Infertility is defined as the failure to conceive after one year of unprotected sexual intercourse. Approximately 15% of couples attempting their first pregnancy meet with failure. In about 50% of couples seeking treatment, the infertility will be caused by a problem in the male. It is therefore important that both partners are seen and investigated together.There have been great technological advances in the development and success of assisted conception in the last two decades, such that many couples with infertility can now be offered treatment.
There are a number of causes of male infertility including erectile dysfunction, hormonal problems, chemotherapy or radiotherapy, previous surgeries on the testis including undescended testis, drugs and medications. It is important to be aware that in some cases a cause may not be found.
All male patients will undergo a thorough history and clinical examination, hormone profile, genetic studies and ultrasound scans depending upon their semen analysis and clinical findings.
Causes of Male Infertility
Causes of infertility in men can be explained by deficiencies in ejaculate volume, sperm concentration (e.g. too few – oligospermia – or no sperm – azoospermia – in ejaculate), sperm motility or sperm morphology (shape of the sperm).
Some specific causes are:
• Hypothalamic disease can include deficiency in GnRH, LH or FSH
• Pituitary disease e.g. tumours, thyroid problems
• Chromosomal abnormalities e.g. Klinefelter’s syndrome
• Trauma to the testicles
• Defective testosterone synthesis or action
• Cryptorchism (undescended testis)
• Systemic disease (renal failure, hepatic disease, sickle cell disease)
• Difficulties with intercourse e.g. ejaculatory failure, impotence
Sometimes a cause for male infertility cannot be found.
Diagnosis of Male Infertility
Your consultant will first take your medical history and conduct a careful physical examination. The history will include noting details of: any childhood illnesses; previous surgery; exposure to occupational and environmental toxins, excessive heat, chemicals or radiation; alcohol, drug and medication use; and any medical conditions related to the reproductive system. The physical examination will include a careful examination of the scrotal contents.
The most useful tool in testing for male infertility is the semen analysis. The ‘normal’ values for different measurements of sperm quality have been worked out by testing large groups of healthy fertile volunteers. When a semen analysis is done, the results are compared with the normal range of values and any abnormalities will suggest a male problem. The tests carried out on a semen sample will look for abnormalities in sperm number (the sperm count), sperm movement and sperm shape.
Blood tests to assess the levels of hormones relevant to sperm production are also used to exclude hormonal factors and/or abnormalities.
Treatment of Male Infertility
Infertility treatment options for each patient will vary according to the results of tests undertaken. Almost all causes of male infertility can be treated, with reasonable chances of pregnancy, provided the woman’s age and fertility are not a problem.
The best form of treatment will be discussed during consultation with your specialist. Treatment options include drug therapy for the man, intrauterine insemination (IUI), in vitro fertilisation (IVF) with or without sperm microinjection into the egg (ICSI) or artificial insemination by donor (DI).
Men who are unable to produce sperm because of an obstruction between the testicles and penis or the testicles may not be working properly can be helped by various techniques of collecting sperm from the testicles or epididymis eg sperm retrieval. The aim is to collect enough sperm to carry out ICSI.
Sperm retrieval techniques commonly used are MESA (microepididymal sperm aspiration) or PESA (percutaneous epididymal sperm aspiration) which are both used for removing sperm from the epididymis and TESE (testicular sperm extraction), where sperm cells are extracted from a biopsy of testicular tissue. TESE is usually reserved for non-obstructive disorders.
Another technique is TESA (testicular sperm aspiration) which is used in men who have normal sperm production but suffer from a blockage. Sperm tubules from the testicle are aspirated with a needle although the quantity of sperm retrieved using this technique is inferior to that of TESE.
There are no drugs to increase sperm count or correct the shape of individual sperm cells. Drugs can, however, be used to treat some of the causes which may lead to infertility, such as impotence or hormone deficiencies or before sperm retrieval.
Lifestyle changes such as giving up smoking, decreasing alcohol intake, following a healthy diet and stress management may be beneficial in some cases.
A diet high in antioxidants such as vitamin C and E has been proven to improve the quality of sperm by decreasing the number of free radicals that may cause membrane damage. The use of zinc, fish oil and selenium has also shown to be beneficial.
