Issuu on Google+

MALE INFERTILITY A CHILD OF MY OWN

A BOOKLET IN THE SERIES OF CONSUMER GUIDES ON MALE REPRODUCTIVE HEALTH FROM www.andrologyaustralia.org


First published in May 2004 by Andrology Australia 3rd Edition, January 2011 © Copyright 2011, Andrology Australia Health information in this booklet describes MALE INFERTILITY. Diagnosis and treatment options are described to help men and their families understand the health problem, make men aware of the available treatment options, and to help make talking with their doctor easier. The information contained in this booklet is based on up-to-date medical evidence. It has been provided for educational purposes only. It is not intended to take the place of a clinical diagnosis or medical advice from a fully qualified health professional. Andrology Australia urges readers to seek the services of a qualified health professional for any personal health concerns. Although the information in this booklet has been carefully reviewed, Andrology Australia does not take any responsibility for any person using the information or advice available in this booklet. Information is given on the understanding that users take responsibility for checking the relevance and accuracy of the information. Andrology Australia (The Australian Centre of Excellence in Male Reproductive Health www.andrologyaustralia.org) is an initiative funded by the Australian Government Department of Health and Ageing.


MALE INFERTILITY Infertility – Not just a female problem! Men are often shocked to discover that difficulties in having a baby are because of reproductive problems on the male side. Problems with the number or quality of sperm being made can stop many couples from becoming pregnant.

Talking with your doctor about personal health concerns is the ďŹ rst step towards improving your health and quality of life

It is estimated that in Australia, male infertility affects about one in every 20 men. Despite the popular belief that infertility is usually because of female (gynaecological) problems, in about one in five infertile couples, there are problems relating only to the male. Coping with male infertility can be very difficult. Men can often become stressed and frustrated as in nearly half of cases, doctors can find no reason for poor sperm production. Today many infertile men become the fathers of healthy children. Some men, when the reason for their infertility can be explained and fixed, have treatment and then conceive naturally. Others use assisted reproductive technologies, donor sperm, adoption or foster parenting.

MALE INFERTILITY 1


Contents Male reproduction ................................ Signs & symptoms ................................ Causes ................................................... Diagnosis ............................................... Semen analysis ....................................... Treatment ............................................... Prevention ............................................... Having a family ..................................... Emotional issues .....................................

3 13 15 19 28 33 38 43 58

Appendices Hormonal problems ................................ Genetic & chromosomal problems ......... Undescended testes ................................. Infections ................................................. Torsion of the testis ............................... Heat ........................................................ Varicocele ................................................ Sperm antibodies ................................... Vasectomy ............................................... Absence of vas deferens ......................... Erection & ejaculation problems ............. Testicular cancer & fertility .................... Medicines & other drugs ....................... Radiation ..............................................

64 66 70 72 75 77 79 81 84 87 89 94 98 101

Support ................................................... 103 Glossary .................................................. 106 Authors ................................................... 113 At a glance ............................................ 114 References ............................................... 116


MALE REPRODUCTION What are sperm? Sperm are the male reproductive cells. To have a child, genetic material from the sperm must combine with the genetic material from an egg, in a process called fertilisation. Healthy, fully developed sperm are very small (0.05 millimetres long) and cannot be seen by the human eye. These mature sperm are highly specialised cells and are made up of three parts: a head, neck and tail. In the head is a structure called the nucleus, which contains 23 tightly packed chromosomes (genetic material). The head is designed to bind to and then penetrate (enter) the egg. The neck joins the head to the tail. The part of the tail nearest the neck contains the mitochondria, which provides the energy for the sperm to move. The tail moves in a whipping motion to push the sperm towards the egg.

A man’s fertility and sexual characteristics depend on the normal functioning of the male reproductive system

Healthy, mature sperm with a normal shaped head, neck and tail.

MALE INFERTILITY 3


MALE REPRODUCTION Where are sperm made? The male reproductive tract is made up of the testes, a system of ducts (tubes) and other glands opening into the ducts. The testes (testis: singular) are a pair of egg shaped glands that sit in the scrotum next to the base of the penis on the outside of the body. Each normal testis is 15 to 35ml in volume in adult men. The testes are needed for the male reproductive system to function normally. The testes have two related but separate roles: • Production of sperm • Production of the male sex hormone, testosterone

Anatomy of male reproductive system.

MALE INFERTILITY 4


Before birth, the developing testes move down from the abdomen into the scrotum. Successful descent of the testes is important for fertility as a cooler temperature in the scrotum is needed for sperm production and normal testicular function. The location of the testes in the scrotum keeps the testes about 2째C below normal body temperature. Sperm are made in the testes in a number of small, tightly packed, fine tubes called seminiferous tubules. These tubules have a total length of 150 metres. Between the seminiferous tubules lies another cell type, Leydig cells. These cells, which produce the male sex hormone testosterone, lie close to blood vessels so that testosterone can be transported throughout the body in the blood.

Cross-section of the testes showing sperm-producing tubes (seminiferous tubules) and Leydig cells.

MALE INFERTILITY 5


MALE REPRODUCTION How are sperm made? Spermatogenesis (sperm production) is a lengthy, but continuous, process. Within the testis, sperm can be at different stages of development, with some sperm at early stages and others at later stages. It takes about 70 days for germ cells (in men, these are the cells in the testis that develop to produce immature sperm cells) to develop into the mature sperm found in semen that can fertilise an egg. This means that the sperm released from the testis today started their development weeks earlier. The germ cells in the lining of the seminiferous tubules divide over and over again to produce sperm. The process of sperm production starts with the earliest germ cell, called a spermatogonium. These dividing cells pass through many stages and undergo a major change in shape, from a round cell (spermatid) to the familiar ‘tadpole-like’ sperm. At this final stage, sperm are released from the lining of the sperm-producing tubes and pass out of the testis into the epididymis.

MALE INFERTILITY 6


Cross-section of sperm-producing tube (seminiferous tubule) in the testis. Sperm develop in the lining of the tube and are supported by larger ‘supporting’ cells called Sertoli cells. After developing through stages of spermatogonium, spermatocyte and spermatid, then when mature, sperm are released into the hole in the middle (lumen) and pass out of the testes.

Where are sperm transported? Leading from each testis is a long, highly-coiled tube called the epididymis that lies at the back of the testes. The epididymis connects the seminiferous tubules to another single tube called the vas deferens. When released from the testis, the sperm spend two to 10 days passing through the epididymis. During this journey, the sperm mature and gain the ability to become motile (swim or move). When ejaculation starts, sperm are transported from the tail of the epididymis, via the vas deferens, to the urethra (urinary tract) in the penis. To achieve a pregnancy, sperm must be put into the vagina at the fertile time of a woman’s menstrual cycle. MALE INFERTILITY 7


MALE REPRODUCTION Sperm must then travel through the woman’s uterus (sometimes called the ‘womb’) and into the uterine tubes where they meet the egg. Fertilisation of the egg happens when moving sperm bind (stick) to and then penetrate (enter) the egg.

How do hormones control sperm production? Hormones from the pituitary, a small gland at the base of the brain, control the testes. The pituitary gland releases both follicle stimulating hormone (FSH) and luteinising hormone (LH) into the blood. These hormones act as ‘keys’ that ‘turn on’ the testes.

The hormonal links between the pituitary and the testes.

MALE INFERTILITY 8


The levels of FSH and LH in the blood rise during the early stages of puberty, and under their influence, the testes grow and mature. With the help of LH, the Leydig cells in the testis make the male sex hormone, testosterone. Testosterone is responsible for many of the physical changes in young boys at puberty including development of the genitals, facial and body hair and other characteristics of the adult male. Together with testosterone, FSH from the pituitary gland acts on the seminiferous tubules in the testes to stimulate the production of sperm.

How are sperm ejaculated? At the start of ejaculation, waves of muscle contractions transport the sperm, with a small amount of fluid, from the epididymis through to the vas deferens. At the back of the bladder, the vas deferens becomes the ejaculatory ducts, which pass through the prostate gland to join the urinary tract, by entering the prostatic urethra (the section of the urethra that is located in the centre of the prostate). The prostate gland produces fluid that mixes with the sperm in the prostatic urethra. Extra fluid from the seminal vesicles enters the urethra via the ejaculatory duct. The passage of fluid along the urethra is further helped by the lubricating fluid made by the Cowper’s glands. MALE INFERTILITY 9


MALE REPRODUCTION This mixture of fluid from the testes and other accessory glands, travels along the penile urethra (the section of the urethra located in the penis) to the tip of the penis where it is ejaculated (released) at the time of orgasm (sexual climax).

What is semen or seminal fluid? Sperm in semen (seminal fluid) are ejaculated from the penis. Semen is the mixture of fluids from the different organs of the male reproductive tract. About 90 per cent of the ejaculated semen comes from the prostate gland and seminal vesicles. Only a small amount of fluid, which also contains the sperm, comes from the epididymis. During ejaculation, usually the sperm and the prostatic fluid come out first and the seminal vesicle fluid follows. How many sperm are needed to achieve pregnancy? The ejaculate of fertile men contains tens of millions of sperm. However, men with much lower numbers of sperm can still achieve pregnancies. Men who never produce any sperm in their ejaculate are sterile and cannot get a partner pregnant without some form of treatment.

MALE INFERTILITY 10


Where can sperm production go wrong? The sperm production process can be interrupted at various stages for a number of reasons: • Absence of germ cells (or Sertoli cell-only syndrome): The testis may completely lack the developing cells (germ cells) that normally divide to become sperm. This is a severe form of sperm production problem and makes the man sterile if there are no sperm in the semen or in the testes • Maturation or germ cell arrest: Sometimes germ cells stop developing and do not become mature sperm • Hypospermatogenesis: When the number of sperm produced is lower than normal, only smaller numbers travel from the testes through the male reproductive system and into the ejaculated fluid.

How common is male infertility? Infertility is a widespread problem. For about one in five infertile couples the problem lies solely in the male partner (male infertility).1 In about one in four couples, there are problems with both male and female partners, and in about one in seven infertile couples, the cause of the problem cannot be found (idiopathic infertility).

MALE INFERTILITY 11


MALE REPRODUCTION It is estimated that one in 20 men have some kind of fertility problem with low numbers of sperm in their ejaculate. However, only about one in every 100 men produces no sperm in their ejaculate.

Both male & female problems

No known cause for infertility

27%

15%

Female problems only

Male problems only

20%

Proportion of couples with infertility problems.2

MALE INFERTILITY 12

38%


SIGNS & SYMPTOMS What is male infertility? Reproduction (or making a baby) is a simple and natural experience for most couples. However, for some couples it is very difficult to conceive. A man’s fertility generally relies on the quantity and quality of his sperm. If the number of sperm a man ejaculates is low or if the sperm are of a poor quality, it will be difficult, and sometimes impossible, for a couple to become pregnant.

