What should I do if I have fertility problems?
If you have been trying unsuccessfully to produce a pregnancy for 1-2 years, without using any form of contraception, you should contact your GP for further advice
Your GP will normally wish to review you and your partner together. 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 page.
What are the facts about male infertility?
- 1 in 7 couples in the UK are unable to have a child;
- in 50% 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 and full assessment by a urologist is recommended in all cases of male-factor infertility;
- in many cases, the underlying cause cannot be reversed, in which case assisted conception may offer the best chance of pregnancy; this may involve surgical sperm retrieval in advanced bases of infertility; and
- infertile couples are often assessed in gynaecology departments so subfertile men may wish to seek a urology assessment from a urologist specialising in andrology.
What should I expect when I visit my GP?
Your GP should work through a recommended scheme of assessment for men with infertility. This will normally include some or all of the following:
A full history
Your GP will enquire about lifestyle factors (e.g. your job, work pressures, smoking habits, alcohol intake and drug consumption) as well as asking whether you have previously fathered children. Your past medical history may also be relevant in identifying a reason for your infertility, especially if you have had previous testicular infections or operations. You will be asked about when you have been having sexual intercourse. Ideally, this should be timed to coincide with your partner's ovulation (approximately 7 - 10 days before the next menstrual period).
A physical examination
A general physical examination will be performed, paying particular attention to the development of your male sexual characteristics.
The usual tests performed are:
a. Sperm counts
You will need to provide 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
Download information on how to do a sperm count.
b. Hormone measurements
Blood levels of testosterone, prolactin, FSH (follicle-stimulating hormone), LH (luteinising hormone) and thyroid hormones will normally be measured. These can be used to give an indication of the nature of the underlying problem
c. Other specific tests
Other blood tests, usually performed by specialists, may include genetics screening tests (including karyotype checks, assessment of cystic fibrosis genes and Y chromosome micro-deletions associated with infertility) and viral screening tests (including checks for hepatitis B, C and HIV in patients where sperm samples may need to be stored or handled by the laboratory for IVF).
Occasionally, an ultrasound of the scrotum and ultrasound of the prostate & seminal vesicles (sperm sacs) may be required.
What could have caused my infertility?
In 75% of infertile men, the cause remains unexplained (this is termed "idiopathic infertility"). It may, however, still be possible for couples to conceive naturally, provided some sperms are present.
Male infertility is either due to a problem making good quality sperm, or a problem with delivery of the sperm to the outside world.
Typical causes of delivery problems can range from issues with erections or ejaculation, to physical blockages, which can occur at any step from where the sperm is made in the testicle, to its point of delivery at the tip of the penis. Some blockages can be more easily overcome, such as a previous vasectomy. Others, such as multi-level obstruction due to infections, or being born without a vas tube cannot. In cases of "obstructive" infertility, the testicle still makes sperm normally, so sperm can usually still be directly retrieved from this source.
Issues that can cause problems with how sperm are made include:
- prescribed drugs such as chemotherapy
- recreational drugs (cannabis, cocaine),
- smoking or excessive alcohol intake
- hormonal imbalances (thyroid/ prolactin)
- previous testicular infection, injury or surgery
- raised scrotal temperatures including varicoceles or recent febrile illness
- genetic problems
The damage associated with some of these situations may be reversed to allow a return to normal fertility. Genetic problems cannot be reversed, but may be overcome using direct surgical sperm retrieval from the testicle, but with a lower overall chance of successfully finding sperm than in cases of obstruction.
What treatments are available for this problem?
Many couples produce a pregnancy whilst undergoing investigations or treatment for infertility (85% within the first year) but, for those who do not, a number of treatments are available
If you have poor sperm counts, you should wear loose-fitting trousers and boxer shorts. You should stop smoking, reduce your alcohol intake, avoid recreation drugs and any gym supplements. You should endeavour to adopt a "healthy" lifestyle with a balanced diet. Fertility vitamin supplements may also have some benefits.
You should avoid using computers directly on your lap, do not carry your mobile phone in your trouser pocket, and avoid long soaks in a hot bath or sauna/ steam rooms, as increased temperatures can affect sperm production.
Management of obstruction
Surgical bypass may be possible depending on where the level of the obstruction lies.
- blockages to the ejaculatory duct in the prostate may be overcome with resection of any obstructing cyst
- blockages of the vas (sperm duct) – most commonly seen post vasectomy & can be overcome with vasectomy reversal
- blockages to the epididymis may be overcome using microsurgical epididymo-vasostomy.
In cases where the obstruction cannot be reversed, direct surgical sperm retrieval (SSR) from the normal but blocked testes caries a 100% success rate in finding sperm for use with assisted conception. The choice to reconstruct or obtain sperm surgically depends on a number of factors, including;
- the female partner's age,
- how many children are planned,
- the time interval since vasectomy (for vasectomy reversal only)
Management of impaired sperm production
Besides the general measures outlined above, correction of any reversible element may result in a return to normal fertility (e.g. correction of any hormonal abnormality).
Varicoceles occur in 20% of infertile men (and in 10% of the normal male population). The treatment of clinical relevant varicoceles has been shown to be associated with an improvement in sperm number and quality, and an increased rate of natural conception (1 in 3 couples) in more recent studies. Treatment of clinically relevant varicoceles is now advocated by both the European and American Guidelines on Infertility.
In cases where no reversible cause is present, and no sperm is present in the ejaculate, sperm may still be successfully retrieved in approximately 50% of cases from the testicle using microsurgical retrieval techniques (MicroTESE).
Assisted conception techniques
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 fertilisation (pictured) a single sperm is injected directly into an egg to fertilise it. It is useful if you have a very low sperm count or in cases of surgically retrieved sperms. As with any IVF technique it carries risks for the female partner due to the drug stimulation required in the egg retrieval process. It has a pregnancy rate of approximately 30-40% per cycle.
What options are available if no sperms can be found?
Donor insemination (DI)
Donor semen is carefully screened for infections and a donor selected to have similar attributes to you. This is the only viable option if you have no sperms at all and you do not have obstruction which can be relieved surgically.
If you are unfortunate and do not to have any success with other treatments, you may wish to consider adopting a child. Your GP and local / national adoption agencies can help with this process.