Abnormalities of male reproduction contribute to at least 30% of all infertility and possibly more.
A common reason why a male is infertile is due to the abnormalities of sperm. These abnormalities could be:
- the number of sperm (called oligozoospermia)
- movement or motility of sperm (called asthenozoospermia)
- appearance or morphology of sperm (called teratozoospermia)
If one of these conditions is present the defect may be called single, if two are present the defect could be called double and if all three are present the defect may be called triple (also know as triple defect, oligoasthenoteratozoospermia or abbreviated to OAT).
To understand the severity of male infertility (mild, moderate or severe), a semen analysis can be performed. It can be difficult to make a diagnosis as sperm production is very variable over a period of time. It generally takes about two months to make a sperm and therefore testing at more frequent intervals is not ideal.
Normal values of semen variables according to the World Health Organisation Guidelines for the Examination of Human Semen (2010):
Volume: 2.0 ml or more
pH : 7.2-8.0
Sperm concentration: 15 million spermatozoa/ml or more
Total sperm count: 40 million spermatozoa per ejaculate or more
Motility: 50% or more with forward progression (categories a and b) or 25% or more with rapid progression (category a) within 60 minutes of ejaculation
Morphology: 4% or more with normal forms
Vitality: 75% or more alive
It is important to examine the semen on at least two occasions and if one analysis shows abnormality, it needs to be examined more than twice. It's important to have at least one semen analysis performed by scientists who specialise in infertility, such as those who work in an IVF laboratory such as Care Fertility.
Fertility of males reduces with age. If the female is 35 years or older and the male partner is greater than 5 years older than his female partner, on average the couple is 30% less likely to conceive a pregnancy. If this is the case, it’s important to seek help early.
Sperm production may be reduced when a man has:
- a history of maldescent of one or both testes
- had a testicular injury
- had past treatment for cancer of the testis including chemotherapy
- family history of male infertility but no identifiable genetic abnormality
- genetic abnormalities or abnormal number or arrangement of chromosomes
The most common genetic reason for male infertiltiy is Klinefelter syndrome and balanced translocations. Sometimes men have genetic abnormalities of part of the Y chromosome or carry a gene for a variant of cystic fibrosis.
Sometimes testicular production of sperm may be poor and unexplained. There's not been sufficient research into the causes of male factor infertility and many questions about the cause of male infertility remain unanswered.
The pituitary, which is a pea-sized gland at the base of the brain, releases two hormones that control sperm and sex hormone production. These two hormones are called luteinizing hormone (LH) and follicle stimulating hormone (FSH). Production of these hormones can be low and the testes don’t receive the right signals to produce sex hormones and make sperm. These hormones can be given by injection which help with sperm production in the testes. After several months of injections, a man may then be able to conceive a child through sexual intercourse if there are no medical problems with his partner that reduce her fertility.
Rarely the pituitary produces an excessive amount of prolactin and this stops sperm production. By taking a tablet, the amount of prolactin is reduced, allowing sperm production.
It’s important that all men with poor sperm count have their prolactin checked.
Drug induced male infertility
The most common cause of reduced sperm count from drugs is administraton of testosterone. Testosterone or other anabolic steroids are sometimes given if a man complains of fatigue or reduced sexual performance. Sometimes they are taken inappropriately to increase exercise performance or muscular development. Testosterone reduces the sperm count and reduces the size of the testes. It may take several months for the testes to resume their normal function.
Sometimes men with pituitary disease or testicular disease who have hormone deficiency are given testosterone and that is appropriate for their well being and bone health but those men must understand that their sperm production will be further reduced whilst they are taking testosterone.
Some other drugs that can influence sperm production include marihuana, sulphasalazine (given for inflammatory bowel disease), anti androgen drugs to reduce hair loss, such as finasteride and also chemotherapy.
Ejaculation defects and retrograde ejaculation
Ejaculation defects are uncommon in most men. However, men with spinal injury or diabetes commonly have difficulty with ejaculation.
Sometimes sperm can be released into the bladder during ejaculation. Though this often can't be resolved, taking medication can avoid injury to the sperm by the urine. This condition is called retrograde ejaculation. Sperm can be collected from the urine after some medical treatment (urinary alkalinisers) and used to fertilise eggs collected from the female partner.
Obstruction to the outflow of semen is treatable.
The most common cause of obstruction is when a man has had a vasectomy. This is treated by reversal of the vasectomy or collection of the sperm from the testis. Sperm antibodies are can be a problem and IVF and ICSI are often necessary.
Another cause of obstruction is from having two genes for a variant of cystic fibrosis. This is called congenital absence of the vas deferens. Sperm is generally available in normal sized testes and can be retrieved by surgical sperm recovery. The female partner should be tested to check if she carries a gene for cystic fibrosis, as 1 in 22 people carry the gene and there’s a 1 out of 4 risk of a baby being born with cystic fibrosis, if both parents are carriers for the gene. Preimplantation genetic testing can be offered in such cases.
There are some lifestyle factors that can help with abnormal sperm production. Some of the most proven ways are:
- Cigarette smoking should be stopped as it reduces success in IVF cycles by a half
- Obese men have reduced sperm count, poor embryo development and increased miscarriage, so it's important to be a healthy weight range.
- Marihuana and excessive alcohol consumption (more than 14 standard drinks per week) should be stopped.
Treatments that are believed to help with infertility, but are unproven include:
- supplements of zinc
- folic acid and multivitamins
- organic diet.
Regular ejaculation, at least two to three times per week, is thought to reduce the production of “aged” or damaged sperm and is therefore recommended for men attempting to conceive a pregnancy.
Long term implications of male infertility
Men with a reduced sperm count are at increased risk of testicular cancer and should have their testicles examined regularly. If a lump is found, they should present promptly for examination and assessment. Some men, especially those with severe reduction in sperm production, may be at risk of male hormone deficiency. This may put them at risk of osteoporosis.
It is important that all men with male infertility are seen and examined by a specialist. Care Fertility is committed to the improvement of men’s health by recognition of male infertility and its implications.