Male Fertility

Infertility affects males and females in almost equal proportions. Thus medical investigation of infertility should, from the outset, involve both the man and the woman.

Male fertility is dependent upon the quality and quantity of semen delivered to the female reproductive tract. Semen is essentially made of two components:
1. Spermatozoa, or sperm cells, made in the testes and containing the genetic package (chromosomes) which will fertilise the female egg.
2. Seminal plasma, the fluid component of the semen, which is made in various sites along the male reproductive tract including the prostate and seminal vesicles. The seminal plasma is essential for the successful transportation and health of the spermatozoa.

During ejaculation these two components, the spermatozoa and seminal plasma, are brought together. Disease processes and lifestyle issues can affect both components, leading to decreased fertility. The maturation process for spermatozoa takes at least three months, and therefore it is to be expected that lifestyle changes to enhance male fertility will require at least three months to start seeing a positive effect and should be continued until a healthy conception is achieved. (Please see Causes of Infertility>Lifestyle Factors and Male Fertility on this website for further information.)

Overview of the male reproductive system

The function of the male reproductive system is to produce, store and transport the sperm outside the body. The organs that produce sperm are the testes. Sperm production begins with immature sperm cells that grow and develop within the seminiferous tubules. These tubes are very tiny and the sperm inside them are not fully mature. As a result they are unable to move on their own. As they travel along the length of the epididymis they mature and become motile. During ejaculation sperm are carried from the epididymis to the penis along the vas deferens (Figure 1).

Infertility tests

Usually clinical examination of the man and semen tests are all that is necessary. More than one semen test is performed because the results may vary considerably from day to day. It should be noted that standard semen analysis is not an absolute guide to fertility, and ultimately the only real test of fertility is the creation of a healthy baby.

Blood tests may be needed to check for sperm antibodies and hormonal abnormalities.

Exploratory operations and testicular biopsies are also performed occasionally to check for blockages in the epididymis or vas (the tubes of the genital tract connecting the testes to the penis).

Sperm Production

A normal semen sample has the following results from a semen analysis: sperm at least 20 million per ml, 50% motile (moving), and greater than 4% normal morphology (shape/form). If low, the test should be repeated as results can vary due to a range of factors. See Lifestyle factors and Male Infertility.

Under usual conditions with sexual intercourse during the fertile phase of the woman’s menstrual cycle, sperm quickly enter the cervical mucus and ascend the uterus and fallopian tubes to the site of fertilisation in the outer third of the tube. Sperm require motility (swimming ability) to get into cervical mucus and to penetrate the outer coverings of the ovum.

There are a number of causes of male infertility associated with impaired sperm production and/or delivery. Sperm are produced by repeated division of cells in small coiled tubules within the testes, at a rate of approximately 100 million per day.Sperm production is a lengthy process; from the beginning of sperm production to the appearance of mature sperm in the semen takes about 3 months. The sperm spend 2 to 10 days passing through the epididymis, during which time they mature and become capable of swimming and fertilising eggs.

The average semen volume for healthy men ejaculating every two days is 3 ml and the sperm concentration, 85 million per ml. The volume of liquid from the testes and epididymides is less than 5% of the total semen volume. About 65% of the semen volume comes from the seminal vesicles and 25% from the prostate gland. During ejaculation the sperm and the prostatic fluid come out first and the seminal vesicle fluid follows. The seminal vesicle fluid coagulates giving the semen a lumpy gel-like appearance. After 10 minutes or so liquefaction occurs and the gel disappears.

The function of the testes is dependent upon hormones from the pituitary gland—follicle stimulating hormone (FSH) and luteinizing hormone (LH). The levels of these hormones rise during the early stages of puberty and stimulates testicular development. LH controls production of the male sex hormone testosterone which in turn is responsible for development of the genitals, beard and body hair, prostate and seminal vesicles, and also bone and muscle development and other aspects of the masculine physique. If LH and FSH are deficient the testes do not develop properly. In contrast, if the testes are damaged directly, the levels of these hormones in the blood rise. Thus the measurement of LH, FSH and testosterone in blood helps in the diagnosis of testicular disorders.

Read more

Male sterility

Most sterile men have no sperm in their semen (azoospermia) because the tubules in the testes which produce sperm did not develop or have been irreversibly damaged.

No sperm in the semen may be associated with failure of the testes to descend into the scrotum during childhood, inflammation of the testes or treatment with certain drugs. In some sterile men, sperm are produced in normal numbers, but they are either not motile (do not swim) or lack structures necessary for penetration and fertilisation of eggs which may be detected by microscope examination of the shape of the sperm and reported as abnormal morphology. Some men with failure of sperm production do not produce normal amounts of the male sex hormone testosterone and their general health and sexual performance is improved by treatment with testosterone.

Read more

The possibilities for couples in this category to have a family include ICSI (with or without testicular/epididymal aspiration of sperm- see Treatments>Surgical Sperm Collection on this website) or use of donor sperm.

Treatable conditions

Hormone Deficiencies

Deficiency of two hormones from the pituitary gland, LH and FSH, can be treated by injection or hormone preparations. Usually the testes increase in size and testosterone is produced in normal amounts and sperm appears in the semen after several months of treatment. At least 50% of the partners of such men conceive during treatment, but the treatment needs to be repeated for each pregnancy unless adequate sperm can be collected and stored (frozen) during the first course for later artificial insemination. This condition affects less than 1% of infertile men.

Sperm antibodies

Antibodies are normally produced in response to introduction of foreign material (such as bacteria) into the body and are protective.

However, antibodies to sperm develop in many men after vasectomy and may interfere with fertility after vasectomy reversal operations. Antibodies are also found in about 5% of other infertile men, some of whom have had injuries to the reproductive organs which may have caused immunization against sperm, but most have no obvious reasons why the sperm antibodies should appear.

The sperm antibodies are often present in the blood as well as in the semen and coating the sperm. The antibodies affect fertility at several levels—interfering with sperm output and reducing sperm numbers in the semen, causing clumping together of sperm and interfering with the sperm motility, preventing sperm from swimming through the liquid in the womb (cervical mucus) and interfering with sperm fertilising the egg. Men with sperm antibodies and sperm which will not penetrate normal fertile cervical mucus are severely infertile and pregnancies rarely occur without treatment. Treatment with cortisone-like drugs may reduce the antibody levels, increase sperm motility and mucus penetration and also increase fertility. However this treatment has high risks of severe side effects and is not usually recommended.

Read more

Obstructions

Approximately 5% of men have blockages in the epididymis because of failure of development, production of thick secretions in association with chronic lung disease (bronchiectasis or cystic fibrosis) or following inflammation (especially gonorrhoea).

Some patients can be treated by bypass surgery joining the tube in the epididymis above the blockage to the vas. Sperm appear in the semen of up to 50% of men after this surgery, but less (10-20%) produce pregnancies because the sperm are immature having bypassed the epididymis in which maturation usually occurs. MESA (microepidydimal sperm aspiration) is the method preferred by many fertility clinics. This procedure involves microsurgery to the testes. For further information see this website under Treatment of infertility>Surgical Sperm Collection

Read more

Disorders of sexual performance

In a small number of couples (less than 1%) the only reason for the infertility is a failure of sexual intercourse due to inadequate penile erection (impotence), failure of ejaculation or retrograde ejaculation where the tube between the bladder and penis does not close during ejaculation so that semen passes into the bladder.

Occasionally, these conditions respond to treatment, but most often they do not. However, if adequate sperm can be obtained from these men, artificial insemination of the female partner is often successful in producing a pregnancy. An IVF cycle (possibly using ICSI microinjection of the sperm into the egg) may be required depending on the amount of sperm obtained.

Read more

Other Disorders of Sperm Production or Function

Over three quarters of men investigated for infertility have sperm present in the semen, but in lower numbers than normal—oligospermia (38%), or in adequate numbers but with reduced motility (33%). Approximately 5% have normal semen tests.

Some men in this group have a reason for the poor sperm test—incorrect sperm collection techniques such as too long or too short an interval since previous ejaculation, recent illness, heavy alcohol consumption, obesity, frequent hot baths or saunas, or treatment with certain drugs. Removing the cause results in improvement within a few months, remembering that sperm require 3 months to form.

