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Male Factor Infertility
After Rachel and I had been trying to conceive for about 18 months we decided to approach our GP about our troubles with trying to get pregnant. I was really nervous and apprehensive because the thought of me having male factor infertility made me feel inadequate and guilty. This process encouraged me to spend hours researching and speaking to other men who suffer with similar. Here is what I found. For those more interesting in the findings in video format, you can watch it below.
- What is male factor infertility?
- How common is infertility in men?
- What is normal for male fertility?
- What types of male factor infertility are there?
- What causes male factor infertility?
- How do I find out if I have male infertility?
- What can you do about male factor infertility?
- What specific treatment options are there?
- What does male factor infertility mean for assisted reproduction treatments?
What is male factor infertility?
The clinical description for Male factor infertility is a man who has greater than or equal to one abnormality in the semen analysis and or the presence of inadequate sexual or ejaculatory function, who haven’t managed natural conception within 12 months of trying.
Let’s break this down a little further:
Trying to conceive for 12 months – This is a caveat which is put into the definition as many men with sub-fertility are still able to conceive normally, they would just have a lower chance per cycle.
Semen analysis – This looks at the count, the concentration, the mobility and the morphology of the sperm. It also looks at the pH and make-up of the semen.
Sexual or ejaculatory – This is those that can’t ejaculate through penetrative sex and or those that don’t produce semen at all through blockage or other physiological problems.
As you can see there are a number of things that can cause male factor infertility.
How common is infertility in men?
A detailed review of literature was performed in 2015 by Naina Kumar and Amit Kant Singh. The key results that came from this study show:
- It is estimated between 60-80 million people worldwide suffer with infertility
- This is between 8-12% of all couples are impacted by infertility
- The fertility rate in men under 30 has decreased by 15% in the past between 2002-2010
- Male factor infertility accounts for between 40%-50% of all infertility cases in couple’s dependent upon where you are in the world.
- Male factor infertility impacts around 7% of all men
- Between 1988 – 2007 a analysis of 10,393 SA’s (Semen Analysis) was performed it showed that sperm concentration is falling by 1.5% per year, total sperm count by 1.6% per year, total motility by 0.4% per year, rapid mobility by 5.5% per year and normal morphology by 2.2% per year. This is also backed by other studies demonstrating similar results.
I find the last finding the most concerning. It shows that male factor infertility is on the rise across the world. The research is also showing that this is more prevalent in certain areas of the world and there is a tight correlation with an increase in testicular cancer and abnormalities within the male genitals. The reasons for this aren’t clear however the most likely culprits are socio-economic factors (including access to healthcare, lack of good quality diet, smoking and alcohol use) and environmental (increased pollutants and chemical exposure).
When I first read this study, I was pretty shocked to say the least, however over time I realise that this actually is reflecting experience. Through our infertility journey we have met many couples who suffer with many forms of infertility including male factor infertility.
The reason that I don’t think that the importance and magnitude of increase in male factor infertility is talked about more is due to not enough men and doctors openly discussing it.
What is normal for male fertility?
As we have seen it’s caused by problems with the sperm or with sexual or ejaculatory dysfunction. Let’s first explore what a normal sperm is.
The image above gives a general overview of a normal sperm, the head which holds the genetic material and the organelle which can help the sperm get into the egg should be smooth and oval and 2.5-3.5μm wide and 5-6μm long. The midsection which looks like a neck should be about 10% of the total sperm size and the tail about 80% of the sperm size. In normal sperm there should be one of each of these and the sperm should be able to move, and the tail create a nice even waveform to propel forwards.
Now that we’ve explored a single sperm let’s explore an entire semen sample. The World Heath guidelines for a normal sperm sample (known as Normozoospermia) are as follows:
- Volume: 1.5 mL
- Sperm concentration: 15 million sperm/mL
- Total sperm number: 39 million sperm per ejaculate
- Vitality: 58% live
- Morphology: 4% normal forms
- Progressive motility: 32%
- Total (progressive + nonprogressive motility): 40%
The above are the minimums that would be expected in a normal Semen Analysis. When I had my semen analysis, my first one had low normal forms of 2% and my second had a low count, concentration and moderate normal forms of around 4%.
