Many male patients will be referred to an urologist for evaluation. The physician will do a physical exam and may do some blood tests to establish whether hormonal levels are normal. During the exam, urologists will generally try to establish whether a varicocele, an abnormal system of veins, is present in the scrotum.
Since a varicocele is a surgically correctable problem that may decrease sperm number and/or quality, most urologists will do either a physical exam or a specialized ultrasound evaluation of the scrotum to look for a varicocele. Unfortunately, in the majority of cases of abnormal sperm, a "cause" is never identified.
There are many other diagnostic tests available. Some may be useful in very specific situations, such as testing for anti-sperm antibodies. Historically, other tests have been used but these tests have limited roles current male evaluations due to a limited ability to predict fertilization outcomes. One test developed in the 70s -- the the Hamster Penetration Assay -- has been totally discredited scientifically, and should not be recommended to you. As a general statement, most couples will not need to have these older tests done because the results will not change the treatment.
The treatment of male factor infertility is dependent on the identified problem. Sexual dysfunction, for example, is often treated by counseling rather than by "medical" therapies. Most commonly, however, we will be treating male factor infertility with therapies such as inseminations or in vitro fertilization.
In order for fertilization and pregnancy to take place, a minimum number of sperm must "find" the egg. When everything is normal, fertilization will take place in the fallopian tube. Unlike the cartoon drawings of the female anatomy that we are accustomed to seeing, the fallopian tube is not just a straight tunnel-like connection; instead it is a complex organ with many "nooks and crannies" such that, from a sperm cell's perspective, it is like a maze. The egg will be hidden in this maze, so a huge number of sperm are necessary at the start in order for a few to find the egg.
Once the sperm find the egg, many are needed to break through the layers of cells and the protein coat that surround the egg before the final step of fertilization by a single sperm can take place. When it comes to working with male factor patients, then, the question boils down to one of numbers. We must determine whether there are enough sperm available at the beginning so that one is likely to ultimately find and fertilize the egg. In normal situations, at least 50 million sperm are ejaculated into the vagina during intercourse. Of these, only 5-10 million will make it out of the vagina into the uterine cavity.
It has been shown that we can easily place sperm directly into the uterine cavity by means of an intrauterine insemination (IUI). This involves passing a small flexible catheter through the cervical canal into the uterus and then injecting the sperm into the uterus. In order for intrauterine insemination (IUI) to be successful, we generally need to have 3-5 million normal, motile sperm available for injection into the uterus.
The procedure of IUI is very straightforward. The husband will produce a specimen that is then processed in the laboratory. Using any number of different techniques, the sperm is processed to remove the sperm cells from the semen (the fluid part of the ejaculate). Then, the best, most normal sperm are concentrated into a droplet which is placed into the uterus. Processing of a sperm specimen will typically take 1-2 hours depending on the method used. The actual IUI is done in the office and is similar to a routine pap smear. Using a speculum to see the opening of the cervical canal, a thin flexible plastic catheter is introduced into the uterine cavity. Once in place, the sperm-containing droplet is injected through the catheter. Most women do not feel this at all, though some may experience a slight cramp when the catheter enters the uterine cavity.