10. Male Infertility

The normal male fertility process involves being able to make enough mature sperm of the right size and shape and get those sperm to reach and fertilise the egg, thereby achieving pregnancy. In general, men reach their peak fertility levels at about the age of 25 and fertility levels start to decline after the age of 40. However, many men can remain fertile right up until the age of 80 and beyond.

Male fertility requires many complex biological conditions to be met, including:

The issue of male infertility is a sensitive one for men and their partners. The psychological impact of infertility upon individuals or couples affected by it may be significant. It can result in distress, anxiety, relationship difficulties and possibly depression.

Infertility for a couple is commonly defined as the failure to achieve pregnancy after regular unprotected sex for at least a year. Some couples have never been able to conceive – this is known as primary infertility. Secondary infertility describes couples who have previously been pregnant at least once, but have not been able to achieve another pregnancy.

Male infertility is common. About one in six couples attempting their first pregnancy meet with disappointment. The cause of infertility tends to follow the rule of thirds. Approximately, the problem is with the male one-third of the time, with the female one-third of the time and with both one-third of the time. Therefore the male is at least partly responsible in about 50 per cent of all cases of infertile couples.

The production of sperm is known medically as spermatogenesis. This process occurs in the ducts and tubes of the testes. Cell division there produces mature sperm cells known as spermatozoa. These sperm cells contain one half of a man’s genetic code. The process of sperm development takes about eighty days to produce a mature sperm from start to finish. Therefore any illness or infection a man may have had at the start of the cycle may still affect sperm production two or three months later, even if he is well at the time of examination.

Sperm are produced better and survive longer in a low-temperature environment. This is the main reason why the testes are outside the body. For this reason you should be cautious about wearing any clothing, such as very tight-fitting underpants or trousers, or activities – such as excessive use of saunas or steam-rooms – that can increase the temperature of sperm. Sitting on a bicycle saddle can also have an adverse effect on sperm production, particularly if you are wearing tight-fitting shorts.

Causes of infertility include a wide range of physical as well as emotional factors. Approximately one-third to a half of all infertility is due to a ‘male’ factor. A ‘female’ factor – scarring from sexually transmitted infection or endometriosis, ovulation dysfunction, poor nutrition, hormone imbalance, ovarian cysts, pelvic infection, tumour, or transport system abnormality from the cervix through the fallopian tubes is responsible for 40–50 per cent of infertility in couples. The remaining 10–30 per cent of infertility cases may be caused by contributing factors from both partners, or no cause may be identified.

Increased risk for infertility can be associated with the following conditions and factors in men:

This affects nearly 1 per cent of males. Our testes start to develop high up in our belly area and have usually come down, or ‘descended’, by the time we are born. However, if they fail to descend they are known as undescended testes. This increases the lifelong risk of testicular cancer. For this reason undescended testes are always ‘brought down’ surgically into the scrotal sac if they have not descended themselves by the age of two.

However, despite this, men with a history of undescended testes still have reduced fertility, even when it is one-sided. This is because it appears that there is reduced ability to produce sperm levels in both the normally descended and the undescended testis.

This results from failure of the bladder neck to close during ejaculation so that sperm goes up into the bladder instead of out through the penis. Clues to this condition may include cloudy urine after ejaculation or reduced or even ‘dry’ ejaculation. It may result from bladder surgery or a disease that affects the nervous system.

Mumps infection can cause swelling and inflammation of the testicles. This is known as orchitis and can have a long-term effect on sperm levels and fertility. Mumps orchitis is usually one-sided but sometimes it can affect both testicles. A complication of this condition is that the testicles can shrink and waste away. Other infections that can affect fertility include sexually transmitted infections, such as chlamydia, and infections like E. coli in the semen, which can affect sperm motility (movement). General infections of the body can also temporarily affect sperm production and lead to reduced fertility.

Steroids, which are used to treat conditions such as arthritis and asthma, can lead to an increased steroid level in the blood, which can reduce the ability of the body to make sperm. This is usually reversible on reducing or stopping the steroid. Some medical conditions such as Cushing’s disease can result in the body making too much steroid.

Anabolic steroids are sometimes taken illegally by athletes and body-builders in the form of supplements. These are highly dangerous for long-term health. Not only will they affect fertility but they can also, amongst other things, cause heart attacks and liver cancer.

Other medications that can sometimes affect fertility include anti-cancer drugs like chemotherapy, some antifungal drugs, cimetidine (used to treat stomach ulcers), spironolactone (used to treat heart failure) and medications to treat high blood pressure.

Many illegal drugs affect fertility levels in many different ways. These include the usual suspects of cigarettes and alcohol, as well as marijuana and others. This can be a reversible process, which is yet another good reason to adopt a healthy lifestyle.

Chronic medical conditions can be associated with infertility. These include diabetes, haemochromatosis, kidney disease, liver disease, high fevers, infections, cystic fibrosis and sickle-cell anaemia.

Testicular injury can impair the ability of the testes to work properly. Examples would include trauma to the scrotal area and testicular torsion (discussed in Chapter 12).

