Male Factor Infertility

Oftentimes couples with a male factor issue will find themselves consulting with two different types of doctors: a reproductive endocrinologist and a reproductive urologist. While both want the best for their patients, what constitutes “the best” and “their patients” can differ depending on the doctor. This can create enormous confusion for the couple and in navigating the best path forward, we think patients need to understand what each doctor’s training is, their priorities, and their biases.

A reproductive urologist is trained in men’s health, views the man as the patient and their objective is to ensure his long-term health. Helping a couple conceive is important, but it’s not the reproductive urologist’s sole focus. If a man demonstrates poor fertility, a reproductive urologist will want to understand why and treat the underlying cause.

There is a rich corpus of data showing that sometimes treating the man with less invasive measures than IVF (for example, making lifestyle adjustments or supplementing hormones) the man can resume normal sperm production and the couple can conceive naturally.

Also, there is data that shows male fertility issues can signify something more ominous: a hormone imbalance can signal a higher risk for a pituitary tumor, a missing vas deferens dramatically raises the likelihood the male is a carrier for cystic fibrosis, and the list goes on.

On the other hand, reproductive endocrinologists are fertility doctors and they are OBGYNs. They are often the first doctors a couple will see when trying to conceive and often will be the first to stumble upon any sign of male factor infertility. The reproductive endocrinologists are not trained in the male anatomy. Their job is not to diagnose and fix issues with the male, but rather to perform interventions and treatments on the female.

The chief tool for the reproductive endocrinologist to help a couple conceive is In Vitro Fertilization (IVF). We’ll cover IVF more thoroughly in a later lesson, but for now it’s worth noting that many couples with male factor infertility are directed immediately to IVF, even if the underlying cause for the male is treatable. Each IVF cycle costs at least $20,000 in the United States, Rs.120,000 in India and R$20,000 in Brazil, and for most couples with a male factor issue, they will undergo multiple IVF cycles before having a child. In the last 20 years, a technique called ICSI, which is used to fertilize eggs during IVF, has been shown to help couples with the most extreme forms of male factor infertility conceive. Yet patients with far milder forms of MFI, whose infertility and underlying issue may be treatable with less invasive or costly approaches, are often shunted directly to IVF with ICSI.

This has created a dilemma for patients. On one hand they may hear from their reproductive endocrinologist, “don’t worry about that male factor issue, we can simply get around it by doing IVF with ICSI.” On the other hand they may also hear from a reproductive urologist, “we need to understand why the man’s fertility is poor, and if we do, we may be able to avoid IVF, improve IVF’s chances of success, or discover something that’s more foreboding.”

If a male factor issue is detected, we encourage the couple, together, to see both a urologist preferably someone who identifies as a “reproductive urologist” (i.e. someone with a specialty interest or training in male infertility) and a reproductive endocrinologist. Many larger fertility clinics and academic medical centers will have both on staff and, theoretically, harmonizing their opinions should be easier. But that may not always be the case. In this field, as much as any, you need to push your clinicians for clarity and data.