Male Infertility

Dr Alex Polyakov is a fertility specialist in Melbourne who has built a reputation as a doctor who combines his experience as a surgeon, obstetrician and gynaecologist with expertise in reproductive endocrinology. He specialises in women’s fertility and also provides male infertility treatment.

CONDITION

What is male infertility?

Male infertility is a common reproductive problem affecting men. When couples are not able to conceive after having unprotected sex across at least one year, it is important for both partners to be checked by their physician. One out of three infertility cases are linked to issues with the male partner.

What is the percentage of population affected by male infertility?

Male infertility accounts for 20-30% of failed pregnancies and contributes to 50% of overall cases. Specifically, in Australia the rate of male infertility is 9%.

How does male factor infertility affect you?

Male fertility is based on the production of healthy sperm and delivering them into a female partner’s reproductive tract. This basic function may be impaired by many structural and functional factors.

Which part of the body is affected?

The male reproductive system consists of the following:

  • Testicles: produce and store sperm
  • Epididymis and vas deferens: ducts that transport sperm from the testicles
  • Scrotum: sac of skin that contains the testes and epididymis outside the pelvic cavity in order to maintain the optimal temperature needed for sperm to survive
  • Accessory glands: seminal vesicles and prostate gland lubricate and form a part of the semen, which is the liquid part of the ejaculate that contains sperm
  • Urethra: carries sperm to the outside. It is also a part of the urinary system.
  • Penis: muscular organ containing the urethra, and responsible for the ejaculation of sperm into a woman’s uterus

Male fertility is dependent on the quantity and quality of sperm produced by the testis, and its transportation to the woman’s uterus through the penis.

What are the causes of male infertility?

Some of the common causes of male infertility may include:

  • Abnormal sperm size, shape, number and motility
  • Enlarged veins in the scrotum (varicocele)
  • Backward ejaculation of sperm (retrograde ejaculation)
  • Undescended testicles
  • Blockage of sperm-carrying ducts
  • Hormonal imbalance
  • Attack of sperm by the body’s own defence system
  • Chromosomal abnormalities
  • Certain diseases and infections such as kidney disease, testicular cancer and sexually transmitted diseases (STD)
  • Certain medications and prior surgeries
  • Problems with sexual intercourse
  • Excessive exposure to radiation, industrial chemicals and heavy metal
  • Excessive use of illegal drugs, alcohol and tobacco smoking
  • Stress and obesity
  • Cancer treatment

Who is at risk of male infertility?

You may be at a risk of male infertility if you have the following factors:

  • Smoking, excessive alcohol intake and drug abuse
  • Overweight
  • Exposure to toxins
  • Overheating or trauma to the testicles
  • Previous major abdominal or pelvic surgery, or vasectomy (permanent birth control)
  • Past or present infections
  • History of undescended testicles
  • Family history of fertility disorder
  • Certain medical conditions, including tumour and sickle cell disease
  • Certain medications
  • Undergoing medical treatments for cancer

What are the signs and symptoms of male infertility?

You may not show any symptoms of infertility until you try for a baby. When symptoms do show, they may include:

  • Changes in hair growth
  • Changes in sexual drive
  • Small, firm testicles that may be painful, or have a lump or swelling
  • Difficulty with erection and ejaculation

What are the related disorders that occur with male infertility?

Male infertility can be associated with many other conditions such as varicocele, tumour, undescended testicles, cystic fibrosis, Klinefelter’s syndrome, Kallmann’s syndrome, hypospadias, celiac disease and Kartagener’s syndrome.

What are the stages of the male infertility?

There are 2 types of male infertility:

  • Primary infertility: you are unable to support a pregnancy after a minimum of 1 year of having unprotected sex
  • Secondary infertility: you have been able to support a conception at least once, but are now unable

How is male infertility diagnosed?

To diagnose male infertility, your doctor will first conduct a general physical examination and medical history to understand your sexual habits, sexual development during puberty, chronic health problems, medications and surgeries that could lead to infertility. Additional tests that may be ordered include:

  • Semen analysis: This is a laboratory test carried out to assess the sperm count and quality from semen sample ejaculated into a sterile bottle.
    Semen analysis
  • Transrectal ultrasound of the prostate: It is an investigation carried out to evaluate the prostate gland and detect any obstruction in the ducts that transport the sperm.
  • Scrotal ultrasound: This is an imaging test to diagnose abnormalities of the scrotum or testicles.

    Scrotal ultrasound

  • Testicular biopsy: A small piece of tissue is removed from the testicle using a sterile needle and evaluated under a microscope.
  • Anti-sperm antibody tests: This test is performed to trace the antibodies that attack sperm.

TREATMENT

What are the consequences of not treating male infertility?

Left untreated, you may not be able to father a biological offspring.

What are the treatment options for male infertility?