Lifestyle factors, including smoking cigarettes, poor diet, excess alcohol, obesity and lack of exercise, can affect fertility levels. Wearing tight trousers or underpants can increase the temperature of the testes and result in reduced fertility. Environmental toxins or pollutants can also potentially be a factor in male infertility.

Testosterone plays an important part in sperm development and a lack of testosterone in the system can lead to a low sperm count. Disorders of the pituitary gland in the brain can also cause testosterone deficiency. These disorders include an over- or under-active thyroid, haemochromatosis and Cushing’s disease, as well as tumours of the pituitary gland.

Some genetic or chromosomal defects can affect the development of the genitals. While most men have one X (female) and one Y (male) chromosome, certain disorders add an extra chromosome to our genetic make-up, with many different consequences.

The most common of these disorders is known as Klinefelter’s syndrome, which affects about one in every 500 males. In this condition, there is an extra X chromosome. Characteristically these men have abnormal breast enlargement (known as gynaecomastia), smaller-than-normal testes, sparse facial and body hair, and no sperm production. There is also delayed onset of other secondary sexual characteristics such as deepening of the voice and development of the genitals.

Another chromosomal disorder is known as XYY syndrome, where-by the affected man has an extra Y chromosome. This again affects about one in every 500 men. These men tend to be very tall, some have had severe acne and some have a tendency to antisocial behaviour. While some of these men have no sperm, some produce normal amounts of sperm.

The extremely rare vanishing testes syndrome affects about one in every 20,000 males; these unfortunate men are born without testicles.

Kallman’s syndrome is another rare cause of infertility. It occurs in only one in every ten thousand men. It is often associated with loss of smell, deafness, cleft lip and palate, kidney problems and colour blindness as well as infertility.

Male infertility may also be caused by sexual dysfunctions, such as premature ejaculation, reduced libido and erectile dysfunction. This may be due to low testosterone levels resulting from an underlying condition. These are all potentially reversible causes of infertility.

Some men have infertility for which there is no known cause at present. In addition, some known causes of infertility do not have any treatments.

Research is ongoing into this important men’s health area. As knowledge and understanding increases, more causes and, hopefully, treatments will be discovered.

Talking to your doctor is a good place to start. He or she can check your medical history and any risk factors for infertility. Your doctor can discuss your ideas, concerns and expectations. A physical examination to check your testes and to see if you have a varicocele in your scrotum is important. The next step usually would be to arrange a sperm test.

Semen analysis is a test used to evaluate male fertility. This test, also called a sperm count, measures the amount and quality of seminal fluid or ejaculate. Seminal fluid contains male reproductive cells (semen or sperm) and normally is expelled through the penis during ejaculation (sexual climax; orgasm).

This is a highly accurate test. However, it is worth noting that a normal result does not guarantee fertility, as fertility is naturally a couple-related phenomenon. However, a normal result is certainly reassuring that your reproductive track is in reasonably good order.

Prior to semen analysis, ejaculation should be avoided for two to three days. The specimen is best analysed within an hour or two of collection for accurate results. It is recommended that up to three separate samples are taken over a six to eight week period to ensure good quality testing and to eliminate lab errors.

Normally, seminal fluid is clear to milky-white in colour, thick and sticky (viscous) in consistency, has a pH (acidity) level between 7.8 and 8.0, and contains few or no white blood cells (leucocytes). A healthy semen sample should contain at least twenty million sperm per ml of semen; have at least 15 per cent normally shaped sperm; and have more than 50 per cent of sperm with forward movement, or 25 per cent with rapid movement within 1 hour of ejaculation. Good sperm motility is the single most important measure of semen quality and can compensate for men with low sperm counts.

Although semen analysis can often suggest male infertility, the results may not identify the cause of the condition. Additionally, some men with low sperm counts are able to reproduce (i.e. are fertile). In many cases, abnormal semen analysis results require additional testing.

Other tests that may be carried out to look at male fertility include analysis of urine to rule out infection. A full screen may be indicated to check for sexually transmitted infections; this would include penile swabs. Blood tests may look at your thyroid, liver and kidney functions, and check your iron and white cell count, as well as blood sugar levels to rule out diabetes. Hormone tests may include serum testosterone and others such as LH and FSH (hormones made by the pituitary gland in the brain: LH stimulates the testes to produce testosterone and FSH stimulates the production of sperm).

Your weight, body mass index and abdominal circumference can be checked to rule out obesity. More specialised tests may include analysis of your chromosomes and checking the immune system, particularly looking for anti-sperm antibodies that may target and attack your own sperm.

There are a variety of ways to treat infertility, which ultimately depend on the underlying cause. It may involve simple education and counselling, medicines to treat infections, surgery or, in some cases, highly specialised procedures such as in vitro fertilisation.

Lifestyle changes may also help alleviate infertility, such as reducing stress, dietary modification, stopping the use of drugs or alcohol, or reducing the temperature around the testes.