I had mild male factor infertility, my first question was why and what causes it.
What types of male factor infertility are there?
We now have a clear understanding of what constitutes normal male fertility. Firstly, let’s explore the types of male factor infertility.
This can be broken down into two broad categories sperm problems and structural problems.
The key sperm problems include
This condition impacts about 2% of the entire male population. It means semen contains no sperm.
This term has two key meanings, the first is to do with the concentration, which if is less than 15 million sperm/ml and secondly the total number of sperm being less than 39 million per ejaculate. This is currently estimated to impact 30% of all couples struggling with fertility.
This is the opposite of Azoospermia it, is where the concentration of sperm is greater than 200 million/ml. This doesn’t always cause infertility however it makes the movement of the sperm difficult so can impact fertility. It is usually associated with someone who has a decreased volume of semen This can usually be helped through artificial insemination of a prepared sample.
This is the most common form of sperm problem. It is a low number of mobile sperm and a high number of sperm cells who aren’t moving. This ranges from complete which means none are moving which is estimated to impact 1/5000 men through severe to moderate with each grading becoming more common. However, all of these grades fall below the WHO recommendation in the section above. It is also important to note that recent research shows that DNA fragmentation is common in men who suffer with this.
This is another common problem and sadly one that is fairly challenging to treat. It is a high proportion of sperm with incorrect structure, i.e. they don’t look like the sperm in the picture above.
This can take many forms, they can have 2 tails, 2 heads, short or long tails, bent tails and unusual shapes and proportions. Anything under 4% is considered Teratozoospermia.
This has major impact to the quality of the sperm’s movement. Often couples with this require ICSI. The image opposite show’s some of the morphological peculiarity’s sperm cells can have.
This is a specific type of Teratozoospermia whereby the sperm have round heads and as such the Golgi apparatus is not changed into the acrosome which means the sperm cannot penetrate the egg leading to male factor infertility
The main structural problems include:
This is a swelling and or twisting of the veins that run through the testicles, this means there is a greater amount of blood flow. Which, in turn increases the temperature within the testicles leading to lower quality sperm which can impact fertility. This is the most common structural reason for infertility, and it is completely reversable.
This can be a problem with ejaculation through intercourse or a specific problem known as retrograde ejaculation. This is a condition where the ejaculate enters the bladder instead of coming out of the penis. Even in non-reversable cases sperm can still be extracted from the testicle’s via surgery for use in IVF.
This condition occurs during foetal development, it can affect one or both testicles. An operation is often performed in childhood to descend the testicle. However, it is commonly associated with fertility problems later.
Defects of tubules that transport sperm:
This is not as simple as it sounds, you have many different tubes which are involved in different facets of sperm and semen production. A blockage in any of these can have serious impacts on your ejaculate and fertility.
So, these are the main reasons for male factor infertility, but what causes these?
What causes male factor infertility?
It is important to remember that in a lot of cases the reason for male factor infertility is not found, in fact it is estimated that 40% of cases don’t have a clearly defined reason. However below are some of the more common reasons:
These are uncommon and include conditions such as cystic fibrosis, Kallmann’s syndrome and Kartagener’s syndrome. One in which a man is born with two X and one Y chromosome instead of one of each is called Klinefelter’s syndrome and affects the development of male reproductive organs.
These are a fairly common medical reason. With the hypothalamus, the pituitary, the testicles all involved in spermiogenesis (the production of sperm) there are a number of things that can go wrong, but an excess or lack of luteinising hormone (LH), testosterone or oestrogen can lead to problems with sperm production.
Sexually transmitted diseases, inflammation of the testes or the fluid around it and inflammation of the prostate can all lead to problems with sperm production and quality. In fact, I suffer with chronic prostitis, which is not due to infection, but it is constantly inflamed and after getting the condition we saw a 60% reduction in my sperm count.
