The UCSF-John Muir Health Jean and Ken Hofmann Cancer Center at the Behring Pavilion is now open.  LEARN MORE >

Infertility Evaluation

Understanding infertility

Here’s how it works:

  • Sperm production: At least one of your testicles must function in order to produce sperm, and your body needs to be able to produce the hormones, like testosterone, in sufficient quantity to start and continue sperm production.
  • Sperm count: If a man produces less than 20 million sperm per milliliter of semen, this can decrease the chances that your partner’s egg will be fertilized. Age can affect sperm count; at about age 35, men typically start to experience a gradual decline in number of sperm produced.
  • Sperm mobility: Sperm needs to be able to travel so that it can reach the egg. It also needs to be shaped correctly to penetrate the egg.

Male infertility is often caused by more than one factor.

What can cause infertility?

Male infertility can be caused by medical or environmental factors. Some of the more common causes include:

Medical causes:

  • Swelling of the veins: An enlargement of the veins in the scrotum or a defect in the valves can cause swelling near the testicles. This is called a variococele and can reduce sperm count.
  • Infection: Infection can interfere with sperm production and can block the passage of sperm. Infection can be caused by sexually transmitted diseases (STDs), inflammation of the prostate or the testicles, or an infection of the urinary tract.
  • Hormone imbalance: In some men, the testicles don’t produce enough testosterone, or the glands in the brain don’t trigger the production of a sufficient quantity.
  • Problems with sexual intercourse: Trouble getting or keeping an erection (erectile dysfunction), low sex drive (low testosterone), or premature ejaculation can interfere with conception.
  • Certain medications: Testosterone replacement therapy, long-term steroid use, chemotherapy, certain antibiotics and some ulcer medications can decrease sperm production.

Environmental causes:

  • Overheated testicles: When the testicles get too warm, sperm production can decline. This can happen because of excess heat from hot tubs or saunas, bicycling or sitting for long periods of time, or even wearing tight clothing.
  • Exposure to radiation or X-ray: Radiation can reduce sperm production, and it can take several years for it to return to normal levels.
  • Exposure to pesticides: Men exposed to pesticides, like ethylene dibromide and organophosphates, have lower sperm counts.
Tips to improve fertility

You might be able to make some changes that will improve your chances of fathering a child. 

  • Certain lifestyle factors can contribute to infertility. Changes you can make to improve fertility include:
  • Avoid drugs: Use of cocaine and marijuana can temporarily reduce the quantity and quality of your sperm.
  • Cut back on alcohol: Excessive alcohol can lower testosterone levels, cause erectile dysfunction, and decrease sperm production. Liver disease caused by over-drinking can also lead to fertility problems.
  • Avoid smoking: Men who smoke often have a lower sperm count than men who don’t. Even secondhand smoke can contribute to infertility.
  • Reduce stress: Severe or ongoing emotional stress can interfere with the hormones that produce sperm.
  • Vitamin supplements: Supplements that show some promise of improving sperm count include: Vitamin C, Vitamin E, Vitamin B-12, zinc and selenium. Talk to your doctor before taking any supplements or herbal remedies. Some can cause problems when taken in high dosages or with certain medications.
  • Watch your weight: Being obese or overweight can reduce fertility, as can being underweight.
  • Avoid using lubricants during sex: Many lubricants are not sperm-safe. These can include K-Y jelly and some lotions.

Infertility is a temporary condition in most cases. But it could be caused by a medical problem that needs to be treated.

What to expect

Treating infertility depends on a number of factors – the cause, the length of time you’ve been infertile, your age, and the way you are most comfortable approaching the problem.

This means that the first step your urologist will take is to gather information about your medical history to rule out or treat any underlying medical condition. In most cases though, infertility is a temporary condition, so your urologist may recommend a wait-and-watch approach.


Treatment can be non-surgical or surgical depending on your condition.

