Why Am I Infertile if My Sperm and Semen Are Healthy?
Pregnancy can be complicated. The process of conceiving itself is intricate and has many moving parts. And that's not even accounting for planned versus unplanned pregnancies and the physical and emotional tolls that come along with them.
A relatively high number of people manage to get pregnant on their own—but a large number of others have trouble conceiving.
"Right off the bat, I tell patients it's surprisingly very difficult for two human beings to get pregnant naturally," said Neel Parekh, M.D., a men's fertility and sexual health specialist with the Cleveland Clinic. "Studies show that for two completely healthy people, the chances of getting pregnant per cycle, per month, is only about 13 to 15 percent. So it's not as easy as everyone makes it out to be."
One couple in every seven meets the clinical definition of being infertile, according to Mayo Clinic. That is, after at least one year of frequent, unprotected sex, they still haven't been able to conceive. The National Institutes of Health (NIH) cites studies suggesting about 15 percent of couples are unable to conceive after a year of trying, and 10 percent are unable to conceive after two years.
We're going to look at the male side of this partnership, but from a sometimes ignored angle: What if the man has healthy sperm and semen and he still can't conceive? What else could be the cause? How is the potential complication detected and treated?
What do fertility specialists test for?
The first step for fertility doctors to help couples trying to conceive is to conduct a semen analysis. A semen sample is sent to the lab to check for various parameters that indicate healthy sperm. These parameters include the following:
- Semen volume. How much ejaculate there is
- Sperm concentration. Aka sperm count
- pH level. How acidic the semen is
- Sperm morphology. The sperm's shape and size
- Sperm motility. How well the sperm move
- Time for liquefaction. How long it takes the semen to liquefy
- Vitality. How many live sperm there are
- White blood cells. Their presence may indicate infection
"Obviously, on the male side, the best test we have is semen analysis," Parekh said. "But we know that semen analysis isn't really the answer to all the issues. There are many factors that we don't really even have the testing for or the knowledge of."
What if semen is too acidic?
Sperm is only one component of semen. If all the sperm-specific tests fall within the correct parameters, where would fertility specialists look for another cause of male infertility?
One relatively common reason a man with healthy sperm might have trouble conceiving is the pH level of his semen.
Under normal conditions, semen's pH should be in the 7.2 to 8.0 range, according to guidelines from the World Health Organization (WHO). This number indicates a substance that's slightly alkaline—more of a base than an acid. This is important because healthy vaginas are slightly acidic, so the semen's slight alkalinity protects the sperm.
"If someone's pH is low, meaning acidic, that might mean they have a blockage," said Amy Pearlman, M.D., a men's health specialist and co-founder of Prime Institute in Fort Lauderdale, Florida. "The seminal vesicles make the pH more basic, or the pH higher. So if the pH is low, then it suggests that there's a blockage where the seminal vesicles empty their fluid into the urethra."
Timing is everything
Another frequent issue for couples trying to get pregnant is not paying close enough attention to the woman's monthly cycle.
"Oftentimes, we'll have patients who have normal sperm parameters, but they're not timing it properly," Parekh said. "The first thing I go over is timing the intercourse, making sure the couple is tracking her ovulation, using an effective method to correctly track it, pee sticks or body temperature, things like that."
What is a varicocele and how does it affect fertility?
A common condition in men is called a varicocele, which is an enlargement of the veins inside the scrotum when blood pools in them.
"Varicoceles can be an issue," Parekh said. "They're pretty common—15 percent of men have varicoceles—and they can sometimes impair sperm parameters."
What happens if semen doesn't go where it's supposed to?
Two other issues that can potentially hamper a man's fertility involve semen not getting where it needs to go.
Hypospadias is one such condition. That's when the urethral opening of the man's penis isn't in its usual spot at the tip. It may be halfway down the shaft or even all the way down at the base. In these cases, when the man ejaculates during normal penetrative sex, the semen won't usually be deposited in the vagina, so it may not be able to reach the egg.
Retrograde ejaculation is another possible culprit. That's when a duct on the man's bladder isn't functioning correctly. Normally, when a man ejaculates, this sphincter closes off access to the bladder so the ejaculate can exit through the urethra and out of the penis.
With retrograde ejaculation, the duct remains open and the semen, or most of it, takes the path of least resistance and goes into the bladder instead of out of the penis. Certain prostate medications, such as Flomax, are known to cause this.
Getting pregnant is often something that requires a willingness to give fertility specialists enough time to explore all the possibilities. As it happens, creating a new life is remarkably complex.
Perhaps the best thing couples can do is support each other in the search for answers, offer empathy and love instead of blame, and above all, be patient with each other and with themselves.