Other specialised treatment will depend on the underlying cause. Chronic medical illnesses, such as cirrhosis, kidney failure, sickle-cell disease or haemochromatosis, may respond to proper treatment of the underlying condition. Male infertility can be treated successfully in many cases.

Drug therapy for male infertility includes medications to improve sperm production, treat hormonal dysfunction, cure infections that compromise sperm, and fight anti-sperm antibodies. Hormone therapy may be effective in cases of testosterone deficiency. Antibiotics may be used to treat infections of the urinary tract, testes and prostate, as well as STIs that can impair fertility.

These are specialised procedures, such as artificial insemination, whereby the woman is injected with carefully prepared sperm from the husband, partner or a donor.

IVF or in vitro fertilisation was originally devised as a means of helping infertile women who had blocked tubes. However, this technique has now been expanded to help men with fertility issues. Human ova can be fertilised using this technique for some men with low sperm counts.

GIFT (gamete intrafallopian transfer) is a technique in which eggs or ova are retrieved in a manner similar to IVF but here the sperm are mixed together with the egg and both are injected directly into the fallopian tube for fertilisation to occur. This can be a successful treatment option for some men who are infertile.

It is generally accepted that the sperm count of men has been declining in recent years. There may be many varied reasons for this. Breakdown products of the female contraceptive pill in recycled drinking water have been suggested as a possible factor. Other environmental, dietary and lifestyle changes may interfere with men’s sperm production. Therefore improving your diet and making healthy lifestyle choices can help your own fertility and reproductive health.

If you smoke, stop. Amongst many other adverse health effects, cigarette smoke lowers both sperm count and its ability to move.

Consuming excess amounts of alcohol reduces both the quantity and quality of sperm, so keep within recommended limits of no more than 21 units per week. Recreational drugs such as cannabis can also be associated with sluggish and unusually shaped sperm.

Being physically active and fit is also good for your fertility. Aim for at least 30 minutes of exercise a day and more if possible.

Carrying excess body fat can potentially affect your hormones so keep your belly in shape, in other words less than 37 inches in girth. Generally your body mass index should be less than 25 unless you are very muscular.

Because infertility is sometimes caused by sexually transmitted infections, practising safer sex behaviours may minimise the risk of future infertility. Gonorrhoea and chlamydia are the two most frequent causes of STI-related infertility. STIs are often asymptomatic so using a condom is essential.

Mumps immunisation has been well demonstrated to prevent mumps and its male complication, orchitis. Immunisation with the MMR vaccine prevents mumps-related sterility.

A healthy diet is essential for optimal health and the reproductive system is no exception. In order for your body to function properly, a well-balanced diet, including plenty of vitamins and minerals, is necessary. Nutritional deficiencies can impair hormone function, inhibit sperm production and contribute to the production of abnormal sperm.

The general rules are to eat a natural diet with foods that focus on fresh fruit and vegetables, wholegrains, fish, poultry, beans, legumes, nuts and seeds. Eat plenty of seeds, particularly pumpkin seeds, which are naturally high in zinc and essential fatty acids, both of which are vital to the healthy functioning of the male reproductive system. Foods that are rich in zinc, such as wholegrain cereals and selenium, which is found in cereals grown in selenium-rich soil as well as in Brazil nuts and mushrooms, are also important. Drink plenty of water each day.

Eliminate processed foods, junk food and sugars, and avoid stodgy carbohydrates such as breads and cakes made with white flour. Avoid hydrogenated oils (trans-fats) and minimise your saturated fat intake; use extra virgin olive oil instead. Minimise your caffeine intake and keep your alcohol intake within safe limits.

The following supplements have been suggested to be good for the male reproductive tract. Make sure you do not exceed the daily recommended limits. Remember it is always preferable to get vitamins and minerals naturally through dietary sources rather than taking them in pill form. A multivitamin is not a substitute for a bad diet. With those provisos in mind, the following supplements may help:

Herbal remedies have been used to treat male fertility. It is important to let your doctor know if you are taking any over-the-counter supplements, including herbs, as there may be potential side effects and also potential interactions with prescribed medication. The following herbs are sometimes taken by men to help their fertility:

As couples nowadays often spend time focusing on contraception and avoiding unplanned pregnancy, there can be an assumption that pregnancy should follow as soon as a couple start ‘trying’. Nothing could be further from the truth. Indeed, we generally only recommend tests or investigations if a couple have been trying for a year with no results. It is important for the couple to recognise and discuss the emotional impact that infertility has on them as individuals and as a couple, and to seek medical help and advice from their doctor. For a man there can be the added self-esteem issues of not feeling like a ‘real man’. Professional counselling can be invaluable in helping to deal with these issues.

A cause can be determined for the majority of infertile couples and appropriate therapy can help many couples achieve their desired outcome.

Male fertility is a complex process and can a sensitive issue for Irish men and their partners.
Male infertility is a common cause of the infertility experienced by up to one in every six couples.
Male infertility can be caused by many different factors, including lifestyle, hormonal and genetic factors, and infection.
In many cases male fertility problems can be treated.
A healthy lifestyle can help with your fertility.