Dilated veins in the scrotum (varicoceles) are present in many men (20-40%). Also common are previous testicular injuries, minor hormone disorders, surgery for torsion (twisting) or failure of descent of testes, inflammation of the genital tract (testes, epididymis, prostate), and sexually transmitted diseases. These conditions may cause or contribute to the poor semen quality, but it has not been shown that treatments always improve the semen test results and increase fertility.

Tobacco smoking, moderate alcohol intake, diet, exercise, mental stress and anxiety, environmental toxins and exposure to heat as a result of tight underpants, are thought to have an impact in causing poor sperm quality however the effects have not been proven.

Effectiveness of treatment

Many treatments have been tried in this group of men in the past including operations for varicoceles, antibiotic treatment for low-grade infections, drugs which alter hormone levels, artificial insemination with partner’s semen, IVF and ICSI. Fertilizing eggs by microinjecting a single sperm into the egg (ICSI) has become an accepted form of treatment and is especially useful for semen samples which have very low numbers of sperm and low motility of sperm.

There are problems in assessing the success of treatment. First, semen test results are variable from day to day within the one man so that an apparent increase in sperm number for example, from 3 to 20 million per ml, may result from a chance fluctuation that has nothing to do with the treatment the man happens to be taking at the time. Second, this group of patients are not sterile; pregnancies occur, but at a lower rate than normal, so that if a pregnancy occurs during treatment, it also may not necessarily be due to the treatment. To demonstrate that a treatment is effective under these circumstances it is necessary to show that semen tests improve more often and pregnancy rates are higher than with similar men given no treatment.

Outlook for fertility

When couples in which the man has poor semen tests are followed over the years, a proportion conceive naturally, whether or not they have been treated.

Factors which were related to the pregnancy rates were as follows:

1) Sperm number—the more, the higher the pregnancy rate.

2) Length of time the couple had been trying to produce a pregnancy—the longer the period of infertility, the lower the pregnancy rate.

3) Age of partners—the older, the lower the pregnancy rate.

4) Previous pregnancy in the couple (same woman and man)—compared with no previous pregnancies. This was associated with a higher pregnancy rate.

By combining these factors future pregnancy rates can be predicted so that couples can be advised about their chances. This should allow them to make plans as to how long they would like to try themselves before changing to other alternatives such as IVF or ICSI. IVF has a much better chance of conceiving than with normal intercourse. ICSI (Intracytoplasmic Sperm Injection) offers an even better chance with very poor quality sperm. Artificial insemination or IVF with donor semen may be considered if fertilisation with the partner’s sperm is repeatedly unsuccessful.

In the general community, pregnancy rates are about 20% per month. That is of women trying to conceive, about one in five is successful in the first month, one in five of the remainder successful in the second month, one in five of the remainder successful in the third month, etc. However, the rate drops with time, so that approximately 40% of couples conceive within four to five months and 60% by one year.

In a large group of infertile men seen in Melbourne who had at least some motile sperm in their semen and whose partners were not sterile, the pregnancy rate was approximately 4% per month for the first few months. Overall, 30% of the female partners conceived in one year and 45% by two years.

Sperm Storage / Cryopreservation

Semen can be frozen and stored long-term for future use at most fertility centres. Thawed sperm can be used in artificial insemination or IVF treatments.
Sperm cryopreservation may be useful in the following circumstances:

prior to starting chemotherapy or radiation treatment for cancer (men and boys who have started puberty)
prior to a vasectomy
prior to taking medications that may cause infertility

Emotional reactions to Infertility

People have many different emotional reactions when their fertility is questioned. Denial of the problem, anger with the partner and medical attendants, resentfulness about having to participate in infertility tests, feelings of depression, loss of self-esteem, relationship disharmony, and temporary sexual problems, such as loss of interest and poor erections are common. These feelings are normal and understandable initial psychological aspects of grief. These problems decrease with time as a realistic perspective of the significance of the infertility is achieved. Some couples may be helped to adjust by discussion with their doctor or a counsellor. (See Counselling> Emotional Reactions to Infertility on this website for further discussion.)

The Andrology Australia website: www.andrologyaustralia.org has booklets and information sheets and brochures that provide a more comprehensive overview of male infertility.