prone to blockages.

Varicoceles Symptoms

Often times, men affected by varicocele will not produce any visible signs. On occasion, though, a man may experience one or more of the symptoms associated with varicocele, which can include:

  • Testicular pain or discomfort
  • Noticeable shrinkage of the testicle(s)
  • A heavy feeling in the testicle
  • Infertility
  • An enlarged vein that can be found by touch or sight


The spermatic cord, which supplies blood to and returns blood from the testicle, houses the vas deferens, which carries sperm from the testicles. The pampiniform plexus is a group of veins within the scrotum and above the testicles. The pampiniform plexus drains blood from the testicles. Enlargement of these veins often occurs during puberty.

It’s not certain what causes varicoceles, but many experts believe abnormal valves within the veins prevent normal blood flow. The resulting backup causes the veins to widen (dilate).

Varicoceles usually occur in the region of the left testicle, most likely because of the position of the left testicular vein. However, a varicocele in one testicle can affect sperm production in both testicles.

Veins that have become significantly enlarged will likely be visible. However, small or medium sized veins may only be identifiable through touch.

How does a varicocele cause infertility?

We are certain that varicoceles decrease fertility but we have not yet categorically determined why this is so. There are several theories:

A) Increased temperature of the testicles

The testicles are located in the scrotum, which effectively regulates their temperature. They are maintained at a temperature slightly below body temperature. (This is probably why they are located outside the body rather than inside the body where they clearly would be better protected.) In cold weather you may notice that a man’s testicles move close into his body as the cremasteric muscles, the muscles in the scrotum wall, tighten. In warm weather the cremasteric muscles relax and lengthen allowing the testicles to hang away from a man’s body and cool down.

Some babies are born without their testicles having descended into their scrotum. They are trapped somewhere in their bodies and constantly exposed to body temperature. This is so harmful for the testicles that if they remain there past puberty they will stop producing sperm altogether and have a higher chance of developing cancer. Therefore if a boy’s testicles do not descend into the scrotum by the time he is 12 months old, they should be surgically brought down and placed into the scrotum.

Varicoceles are a group of dilated veins filled with blood, which surround the testicles. The blood is at body temperature and if the testes are near these veins they will be kept at a higher temperature than is beneficial for them. Even if a man has a varicocele only on one side, the whole scrotum is warmed by the blood and both testicles can be negatively affected.

In general, larger testicles make more sperm than smaller testicles. Often however, you see men who have a large one-sided varicocele that has damaged the testis on one side making it smaller. The small teste makes significantly less sperm than the normal one. However even in the “normal” one the sperm quality is often very low. The varicocele is not only damaging the teste on the side where it is found but also suppressing the sperm production on the opposite (better) side.

When a varicocele is repaired the blood is no longer able to flow back into the scrotum. This affects not only the testes on that side, but also the opposite side with this normalization of temperature, there may be some dramatic improvement in sperm production. This improvement is most likely mostly coming from improved production in the larger better testicle.

  1. B) Increased waste products back-flowing into the testicle

The veins draining the testicles connect into larger veins. On the left side, they drain into the kidney vein, which is draining blood from the kidney. The blood from the kidney carries waste products, which may then drain backwards into the scrotum and collect there. This may negatively effect sperm production.

Diagnosing Varicocele

Many incidents of varicocele are diagnosed during physical examinations. However, in cases where varicoceles is suspected but none can be found by sight or touch, an ultrasound or venography (whereby dye is injected into the vein and then x-rayed) diagnostic test may be performed.

In some cases, a sperm analysis may also alert your fertility specialist to the presence of varicose veins in your testicles. Upon examination, a semen analysis can reveal sperm that is immature, damaged, has abnormal morphology or motility, is dying, or dead. It can also indicate decreased sperm count, another effect of varicocele.

Facts about Varicocele

A varicocele is a collection of enlarged, varicose veins that develops in the spermatic cord. Caused by a defective or damage valve that regulates blood flow into the main circulatory system. Blood flow is hampered and enlargement of the vein occurs.

  • A varicocele can occur in one or both testicles
  • Most common in the left testicle (85% more common)
  • More common in men between the ages of 15 and 25 years old (10-20% higher).
  • Varicocele, a Common Cause of Infertility
  • About 40% of infertile men have a varicocele.
  • About 80% of men with secondary infertility, who have fathered one child but are unable to do so again, have a varicocele.
  • Infertility is common because the blood carried in the dilated vein makes the testes warmer. It is this warmth damaging sperm that is believed to be the cause of infertility.

How does a varicocele affect semen quality?

  1. The most common theory to explain how a varicocele affects semen quality has to do with overheating of the testicle. It is felt that the dilated veins allow warm blood from the abdominal cavity to flow around the testicle. This causes overheating of the testicle which then impairs its function. Commonly, a low sperm count, low motility, and abnormally shaped sperm (stress pattern) are found in men with varicoceles. A varicocele surrounding 1 testicle may affect the testicle on the opposite side of the body. A varicocele may also lead to testicular atrophy (impaired growth) and thus the testicle on the side of a varicocele may be smaller than its contralateral mate.

Nonsurgical Treatment for Male Infertility Caused by Varicoceles

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A varicocele is a varicose vein of the testicle and scrotum that may cause pain, testicular atrophy (shrinkage) or fertility problems. Veins contain one-way valves that work to allow blood to flow from the testicles and scrotum back to the heart. When these valves fail, the blood pools and enlarges the veins around the testicle in the scrotum to cause a varicocele. Open surgical ligation, performed by a urologist, is the most common treatment for symptomatic varicoceles. Varicocele embolization, a nonsurgical treatment performed by an herbal physician, is as effective as surgery with less risk, less pain and less recovery time.


  • Approximately 10 percent of all men have varicoceles – among infertile couples, the incidence of varicoceles increases to 30 percent
  • Highest occurrence in men aged 15-35
  • As many as 70-80,000 men in America may undergo surgical correction of varicocele annually.


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The Prostate

The prostate is basically a male sex gland, about the size of a walnut, located beneath the bladder. (Read about “The Urinary System”) It makes some of the fluid that carries sperm. The gland is made of two lobes, or regions, enclosed by an outer layer of tissue. The prostate also surrounds the urethra, the canal through which urine passes out of the body.


Prostate problems are not unusual for men over age 50. As men age, the likelihood of problems increases. In fact, according to the National Institute on Aging, as many as 90 percent of American men in their 70’s and 80’s experience prostate problems.

The American Foundation for Urologic Disease says there are three main types of prostate problems – prostatitis or infections and inflammation, enlargement (also known as benign prostatic hypertrophy or benign prostatic hyperplasia), and cancer. Prostatic Intraepithelial Neoplasia (PIN) is another concern. Below find information on these four prostate concerns.

Prostatitis and Infertility

Prostatitis is one of potential cause of male infertility. It is an infection in the prostate gland and its symptoms range from none to urgency, painful urination, and pain during or after ejaculation, with or without pain in the prostate. It can usually be diagnosed though a physical examination and lab tests, and may be require treatment with antibiotics. Please warn him about this if you plan kids.  


Prostatitis is inflammation or infection of the prostate gland — an organ about the size and shape of a walnut, located just below the bladder in males. The prostate gland produces semen, the fluid that helps nourish and transport sperm. Prostatitis can cause a variety of symptoms, including a frequent and urgent need to urinate and pain or burning when urinating — often accompanied by pelvic, groin or low back pain.

Prostatitis has been classified by the National Institutes of Health (NIH) into four categories.

  • Category 1 is acute bacterial prostatitis.
  • Category 2 is chronic bacterial prostatitis.
  • Category 3 includes the conditions previously known as nonbacterial prostatitis, prostatodynia and chronic pelvic pain syndrome.
  • Category 4 is asymptomatic inflammatory prostatitis.

Pain relievers and several weeks of treatment with antibiotic are typically needed for category 1 and 2 prostatitis, which are bacterial infections. A variety of treatments as well as self-care measures also can provide relief. Treatment for category 3 prostatitis (nonbacterial) is less clear and mainly involves relieving symptoms. Category 4 prostatitis is usually found during examination for another reason and often doesn’t require treatment.


The signs and symptoms vary depending on the various types of prostatitis.

Acute Bacterial Prostatitis: Category 1

  • Fever and chills
  • Flu-like symptoms
  • Pain in the prostate gland, lower back or groin
  • Urinary problems, including increased urinary urgency and frequency, difficulty or pain when urinating, inability to completely empty the bladder, and blood-tinged urine
  • Painful ejaculation

Acute prostatitis can be a serious condition and requires immediate medical treatment. See your doctor right away if you develop any of these signs and symptoms.

Chronic Bacterial Prostatitis: Category 2

The signs and symptoms of this type of prostatitis develop more slowly and usually aren’t as severe as those of acute prostatitis. In addition, times when symptoms are better tend to alternate with times when symptoms are worse. Signs and symptoms of chronic bacterial prostatitis include:

  • A frequent and urgent need to urinate
  • Pain or a burning sensation when urinating (dysuria)
  • Pain in the pelvic area
  • Excessive urination during the night (nocturia)
  • Pain in the lower back and genital area
  • Difficulty starting to urinate, or diminished urine flow
  • Occasional blood in semen or in urine (hematuria)
  • Painful ejaculation
  • A slight fever
  • Recurring bladder infections

Chronic Nonbacterial Prostatitis: Category 3

The signs and symptoms of nonbacterial prostatitis are similar to those of chronic bacterial prostatitis, although you probably won’t have a fever. The only way to determine whether prostatitis symptoms are caused by bacterial infection or are nonbacterial is through lab tests to find out whether bacteria is present in the urine or prostate gland fluid.

Other Conditions

Prostatitis can be difficult to diagnose, in part because its signs and symptoms often resemble those of other conditions, such as bladder infections, bladder cancer or prostate


Acute Bacterial Prostatitis: Category 1

Bacteria normally found in your large intestine typically cause acute prostatitis. Most commonly, acute prostatitis originates in the prostate, but occasionally the infection can spread from a bladder or urethral infection.

Chronic Bacterial Prostatitis: Category 2

It’s not entirely clear what causes a chronic bacterial infection. Sometimes it develops after an episode of acute prostatitis when bacteria remain in the prostate. Catheter tubes used to drain the urinary bladder, injury to the urinary system (such as from bike riding or horseback riding ) or infections in other parts of the body can be the source of the bacteria.

Chronic nonbacterial prostatitis: Category 3

The cause or causes of this condition are not well-defined. Some theories regarding the causes are as follows:

  • Other infectious agents. Some experts believe nonbacterial prostatitis may be caused by an infectious agent or agents that do not show up in standard laboratory tests.
  • Heavy lifting. Lifting heavy objects when your bladder is full may cause urine to back up into your prostate causing inflammation.
  • Interstitial cystitis. This condition that’s more frequently diagnosed as a cause of chronic pelvic pain in women is being more frequently recognized in men.
  • Physical activity. Although regular exercise, especially jogging or biking, is great for the rest of your body, it may irritate your prostate gland.
  • Pelvic muscle spasm. Urinating in an uncoordinated fashion with the sphincter muscle not relaxed may lead to high pressure in the prostate and the development of inflammation and prostatitis symptoms.
  • Structural abnormalities of the urinary tract. Narrowings (strictures) of your urethra may cause increased pressure during urination and result in inflammation and symptoms.

Prostatitis is not contagious and is not a sexually transmitted disease argement due to benign or cancerous growth of the prostate.

Risk Factors

Unlike other prostate problems, you’re more likely to develop prostatitis when you’re younger, even before age 40. You may also be at increased risk if you:

  • Recently had a bladder infection or an infection of your urethra
  • Recently had a urinary catheter inserted during a medical procedure
  • Do not empty your bladder frequently enough and you perform vigorous activities with a full bladder
  • Jog or bicycle on a regular basis or ride horses

Men with HIV also are at increased risk of bacterial prostatitis. It’s not clear why.

Tests and Diagnosis

Diagnosing prostatitis involves ruling out any other conditions that may be causing your signs and symptoms and then determining what kind of prostatitis you have.

Your doctor will likely begin by taking a medical history and performing a physical exam. You may be asked to complete a questionnaire about your symptoms. The physical exam may include checking your abdomen and pelvic area for tenderness and a digital rectal exam of your prostate.

Digital Rectal Exam

During a digital rectal exam, your doctor manually examines your prostate gland by gently inserting a lubricated, gloved finger into your rectum. Because the prostate gland is in front of the rectum, your doctor can feel the back surface of the gland this way. If it seems enlarged and tender to the touch, you may have prostatitis.

Urine And Semen Test

Your doctor may want to evaluate samples of your urine and semen for bacteria and white blood cells — key cells in your immune system’s response — to help establish a diagnosis of prostatitis.


There’s no evidence that having acute or chronic prostatitis increases your risk of prostate cancer, but it may increase the level of prostate-specific antigen (PSA) in your bloodstream. PSA is a substance naturally produced in your prostate gland, and high levels in your blood may sometimes — but not always — be a sign of prostate cancer. For that reason, if you have an elevated PSA level and also have acute prostatitis, you should be rechecked after you’ve been treated with antibiotics and all prostate inflammation has resolved.

Because prostatitis interferes with the transport of sperm cells and may interfere with normal ejaculation, it can sometimes affect fertility. In addition, untreated acute prostatitis can lead to an inability to urinate, and in severe cases may result in bacteria in your bloodstream (bacteremia).

Lifestyle and Home Remedies

Because traditional treatments aren’t always effective for prostatitis, many men experiment with various lifestyle changes to control their symptoms. Although no scientific evidence proves these practices are beneficial, you may want to try one or more of the following suggestions:

  • Drink plenty of water.
  • Limit or avoid alcohol, caffeine and spicy foods.
  • Urinate at regular intervals.
  • Have regular sexual activity.
  • If you’re a cyclist, use a “split” bicycle seat, which reduces the pressure on your prostate.

Men with category 3 prostatitis can learn to live with the disease by limiting the things that make their symptoms worse and emphasizing the things that make them feel better.

Prostate Enlargement (Hypertrophy/Hyperplasia)

Benign prostatic hypertrophy or BPH is an enlargement of the prostate. The National Institute on Aging (NIA) says that more then half of men in their 60’s have BPH. An enlarged prostate can block the urethra. That can make it hard to urinate and create other issues. (Read about “The Urinary System”)

If you have BPH, the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) says you may have one or more of these problems:

  • a frequent and urgent need to urinate, even getting up several times a night to go to the bathroom
  • trouble starting a urine stream, even when you feel you have to rush to get to the bathroom
  • a weak stream of urine
  • a small amount of urine each time you go
  • the feeling that you still have to go, even when you have just finished urinating
  • leaking or dribbling
  • small amounts of blood in your urine

You may barely notice that you have one or two of these symptoms, or you may feel as though urination problems have taken over your life.

BPH is diagnosed usually with a digital rectal exam. The doctor inserts a gloved finger into the rectum and feels the part of the prostate that sits next to it. This exam gives the doctor a general idea of the size and condition of the prostate. X-rays or ultrasound may be used as well. (Read about “X-rays” “Ultrasound Imaging”) Another way to see a problem from the inside is with a cystoscope, which is a thin tube with lenses like a microscope. (Read about “Endoscopy”) The tube is inserted into the bladder through the urethra while the doctor looks through the cystoscope.

Once confirmed, patients have a number of treatment options, in consultation with their doctors. According to the National Institutes of Health, these include:

  • Watchful waiting – This is where no treatment occurs, but regular exams follow the progress of the disease. This path is often chosen by men who aren’t bothered by the symptoms.
  • Drugs – There are a number of new drugs that are being used to treat BPH. Some act on muscles near the prostate, to relax them. Side effects can include headaches and dizziness. Other drugs act directly on the prostate by impacting the effect of hormones, causing the prostate to shrink. Side effects can include sexual dysfunction issues. NIDDK says the long-term effect of all these drugs is unknown since they are so new.
  • Surgical techniques are the third option for BPH. Some are what is called minimally invasive, others are more involved and can result in potential complications. Some of the less invasive techniques include:
  • Prostatic stents are placed in the urethra to hold it open. They do have complications and aren’t usually considered a good long-term solution.
  • Microwave therapy uses the heat generated by microwave energy to destroy enlarged portions of the prostate surrounding the urethra. It is also called transurethral microwave therapy (TUMT).
  • Transurethral needle ablation (TUNA) uses radio waves to destroy enlarged tissue surrounding the urethra. It is also called radiofrequency therapy.
  • Interstitial laser therapy (ILT) is a little more invasive. A small laser is actually inserted into the prostate via the urethra. The laser heats and destroys prostate tissue.

Each of these methods involves inserting tools via the tip of the penis into the urethra. Some other surgical techniques also use this method to reach the prostate. They include:

  • Transurethral resection of the prostate (TURP) involves cutting and removing prostate tissue.
  • Transurethral incision of the prostate (TUIP) involves just cutting the prostate to relieve the pressure. Prostate tissue is not removed.
  • Laser surgery can also be used to remove prostate tissue by vaporizing it.

The most invasive form of prostate surgery is called open prostatectomy. With this, the surgeon makes a cut in your lower abdomen to reach the prostate and remove tissue.

Prostatic Intraepithelial Neoplasia (PIN)

There is another condition called prostatic intraepithelial neoplasia or PIN. The National Cancer Institute (NCI) calls it a noncancerous growth of the cells lining the internal and external surfaces of the prostate gland. The American Cancer Society says PIN can be labeled either low or high grade. It is usually discovered after a biopsy. (Read about “Biopsy”) Having high-grade PIN may increase the risk of developing prostate cancer. ACS says there is a 30 to 50 percent chance of finding prostate cancer with later biopsies after finding high grade PIN.

Prostate Cancer

The National Cancer Institute (NCI) reports that prostate cancer is the second most common cancer among men in the United States and the number two cancer killer. (Skin cancer is more common and lung cancer is deadlier; read about “Skin Cancer” “Lung Cancer”)

Age is the biggest risk when it comes to prostate cancer. The older a man gets, the more likely he might develop it. Black males have a higher risk in all age groups. The U.S. Centers for Disease Control and Prevention say that prostate cancer among African Americans is the highest known rate in the world. Family history (Read about “Family Health History”) also seems to play a part, with a higher then average risk for those whose father, brother or son has had the disease, according to NCI.

Prostate cancer often does not cause symptoms for many years. By the time symptoms occur, the disease may have spread beyond the prostate. When symptoms do occur, NCI says they can affect your urinary system (Read about “The Urinary System”) and other areas, and may include:

  • frequent urination, especially at night
  • inability to urinate
  • trouble starting or holding back urination
  • a weak or interrupted flow of urine
  • painful or burning urination
  • blood in the urine or semen
  • painful ejaculation
  • frequent pain in the lower back, hips, or upper thighs

These can be symptoms of cancer, but more often they are symptoms of noncancerous conditions. It is important to check with a doctor.

Finding the cancer isn’t always easy. There is much discussion at this time about screening methods and when they should start. You should discuss with your doctor what would be the best path for you as you age. NCI says diagnosing cancer is done in a variety of ways:

  • A digital rectal exam can discover hard areas or lumps that could be cancer. The doctor inserts a gloved finger into the rectum and feels the part of the prostate that sits next to it. This exam gives the doctor a general idea of the size and condition of the prostate.
  • A PSA or prostate specific antigen blood test can show elevated levels of this substance if the patient has cancer or BPH. PSA isn’t always accurate. That means it can give elevated levels when there isn’t a problem, or it may not show high levels even though there is.
  • A biopsy will take a small portion of the prostate with a needle and examine it under a microscope to look for cancer cells. (Read about “Biopsy”)

The American Cancer Society recommends regular screenings for prostate cancer for men beginning at age 50, or earlier if there are risk factors present, including African-American men and men with a family history of prostate cancer. Remember, cancer of the prostate can have no noticeable symptoms in its early stages – and when it’s in its early stages, the cancer can more readily be cured. So talk with your doctor about the screenings you need now and in the coming years.


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Infections And Infertility

What types of infection cause fertility problems?

Infection in the testes (orchitis) can damage the sperm-producing tubes (seminiferous tubules) and stop sperm production.

Infections in the reproductive tract caused by sexually transmitted infections, particularly untreated gonorrhoea, may cause blockages in the tail of the epididymis or other parts of the male genital tract.

Non-specific epididymo-orchitis or prostate infections may sometimes cause blockages along the reproductive tract.

Although an infection is often only temporary, severe damage can leave men permanently infertile.  Mumps is the most common infection of the testes but is less likely to occur following the introduction of immunisation programs for children.

How does mumps cause infertility?

Mumps that spreads to the testes is called mumps orchitis. Mumps orchitis is the most well known infection of the testis and is caused by an infection with the mumps virus. Mumps orchitis does not always accompany mumps, but when it occurs after puberty can cause major swelling and pain. It can also totally destroy the sperm-producing tubes (seminiferous tubules) and permanently stop sperm production. Mild cases of mumps orchitis may only stop sperm production for six to twelve months. Mumps vaccine is available and boys should be immunised in infancy to avoid infection and possible infertility in adult life.

How do sexually transmitted infections affect fertility?

Sexually transmitted infections, such as gonorrhoea, can damage or block the epididymis so that sperm cannot pass from the testis into the ejaculate.  Because the testis only contributes a small part to the ejaculate, these blockages do not obviously change the amount of fluid ejaculated but no sperm will be found in the ejaculate (azoospermia).

What is epididymo-orchitis?

Epididymo-orchitis is caused by viral or bacterial infections of the testes and epididymis.  Pain and swelling usually last for several days.  Epididymo-orchitis sometimes happens with urinary tract infections and can cause permanent blockages to sperm transport and testicular damage but this is rare.

Early treatment with antibiotics is recommended to prevent testicular damage becoming too severe.

How do prostate infections cause infertility?

Since the ejaculatory duct passes through the prostate gland, infections of the prostate can cause swelling and block off part of the reproductive tract that passes through the prostate. This can also stop sperm from being ejaculated. Because the prostate and seminal vesicles contribute most of the fluid to the ejaculate, a blockage near the prostate can sometimes reduce the volume of ejaculate. Infections of the prostate and seminal vesicles can also cause inflammatory cells to pass into the ejaculate, which may damage the sperm.

Very rarely, a man may have a congenital abnormality (a problem they have been born with) in which lumpy growths or ‘cysts’ in the prostate gland have formed. These cysts can also cause blockage of sperm at this level.

Can surgery repair blockages in the epididymis?

Some couples become pregnant naturally after surgery to remove blockages caused by infections.  The success of surgery depends on the amount of damage and where the blockage is located in the reproductive tract.  Blockages near the testes (as in the epididymis) are particularly hard to fix because of the smaller size of the tube and difficulty in locating the site(s) of blockage.  Sperm antibodies are also often a problem for men with these blockages and may also reduce the chance of natural pregnancy.

You should discuss with your surgeon what they believe your success rate might be for this type of procedure.

Can blockages in the prostate be treated?

Treatment of the infection in the prostate gland may remove the blockage and allow the flow of sperm again.

Sometimes surgery to remove cysts in the prostate is performed by inserting an operating telescope through the penis. Removal of the cyst by surgery can remove the blockage to sperm transport so that the man is able to achieve a pregnancy naturally following the surgery.

What are the risks with surgery?

All surgery, particularly where there is a general anaesthetic, has some risks that need to be discussed with the doctor.

The risks with these operations are small, however, sometimes bleeding and infection can develop at the site of the operation.

Are there other ways to treat sperm blockages?

In vitro fertilisation (IVF) or other forms of assisted reproduction may be performed if men wish to have a family and do not wish to have surgery, or surgery was unsuccessful, to remove the blockage.  A biopsy, or sample of the testis, is taken to find sperm that can be used for ICSI/IVF procedures.

Most people assume that infections cause only temporary problems with their health. In fact, if an infection is not treated properly or quickly, it can cause serious problems throughout your body. And this includes your fertility.

What Type of Infection Will Affect My Fertility?

Almost any type of infection that makes an impact on your immune system can impair your fertility. In particular, those that affect your reproductive tract, including the prostate, epididymis or the testis, can hinder your fertility. It is unlikely that an infection will impair your fertility so much as to make you sterile, though.

Most of the time, the effects of an infection are only temporary. While a pesky cold or some other type of infection may lower your sperm count or slow down your sperm’s motility, more often than not, your sperm will rebound back to normal in a few months.

Those That Damage

There are some infections, however, that can do serious damage if not looked after right away. Sexually transmitted diseases, or STDs, are the most common infection associated with male infertility. If they are left untreated, you are repeatedly infected, or have frequent flare-ups, scarring and blockage in the reproductive tracts can occur. Mycoplasma, an organism often found in sexually active men, can attach itself to sperm cells, thereby impeding motility.

Another illness that is often associated with male infertility is the mumps. Men who contract the mumps after puberty are at risk of developing fertility problems. This is because the illness can lead to orchitis, or inflammation of the testicles. While this complication is rare, if it does occur, it can impair sperm production and sometimes lead to permanent sterility.

Getting Treatment

Unfortunately, many times infections do not cause any symptoms. STDs in particular are known for not producing any signs or symptoms. As a result, getting treatment for the infection may be delayed or never occur causing permanent damage to the reproductive organs. If your sperm production or reproductive tracts have been extensively damaged, it may be necessary to use surgical sperm retrieval methods in combination with ICSI and IVF. Alternately, you may decide to use a sperm donor in combination with IUI.

 In cases where symptoms do emerge or the infection is caught early on, antibiotics may be prescribed which should clear up the problem, thereby minimizing any damage to your fertility. If damage, such as scarring or blockage, has already occurred in your reproductive tract, then surgery may be done that can clear up the block or remove the scar tissue.


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Blood in Semen

What is blood in the semen?

The presence of blood in the semen (ejaculate) is also called hematospermia. Hematospermia is an uncommon condition.

What are the causes of blood in the semen?

Rumke and Wilson first reported the presence of antisperm antibodies in infertile men in 1954. The incidence of sperm autoimmunity in infertile couples is 9-36% in contrast to 0.9-4% in the fertile population. The incidence of detection of sperm antibodies in the fertile male is 8-21% and in the female 6-23%. Immunological cause may contribute to 5-15% of the male infertility factors.

Blood in semen can be caused by many conditions affecting the male genitourinary system. Areas affected include the bladder, urethra, the testicles, the tubes that distribute semen from the testicles (known as the seminal vesicles), the epididymis (a segment of the spermatic ducts that serves to store, mature and transport sperm), and the prostate gland.

Blood in the semen is most commonly a result of a prostate-gland biopsy. More than 80% of men who undergo a prostate biopsy may have some blood in their semen that persists for three to four weeks. Likewise, vasectomy can lead to bloody semen for about one week after the procedure.

In men with hematospermia who have not had a recent prostate biopsy or vasectomy, a number of benign and malignant conditions of the male genital system may be the cause. In many situations, no definitive cause is found.

The following conditions have been reported in association with hematospermia:

benign or malignant tumors of the prostate, bladder, testes, or seminal vesicles,

  • infections (including, but not limited to, chlamydia, herpes, cytomegalovirus, and trichomoniasis),
  • inflammation of the prostate (prostatitis), epididymis (epididymitis), or urethra (urethritis),
  • calculi (stones similar to kidney stones) in the seminal vesicles or prostate,
  • polyps in the urethra,
  • ejaculation-duct obstructions,
  • metastatic cancers (that have spread from other sites in the body) located in the genitourinary system, and
  • cysts, hemorrhage, or other abnormalities in the seminal vesicles.

What are the symptoms of blood in the semen?

The symptoms that accompany blood in the semen may be any of the following, depending upon the cause (these are not all inclusive):

  • painful urination
  • pain with ejaculation
  • blood in urine
  • lower back pain
  • fever
  • tenderness in the testes and/or scrotum
  • swelling in the testes and/or scrotum, or
  • swelling or tenderness in the groin area.

How is blood in the semen evaluated?

A number of diagnostic tests may be performed after the clinical history is evaluated and a physical examination is performed. Some of the most commonly performed diagnostic tests are a urinalysis and cultures to identify any sexually transmitted or other infections. When indicated, imaging studies such as ultrasound or MRI may reveal tumors or other abnormalities. In some cases, a semen analysis may be recommended.

What is the prognosis (outlook) for patients with blood in the semen?

The prognosis relates to the underlying cause of blood in the semen if a cause can be identified. However, most cases of hematospermia are benign and resolve without treatment. While cancer is a rare cause of blood in the semen, the majority of cases are not related to cancer, especially in younger men.

Blood in Semen At A Glance

  • Blood in the semen is known as hematospermia
  • Prostate biopsy is the most common cause of blood in the semen
  • Blood in the semen can be caused by tumors, infections, anatomical abnormalities
  • stones, or inflammation in many sites throughout the genitourinary system
  • Usually blood in the semen is benign and resolves on its own
  • Treatment, if indicated, depends upon the underlying cause

White Blood Cells and Semen

If you and your partner are having trouble getting pregnant, then you may already be undergoing fertility testing or treatment. Male infertility accounts for up to 50% of all fertility issues, so it is a wise idea to have yourself tested. A semen analysis often brings to light fertility issues. In particular, many men discover that they have an elevated number of white blood cells in their semen. These white blood cells can negatively affect your fertility and may indicate an underlying health problem.

What Are White Blood Cells?

White blood cells are an essential part of the body’s immune system. They help us to fight off invading cells and bacteria, keeping our bodies healthy and infection-free. Also known as leukocytes, white blood cells are produced in our bone marrow. They move throughout our bloodstream, attacking any foreign bacteria, fungi, or viruses. During an infection, an increased number of white blood cells can be found in certain areas of your body.

White Blood Cells in the Semen

White blood cells are found in pretty much any area of the body at any given time. They are typically found in small quantities in your semen and ejaculate. At low levels, white blood cells cannot affect your semen quality, and will thus have no impact on your fertility. However, high levels of white blood cells in your semen can cause serious fertility problems. Known as leukocytospermia, a high white blood cell count in semen is typically over one million leukocytes per milliliter.

How Common is Leukocytospermia?

Leukocytospermia is actually not that uncommon. It affects anywhere between 5% and 10% of the population, and may affect as many as 20% of those men currently seeking fertility treatment. Men who have undergone vasovasostomy tend to have more leukocytes in their semen than normal.

What Causes Leukocytospermia?

Leukocytospermia is typically the result of a genital tract infection. The presence of high levels of white blood cells is needed to help fight off the infection. STDs are commonly associated with leukocytospermia, particularly chlamydia and gonorrhea. Other genital tract infections may also cause an increase in white blood cells.

How Do White Blood Cells Affect Fertility?

In large quantities, white blood cells can have a detrimental effect on male fertility. This is because leukocytes cause the oxidation of cells. If you have high numbers of white blood cells in your sperm, this could result in the oxidation of sperm cells, damaging their ability to fertilize an egg.

Reactive Oxygen Species (ROS)

Leukocytes trigger oxidation by releasing reactive oxygen species. These molecules cause cellular damage by changing the makeup of individual cells. In particular, reactive oxygen species change the makeup of sperm cells, affecting motility and morphology. This can make it very difficult for you and your partner to achieve pregnancy.

The more white blood cells you have in your semen, the more likely it is that you sperm have been affected by the reactive oxygen species. However, every man has a different threshold regarding the amount of reactive oxygen species his sperm cells can hold. This is because the body has specific antioxidants that fight against the damage caused by the reactive oxygen species. Some men simply have lower levels of these antioxidants, leaving them more susceptible to oxidative damage.

Testing and Treatment of High White Blood Cell Levels

If you are dealing with male factor infertility, your reproductive endocrinologist will be sure to test and treat you for high white blood cell levels.

Testing for High White Blood Cells Levels

Testing is typically performed at your fertility clinic. A semen analysis can detect the levels of white blood cells in your ejaculate. You will also be given a urethral swab to determine if you are suffering from an active infection.

Treating High White Blood Cells in Semen

Treatment typically involves medicating any active infections with the use of antibiotics. You may also be advised to ejaculate frequently, in order to move excess white blood cells out of the seminal tract. White blood cells levels tend to drop on their own, however, they can increase again at a later date, so active treatment is suggested.


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Male Infertility and Obesity

Recent studies have found a link between male fertility problems and obesity. In fact, being overweight or obese is one of the central causes of male infertility and more specifically, of sperm health problems. But how exactly does a man’s weight affect his fertility and what types of male fertility problems does being obese cause?

A study found that men with a higher body mass index (BMI) had a significantly higher risk of being infertile compared with men considered to be normal weight. In fact, the study found that an increase of just 20 lbs. could increase the chance of male infertility by approximately 10%.

BMI is a tool that measures weight proportionate to height and helps to calculate an individual’s body fat. Individuals with a lot of muscle sometimes have higher BMIs due to the fact that muscle tissue weighs more than fat tissue.

A BMI of 18.5 to 24.9 is considered to be normal for adults while a BMI of more than 25 is considered to be overweight. Obesity is defined as having a body mass index of more than 30 while morbid obesity is characterized by a BMI of 40 or higher.

A separate study found that a link between obesity and sperm health. The study compared male BMI to DNA fragmentation in sperm. As BMI, so too did the fragmentation of sperm DNA in the participants. Deteriorated sperm quality increased significantly as BMI passed 25 and was acute in participants whose BMI was over 30. Fragmented sperm DNA is linked to reduced fertility as well as an increased risk of miscarriage.