Male infertility treatment depends upon the cause of infertility. Sometimes, a combination of treatment options will be suggested to overcome the underlying problem. These include:

  • Surgery: indicated in cases of obstruction of the sperm duct, to improve the sperm motion and backward ejaculation of sperm
  • Medications: drugs such as antibiotics prescribed to treat infections of the reproductive system
  • Male hormone replacement therapy: may be used to treat hormonal imbalances

What are the alternative treatments for male infertility?

Some of the alternative treatments for male infertility may include:

  • Counselling for sexual intercourse problems and relationships: This can help to boost fertility levels.
  • Lifestyle modifications may be suggested: This includes changing habits such as illegal drugs, smoking and alcohol intake, and using stress reduction techniques.

Am I candidate for male infertility surgery?

You may be a good candidate for male infertility surgery if you have:

  • Obstructive or nonobstructive azoospermia: lack of motile sperm in semen
  • Oligospermia: low sperm count
  • Varicocele: enlarged scrotum veins
  • Ejaculatory duct obstruction (EDO)
  • Problems with ejaculation
  • Want to reverse previous vasectomy

How is male infertility surgery performed?

Some of the common surgeries performed to treat male factor infertility are:

Varicocelectomy

Varicocelectomy is surgery to treat a varicocele, which is the most common cause of infertility in men. The enlarged veins in the scrotum are ligated, sparing the neighbouring arteries and lymph vessels.

Vasovasostomy

This involves the reversal of a vasectomy surgery, where the vas deferens are cut, clamped or sealed. During vasovasostomy your surgeon reconstructs the severed vas deferens with stiches, allowing the easy passage of sperm.

Transurethral Resection of Ejaculatory Ducts

This procedure involves opening the ejaculatory ducts and allowing the normal flow of ejaculate.

Electroejaculation

An electroejaculator or electric probe is introduced into the rectum and placed against the prostate gland. High frequency energy is used to stimulate ejaculation. The ejaculate is collected and used for IVF procedures.

Sperm retrieval techniques

Sperm can be retrieved from the testis or epididymis, by either inserting a needle through the skin or by making a small incision, and aspirating it.

What is assisted reproductive technology?

Assisted reproductive technology (ART) uses special methods to help infertility. Success rates vary and depend on many factors. ART can be expensive and time-consuming, but ART has made it possible for many to have children that otherwise could not have been conceived.

In vitro fertilisation (IVF)

In vitro fertilisation (IVF) is a procedure made famous with the 1978 birth of Louise Brown, the world’s first “test-tube baby.” IVF is often used when you have low sperm count. A drug is used to stimulate your partner’s ovaries to produce multiple eggs. Once mature, the eggs are removed and placed in a culture dish with your ejaculated or aspirated sperm for fertilisation. After about 40 hours, the eggs are examined to see if they are fertilised by the sperm and are dividing into cells. These embryos are then placed in the uterus, bypassing the fallopian tubes.

Some of the other techniques used in IVF include

  • Intracytoplasmic sperm injection: a single healthy sperm cell is directly injected into a mature egg
  • Assisted hatching: the outer covering of the embryo is removed to facilitate embryo implantation into the uterus

Am I a candidate for IVF?

You are a candidate for IVF if you have the following:

  • Low count of motile sperm (<5 million sperm)
  • Poor sperm structure
  • Failed IUI
  • Presence of antisperm antibodies

How do I prepare for IVF?

IVF involves a series of steps that are performed in accordance with your partner’s monthly menstrual cycle. It can be a long a laborious process for some, so it is best for you and your partner to be physically and mentally prepared for each stage of treatment as well as its outcomes.

How is IVF performed?

IVF involves many steps:

  • Ovulation induction: The doctor will administer fertility drugs to boost the production of your partner’s eggs. Transvaginal ultrasounds will help monitor the development of the eggs and blood tests are done to check hormone levels.
  • Egg retrieval: Follicular aspiration, a minor surgical procedure is performed to remove the eggs from the ovaries.
  • Sperm retrieval: On the same day as egg retrieval, you will be asked to provide your sperm through masturbation. The semen is washed.
  • Insemination and fertilisation: The eggs are mixed with the sperm in an environmentally controlled chamber to facilitate the process of insemination. The egg is fertilised a few hours after insemination.
  • Embryo culture: Division of the fertilised egg forms an embryo. The development of the embryo is monitored and within 5 days, a normal embryo has several actively dividing cells.
  • Embryo transfer: Embryo transfer is performed 3 to 5 days after egg retrieval and fertilisation. A thin tube containing one or more embryos is inserted into the vagina through the cervix and into the uterus. After transfer, if an embryo attaches to the womb lining, it results in pregnancy.

IVF Procedure

IVF Procedure

What is IUI?

Intrauterine insemination (IUI) is a procedure by which washed ejaculated sperm are placed in the uterus at the time of your partner’s ovulation.

