Chances of pregnancy
Unless there is absent sperm production or an extremely low count (less than 5 million/ml) it is the circumstances of the couple’s infertility such as the duration of infertility, previous pregnancy history and also female partner’s age that are the most important factors in predicting future chances of conception. The results of the semen analysis therefore for each couple must be interpreted in the light of each couple’s individual circumstances.
(b) Symptoms and diagnosis
Physical symptoms will only be present in a small number of male infertility cases, such as with retrograde ejaculate (where the semen is not ejaculated), or an anatomical factor is present (such as an undescended testicle). For most couples trying to conceive, a semenanalysis will be recommended by either a GP or a fertility clinic, early in the investigation stage into a couple’s fertility. It is often not until the results of the semenanalysis are revealed that the man learns that there is an issue with his sperm.
Although a semen analysis is essential for diagnosing male infertility, a detailed history should also be taken, including a sexual history, and also possible exposure to any environmental toxins.
Previous genital surgery, including for an undescended testicle, previous inguinal hernia repair or previous significant infections such as chlamydia or mumps orchitis will also be relevant.
Physical examination is important, looking at the size and consistency of the testicles, whether any abnormal swellings are noted, if there is a varicocele present and also whether the vas deferens is palpable. If there is any abnormality on the initial semen analysis, a further analysis should be undertaken at a tertiary fertility laboratory looking carefully at sperm motility and morphology (shape) and testing for antisperm antibodies. Hormone assays may be useful and should include FSH, testosterone and prolactin levels.
A blood test for Karyotyping, to check the chromosomes, may be useful to exclude certain genetic conditions. There are also newer tests that measure the integrity of sperm DNA (SCSA, Tunel, Comet) and the ability of sperm to bind to the zona (HBA).
(c) Causal factors
For at least half of sperm problems, the cause remains unknown (idiopathic) although there is an increasing understanding that genetic factors may play an important role. Ten percent of men with absent sperm production
or an extremely low count (azoospermia and severe oligospermia) will have small pieces missing from their Y chromosome (microdeletions) as the cause for the abnormal sperm production. There are tests for Y micro-deletions.
Male obesity with reduced circulating testosterone levels can influence sperm quality as can heavy alcohol intake, cigarette and marijuana smoking and certain medications.
Oxidative stress-related damage to sperm caused by free radicals has been shown to be an increasingly important issue. Recent research suggests obesity can cause oxidative stress to sperm.
Free radicals are toxic metabolites that can impair the ability of sperm to fertilise and can damage the DNA contained in the head of the sperm. These toxic substances are found in a number of environmental chemicals that we are exposed to. Blocking the free radical damage by the use of anti-oxidant preparations can be a useful management option if increased DNA damage is thought to be a contributing factor.
Regret following a vasectomy is an increasing problem and it is estimated that 10% of men will seek either reversal of vasectomy or surgical retrieval of sperm for use with micro-injection.
(d) Treatment options
Occasionally a hormonal imbalance will be discovered on testing which can be treated with replacement gonadatrophin injections to improve the sperm count. Unfortunately, cases where medication will improve the sperm count are relatively rare.
• Lifestyle changes such as losing weight if obese, reducing alcohol and cigarette intake and wearing boxers rather than tight underwear, can improve quality of sperm. Note that this may not help if there is significant abnormality present. See the Self Help section below for more information on how lifestyle can improve sperm quality.
• Donor insemination is used much less frequently now as a treatment for male infertility, mainly because of the introduction of micro-injection. Treatment with donor sperm in an otherwise healthy woman should result in pregnancy rates of 15-20% per cycle.
• Intrauterine insemination – IUI (artificial insemination using partner’s sperm) is used occasionally for the treatment of male infertility but is again is unlikely to be useful if a significant sperm abnormality is present. Randomised controlled trials show that intrauterine insemination is better than timed intercourse for the treatment of male infertility, particularly when used with ovarian hyperstimulation. Nevertheless, success rates of only 5-10% per cycle are reported in most studies when IUI is performed for male fertility.
• ICSI (micro-injection) involves the direct injection of the sperm into an egg as part of in vitro fertilisation (IVF) treatment. It is primarily used when a major sperm defect has been identified or where there has been poor fertilisation with ordinary IVF.
It has been particularly successful when there is low sperm morphology.
There are new methods available which attempt to isolate mature, structurally-intact sperm with high DNA integrity which are then injected into the egg.
• PICSI selects a mature sperm which could bind to the zona.
• IMSI uses high magnification to select a sperm without vacuoles.
These methods may be suggested after a failed ICSI cycle. Studies are needed to confirm that PICSI and IMSI improve outcomes over conventional ICSI.
Clinical pregnancy rates of 30-40% per cycle are usual with micro-injection so long as there is good fertilisation and the woman is aged less than 40.
Long-term follow up of children born after using ICSI has been documented. The chance of congenital abnormalities may be slightly higher with ICSI than with standard IVF, and there may be slightly more children born with X or Y chromosome abnormalities. If the male infertility is caused by a micro-deletion of the Y chromosome, it is very likely that a male child will inherit the same Y micro-deletion as his father.
(e) Self Help
The formation of sperm may take up to 100 days and during this time the rapidly dividing germ cells are susceptible to damage. Ideally, to ensure sperm are as healthy as they can be, it is important that conception attempts are preceded by 3 months of healthy lifestyle changes so that the sperm can develop in optimal conditions.
- Stay cool. Increased scrotal temperature can hamper sperm production. To protect your fertility, don't wear tight underwear or athletic shorts. If you bike or remain seated for long periods of time, take frequent breaks. Don't place a laptop computer directly on your lap, or carry your mobile phone in your trouser pockets. Avoid hot tubs, saunas and steamy baths.
- Don't smoke. Men who smoke cigarettes are more likely to have low sperm counts. Smoking can also decrease sperm movement and cause sperm to be misshapen. If you smoke, ask your doctor to help you quit.
- Limit the amount of alcohol you drink. Heavy drinking can reduce the quality and quantity of sperm. If you choose to drink alcohol, do so only in moderation. Heavy consumption of alcohol affects your hormone levels, in particular your testosterone levels. It also affects the ability of your testes to mature the sperm properly. This leads to poor semen quality but the effect is reversible, so if you cut down on alcohol over several months your semen quality could improve.
- Steer clear of illegal drugs. Like cigarettes, marijuana can decrease sperm movement and cause sperm to be misshapen. Cocaine and heroin also interfere with healthy sperm. The effect of synthetic drugs such as methamphetamine (‘P’) is less known……
- Caffeine Recent reports suggest that an excessive amount of caffeine can reduce and retard the quality of sperm a man produces. As little as 3 cups of coffee a day can have a seriously detrimental effect. Be aware of other sources of caffeine, such as energy drinks and chocolate.
- Be cautious with medications. Calcium channel blockers, tricyclic antidepressants, anti-androgens and various other medications can contribute to fertility issues. Anabolic steroids can have the same effect. Chemotherapy drugs and radiation treatment for cancer can cause permanent infertility. If you're considering medications, ask your doctor about the impact on your fertility — or the possibility of retrieving and storing sperm before treatment.
- Manage stress. Stress can decrease sexual function and interfere with the hormones needed to produce sperm.
- Ageing Women aren't the only ones who have biological clocks. Sperm motility and the number of healthy sperm might decline after age 50, affecting a man's fertility. Some research suggests that women who become pregnant by older men have a slightly higher risk of miscarriage. A father's increasing age has also been associated with a higher risk of both autism and schizophrenia in children.
- Exercise Regular moderate exercise (25-30mins at least 5 days per week) can benefit overall physical, emotional and general wellbeing which has a positive effect on fertility. Excessive exercise (more than 8 hours per week) can negatively affect fertility in both men and women.
- Frequency of sex Frequent ejaculation is better for the health of sperm while trying to conceive. One day’s abstinence gives better quality sperm. Periods of abstinence longer than three days can be detrimental because of the accumulation of aged sperm. These are also the guidelines given when producing a sperm sample to be tested.
- Maintain a healthy weight. Some research suggests that obesity negatively affects sperm quality, reducing both sperm count and sperm movement. It can also cause decreased libido and erectile dysfunction.
- Nutrition Eating a healthy fertility diet in the 3 months preceding conception attempts can help protect and encourage healthy DNA, promote sperm health and encourage and support a healthy libido.
- Important Nutrients for Male Fertility
Zinc – having a zinc deficiency can reduce testosterone levels. Zinc has been shown to raise testosterone and increase fertility. Zinc deficiencies are very common in both men and women due to our soils being low in this nutrient and also zinc can be damaged when foods are cooked or processed. It is recommended therefore to eat a diet with a good proportion of raw, unprocessed food. Foods rich in zinc are beef, lamb, oysters, shrimp, venison, sesame seeds, pumpkin seeds, green peas.
Folic acid Folic acid is a very important nutrient - not just for women but also for men who are trying to conceive. Men with low levels of folate had increased risk of chromosomally abnormal sperm which could result in birth defects such as Down’s syndrome, or an increase in miscarriage. Folic acid is found in lentil beans (1 cup provides almost your entire daily needs), pinto beans, garbanzo beans, asparagus, spinach, black beans, navy beans, kidney beans and collard greens. One serving a day of any of these foods provides anywhere from 50-90% of your daily needs.
B12 Has been shown to increase sperm counts. Many people are deficient in B12; meat eaters and vegetarians alike. Some foods rich in B12 are dairy and animal products. For most people, healthy levels of B12 depend on healthy digestion, which most people lack due to eating a highly processed diet. Foods high in B12 are chicken liver, sardines, mussels, oysters, eggs, beef and lamb.
Vitamin C Vitamin C protects sperm from oxidative damage. It will help to increase the quality of sperm in smokers and rescues sperm agglutination (when they clump together). Vitamin C is another nutrient that is sensitive to cooking and processing, so it important to get it from eating foods raw. Some foods that are rich in vitamin C (and should be eaten raw) are kiwifruit, papaya, bell peppers, broccoli, brussels sprouts, strawberries, oranges,, cauliflower and kale.
L-Carnitine This amino acid is a necessary nutrient for sperm cells to function normally. Studies show that supplementing with L-Carnitine helps to normalize sperm motility in men with low sperm quality. Foods rich in L Carnitine are nuts, seeds, and many vegetables, including artichokes, asparagus, beet greens, broccoli, brussels sprouts, collard greens, garlic, mustard greens, okra, and parsley.
CoQ10 Acts as an antioxidant protecting the sperm cells from damage. Studies have shown a connection between CoQ10 levels and sperm health. CoQ10 has also been shown to increase sperm motility. It has been shown that our CoQ10 levels decrease as we age. Foods rich in CoQ10 are beef, marinated herring, rainbow trout, salmon, organ meats, peanuts, pistachios, sesame seeds, raw broccoli, strawberries, oranges, eggs, plus whole grains that still contain the germ.
Betacarotene/Lycopene Has been shown to improve both sperm concentration and motility. Food sources are fish liver oils, egg yolk, carrots, tomatoes, rockmelon, pumpkin, kumara and spinach.
Selenium is a very important nutrient for all parameters of sperm health. It is also necessary for mitochondrial protection and function. Unfortunately, it is also a nutrient that is low in our soils. Food sources include brazil nuts, mushrooms, egg yolks, wholemeal flour, oats, fish and sesame seeds.
Essential Fatty Acids Lowered levels of essential fatty acids have been demonstrated in infertile men. It is very important for the formation of sperm. Food sources include fish, fish oils, flaxseed oil and walnuts.
N.B. Although many of our required vitamins, minerals, amino acids, essential fatty acids, and other constituents are found in food, the physiologic demands of couples during preconception and pregnancy may require extra dietary supplementation.
Always see your practitioner first about the proper regime for you.
General Dietary Guidelines
- Eat plenty of antioxidant rich foods, including vegetables and fruit
- Ensure adequate protein – fish, chicken, lean red meat, eggs, dairy, legumes
- Reduce saturated fats and trans fats
- Ensure sources of healthy fats – olive oil and other vege oils, nuts, seeds, avocados
- Reduce sugars and refined carbohydrates , ensure adequate amounts of whole grains
- Avoid processed foods which are often high in fat, sugar and/or salt
- Eat organic where possible
- Drink plenty of fresh water
- Limit caffeinated beverages such as coffee, tea, caffeinated soft drinks, energy drinks
- Avoid or reduce alcohol consumption
Environmental Toxicity and Sperm Health
Hidden environmental toxins and hormone disruptions (xenoestrogens) are the most probable culprits for the reduction in sperm numbers and quality over the last 50 years. They are found all around us in a variety of unsuspecting places, such as cleaning products in the home, plastic food packaging, and personal care products that we use on a daily basis. Many men also work with and around toxic substances, chemicals and heavy metals, which can be damaging to sperm cells. Precautionary measures should always be taken when exposed to such substances
Exposure to various kinds and amounts of radiation can ultimately affect fertility. This is due to the sensitivity of germ cells to x-rays and gamma rays. This includes laptops on laps, cell phones in pockets and electric blankets.
Cell phone usage has been linked with decreases in progressive motility of sperm, sperm numbers and morphology.
One study evaluating 52 men demonstrated that men who carried a cell phone around the belt line or hip region were more likely to have decreased sperm motility compared to men who carried them elsewhere or who did not carry one at all.