Many men will still be able to father children naturally even though they may have a lowered sperm count

Male infertility is diagnosed when, after testing of both partners, reproductive problems have been found in the male partner.

Are there any signs or symptoms of male infertility? In most cases, there are no obvious signs of infertility. Intercourse, erections and ejaculation will usually happen without difficulty. The quantity and appearance of the ejaculated semen generally appears normal to the naked eye. Medical tests are needed to find out if a man is infertile.

MALE INFERTILITY 13


SIGNS & SYMPTOMS When should couples get medical advice for fertility problems? Couples not using any form of contraception, who do not become pregnant after a year of regular (at least twice weekly) sexual intercourse should see a doctor and have some tests. However, couples should seek medical help earlier if there are known reproductive problems, or if the female partner is nearer the end of her reproductive life (older than 35 years). A doctor can be asked questions about the timing of sexual intercourse and other facts about the reproductive system. Some basic answers can sometimes help couples and lower their stress and anxiety. Some couples will be worried that things are ‘not working’ after only a few months, and they may find it helpful to talk about their concerns with their doctor.

MALE INFERTILITY 14


CAUSES What are the known causes of male infertility? Male infertility can be caused by problems that affect sperm production or the sperm transport process. With the results of medical tests, the doctor may be able to find a cause of the problem. Known causes of male infertility can be: Sperm production problems: The most common cause of male infertility is due to a problem in the sperm production process in the testes. Low numbers of sperm are made and/or the sperm that are made do not work properly. About two thirds of infertile men have sperm production problems. Blockage of sperm transport: Blockages (often referred to as obstructions) in the tubes leading sperm away from the testes to the penis can cause a complete lack of sperm in the ejaculated semen. This is the second most common cause of male infertility and affects about one in every five infertile men, including men who have had a vasectomy but now wish to have more children. Sperm antibodies: In some men, substances in the semen and/or blood called sperm antibodies can develop which can reduce sperm movement and block egg binding (where the sperm attaches to the egg) as is needed for fertilisation. About one in every 16 infertile men has sperm antibodies.

MALE INFERTILITY 15


CAUSES See Andrology Australia’s guide on Erectile Dysfunction for more information

Sexual problems: Difficulties with sexual intercourse, such as erection or ejaculation problems, can also stop couples from becoming pregnant. Sexual problems are not a common cause of infertility. Hormonal problems: Sometimes the pituitary gland does not send the right hormonal messages to the testes. This can cause both low testosterone levels and a failure of the testes to produce sperm. Hormonal causes are uncommon, and affect less than one in 100 infertile men. [See Section: ‘Appendices’ for more information on the known causes of male infertility]

Why is there no known reason for some fertility problems? Unfortunately, medical scientists do not yet understand all the details of sperm production and the fertilisation process. As a result, for many men with a sperm production problem, the cause cannot be identified. Medical research continues to try and understand the cause of male infertility problems.

MALE INFERTILITY 16


Known causes of male infertility

Sperm production problems

• Chromosomal or genetic causes • Undescended testes (failure of the testes to descend at birth) • Infections • Torsion (twisting of the testis in scrotum) • Heat • Varicocele (varicose veins of the testes) • Medicines and chemicals • Radiation damage • Unknown cause

Blockage of sperm transport

• • • •

Sperm antibodies

• Vasectomy • Injury or infection in the epididymis • Unknown cause

Sexual problems (erection and ejaculation problems)

• • • • • • •

Hormonal problems

• Pituitary tumours • Congenital lack of LH/FSH (pituitary problem from birth) • Anabolic (androgenic) steroid abuse

Infections Prostate-related problems Absence of vas deferens Vasectomy

Retrograde and premature ejaculation Failure of ejaculation Infrequent intercourse Spinal cord injury Prostate surgery Damage to nerves Some medicines

MALE INFERTILITY 17


CAUSES Why is timing of intercourse important? Infrequent sexual activity is a common reason couples do not become pregnant within the first few months. For the best chance of conception, sexual intercourse should take place at the time of ovulation (i.e. when an egg is released into the female reproductive tract). This usually happens about 14 days (range 12 to 16 days) after the first day of a woman’s period, as is the most fertile time of the month (for a woman with regular 28 day cycles). Doctors usually suggest to couples that to improve their chances of fertility, they should have sex daily or at least every second day over this fertile period.

MALE INFERTILITY 18


DIAGNOSIS How is male infertility diagnosed? If a couple has been trying to get pregnant without success, they should go to their local doctor, family planning or women’s health clinic, and have some initial tests. Both partners should be tested, even if one has already had a child in another relationship. In many cases, both male and female problems are found to be contributing to the difficulties couples experience when trying to get pregnant.

What will the doctor do? A doctor will take a medical history from the man to find out whether there are any obvious health problems that could affect fertility. A doctor will also ask questions that include how long the couple has been trying to get pregnant, and how often sexual intercourse happens. A physical examination is also done. This can be the first full health check for many young men and sometimes identifies other unrelated health problems. A doctor will refer the man to a laboratory for a semen analysis. A semen analysis will check the number, movement and shape of the sperm in the ejaculate. Blood tests may also be done to check the hormone levels that control sperm production. Genetic investigations and testicular biopsies are sometimes done.

MALE INFERTILITY 19


DIAGNOSIS What is involved in a physical examination? During the physical examination, the doctor will check: • The amount and spread of body, pubic and facial hair • Possible swelling in the breasts • Any sign of previous surgical scars in the groin or scrotal areas • Size and shape of the penis • Position of the testes in the scrotum • Size and feel of the testes • Possible enlargement or lumps on the epididymis • Presence of the vas deferens, usually felt at the neck of the scrotum just above the testes • Possible varicocele development which means checking the blood vessels at the top of the scrotum, both while the man is lying down and standing up • In some cases, a rectal examination is done to check the prostate gland for signs of possible inflammation

MALE INFERTILITY 20


Ultrasound may be used if the testes are difficult to feel or if there are lumps that need further testing.

What is tested as part of a semen analysis? Semen analysis is the laboratory testing of freshly ejaculated semen that usually has been produced by masturbation. It is a vital part of the testing of the male partner. Specially trained laboratory personnel are needed to do this test accurately and therefore semen analysis should be done in laboratories with this expertise. A semen analysis checks that sperm are present in the ejaculate and helps find if there is a problem with the number or quality of sperm being produced. [See Section: ‘Semen Analysis’ for more information]

The semen analysis includes checking: • The volume, pH (measure of acidity/alkalinity) and consistency of the semen sample • Sperm concentration: The number of sperm in the ejaculate • Sperm motility: The number of sperm that are moving and if they travel in a fast, forward movement • Sperm morphology: The number of sperm with an abnormal shape

MALE INFERTILITY 21


DIAGNOSIS Semen analysis checks all the components of semen

• The presence of sperm antibodies. Sometimes, the immune system recognises the man’s own sperm as foreign and develops antibodies against them which can cause fertility problems • The presence of white blood cells in the ejaculate. High numbers of white blood cells may be a sign of an infection of the reproductive tract

What hormones are tested? Testosterone and the pituitary hormones, FSH (follicle stimulating hormone) and LH (luteinising hormone) circulate in the blood and can be easily measured in a blood test if hormonal problems are suspected. Combined with results from a semen analysis, the following diagnoses can be possible causes of male infertility. However, reasons for infertility can be different for each individual man.

MALE INFERTILITY 22


Sperm FSH numbers

LH

Testosterone

Low or zero

Very Low

Very Low

Very Low

Pituitary gland problems can cause poor FSH and LH production, which lead to low testosterone and infertility

Low or zero

Very High

Very High

Low to Normal

High levels of FSH and LH, together with low to normal levels of testosterone, show a problem in the testes

Low or zero

Very High

Normal

Normal

In many infertile men, the testosterone producing cells (Leydig cells) in the testes are working normally and only the sperm-producing tubules (seminiferous tubules) are a problem. The body makes more FSH to try and overcome the problem

Zero

Normal Normal

Normal

Possible blockage to sperm flow

MALE INFERTILITY 23


DIAGNOSIS What genetic tests may be done? Chromosomes are found in each cell of the human body. They carry the genetic material that determines growth and development of all human characteristics including hair colour, eye colour, height and gender. Each cell in the body normally has 23 pairs of chromosomes (or a total of 46). Of the 23 pairs of chromosomes, one pair are sex chromosomes which determine a person’s gender. The normal male chromosome arrangement is 46XY. One of each chromosome comes from the mother and the other from the father. Females always pass on an X chromosome, but males can pass on an X or a Y chromosome. The Y chromosome directs the development of the testes. Changes to chromosomes can lead to poor sperm production. Sometimes otherwise healthy men with very low sperm counts can have genetic disorders, particularly in the number of their chromosomes that they may not have known about before. A blood test called a karyotype measures the number and structure of chromosomes in each cell. A common genetic disorder that causes infertility is Klinefelter’s syndrome. Men with this problem have an extra X chromosome (47XXY).

MALE INFERTILITY 24


Another blood test which can be done by a few specialised laboratories in Australia is called the Y chromosome deletion test. The Y chromosome deletion test checks if important genetic material, which controls sperm production, is missing on the male sex chromosome (Y chromosome). This genetic problem is found in about one in 20 men with low sperm counts. Rarer genetic causes of infertility are usually recognised when the doctor does a clinical examination. Special tests may then be done, particularly if there is a risk of passing on a serious condition to the children, such as cystic fibrosis, which is a condition associated with the absence of the vas deferens.

MALE INFERTILITY 25


DIAGNOSIS What other tests may be done? Other medical tests may be needed to identify specific medical conditions: Testicular biopsy: Tissue samples are sometimes removed from the testes for testing under local anaesthetic. Sometimes this procedure is done under general anaesthetic. A small needle is inserted into the testes a few times and tiny pieces of testicular tissue, about half the size of a match head, are removed. These tissue samples are then checked for sperm under a microscope. A testicular biopsy is quite safe but infection and bleeding can sometimes happen. These problems generally clear up in a few days. In a man with no sperm seen in his semen, this test can help determine if a blockage in the reproductive tract is the problem or if sperm are not being produced Urine analysis: Tests on urine are sometimes done to check for retrograde ejaculation which means that semen moves into the bladder during orgasm, rather than being ejaculated out of the tip of the penis. For men with this problem, the sperm is washed out when they next urinate after ejaculation. This test is most commonly done if the ejaculate volume (amount of semen ejaculated) is low or zero.

