Male Infertility Facts

Check out Michael Close’s Bourn Hall Fertility Fair Video - which may help understand what we do at LogixX Fertility and what we can do to help!.

What should I do if I have fertility problems?

If you have been trying unsuccessfully to produce a pregnancy for 1-2 years, without using any form of contraception, you should contact your GP for further advice

Your GP will normally wish to review you and your partner together. Further investigations may reveal that only one partner has a problem contributing to the infertility. As a general rule, most urologists only deal with problems affecting the male partner. Investigations in the female partner are not considered on this page.

What are the facts about male infertility?

• 1 in 7 couples in the UK are unable to have a child; approximately 3.5 million people

• in 50% of these couples, the problem lies wholly or partly with the male partner, this means around 2 million men in the UK could experience male fertility issues in trying to conceive.

• urological investigations are essential in revealing reversible underlying causes for male-factor subfertility and full assessment by a urologist is recommended in all cases of male-factor infertility;

• in many cases, the underlying cause may not be able to be reversed, in which case assisted reproductive technologies (ART e.g IVF) may offer the best chance of pregnancy; this may involve surgical sperm retrieval in advanced cases of infertility or using sperm selection technologies

• infertile couples are often referred and assessed by gynaecology departments (Fertility Clinics) so subfertile men may wish to seek a urology assessment from a urologist specialising in andrology.

What are the causes of Male Fertility Issues?

There are a number of causes of male infertility including lifestyle factors, erectile dysfunction, hormonal problems, varicocele, 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 should undergo a thorough history and clinical examination of the genital tract, hormone profile, genetic studies and ultrasound scans depending upon their semen analysis and clinical findings.

What should I expect when I visit my GP?

Current practice guidelines recommend a “Semen Analysis Test” in patients suspected of Male Infertility Factor due to:

• 12 months of unprotected intercourse without pregnancy (success).

• Anatomical issues involving blocking or obstruction to transport of sperm.

• Chronic infections and or immunocompromised conditions.

• Lifestyle issues associated with health, environmental, or age factors.

Your GP should work through a recommended scheme of assessment for men with infertility according to NICE guidelines.

**Please note: Not all advanced tests for Male Fertility Assessment are available on the NHS such as Sperm Reactive Oxygen Species (Sperm Oxidative Stress tests) or Sperm DNA Fragmentation tests. Current published NICE guidance on Male Fertility is considered outdated and inaccurate and may not reflect current advances in urological medical knowledge available in the private sector.

However, GP’s will normally include some or all of the following:

A full history

Your GP will enquire about lifestyle factors (e.g. your job, work pressures, smoking habits, alcohol intake and drug consumption) as well as asking whether you have previously fathered children. Your past medical history may also be relevant in identifying a reason for your infertility, especially if you have had previous testicular infections, issues or operations. You will be asked about when you have been having sexual intercourse. Ideally, this should be timed to coincide with your partner's ovulation (approximately 7 - 10 days before the next menstrual period).

A physical examination

A general physical examination will be performed, paying particular attention to the development of your male sexual characteristics and any testicular pain or aches.

Additional tests

The usual tests performed are:

a. Sperm counts

You will need to provide at least two semen specimens for analysis. A sperm count of more than 15 million normal, motile (active) sperms per ml should be sufficient to allow pregnancy by natural means

Download information on how to do a sperm count.

b. Hormone measurements

Blood levels of testosterone, prolactin, FSH (follicle-stimulating hormone), LH (luteinising hormone) and thyroid hormones will normally be measured. These can be used to give an indication of the nature of the underlying problem

c. Other specific tests

Other blood tests, (usually performed by specialists), may include genetics screening tests (including karyotype checks, assessment of cystic fibrosis genes and Y chromosome micro-deletions associated with infertility) and viral screening tests (including checks for hepatitis B, C and HIV in patients where sperm samples may need to be stored or handled by the laboratory for IVF). 

Occasionally, an ultrasound of the scrotum and ultrasound of the prostate & seminal vesicles (sperm sacs) may be required and certainly where sub-optimal sperm analysis has been detected.

WHO Reference values for Human Semen

The results of the semen analysis conducted as part of an initial assessment should be compared with the following World Health Organization reference values:

• semen volume: 1.5 ml or more

• pH: 7.2 or more

• sperm concentration: 15 million spermatozoa per ml or more

• total sperm number: 39 million spermatozoa per ejaculate or more

• total motility (percentage of progressive motility and non‑progressive motility): 40% or more motile or 32% or more with progressive motility

• vitality: 58% or more live spermatozoa

• sperm morphology (percentage of normal forms): 4% or more.

The reference ranges are only valid for the semen analysis tests outlined by the World Health Organization.

[Fertility (NICE guideline CG156), recommendation 1.3.1.1]

Sperm Oxidative Stress & DNA Fragmentation (Not available on the NHS)

High levels of oxidative stress can damage normal spermatozoa by inducing lipid peroxidation and sperm DNA damage and are associated with poor sperm function and subfertility. It is advised that in couples with Recurrent Miscarriage, men should be checked for Oxidative Stress such as MiOXSYS or DNA Fragmentation (Comet Test, Tunel or SCSA) other reasons include:

• Idiopathic male infertility

• Male partners of Recurrent Pregnancy Loss or history of failed IUI or IVF cycles

• Infection of male accessory glands (example: prostatitis)

• History of smoking

• Older males – over the age of 40

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 in ejaculate (azoospermia) , sperm motility (asthenozoospermia) or sperm morphology - shape of the sperm (teratozoospermia).