Antibodies that attack sperm:
Certain auto-immune diseases mean that the body can interprets sperm as invaders as it would with bacteria or viruses, and it creates antibodies, which can effectively ‘kill’ the sperm.
The key medications which can impact male fertility are hormones such as testosterone, long term steroids, chemotherapy medications, specific antibiotics and antifungal meds as well as others can impair fertility.
These can be cancerous or benign, they often impact fertility through hormone regulation of impacted glands. So, tumours of the brain, testicles, prostate are particularly impactful upon fertility.
These medical issues make up a fairly small percentage of male factor infertility diagnoses, the bigger cause, although it’s much harder to directly attribute is environmental and lifestyle.
Environmental and Lifestyle causes
This section includes, smoking, illegal drugs and excessive alcohol consumption. All of these can have serious impacts on male fertility. For example, smoking reduces normal forms and sperm count, anabolic steroid misuse shrinks testicles and reduces sperm count and finally alcohol reduces testosterone levels which reduces sperm production.
Depression, severe anxiety and emotional stress are all shown to impact sperm production in a negative way.
Sperm don’t like heat, that’s why the testicles sit outside the body, so regular hot baths, wearing very tight underwear, use of saunas all increase the heat around the testicles. This leads to lower sperm production and quality, although this is usually temporary.
Being over or underweight impacts your hormonal balance which in turn impacts the production and quality of your sperm which can lead to fertility problems.
Exposure to harmful substances:
Exposure to chemicals, heavy metals and radiation can have varying impacts on fertility from complete infertility from high doses of radiation and lead through to varying degrees of sub fertility with chemicals such as benzines, organic solvents, pesticides and herbicides.
Your diet and intake of nutrients and vitamins is shown to impact your production and quality of sperm so ensuring that you eat a balanced and varied diet will support your sperm health.
How do I find out if I have male infertility?
Most men only find out they are suffering with fertility problems when you have been trying to get pregnant for a long time over 12 months at least and often 2-3 years in the UK and you go for a semen analysis, which you can read more about in our fertility testing guide.
We still live in a society where when people talk about infertility the conversation immediately goes to women’s fertility problems and men often don’t speak up. However, one thing I wish I had done more on our fertility journey is to engage in the conversation about fertility as a couple. This means being open about how I was feeling about my own fertility.
For the record,
I felt nervous because I know I didn’t exercise enough; work was stressful, and I didn’t eat as well as I should.
I felt guilty because I didn’t want to think I was letting Rachel down when I know how much she wanted children.
I felt inadequate, because if I could perform then I should be able to get Rachel pregnant.
After speaking to more men who suffer with male factor infertility, I realised these are common feeling which men experience which stops them from engaging in the conversation earlier.
So I recommend after 6 months of trying you should do a home sperm test (link to detailed article on home sperm testing) to look at concentration, and mobility of your sperm, if these come back very low you can seek help straight away, but if they come back borderline then you can work on lifestyle to improve your sperms overall quality to help with natural conception.
This is much more empowering because you are taking control of a situation which feels completely out of your power. The way most men find out is as I say from a doctor who did a semen analysis because you had been trying to conceive for so long.
What can you do about male factor infertility?
This is a difficult one because the treatment often depends upon the cause and as we said above about 40% of male infertility have no cause but is often attributed to lifestyle choices.
What are the main ways I can improve my sperm health?
Now that you understand what impacts and causes male infertility, what can you do to improve your sperm health and reduce your fertility problems to increase your chance of conceiving.
Well the main things are:
- Stop smoking if you do
- Reduce your alcohol consumption if you drink regularly
- Eat a balanced healthy diet with at least 5 portions of fruits and vegetables a day. Zinc, vitamin C, folic acid, Vitamin B12 and Vitamin D are all heavily involved in male fertility
- If you are over or underweight, try and bring your weight more into balance with your height. I know this can be very difficult and I don’t advocate the crazy diets which guarantee rapid weight loss. Try to focus on just cleaning up your lifestyle a little and creating a long-term plan which you can stick to. Long term change will be more effective and easier to maintain than fad diets.
