Male infertility is very common. About one in twenty men is sub-fertile and a male factor is present in half of all infertile couples. About one third of all in vitro fertilization (IVF) procedures are performed for male infertility. For most men, the discovery that they are infertile comes as a total surprise.
The roles of the testis
The male reproductive system is a bit less complex than the female reproductive system. This doesn’t mean it’s simple; far from it.
It must be remembered that the testis has two distinct roles. The first is to produce the male sex hormone, testosterone, which is important for sexual function, providing sex drive and erections. It also helps build strong muscles and basically gives a man a general feeling of well-being. All these things can be described as virility.
The second function of the testis is to produce millions of sperm every day, a process that occurs inside the approximately 45 cm of fine tubes in each testis. For most infertile men, it is only this process that is at fault and, as a result, a reduced number or poor-quality sperm are produced.
Most infertile men produce low numbers of sperm which might also have poor motility and be abnormally shaped. Various sperm disorders can be the cause of male infertility.
In such men, only a small number of normally shaped, motile sperm in the total sperm count are likely to swim up the woman’s fallopian tube into the vicinity of the egg and even then might be unable to fertilize the egg. The sperm’s ability to fertilize the egg is really pushed to the limits.
Why does low sperm count develop?
We now believe that most cases of low sperm count are genetic. In other words, some men are born without the genetic information that would allow sperm production to occur normally. Researchers at Monash University have been looking at this problem and find that small pieces of the Y, or so called ‘male chromosome’, are missing in men with severe infertility. Presumably these missing pieces of genetic information are the cause for the poor sperm production that affects the sperm function. Much more research is needed before we can point to particular genes. Without that knowledge, no treatment to improve sperm count is likely to become available. IVF techniques, however, offer some hope, as they require far fewer normal sperm than nature does.
In the remaining one third of infertile men, there are other likely causes for their infertility, including the blockage or absence of the vas deferens, which causes an obstruction to the passage of sperm from the back of the testis to the outside. This means the sperm cells cannot travel thru the vas deferens from the testicles up to the urethra when they would be ejaculated. Although sperm production first happens in the testicles, sperm need to join with the seminal fluid and travel to the prostate to become fully functioning and healthy sperm.
Making healthy sperm requires lots of viable sperm cells and the tubes that transport sperm need to be fully functional.
Other common causes of a reduced sperm volume obviously include vasectomy. Any history of injury, other surgery or sexually transmitted disease might also be important.
In other cases, anti sperm antibodies can be the cause of low sperm production. Some men make anti sperm antibodies following vasectomy or other trauma or infection. These antibodies are a common cause of infertility and prevent sperm swimming or sticking to the egg. Such antibodies can only be found using a special test, done on fresh sperm, and available only in a few laboratories.
The testis can be damaged by a wide number of treatments including chemotherapy or X-Ray therapy.
Although not located with the rest of the male’s reproductive system, let’s not forget the pituitary gland in the brain. This gland is in charge of releasing gonadotropins that will then help testosterone production and spermatogenesis.
Rarely, a deficiency in the brain pituitary hormones can result in low sperm counts. Its detection is important, as it is readily treated with hormone therapy.
Some men have difficulty obtaining an erection or ejaculating, due to a wide range of problems, such as diabetes, multiple sclerosis (MS) or previous prostate surgery. In these cases sperm can be found and used for IVF.
Is it true that there has been a worldwide decline in sperm count?
There remains great controversy as to whether sperm counts have declined worldwide. The alleged change is quite small (about 15%) and no cause has been confidently identified.
Although the causes of infertility are uncertain in many men, certain conditions can be identified and treated. These facts make it essential that all infertile men have their situation thoroughly investigated.
Investigations of male infertility
Often the infertile man is entirely healthy but for some reason doesn’t produce healthy sperm. Some men, however, have serious medical problems, such as a low male sex hormone level (testosterone), that can cause male infertility. It is therefore very important that men in infertile relationships see a doctor who is trained in reproductive medicine. It is important to investigate previous fertility, genital surgery or infections, undescended testes and certain systemic diseases. The adequacy of sexual development, the size and texture of the testes and the condition of the tubes attached to the back of the testes are also assessed.
The most important test is the semen analysis, which requires a great deal of expertise to comply with the high standards prescribed by the World Health Organisation. The laboratories of Monash IVF in Melbourne and Queensland are two of only a few that meet these criteria.
Semen quality varies widely between men. Semen analysis is done to determine this. Even for one particular man, a minimum of two sperm counts, at least three weeks apart, need to be taken to give a true indication of his sperm quality. The test is performed after two to five days of sexual abstinence. Ideally the laboratory provides an appropriate collection room so as to avoid a change in temperature during the transport of samples to the laboratory.
What is a normal sperm count?