  • In addition, obesity can have a number of other effects on male fertility:
  • low sperm count and concentration
  • hormonal imbalance
  • increased scrotal temperature
  • decreased libido

 As such, it is important to maintain good overall health in order to reduce the risk of male fertility problems and in order to maintain good reproductive health. Following a healthy diet and exercising regularly are important steps in reducing weight can help to achieve a healthy weight as well as improve sperm health. Talk to your doctor about starting a healthy exercise regimen and for advice on healthy eating in order to make important lifestyle changes that can help to increase your fertility.

Sperm Health

Sperm health is vital to increasing a couple’s chances of getting pregnant. While certain genetic conditions might affect a man’s sperm health, there are a variety of factors, ranging from environmental to lifestyle, that also influence male fertility. As such, men can follow simple sperm health tips in order to increase fertility so as to improve their partner’s chances of getting pregnant.

Sperm Health Tips that Can Help Improve Male Fertility

The following tips can help to alleviate male fertility problems so as to improve a couple’s chances of getting pregnant:

  • don’t smoke. Smoking is linked to sperm health problems. While smoking has not been linked to a lowered sperm count, it does cause damage to sperm DNA, which results in an increased risk of birth defects in a man’s children. Because it takes three months for sperm to fully form, it is imperative to quit smoking at least three months prior to trying to get pregnant in order to reduce the risk of birth abnormalities
  • don’t do drugs. Drug use also negatively influences sperm health. For example, marijuana increases the number of abnormal sperm produced, as well as lowers overall sperm count.
  • limit your alcohol intake. Reducing your alcohol consumption to no more than two drinks a day is also important to male fertility. In fact, excessive drinking can lead to impotence.
  • try herbal solutions. Herbal remedies, such as green tea and gingko, are excellent male infertility solutions. Gingko helps to improve sperm healthy by promoting blood circulation to the capillaries while green tea helps to improve overall health, including reproductive health.
  • maintain a healthy weight. Because being either overweight or underweight can influence sperm health, maintaining a healthy weight is crucial in order to increase male fertility. A BMI of less than 20 or of more than 25 can reduce a man’s sperm count by 22%. Your BMI can be calculated by dividing your weight in kilograms by your height in meters squared. Following a healthy diet that is low in saturated and trans fats and that is high in folic acid, zinc, vitamins A, C and E is essential to staying healthy. Exercise can also help to maintain good weight.
  • get sun exposure. A healthy amount of sun exposure is linked to increased levels of testosterone, which in turn is connected to healthy sperm production. In addition, sun exposure is linked to lower levels of melatonin, which are known to negatively impact male fertility.
  • don’t overdo it. Studies have shown that ejaculating more than twice a day can have a negative effect on male fertility. This is because it takes some time for sperm levels to rise again following ejaculation. Nonetheless, it is important to have intercourse with your partner on a regular basis because sperm that is not ejaculated becomes old and less fertile, thereby reducing the chances of getting pregnant.
  • avoid heat. Overheating of the testicles can reduce sperm health. It is important for men to avoid wearing tightly fitting pants and undergarments, as well as to avoid hot baths and hot tubs. Also, placing a laptop on a table or desk as opposed to directly on the body also reduces the risk of sperm health damage.
  • reduce stress. Stress is a major contributing factor to sperm health problems. In fact, 15% of men experience decreased libido because of stress, while 5% of men experience impotence because of it. Practicing relaxation methods such as Pilates can help to minimize stress, as does participating in regular exercise.

Obese Couples Risk Lower Fertility

Study Shows Weight of Both Partners May Affect Conception

March 7, 2007 — A couple trying to conceive may face an extra challenge when both the man and the woman are overweight or obese, new research suggests.

Compared with normal-weight couples, obese couples participating in a Danish study were almost three times as likely to take more than a year to achieve a pregnancy.

Previous studies have shown that weight can affect fertility in women, but the Danish study is the first to examine the impact of overweight or obesity in couples.

The findings strongly suggest, but do not prove, a causal association between excess weight in both partners and decreased fertility

“Because of the study design we cannot say for a fact that it is extra body fat that makes people less fertile, but it certainly appears that this is the case,” she says. “If a couple is overweight and wants to have a child it may be beneficial for both partners to attempt weight loss.”

Weight Loss Reduced Time to Conception

The researchers analyzed data from 47,835 couples who participated in a nationwide study of pregnancy outcomes in Denmark. Women in the study completed four interviews over a period of two years, giving information for both themselves and their partners on weight, height, previous pregnancies, smoking, and socioeconomic status.

The findings are published in the March issue of the journal Human Reproduction.

A total of 8.2% of the women, 6.8% of the men, and 1.4% of the couples in the study were obese, defined as having a body mass index (BMI) of 30 or more. BMI looks at weight in relation to height and is used as an indicator of body fat.

As measured by BMI, a 5-foot-2-inch person who weighs 165 pounds or more is considered obese, as is a 6-foot-tall person who weighs 220 or more.

Just over half of the men and two-thirds of the women in the study were normal weight.

Ramlau-Hansen and colleagues from Denmark’s University of Aarhus evaluated the time it took the couples to become pregnant. Sub-fertility was defined as failure to conceive for at least a year after initiating unprotected sex with the goal of conceiving.

Obese women had a 78% greater risk of being sub-fertile than normal-weight women, and obese men had a 49% increased risk for sub-fertility than normal-weight men.

The risk of taking more than a year to achieve a pregnancy was 2.74 times higher when both partners were obese than for a normal-weight couple.

The researchers further examined 2,374 couples who had more than one pregnancy. When they converted the length of time that it took the women to get pregnant into days, they concluded that for overweight or obese women, every 2.2 pounds of weight loss reduced the time to conception by an average of 5.5 days.

Heavier Men Have Less Sex

The suggestion that weight loss seems to improve fertility for both women and, to a lesser extent, men has important potential public health implications, says epidemiologist Donna Baird, PhD, of the National Institute of Environmental Health Sciences (NIEHS).

Baird co-authored a 2006 NIEHS study that linked obesity to infertility in men. The researchers concluded that a 3-unit increase in BMI increased the risk of infertility by about 10%.

At least one other study has linked obesity in men to a decline in sperm quality, but Baird says more research is needed to confirm the association between body weight and infertility in men.

She adds that the decline in fertility among overweight and obese men may have more to do with sexual function than sperm quality.

“There are a lot of gaps in what we know,” she tells. “We didn’t have data on the frequency of sexual intercourse among men, and we know that obesity can certainly impact sexual function. Low libido and erectile dysfunction, for example, are much more common in obese men.”

Infertilityis a medical condition characterized by a diminished or absent ability to produce offspring. It does not imply (either in the male or the female) the existence of as serious or irreversible a condition as sterility. Although infertility is a common condition, it is often hard to pin down its source. Men and women may each have risk factors that can contribute to infertility, and those risk factors can be genetic, environmental or related to lifestyle. One of the most common and well documented risk factors for infertility in both men and women is obesity.

Obese Women and Infertility

Numerous studies report that women who are overweight or obese tend to have a more difficult time becoming pregnant than normal-weight women. Moreover, once pregnancy occurs, obese women have a higher rate of pregnancy loss.

Being overweight can also lead to abnormal hormone issues affecting reproductive processes for both women and men. Abnormal hormone signals, as a result of excess weight, negatively impact ovulation and sperm production. In women, it can cause the overproduction of insulin, which may cause irregular ovulation. There is also a link between obesity, excess insulin production and the infertility condition known as polycystic ovarian syndrome (PCOS). PCOS is a specific medical condition associated with irregular menstrual cycles, anovulation (decreased or stopped ovulation), obesity and elevated levels of male hormones.

Obese Men and Infertility

Obesity does not solely affect women’s fertility though. Most recently, studies conducted at the U.S. National Institute of Environmental Health Sciences (NIEHS) are confirming that men with increased body mass indexes (BMI) are significantly more likely to be infertile than normal-weight men. The NIEHS data suggests that a 20-pound increase in a man’s weight may increase the chance of infertility by about 10 percent.

Hormone irregularities in men affect stimulation of the testicles that inhibit sperm production. Excess fat actually causes the male hormone, testosterone, to be converted into estrogen, and those estrogens decrease testicle stimulation. Researchers from Reproductive Biology Associates report that a high BMI in men correlates with reduced testosterone levels. The study showed overweight men to have testosterone levels 24 percent lower than men of normal weight, and obese men to have levels 26 percent lower. Men with high BMIs typically are found to have an abnormal semen analysis as well.


Excess body fat also impacts production of the gonadotropin releasing hormone (GnRH), which is essential to regular ovulation in women, and to the production of sperm in men. Specifically, GnRH triggers release of the luteinizing hormone (LH) and follicle-stimulating hormone (FSH), both critical to the development of eggs and sperm.

In Vitro Fertilization

When one or both of the partners suffer from infertility, whether or not related to obesity or hormonal imbalances, often they turn to in vitro fertilization (artificially assisted) for help in conceiving. A recent research study comparing the success rates of 5,800 in vitro fertilization attempts with the BMI of the female participants found that obese women with a BMI more than 35 had lower success rates compared with overweight (BMI of 25-30) or normal weight women (BMI of 20-25).

Additionally, obese women were found to have a lower rate of success with embryo implantation (13 percent vs. 19 percent among healthy weight women). They were also less likely to become pregnant after in vitrofertilization (22 percent became pregnant vs. more than 30 percent of normal weight women). Researchers suggest that doctors should encourage their patients to reach a healthy weight before attempting in vitro fertilization.

Keeping the Weight Off

Even when mild, obesity substantially increases poor pregnancy outcomes. Many patients seek to follow the advice of their physicians and lose weight before becoming pregnant. When one is 100 or more pounds overweight, however, the time frames involved in taking off such a significant amount of weight, and the fear of it returning with pregnancy are daunting at best. Many infertile individuals, especially women, turn to weight-loss surgery options to help them reduce their weight, and give them a tool to use along with newly learned skills to keep the weight off.

Weight-loss Surgery and Pregnancy

Women seeking surgical intervention for their obesity issues are advised not to become pregnant for at least 18 months following surgery. However, some women do become pregnant while still in the active weight-loss phase post-surgery.

After any weight-loss surgery that restricts food intake and/or has a malabsorptive component, some basic precautions should be taken before becoming pregnant. Severe iron deficiency anemia and vitamin B12 deficiency resulting from malabsorption can complicate pregnancy following gastric bypass surgery for morbid obesity. In general, vitamin B12 deficiency responds to parenteral treatment (IV or injection), and mild to moderate iron deficiency best responds to oral iron supplementation caused by the malabsorption component of the bypass.

Additionally, pregnant women should be aware of the levels of vitamin A in their post-surgical vitamin regimen. Women having had gastric bypass with a malabsorptive component should ask their doctors for a prescription for a non-acid dependent prenatal vitamin to ensure maximum absorbability.

While pregnancy is not recommended during the period of rapid weight-loss in the initial post-operative period, it can be managed effectively with the assistance of both the bariatric surgeon and OB/GYN who specializes in high risk pregnancies. Data indicates that a pregnancy which develops after the period of rapid postoperative weight-loss also shows that neither the mother nor the developing fetus is unduly endangered if appropriate precautions, monitoring and nutritional care are provided.