MALE INFERTILITY 26


What if no cause is found? For most men, test results can show if there is a sperm production problem, a hormonal problem, a blockage to sperm transport or an ejaculation problem and treatment can then be chosen. Unfortunately, for men with a sperm production problem, the cause is often not known. For other men, everything can seem normal, including the semen test results, and there is no clear reason why pregnancy is not happening. Infertility, where the cause is unknown, is called idiopathic infertility. Couples with this problem can seek help to conceive using assisted reproductive technologies (ART) such as IVF (in vitro fertilisation). [See Section: ‘Having a Family’ for more information]

Is a specialist referral needed? General practitioners can do initial testing for couples who are having difficulty getting pregnant. However, if the semen analysis is abnormal, a referral to an infertility specialist, who may also be an endocrinologist, urologist or gynaecologist, is needed, as the treatment is often more involved.

MALE INFERTILITY 27


SEMEN ANALYSIS A semen analysis is a vital part of diagnosing male infertility

What is semen analysis? Semen analysis is the laboratory testing of freshly ejaculated semen. Under a microscope, the number, shape and movement of sperm are measured. Where should men go for semen analysis? Special equipment and expertise are needed to accurately do a semen analysis. Therefore testing should take place at specialised laboratories that use methods approved by the World Health Organisation (WHO). How is semen collected for testing? Semen testing should be done on a freshly ejaculated semen sample (within two hours of being produced). For the test, a semen sample is best produced into a jar by masturbating in a private room at the laboratory. It is important that none of the semen sample is lost. As sperm are mostly in the first part of the ejaculate, losing the first part of the ejaculate can give a false reading of a lower sperm count. It is also important that the man does not have sexual intercourse or masturbate for about two (but up to five) days before the test, as frequent ejaculations could also lower the sperm count. Too long a period between ejaculations may also lower the sperm quality. An individual’s semen quality can vary greatly between samples, even in fertile men. Sperm counts can be affected by illness. Fevers and infections can

MALE INFERTILITY 28


temporarily lower a sperm count for several months. At least two semen analyses are needed to properly check fertility. These tests should be done at least six weeks apart.

What does a semen analysis report cover? A number of different items are tested and recorded in a semen analysis report, including: Semen volume (also known as the ‘volume of semen’): The total amount of fluid ejaculated. Men normally produce two to five millilitres (mls) of semen when they ejaculate. Sperm concentration (commonly known as a sperm count): the number of sperm in a measured volume of the ejaculate is counted. The sperm concentration is reported as the number of sperm per millilitre (ml) of semen. Sperm output per ejaculate (also known as the total sperm count): This is total number of sperm in the ejaculate as is calculated by multiplying the semen volume by the sperm concentration. Sperm motility (the ability of sperm to swim or move forward): The number of motile (moving) sperm compared to non-motile sperm is reported as a percentage of the total number of sperm. Sperm morphology (the sperm’s shape and physical features): The number of sperm that are imperfectly shaped (often referred to as ‘abnormal’) MALE INFERTILITY 29


SEMEN ANALYSIS is compared with the number of normally shaped sperm. This is recorded as a percentage of the total number of sperm. Defects in the shape of the sperm heads or tails can affect their movement and ability to bind to and fertilise an egg. When checked using strict WHO methods, this morphology result can give an indication of the sperm’s chances of fertilising an egg in a test-tube (in vitro). It is quite common for fertile men to have a small number of normally shaped sperm however, the chance of a man being fertile falls when the proportion of perfectly normal sperm is less than 4 per cent of all the sperm. In very rare cases, some men have sperm that all have round heads (globozoospermia) and these men will not be able to get pregnant naturally. White blood (inflammatory) cells: Often found in the semen ejaculate. Large numbers of white blood cells in the ejaculate can be a sign of an infection of the reproductive tract. However, in some men, large numbers of white blood cells can ‘come and go’ over time for no known reason. Semen pH: Levels are measured to determine if the ejaculate is acidic or alkaline. Semen should be slightly alkaline. More acidic semen, together with a low amount (volume) of semen, can mean there is a possible blockage in the ejaculatory ducts. Sperm antibodies in semen: An important test, normally done in specialised laboratories MALE INFERTILITY 30


using methods approved by the World Health Organisation. Sperm antibodies can happen in some men when the immune system considers its own sperm to be foreign and develops antibodies against them. Sperm antibodies commonly happen in men after vasectomy. Antibodies attach themselves to the sperm to reduce the sperm’s movement. The sperm clump together, making it difficult to pass through the mucus in a woman’s cervix. In the fertilisation process, the sperm and egg recognise each other by substances (receptors) on their surface. If antibodies are bound to sperm, these receptors are covered by the antibodies and stop the sperm from binding (sticking) to the egg.

What is a normal semen analysis result? The World Health Organisation (WHO 2010)3 published reference values to help work out how an individual semen analysis result compares to a fertile population of men. A semen analysis value within the reference ranges does not guarantee fertility in an individual man, but gives a guide as to whether a man may be fertile. Men whose semen analysis falls within these ranges may not be fertile as a result of other unknown reasons. In the same way, men who have very low counts and are not within these reference ranges might still be able to get a partner pregnant naturally. So for example while 15 million sperm per ml is the new lower value for sperm MALE INFERTILITY 31


SEMEN ANALYSIS concentration, this does not mean that men with 2 million sperm per ml are always infertile. About 30 per cent of such couples will have a spontaneous pregnancy over a 2 to 3 year period. Other major factors that can affect a couple’s chance of getting pregnant, include how severe the sperm defect is, the length of time the couple have tried to conceive, and the age and fertility of the female partner. A man’s semen quality needs to be interpreted with other clinical information by a doctor. It is also important to remember that a couple’s chance of getting pregnant and the time it takes to become pregnant is also affected by the female partner’s fertility.

Are other tests done as part of a semen analysis? In some instances, men may need to provide a urine sample after ejaculation if the doctor thinks there is an ejaculation problem (retrograde ejaculation). The urine is checked for sperm. In severely infertile men, sperm DNA may be damaged which reduces the chance of the sperm producing a healthy embryo and live birth. Different methods for testing sperm DNA damage are available; however, more research is needed to decide if these tests have a role in routine clinical practice.

MALE INFERTILITY 32


TREATMENT Can male infertility be treated? The results of medical tests help doctors decide whether the male infertility problem can be treated.

IVF does not cure infertility, but it may help a couple achieve a pregnancy

Treatable conditions: One in eight infertile men has a treatable condition, and after treatment couples can become pregnant naturally. Untreatable sub-fertility: Three quarters of infertile men have sperm present in the semen, but in lower numbers than normal. The problem causing the poor production or function of their sperm is often not able to be identified and cured. These men are often referred to as being ‘sub-fertile’ as pregnancies may happen but at lower rates than usual. On average, more months of trying are needed for conception to happen, however it still may never happen. Assisted reproduction or in vitro fertilisation (IVF) can help some of these men to become fathers. Untreatable male sterility: About one in nine infertile men have no sperm in their semen or in their testes and cannot often be treated. Sperm producing cells in the testes either did not develop or have been irreversibly destroyed. Adoption or donor insemination are the only possibilities for couples in this group who wish to have a family.

MALE INFERTILITY 33


TREATMENT How is the best treatment decided? Using the results of physical examinations and the laboratory tests, a doctor can usually work out if difficulties in becoming pregnant are because of a problem with the male partner and if the condition is treatable. Possible treatments may then be explained. Doctors will also discuss the chances of becoming pregnant naturally, when certain male infertility problems exist. Many men will still be able to father children naturally even though they may have a lowered sperm count. In some cases, the doctor will recommend that the couple seek assisted reproductive technologies (such as IVF) in order to become pregnant. These techniques do not cure or treat the cause of the male infertility problem, but they may help the couple conceive even if the man’s sperm count is very low. [See Section: ‘Appendices’ for more information about specific infertility conditions and their treatment]

What causes of male infertility can be treated? In some cases, the cause of the male infertility problem can be treated and a couple can try and become pregnant naturally.

MALE INFERTILITY 34


Treatable causes of male infertility include: • Blockage of sperm transport (e.g., vasectomy) • Hormonal problems • Some sexual problems (for example, problems with getting and keeping an erection) • Some reversible conditions (for example, use of anabolic steroids)

When is male infertility completely untreatable? Male infertility is completely untreatable when a man has no sperm in his semen (azoospermia) or in the testes, because the sperm producing cells in the testes either did not develop or have been permanently destroyed. Azoospermia may be caused by chromosomal or genetic disorders, inflammation of the testes or certain medicines (especially cancer treatments). It may also be because the testes did not descend into the scrotum at the time of birth (undescended testes). The only options for such couples who want to have a family are to think about adoption, foster parenting or donor insemination. [See section: ‘Having a Family’ for more information]

MALE INFERTILITY 35


TREATMENT See Andrology Australia’s guide on Androgen DeďŹ ciency for more information

Some men with testicular damage and failure of sperm production do not produce normal amounts of the male sex hormone, testosterone, resulting in lower levels in the blood. Lower levels of testosterone can lead to lower libido (interest in sex) and lower energy levels, hot flushes and other symptoms. The general health and sexual interest of such men can be improved through testosterone replacement therapy, but sperm production does not improve with such treatment.

Can natural therapies improve sperm production? There have been many natural products marketed to improve unexplained sperm production problems, such as vitamins, antioxidants and zinc supplements, antibiotics (even when no infection is present) and various other natural therapies. At this stage, there is no good medical research that such therapies improve the chance of having a child. Men should talk to their doctor when thinking about using natural therapies that are marketed as products to improve fertility.

MALE INFERTILITY 36


What about assisted reproductive technologies (ART) as a treatment option? If the chance of conceiving naturally is low, assisted reproductive technologies (such as IVF) can greatly increase the couple’s chance of becoming pregnant. It is important to realise that with all medical treatments, including IVF, there are some risks. Even when the fertility problem relates only to the man, IVF procedures place the female partner at risk of side-effects and problems. Deciding on treatment needs careful thought and should be talked about with the doctor. [See section: ‘Having a Family’ for more information]

MALE INFERTILITY 37


PREVENTION Lifestyle behaviours can affect fertility

Can male infertility be prevented? Cigarette smoking, alcohol, sexually transmitted diseases, heat stress from tight fitting underwear, and anabolic steroids (taken for body building or sporting purposes) can be harmful to the production of sperm and should be avoided. How does cigarette smoking affect male fertility? Research on the effect of smoking on semen quality is unclear. However, it is generally recommended that men quit smoking for their long term health. Quitting smoking is particularly important if a man is trying to have children because of the passive smoking effects on their partner and children. How does alcohol affect fertility? Moderate alcohol intake (one to two standard drinks per day) does not affect sperm production. However, a large amount of alcohol may cause liver damage, which could have an effect on general and reproductive health.

What sexually transmitted infections can affect fertility? Sexually transmitted infections (STIs), such as gonorrhoea and chlamydia, can damage the epididymis and stop sperm passing from the testes into the ejaculate. Genital herpes, while MALE INFERTILITY 38


not affecting sperm production or transport, is a problem when spread to a female partner, particularly if a couple is trying to get pregnant. HIV may stop sperm production in the later stages of the disease.

There is ongoing debate about the effect of underwear styles on sperm production

It is important for men who think they may have a STI to get immediate treatment from a doctor. This can stop the spread of the disease to a partner and also reduce the chance of blockages developing in the male reproductive tract. For men not wanting a family, safe sex practices using condoms are recommended outside stable monogamous relationships. Both partners may want to be tested for STIs before trying to have a family. This may stop any disease being passed on to partners or children.

Do underwear styles really affect fertility? Whether looser (cooler) boxer shorts are better than tighter (warmer) briefs is unclear. Some research has suggested that wearing tight underwear can decrease sperm counts, although other studies have not found this to be the case. Doctors usually suggest that men reduce the chances of heat stress on sperm production by avoiding tight-fitting clothing before and while trying to conceive.

MALE INFERTILITY 39


PREVENTION How do spas and saunas affect fertility? It is generally recommended that men avoid spas, saunas and hot baths if trying to father a child. Raising body temperature, and particularly the temperature around the testes when sitting in hot water for a long period of time, can reduce sperm production. How do vaginal lubricants affect the chances of becoming pregnant? Many vaginal lubricants kill sperm. If couples are trying to become pregnant, vaginal lubricants should not be used during the fertile time in the female partner’s menstrual cycle. Do recreational drugs affect fertility? Androgens (anabolic steroids), taken for body building or sporting purposes, reduce sperm production by stopping the hormones made by the pituitary gland. Androgens can also be harmful to general health if men who have normal testosterone levels take them. These drugs should be stopped straight away, particularly if a couple is trying to have a baby. Other illegal use of drugs, such as marijuana and heroin, may also affect fertility.

What work environments affect fertility? Although there is no clear scientific research that some work environments affect fertility, it is generally recommended that couples trying to MALE INFERTILITY 40


become pregnant avoid exposure to any possible harmful chemicals. Pesticides, heavy metals, toxic chemicals and radiation may affect the quality and quantity of sperm produced. For men who work in occupations that may affect fertility, it’s important to wear protective clothing and follow all occupational health and safety guidelines.

Is age important when trying to have a family? Healthy men in their 70s and beyond can still father children, however the time taken to cause a pregnancy is longer from middle-age onward.4 Reasons for this may include a decrease in sexual activity, semen volume, sperm motility (movement), the total number of motile sperm and possibly sperm function and DNA quality.5 Some genetic and chromosomal problems in offspring also increase as the male age increases.

Can storing sperm prevent loss of fertility with some treatments? Sperm storage is the collection (through masturbation) and freezing of semen. Men about to start treatment that could make them infertile, such as treatment for cancer, may want to consider storing sperm before starting treatment. If and when a couple want to have a family this semen can be thawed and used in fertility

MALE INFERTILITY 41


PREVENTION Infertility centres, which provide assisted reproductive technologies, usually offer longterm sperm storage facilities

treatments such as vaginal insemination at the time of ovulation or, in some cases, through IVF. All men and teenage boys who have started or passed puberty and who are about to receive chemotherapy or radiotherapy should consider sperm storage before their cancer treatment starts. Men who need to take medicines for other health reasons when they are also trying to start a family, should check with their doctor to make sure that the medicine does not cause infertility. If medicines cause infertility, such as Salazopyrin® (used to treat inflammatory bowel disease), men can also store sperm before starting treatment. Men who have taken pituitary hormone treatments in order to improve sperm production, but wish to stop this therapy after their first child has been born, may wish to store some sperm for possible later pregnancies. Men planning a vasectomy should think about storing sperm before having this procedure. Semen storage may remove the possible need for a vasectomy reversal or IVF at a later stage. [See section: ‘Appendices’ for more information on vasectomy]

For more information on semen storage, contact the nearest IVF or fertility clinic, or talk to an infertility specialist. [See Section: ‘Support’ for more information and contact details]

MALE INFERTILITY 42


HAVING A FAMILY What are the chances of natural conception? It can often take up to a year, even for healthy fertile couples, to become pregnant. In a study 6 of the time it took women who were planning families to become pregnant: • About one third (38%) conceived in the first month of trying

Fertility drops with female age from the mid 30s onwards and rapidly from age 40, so this should be taken into account when planning a family

• About two thirds by the third month (68%) • More than three quarters by the sixth month (82%) • More than nine out of every 10 couples (92%) had conceived within a year About three to four per cent of couples who want to have children, remain childless at the end of their reproductive life phase. A small number of men who are sub-fertile and have at least some moving sperm in their semen, father children naturally whether or not the infertility problem is treated. However, it can take longer and possibly a number of years before men with sub-fertility conceive. About one third of sub-fertile couples get pregnant naturally in the first year after investigation for infertility, with almost half (45%) by two years.

MALE INFERTILITY 43


HAVING A FAMILY Even men with a zero sperm count may produce sperm in their testes that can be collected and used in assisted reproductive technologies

What are the options if natural conception is not possible? If an infertility problem cannot be treated, or treatment is unsuccessful, and it is not possible to become pregnant through sexual intercourse, there are several options available to couples wishing to have a family. These options include: • Assisted reproductive technologies (ART) such as IVF • Donor insemination • Adoption, foster parenting or permanent care • Deciding not to have children

What are assisted reproductive technologies (ART)? Assisted reproductive technologies (ART), such as IVF, do not treat the cause of male infertility. However, they can help couples become pregnant. Assisted reproductive technologies are now often used to help infertile men father children. In Australia, about four in every 10 infertile couples use ART because of a male infertility problem. Originally, IVF was developed as a medical technique to overcome female infertility. In 1993, the introduction of a technique called intracytoplasmic sperm injection (ICSI) greatly helped men with MALE INFERTILITY 44


very low sperm counts who previously could not be treated by standard IVF procedures.

What is in vitro fertilisation (IVF)? In vitro fertilisation (IVF), developed in the late 1970s, is a form of assisted reproductive treatment where sperm collected from the male is mixed with the eggs from the female partner. The female partner is given fertility drugs to produce an increased number of eggs that are removed surgically from the woman’s ovary. Sperm is collected by masturbation (or a frozen sample) and mixed with the eggs in a dish or tube. After fertilisation, the resulting embryos are then placed back into the woman’s uterus. This form of IVF works for many couples, but the pregnancy rates for couples with severe male infertility are generally quite low.

What is intracytoplasmic sperm injection (ICSI)? ICSI is a form of IVF where a single sperm is injected directly into each egg by piercing the outer covering of the egg, and is particularly helpful for men with poor sperm production. ICSI can achieve pregnancies even when only a few sperm are produced.

MALE INFERTILITY 45


HAVING A FAMILY Sperm are collected from the semen or removed carefully from the testis or epididymis. A skilled medical scientist (embryologist) injects a single sperm directly into each egg by piercing the outer covering of the egg. As for IVF, after fertilisation the resulting embryos are then placed back into the woman’s uterus.

The intracytoplasmic sperm injection technique where a sperm is placed directly into the egg.

Pregnancy rates for ICSI are the same as those for standard IVF with normal semen. Pregnancy success largely depends on other factors, such as the age and reproductive health of the female.

MALE INFERTILITY 46


What issues need to be thought about when having ICSI? Research has shown that the quality of sperm collected for ICSI is often quite poor. Some men with low sperm counts have a change in the number of their chromosomes (aneuploidy) in their individual sperm. Such extra, rearranged or missing chromosomes do not allow normal embryo development to happen. Some genetic disorders may be passed on to the child and may not appear until after birth or later in life. Male children may be at greater risk of inheriting fertility problems, especially those whose fathers have been shown to have pieces of the Y chromosome missing.

What are the risks with ART? If a couple decides to go ahead with ICSI, it should be remembered that these assisted reproductive technologies expose women to risk, such as those associated with surgical collection of eggs, and switches the focus from the man to the woman. Is there a higher rate of birth defects in children born through IVF and ICSI? Current research is looking at whether children born through IVF/ICSI are at a greater risk of birth defects or other health problems when adults.

MALE INFERTILITY 47


HAVING A FAMILY Some things a couple may want to discuss with an infertility specialist in more detail include: Congenital abnormalities Research has shown a significant increase in reported congenital abnormalities (birth defects) in babies born as a result of IVF or ICSI compared with those for babies born in the general population. Research shows that the number of babies born with birth defects increases from three to four in every 100 live births, to five to six in every 100 after IVF. There does not appear to be a difference between babies born from IVF and ICSI procedures. Congenital abnormalities do not appear to be due to the IVF or ICSI procedure but rather to the original problems in the infertile couple. Genetic problems Early studies showed a small increase in chromosomal defects in IVF or ICSI children, but a recent Australian study 7 did not find a higher risk of such chromosomal defects when conceiving a child through ART. Genetic diseases in some parents can be passed to offspring, such as inherited infertility in male children from men with part of their Y chromosome missing (Y chromosome deletions).

MALE INFERTILITY 48


Childhood development Large studies have not found any major differences in the development or abilities of children born after IVF or ICSI, when compared to those from natural conception. Premature birth Multiple pregnancies are common in IVF and ICSI when more than one embryo is transferred, which increases the chance of babies being born premature and with low birth weight. Single babies are also more likely to be premature, which seems to be related to factors in the woman not the IVF or ICSI procedures. Long term adult disease Low birth weight and premature birth is linked with an increased risk of diabetes and heart disease in later life, in both babies conceived naturally and those born through IVF or ICSI It is not clear whether IVF and ICSI babies are at any other increased risk of health problems as adults. Some research has shown that the rates of cancer in IVF children are the same as the general population.

