Male Factor infertility

What is male factor infertility?

The World Health Organisation (WHO) standard for ‘normal’ sperm is as follows:

• Volume >1.5 ml
• Sperm count >15 million / ml
• Motility (progressive) >32%
• Motility (total) >40%
• Morphology >4%

Male factor infertility will be present in 30–50% of couples, either as the single major cause of their fertility problem or as part of multi-factorial problem with both male and female factors being present.  The number of myths surrounding male potency and fertility are reducing as we develop an increased understanding of some of the causes.  It is important to note there is no good evidence of a world-wide decline in fertility rates, although there have been some reports from individual countries suggesting a decline in sperm quantity, possibly due to environmental causes.

Low sperm morphology (fewer than 5% of the sperm appear normal when assessed microscopically) can contribute to infertility. It can occur even with normal sperm numbers and motility. It is an important part of detailed semen analysis but is not always done at some pathology laboratories.  However, accurately measuring sperm morphology notoriously difficult.

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 semen analysis 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 semen analysis 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 fertility clinic 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).

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.  See below for more details
• 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 (one serve with each meal) – 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

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.

Options for male factor infertility

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.

There are several treatment options in the ‘Making Babies: with Help’ section