It is difficult for any person to admit that they have a fertility problem. However, because of the old fashioned idea that women are typically the cause of infertility issues, many men find it especially hard to admit that they might be the one with the problem. When going for fertility testing, it is important for the male partner to undergo a semen analysis in order to assess how well his sperm work. This simple test can provide fertility specialists with a great deal of insight into a man's fertility.
In almost half the cases of subfertility, there is a male contribution to the problem. The initial investigation requires a sample of semen for analysis. This is usually produced at home after abstaining from ejaculation for 2 to 3 days. A shorter time than this will reduce the total number and longer abstinence can lead to a falsely high number of poorly motile (slow swimming) sperms. The sample needs to be delivered to the laboratory within one hour for analysis. The following are considered a normal result:
- Volume: 2-5mls
- Concentration: more than 20 million per ml
- Motility: more than 50% progressively motile
- Form: more than 30% normal appearance
- White blood cells: less than 1 million per ml
Most clinics suggest two samples be received for analysis, particularly if there are any abnormalities with the first test. It takes around 74 days to make sperm, so if 2 samples are checked in a shorter time than this, it is likely that they are from the same population. This might be important if, for example, a man had a viral infection, or a poor result followed a period of particularly heavy alcohol intake. In this case, it would be better to delay the second sample for 3 months.
There are several other specialised tests for semen analysis, but these are not routinely recommended, as their ability to predict infertility and direct the correct treatment has not been proven. One particular test is the anti-sperm antibody test.
Antibodies normally fight infections, but sometimes a man produces antibodies that bind to his own sperm, either reducing the motility or interfering with fertilisation of the egg. Many studies have looked at the exact implications for this and it now seems that only heavy antibody binding seen on the semen analysis, when associated with the problems mentioned above, are likely to be significant. In any case, there is no proven treatment apart from intracytoplasmic sperm injection (ICSI).
Causes of Male Infertility
Almost 90% of male problems are not amenable to treatment to improve the sperm count, and will require some form of assisted conception if pregnancy does not occur naturally. The main troubles include:
Idiopathic Abnormal Sperm Count
’Idiopathic’ refers to the fact that no cause for the problem is found. This happens about 75% of the time when there is a male contribution to the infertility. Even with moderate problems such as low counts less than 5 million/ml or poor motility, it is still possible to conceive normally. When there is no sperm (azoospermia) then clearly it is unlikely.
An absence or blockage in the tube from the testes to the urethra (the vas deferens) is an uncommon cause of male infertility. It may be discovered on a scan if there are no sperms found at all, but it is treatable by surgery. A varicocele is a swelling of the veins around the testes and for some time this was thought to be a significant cause of infertility, but it is now clear that this is less likely. As only one in 15 to 20 men who have surgery would be likely to benefit, it is important to consider the risks of an operation.
Gene problems are unusual, but are more common in men who have very few or no sperms (about 10%). Whilst most gene abnormalities are not overtly apparent, there is concern that one particular type which is associated with infertility (Y-chromosome deletions) may be passed on to male offspring when assisted techniques such as ICSI do result in pregnancy.
Once again, a hormone disorder is an unusual cause of male infertility. This is sometimes treatable if the signal from the brain is the problem (gonadotrophin deficiency), but if the testes have stopped working altogether, as happens in around 13% of male infertility, success is unlikely.
Men who smoke have a 13-17% lower sperm count that those who do not. High alcohol intake can markedly reduce the sperm count and motility, however low and moderate consumption up to normal recommended levels has not been found to lead to problems. Tight fitting clothes and prolonged periods of sitting can lead to a reduction in sperm count through excessive heating of the testes. Men who have an abnormal semen analysis should wear loose fitting trousers and underwear such as boxer shorts. Cannabis, cocaine and anabolic steroids all reduce the sperm count and affect motility and number of normal sperm.
Treatments for Male Infertility
Depnding on the exact cause of male infertility, a variety of treatments may be offered, though their effectiveness varies.
Several drugs have been tried to improve the sperm count, including androgens (mesterolone), FSH injections, kallikrein, testolactone, clomiphene, steroids, and antioxidants (vitamins E and C). None of these have been found to be beneficial, though variable successes have been described with steroids for antisperm antibodies and antioxidants, and further studies are awaited.
Intrauterine Insemination (IUI)
IUI involves preparing a semen sample in some way, so that higher concentrations of the most motile sperms are selected and injected through the cervix around the time of ovulation. The procedure for the woman is like having a smear test done, and is no more uncomfortable. IUI is often combined with using drugs to stimulate the ovaries to make larger numbers of eggs, which further improves the chances of pregnancy. For male infertility the success rate of ovarian stimulation and IUI is about 7% to 8% per cycle, as compared to a 2% to 3% per cycle with no treatment at all.
Intracytoplasmic Insemination (ICSI)
ICSI is a type of in vitro fertilisation (IVF) where one sperm is injected directly into one egg to fertilise it. This is useful for men with even very low sperm counts. Sometimes it is possible to retrieve a few sperms from men who have none seen on semen analysis, by taking a testicular biopsy under anaesthetic. IVF is an expensive and psychologically intensive undertaking, not without risk to the woman. The overall success rate is 15% to 20% per cycle.
Donor Insemination (DI)
Many couples decide against the more invasive and expensive treatments such as ICSI, and opt to use donor sperm for IUI. The donors are unknown to the couple and have been thoroughly screened for infections. It is usual to choose a donor whose physical attributes are similar to the partner. For men who have no sperms at all, the only options available are DI, adoption or acceptance of childlessness.