What if there is no sperm in the ejaculate to use in ICSI? Men who have azoospermia (produce no sperm in their ejaculate) because of a sperm production problem or a blockage in the reproductive tract,

MALE INFERTILITY 49


HAVING A FAMILY can sometimes have sperm collected from the sperm-producing tubes in the testis or other parts of the genital tract. A needle biopsy (an operation to remove a small sample of tissue or cells from part of the body for testing and examination under a microscope) is sometimes done for these men. A fine needle is inserted into the testis under local anaesthetic. A biopsy can also help determine the type of problem. If mature sperm can be found in the tissues of this small sample, these can sometimes be frozen or more needle biopsies can be done to collect enough sperm for use in ICSI. For men with severe sperm production problems, where no mature sperm can be seen in a small needle biopsy sample, it still may be possible to get sperm from an open biopsy of the testis which is done under general anaesthetic. More tissue samples can be collected from several sites in this surgical procedure, which increases the chance of finding some usable sperm for ICSI.

What are the chances of finding sperm by testicular biopsy? Success rates for both needle and open testicular biopsies vary and depend on the reason for the infertility problem. The chance of finding sperm using a needle biopsy is excellent in all cases of azoospermia caused by a blockage of the reproductive tract. MALE INFERTILITY 50


Chances of finding sperm are low for men who have sperm production problems, such as germ cell arrest or Sertoli cell-only syndrome. However, the chances are better for men with hypospermatogenesis. Many couples decide that a small chance of finding sperm in an open biopsy is not worth the risk and may want to use donor sperm instead. Others may wish to take every opportunity to have their own child.

What are the risks with a testicular biopsy? A needle biopsy has an excellent safety record. Sometimes, infection and bleeding can happen and the testis can swell and be sore for several days, but these problems generally clear up easily. Less than one in 100 men has bleeding or infection after a biopsy. Discomfort is common for a few days after an open biopsy procedure. Supportive underwear may help. In some men, removal of larger biopsy samples may damage the testis and lower its ability to make the male sex hormone, testosterone. This may lead to a life-long need for testosterone replacement therapy.

See Andrology Australia’s guide on Androgen DeďŹ ciency for more information

MALE INFERTILITY 51


HAVING A FAMILY What should be expected at an infertility clinic? If a couple chooses to have assisted reproduction such as IVF, the infertility clinic will explain all the procedures and success rates for the type of infertility problem. Some things couples need to think about before starting treatment include: Possible setbacks and failure When making a decision to take part in an assisted reproduction or IVF program, it is important to know that the chance of success depends on many factors. The success of the treatment depends on the type of fertility problem, the age of the female partner and the type of treatment used. Many couples have a number of treatment cycles before conceiving while some still may never have children. Female focus Most attention during assisted reproduction is given to the woman as she has more medical procedures and the infertility specialists are gynaecologists. Men are encouraged to support their partners and to have an active role in the process. Men also have concerns such as the pressure of producing sperm when needed or about the testis biopsy procedure. It is important that men ask for help or information when needed. Staff at infertility clinics recognise the importance of men’s concerns and will try to provide support where they can.

MALE INFERTILITY 52


Semen collection For most types of IVF procedures, men will need to produce a semen sample on the day of their partner’s egg collection. In some men with very low numbers of sperm, ejaculates may be frozen before treatment as a back-up in case not enough sperm are produced on the day of IVF treatment. Private rooms at infertility clinics are available for men to produce semen samples by masturbation into the sterile containers provided. Many men have difficulty producing a semen sample under pressure. Clinics can sometimes arrange for the female partner to join the man in the room and can also provide special condoms for the collection of semen by sexual intercourse. Standard condoms cannot be used to collect semen for IVF as they usually have lubricants and spermicides in them that kill sperm. Blood tests Both male and female partners may need to have blood tests to check for infectious diseases such as HIV and hepatitis, before starting on an IVF program.

MALE INFERTILITY 53


HAVING A FAMILY Legislative guidelines on ART differ between states and territories

Legislation and Code of Practice Most clinics offering assisted reproductive technologies operate under legislative guidelines which may differ between each state and territory. When deciding to start infertility treatment, couples will be fully informed of any legislation that may affect treatment, donation and storage procedures. The treating doctor and counsellors specially trained in infertility problems are available to discuss any legislative issues and help couples make informed decisions about their treatment. The Reproductive Technology Accreditation Committee (RTAC), established by the Fertility Society of Australia, also provides a Code of Practice for clinics offering IVF and related technologies. Clinics offering assisted reproductive technologies must be accredited by RTAC. Counselling Specialised counselling services are provided in clinics offering assisted reproductive technologies. The services of a professional counsellor may help individuals and couples at times of stress, such as at initial diagnosis, and also provide information and support at any stage of treatment. In some states in Australia, counselling is compulsory before treatment starts.

MALE INFERTILITY 54


What are the success rates with ART? ICSI can result in pregnancy rates up to 50 per cent per treatment cycle. This is a major increase on traditional IVF techniques for the treatment of male infertility, which were used before ICSI was developed. A number of factors, such as the age and fertility of the female partner, need to be considered when reviewing a couple’s chance of getting pregnant by different assisted reproductive technologies. Infertility clinics can often provide more detail about pregnancy outcomes for the different treatment options they offer. The Fertility Society of Australia supports and funds the collection of the data used in the provision of overall success rates of ART throughout Australia and New Zealand. This data is collated by the Perinatal and Reproductive Epidemiology Research Unit, University of NSW (www.preru.unsw.edu.au/preruweb.nsf ).

What is donor insemination? For men who do not produce any sperm or have been unsuccessful with ICSI, donor insemination using sperm donated by another anonymous or known male may be an option. About one in 14 infertile couples need to use donor sperm to become pregnant.

MALE INFERTILITY 55


HAVING A FAMILY With donor insemination, the child receives half its genetic material from the mother. The donor is the biological father, however, in all other ways the male partner will become the legal parent. Couples using donor insemination can still share the experience of pregnancy, birth and child-rearing. Men who donate sperm go through a major screening process before becoming a donor. Legislation about the amount of information made available about the donor varies around Australia. The National Health and Medical Research Council (NHMRC) Ethical Guidelines on Assisted Reproductive Technology stipulates that procedures must be in place to allow children born from the use of donor sperm to contact their donor when they reach 18 years of age.

What other options are available to be a father? Some infertile couples, who have either been unsuccessful when trying ART or do not want to have medical treatment, choose to adopt, foster or provide permanent care to children. Adoption is a permanent legal appointment of another person as the parent of a child, whose biological parents for some reason cannot care for them. There are very few babies available for adoption in Australia, however, there are some older children in need of families.

MALE INFERTILITY 56


Adoption of babies and children from overseas is sometimes chosen by couples who are unable to conceive naturally. There are many children, especially in war torn or developing countries, who are in need of families. State government bodies are normally responsible for adoptions. For more information contact the local community or family services department. Foster parenting is also a legal arrangement but normally only short-term. Many babies and children are in need of families who can care for them for varying lengths of time. More information can be obtained from local government agencies. Permanent care is a long-term arrangement where couples or single people are given legal custody and guardianship of a child unable to live with their own family. However, the child’s name, birth certificate and inheritance rights do not change. More information can be obtained by contacting state community services departments.

MALE INFERTILITY 57


EMOTIONAL ISSUES An emotional response to infertility is normal

What emotions can a man experience when diagnosed with infertility? Most men are shocked when they find out they are infertile. There is still a common but incorrect belief that infertility is a female condition. Therefore when men are told that there is a sperm problem, they are often quite unprepared. It is not unusual for men to feel stressed about an initial diagnosis of infertility. They may also find it difficult to deal with their stress, particularly if they do not feel comfortable talking to others about their emotions. Men do not usually express their feelings in the same way as women, but the anger, guilt and anxiety felt can appear in many ways. Stress often comes from feelings of vulnerability. Being told that there is a sperm problem can have a major impact on a man’s sense of masculinity. Most infertile men at some time struggle with the idea that they are not able to do what other men can. This may lead men to confuse their infertility with their sense of masculinity, sexuality, virility and potency. It is not unusual for these men to experience erection difficulties while they try to come to terms with their diagnosis, which can sometimes affect their relationship with their partner overall.

MALE INFERTILITY 58


Most men also feel the need to understand why they are infertile. Sometimes no reason can be given, which can lead to feelings of frustration. Where possible, knowing the cause can help men accept the problem, but it can also leave them with a sense of injustice. Men and women often have different responses to a diagnosis of infertility. Women may commonly feel a sense of loss or bereavement whereas men often sense that their infertility exposes them to potential ridicule and humiliation from others. Men may then feel added stress as they try to find ways to manage this perceived situation. An emotional response to infertility is normal. Talking with a doctor and if needed a sexual therapist or a counsellor to work through these feelings can help some men at this difficult time.

What part do partners play? Female partners can play many roles in helping men cope with infertility. Many men rely heavily on their spouses or partners to talk through their concerns and uncertainties. It is common for men to be concerned about the effect of their infertility on their partners, as it is the women who must go through most of the often invasive treatment to achieve a family. These men feel it is unfair that women should be inconvenienced when the infertility treatment is not needed because of the woman’s reproductive problem.

MALE INFERTILITY 59


EMOTIONAL ISSUES Men are encouraged to talk to a doctor or a counsellor about any emotional issues

Some women try to ‘protect’ their partners by telling others that the infertility problem is solely their problem. They are concerned people might judge their husbands to be less masculine, and want to avoid unwanted curiosity from those who are not emotionally close to the couple.

Can extended family help? Due to the sensitive nature of infertility problems, it is important for men to find people they can rely on to be supportive. For some men, families provide this support. Some men have continued close relationships with both or either parents and some have brothers or sisters they can talk to. How important are men’s friends or mates for support? Australian men are known for their mateship. Many infertile men have close male friends (mates) with whom that they can talk to and discuss personal matters. The important point is that these mates are trustworthy. The conversations that these men have with each other are valuable in helping men to come to terms with their problem. What strategies help men cope? Many men see infertility problems often published in women’s magazines, usually with a positive outcome. There is usually no detail about the pain or upset involved for the couple and little, if any,

MALE INFERTILITY 60


attention is paid to the infertile man’s feelings. Many infertile men, however, experience the same dilemmas and distress and it helps to talk with men who are experiencing or have experienced the same situation.

Local patient support groups exist to help and support couples dealing with the emotional aspects of infertility

Acknowledging that infertility can create feelings of stress and anxiety is an important step towards coping with the health problem. A common stress management technique used by men is to look for a solution to the cause of the stress. In the case of infertility, this often means searching for available treatments and putting aside emotional responses. Many men see emotions as distractions. In some cases, men want solutions for their infertility, but rely on their partner to organise the details and the appointments. It is usually helpful for men to take responsibility for these matters that directly affect them.

Does knowledge and understanding help emotionally? Understanding the problem and ideally finding a reason for their infertility can help men accept their health problem. For some, knowledge can give them back a sense of control. Therefore searching the Internet, reading journal articles and finding other sources of information can be quite useful.