A sperm count greater than 20 million/ml is considered normal; however, the average for the population is about 60 million and some men have a sperm count of above 200 million/ml. Sperm counts between 5 million and 20 million do not necessarily indicate a severe infertility problem. The ability of sperm to swim is termed motility. Normally greater than fifty per cent of sperm show some motility. Markedly reduced motility problems can greatly reduce fertility. The sperm shape, termed ‘morphology’, is also an important predictor of fertility and the accurate assessment of this feature requires great skill.
Sperm antibodies are an important cause of infertility as they reduce the sperm’s motility and ability to stick to the egg. They can be readily detected on fresh sperm at the time of semen analysis and this an essential initial test performed in the better laboratories. A complementary test is the sperm mucus interaction test, which examines the ability of sperm to swim through mucus.
Blood hormone tests are also frequently performed. Poor testicular function can reduce testosterone levels, which in turn impairs sex drive and energy levels. The FSH (Follicle Stimulating Hormone) test gives an indication of the amount of sperm being produced. In normal men or those with a blockage of sperm outflow, FSH levels are normal. However, when the testicle is severely damaged and few or no sperm are being produced, FSH level rises progressively.
A zero sperm count might be due either to blockage in the tubes or to the failure of sperm production. A testicular biopsy, often done using a fine needle under local anaesthesia, with microscopic examination readily clarifies whether sperm are present in the testis. In some cases of blockage, further tests, such as ultrasound of the prostate and bladder region, are performed.
Finally, in men with very poor sperm production who are considering using the new single sperm microinjection procedure, there are two genetic tests that are frequently recommended to help understand why they have this problem and to assess the risk to their future children. One involves counting the number of chromosomes and the other looks for damage to the male, or Y, chromosome, which is important in controlling sperm production.
In conclusion, a thorough clinical assessment of the man and the performance of a range of specialised hormone and sperm tests are needed to make a full evaluation of the infertile man.
Male infertility – causes
There are different causes of male infertility. The most severe male factor infertility and, unfortunately, the most common causes of male infertility are those that affect how testicles work. Let’s look at the most common causes of male fertility problems.
#1. Hormonal imbalances
Testosterone, together with other hormones, plays a significant role in sperm production. Any imbalances can affect sperm quality.
#2. Undescended testicles
Some men have undescended testicles and that can stop the sperm production chain at the very beginning. Undescended testicles are usually identified in childhood, as it’s one of the things tested in young boys during medical checkups. If either of the testes fails to descend, this will be corrected by surgery, usually before the young boy reaches puberty.
Check with your doctor if undescended testicles might be a cause in your case.
Varicocele is an enlargement of the veins inside the scrotum. When this happens, there is an abnormal blood flow in the testicles that might cause infertility.
Check with your doctor if varicocele might be a cause in your case.
Some infections can interfere with sperm production. Others produce scar tissue that might then block the passage of the sperm.
Any abnormal growth might block the sperm passage. A prostate or testicular cancer might cause severe male infertility.
#6 Defects in tubes that transport sperm
If the vas deferens are blocked or there’s scar tissue or the tubes were not properly developed, then sperm might not be able to make it all the way to the urethra.
Of course, if the man has had a vasectomy, sperm cells will never make their way out in an ejaculation.
You can read more about vasectomy in Vasectomy | Having A Vasectomy.
#7. Ejaculation problems
Sometimes the cause of male infertility has to do with ejaculation. If there’s a problem, such as retrograde ejaculation, this might make it difficult for the healthy sperm to reach the egg.
#8. Idiopathic infertility
When both partners have been checked for infertility and the tests come back as normal and no cause can be identified, this is called idiopathic or unexplained infertility. This condition affects around 1 in 3 infertile couples. Usually, the stress of trying for a baby is what prevents these couples from having one.
You can learn more about this and how to boost your chances of conception in this Natural Fertility Course, recommended by BellyBelly.
The first step is to contact your healthcare provider and explain the problems you’re facing. A physical examination and some tests will then follow until the cause of infertility is identified.
Male infertility treatment
Male infertility can be treated depending on the causes.
Regardless of where the cause of infertility is, the problem affects both partners. Once the cause of infertility has been identified the right referral will be made. If the cause of infertility is identified in the male partner, the male reproductive medicine specialist team should take over the couple’s care.
Nowadays, reproductive medicine has advanced a lot and there are many procedures that can help sperm fertilize an egg. Testicular sperm extraction is possible and fertilization can happen in several different ways. Artificial insemination is a possibility, with either vaginal or intrauterine insemination.
If the problem is in the sperm mobility, an intracytoplasmic sperm injection is also a possibility. In this procedure, the sperm is injected directly into the egg and then the fertilized egg in inserted in the woman’s womb.
You can read more in these BellyBelly articles: