How common is male factor infertility?
Male factor infertility (MFI) is believed to play a role in 30-50% of all cases of couples having difficulty conceiving.
It’s worth seeing a urologist
Problems with a semen analysis are usually found first by an OB/GYN or RE, both of whom are trained to deal with female reproductive issues. Often these specialists will want to progress straight to IUI or IVF, but there might be other less expensive or intrusive options. It is worth the time and cost to see a urologist trained in male reproductive health. Also, problems with a semen analysis may reflect an underlying health issue, which is likely to go undiagnosed without the help of a urologist. In the experience of one specialist, 75% of the time he finds a good explanation of what is causing the MFI, which makes it possible to determine whether treatment is possible or not. If treatment is possible, IVF may not be necessary for the couple.
Understanding a semen analysis
Semen analysis in an individual male can vary tremendously from day to day and month to month even when there is no fertility issue. For that reason, it’s best to do a minimum of two semen analyses so they can be compared. Urologists tend to emphasize concentration and motility and are less concerned about morphology. Total motile count is the amount of sperm that can swim forward. Only about 1 in 14 million sperm make it from vagina to fallopian tube, so a good number of sperm is needed. Sperm morphology is subjective and often misinterpreted. If there is a low percentage of normally shaped sperm, but a good concentration, there is often no effect on fertility. In general, if you are low on one parameter it is 2.5 times harder conceive. If you are low on all three parameters it is 16 times harder to conceive.
Treatment options: IUI, IVF and ICSI
Most male factor infertility patients require multiple IVF attempts before they are able to conceive and have a live birth. For men with major fertility issues whose sperm would not be able to fertilize an egg, ICSI is extremely helpful. If both partners have fertility issues, many doctors feel it is important to move to IVF quickly.
ICSI is necessary when a man produces no sperm and it has to be surgically removed from the testes, or because the sperm would not be able to fertilize the egg. ICSI does not improve outcomes in some cases, though. If a man has normal count and motility but poor morphology, ICSI does not improve outcomes. ICSI is a delicate procedure and not every lab is good at it. If the woman is a poor responder and there are fewer eggs, doing ICSI can be a risk.
There are times when a man with MFI should wait before doing IVF. If the man has poor dietary or lifestyle factors, that can be easily addressed and can have a big impact on semen quality. If the man has hormone imbalances, they can potentially be addressed. Finally, varicoceles can be treated with surgery, which improves live birth rates. Even if the couple eventually needs to use IVF, men who have had the varicocele surgery have higher live birth rates.
Is it worth treating a varicoceles?
One in three men with MFI have a varicocele, which is an abnormal collection of enlarged veins around the testicles. This raises the temperature of the testicles and negatively impacts sperm quality. It is very treatable. Surgery is most effective if the varicocele is large enough to be causing an issue, for example if it’s big enough to be felt on a physical examination, causing pain, or if semen parameters are clearly being affected.
Lifestyle factors make a difference
Sperm take three months to be produced and work their way out of the body, so it is possible to see the impact of lifestyle changes relatively quickly. The following factors have been shown to have an impact on semen quality, but it isn’t clear how much that carries through to a man’s ability to conceive naturally or through IVF.
Smoking is very negative for fertility, as it appears to damage sperm. Alcohol appears to have an impact if a man is having more than two drinks a day. There is also a threshold effect with caffeine around two cups a day. Being overweight or underweight impacts a man’s hormones, which affects semen production and quality. Exercising to exhaustion, particularly biking, can be a problem. Exercising 30-45 minutes a day is helpful, but 70-90 minutes starts to have a negative impact on sperm count. Avoid overheating the testicles through underwear, too much exercise, keeping a cellphone in the front pocket of your pants, using a laptop on your lap, or sitting in a hot tub. Finally, SSRIs (a class of anti-depressants) can have a negative impact on semen quality.
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