Non-surgical options
  • Treatment of sexual problems: Treating conditions, such as erectile dysfunction, low testosterone, or premature ejaculation, can improve fertility.
  • Treatment of infections: If a blood test shows high levels of white blood cells, this can mean that you have an infection that’s getting in the way of the production or mobility of your sperm. Infections might be caused by sexually transmitted diseases (STDs), inflammation of the prostate or the testicles, or an infection of the urinary tract.
  • Hormone treatments and medications: If infertility is caused by high or low levels of certain hormones, hormone replacement or medications can be used to balance levels.
Surgical options

Zero Sperm Count (Azoospermia)

Some men are found to have a zero sperm count.  Men with azoospermia are divided into two separate categories: Obstructive Azoospermia and non-Obstructive Azoospermia.  Appropriate tests will be determined to determine which group each patient falls into, so they can be treated appropriately.  Blood tests are very helpful in determining if the cause is Obstructive or Non-Obstructive Azoospermia.  A testicle biopsy is needed to make a definitive diagnosis.

In men with Obstructive Azoospermia, the testicle is making sperm normally, but there is a blockage in the sperm transport system, so that no sperm appear in the semen. A vasectomy is an example of obstructive azoospermia, but there are many other causes.  For many cases of obstructive azoospermia, the cause of the obstruction can be identified and repaired, using microsurgical techniques or endoscopic techniques.  If it cannot be repaired, sperm can be removed directly form the testicle and used for Intracytoplasmic Sperm Injection (ICSI).  The methods to obtain sperm include Microepididimal Sperm Aspiration (MESA), Percutaneous Epididimal Sperm Aspiration (PESA), Testicular Sperm Aspiration (TESA), Testes Biopsy, and Extended Testes Biopsy.

ICSI is an advanced reproductive technique where sperm are obtained from the man and injected directly into the women’s egg (one sperm injected into each egg) to achieve fertilization.  The fertilized egg is then placed directly into the women’s uterus in order to achieve a pregnancy. 

For patients with non-obstructive azoospermia, the task of the urologist is to determine the cause and find out is there are treatment options.  Sometimes the testicle is not making sperm, and there is nothing that can be done. Sometimes there is a hormonal imbalance which can be treated.  Sometimes, even when the sperm count is zero, we can still find a few sperm for Intracytoplasmic Sperm Injection (ICSI).

A surgical procedure called a varicocelectomy can correct problems caused by swelling in the veins. Two different procedures are used:

  • Open varicocelectomy: This minor surgery ties off the enlarged veins around the testicles. The veins deeper in the scrotum then take over the job of carrying blood away from the testicles.
  • Laparoscopic varicocelectomy: Instead of open surgery, this procedure is done by making small incisions with an instrument called a laparoscope – a thin device that looks like a miniature telescope. The enlarged veins are then clamped to seal them off.

Permanent contraception

When you and your partner have made the decision not to have children at any time in the future, permanent birth control might be right for you.

Permanent contraception, or sterilization, is meant only for men who have made the decision – along with their partner – not to father any children now or in the future.


This is the most common method of permanent contraception. It ensures that sperm do not leave the penis during ejaculation.

During a vasectomy, the muscular tubes, called the vas deferens, that carry sperm from the testicles into the urethra are cut and sealed off, or blocked.  The procedure involves making two small openings in the scrotum. After a vasectomy, you might feel some tenderness or bruising around the incisions.

A vasectomy does not interfere with a man’s ability to have an erection or the amount of semen released. After a vasectomy, you should use a second form of birth control until your semen is tested by your urologist to make sure it is free of sperm. This usually takes 10 to 20 ejaculations.  

A vasectomy should be considered a permanent form of birth control. Reversal is possible, but not guaranteed.

Vasectomy Reversal - A common procedure

Doctors have estimated that 10 percent of men who have a vasectomy change their minds and want their vasectomy reversed. 

Microsurgical vasectomy reversals

A microsurgical vasectomy reversal is performed as an outpatient in an outpatient surgery center.  The procedure can take three to five hours, depending on the complexity of the reversal.  It is usually performed under general anesthesia, but in some cases it can be performed under local anesthesia.  The risks are quite small, but include bleeding or infection in less than 1 percent of patients.

Need a Referral?

It helps to have a urologist from John Muir Health who knows your health history and can help you get the treatment that’s right for you more quickly.

For more information about our urology services, please call (925) 937-7740.