Reproduction (or making a baby) is a simple and natural experience for most couples. However, for some couples it is very difficult to conceive. A man’s fertility generally relies on the quantity and quality of his sperm. If the number of sperm a man ejaculates is low or if the sperm are of a poor quality, it will be difficult, and sometimes impossible, for him to cause a pregnancy. Male infertility is diagnosed when, after testing both partners, reproductive problems have been found in the male.
In most cases, there are no obvious signs of infertility. Intercourse, erections and ejaculation will usually happen without difficulty. The quantity and appearance of the ejaculated semen generally appears normal to the naked eye.
Medical tests are needed to find out if a man is infertile.
Male infertility is usually caused by problems that affect either sperm production or sperm transport. Through medical testing, the doctor may be able to find the cause of the problem. About two-thirds of infertile men have a problem with making sperm in the testes. Either low numbers of sperm are made and/or the sperm that are made do not work properly.
Sperm transport problems are found in about one in every five infertile men, including men who have had a vasectomy but now wish to have more children. Blockages (often referred to as obstructions) in the tubes leading sperm away from the testes to the penis can cause a complete lack of sperm in the ejaculated semen.
Other less common causes of infertility include: sexual problems that affect whether semen is able to enter the woman’s vagina for fertilisation to take place (one in 100 infertile couples); low levels of hormones made in the pituitary gland that act on the testes (one in 100 infertile men); and sperm antibodies (found in one in 16 infertile men). In most men sperm antibodies will not affect the chance of a pregnancy but in some men sperm antibodies reduce fertility.
Some changes to chromosomes or gene mutations cause abnormal sperm production or blockages to sperm flow that lead to male infertility. The most common genetic causes of infertility are chromosomal conditions that affect sperm production. These include:
Infertility due to mutations in single genes are less common. Congenital absence of the vas deferens, where there is a blockage to sperm flow, is caused by mutations in the cystic fibrosis gene. It is likely that other genetic disorders will be found in the future that will help explain other sperm production problems that currently have no known cause.
If a couple has been trying for a pregnancy without success, they should go to their local doctor or family planning clinic, and have some initial tests.
Infertility should be considered a couple’s problem requiring review of both the male and female partner even if one partner has a child from another relationship. Male infertility may be a sign of other (possibly undiagnosed) health problems such as testosterone deficiency or coexisting testicular cancer, so it is important that it is investigated.
Diagnosis can involve a medical history from the man and a physical examination along with a semen analysis to check the number, shape and movement of sperm in the ejaculate. Blood tests may also be done to check the levels of hormones that control sperm production or for genetic testing. Testicular biopsies or testicular ultrasound are sometimes done.
One in eight infertile men has a treatable condition, and after treatment, couples can become pregnant naturally.
In some cases, the doctor will recommend that the couple seek assisted reproductive technologies (ART), such as IVF (in vitro fertilisation). ART do not cure or treat the cause of infertility but they can help couples achieve a pregnancy, even if the man’s sperm count is very low.
At this stage there are no treatments that can fix the genetic problems that cause poor sperm production or transport. While some men with genetic problems can father children naturally, IVF, ICSI or other forms of assisted reproduction offer the best chance for these men to have biological children.
Some genetic problems, such as Y chromosome deletions, will be passed on to any male child born through the use of sperm in IVF or ICSI procedures. However, for most men with presumed genetic causes of infertility, we don’t yet know whether their children will be affected.
The investigation of men with unexplained low sperm counts (less than 10 million sperm/mL) should include a karyotype and, when less than 5 million sperm/mL, also a Y chromosome deletion test.
Couples where the man has CAVD should have genetic counselling to discuss the risk of cystic fibrosis in their children, and the possibility of pre-implantation genetic diagnosis and embryo selection in IVF.
Intracytoplasmic sperm injection (ICSI) is a form of IVF where a single sperm is placed directly into each egg by piercing the outer covering of the egg. ICSI is particularly helpful for men with poor sperm production. Sperm are collected from the semen or removed carefully from the testis or epididymis.
Men may be shocked when they find out they are infertile. There is still a common but incorrect belief that infertility is a woman’s problem. Therefore, when men are told there is a sperm problem, they are often unprepared.
Being told that there is a sperm problem can affect a man’s sense of masculinity, sexuality and potency. Most infertile men at some time struggle with the idea that they are not able to do what other men can.
An emotional response to infertility is normal. Talking with a doctor or a sexual therapist or counsellor can help some men with their feelings about infertility.
It is best to avoid cigarette smoking, excess alcohol, sexually transmitted infections, heat stress from tight fitting underwear, and anabolic steroids (taken for body building or sporting purposes) as these factors can be harmful to the production of sperm.
If you work in an occupation that may affect your fertility, it’s important to wear protective clothing and follow all occupational health and safety guidelines. It is recommended that couples trying to conceive avoid exposure to any possibly harmful chemicals.
Because of the possible effects on fertility, it’s important to tell your doctor if you have had hormone treatment or had surgery as a child to move your testes into the scrotum..
ICSI can achieve pregnancies even when only a few sperm are produced.
As for IVF, after fertilisation the resulting embryos are then placed into the woman’s uterus.
Healthy men in their 70s and beyond can still father children, however the time taken for a partner to become pregnant is longer when a man is middle-aged or older. Reasons for this may include a decrease in sexual activity, lower semen volume, changes to sperm motility (movement), a lower number of motile sperm, and possibly lower sperm function and DNA quality.
The chance of the child having some genetic or chromosomal problem is also increased for older men.