Definition of Infertility
Inability of a couple to produce a pregnancy following a minimum of 1 year of trying without contraceptive precautions
The doctor will normally wish to review both partners initially although 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 website.
- 1 in 7 couples are unable to have a child.
- In 60% of these couples, the problem lies wholly or partly with the male partner
- Urological investigation may reveal a reversible underlying cause for male-factor subfertility. Full assessment by a urologist is recommended
- In many cases, no underlying cause is found, in which case assisted conception may offer the best chance of pregnancy
- Infertile couples are often assessed in gynecology departments and, therefore, subfertile men may wish to seek a urology assessment from a urologist specializing in andrology
Causes of male infertility
- Cause remains unexplained in 75% of infertile men, (this is termed "idiopathic infertility"). It may, however, still be possible for couples to conceive naturally, provided some sperms are present
- Absence or blockage of the tubes that carry sperms (vas deferens) is uncommon but may be treatable. The best-known cause of blockage is, of course, vasectomy which, like scarring due to infection, may be treatable surgically by reconstruction or bypass.
- Varicocele is seen in 20% of infertile men (and in 10% of the normal male population). Surgical treatment has little effect on natural pregnancy rates and is usually reserved for those with symptoms (aching discomfort) or to improve semen quality in couples undergoing assisted conception.
- Childhood surgery for undescended testicles or hernias, may be associated with reduced fertility in later life.
- Genetic causes 10% of infertile men have an underlying genetic problem and typically have very poor sperm counts or no sperms at all. In men with no sperms, hormone measurements help to determine whether this is genetic (primary testicular failure) or associated with obstruction; the former is untreatable whilst the latter can usually be treated successfully.
Other factors known to have harmful effects on sperms are: -
- excess alcohol consumption
- tight-fitting clothing
- prolonged sitting
- Some prescribed drugs (e.g. steroids)
- Some recreational drugs (e.g. cannabis, cocaine)
- A full history to enquire about lifestyle factors (e.g. job, work pressures, smoking habits, alcohol intake and drug consumption), past medical history especially if previous testicular infections or operations.
- A physical examination paying particular attention to the development of male sexual characteristics and the genitals The usual tests performed are:
- Sperm counts- 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
- Hormone measurements - blood levels of testosterone, prolactin, FSH (follicle-stimulating hormone), LH (luteinizing hormone) and thyroid hormones will normally be measured. Anti-sperm antibodies are not routinely measured during assessment of male infertility
- Other specific tests may include chromosomal studies, ultrasound of the scrotum and, possibly, the prostate area
Treatments Options for Male Infertility
Many couples produce a pregnancy whilst undergoing investigations or treatment for infertility (85% within the first year). For those who do not, a number of treatments are available
- Wear loose-fitting trousers and boxer shorts
- Stop smoking
- Reduce drug consumption – prescription and recreational
- Adopt a "healthy" lifestyle
- Steroids may be useful for men found to have anti-sperm antibodies after vasectomy reversal
- Surgical bypass for obstruction caused by infection / surgical injury.
- Sperm retrieval with assisted conception
- Vasectomy reversal - 75-90% successful in restoring sperm production. Unfortunately, restoration of sperms does not guarantee a pregnancy if sperm count or quality is low
- 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 fertilization (IVF) a single sperm is injected directly into an egg to fertilize it. This is useful if you have a very low sperm count when it may be necessary to extract useful sperms directly from the testicle or from the epididymis (sperm-carrying mechanism). The procedure carries risks for the female partner and has a pregnancy rate of 20-30% per cycle
- Donor insemination (DI) Donor semen is carefully screened for infections and a donor is usually selected to have similar attributes to the patient. This is the only viable option if the patient has no sperms at all and he does not have obstruction, which can be relieved surgically.
- Adoption for those who are unfortunate and do not to have any success with other treatments