NOTE: Some of the information provided contains graphic, medical images which individuals may find upsetting
What should I do if I have fertility problems?
If you have been trying unsuccessfully for a pregnancy for 12 mmonths, 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. During the assessment, both you and your partner need to be fully checked. Your GP may refer the male partner to see a urology specialist,called an Andrologist, who looks after male fertility issues. Your female partner will be referred to see a Gynaecologist. Sometimes, you might see both a Urologist and a Gynaecologist, as a couple, in the same clinic. 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; and
- 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.
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, exposure to excess heat 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, injuries or operations in the groin/scrotal area in the past. You will be asked about when you have been having sexual intercourse, and about any issues with ejaculation. 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 genital region (your testicles and scrotal contents).
The usual tests performed are:
a. Sperm counts
You will need to provide at least two semen specimens for analysis. These should be done at least three months apart to check two different cycles of sperm production (each normally about 74 days). The most important levels are the amount of sperm per drop (i.e. the sperm count per millilitre, typically more than 15 million per ml), the swimming ability of the sperms (i.e. their motility, typically more than 32% - one third - progressive motility) and the number of normal-looking sperm (i.e. normal morphology, typically more than 4% - 1 in 25). The two semen analyses should be done before you go to see a Urologist.
Download information on how to do a sperm count.
b. Hormone measurements
Blood tests are done to check your levels of testosterone, prolactin, FSH (follicle-stimulating hormone), LH (luteinising hormone) and thyroid hormones. These can be used to give an indication of the nature of the underlying problem. They are best done as an early-morning, fasted sample (i.e. before 09.30hr when you have had nothing to eat or drink since midnight). The blood tests are best done before you go to see a Urologist.
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.
Before you see a Urologist, you should have had two semen tests and your early-morning blood tests. Please take a copy of any results with you to your appointment; this will save a considerable amount of time in investigating and managing your fertility problems
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 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 recreational drugs, do not use any gym supplements and lose weight. 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, avoid long soaks in a hot bath or sauna/ steam rooms, and do not use a seat heater in your car because 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 which can be used 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 about 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 is 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 do not to have any success with other treatments, you may wish to consider adopting a child. Your GP, local fertility centre and local/national adoption agencies can help with this process.