What is male infertility?

As with female infertility, the same applies to the male. There are no obvious symptoms indicating infertility. The main symptom of infertility is struggling to fall pregnant after having unprotected intercourse for 12 months. With that said, however, there are some indirect symptoms that may be indicative of, or elude to, male infertility.

These symptoms include:

• Pain or swelling in the groin, penis or testes
• Physical trauma to the testes
• Sexual dysfunction
• Severe decrease in libido
• Any signs of chromosomal or hormonal abnormalities (these include factors such as decreased body hair and/or secondary sexual characteristic development)
• Abnormal growth on the testes
• Genital or testicular surgery as a child (e.g. undescended testis as a child)

There are several causes for fertility problems in males. These can include the following:

Semen analysis diagnoses: (WHO manual, 2010)

• Aspermia: no semen (no or retrograde ejaculation)
• Asthenozoospermia: percentage of progressively motile (PR) spermatozoa below the lower reference limit
• Asthenoteratozoospermia: percentages of both progressively motile (PR) and morphologically normal spermatozoa below the lower reference limits
• Azoospermia: no spermatozoa in the ejaculate
• Cryptozoospermia: spermatozoa absent from fresh preparations but observed in a centrifuged pellet
• Haemospermia (haematospermia): presence of red blood cells in the ejaculate
• Leukospermia (leukocytospermia, pyospermia):presence of white blood cells in the ejaculate above the threshold value
• Necrozoospermia: low percentage of live, and high percentage of immotile, spermatozoa in the ejaculate
• Normozoospermia: total number spermatozoa, and percentages of progressively motile (PR) and morphologically normal spermatozoa, equal to or above the lower reference limits
• Oligoasthenozoospermia: total number of spermatozoa, and percentage of progressively motile (PR) spermatozoa, below the lower reference limits
• Oligoasthenoteratozoospermia: total number of spermatozoa, and percentages of both progressively motile (PR) and morphologically normal spermatozoa, below the lower reference limits
• Oligoteratozoospermia: total number of spermatozoa, and percentage of morphologically normal spermatozoa, below the lower reference limits
• Oligozoospermia: total number of spermatozoa below the lower reference limit
• Teratozoospermia: percentage of morphologically normal spermatozoa below the lower reference limit

Obstructive Azoospermia
This is a condition where no sperm is present within the ejaculate, however sperm are found upon dissection of a testis biopsy sample. This concludes that the primary reason for there being no sperm within the ejaculate is that there is a blockage whereby the sperm fail to be released in the ejaculate. Testis biopsy sperm can only be used in an in vitro setting, only with ICSI (intra cytoplasmic sperm injection) (please link to ICSI page).

Non-obstructive azoospermia
This is a condition where no sperm are found in the ejaculate as well as upon dissection of a testis biopsy sample. This type of azoospermia usually eludes to an underlying condition that could have caused the failure of ones testes to produce (make) sperm. For these cases, making use of donor sperm is the only option.

Anejaculation
A condition whereby one is unable to ejaculate and therefore unable to release semen. This can be caused by a plethora of reasons such as: spinal cord injuries, diabetes, multiple sclerosis, abnormalities present at birth and other mental, emotional or unknown problems. Medication is usually the first prompt to resolving this problem. Other treatment options include rectal probe electroejaculation (RPE) (done under anaesthetic) and/or penile vibratory stimulation (less severe cases and non-invasive), or testis biopsy (done under anaesthetic).

Congenital disorders (condition present from birth)

• Congenital Adrenal Hyperplasia (CAH): CAH is a rare condition that involves the abnormal production of certain hormones and be treated with hormone replacement therapies.
• Klinefelter’s syndrome (KS): KS is one of the main causes of azoospermia, however, having azoospermia does not equal having KS. KS individuals present with an extra X-chromosome (47,XXY) and infertility is one of the main features of this disorder.
• Cryptorchidism: a condition in which one or both of the testes fail to descend from the abdomen into the scrotum. This disorder may have a negative effect on sperm production in men. A testis biopsy is recommended for these cases when there is no sperm in the ejaculate.
• Anorchia: a condition where a male is born without testicles.
• Sertoli cell-only syndrome (SCO): These patients are typically normal on physical examination as this condition presents with infertility without sexual abnormality. SCO is usually diagnosed by testis biopsy findings. Individuals with SCO can still achieve a pregnancy, however will need fertility treatment.
• Congenital bilateral absence of the vas deferens (CBAVD): occurs in males when the tubes that carry sperm out of the testes (vas deferens) fail to develop properly. Although the testes usually develop and function normally, sperm cannot be transported through the vas deferens to become part of semen. A testis biopsy may be used to harvest sperm from CBAVD affect individuals. Notably, CBAVD mostly occur in men that present with cystic fibrosis.

