You and your partner have decided it’s time: You want to have a baby. But sometimes the process isn’t as easy as couples would hope. 

"When you want to start a family, fertility can be a complicated health issue with physical, emotional and psychological ramifications," says Stanton Honig, MD, a urologist and director of Yale Medicine's Male Reproductive Health/Sexual Medicine Program. 

Yale Medicine Urology is at the forefront of scientific research and clinical care, and our track record in the field goes back decades. When cutting-edge research offers a new treatment option or our doctors have developed a new procedure, our patients are the first to benefit. We are here every step of the way to help couples deal with male-factor fertility issues.

Male infertility is caused by multiple factors such as abnormal sperm production, motility, blockage of delivery of sperm or low sperm production. Roughly 15 percent of couples in the United States have trouble conceiving. Over 50 percent of the time, there is a male infertility issue. Infertility affects both members of a couple.

There are a number of medical conditions that put patients in a high-risk group for male infertility. These include:

• Endocrine disorders or hormone imbalances
• Physical injury to the testicle
• Undescended testes
• Surgery on the testis or in this area, such as hernia repairs
• Exposures to toxic chemicals including chemotherapy or radiation
• Physical blockage of the sperm delivery routes
• Use of testosterone or other anabolic steroids

Our physicians also often tell male patients that what is good for their general health is good for their sperm health. Some lifestyle habits may put a man at higher risk for infertility. They include:

• Smoking: Tobacco use has been shown to damage sperm and also to limit the chances of survival for embryos that are created.
• Excessive alcohol consumption: Drinking to excess can lower testosterone levels and cause erectile dysfunction.
• Exposure to heat: Spending too much time in the sauna or hot tub can lead to lower sperm counts. Patients are also warned against working with laptop computers on their laps.
• Poor diet: Recent studies have shown that poor diets – those high in saturated fats and low in nutrients – can decrease sperm production
• Stress: Just as unmanaged stress can wreak havoc on the body as a whole, it can contribute to a male fertility problem.
• Drugs: From marijuana to anabolic steroids to the whole family of opiates, many medications or illicit drugs are linked to lower sperm counts.

According to Dr. Honig, it is important to be evaluated if you think you have male infertility issues because there may be treatable or reversible procedures available. The initial evaluation will include a semen analysis, and if abnormal, a referral to a reproductive urologist is recommended.

The first step in evaluation involves a detailed patient history questionnaire and physical examination. This step is important because a small number of patients will present with a life-threatening condition (such as a testis cancer, brain tumor, etc.) or a significant medical condition such as diabetes or genetic abnormalities.

The physical examination may identify enlarged veins or a varicocele that can be treated to improve semen quality. Blood tests may also be recommended to identify hormone imbalances or genetic abnormalities.

Couples will meet to discuss their medical history, physical examination findings coupled with the results of blood tests and semen analyses, including semen volume, sperm concentration, motility and sperm morphology (sperm shape).

Treatments will vary depending on the cause of the infertility. Some common treatments include:

• Medication: A regimen of drugs to improve sperm production, correct hormone imbalances, treat infections that affect sperm or bolster testosterone.
• Repair of a varicocele: A minor procedure to correct a physical condition that can heat up the testicles and affect sperm quality.
• Surgery: A surgical approach can remove anatomical barriers that may be blocking sperm production, maturation or ejaculation.
• Microsurgical fertilization procedures: These techniques involve sperm retrieval through a minimally invasive approach, developed by Dr. Honig, or a more extensive approach based on the patient's specific condition. Typically this is an out-patient procedure and men may be able to go home the same day.
• Assisted reproductive technologies: If there is no evidence of treatable or reversible causes, patients are directed towards assisted reproductive technologies such as artificial insemination and in virto fertilization (IVF). 

The Male Reproducive/Sexual Medicine Program provides specialized care to patients who seek fertility after vasectomy. A biological pregnancy after vasectomy can be achieved with either vasectomy reversal or with sperm retrieval to be used with IVF and intracytoplasmic sperm injections (ICSI).

Our experts specialize in microsurgical reconstructions—both vasovasostomy and complex microsurgical epididymovasostomy—in patients seeking vasectomy reversal.

Dr. Honig and other specialists in Yale Medicine's urology department have the capability to perform complex reconstructions to help you achieve a pregnancy.

Many factors impact the success of vasectomy reversal. We evaluate all the factors that are predictive of a good outcome after vasectomy reversal including:

• Years since vasectomy
• Prior children
• Age and fertility status of the partner
• Physical examination findings such as swollen epididymis, presence of a lump at vasectomy site called a granuloma, and the location of the vasectomy site

In a significant number of cases, vasovasoctomy is inadequate. A more complicated reconstruction called an epididymovasostomy (epididymis to vas) may be required. The type of surgical reconstruction required is determined on a patient-by-patient basis at the time of surgery. Dr. Honig has more than 20 years of experience with excellent results doing complex reconstructions, surgical procedures not performed by all urologists.

Most patients who had their vasectomy fewer than 10 years ago have a 90 percent chance of having sperm in the ejaculate after surgery.

We offer all patients the option of sperm retrieval at the time of reconstruction. On average, a patient’s ability to achieve pregnancy is about one year and depends on multiple factors including quality of sperm in the ejaculate, and the age and fertility status of the partner.

We are a world-class center for treatment of azoospermia, a condition in which there is no sperm present in the ejaculate. 

Dr. Honig recommends two semen analyses for all patients—with at least one semen analysis using advanced sperm technology. This procedure can be done at Yale Medicine Urology or at a lab associated with an IVF center. Labs using advanced sperm technology perform a more comprehensive sperm test that may show sperm in 10 percent of cases in which no sperm in the ejaculate were seen previously. This advanced procedure may prevent a patient from needing surgery to extract sperm.

There are four possible explanations for azoospermia or no sperm in the ejaculate:

• The testis are making sperm, but there is a blockage.
• The brain is not stimulating the testis to make sperm.
• The testis are not producing any sperm.
• The testis may be producing a tiny amount of sperm, but it is not coming out in the ejaculate.

With a thorough discussion, blood tests and physical examination, an experienced reproductive urologist can help diagnose the source of the azoospermia in approximately 90 percent of cases. Dr. Honig reports that in the event of a blockage, couples can still achieve pregnancy.

If there is a reversible blockage, this can sometimes be fixed with a minor procedure. If there is not a reversible problem such as a missing vas deferens (tube that carries the sperm), success rates of sperm retrieval approach 100 percent. Pregnancy rates in this situation are usually greater than 50 percent with IVF, depending on the age and health of the female partner.

In cases of "nondestructive azoospermia," biological pregnancies are still possible. In about 50 percent of such cases, patients benefit from sperm retrieval, using a procedure called testis sperm aspiration or extraction with or without micro dissection. Yale Medicine urologists collaborate with the reproductive endocrinology team as these procedures need to be combined with in vitro fertilization and intracytoplasmic sperm injection.

Genetic testing may be done in preparation for a sperm retrieval procedure, and if tests are abnormal (5 to 10 percent of cases are), discussion with a genetic counselor is recommended.

We understand how challenging fertility issues can be and how this time can be so many things at once: exciting, stressful, time-consuming, expensive, promising and joyful when a child finally arrives.

"I've been helping couples through the highs and lows of this journey for over 20 years," says Dr. Honig, who puts an emphasis on listening to every couples' needs as they work through fertility issues together.