June is Men’s Health Awareness Month, and unfortunately many men are unaware that they may also be the casualty of an infertility problem. Traditionally infertility has been thought of as a female problem; however, this is far from the truth. A male problem can be identified in nearly half of all couples who have difficulty achieving conception.The term ‘infertility’ is used when the ability to fall pregnant is diminished or absent. It does not mean that you are unable to have children but that you may require treatment or assistance to achieve a pregnancy. For men the infertility problem may involve the sperm, the testes, the ducts that lead out from the testes, or it may be a functional problem in relation to sexual activity.
One of the most important tasks is to establish the cause of a man’s infertility. While it is often difficult to diagnose the cause, it is important in the indication of the best method of treatment. The most common causes of infertility for men are:
- Damage to sperm production – affects two thirds of infertile men
- Obstruction to the ducts leading our from the testes
- Functional problems
- Hormonal problems
- Genetic problems
Sperm Production Problems: One of the most common causes of infertility in men is damage to the production of sperm resulting in a low sperm count (oligospermia). This can also be associated with reduced sperm movement and abnormally shaped sperm. A severe case of this results in azoospermia which means the total absence of sperm in the ejaculate. Common causes of damage to sperm production are testicular injury, undescended testes, a twisted testes, cancer treatments, varicocele and genetic problems.
Obstruction: Obstruction occurs when the fine tubes in the epididymis become blocked preventing the sperm from reaching the penis. Obstruction can be caused by infection, congenital disorders, vasectomy and other surgery.
Functional Problems can cause or be due to the following:
Impotence – the ability to maintain an erection sufficient for sexual intercourse
Failure to ejaculate or retrograde ejaculation (ejaculating backwards into the bladder)
Side effects of prostate surgery
Anti-sperm antibodies – where the man’s immune system makes antibodies that hinder the activity of the sperm
Hormonal Problems: Low testosterone levels in men can result in the inability to produce sperm. Endocrine disorders can cause a drop in the sperm count. These disorders include thyroid disease, diseases of the pituitary gland, hereditary haemochromatosis, sickle cell anaemia and thalassaemia.
Genetic Problems: Approximately one-half of all infertility is caused by sperm abnormalities. Many sperm disorders are due to a chromosome abnormality such as aneuploidy or a structural chromosome abnormality. Men who carry a balanced translocation chromosome are at risk of producing sperm with a structural chromosome abnormality. Couples with infertility due to male factor should consider chromosome analysis of the male’s sperm prior to IVF. Y chromosome deletions are found in approximately 5 to 20 percent of males with a very low sperm count. These deletions appear to impair normal sperm development. While these deletions do not appear to cause any genetic disease, they appear to decrease the chance of men with a low sperm count to successfully fertilise eggs in a normal way.
Genetic diseases, most of which are either directly or indirectly associated with sperm abnormalities:
- Cystic fibrosis
- Noonan syndrome
- Myotonic dystrophy
- Sickle cell disease
- Sex reversal syndrome
- Androgen receptor gene mutations
- Chromosomal abnormalities
- Chromosome rearrangements
- Deletions in the Y chromosome
It is important to understand that men who have genetic problems that cause their infertility, such as a deletion in the Y chromosome, can pass this problem to their sons, who would also have infertility, if they elect to use their own sperm in achieving a pregnancy.
Male Infertility Tests
Presuming that the problem is male infertility we will check for:
A good quantity and quality of male sperm. There will be a decrease in fertility if the sperm are not being produced in adequate numbers, obstructed and cannot reach the penis, not swimming very well, being attacked by antibodies from either the male himself or his female partner.
The right balance of hormones to allow sperm development and support.
Semen Analysis: A semen analysis measures the amount of semen a man produces and determines the number and quality of sperm in the semen sample. A semen analysis is usually one of the first tests done to help determine whether a man has infertility problems. Problems with the semen or sperm affects more than one-third of infertile couples. Tests that may be done during a semen analysis include:
- Volume. This is a measure of how much semen is present in one ejaculation.
- Liquefaction time. Semen is a thick gel at the time of ejaculation and normally becomes liquid within 20 minutes after ejaculation. Liquefaction time is a measure of the time it takes for the semen to liquefy.
- Sperm count. This is a count of the number of sperm present per millilitre of semen in one ejaculation.
- Sperm morphology. This is a measure of the percentage of sperm that have a normal shape.
- Sperm motility. This is a measure of the percentage of sperm that can move forward normally. The number of sperm that show normal forward movement in a certain amount of semen can also be measured (motile density).
- pH. This is a measure of the acidity (low pH) or alkalinity (high pH) of the semen.
- White blood cell count. White blood cells are not normally present in semen.
- Fructose level. This is a measure of the amount of a sugar called fructose in the semen. The fructose provides energy for the sperm.
A normal semen analysis will met the following criteria:
- Volume of semen: More than 2ml
- Sperm concentration: More than 20 million sperm per ml
- Sperm motility (the ability to swim): More than 50% of the sperm are moving forward or 25% are moving forward very quickly
- Sperm morphology (shape): More than 15% have a normal shape
- White blood cells: Less than 1 million cells per ml
- Sperm antibodies: Less than 50% coated sperm
Ultrasound: An ultrasound examination of the testes and prostate can be a useful diagnostic test. An ultrasound probe is placed on the testicles to provide a picture of the testes and epididymis. It is alo useful for diagnosing testicular cancer and varicocele.
Testicular Biopsy: A testicular biopsy involves the removal of a small sample of the tissue from a testicle. This allows for direct inspection of the sperm making tissue.