Nonsurgical Treatments of Male infertility

Specific Therapy

Specific therapy seeks to reverse known pathophysiologic effects to improve fertility. For the most part, they are cost-effective treatments.

A. Pyospermia
The presence of elevated numbers of leukocytes in semen is termed pyospermia and has been associated with (1) subclinical genital tract infection, (2) elevated reactive oxygen species, and (3) poor sperm function and infertility. Sperm are highly susceptible to the effects of oxidative stress induced by leukocytes or infection because they possess little cytoplasm and therefore little antioxidant activity. The treatment of pyospermia is controversial in the absence of overt bacteriologic infection. It is important to evaluate the patient for sexually transmitted diseases, penile discharge, prostatitis, or epididymitis. An expressed prostatic secretion is examined for leukocytes, and urethral cultures are obtained for chlamydia and mycoplasma. The use of broad-spectrum antibiotics such as doxycycline and trimethoprim-sulfamethoxazole has been shown to reduce seminal leukocyte concentrations, improve sperm function, and increase conception. Generally, the female partner is also treated.

In pyospermia with a documented prostatic source (> 20 leukocytes per high-power field in expressed prostatic secretion), frequent ejaculation (more than every 3 days) and doxycycline may result in a more durable resolution of pyospermia (55% of treated men) than either treatment alone (5-17% resolution) (Branigan and Muller, 1994). There is increasing evidence that the antioxidant vitamins (A, C, and E) as well as glutathione and other antioxidants may help scavenge reactive oxygen species within semen and improve sperm motility in pyospermic men (Baker et al, 1996).

B. Coital Therapy
Simple counseling on issues of coital timing, frequency, and gonadotoxin avoidance can improve fertility. It is important to review the essentials of basal body temperature charting or home kits that detect the LH surge in the urine immediately (< 24 h) before ovulation. Since sperm reside in the cervical mucus for 48 h and are released continuously, it is not necessary that coitus and ovulation occur at the exact same time, a fact that can reduce the stress associated with infertility. Coitus every other day around ovulation is the best recommendation. Coital lubricants should be avoided if possible. If necessary, vegetable oils, olive oil, and petroleum jelly are the safest.

Retrograde ejaculation results from a failure of the bladder neck to close during ejaculation. Diagnosed by the finding of sperm within the postejaculate bladder urine, it can be treated with a trial of sympathomimetic medications. Approximately 30% of men will respond to treatment with some degree of antegrade ejaculation. Begun several days before ejaculation, imipramine (25-50 mg twice a day), Nasal-D (twice a day), Ornade (twice a day), or Sudafed Plus (60 mg 4 times a day) have all been used with success. The side effects associated with these medications usually limit the efficacy of this therapy. For medication failure, sperm harvesting techniques can be used with IUI to achieve a pregnancy. Premature ejaculation occurs when men ejaculate before the partner is ready. Sexual counseling combined with tricyclic antidepressants, Prozac, or other serotoninergic uptake inhibitors can be very effective.