MALE INFERTILITY 61


EMOTIONAL ISSUES Is it healthy to laugh about infertility? Men often cope with the stress of their infertility through humour. It is typical for Australian men to respond to a problem with a joke. By laughing at their condition, men make themselves less vulnerable in a way that is socially acceptable. Ironically, by making themselves the butt of jokes, men can feel more confident and in control of difficult situations. A sense of humour often helps and can be a way of being optimistically motivated to do whatever has to come next. Is counselling worthwhile? Infertility can be a distressing condition, which is difficult to accept for many couples. Many men are reluctant to seek psychological counselling, fearing it is an admission of weakness. However, when partners set up counselling consultations, they often find such conversations surprisingly helpful. An emotional response to infertility is normal and getting expert help to work through these feelings is strongly recommended. All infertility clinics provide psychological counselling and support with counsellors specially trained in infertility problems.

MALE INFERTILITY 62


APPENDICES

MALE INFERTILITY 63


APPENDICES

HORMONAL PROBLEMS See Andrology Australia’s guide on Androgen DeďŹ ciency for more information

What hormonal problems cause infertility? Low levels of pituitary hormones is a rare cause of infertility. Low production of follicle stimulating hormone (FSH) and luteinising hormone (LH) by the pituitary gland can affect testosterone levels in the testes and reduce sperm production. The most common hormonal problems are pituitary tumours or problems with the development of the pituitary leading to a lack of FSH/LH. How are hormonal problems treated? Hormonal (often referred to as endocrine) problems are rare causes of infertility with about one in 100 infertile men having this problem. However, it is vital that these men are properly diagnosed because effective treatments can sometimes be given. FSH and LH treatments can usually improve sperm production. Human chorionic gonadotrophin (hCG) injections (which is similar to LH) once or twice a week can stimulate the Leydig cells to produce testosterone. After four to six months of treatment, FSH may also be given if sperm production has not improved using just hCG. Testosterone treatment does not boost sperm production and should not be given to men seeking fertility without specialist review.

MALE INFERTILITY 64


What are the risks of hormonal treatment? There are very few risks associated with these hormone medicines, but breast tenderness and swelling sometimes happen. What are other considerations for men with hormonal problems? Sperm production is a long process (about three months for mature sperm to be produced), so treatment with these hormones is usually over a very long period of time, sometimes two or more years. Sperm production usually stops when these hormone treatments are withdrawn. Therefore freezing some sperm at the end of treatment for later pregnancies should be considered. Some men with zero or very low sperm counts can have low testosterone levels. Such men with poor semen quality should always have a serum testosterone level measured and if their testosterone is low, careful consideration should be given to treatment. Men who are clinically diagnosed with low testosterone (androgen deficiency) will need testosterone treatment for life, even if not having infertility treatment.

MALE INFERTILITY 65


APPENDICES

GENETIC & CHROMOSOMAL PROBLEMS Each cell in the body normally has 46 chromosomes

What are the genetic and chromosomal causes of infertility? Changes to chromosomes and genes can cause abnormal sperm production or blockages to sperm flow. Chromosomes are the structures in cells that pass on genetic information. Genetic and chromosomal disorders that affect fertility include: • Klinefelter’s syndrome • Y Chromosome deletions • Congenital absence of vas deferens (CAVD) • Other genetic problems, such as Down Syndrome It is likely that other genetic disorders will be found in the future, which can help explain other sperm production problems that currently have no known cause.

What is Klinefelter’s syndrome? Klinefelter’s syndrome is the most common chromosomal disorder in men. About one in 650 men, have an extra X chromosome, so instead of having the normal 46XY chromosomes, there are 47XXY or similar abnormalities.

MALE INFERTILITY 66


Most men with Klinefelter’s syndrome (about 95%) do not produce sperm in their ejaculate and are sterile. However, recent scientific research suggests that in up to half of men with Klinefelter’s syndrome, sperm can develop in small areas of the testes, which never get into the ejaculate.

See the Andrology Australia guide on Androgen Deficiency for more information

In many men with Klinefelter’s syndrome, as well as poor sperm production, testosterone production by the testis is less than normal. Most men with Klinefelter’s syndrome will need testosterone treatment at some time in their life.

What are Y chromosome deletions? Some men have some genetic material missing from their Y chromosome. This has recently been shown to be the cause of infertility in about one in 20 men with low sperm counts (less than 5 million sperm per millilitre. Tests are now available that can pick up these changes on the Y chromosome. What is congenital absence of the vas deferens (CAVD)? Congenital absence of the vas deferens (CAVD) is a rare genetic problem that causes infertility in about one in 2500 men. Many men with CAVD have a mutation (genetic change) in the cystic fibrosis gene (cystic fibrosis transmembrane regulator, CFTR).

MALE INFERTILITY 67


APPENDICES

GENETIC & CHROMOSOMAL PROBLEMS In most men with cystic fibrosis, the vas deferens is absent

Several parts of the reproductive tract (including the vas deferens) are missing from birth. This stops sperm moving from the testes out into the ejaculate. [See section: ‘Appendices’ for more information on the absence of the vas deferens and seminal vesicles]

What is Down syndrome? Down syndrome can affect both men and women. People with this condition have an extra copy of chromosome 21 and have a range of disabilities. They have distinctive physical features and varying degrees of mental disability. Men with Down syndrome also have abnormal sperm production and are usually infertile. How are genetic problems treated? At this stage there are no treatments that can fix the genetic problems that cause poor sperm production. While some men with these problems can sometimes father children naturally, IVF or other forms of assisted reproduction is the most likely chance of these men having biological children. [See section: ‘Having a Family’ for more information]

MALE INFERTILITY 68


What are other considerations for men with genetic problems? Some genetic problems, such as Y chromosome deletions, will be passed onto any male child born through the use of sperm in IVF/ICSI procedures. The investigation of men with low sperm counts (less than 10 million sperm/ml) should include a Y chromosome deletion test. Men with CAVD (congenital absence of the vas deferens) have a high risk of carrying a genetic change of mutation of the CFTR (cystic fibrosis) gene. About one in 25 of the general population (including females) also carry this gene mutation. It is therefore important that both the male and female partner are tested for the gene mutation if the couple decides to start IVF. If both the male and female are found to carry this gene mutation, there is an increased risk that children will be born with cystic fibrosis. The couple may then need to think about genetic counselling and preimplantation genetic diagnosis (PGD) and embryo selection before starting IVF/ICSI procedures.

MALE INFERTILITY 69


APPENDICES

UNDESCENDED TESTES Remember to tell your doctor if you have had hormone treatment or had surgery as a baby to move your testes into your scrotum

What is an undescended testis? Before birth the testes develop in the abdomen (where they develop before birth) and then descend (drop down) into the scrotum at or shortly after birth. In a condition known as undescended testes (cryptorchidism), the testes of some boys remain in their abdominal cavity or groin after birth. As the testes normally descend in the eighth month of pregnancy, about one in three premature baby boys have undescended testes. About three in every 100 full-term baby boys can also have this problem. In most boys born with undescended testes, the testes drop naturally into the scrotum before they are six months old. About one in every 100 boys will need an operation (orchidopexy) to bring the testes down into the scrotum when the child is between six and twelve months of age.

Why do undescended testes at birth cause later fertility problems? Testes need to be kept cool to produce sperm. The temperature in the scrotum is usually a few degrees lower than normal body temperature. It is believed that the warmer temperature in the abdomen damages the sperm-producing tubes in the testes. The longer the testes spend in the abdomen, the greater the effect on sperm production.

MALE INFERTILITY 70


Even when this problem is surgically corrected in early childhood, ideally before the age of one, men who have had this problem as a child have a much higher chance of being infertile. Men born with undescended testes have a greater chance of developing testicular cancer and bringing the testis down into the scrotum does not reduce this risk. Men with a history of undescended testes need to be checked regularly throughout life for testicular cancer.

How is infertility from undescended testes treated? Sperm output is variable for men with undescended testes. If the testes have remained undescended for a long time, they do not produce sperm.

Regular testicular self-examination is recommended for men born with undescended testes to check for any lumps or changes in the testis

See the Andrology Australia guide on Testicular Cancer for more information

If small numbers of sperm are present, IVF or other forms of assisted reproduction are usually needed if the man wishes to have a family. [See section: ‘Having a Family’ for more information]

MALE INFERTILITY 71


APPENDICES

INFECTIONS What types of infection cause fertility problems? Orchitis (infection in the testes) can damage the sperm-producing tubes (seminiferous tubules) and stop sperm production. Although the infection is often only temporary, severe damage can leave men permanently infertile. Mumps is the most common infection of the testes but is less likely to happen since the introduction of immunisation programs for children. Infections in the reproductive tract caused by sexually transmitted infections, particularly untreated gonorrhoea and chlamydia, may cause blockages in the tail of the epididymis or other parts of the male genital tract. Non-specific epididymo-orchitis or prostate infections may sometimes cause blockages along the reproductive tract. How does mumps cause infertility? Mumps that spreads to the testes is called mumps orchitis. This can cause major swelling and pain in the testes. It can also totally destroy the spermproducing tubes (seminiferous tubules) and permanently stop sperm production. Mild cases of mumps orchitis may only stop sperm production for six to twelve months. Mumps vaccine is available and boys should be immunised in infancy to avoid infection and possible infertility in adult life. MALE INFERTILITY 72


How do sexually transmitted infections affect fertility? Sexually transmitted infections, such as gonorrhoea and chlamydia, can damage or block the epididymis so that sperm cannot pass from the testis into the ejaculate. Because the testis only contributes a small part to the ejaculate, these blockages do not obviously change the amount of fluid ejaculated but no sperm will be found in the ejaculate (azoospermia). What is epididymo-orchitis? Epididymo-orchitis is caused by viral or bacterial infections of the testes and epididymis. Pain and swelling usually last for several days. Epididymoorchitis sometimes happens with urinary tract infections and can cause permanent blockages and testicular damage but this is rare. Early treatment with antibiotics is recommended to prevent testicular damage becoming too severe. How do prostate infections cause infertility? Infections of the prostate can cause swelling and block off part of the reproductive tract that passes through the prostate. This can also stop sperm from being ejaculated. Because the prostate and seminal vesicles contribute most of the fluid to the ejaculate, blockage near the prostate can sometimes reduce the volume of ejaculate. Infections of the prostate and seminal

MALE INFERTILITY 73


APPENDICES

INFECTIONS vesicles can also cause inflammatory cells to pass into the ejaculate, which may damage the sperm.

