Over their lifetimes, approximately one in every five couples in the United States seeks infertility care. In Europe, around one in four couples have difficulty conceiving. Surprisingly, only half of couples who are trying to become pregnant achieve pregnancy easily, and about one in ten American couples of reproductive age are involuntary infertile. Male infertility accounts for half of these cases.
Despite the importance of infertility due to the male, infertility evaluations have traditionally focused on women, because women tend to seek gynaecological care and because men often are reluctant to seek advice.
Infertility is grouped into two categories:
- Primary infertility refers to couples who have not become pregnant after at least one year of unprotected sex
- Secondary infertility refers to couples who have been pregnant at least once, but never again
Infertility is still a relatively new science. There are a lot of estimates on the major causes and what goes wrong. As far as we can determine, male infertility causes account for around 30% of overall infertility causes. This is considered to be the same percentage as female infertility causes. Male infertility can be as a result of one specific problem or as an accumulation of several ’smaller’ problems.
There are a host of tests that men can do to try and identify the problem. These tests can be performed by your doctor or a fertility clinic. It is always useful to know the results of these tests if you suspect there may be an underlying cause. By identifying the cause it is easier to put a protocol in place to try and improve your chances of conceiving naturally.
For example, the mineral Selenium can contribute significantly to spermatogenesis. Selenium is also involved in the antioxidant enzyme Glutathione Peroxidase that is found in seminal fluid. In most cases, researchers are beginning to realise that quality is much more important than quantity. A high sperm count means nothing if the percentage of healthy sperm is not high.
It’s not just you!
Male fertility causes are by no means permanent. At Pillar Healthcare, we are very conscious of the stress associated with conception problems. We appreciate that it is not an easy period to go through. Latest research shows that in healthy couples under age 30 who have sex regularly, the chance of getting pregnant is about 25 to 30% per month. The definition of ‘healthy’ is open to debate as well. The total sperm count has been in decline for decades now. In 1940, the average sperm count was 113 million/ml. In 1990, that value had dropped to 66 million/ml. Also, the amount of semen fell by nearly 20%, from 3.4ml to 2.75ml. These are not the only statistics on this matter. This is not just your issue or your partner’s issue. This is now a global concern and a global problem which has been highlighted by the United Nations and The World Health Organisation.
Male Infertility: What Goes Wrong?
Male infertility has many, many causes. Thankfully, many of these are reversible. There have been many therapies and procedures that can reverse male infertility, in some cases completely. Causes range from hormonal imbalances, to physical problems, to psychological and/or behavioural problems. There is an interesting correlation between men’s overall health and their fertility. Men who live a healthy lifestyle are more likely to produce healthy sperm. However, the main underlying causes of male infertility include:
Hormonal problems can impact on male fertility. The hormonal system of a male is regulated by the hypothalamus, pituitary and endocrine system. The main problem is that the brain fails to release a hormone called gonadotrophic-releasing hormone (GnRH). This controls testosterone synthesis and sperm production. If there is a deficiency in GnRH, then there is a deficiency in testosterone, and ultimately, sperm production stops. Meanwhile, the pituitary gland releases two hormones, Follicle Stimulating Hormone (FSH) and Lutenizing Hormone (LH). These hormones stimulate the testes and testosterone and sperm production. Again, if there is a deficiency in these hormones, infertility can arise.
Hyperprolcatinemia is a condition where men produce too much prolactin hormone. Elevated prolactin is noticed in men in around 10% to 40% of infertile males. High levels of this hormone are associated with low sperm counts, reduced libido and possibly impotence.
Hypothyroidism can affect men as well as women. Low thyroid hormone levels can cause poor semen quality, poor testicular function, interrupt hormonal patterns and reduce libido.
Other hormonal problems
There are three other hormonal conditions that can affect men. These three, even combined, are often seen as a very small player in the greater picture of infertility. However, there is strong evidence to suggest that this may be undervalued. Congenital Adrenal Hyperplasia, Hypogonadotropic Hypopituitarism and Panhypopituitafism are names that do not roll of the tongue but can have an impact in male infertility. The synopsis of these are a suppressed pituitary by increased androgens, suppressing FSH and LH for CAH, for HH low pituitary gland output of LH and FSH can be expected and panhypopituitafism is complete pituitary gland failure, which is quite rare.
With men, the main causes of infertility are physical problems. These problems either interfere with the sperm production process or disrupt the pathway down which sperm travel from the testes to the tip of the penis. These problems are usually characterized by a low sperm count and/or abnormal sperm morphology. The following is a list of the most common physical problems that cause male infertility:
A variocele is an enlargement of the internal spermatic veins that drain blood from the testicle to the abdomen and are present in 15% of the general male population and 40% of infertile men. In spermatic veins, like all veins, there are valves that stop the blood from flowing backwards. In a variocele, these valves get damaged and the blood flows back down through the valve and pools in the scrotum creating a very hostile environment for sperm development. As a result, there is a reduced sperm count and sperm is produced at a severely reduced quality.
Damage to sperm ducts, the duct that transports sperm from the testes to the penis, can be the cause of around 10% of male infertility. This can mean that you produce good quality sperm within all the right parameters but never get it to where it is needed. There are a handful of causes for this and the main two are a genetic abnormality or damage/ scarring to the ducts and blocking the transportation of sperm.
Torsion is a common problem that can have a big impact on fertility. Torsion is caused by a supportive tissue abnormality which allows the testes to twist inside the scrotum. This is characterised be severe swelling. The twisted testes and the swelling both hamper blood flow to the testes and can restrict their blood and nutrient supply. Torsion can cause permanent infertility if both testes twist.
Infection and disease
Infection and disease are other common causes of infertility in men. Sperm count and motility are often impaired as a result. In men, STDs are obviously associated with infertility but non-STDs can also affect fertility. Mumps, tuberculosis and even the common cold have all been shown to negatively impact on fertility. Male fertility can be a reflection of male overall health!
There are two other known causes of male infertility, apart from mental disorders. Klinefelter’s syndrome is a genetic condition where men have the usual Y chromosome but have two X chromosomes. This condition will generally be detected from an early age as it has physical symptoms that are easy to identify.
Retrograde ejaculation affects around 2% of men and is a very minor cause of infertility. The ejaculated semen flows back into the bladder instead of out of the urethra and the penis. The sphincter (door) of the bladder does not close, either partially or fully. This will result in a very small amount of ejaculate and very cloudy urine.
Several sexual problems exist that can affect male fertility. These problems are most often both psychological and physical in nature: it is difficult to separate the physiological and physical components. Erectile Dysfunction, Premature Ejaculation and Ejaculatory Incompetence (failure to ejaculate during intercourse) will obviously affect fertility and conception. Sex therapy as it has become known can be a big help in overcoming these issues and even some other psychological issues. It has now become very common in the United States and it is even recommended to see a therapist during assisted conception.