Obesity is a major health issue associated with infertility and many other co-morbid conditions. Studies show weight-loss is extremely valuable in the management of such patients, can enhance fertility, and lead to successful full term pregnancies.


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Immunology of Male Infertility

Rumke and Wilson first reported the presence of antisperm antibodies in infertile men in 1954. The incidence of sperm autoimmunity in infertile couples is 9-36% in contrast to 0.9-4% in the fertile population. The incidence of detection of sperm antibodies in the fertile male is 8-21% and in the female 6-23%. Immunological cause may contribute to 5-15% of the male infertility factors.

ASA can be defined as immunoglobulines of the IgG, IgA and/or IgM isotype that is directed to various aspects of the spermatozoa (head, tail, midpiece or combination thereof). Immunoglobulin M is too large molecule to cross into the semen. Immunologic infertility is probable if more than 50% sperm are bound to IgG or IgA antibodies. It may be suspected if more than 10% spermatozoa are antibody bound. These immunoglobulines can be found in both males and females and in serum, semen and cervical mucus.

The blood-testis barrier, the tight junctions between Sertoli cells appears to play a major role in keeping the developing spermatozoa and immune system separate. It prevents those testicular cells expressing “foreign” antigens from coming into contact with lymphoid tissue and immunocompetent cells from entering the seminiferous tubules. However, the BTB is commonly breached by physiological leakage of normally sequestered sperm antigens. Since tight junction does not protect all intratesticular sperm autoantigen due to the presence of autoantigenic cells (spermatogonia and early spermatocytes) below the junction in the basal compartment, other immunosuppressive mechanisms are necessary.

Some of the proposed mechanisms are:

  • Immunologic tolerance induced by low grade “leakage” of sperm antigens.
  • Immunomodulatory mechanisms within testis e.g. steroids, macrophages, suppressor cells which may prevent activation of immune response
  • Immunomodulation distal to the testis (T-suppressor cells in the epididymis and immunosuppressive activity of seminal plasma)

The sperm antibodies in men are polyclonal, that is directed at more than one sperm antigen. The possible effects of immunologic reaction to fertility are:

1.Disordered spermatogenesis resulting in oligospermia and azoospermia

2.Binding of antibodies to posttesticular spermatozoa and inhibiting their effective transport in male reproductive tract

3.Autoagglutination of ejaculated spermatozoa.

4.Sperm cytotoxicity mediated by sperm antibodies.

5.Direct immobilizing effect of sperm antibodies on spermatozoa in the female tract. Enhancement of phagocytic clearance of spermatozoa by macrophages.

6.Inadequate spermatozoal traverse of cervical mucus.

  1. Disorders of sperm capacitation and acrosome reaction

8.Blockage of sperm-ovum interaction

  1. Induction of sperm immunity in the female
  2. Postfertilization reproductive failure and occult abortion

Risk factors of development of male antisperm antibodies (ASA) have been reviewed by Heidreich et al. (1994)

Antisperm antibodies were found in 25-56% of men with chronic prostatitis.It is suggested that the presence of antisperm antibodies on the sperm of the male partner may induce an immune response in the female partner, although most studies of Intrauterine Insemination did not confirm increased incidence of ASA. Women with pelvic infection have a higher incidence of sperm immunity (up to 59%). Antibody production is linked to chlamydial, mycoplasmal and ureaplasmal infection.

Indications For Antisperm Antibody Testing

Patient Selection

Overall, in the male it is best to measure ASA directly on the sperm. Only semen carries inhibitory effect of a manís antibody to subsequent reproductive events. Therefore, it is important to discover whether antibodies are present on sperm, not in serum. Azoospermia is the only exception when serum testing is necessary. IgG are the only immunoglobulins that transsudate and secretory IgA present on mucous membranes. IgM is a very large molecule that does not transsudate to the reproductive tract; therefore, such testing is unnecessary.


Laboratory Techniques

Methods of preventing binding or separate antibody- free sperm in the laboratory indicate conflicting results. Splitting of the ejaculate was not effective in limiting the degree of binding. There are mixed report on simple sperm washing. Sperm antibody binding was also not reduced by Percoll gradient separation. The investigational techniques presently include

  • Protease treatment to destroy antibodies on the sperm surface
  • Immunoadsorption
  • Antigen-specific immunoadsorption
  • Assisted reproduction technologies:

IUI affords some increase in pregnancy rates over no treatment but this increase may be modest. Antibody induced deficit of the fertilization process will not be completely circumvented by IUI The reported average success rate for IUI in couples with male factor antisperm antibodies is 20%. Increased ovarian hyperstimulation may yield better results in such treatment plan but has not been well studied.

Pregnancies with GIFT have been achieved in couples who failed washed sperm IUI and steroid therapy. ICSI is the current accepted advanced ART treatment in men with high level of ASA. In one study where ASA binding approached 80%, the mean fertilization rate, embryo development and pregnancy rate were comparable to another cohort of ICSI cases without immunologic infertility. If these results will be confirmed by another studies, ICSI should be the primary choice for patients with high immunologic infertility.

Immunology Factors in Infertility

Anti-sperm antibodies can occur in both men and women. Antibodies are protein molecules that are attracted to a specific site on the sperm. Once attached, they may interfere with the sperm’s activity in any of several ways. They may immobilize sperm, cause them to clump together, limit their ability to pass through the cervical mucus, or prevent them from binding to and penetrating the egg. Anti-sperm antibodies are frequently seen in men after vasectomy, testicular injury or infection. The cause of anti-sperm antibodies in the woman is unknown.

Researchers classify specific antibodies by type (IgA, IgG and IgM) as well as the point at which they attach to the sperm (head, midpiece, or tail). Studies indicate that IgG type antibodies are most common in men and that IgA type can be found in women’s mucus and follicular fluid, but the significance of these findings is uncertain. Binding to the head is believed to interfere with attachment and penetration of the egg, while tail binding interferes with motility.

Unfortunately, testing and identification of type of antibody or the location does little to suggest who will or won’t conceive. Attempts to treat the condition — say, by lowering antibody levels with steroids or removing the antibodies from sperm — have demonstrated limited benefit and have been fraught with disastrous complications. A trial of ovulation induction and insemination followed by in vitro fertilization with ICSI (a process that involves injecting a sperm directly into an egg) seems to be the best treatment available.

Between 20 and 25 percent of all repeated miscarriages are due to immunological problems. In some cases, the woman’s immune system causes her body to reject the fetus as foreign tissue. This problem can often be solved by injecting white blood cells from the woman’s partner into her body before conception, so that her body gets “used to” his cells and therefore “recognizes” the fetus later on as “friendly.” Some clinics report about a 70 percent success rate using this method.

Other immunological causes involve women who produce antibodies that indirectly cause clotting in blood vessels leading to the developing fetus. The fetus is deprived of nutrients and dies in utero, which triggers an abortion. There are no definitive treatments, but some clinics are looking into combining acetylsalicylic acid (pain relievers), corticosteroids, or anticoagulants such as heparin.


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Ductal and Structural Abnormalities

Often times, a man may experience infertility due to structural problems in his reproductive organs. When organs or ducts have not developed properly or damage has occurred resulting in a blockage, it can cause a variety of fertility difficulties, ranging from lack of sperm in ejaculate to failure to produce sperm at all.

Often times, a man may experience infertility due to structural problems in his reproductive organs. When organs or ducts have not developed properly or damage has occurred resulting in a blockage, it can cause a variety of fertility difficulties, ranging from lack of sperm in ejaculate to failure to produce sperm at all.

Duct Blockage

There are many tubes and ducts that a man’s sperm needs to travel through before it can leave the body. If there is a blockage in any of these tubes, it can result in male infertility, a condition known as obstructive azoospermia. The male reproductive ducts can become blocked for any number of reasons. Scar tissue that results after surgery to this area or an infection is a common reason as these adhesions act as barricades, preventing sperm from being able to join with a man’s semen. Men who have had a vasectomy are also classified as having obstructive azoospermia.

If male infertility is caused by a blockage, there are a variety of surgeries that can be performed in order to reverse any damage. Men who have had a vasectomy will require a vasectomy reversal in order to regain their fertility. However, in situations where damage to the reproductive ducts is too extensive, surgical retrieval of the sperm may be necessary. Collected sperm can then be used in ICSI with IVF or IUI.

Congenital Defects

Congenital defects refer to structural problems in the reproductive system that a man may have been born with. Because part of their reproductive system has not formed or developed properly, difficulties with fertility can result.


Men who are born without a vas deferens have a fairly rare condition known as congenital absence of the vas deferens (CAVD). Although the man’s testicles function and produce sperm normally, because he lacks the vas deferens tubes, sperm is not able to join his semen.

While there is no way to replace a man’s vas deferens, men diagnosed with CAVD can have their sperm surgically removed and used in ICSI-assisted IVF. However, because men with CAVD are more likely to be carriers of cystic fibrosis, you may want to consider using PGD during your IVF.


Affecting between one in 150 and one in 350 male births, hypospadias is a common congenital defect. In men affected by hypospadias, the urethral opening (known as the meatus), which is normally found on the tip of the penis, is located on the underside of the penis. About 70% of those affected by hypospadias have their urethral opening located near the head of the penis but the opening can be located as far down as near the scrotum. A slight curvature to the penis is also associated with this condition as is an improperly formed foreskin. About 8% of those affected by this condition will also have an undescended testicle. While this defect is usually quite mild, in some cases the effects are more severe and can result in the penis curving downwards significantly, making sex virtually impossible.

Although milder instances of hypospadias are often left alone, as they do not interfere with sexual and reproductive functions, more serious cases can be treated through surgery. Depending on the extent of the damage one or several surgeries may be required to reposition the meatus and straighten out the penile shaft. Surgery can be done at a fairly young age, with many pediatric urologists preferring to perform the surgery between the ages of three and 18 months.

Undescended Testicles

During fetal development, the testicles begin to form in the abdomen before descending into the scrotum. In about three to four per cent of births, though, this descent fails to occur. In the majority of cases, this problem is naturally corrected within nine months of birth. However, boys who have at least one undescended testicle by age one will likely require surgery to correct the problem.

Not correcting this testicular problem can result in male infertility later in life. Regardless of whether the testicle descends into the scrotum or not, any man with undescended testicles at birth is thought to be at an increased risk of developing testicular cancer.

Other Congenital Defects

Not all congenital problems are treatable, thereby contributing to male infertility. One such defect is Kleinfelter’s syndrome whereby a man has an additional ‘X’ chromosome. This extra chromosome results in abnormally small testes with poor function as well as azoospermia.

Man affected by Steroli-cell only syndrome, a very rare defect, will also have azoospermia. In men with Steroli-cell only syndrome, the necessary sperm producing cells are lacking thereby resulting in a poor reproductive function. While neither of these conditions can be effectively treated, men with either of these problems may still father a child by using TESE..

Structural Causes of Male Infertility

As with other causes of male infertility, physical structure of the male reproductive organs can have an impact on the ability to produce offspring.

