25 February 2019
Male fertility issues
A common misconception is that infertility is a woman's problem and once that ‘problem’ is fixed the couple will be able to conceive. This couldn’t be further from the truth, as after a woman’s age the most common cause of infertility is directly attributed to a factor in the male.
Just a decade ago treatment for severe male infertility was limited to insemination (IUI) or in vitro fertilization (IVF) using donor sperm, adoption or living a childless life.
Fortunately, advances in male infertility have introduced innovative therapeutic options that offer most men, including those with no sperm in their ejaculate, a greatly improved chance to conceive a child.
To understand how far fertility treatment for male factor infertility has come, it helps to understand the common causes, how and what we test for and the treatment options available depending on the diagnosis.
What causes male infertility?
There are many reasons why men can have an abnormal sperm count:
- Problems in the testicles: a block in the path the sperm takes to reach the penis caused by a past infection or a vasectomy
- Physical problems: Testicular trauma or undescended testes at birth
- Hormonal imbalances: Low levels of testosterone, follicle stimulating hormone (FSH) or luteinizing hormone (LH)
- Genetic causes: Where the man is born with defects on the Y chromosome
- Medical treatment: Past medical or radiation treatment can cause a low sperm count
- Lifestyle: Smoking, excessive alcohol, recreational drugs, unhealthy diet, lack of exercise and/or being significantly overweight
How do we assess a man’s fertility?
A semen analysis is the first test your general practitioner or a fertility specialist will order to assess your fertility. This test evaluates the semen sample to check the number of sperm, motility (ability to swim) and morphology (size and shape.)
For this test, a man needs to provide a sample of his sperm either produced at home (delivered to the laboratory within one hour of collection), or onsite at a fertility clinic in a private room close to the laboratory.
The results are either normal, in which case further investigations are conducted to identify female causes or sometimes couples fall in an unexplained infertility category.
Abnormal sperm may be described as:
- Azoospermia: no sperm at all
- Oligospermia: not enough sperm
- Poor motility: sperm might move slowly
- Poor morphology: sperm have abnormal shapes
- Positive sperm antibodies
- It’s often difficult to explain why a man has an abnormal sperm count. If the sperm count is low, I usually suggest repeating the test in six weeks or after three months if lifestyle modifications are recommended.
If repeat sperm counts are still abnormal, further tests may be indicated:
- Blood tests: for endocrine abnormality
- Physical examination: to measure the size of your testicles
- Ultrasound: of the genitalia to look for possible cause for abnormal sperm
- Tests to see if there is a block in your testicles
How do we treat male infertility?
Different treatments help men with infertility father children:
Hormone treatment to increase sperm count: some men have low hormone levels in the brain that can be treated with hormone injections.
Vasectomy reversal: ideally performed within eight years of the vasectomy as this is usually when the process is most successful.
Intrauterine Insemination (IUI): this can overcome some minor sperm abnormality i.e. low motility (ability to swim) by placing the pre-prepared sperm directly in the woman’s uterus.
In vitro fertilization (IVF): a fertility specialist takes eggs from a woman and sperm from a man and puts them together in the laboratory to fertilise. Then the fertilised egg is placed back into the woman’s uterus.
Intracytoplasmic Sperm Injection (ICSI): when there is a significantly low sperm count or abnormal morphology (shaped) IVF alone is not enough. ICSI together with IVF involves injecting a single sperm using fine micro manipulation equipment in the laboratory into an egg before it is placed back into the woman’s uterus.
Testicular biopsy: for men with azoospermia (no sperm in the ejaculate) there might be sperm in their testicles that a fertility specialist can sometimes remove from the testes. This is done during a minor surgery (open biopsy) or by using a needle to locate semen under local anesthesia. The sperm will then be used for IVF with ICSI.
How do we know what treatment will be right for us?
To choose the treatment that is right for you and your partner, you might want to think about:
- How well your fertility specialist thinks the treatment will work for you
- Cost of the treatment: how long your fertility specialist thinks the treatment will take to be successful
- Consider any downsides of the treatment depending on your individual situation
When should we see a fertility specialist?
We would recommend a man be tested if a couple cannot get pregnant after having unprotected sex for twelve months if the woman is 36 years of age or younger (or after six months if the woman is older than 36.)