We all know about female infertility, but did you know the male factor comes in to play in about 40% of cases? Dr Gary Swift reveals the facts on male fertility and subfertility.
How common is male subfertility?
In this day and age in an infertility practice as many as 40% of couples will have male factors as the major or at least contributing factor to delayed conception or the need for IVF or assisted reproductive technology (ART)
How do we reliably assess male fertility and subfertility?
Most cases of reduced male fertility don’t have any identifiable cause. At QFG Gold Coast we rely on the analysis of ejaculated semen after 72 hours abstinence analysed in a specialized laboratory by a qualified embryology scientist. The specimen is often collected at home but can be done on site and needs to be received by the laboratory within 1 hour.
The parameters used are based on World Health Organisation (WHO) recommendations based on a study of 2,000 fertile men using the 5th centile as the lower limit of normal. This gives us minimum parameters of 15Million/ml concentration, 34% progressive motility and 4% normal sperm morphology. Below this men can still father children but the chances are reduced and compounded if there is any contribution to subfertility by the female partner.
What other factors impact on male fertility?
As mentioned most cases are unknown or “idiopathic”. Some men have underlying genetic problems from birth due to altered chromosomal structure (translocations, inversions), missing parts of the Y Chromosome (DAZ gene deletions) or missing parts of the Vas Deferen ducts associated with aCystic Fibrosis gene (CBAVD).
Undescended testes at birth “cryptorchidism”, particularly if surgery is delayed, can lead to permanent damage to the sperm producing cells in the testes.
Major trauma to the testes from sporting injuries or other accidents may likewise cause damage. Infections such as Mumps after puberty can cause severe inflammatory damage “orchitits” with permanent effects. Varicocoeles (dilated veins in the scrotum) may have an adverse effect but there is not universal agreement in the medical profession on this).
In later life sexually transmitted infections, toxic chemical or radiation exposure in the workplace and both prescribed and recreational drugs may reduce sperm quantity and quality. Marijuana and anaobolic steroids are the worst in this regard.
Some men develop antibodies which bind to sperm and reduce motility. This can occur after trauma or vasectomy and occasionally for no definable reason. Age has a gradual effect on sperm quality and concentration in men though generally fertility is maintained much later in life.
Lifestyle issues are becoming increasingly important with obesity, sedentary behaviour, cigarettes, alcohol and poor nutrition and dietary choices having adverse effects.
The testes are outside the body because sperm production occurs optimally at 35 degrees Celcius with normal core body temperature being between 36 and 37 degrees. A certain amount of auto-regulation occurs however overheating either in the environment or with persistent wearing of tight fitting underwear may have an effect. The old fashioned view of “boxers are better than briefs” may be relevant for some men.
What is the treatment for male subfertility?
Lifestyle adjustments are important. Stopping smoking and reducing alcohol ingestion to less than 2 drinks per day and at least 2 alcohol free days per week can have a dramatic improvement. Avoiding recreational drugs and visiting the family GP to ensure any prescribed medication is not adversely affecting fertility is a good plan.
A healthy balanced diet, weight loss if necessary and modest exercise with a good multivitamin rich in Zinc and anti-oxidants is advisable.
Men who do work in potentially toxic environments should strictly adhere to OH&S guidelines regarding breathing, radiation shielding etc.
For some men surgery may be necessary though this is a minority.
For minor problems timed intrauterine insemination (IUI) with or without ovulation induction (OI) may be successful. In this procedure ejaculated sperm is concentrated in a centrifuge and injected into the uterus through the cervix (like a PAP smear).
This gives on average a 10-15% chance of pregnancy per attempt (compared to naturally 22%) and this is additive for up to 4 cycles after which IVF is considered) Current technology in ART allows us to directly retrieve sperm from the testes for some genetic conditions and after vasectomy or failed reversal. This sperm can then be directly injected into the woman’s eggs (oocytes) in a process called ICSI as part of an IVF cycle.
In couple where the female partner is less than 35 years of age success rates up to 45% per cycle are achievable.Some couples where men have very poor semen parameters regardless of cause will require IVF + ICSI. Genetic testing of the embryos (PGD) may be required in some genetic conditions to avoid transmitting problems to the nest generation.
When should couples seek advice?
Generally a healthy couple under 35 years of age should conceive within 12 months. 15% of couples will potentially have difficulty. If pregnancy has not occurred in this time frame a semen analysis is one of the first line tests. If the female partner is over 35 evaluation should be considered after 6 months. Any problem in the personal or family history or any of the risk factors mentioned above should prompt an earlier review by a fertility specialist. Any couple though if they are concerned can attend for an evaluation at any time.
This information is of a general nature only and many factors can impact on a couples chances of pregnancy. Each situation is individual and is treated as such.
Dr Gary Swift is a senior Obstetrician Gynaecologist and IVF Infertility specialist at Queensland Fertility Group Gold Coast at Pindara Private Hospital.