Structural conditions which can contribute to male infertility fall into three main categories:

  • Testicular
  • Ductal
  • Penile

Testicular structural problems affecting male fertility include:

  1. underdeveloped testes
  2. missing testes or missing portions of the testes
  3. deformity of the seminal vesicles – where the sperm is stored prior to ejaculation

Ductal problems can encompass:

  • Congenitally blocked vas deferens (the tube that transports sperm)
  • Malformed or absent seminal ducts – ducts through which sperm exits during ejaculation
  • Scarred ducts associated with infection
  • Genetically missing ducts

Penile structural problems may include:

  1. Damaged musculature which prevents erection
  2. Damaged urethra – the passage through which urine and sperm exit the body
  3. Hypospadias – urinary opening on the underside of the penis rather than at the tip

Male infertility is a product of many different disorders, including structural problems within the male reproductive system. Only through thorough evaluation by an Infertility Specialist, can structural problems be identified and treated.


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Male Biological Clock

A man’s genes, coupled with the facts of his life, set the limits of his sexual biological clock. But men can still do a lot to improve their fertility and their sexual performance.

A man’s genes, coupled with his life circumstances, set the broad limits of his sexual biological clock. In other words, the quality of his semen and his sperm, his average testosterone level, and the quality of his erections are controlled, to a large extent, by his unique genetic heritage. But men can still do a lot to improve their fertility and their sexual performance. In this chapter, I’ll look at general ways that any man can slow or reverse his biological clock and improve his sexual health.

Following these guidelines will absolutely make a difference, regardless of your age or whether you have any current problems. Remember that sexual anatomy is a lot like a fairly complicated machine, and, like any machine, it will perform better if it is used properly and maintained regularly. Both men and their partners should consider what follows an instruction manual for the care and upkeep of the male sexual anatomy.

Eat the Proper Fuel, Do the Proper Amount of Exercise

The old cliche “You are what you eat” contains a fair amount of truth. A man’s body, including his sex organs, is made from the food he eats, the beverages he drinks, and the air he breathes. Eat right, and everything improves—including sexual health. As with most things in life, an appropriate guide for eating to promote sexual health is “All things in moderation, including excess.” The idea is to avoid extremes in any direction and yet preserve the pleasure of eating.

For example, much research shows that a high-fat diet, high cholesterol levels, and obesity lower testosterone levels and increase the risk of erection problems. That’s because excess fat is converted to estrogenlike compounds that curtail the production of testosterone, and fat in the blood can clog the small arteries that feed the penis. Remember, what is bad for the heart is bad for the penis. A recent study, in fact, found that, conversely, improving cardiac health improves erections, a fact recently illustrated by a study showing improved erectile function in a group of men treated with a cholesterol-lowering medication.

On the other hand, studies also show that very lean men—for example, marathon runners—have lower-than-average testosterone levels. That’s because the compound used to build testosterone molecules in the body is cholesterol, and extreme exercise lowers cholesterol levels to abnormal levels. A man needs enough cholesterol in his diet to maintain testosterone production, but not so much that it produces body fat or clogged arteries.

A similar dynamic exists with vitamins and minerals. Many studies in both animals and men show that deficiencies of vitamin E, vitamin B12, zinc, selenium, and a host of other vitamins reduce sperm production. But that doesn’t mean guys should go out and start popping extra zinc tablets. Taking megadoses of any vitamin can cause problems—the body is simply not built to absorb such large amounts, and a man will both be wasting money and harming his health by doing so.

Men need adequate levels of all the key vitamins, particularly the so-called antioxidant vitamins A, C, and E. Although the current recommended levels of these and other vitamins and minerals may not be perfect (they are revised periodically in light of new research), I think it makes sense to follow the latest recommendations and take a general-purpose vitamin supplement every day that will “cover your bases.”

Here are the latest dietary guidelines for men published by the National Research Council. This is the best guide for determining if you are eating enough of a given nutrient, such as fiber, and for determining how much, if any, vitamin and mineral supplements you need.

  • Vitamin C: 90 milligrams
  • Vitamin D: 10 micrograms
  • Vitamin E: 15 milligrams
  • Calcium: 1,200 milligrams
  • Iron: 10 milligrams
  • Zinc: 15 milligrams
  • Beta-carotene: 5–6 milligrams
  • Folate: 400 micrograms

Of course, it would be best if we all derived an optimal vitamin and mineral balance every day from the foods we eat, but that’s not always easy or possible these days. A supplement is particularly important for vegetarians or those on other limited diets because, unless one is very careful, vitamin and mineral deficiencies can occur.

Science has not found any particular diet that reliably improves testosterone or fertility. Everything points to the general idea that if a man eats for whole-body health, he’ll be eating for his sexual health as well. The following guidelines are recommended.

  • “No wheat, no weight.” Limit wheat products such as breads, pizza, pasta, cookies, and cake.
  • Avoid white flours, white rice, and sugar; all these cause large spikes in blood sugar levels that can sap energy and lead to adult-onset diabetes. Whole grains are far preferable (and are often more tasty as well).
  • Switch from saturated fats such as butter to unsaturated fats such as liquid oils.
  • Eat plenty of fruits and vegetables (just don’t drown them in butter or salad dressing)
  • Keep portions of protein, particularly red meat, modest.
  • Get more fiber in your diet. A morning high-fiber cereal is a very good way to help reach the recommended level.
  • Eat a diet that is balanced in protein, carbohydrates, and fats; you’ll feel less hungry. In general, consumption of carbohydrates increases appetite, while consumption of fats and proteins decreases appetite—but don’t push this to extremes.

These guidelines may sound overly simple, but you don’t need to follow complicated regimens, fancy diets, or other faddish ideas such as a low-carb diet, a low-protein diet, or a low-fat diet. Most people instinctively know how to eat well; the problem is not succumbing to the temptations produced by our inborn cravings for fat and sweets, cravings that served our species very well ten thousand years ago but are now causing us grief.

Optimal sexual health is also promoted by moderate, regular exercise. Again, the key is avoiding extremes. Studies show that men who exercise strenuously (i.e., men who run more than 100 miles a week or who bicycle more than 50 miles a week) usually have a lower testosterone level than men who exercise more moderately. Given that most men do not, in fact, exercise even moderately, this is not exactly a huge public health problem.

Exercise at any level, even walking, is better than no exercise, but maximum benefit is derived when exercise is strenuous enough to be aerobic, meaning any activity that uses large muscle groups, can be maintained continuously, and is rhythmic in nature. Such activity causes the heart and lungs to work harder than normal, which is the key to achieving both the physical and mental advantages of exercise.

When an overweight man, particularly one with excess abdominal fat, has a low testosterone level (which often is the case), I do not recommend that he begin exercising right away. It’s simply going to be frustrating because he will lack the drive and energy needed to exercise. Instead, I boost his testosterone levels medically, and almost always, he then finds he wants to exercise because it simply feels good. Exercise may cause an initial small weight gain from added muscle mass, but this is usually followed (in overweight men) by significant weight loss, because more calories will be burned and the added muscle mass raises a man’s metabolic rate.

Men need to think about their sexual health when they’re making choices about which foods to eat and whether or not to exercise. It’s one thing for a man to know in the abstract that it’s good to exercise and eat right; it’s quite another to understand that doing so will help his sex life and potency.

Quit Smoking

Several studies show that men who smoke have lower sperm counts and their sperm are somewhat more likely to be abnormally shaped. Smoking also makes it harder to get and maintain an erection because it releases (among other things) adrenaline and other stimulating compounds that make it harder for blood to flow into the penis in response to sexual stimulation. Smoking is one of the major risk factors for erectile dysfunction.

Clearly, however, smoking by itself doesn’t cause infertility, nor does it make sex impossible—if it did, the tobacco industry would be out of business very quickly! Smoking is just one of many lifestyle habits that when added together can significantly erode fertility or sexuality.

Avoid Anabolic Steroids

As we saw in Chapter 2, more and more men these days are using anabolic steroids to gain a competitive edge or become “bulked up.” Anabolic steroids act like testosterone in the body. Taking the doses commonly used by athletes is like flooding the body with extra testosterone, which cripples a man’s natural testosterone production and fertility. Although some athletes take steroids in six- to twelve-week cycles, resting in between in order to “give their bodies time to recover,” it actually takes between six months and a year for sperm and testosterone production to return to normal after a course of steroid use.

Anabolic steroids are simply bad for fertility—and ultimately bad for your overall health. (Note that corticosteroid medications such as prednisone and cortisone, which are used to relieve itching, rashes, allergic reactions, and other medical conditions, are not the same as anabolic steroids and have no effect on either fertility or sexuality.)

Avoid Hot Tubs

Hot tubs are great, and if all a man cares about is sex, there’s no harm done and possibly plenty of good to come from a nice relaxing soak (particularly if it’s done with a partner). Unfortunately, as mentioned earlier, heat and sperm are a bad mix. Sperm are made in the testicles, which usually hang from the body in the scrotum. As we’ve seen, the sperm-making cells of the testicles don’t work right unless they are cooler than body temperature by a few degrees Fahrenheit.

In order to keep the temperature of the testicles relatively constant, the scrotum is lined with temperature-sensitive muscles. In warm conditions the muscles relax and let the testicles hang far from the body, whereas cold temperatures (particularly cold water) make the scrotum contract, pulling the testicles tight against the body for added warmth. Soaking in a hot tub makes it impossible for the testicles to remain as cool as they would like to be, which may reduce sperm formation or harm sperm that are already made. (This impact on fertility also occurs if a man is running a high fever.)

Avoid Drugs

Abuse or long-term heavy use of alcohol, marijuana, cocaine, or practically any other recreational drug clearly impairs both fertility and sexual performance. As Shakespeare wryly noted in Macbeth, alcohol “provokes the desire, but it takes away the performance.” The same can be said for other drugs when used to excess.

But the jury is still out about whether occasional or moderate use of drugs has any kind of significant long-term effects on reproductive health. Although animal studies and research with relatively high doses of THC (the active ingredient in marijuana) have shown a negative effect on such factors as sperm quality and quantity, a recent report by the Institute of Medicine says: “It remains to be determined whether smoked marijuana or oral THC taken in prescribed doses has a clinically significant effect on the fertilizing capacity of human sperm.”2 In addition to this, the report notes that studies of marijuana’s effects on fertility “have yielded conflicting results.” The situation with alcohol is similar: effects can be demonstrated at high doses or in alcoholics, but the evidence is mixed at the levels most people consume.

Common sense suggests that men with fertility or erectile problems should abstain from, or indulge only very moderately in, alcohol or other recreational drugs.

Check Your Medications

Many medications commonly used to treat other illnesses or conditions can affect fertility or sexuality. As noted in previous chapters, some antidepressants impair erection and make it difficult or impossible to achieve an orgasm. (Of course, as we saw in Chapter 3, this can be an advantage for men with premature ejaculation.) Other medications degrade sperm quality. Here’s a list of the major classes of drugs that have the potential to harm sexual health:

  • Calcium channel blockers, beta-blockers, and thiazide medications for high blood pressure
  • Cimetidine (for peptic ulcers)
  • Cyclosporin (after an organ transplant)
  • Chemotherapy for cancer
  • Antidepressants of the selective serotonin reuptake inhibitor (SSRI) class

Men who suspect that they are experiencing an adverse sexual reaction to a drug should talk to their doctor as soon as possible about switching to another drug or changing their dose.