- If you have a chronic condition or are taking regular medications book an appointment with your GP to discuss if it can impact your fertility and if there are better medication options whilst you’re trying to conceive.
- Try to avoid long term exposure to chemicals, heavy metals and ionizing radiation.
- Look for ways to reduce your overall stress and anxiety. I appreciate that life can be stressful but try to increase the things that bring you joy and focus on taking time out for rest and relaxation. I also used the mindfulness apps, which were great at trying to prevent overthinking and destructive thoughts.
- Limit your exposure to heat, this doesn’t mean NEVER take a bath, Jacuzzi or sauna it just means moderate it. It doesn’t mean don’t wear tight underwear just give yourself time in looser fitting garments.
What specific treatment options are there?
This one is very specific to your personal circumstances.
- For some types of blockages and sperm production issues surgery can be used to clear the blockage or correct the anatomical issue.
- For hormone imbalance sometimes hormone treatments can be used to encourage more regular sperm production
- For infections, those that are treatable can be treated with medications
- Other than these the main treatments are those mentioned in the above tips.
Most couples with male factor infertility are likely to need some form of assistance by having assisted reproduction treatments which we will discuss next.
What does male factor infertility mean for assisted reproduction treatments?
Male factor infertility can seem straightforward on paper, there are only really so many things that can go wrong. However, the variety in severity and the lack of understanding of the causes of most cases of male infertility means that it’s hard to treat at the source. This means that a variety of assisted reproduction treatments may be offered depending upon your specific diagnosis.
We did a detailed overview of what artificial insemination involves. This is often the first treatment in younger couples who are suffering with male factor infertility where the chances of conception with IUI or IVI are good. IUI is the least invasive option and is often suggested as first line treatment.
A 2004 study showed that if specific factors are taken into consideration then couples can achieve a 28.1% chance of pregnancy per IUI cycle, which is close to if not in excess of natural conception rates.
This and other studies show that those with normal forms under 4% , those with very low concentration and those that fall outside of the progressive mobility will be unlikely to benefit from IUI but others will.
For those who are slightly older or have serious sperm problems, have very low normal forms or very low concentrations or mobility are likely to be referred for IVF. We have a detailed article explaining the IVF procedure. IVF allows the semen to be analysed at the point of egg retrieval before fertilisation which will allow your clinic to decide if ICSI will be required
ICSI (Intracytoplasmic Sperm Injection):
This treatment is used if the embryologist thinks your sperm don’t have a good chance of naturally fertilising the eggs of your partner. In a nutshell it means that the sperm are directly injected into the egg to cause fertilisation. There are small additional risks with using ICSI so this is only used when required, you can learn more about this treatment in our guide to ICSI article.
Surgical sperm extraction:
Surgical sperm extraction is used when sperm are blocked from leaving, you have non-reversable retrograde ejaculation or if you can’t produce a sample on the day of egg retrieval through masturbation or prostate assisted ejaculation. This procedure is often performed under a light general anaesthetic and has two specific types:
- Percutaneous epididymal sperm aspiration (PESA) – A fine needles is inserted into the space just above the testicle called the epididymis which is where the sperm are stored after production. It is performed for men with obstructive azoospermia.
- Testicular sperm extraction (TESE) – Sperm is collected from 1 or more biopsies of the tissue in the testicles. This is done after a small cut is made in the skin on the scrotum. It is performed for men with non-obstructive azoospermia.
You may produce no sperm at all, they may have too much DNA damage or just not be enough of a high enough quality to safely fertilise an egg, in this instance it is possible that you may have to use a sperm donor. Many clinics offering IVF and IUI will have a list of donor sperm available so that you can match specific characteristics of yourself. This is a highly complex area and one which we will write a detailed guide on shortly.
Your treatment pathway is not always clear cut and your specialist will devise the most effective treatment plan for you and your partners circumstance.
I hope this guide has helped you understand a bit more about male factor infertility. I really would like to encourage more men to talk about it and discuss their own personal infertility journey so please either leave us a comment or get in touch through the contact form on Our IVF Journey page and we can discuss.