Can surgery repair blockages? Some couples become pregnant naturally after surgery to remove blockages caused by infections. The success of surgery depends on the amount of damage and where the blockage is located in the reproductive tract. Blockages near the testes are particularly hard to fix. Sperm antibodies are also often a problem for men with these blockages and may also reduce the chance of natural pregnancy. [See section: ‘Appendices’ for more information on sperm antibodies]

What are the risks with surgery? All surgery, particularly when a general anaesthetic is needed, has some risks that need to be discussed with the doctor. The risks with surgery to repair blockages are small, however, sometimes bleeding and infection can happen at the site of the operation. Are there other ways to treat sperm blockages? IVF or other forms of assisted reproduction may be done if men wish to have a family and do not wish to have surgery, or surgery was unsuccessful, to remove the blockage. A biopsy, or sample of the testis, is taken to find sperm that can be used for IVF/ICSI procedures. [See section: ‘Having a Family’ for more information]

MALE INFERTILITY 74


APPENDICES

TORSION OF THE TESTIS What is torsion of the testis? The spermatic cord, which is made up of the vas deferens, nerves and blood vessels, attaches the testes to the body. Torsion of the testis happens when the testis rotates (twists) in the scrotum around the spermatic cord, blocking blood flow to the testis. This causes severe pain and swelling. Testicular torsion, which normally affects teenagers or young adults, happens when there are structural problems that make it easier than normal for the testis to twist. Testicular torsion can be triggered by hard, physical activity and can happen in one or both testes. Sometimes, torsion of the testis is confused with an infection.

A diagnosis of an infection should NOT be made unless torsion of the testis is ruled out

How does torsion of the testis affect sperm production? The twisting of the testis cuts off the blood supply to the testis, causing damage to the tubes that produce sperm. If the blood supply is stopped, even for a short period of time, the testis does not recover and stops producing sperm.

MALE INFERTILITY 75


APPENDICES

TORSION OF THE TESTIS Torsion of the testis should be treated as a medical emergency

MALE INFERTILITY 76

How is torsion of the testis treated? This condition is a medical emergency and immediate surgery is needed to not only relieve the pain, but also to ‘save’ the testis. It is also usual to fix the other testis during surgery to prevent torsion happening in the other testis. If this problem only happens in a single testis, the other testis should continue to produce sperm, which would make natural conception possible.


APPENDICES

HEAT How does temperature affect sperm production? A cooler temperature in the testis is necessary for sperm production. Outside the body, in the scrotum, the testes are a few degrees below normal body temperature. Illness with fever can temporarily reduce sperm production in the short term. Men who have had undescended testes can also experience sperm production problems because their testes were exposed to higher temperatures inside the body. Regular immersion of the testes in hot water through hot baths, spas and saunas can also affect the testes and sperm production. Some research has suggested that wearing tight underwear may also decrease sperm counts, although this finding has not been proven in other studies.

MALE INFERTILITY 77


APPENDICES

HEAT How can problems with over-heating of the testis be overcome? Doctors usually suggest that patients with lower than normal sperm counts keep away from hot baths and tight-fitting clothing. Wearing boxer shorts may be recommended. The number of sperm produced will generally increase once the temperature of the scrotum stays at its normal lower level, which is a few degrees lower than body temperature. However, as it takes about 70 days for sperm to develop, it may take a few months of keeping the testes cooler for the number of sperm produced to improve.

MALE INFERTILITY 78


APPENDICES

VARICOCELE What is a varicocele? A varicocele is a swelling of the veins above the testis. It usually happens on the left side and is caused by a lack of normal valve function which would normally stop the backward flow of blood. Blood pools in the veins around the testis, which forms a varicocele. These ‘varicose veins of the testes’ are quite common. About three in 20 men who have no fertility problems have varicoceles. To check for varicoceles, the man has to be examined standing up. The testis below a varicocele is usually smaller than a testis where there is no varicocele.

How does a varicocele affect sperm production? Men with varicoceles often have a lower than average number of sperm, poorer sperm movement and an increase in the number of abnormally shaped sperm. Even so, some men with varicoceles can also have normal sperm counts and many men with varicoceles have fathered children. There is some scientific research that shows that the temperature of the testes with a varicocele is higher. How are varicoceles treated? Varicoceles can be surgically removed under general anaesthetic by a urologist. This is often MALE INFERTILITY 79


APPENDICES

VARICOCELE done as a day procedure but at the most may need an overnight stay in hospital. Alternatively, an embolisation (closing of the vein) can be done under local anaesthetic. A catheter (very fine long flexible tube) is inserted into a vein in the groin and guided through a network of veins and into the left testicular vein. A small coil or a plug is passed through the catheter to block the blood flow and stop the varicocele from forming. Dye may also be injected into the testicular vein to clearly show the location of the varicocele.

Is treatment for varicoceles helpful? The benefits of both these varicocele operations are not clear. Improved semen quality and increases in pregnancy rates after varicocele surgery have not been proven. What are the risks with varicocele treatment? Both procedures have a small number of risks. Sometimes the wounds bleed after the operation. The blood supply to the testis can also be affected in these procedures, which can cause permanent testis damage and increase the chances of infertility. In some men, a hydrocele (collection of fluid in a sac around the testis) can happen as a result of surgery but this does not affect testicular function.

MALE INFERTILITY 80


APPENDICES

SPERM ANTIBODIES What are sperm antibodies? Antibodies are proteins made in the body by the immune system to fight infection or disease. They attack anything in the body that is foreign (that is not naturally part of the body). Sperm antibodies, also known as sperm autoimmunity, affect about one in every 16 infertile men.

Sperm antibodies are common in men who have had a vasectomy

As sperm are produced at puberty, well after the immune system has developed, the body will make antibodies against the sperm (antisperm antibodies). Normally, there are systems in the testes that limit the response of the immune system to sperm and stop the production of sperm antibodies. When these systems breakdown, for reasons that are not clear, the immune system develops antibodies against sperm. Sperm antibodies are commonly found in two thirds of men who have had a vasectomy, injury or infection in the epididymis. However, in many cases, the presence of sperm antibodies cannot be explained.

MALE INFERTILITY 81


APPENDICES

SPERM ANTIBODIES How do sperm antibodies affect fertility? Sperm antibodies can reduce fertility in a number of ways, by: • Reducing the number of sperm in the semen • Coating sperm, causing them to clump together and reduce the motility (movement) of sperm. This stops the sperm from swimming through the fluid in the female cervix and reproductive tubes, when ejaculated into the vagina • Preventing sperm binding to and penetrating the egg during the fertilisation process There are usually no other effects on a man’s general health and no signs that might mean that sperm antibodies are present. Some men with genital tract blockages also have sperm antibodies.

How are sperm antibodies treated? Prednisolone, a cortisone-like medicine, can be used to lower the levels of sperm antibodies. About one in four couples become pregnant while the man is taking this medicine.

MALE INFERTILITY 82


What are the risks of medicine treatment for sperm antibodies? High doses of prednisolone can cause weight gain, a rise in blood pressure, mood swings, acne, diabetes or peptic ulcers. Some of these side-effects disappear after treatment stops. However, high doses of prednisolone can severely affect the blood supply to the femur (head of the thigh bone) and about one in 200 men using this treatment will have permanent hip damage and need a hip replacement.

Are there other ways to treat men with sperm antibodies? Today, ICSI is almost always used if men with sperm antibodies wish to have a family. The use of ICSI can overcome problems related to the presence of sperm antibodies. By directly placing the sperm into the egg, there is no need for the sperm to move to or to bind to the egg. [See section: ‘Having a Family’ for more information]

MALE INFERTILITY 83


APPENDICES

VASECTOMY Vasectomy should NOT be considered reversible. Sperm storage (banking) however, does offer an ‘insurance policy’ to couples considering vasectomy

Why is a vasectomy considered a fertility problem? Vasectomy is a safe and effective way to stop couples becoming pregnant. It should be considered permanent contraception. Almost one in three Australian men aged between 40 and 49 years of age have had a vasectomy. Men planning to have a vasectomy should think about storing sperm before having this procedure. This may remove the possible need for a vasectomy reversal in the future. Vasectomy involves cutting and removing a section of the vas deferens, the tube that carries sperm from the testis to the urethra at the base of the bladder. Only a small percentage of the large number of men having had a vasectomy each year will, at some time, want to have more children. However, this still means that each year many hundreds of these men will think about surgical reversal of the vasectomy or fertility options such as IVF. Vasectomy reversal surgery can be difficult due to the small size of the tubes that need to be joined back together and often does not enable couples to become pregnant naturally. If sperm have been stored before the vasectomy, a female partner can be inseminated at the time of ovulation (the fertile time of a woman’s menstrual cycle).

MALE INFERTILITY 84


Alternatively, sperm can be collected from the man’s epididymis by a needle puncture aspiration. Or in another approach, in a small operation called a biopsy, sperm can be taken from the testes of a man who has had a vasectomy.8 These sperm can be used in ICSI treatment cycles, as for those men with naturally occurring fertility problems. The choice of surgical vasectomy reversal versus sperm aspiration/ICSI, including costs, risks and benefits, should be carefully talked about with the doctor. [See section: ‘Having a Family’ for more information]

What happens with a vasectomy reversal? Vasectomy reversals involve rejoining the cut ends of the vas deferens using microsurgery. Factors from the original vasectomy can affect the chances of a vasectomy reversal being successful. The outcome is reduced by: • Diathermy (the use of burning to close either end of the vas deferens) • A larger amount of the vas deferens having been removed • The increasing time between the vasectomy and reversal • Sperm antibodies

MALE INFERTILITY 85


APPENDICES

VASECTOMY If 10 years or more has passed since the vasectomy, the chance of having a normal sperm count after a vasectomy reversal is lower. The development of other blockages in the epididymis can also reduce the chance of success. An epididymal blow-out may happen, where the epididymis bursts because of pressure from sperm build-up. As the blow-out heals, scarring can create an extra blockage. Sperm antibodies are present in four in every five men after a vasectomy. These can still stop pregnancy happening, even if the vas deferens is successfully joined back together. [See section: ‘Appendices’ for more information on sperm antibodies]

MALE INFERTILITY 86


APPENDICES

ABSENCE OF VAS DEFERENS What is absence of the vas deferens? Men who have an absence of the vas deferens are missing part of the tube that sperm travel along after they leave the testes. These tubes either do not grow as a child or they degenerate at an early age so that the men are infertile, as sperm cannot pass from the testis into the ejaculate. Men born with this problem, known as congenital absence of the vas deferens (CAVD), are usually missing both their vas deferens and two-thirds of their epididymis. How does CAVD happen? CAVD is a genetic problem. The most common cause is a genetic change or mutation in the gene called the ‘cystic fibrosis transmembrane regulator’ (CFTR). Men with CAVD do not have cystic fibrosis even though they have the genetic change linked with this disease. Cystic fibrosis is a serious condition that causes breathing and bowel problems from early life and premature death before the age of 40 years. Most men with severe cystic fibrosis have absence of the vas deferens. What is absence of the seminal vesicles? Very rarely the seminal vesicles do not develop. This problem usually happens with congenital absence of the vas deferens, as the seminal vesicle develops from the vas deferens. The prostate and seminal vesicles provide about 90 per cent of the MALE INFERTILITY 87


APPENDICES

ABSENCE OF VAS DEFERENS fluid in the ejaculate, so absence of the seminal vesicles can cause a smaller amount of ejaculate (usually about 0.5 ml, compared with a normal man of more than 2 ml). The seminal vesicles also make the ejaculate alkaline, so when they are not there the ejaculate is more acidic.