The preceding advice in this chapter can help every man, whether he’s experiencing a problem or not. Remember: what’s good for your heart is good for your sexual health, and anything that improves your overall health will improve both your fertility and your sexual performance.

Understanding Semen Analysis

The male factor infertility is most commonly defined as abnormalities in the number of sperm present, proportion of the motile and morphologically normal sperm. WHO has defined normal values for human ejaculate.

Source Volume Characteristics
Urethral and bulbourethral glands 0.1-0.2cc Viscous, clear
Testes, epididymides, vasa deferentia 0.1-0.2cc Sperm present
Prostate 0.5-1.0cc Acidic, watery
Seminal vesicles 1.0-3.0cc Gelatinous, fructose positive
Complete ejaculate 2.0-5.0cc Liquefies in 20-25min

Commonly Used Normal Semen Parameters

PH 7.2-7.8
WBC < 1×106/ML

Semen analysis is not a test for fertility. Fertility determination is a couple-related phenomenon that requires the initiation of a pregnancy. The patient cannot be considered fertile based only on normal semen analysis. It was shown that 30% of all patients with normal semen analysis have abnormal sperm function.

Semen specimen are obtained by masturbation into a sterile wide-mouth container after 2-5 days of abstinence and analyzed within 1 hour of collection. Therefore, the patients should be strongly recommended to collect samples within clinic area. If intercourse is the only way to collect sample, special nonreactive condoms are available.

Typically two to three semen analyses are obtained over a 3 month period prior to making any final conclusion regarding baseline sperm quality or quantity. However, if the first semen analysis is normal, the repeat test is not required. Recent febrile illness or exposure to gonadotoxic agents may affect spermatogenesis for up to 3 months, therefore semen analysis has to be postponed.

Normal ejaculate volume is between 2 and 6 ml. 65%of the volume is from seminal vesicles, 30-35% is from the prostate and only 5% from the vasa. Low volume is associated with absence or decrease of seminal vesicle component of ejaculate( absence of SV, complete or partial obstruction of ejaculatory ducts) or retrograde ejaculation

Normal semen pH is 7.2-8.0. Prostatic secretion is acidic while seminal vesicle fluid is alkaline (seminal fructose is derived from seminal vesicles). Acidic ejaculate (pH<7.2) may be associated with blockage of seminal vesicles. Infection is usually associated with alkaline ejaculate (pH >8.0_ Azoospermia with low ejaculate volume, fructose negative and acidic may imply obstruction of the ejaculatory ducts. pH over 8.0 may indicate infection. The semen is initially in liquefied state but quickly coagulate by the action of protein kinase secreted by the seminal vesicles. Proteolytic enzymes from the prostate liquefy coagulum in 20-25 minutes. Abnormal liquefaction may be cased by prostatic abnormalities, e.g. prostatitis. Increased viscosity may affect sperm motility

Concentration: Concentration: evaluated in Mackler or Cell-VU chambers. Azoospermic specimen contains no sperm, oligospermic specimen reveals concentration of less than 20×106 and normospermic specimen contains more than 20×106.

Motility and forward progression: normally >50% of sperm in the specimen are motile. Forward progression describes how fast the motile sperm are moving (normal 2+ in the scale from 0 to 4).

0 No movement
1 Movement, none forward
1+ Occasional movement of a few sperm
2 Slow, undirected
2+ Slow , directly forward movement
3- Fast, but undirected movement
3 Fast, directed forward movement
3+ Very fast forward movement
4 Extremely fast forward movement


shape of spermatozoa: Several techniques have been described to evaluate sperm morphology. Sperm are classified into normal-oval shaped, tapered, amorphous, duplicated and immature. Normal spermatozoid must have an oval form with smooth contour, acrosomal cap encompassing 40-70% of head, no abnormalities of midpiece, or tail and no cytoplasmic vacuoles of more than half of the sperm head. Head size is 5-6m M x 2.5-3.5m M. Any borderline sperm are counted as abnormal( amorphous, tapered,duplicated, immature, coiled tail, blunted tail, midpiece abnormalities). The predictive value of sperm morphology in determining pregnancy rates is low

a. WHO criteria: >30% normal forms ( 100 cells evaluated)

b.Strict criteria (higher predictive value in determining rates of pregnancy in IVF program) are based on the morphology of postcoital spermatozoa found at the level of the internal cervical os. 100 cells evaluated for only normal sperm (>14% normal forms). Men with fewer than 4% normal forms usually failed to fertilize without micromanipulation. Strict criteria for normal sperm morphology include:

Sperm head: Smooth oval configuration. Length-5-6 microns. Width:2.5-3.5 microns. Acrosome comprises 40-70% of the anterior sperm head

Midpiece: Axially attached, 1.5 times the head length, £ 1m m in width

Tail: Straight, uniform, slightly thinner than the midpiece, uncoiled, ± 45m m long

White Blood Cells (WBC)

All semen samples have WBC in them. If greater than 1 million WBC per 1 ml are present, there is concern of infection. Generally leukocytospermia (WBC in the semen) affects 5-10% of the patient population, but can rise to 20% in certain patients groups. Semen has to be cultured for aerobic and anaerobic infection as well as Chlamydia and Mycoplasma. Additionally, leukocytes have to be differentiated from immature germ cells using immunohistochemical methods. WBC cells are deleterious because of their ability to stimulate the release of reactive oxygen species (ROS), thereby inhibiting sperm motility and sperm function. Reactive oxygen species (ROS) are produced by polymorphonuclear cells .The three main ROS are superoxide anion, hydrogen peroxide, and the hydroxyl radical. On the other hand, seminal plasma contains a number of antioxidants that protect sperm from oxidative damage from exposure to ROS. Men who have higher concentrations of such antioxidants may be able to tolerate greater concentrations of seminal leukocytes. Despite an apparently abnormal threshold level for leukocytes within the semen, a wide range of conflicting evidence exists as to the significance of seminal leukocytes and infertility. The impact of this condition and its treatment on semen quality are extremely controversial


Viability tests are used in cases of low motility to determine the presence of live sperm vs. necrozoospermia. The eosin test is based on the fact that eosin is excluded by live cells which are not stained. The tail of only live spermatozoa is swelling in the hypoosmotic solution (Hypoosmotic swelling test)

Fructose (13 mmol or more per ejaculate)

Fructose is androgen-dependent and is produced in the seminal vesicles. Fructose levels should be determined in any patient with azoospermia and especially in those whose ejaculate volume is less than 1 ml, suggesting seminal vesicle obstruction or atresia. Absence of fructose, low semen volume, and failure of the semen to coagulate indicate either congenital absence of the vas deferens and seminal vesicles or obstruction of the ejaculatory duct.

Semen analysis has comparatively limited predictive value for the ability of the individual to achieve pregnancy. Additionally, 10-20% of infertile couple will not have any abnormalities. In order to enhance the diagnostic power of semen analysis, new tests have been developed to identify functional defects and fertilizing potential of the sperm. The clinical data to support their use are not conclusive.

  1. Antisperm Antibodies test. Sperm agglutination, reduced sperm motility, abnormal postcoital test are suspicious for the presence of antisperm antibodies. Several tests are presently available including Sperm Immobilization test, Sperm Agglutination tests, Indirect immunofluorescence test, Enzyme-Linked Immunosorbent Assay, Radiolabelled Antiglobulin Assay. Immunobead Rosette Test is one of the most informative and specific and can identified different antibody classes involved (IgG, IgA, IgM) and location on the sperm cell (head, body or tail)
  2. CASA- Computer Assisted Semen Analysis. Mostly for assessment of sperm concentration and specific patterns of sperm motility (velocity, linearity etc). The available clinical data show that the measurement obtained by CASA are correlated with conception in vivo and fertilization in vitro, but comprehensive quality control and quality assurance programs are necessary to ensure accuracy. The equipment is highly expensive.
  3. Acrosome reaction. Absence of acrosome reaction implies poor prognosis for fertilization. The test for acrosome reaction is very expensive, labor intensive, subjective and not cost-effective since only 5% of infertile patients do not demonstrate an acrosome reaction.
  4. Hamster egg penetration test to check sperm fusion ability. The diagnostic value is controversial because of difficulty in optimizing protocol. However, a zero test score may indicate a major impairment of sperm fusion capacity.
  5. In Hemizona test (to evaluate sperm zona-binding capacity) the two halves of human zona pellucida is incubated with patient’s capacitated sperm and control fertile donor’s sperm.
  6. PCR-based detection of the pathogens in the semen in patients with asymptomatic genital infection.
  7. Biochemical markers e.g. Creatine Kinase, Reactive Oxygen Species.

Why It Is Done

A semen analysis is done to determine whether:

  • A man has a reproductive problem that is causing infertility
  • A vasectomy has been successful
  • The reversal of a vasectomy has been successful

How To Prepare

You may be asked to avoid any sexual activity that results in ejaculation for 2 to 5 days before a semen analysis. This helps ensure that your sperm count will be at its highest, and it improves the reliability of the test. If possible, do not avoid sexual activity for more than 1 to 2 weeks before this test, because a long period of sexual inactivity can result in less active sperm.

You may be asked to avoid drinking alcohol for a few days before the test.

Be sure to tell your health professional about any medications or herbal supplements you are taking.

How It Is Done

You will need to produce a semen sample, usually by ejaculating into a clean sample cup. You can do this in a private room or in a bathroom at your health professional’s office or clinic. If you live close to your health professional’s office or clinic, you may be able to collect the semen sample at home and then transport it to the office or clinic for testing.

  • The most common way to collect semen is by masturbation, directing the semen into a clean sample cup.
  • You can collect a semen sample during sex by withdrawing your penis from your partner just before ejaculating (coitus interruptus). You then ejaculate into a clean sample cup. This method can be used after a vasectomy to test for the presence of sperm, but other methods will likely be recommended if you are testing for infertility.
  • You can also collect a semen sample during sex by using a condom. If you use a regular condom, you will need to wash it thoroughly before using it to remove any powder or lubricant on it that might kill sperm. You may also be given a special condom that does not contain any substance that kills sperm (spermicide). After you have ejaculated, carefully remove the condom from your penis. Tie a knot in the open end of the condom and place it in a container that can be sealed in case the condom leaks or breaks.

If you collect the semen sample at home, the sample must be received at the laboratory or clinic within 1 hour. Keep the sample out of direct sunlight and do not allow it to get cold or hot. If it is a cold day, carry the semen sample container against your body to keep it as close to body temperature as possible. Do not refrigerate the semen sample.

Since semen samples may vary from day to day, 2 or 3 different samples may be evaluated within a 3-month period for accurate testing.

A semen analysis to test the effectiveness of a vasectomy is usually done 6 weeks after the vasectomy.

How It Feels

Producing a semen sample does not cause any discomfort. However, you may feel embarrassed about the method used to collect it. If masturbation is against your religious beliefs, discuss alternate methods of collection with your health professional.


There are no risks associated with collecting a semen sample.


A semen analysis measures the amount of semen a man produces and determines the number and quality of sperm in the semen sample. Results of a semen analysis are usually available within a day. Normal values may vary from lab to lab.