What could have caused my infertility?

In 75% of infertile men, the cause remains unexplained (this is termed "idiopathic infertility"). It may, however, still be possible for couples to conceive naturally, provided some sperms are present.

Male infertility is either due to a problem making good quality sperm, or a problem with delivery of the sperm to the outside world.

Typical causes of delivery problems can range from issues with erections or ejaculation, to physical blockages, which can occur at any step from where the sperm is made in the testicle, to its point of delivery at the tip of the penis. Some blockages can be more easily overcome, such as a previous vasectomy. Others, such as multi-level obstruction due to infections, or being born without a vas tube cannot. In cases of "obstructive" infertility, the testicle still makes sperm normally, so sperm can usually still be directly retrieved from this source.

The damage associated with some of these situations may be reversed to allow a return to normal fertility. Genetic problems cannot be reversed, but may be overcome using direct surgical sperm retrieval from the testicle, but with a lower overall chance of successfully finding sperm than in cases of obstruction. 

What treatments are available for this problem?

Many couples produce a pregnancy whilst undergoing investigations or treatment for infertility (85% within the first year) but, for those who do not, a number of treatments are available

General measures

If you have poor sperm counts, you should wear loose-fitting trousers and boxer shorts. You should stop smoking, reduce your alcohol intake, avoid recreation drugs and any gym supplements. You should endeavour to adopt a "healthy" lifestyle with a balanced diet. Fertility vitamin supplements may also have some benefits.

You should avoid using computers directly on your lap, do not carry your mobile phone in your trouser pocket, and avoid long soaks in a hot bath or sauna/ steam rooms, as increased temperatures can affect sperm production.  

Management of obstruction

Surgical bypass may be possible depending on where the level of the obstruction lies.

• blockages to the ejaculatory duct in the prostate may be overcome with resection of any obstructing cyst

• blockages of the vas (sperm duct) – most commonly seen post vasectomy & can be overcome with vasectomy reversal

• blockages to the epididymis may be overcome using microsurgical epididymo-vasostomy.

In cases where the obstruction cannot be reversed, direct surgical sperm retrieval (SSR) from the normal but blocked testes caries a 100% success rate in finding sperm for use with assisted conception. The choice to reconstruct or obtain sperm surgically depends on a number of factors, including;

• the female partner's age,

• how many children are planned,

• the time interval since vasectomy (for vasectomy reversal only) 

Management of impaired sperm production

Besides the general measures outlined above, correction of any reversible element may result in a return to normal fertility (e.g. correction of any hormonal abnormality).

Varicoceles occur in 20% of infertile men (and in 10% of the normal male population).

Varicocele is an enlargement of the veins within the loose bag of skin that holds your testicles (scrotum). A varicocele is similar to a varicose vein you might see in your leg. Varicoceles are a common cause of low sperm production and decreased sperm quality, which can cause infertility.

The treatment of clinical relevant varicoceles has been shown to be associated with an improvement in sperm number and quality, and an increased rate of natural conception (1 in 3 couples) in more recent studies. Treatment of clinically relevant varicoceles is now advocated by both the European and American Guidelines on Infertility.

Treatment Options for Varicocele :

• Varicocele Embolization is a non-surgical, image guided, minimally invasive procedure to block the back pressure in the testicular veins, relieving pain, improving sperm production and increasing testosterone.

• The traditional surgical alternate involves an incision in the scrotum or groin and tying off of the problematic veins, usually under general anaesthetic by a Urologist.

For more information on treatment of Varicocele please visit DON’T SUFFER WITH BALL ACHE! - https://www.imageguidedhealthlondon.com/treatments/varicocele-embolization-ve

In cases where no reversible cause is present, and no sperm is present in the ejaculate, sperm may still be successfully retrieved in approximately 50% of cases from the testicle using microsurgical retrieval techniques (MicroTESE).

Assisted conception techniques

Intrauterine insemination (IUI)

Selecting out the most motile sperms and injecting them directly through the cervix at the time of ovulation, whilst employing drug-induced ovarian stimulation in the female partner, results in a 7 - 8% pregnancy rate for each cycle of treatment.

Intracytoplasmic insemination (ICSI)

In this type of in vitro fertilisation (pictured) a single sperm is injected directly into an egg to fertilise it. It is useful if you have a very low sperm count or in cases of surgically retrieved sperms. As with any IVF technique it carries risks for the female partner due to the drug stimulation required in the egg retrieval process. It has a pregnancy rate of approximately 30-40% per cycle.

What options are available if no sperms can be found?

Donor insemination (DI)

Donor semen is carefully screened for infections and a donor selected to have similar attributes to you. This is the only viable option if you have no sperms at all and you do not have obstruction which can be relieved surgically.

Adoption

If you are unfortunate and do not to have any success with other treatments, you may wish to consider adopting a child. Your GP and local / national adoption agencies can help with this process.

Further Support

If you feel you need a thorough investigation - check out our Urology/Andrology Referral Page or Support Partners for further support.

There is also support from Fertility Network UK and HimFertility pages

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