Male Infertility

About 15 per cent of the couples in Singapore do not get pregnant successfully within 12 months of trying to have a child. Infertility in 50 per cent of these couples is due to the man who may have a medical disorder. Infertility can be attributed to either the man or woman, or both (Table 1 shows the incidence of the causes of infertility). Therefore, medical investigation for infertility should involve both from the beginning.

In nearly all cases of male infertility, the man will not observe any obvious signs and symptoms. Sexual intercourse, erection and ejaculation usually occur without any difficulty. The quantity and the appearance of the semen will appear normal to the naked eye. Medical tests will be needed to tell whether there is a problem in most cases.

These tests are recommended when the couple fails to conceive after regular, unprotected sexual intercourse for 2 years, in the absence of any known reproductive disorders.

Semen analysis

Semen analysis is the most essential part of diagnosing male infertility. It is a laboratory test of freshly ejaculated semen, of which the number, shape and movement are measured under a microscope. These tests should be done at specialised laboratories that use methods approved by the World Health Organisation.

Table 2 shows the parameters of normal semen. Based on results of the semen analysis, physical examination and other tests can help to determine the different types of male infertility.

Types of male infertility and treatment

• Treatable conditions
  One in eight infertile men has a treatable condition that can be overcome. After appropriate treatment, the couple can try to get pregnant naturally without any other assisted reproductive techniques.
  • Hormonal disorders.Deficiency of two hormones from the pituitary gland – luteinising hormone (LH) and follicular stimulating hormone (FSH) – can occur either congenitally or as a side effect of treatment of other disorders. Usually the patient will present with azoospermia (absence of sperm in ejaculation) and androgen deficiency. Treatment with synthetic LH and FSH readily kick-start the sperm producing function of the testes and spontaneous pregnancies are common after treatment.
  • Blockages of sperm transport as a result of disorder of development of the genital tract, a previous bad infection or a previous vasectomy. This occurs in about 6 per cent of men with infertility. A bypass surgery is sometimes possible depending on the level of obstruction. Otherwise, sperm can be readily obtained by surgery for use in in-vitro fertilisation (IVF) to achieve pregnancy.
  • Medical therapy such as anabolic steroids and cytotoxic therapy. Sperm production usually recovers with cessation of therapy or change of medication.
  • Sperm antibodies. The reason for the occurrence is usually not obvious. Sperm antibodies interfere with fertility by reducing sperm motility and severely affecting fertilisation. Pregnancy chances increase with therapy targeted at the sperm antibodies, however in some cases IVF is necessary for a good result.
  • Disorder of sexual function. This includes failure of sexual intercourse because of inadequate penile erection, failure of ejaculation, low sexual frequency and poor timing of sexual intercourse. Frequently, these conditions respond to treatment including proper counselling.
• Untreatable Sterility
  Men with untreatable sterility have azoospermia. The sperm producing cells in the testes either did not develop or have been irreversibly destroyed due to chromosomal or genetic disorders, inflammation of the testes or treatment with certain drugs. Couples facing this predicament can consider adoption and donor insemination.
• Untreatable Sub-fertility
  Most men investigated for infertility have untreatable sub-fertility. The sperm could be of lower number, reduced motility, and lower normal forms and shapes, which affect the fertilising ability and greatly reduce pregnancy rate.
  
  Spontaneous pregnancy then depends very much on the presence of any adverse factors of the female partner, such as age being above 35 and medical conditions like endometriosis. Early recourse to assisted reproduction is therefore the key to a good outcome in fertility treatment.
  
  At present, very little is known about the mechanisms by which sperm production and function are reduced. Many empirical treatments have not been proved to be effective, which include operations for varicocoele, nutritional supplements, traditional herbs and some drugs that alter hormone levels.
  
  There are problems in assessing the success of the treatment of infertile men:
  • Semen test results are very variable from day to day in the same man. An apparent improvement in the sperm quality may be a result of a chance fluctuation instead of any real effect from the treatment the man happens to be undergoing at the time.
  • These men are sub-fertile, not sterile. Pregnancies occur but at a lower rate than normal. Any pregnancies occurring during treatment may not necessarily be due to the treatment.

Intracytoplasmic sperm injection

Intracytoplasmic Sperm Injection (ICSI) is now the method of choice for treating severe sperm problems. This technique involves the injection of a selected sperm into the body of the egg cell to enable fertilisation.

It has revolutionised the treatment of male factor infertility; provided a live sperm can be found. The chances of failed fertilisation has been substantially reduced compared to when conventional IVF is used.

Male infertility deserves the same medical attention as female factor infertility. Assessment of an infertile couple should include the assessment of the male partner at the outset in view of the frequency of male contribution to this problem.

This will enable detection and early treatment of the many treatable conditions that can potentially negate the need for any sophisticated assisted reproduction technique. Furthermore, with the exclusion of these conditions, any unnecessary delay to assisted reproduction can be reduced, which may have a significant impact on the eventual success rate.