Hyperprolactinemia
This condition includes the overproduction of the hormone prolactin. This condition is often linked to erectile dysfunctions in men. Treatment of this depends on what the cause of the condition is. Certain medication can cause the onset of this condition, so in these cases ceasing the causative medication is strongly recommended. Another cause of this condition could be due to a growth in the pituitary gland, which can be removed via surgical interventions.

Immunologic Infertility
Immunologically caused infertility refers to the presence of anti-sperm antibodies (ASAB). This immunological obstacle, however, can be bypassed via the use of sperm preparation methods used in fertility treatments.

Reactive Oxygen Species (ROS)
It is normal for semen to contain levels of ROS to aid the fertilization of a sperm and egg, however, too many ROS can have detrimental effects on sperm parameters. ROS can be reduced by the administration of antioxidant supplements, however the recovery is not guaranteed.

Retrograde Ejaculation
Whereby the semen flows backwards into the bladder, instead of outwards forming the ejaculate. This is caused by many different factors and be relatively easily rectified by means of sperm preparation methods that assist in harvesting the sperm out of the urine.

Genital tract infections
Infections are not a common cause for male infertility, however it does occur. A genital tract infection is picked up during a semen analysis whereby the amount of white blood cells usually exceed the normal reference limit. Having a white blood cell count that exceeds the reference limit, does not however, always indicate an infection. Indicative cases are usually sent off for separate culture tests that are done on the same sample used during the semen analysis. Large amounts of white blood cells in a semen sample cause higher levels of reactive oxidative stress (ROS) within the sample, which could negatively affect semen parameters by possibly lowering chances of fertilization (DNA damage), causing possible blockage, and causing possible testicular shrinkage.  Infections can usually be treated by prescribing the appropriate antibiotics.

Varicocele
Varicoceles refer to the physical swelling and entangling of veins within the scrotum. Varicoceles can have a negative effect on sperm count and quality. Varicoceles can be surgically removed, however, the improvement of sperm parameters post-surgery do not always improve.

Lifestyle factors
Although most types of infertility aren’t preventable in men, these strategies may help:

• Avoid drug and tobacco use and drinking too much alcohol, which may contribute to male infertility.
• Avoid high temperatures found in hot tubs and hot baths, as they can temporarily affect sperm production and motility.
• Avoid exposure to industrial or environmental toxins, which can affect sperm production.
• Limit medications that may impact fertility, both prescription and non-prescription drugs.
• Exercise moderately. Regular exercise may improve sperm quality and increase the chances for achieving a pregnancy.

To determine a male’s fertility status is relatively easy and inexpensive. A semen analysis (sperm test) is a test that is performed on a male’s ejaculate. This test concludes a fertility-related diagnosis that relates to parameters of the semen sample.

A minimum of two separate semen analysis is recommended, with a preferred time frame of 4 weeks between tests, in order to get the most accurate results.

A more comprehensive work-up, along with the semen analysis results, includes a physical examination as well as an extensive medical history with or without blood-hormone tests done by our men’s fertility clinic.

An important factor to remember when using a semen analysis for fertility treatment is that a semen analysis doesn’t measure fertilization potential of sperm, but it does measure and gives insight into the possible underlying aetiologies of male-related fertility. If a semen analysis is abnormal, it is advised that the test be repeated at a fertility unit. These repeat tests will then be evaluated by an embryologist and a fertility specialist, who can then propose the appropriate treatment to achieve a pregnancy.

We understand that no man enjoys being subjected to these kinds of tests, and you might feel tempted to put them off! However, the sooner you’re aware of potential problems, the easier it becomes for our male fertility center to facilitate your path to becoming a father.

The staff at our male fertility clinic are incredibly professional, and we guarantee to make the process as straightforward and comfortable as possible.

Once we’ve ascertained that your trouble conceiving does stem from a male factor (or a combination of factors between you and your partner), there are several Assisted Reproductive Techniques (ARTs) we can try at our male fertility clinic:

Less severe cases
In cases where retrograde ejaculation, erectile dysfunction or low sperm count is an issue, Intrauterine Insemination (IUI) may be sufficient. This is a relatively simple procedure in which your sperm is transferred directly to your partner’s uterus, overcoming any potential sperm motility issues. Essentially, this gives your sperm a head start on their way to fertilising the egg!

In cases of very low sperm count, IVF (where fertilisation happens in the lab rather than in your partner’s uterus) may also be successful.

