Examining Male Infertility

Susanne Quallich

Disclosures

Urol Nurs. 2006;26(4):277-288. 

In This Article

Male Infertility and Medical Management

Medical management of male infertility occurs when a specific contributing factor that is potentially amenable to attempts at medical treatment is identified. This routinely includes the recommendation to remove any environmental toxins, such as smoking cessation, cessation of recreational drug use, and cessation of alcohol intake. Medical management is often related to addressing some endocrine abnormality; in the case of a specific hormone deficiency, administration of the hormone, or a substance that promotes its production, can restore the patient to normal hormone levels. After a period of time, 6, 9, 12 months or more, there can be improvements in overall semen parameters either to normal ranges or such that the couple becomes a candidate for low-tech interventions.

This is true for all attempts at hormone replacement except for testosterone. The patient who is given any form of testosterone replacement will suffer a progressive decline in the function of the testicles, as the exogenous testosterone is a powerful inhibitor of the feedback loop that governs spermatogenesis and testicular testosterone production. To boost testosterone levels in the subfertile male, clomiphene citrate (ClomidAE), a synthetic nonsteroidal anti-estrogen is given, commonly at 25 mg daily. In men, it blocks feedback inhibition and so increases FSH and LH, thus increasing testosterone and sperm production. In part, because of its estrogenic effects, there is the potential for alterations in libido, gynecomastia, weight gain, and headache (see Table 6 ). There have been a variety of uncontrolled studies as to the effectiveness of clomiphene citrate in treating male subfertility, but when the outcome is measured as an increase in pregnancy rate, clomiphene citrate fares little better than placebo (Sokol, Steiner, Bustillo, Petersen, & Swerdloff, 1988). It will not have an effect on the male who has a normal testosterone level and a decreased semen analysis.

If there is retrograde or low-volume ejaculation, a trial of sympathomimetics can be useful. The goal of this therapy is to convert the retrograde ejaculation to antegrade or partially antegrade ejaculation; a variety of medications have been used, with varying degrees of success (Schuster & Ohl, 2002). This approach is more successful with patients who suffer a progressive decline in their ejaculatory function, such as that seen with neurologic disease, than with the abrupt onset seen as a result of a variety of surgeries, such as radical retropubic prostatectomy.

Use of the supplement L-carnitine, either by itself or in a mixture of additional substances, has been proposed as a supplement that can improve overall sperm motility and the total sperm count, and enabling a patient to avoid invasive procedures such as varicocele repair or testicular biopsy. However, its use remains somewhat unfounded. Although carnitine serves a role in the maturation of sperm, there have been no prospective, randomized, double-blind, placebo-controlled trials to evaluate this supplement's utility in improving male-factor infertility (Siddiq & Sigman, 2002).

Generally, attempts at medical treatments for male infertility have been limited by poorly designed research studies, and by wide variations in dosage and duration of therapy, lack of a placebo-control arm, and a failure to control for the variation seen in semen quality with time.

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