When is IUI indicated to treat male infertility?

IUI is indicated in the following cases:

  • Low sperm count
  • Low motility
  • Presence of antisperm antibodies
  • Erectile dysfunction or inability to ejaculate

What is ICSI?

Intracytoplasmic sperm injection is a technique where a mature sperm is injected directly into an egg that is isolated from your partner.

When is ICSI indicated to treat male infertility?

ICSI is indicated in the below cases:

  • Few or dysfunctional sperm
  • Presence of antisperm antibodies
  • Ejaculated, surgically removed or cryopreserved sperm (from cancer patients)
  • Repeated failure with IVF

How is ICSI performed?

A mature sperm and egg are recovered from you and your partner through the same procedure followed for IVF. The sperm tail is crushed to prevent motility. It is picked up by a micropipette and injected directly into the egg. This is then allowed to fertilise and the fertilised embryo is inserted into your partner’s womb for implantation.

What are the advantages and disadvantages of IVF?

The primary advantage of IVF is the achievement of a successful pregnancy and healthy birth. It allows couples who are otherwise unable to get pregnant, to have a baby.

Other advantages include:

  • It is more successful than other assisted reproductive technology methods and these success rates have been increasing since its conception.
  • It can help identify fertilisation problems in those with unexplained infertility.
  • It can help screen for inherited diseases.

The disadvantages of IVF include:

  • You may have to undergo many cycles before you can have a healthy live birth.
  • It is associated with side effects such as ovarian hyper-stimulation syndrome (OHSS), multiple pregnancies and ectopic pregnancy.
  • IVF can cause a lot of stress and affect your emotional and psychological wellbeing.
  • It can be expensive.

Describe the stages of recovery and care plan after sperm retrieval for IVF-ICSI?

All ART procedures require the recovery of sperm. If sperm are retrieved through surgery, you will be able leave the hospital in a short while. You may experience pain or mild discomfort for a few days, for which you will be prescribed pain medication. You are advised to wear a scrotal support (jock strap) for about 48 hours to protect your scrotum and testes and reduce discomfort. Stitches are usually dissolvable and do not require removing. You will be able to resume your normal activities in about 4 to 5 days after surgery.

What are the outcomes of IVF?

IVF success is not only restricted to the attainment of pregnancy, but also the birth of a healthy child without any related complications. According to the Centers for Disease Control and Prevention (CDC), IVF results in an average of 29.4% pregnancy and 22.4% live births.

What are the potential complications of IVF?

As with most therapeutic procedures, IVF may be associated with certain risks and complications such as:

  • Multiple births
  • Premature and low birth weight baby
  • Ovarian hyper stimulation syndrome (OHSS): a condition of ovarian enlargement accompanied by fluid accumulation in the abdominal cavity
  • Miscarriage
  • Bleeding
  • Infection
  • Damage to testes
  • Possibility of ectopic or tubal pregnancy
  • Complications associated with surgery such as pain, tenderness, cloudy discharge, haematoma (swelling)
  • Birth defects and chromosomal abnormalities

What is the downtime of IVF?

IVF is performed in cycles, with each cycle lasting about 6-9 weeks. You are suggested about 3 months for you and your partner to physically and emotionally recover from a failed pregnancy before you start with the next cycle. Some would require 3 such cycles for a positive pregnancy. However, you will be able to continue with your normal activities after the procedure, with caution against vigorous activities.

What is the cost of IVF?

Any costs involved will be discussed with you prior to your surgery.

How can male infertility be prevented?

Male infertility cannot be prevented, but there are certain strategies that can help maintain the quality and quantity of sperm:

  • Avoid smoking, drugs and excessive alcohol intake.
  • Avoid high temperatures such as hot tubs and steam baths.
  • Avoid exposure to environmental and industrial toxins.
  • Discuss with your doctor on the use of certain medications that may affect your fertility.
  • Exercise regularly in moderation.
  • Consider ways of protecting your fertility from cancer treatment.

What is the current research regarding male infertility?

Extensive research is being done to find better treatment options for male infertility. Some of the recent studies are listed below:

  • Min KB, Min JY. Exposure to environmental noise and risk for male infertility: A 2population-based cohort study. Environ Pollut. 2017 Apr 12;226:118-124.
  • Halder A, Kumar P, Jain M, Kalsi AK. Genomics: Tool to predict and prevent male infertility. Front Biosci (Schol Ed). 2017 Jun 1;9:448-508.
  • Sinha A, Singh V, Yadav S. Multi-omics and male infertility: status, integration and future prospects. Front Biosci (Schol Ed). 2017 Jun 1;9:375-394.
  • Mittal PK, Little B, Harri PA, et al. Role of Imaging in the Evaluation of Male Infertility. Radiographics. 2017 Apr 14:160125.