More severe male infertility
Intra Cytoplasmic Sperm Injection, or ICSI, and
Intracytoplasmic Morphologically-selected Sperm Injection, or IMSI

Both of these procedures will be performed at our male fertility clinic in conjunction with IVF (In Vitro Fertilisation) for your female partner or surrogate, wherein in the resulting embryo is transferred into the uterus for the best chance of pregnancy.

ICSI
The development of Intracytoplasmic Sperm Injection has revolutionised the field of ARTs, allowing men who would otherwise be considered unable to ever have children of their own to become fathers. It consists of using a tiny needle to inject a single sperm directly into the egg cell.

If required, sperm can even be surgically extracted from the testes for this procedure, which can be helpful in cases where the reproductive tract has been damaged or obstructed through an accident or from birth.

ICSI may also be employed when couples have had several unsuccessful rounds of IVF.

IMSI
Intracytoplasmic Morphological Sperm Injection takes ICSI to an even more advanced level, as an extremely strong microscope is used to examine the individual sperm cells in great detail. This allows our experienced embryologists to study and select the most viable sperm.

IMSI can be particularly helpful in cases of abnormal sperm shape (Severe Teratozoospermia), or where standard ICSI has unfortunately failed.

In both IMSI and ICSI procedures, the embryo created is incubated in our incredible EmbryoScope at our male fertility clinic for the greatest possible chance of a successful pregnancy.

In a small number of cases, there is no suitable surgery or treatment for male infertility. Even then, it’s not the end of the line! You and your partner can still become parents through the services of a sperm donor.

Wijnland’s men’s fertility clinic, in conjunction with our sperm donor bank, can assist men who aren’t able to father their own biological children for whatever reason.

We also provide specialist counselling for infertile men, as your diagnosis can understandably be accompanied by some complex emotions.

While there is less ‘time pressure’ on men who wish to start their family later in life, there are still a number of reasons you might want to consider freezing your sperm or testis biopsy tissue. These include:

• Keeping the option to have children later open before undergoing a vasectomy
• Prior to undergoing treatment for cancer or other serious diseases
• If there are indications your female partner may need several rounds of IVF
• Immediately after an accident which could impair your fertility
• If there is a history of low or decreasing sperm count in your family
• Simply not having found the right partner to start a family with yet

When
Ideally, you should freeze sperm before you turn 40.

How
Our embryologists use a specialised cryoprotectant to help preserve sperm cells before freezing, so that the majority will survive and remain viable indefinitely.

There are many behavioural and environmental factors which can have a direct or indirect impact on how your body produces sperm. Whether you’re trying to have a baby with your partner naturally or are currently undergoing male fertility treatment, you should adopt the following healthy lifestyle habits:

• Avoid drug and tobacco use and drinking too much alcohol, which may contribute to male infertility.
• Avoid high temperatures found in hot tubs and hot baths, as they can temporarily affect sperm production and motility.
• Avoid exposure to industrial or environmental toxins, which can affect sperm production.
• Limit medications that may impact fertility, both prescription and non-prescription drugs.
• Exercise moderately. Regular exercise may improve sperm quality and increase the chances for achieving a pregnancy. However, avoid excessive exercise.
• Avoid wearing very tight underwear for prolonged periods of time
• Cut back on caffeine consumption. (Two cups of coffee a day is fine)
• Avoid steroids used in body building. These compounds disrupt hormone production, and can actually stop your body producing sperm.
• Eat more antioxidant-rich foods like fresh fruit and vegetables. Not only can this assist in conditions like high levels of ROS (Reactive Oxygen Species) in semen, but will improve your overall health too!

Is infertility just a man’s problem?
No, in short, it is not. Couples struggling to fall pregnant may experience female factor-, male factor- and combination factor- infertility complications. Notably, male factor infertility makes up approximately 40% of South African couples struggling to conceive.

How can I get my sperm tested?
Sperm testing is quick, easily and relatively inexpensive. One can simply book an appointment for a semen analysis, arrive at the decided time and date, pass a sample and receive the results up to 3 working days later. Make a booking here.

Can I take any medication to improve my sperm?
There is a multivitamin available that has shown to have a positive effect on sperm parameters. With that said, improvements are not guaranteed. This supplement is inexpensive and available over the counter at most pharmacies. There are products available (e.g. Sperm-i-Prove).

We know that seeing a fertility doctor for men can feel awkward and embarrassing, but some momentary discomfort will be quickly forgotten once you’ve got all the facts and know exactly where you stand.

Take your first step towards fatherhood today, and get in touch!