The days when a woman had tests under general anaesthetic before her partner even had his sperm counted are long gone. Dr Gill Lockwood, medical director of Midland Fertility Services, looks at male fertility tests
The latest statistics suggest that about a third of couples having difficulty conceiving will be diagnosed as 'male-factor infertility'. In another third of cases there will be problems 'on both sides', so it's vitally important that couples have their fertility investigated together.
Declining Male Fertility
Male fertility is declining in the Western world quite rapidly while testicular cancer in adult males and genital deformities in baby boys are on the rise. This all points to environmental causes, and chemical pollutants that mimic the action of female hormones (like oestrogen), have been blamed.
Modern male lifestyles are bad for sperm production
The testicles were designed to hang free and cool and anything that raises them up to body temperature (hot baths, saunas, tight jeans, cycling, long periods of driving) 'cooks' the testes and reduces fertility.
Smoking damages the ability of the sperm to find the egg and may even damage the sperm DNA. Although many babies get made because of alcohol and not despite it, binge drinking is bad for sperm as alcohol is quite toxic. Unlike women, who are born with every egg they are ever going to have, most men go on making sperm into their eighties. . .but the quality and quantity deteriorates.
Sperm tests
Routine sperm tests investigate:
- The concentration of sperm ('the count')
- Their swimming ability ('the progressive motility')
- The shape and structure of the sperm ('the percentage normal morphology').
The scientists also look for evidence of 'clumping' (which could suggest anti-sperm antibodies) and for 'white cells', which suggest that an infection may be present. An average sperm count should be more than 20 million sperm per millilitre of ejaculate and about 50% of the sperm should be active.
A sperm sample should be analysed after a 'period of abstinence' of 35 days.
Any longer than that and the motility may be low because the sperm will have started to die off. Even in a normally fertile sample, the majority of sperm will be misshapen, many will swim round in circles and up to 20% will be non-swimmers. The sperm cycle (the time from production of immature spermatids to the release of fully-formed mature sperm capable of finding and fertilising an egg) takes about 70 days, so sperm tests should not be repeated too close together as this does not leave time for the sperm to recover.
If a first sample is abnormal, it should be repeated after 34 weeks, ideally with the sample being produced at the clinic, rather than brought in from home. For men who find it impossible to produce a sample by masturbation, then special silastic condoms are available so their partner can help.
Andrology Assessment
If routine analysis suggests a significant sperm problem then the man should have an 'andrology assessment'. This will include a general health check (stress, hypertension and diabetes are all bad for sperm) and physical examination of the genitalia looking for problems such as:
- Varicocele (varicose veins on the scrotum)
- Undescended testes
- Levels of FSH (follicle stimulating hormone), LH (luteinising hormone) and testosterone a blood test will give these results.
The sperm samples are further tested to assess 24-hour survival, the proportion of sperm that have rapid forward progressive motility ('gold medal swimmers'!) after preparation and for the presence of anti-sperm antibodies (the MAR test).
Treatments that work
IUI (intrauterine insemination)
For mild 'male factor' problems, the first treatment that the couple can try is IUI (intrauterine insemination). This can be performed in a natural cycle or with ovarian stimulation. The woman's cycle will be monitored with ultrasound scans and/or urinary LH-testing sticks and just prior to ovulation her partner will produce a sperm sample.
This will be processed to extract the best, most active sperm. These are then loaded into a fine plastic catheter, which is passed through the cervix, and the sperm are deposited at the top of the uterus near to the entrance to the Fallopian tubes.
The idea is to flood the tubes with active sperm so they are in a position to 'pounce' when the egg is released at ovulation. Only one sperm will actually penetrate the egg and fertilise it, but sperm hunt better in packs, so IUI is only likely to be successful if at least 12 million active sperm can be obtained. If sperm counts are very low, then it is possible to 'bank' sperm and freeze the samples until enough have been obtained. Success rates with IUI vary between 5% and 20% per cycle depending on the age of the woman and the severity of the male factor.
IVF (in vitro fertilisation)
Where sperm concentrations are very low then IVF will offer the best chance of achieving a pregnancy. The woman's ovaries are stimulated to produce 815 eggs with daily injections of the hormone FSH. When the ultrasound scans show that the eggs are likely to be mature, they're collected using a minor surgical procedure and placed in little glass dishes with specially prepared sperm. Fertilisation rates of about 60-70% can be obtained with IVF and two or three of the resulting embryos are transferred directly to the womb after a couple of days. Any spare embryos can be frozen for further attempts in the future. Typical success rates for IVF are 2025%+ per embryo transfer for women under 38 years who respond normally to ovarian stimulation.
ICSI (intracytoplasmic sperm injection)
Where the sperm parameters are very poor (zero motility or low morphology) then the ICSI technique can be used to achieve fertilisation in vitro. In ICSI, the egg is fertilised by introducing a single immobilised sperm directly into the cell by using a fine hollow glass needle.
Although this seems to be a very invasive procedure, fertilisation rates of 6070% can be achieved and there's no increased incidence of abnormality in the babies born following ICSI. This procedure does require highly skilled embryologists and it's more expensive than standard IVF, but it offers almost all couples the chance of a baby that is genetically theirs.
Options for the azoospermic male
Some men produce no sperm in the ejaculate and yet are producing sperm in their testes. This can happen if a blockage has occurred due to infection or surgery. Some men are born with a congenital absence of the tiny tubes called the vas deferens, which carry the sperm from the testes to the outside world. A man who has suffered a premature andropause (the male equivalent of the premature menopause) may also be azoospermic, but still be producing tiny quantities of sperm.
A technique that can help here is PESA (percutaneous epididymal sperm aspiration) or TESE (testicular sperm extraction). These are minor surgical techniques that do not require a general anaesthetic and which can obtain sperm directly from the testis or epididymus for use in an ICSI cycle. Hormone tests on the man, especially measurement of the newly identified hormone called inhibin B will identify which azoospermic men are likely to be producing sperm and therefore likely to succeed with PESA/TESE. ICSI is the most successful of the fertility treatments available at present with success rates of 2530% per cycle being reported at the better clinics.
If all else fails.
For couples with very severe male factor infertility where the cost of ICSI is prohibitive or where the man is carrying a genetic problem which he doesn't wish to risk passing on, then the use of donor sperm is still an option.
Donor sperm is donated by generous, altruistic men who have high natural fertility and who have been screened for all known genetic and infective diseases. Donor sperm inseminations can be performed in natural or stimulated cycles and success rates are 1015% per cycle for young women under 35 and 510% per cycle for older women. By law in the UK, the woman's husband or partner is the legal father of a baby who is born following the use of donor sperm and his name goes on the birth certificate. Donors are 'matched' to the physical characteristics (height, skin colour, eye colour, hair colour, blood group etc) of the man who will be the baby's father and sperm donors are, at present, guaranteed anonymity.