Artificial insemination (AI)
This form of treatment can be used if the sperm sample has moderate reduction in count or motility. The sample is prepared to allow the most actively moving sperm to be isolated and used for insemination. The sperm is then placed directly into the cervix (intracervical insemination –ICI) or the uterus (intrauterine insemination – IUI). Ovulation is controlled and stimulated by fertility hormones, which is also known as ‘superovulation’
Fertility drugs are used to induce the growth of more than one egg during a single menstrual cycle, therefore monitoring is important during superovulation to ensure the side-effects of treatment and the risk of multiple pregnancies is avoided. Monitoring is usually carried out by blood tests to measure hormone concentrations and by ultrasound to track the development of the follicles. The aim is to generate two to three follicles.
When they have reached their target size, a single injection of human chorionic gonadotrophin (hCG) is given to the woman. Ovulation will then occur about 36 hours later at which time the sample of semen is prepared and placed into the uterus of the woman through a fine catheter.
In vitro fertilisation (IVF)
IVF involves removing several eggs from the ovary, fertilising them in the laboratory with sperm from the male partner and transferring one or two of the resulting embryos into the woman’s uterus.
This form of treatment was developed to treat couples whose principle cause of infertility is tubal damage in the female but can be useful in those whose problems are caused by low sperm count, motility or poor shape. The introduction of ICSI in the 1990s, however, means that IVF is less commonly used.
Intracytoplasmic sperm injection (ICSI)
ICSI makes use of a powerful microscope to guide a micro-needle containing a single sperm into the egg. Fertilisation can be achieved with just one sperm cell injected into an egg. This fertilised egg is then implanted into the woman’s uterus. More recently the technique of IMSI has been used at The Lister hospital
The female partner must undergo procedures of ovarian stimulation and egg collection, while the male partner must produce a sperm sample by masturbation or PESA, MESA, TESA or microdissection TESE if appropriate.
The sperm are then prepared and a few viable cells are salvaged for use.
Some groups of men need to be carefully screened prior to this form of treatment. Men with a low sperm count or who do not ejaculate sperm should be tested for chromosomal problems and cystic fibrosis genes. Children born after ICSI have been intensively studied to look for increased occurrences of abnormalities, although most studies have not shown significant risk of abnormalities compared to natural conception. There may, however, be a small risk of congenital abnormalities of the genitalia and of an imprinting disorder known as Beckwith-Widemann syndrome.
Your specialist will discuss these possible risks with you before treatment starts.
Donor sperm is reserved for cases of male infertility where the male partner’s sperm is severely abnormal (with a very low or zero sperm count) or the man carries genes that would result in abnormalities to the child. Couples should see a counsellor to explore the implications of using donor sperm before treatment takes place.
Recent changes to the UK law have removed the anonymity for sperm donors and a child born after sperm donation can now apply to make contact with the donor when they reach the age of 18. This has made it more difficult to recruit suitable sperm donors and has increased the costs.
Counselling for Male Infertility
Infertility and its treatment are significant causes of stress for many couples. Both partners can be affected and the relationship can be threatened by the pressures of treatment. Counselling can be a lifeline during the difficult times of treatment and should be available to all couples undergoing assisted conception. The frustrations of childlessness can impose severe emotional strains, so guidance and support through this period is vital.
The passage through a cycle of treatment is not easy and, as the statistics show, success cannot be guaranteed. Even couples who achieve pregnancy may experience the severe disappointment of pregnancy loss. Some couples also find that the dilemmas raised by assisted conception are more easily resolved after discussion with a trained counsellor.
Success Rates for IVF and ICSI
Studies of IVF and ICSI suggest a pregnancy rate of 30% and a live birth rate of 25% in woman under 36 years of age. The results are halved by the time the woman is 38 and few are successful when the woman is 40. (see published outcomes).
The rate of pregnancy following IUI is about half of that for ISCI but it is a less stressful, complex and costly treatment and has a place in less severe male infertility.
DNA fragmentation and Sperm Aneuploidy
It has now become quite clear that it is not just the quality of sperm on standard semen analysis that may predict outcome from treatments such as IVF. It has become clear that up to 30% of men with unexplained subfertility may have a raised or damaged sperm DNA.
It has been shown that a raised DNA fragmentation of >30% may lead to recurrent failure in IVF treatments. There are a number of causes of raised DNA fragmentation including infections, varicoceles and dietry problems and should be excluded in men and their partners before or after failing IVF treatment.
Interestingly, there may also be an abnormal complement of chromosomes in the sperm which can also lead to failure of success of ART. This is called sperm aneuploidy.
Both of these tests are complex tests which are offered by our clinic.