What is male infertility?
Fertility issues in Australia affect 1 in 6 couples – 1/3 is due to male, 1/3 to female and 1/3 to the couple
What is male infertility?
Male infertility is defined as the inability to cause pregnancy in a fertile female after one year of regular, unprotected intercourse. And can be due to a variety of reasons from sperm, genetics, environment, testicular issues and of course the hormones.
Sperm-related issues are the most common, including low sperm count, poor sperm motility, or abnormal sperm morphology.
Hormonal related – this can be from the brain (pituitary and hypothalamus) or from the testis (not making enough testosterone)
Other causes such as genetic defects, lifestyle factors like smoking, excessive alcohol consumption, and exposure to environmental toxins can also play significant roles. Additionally, medical conditions such as varicoceles, infections, and chronic illnesses contribute to infertility.
How many people does it affect?
Fertility issues in Australia affect 1 in 6 couples – 1/3 is due to male, 1/3 to female and 1/3 to the couple
1 in 20 men have low sperm count
1 in 100 have no sperm
What are the common causes?
The most common causes of infertility are low sperm volume, abnormal sperm production and blockages (obstruction).
There are lots of way of looking at potential causes. This can be broken down into testicular issues, pretesticular issues and then issues with sperm transport. Another way to look at it is to think about if there is a blockage or not – obstructive and non-obstructive causes. This could be a whole talk. But briefly:
Obstructive causes can be due to infections (STIs, orchitis, epididymitis, mumps), damage to the tube, vasectomy is the most obvious cause.
Non-obstructive causes are things like medical or genetic conditions, medications, infections, tumours (which can be in the brain or the testicle). Erectile and sexual dysfunction also contribute to infertility for obvious reasons.
Varicocele is the most reversible common cause – occurring in 40% - this is a swelling of the veins that drain the testicle (like various veins in the scrotum). The exact mechanism is not known – but it is thought to be due to abnormal blood flow as well as issues with heat regulation. Corrective procedures have been shown to make an improvement.
Idopathic or unexplained is the next common – this is where all investigations and examinations are normal – about 15-40%. .
This year there has been a new categorisation of male infertility been proposed – this is called the Aphrodite criteria and categorises men based on semen parameters in conjunction with hormonal status either issues with the hormones produced from the brain and or the testicles.
How is it assessed?
its important to think about how sperm is produced and how it gets to where it needs to go to make a baby. Sperm is made in the testis every 72 days and is stored in the epididymis (on top of the tesits) and then needs to pass out the vas deferens.
Semen analysis is the main way to investigate an issue for a man – if one test is abnormal then we will usually ask them to repeat it again after 2-3 months (as it usually take 70 days for the sperm to develop).
When looking at a semen analysis it is important to understand the different parameters
The volume
Concentration
Motility – how many are moving, how many are moving forward
Morphology – what they look like
We use WHO cut-offs
What else do you look at to help work out what is going on for the patient?
Once it has been established that there is a problem with the sperm then we need to look at the hormones:
This can help us work out if it is a problem with the testicle or the signals to the testicle, which come from the brain.
Genetics test looking at the number of chromosomes, any defects in the Y chromosome specifically and also cystic fibrosis.
Physical examination is important to assess for varicocele, size of testis (as this is one of the best predictors for success in surgical sperm retrieval).
A scrotal USS is also often needed.
What can you do about it?
One of the most beneficial interventions is to look at your lifestyle.
Stop smoking, reduce alcohol intake, eat a diet with nutrient dense food. Good amount of exercise – trying not to spend too much time on a bike (as this increases the heat in the testicle area).
Avoid endocrine disrupters – plastics ……
Weight loss
Stress management
Consider taking an antioxidant – something that contains zinc, vit C/E have bene shown to potentially have some benefit.
Frequent ejaculation has also been shown to improve outcomes.
Some male infertility may come from break down of DNA in the sperm – Antioxidents and frequent ejaculation are thought to help with this.
So how often should we have sex? Every day or every second day?
This is a good question – it was always though to be best every second day to give the opportunity for the prostate to build up enough fluid to aid with transport. But recently a paper has been published looking at time of abstinence – and it suggested that sperm had less DNA breakdown with a shorter abstinence period – which was 1 day. Or less. Based on this daily is ok around the ovulation window – but remember that sperm last for 4-5 days max and the egg lasts for 24-36 hours at best. Only a few sperm make it to the egg and only 1 will penetrate it.
From the millions of sperm in the ejaculate, only 5,000 sperm that make it to the tubal, around 1,000 of these reach the inside of the Fallopian tube. And only 200 actually reach the egg. It takes a lot of sperm - so its best to preload the system before ovulation.
How can fertility specialists help men with sperm issues?
Fertility treatments are now advanced that many male factor concerns can be overcome with IVF or IUI (if there is only a minor deficit).
IVF can be used if there is mild issues with the sperm, but often couples will need to use ISCI for fertilisation. This process is where the egg (that has been generated from a stimulation cycle) is injected with an individual sperm to aid fertilisation.
What if there is no sperm found. What can you do then?
If there is no sperm at all (also known as azoospermia) then it can be a bit harder but not impossible.
Once again it is important that an in-depth investigation has been undertaken as treating the underlying cause is important. If it is due to a previous vasectomy then there is a possibility of surgical sperm retrieval or vasectomy reversal.
Surgical sperm retrieval is also possible for other causes of azoospermia. There are certain genetic causes that may affect the ability to get sperm regardless of the treatments offered. In this situation there can be a consideration of donor sperm.
There are a few different ways to surgically hunt for sperm – an open biopsy or a Micro TESE which is looking at the tubules inside the testis to find healthy ones to give to the lab in hope to find sperm which can then be used in an ICIS cycle.
Are there medical ways to try to get sperm?
In some cases it may be appropriate to try to get the body to regenerate sperm in a process called induction of spermatogenesis. Depending on the cause, we can use medication taken orally or injected to aid this process. It can take months, if not years to get sperm in some cases.
These processes hugely impact the psychological well-being – so I always ensure they have good supports throughout the process.
What is a myth about male infertility that you think needs to be dispelled?
Testosterone is the male hormone – then surely it can help me get better sperm. Right? Wrong! In fact it does the opposite.
Taking testosterone makes the brain think there is enough in the body, so it stops sending signals to the testicles to make more. The brain stops sending the signal to the testis so the activity is decreased. The testicles over time will shrink as they are no longer needed to make the male hormone.
Is it true that male infertility has increased in the past 50 years?
There was a big study in 2017 that showed sperm counts have nearly halves in the past 50 years.
The exact cause is not known but it is thought to be related to environment.
Toxins,
Endocrine disrupters
Obesity
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6455044/
Written by Dr Rebecca Mackenzie-Proctor
Rebecca is a specialist Obstetrician and Gynaecologist (FRANZCOG) with over 10 years’ experience in Women’s health and infertility.
Her fertility specialist skills include managing patients undertaking Intrauterine insemination, ovulation induction, in vitro fertilization (IVF) and male infertility.
Fertility and gynaecological issues can impact all aspect of health - mental, physical and sociological. Rebecca’s practice ensures a holistic focus for all her patients, having undertaken Ayurveda and yoga training in India as well as a certificate in sports medicine and nutrition.