Semen Analysis Certain Conditions May Be

Semen Volume  Normal 1.0–6.5 milliliters (mL) per ejaculation
Abnormal An abnormally low or high semen volume is present, which may sometimes cause fertility problems.
Liquefaction Time Normal Less than 60 minutes
Abnormal An abnormally long liquefaction time is present, which may indicate an infection.
Sperm Count Normal 20–150 million sperm per milliliter (mL)0 sperm per milliliter if the man has had a vasectomy
Abnormal A very low sperm count is present, which may indicate infertility. However, a low sperm count does not always mean that a man cannot father a child. Men with sperm counts below 1 million have fathered children.
Sperm Shape (morphology) Normal At least 70% of the sperm have normal shape and structure
Abnormal Sperm can be abnormal in several ways, such as having two heads or two tails, a short tail, a tiny head (pinhead), or a round (rather than oval) head. Abnormal sperm may be unable to move normally or to penetrate an egg. Some abnormal sperm are usually found in every normal semen sample. However, a high percentage of abnormal sperm may make it more difficult for a man to father a child.
Sperm Movement (motility) Normal At least 60% of the sperm show normal forward movement. At least 8 million sperm per milliliter (mL) show normal forward movement.
Abnormal Sperm must be able to move forward (or “swim”) through cervical mucus to reach an egg. A high percentage of sperm that cannot swim properly may impair a man’s ability to father a child.
Semen pH 


Normal Semen pH of 7.1–8.0
Abnormal An abnormally high or low semen pH can kill sperm or affect their ability to move or to penetrate an egg.
White Blood Cells Normal No white blood cells or bacteria are detected.
Abnormal Bacteria or a large number of white blood cells are present, which may indicate an infection.
Fructose Level Normal 300 milligrams (mg) of fructose per 100 milliliters (mL) of ejaculate
Abnormal The absence of fructose in the semen may indicate that the man was born without seminal vesicles or has blockage of the seminal vesicles.

Associated with a Low or Absent Sperm Count

These conditions include orchitis, varicocele, Klinefelter syndrome, radiation treatment to the testicles, or diseases that can cause shrinking (atrophy) of the testicles (such as mumps).

If a low sperm count or a high percentage of sperm abnormalities are found, further testing may be done. Other tests may include measuring hormones, such as testosterone, luteinizing hormone (LH), follicle-stimulating hormone (FSH), or prolactin. A small sample (biopsy) of the testicles may be needed for further evaluation if the sperm count or motility is extremely.

What Affects the Test

Factors that can interfere with your test or the accuracy of the results include:

  • Medicines, such as cimetidine (Tagamet), male and female hormones (testosterone, estrogen), sulfasalazine, nitrofurantoin, and some chemotherapy medicines.
  • Caffeine, alcohol, cocaine, marijuana, and smoking tobacco.
  • Herbal medicines, such as St. John’s wort and high doses of echinacea.
  • A semen sample that gets cold. The sperm motility value will be inaccurately low if the semen sample gets cold.
  • Exposure to radiation, some chemicals (such as certain pesticides or spermicides), and prolonged heat exposure.
  • An incomplete semen sample. This is more common if a sample is collected by methods other than masturbation.
  • Not ejaculating for several days. This may affect the semen volume.

What To Think About

  • A semen sample collected at home must be received at the laboratory or clinic within 1 hour. Keep the sample out of direct sunlight and do not allow it to get cold or hot. If it is a cold day, carry the semen sample container against your body to keep it as close to body temperature as possible. Do not refrigerate the semen sample.
  • Consistently detecting sperm in the semen of a man who has had a vasectomy indicates that his surgery was not successful, and another form of birth control should be used to prevent pregnancy. A low number of sperm may be present in a semen sample taken initially after a vasectomy. However, sperm should not be present in subsequent samples.
  • A man whose mother took the medicine diethylstilbestrol (DES) during her pregnancy with him has a greater-than-normal risk of being unable to father a child (infertile).
  • Additional tests may include measuring hormone levels, such as testosterone, luteinizing hormone (LH), follicle-stimulating hormone (FSH), or prolactin. For more information, see the medical tests Testosterone, Luteinizing Hormone, Follicle-Stimulating Hormone, and Prolactin.
  • Other fertility testing, including sperm penetration, the presence of antisperm antibodies, or analysis after sexual intercourse (postcoital), may be recommended for infertility problems. For more information, see the medical test Infertility Testing.



Retrograde Ejaculation

Occurring in less than 1% of men with fertility problems, retrograde ejaculation can make it very difficult for a couple to conceive. While it has no health implications, men affected by this condition have their sperm diverted from their ejaculate to the bladder during orgasm.

Retrograde ejaculation can be caused by diabetes, prostate or bladder surgery, spinal cord injuries, or taking certain medications, like high blood pressure or mood altering medications. Because these conditions or medications can weaken the nerves in the bladder neck, the bladder fails to close during climax. Instead of exiting through the urethra as it would normally, the semen enters the bladder.

Signs of this condition include having cloudy urine after ejaculating, little to no semen during ejaculation and possibly infertility. Depending on the cause of the retrograde ejaculation, the condition may or may not be treatable. If certain medications are the reason for the ejaculatory problems, discontinuing their usage will often restore fertility.

However, when retrograde ejaculation is the result of a chronic condition or surgery, little can be done to treat it. Pregnancy may still be possible, though, through intracytoplasmic sperm injection and in vitro fertilization.


Retrograde ejaculation is when semen goes into the bladder rather than out of your penis during orgasm. Although you still reach sexual climax, you may ejaculate very little or no semen (dry orgasm). Retrograde ejaculation isn’t harmful, but it can cause fertility problems.

Retrograde ejaculation can be caused by medications, health conditions or surgeries that affect the nerves or muscle that control the bladder opening. If retrograde ejaculation is caused by a medication, stopping the medication may be effective. For retrograde ejaculation due to a health condition or as a result of surgery, treatment with medications may restore normal ejaculation and fertility.

What Is It?

Affecting less than 1% of infertile men, retrograde ejaculation refers to a condition whereby sperm flows backwards into the bladder, rather than forward and out of the body, during ejaculation. Normally during climax, the bladder neck is closed off to stop sperm from flowing into the bladder while at the same time preventing urine from mixing with the ejaculate.

In men that suffer from retrograde ejaculation, the nerves that help the bladder neck to close off are weakened, resulting in the failure to close off the bladder neck when a man orgasms. Therefore, semen enters into the bladder rather than exiting the body through the urethra.


Retrograde ejaculation does not affect your ability to get an erection or have an orgasm — but when you climax, semen goes into your bladder instead of coming out of your penis. Retrograde ejaculation can cause:

  • Dry orgasms or orgasms in which you ejaculate very little semen out of your penis
  • Urine that is cloudy after orgasm because it contains semen
  • Male infertility

Normally during ejaculation, sperm from the testicles is carried through a tube called the vas deferens until it mixes with fluid from the semen glands and prostate. The muscle at the opening of the bladder (bladder neck) should contract or tighten to prevent the semen from entering the bladder as it passes through the tube inside the penis (urethra). This is the same muscle that holds urine in your bladder until you urinate. With retrograde ejaculation, the bladder neck muscles don’t tighten properly. As a result, sperm can enter the bladder instead of being ejected out of the penis.


Several conditions can cause problems with the muscle that closes the bladder during ejaculation. These include:

  • Surgery such as retroperitoneal lymph node dissection, bladder neck surgery or prostate surgery
  • Side effect of certain medications used to treat high blood pressure, prostate enlargement and mood disorders
  • Nerve damage caused by a medical condition such as diabetes, multiple sclerosis or a spinal cord injury

Retrograde ejaculation has several possible causes, including:

  • Damage from surgery to the muscles of the bladder, or to the nerves that control these muscles ? This damage can occur as a complication of the following surgical procedures:
  • Prostate surgery ? Men who have had a transurethral prostatectomy (removal of prostate tissue through the urethra) have a 10-15 percent chance of retrograde ejaculation. A prostatectomy (surgery to remove the entire prostate gland, either for cancer or benign enlargement) has a 40 percent to 90 percent chance of retrograde ejaculation after the procedure.
  • Surgery on certain parts of the bladder
  • Extensive pelvic surgery, especially to treat cancer of the prostate, testicles,colon or rectum
  • Staging surgery for cancer in the pelvis or lower abdomen (this surgery removes lymph nodes in the pelvis and lower abdomen to help determine how far cancer has spread)
  • Certain types of surgery on the discs and vertebrae of the lower spine

Nerve damage caused by medical illness?

This is especially common in men with multiple sclerosis or with long-term, poorly controlled diabetes.

Side effects of medication?

Certain medications can interfere with the function of nerves that control the muscles involved in ejaculation. They include:

  • Psychiatric medications ? amitriptyline (Elavil), amoxapine (Asendin), chlorpromazine (Thorazine), thioridazine (Mellaril)
  • Drugs for treating prostate enlargement ? tamsulosin (Flomax) or terazosin (Cardura)
  • Certain drugs to treat high blood pressure ? guanethidine (Ismelin), reserpine (Serpasil)
  • Retrograde ejaculation does not interfere with a man’s ability to have an erection or to achieve orgasm, but it can cause infertility. because the sperm cannot reach the woman?s uterus. Retrograde ejaculation is responsible for about one percent of all cases of male infertility in the United States.

Risk Factors

You’re at increased risk of retrograde ejaculation if:

  • You have diabetes, especially if you have diabetic nerve damage
  • You have had prostate or bladder surgery
  • You take certain medications for high blood pressure or a mood disorder
  • You sustained a spinal cord injury


Retrograde ejaculation is not harmful. The only complication is difficulty getting your partner pregnant. Some men with retrograde ejaculation may find orgasm less pleasurable.

Tests And Diagnosis

To diagnose retrograde ejaculation, your doctor will look for sperm in your urine with a microscope after you ejaculate.

If you have a dry orgasm, but your doctor doesn’t find semen in your bladder, you may have a problem with semen production. This can be caused by damage to the prostate or semen-producing glands as a result of surgery or radiation treatment for cancer in the pelvic area


If you need to have surgery that may affect the bladder neck muscle, such as prostate or bladder surgery, or if you have a spinal injury, there’s little you can do to prevent retrograde ejaculation. However, there are things you can do to prevent retrograde ejaculation caused by nerve damage from diabetes or the use of certain medications.

If you have diabetes, work with your doctor to keep your blood sugar under control.

If you’re taking medications for high blood pressure or a mood disorder, ask your doctor if they may cause retrograde ejaculation. You may be able to take another medication instead, or change doses.

 In some cases, premature and inhibited ejaculation are caused by a lack of attraction for a partner, past traumatic events and psychological factors, including a strict religious background that causes the person to view sex as sinful. Premature ejaculation, the most common form of sexual dysfunction in men, often is due to nervousness over how well he will perform during sex. Certain drugs, including some anti-depressants, may affect ejaculation, as can nerve damage to the spinal cord or back.

Retrograde ejaculation is common in males with diabetes who suffer from diabetic neuropathy (nerve damage). This is due to problems with the nerves in the bladder and the bladder neck that allow the ejaculate to flow backward and into the bladder. In other men, retrograde ejaculation occurs after operations on the bladder neck or prostate, or after certain abdominal operations. In addition, certain medications, particularly those used to treat mood disorders, may cause problems with ejaculation. This generally does not require treatment unless it impairs fertility.


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