How is absence of the vas deferens and seminal vesicles treated? At this stage there are no surgical treatments that will cure CAVD. ICSI is usually needed if men wish to have a family. When the vas deferens and seminal vesicles are missing, it is usually possible to collect sperm directly from the testis or from the small remaining part of the epididymis. [See section: ‘Having a Family’ for more information]

What are other considerations for men with CAVD? Due to the genetic basis of this problem, both the man and his partner must have a blood test to check for changes in the CFTR gene, before starting assisted reproduction treatments. If both partners have CFTR mutations, then there is a one in four chance of severe cystic fibrosis in their children. It may be possible to test the fertilised eggs, using a technique known as pre-implantation genetic diagnosis (PGD). Only the embryos that are not affected by the CFTR mutations are transferred to the woman’s uterus. MALE INFERTILITY 88


APPENDICES

ERECTION & EJACULATION PROBLEMS How do erections and ejaculation problems affect fertility? For semen to be placed in the vagina, an erection must be hard enough to allow penetration. Many factors can affect a man’s ability to get and keep an erection, causing erectile dysfunction and failure of penetration. Often two or three factors are present at one time. At other times there may be no clear reason for the erectile dysfunction.

See Andrology Australia’s guide on Erectile Dysfunction for more information

Sometimes even with a satisfactory erection, problems may happen with ejaculation so that sperm is not deposited appropriately. Problems with ejaculation that can cause infertility include: • Retrograde ejaculation - a problem where semen flows backwards into the bladder rather than out of the penis during orgasm • Premature ejaculation - ejaculation that occurs sooner than desired • Failure of ejaculation - ejaculation does not happen at all About one in every 100 infertile couples has trouble getting pregnant because of erection, ejaculation or other sexual problems.

MALE INFERTILITY 89


APPENDICES

ERECTION & EJACULATION PROBLEMS Causes may include: • Nerve damage following prostate or other abdominal surgery, spinal cord injury or diabetes • Poor blood supply into the penis and poor function of the blood vessels in the penis (such poor blood vessel function is more common in men with cardiovascular problems like heart disease, stroke and diabetes) • Interactions with other medicines • Psychological or relationship problems

How is erectile dysfunction or impotence treated? Most often erectile dysfunction is due to conditions affecting the blood flow to the penis or the nerves which supply the blood vessels. These are not usually reversible but medicines, which relax blood vessels in the penis, can help men get erections. Tablets such as Viagra®, Cialis® and Levitra® (PDE5 inhibitors), work well for many men with erectile dysfunction. Injections for the penis, such as Caverject Impulse®, can be used if these oral medicines don’t work or can’t be used. Erectile dysfunction can be caused by psychological problems, and even if a physical cause is found, psychological problems may still happen. Counselling can often help overcome performance anxiety and other concerns. MALE INFERTILITY 90


What are the risks with erectile dysfunction treatments? The PDE5 inhibitor tablets are not recommended for men with serious heart disease or men taking nitrate medicines for a heart condition. These medicines must only be used when prescribed by a doctor who understands the man’s medical history. How is premature ejaculation treated? Men with premature ejaculation sometimes ejaculate before the penis has entered the vagina (vaginal penetration). Medicines called serotonin reuptake inhibitors (SSRIs) may help delay ejaculation. Other non-medicine treatments include couple counselling, pelvic floor exercises, methods of reducing sensation and psychotherapy. Talking to a doctor or experienced sex therapist is important and is recommended.

How is retrograde ejaculation treated? During normal ejaculation, a ring of muscle around the opening of the bladder closes to stop semen from entering the bladder during orgasm. This muscle does not close in men with retrograde ejaculation, allowing semen to flow back into the bladder. Retrograde ejaculation can be caused by a number of problems, and is common after surgery on the prostate.

MALE INFERTILITY 91


APPENDICES

ERECTION & EJACULATION PROBLEMS Some men with retrograde ejaculation can be treated with medicines like pseudoephedrine or imipramine, which help improve the muscles in the bladder neck. These medicines are not recommended for men with heart or blood pressure problems. For men who wish to have a family, sperm may be collected for use in ART. Sometimes sperm can be taken directly from the testes in a biopsy or removed from urine samples in the laboratory. [See section: ‘Having a Family’ for more information]

How are erectile and ejaculation problems due to spinal cord injury treated? Medicines, like Viagra®, Cialis® and Levitra®, or injections into the penis, like Caverject®, usually help men with spinal cord injury get erections. However, ejaculation does not happen very often. Applying a vibrator to the penis (vibro-ejaculation) can sometimes bring on ejaculation. This can be done at home. Electro-ejaculation is another option for men with spinal cord injury. An electrical charge is given to the back of the penis via the rectum. Sperm is then ejaculated and collected for use in ART. A qualified health professional experienced in these techniques must perform electro-ejaculation treatment. Alternatively, sperm can be isolated from the testis by needle biopsy and used in IVF/ ICSI procedures. [See section: ‘Having a Family’ for more information]

MALE INFERTILITY 92


What are the risks of ejaculation treatment? The quality of the sperm collected using vibro or electro-ejaculation treatments for men with spinal cord injuries may not be good and the procedure may need to be repeated several times to collect enough quality sperm. There are several risks linked with the electroejaculation procedure, which should be discussed with a doctor. These can include severe rises in blood pressure and internal bleeding in the brain (cerebral haemorrhage). There is also a small risk of rectal burns. General anaesthesia is sometimes needed if the man has some sensation or feeling in the lower part of the body.

Why is treating erectile problems alone not always enough?  Erectile dysfunction is a common health problem often caused by other more serious life-threatening health problems such as heart disease, diabetes, hypertension, high cholesterol, obesity and depression. Treating the erectile difficulties alone will not fix the underlying health problem, which if left untreated can have serious health outcomes. This is why men with erectile dysfunction need to see their doctor and be properly checked. It is important that any underlying problems are identified, and also treated, as a priority. MALE INFERTILITY 93


APPENDICES

TESTICULAR CANCER & FERTILITY See Andrology Australia’s guide on Testicular Cancer for more information

Does testicular cancer affect the chances of having children? Cancer in a single testis may not affect the chance of having children. In many men, after a cancerous testis is removed, the remaining testis continues to produce of sperm and amounts of testosterone, the male sex hormone, that is important for reproductive and general health. Men who are diagnosed with testicular cancer are more likely to have reduced fertility before any treatment starts as it seems they have a preexisting tendency to poor sperm production. Fertility can be further affected by the followup cancer treatments such as radiotherapy and chemotherapy. It is therefore possible that some men who have had testicular cancer may have trouble having children.

How does radiotherapy affect fertility? During radiotherapy, the other non-affected testis is shielded from the x-rays but some exposure may happen, which sometimes lowers sperm counts for a short-time afterward. As radiation can cause genetic damage in the early development stages of sperm (germ cells), it is best to avoid attempting a pregnancy for six months after radiation treatment.

MALE INFERTILITY 94


How does chemotherapy affect fertility? Chemotherapy can temporarily or permanently destroy developing sperm cells. Most patients will return to the level of fertility they had before chemotherapy, but this can take up to five years. In some cases, fertility is permanently reduced or eliminated. Why is sperm storage important? Even though surgical removal of one testis does not affect the sperm-producing ability of the remaining testis, both radiotherapy and chemotherapy can lower sperm counts for a short-time or permanently after treatment. Men with testicular cancer often have lower fertility before treatment starts. Treatment can reduce their fertility further. All men who are going to have chemotherapy or radiotherapy should talk to their doctors about their fertility before treatment begins. It is highly recommended that men produce semen samples (through masturbation) for sperm storage (also known as sperm banking). Sperm storage must take place before chemotherapy or radiotherapy starts. Semen can be frozen, using special equipment, and stored long-term for future use. If men want children at a later stage, the frozen semen is thawed and used in fertility treatments ranging from insemination of their partners to IVF. MALE INFERTILITY 95


APPENDICES

TESTICULAR CANCER & FERTILITY For more information on sperm storage speak to your specialist or contact a local infertility clinic

When should sperm be stored? To avoid having to delay treatment for testicular cancer, it is important to think about sperm storage early and before treatment starts. Some men may have poor sperm counts and may need to visit the sperm-banking unit on two or three separate occasions. Even if the sperm quality before treatment is poor, sperm storage is recommended as advances in reproductive technologies, just a few moving sperm can be used successfully to produce children at a later stage. Should teenage patients be encouraged to store sperm?  Sperm storage for teenagers with testicular cancer can be a difficult issue and needs careful and delicate management. It can be extremely difficult for young males to come to terms with the diagnosis of cancer at a young age and possible body image problems they may have following surgery. Fatherhood is therefore not likely to be a priority concern. Producing a semen sample by masturbation can also be stressful for a very young male in these circumstances. Family support and encouragement without pressure can be extremely valuable to teenagers with testicular cancer. Parents may need to help communicate future fertility problems to their child.

MALE INFERTILITY 96


Where can sperm be stored? Sperm is frozen using special technologies and then kept in liquid nitrogen (-196ËšC) for longterm storage. Specialist reproductive centres providing IVF and other ART usually also offer long-term sperm storage facilities.

MALE INFERTILITY 97


APPENDICES

MEDICINES & OTHER DRUGS What medicines and other drugs affect sperm production? There are a number of commonly used medicines that may have a negative effect on sperm production and function. Medicines used in the treatment of cancer are designed to attack the multiplying or dividing cells. The cells in the lining of the spermproducing tubes in the testis are continually multiplying to produce the new cells needed to make sperm. These cells are therefore open to attack during cancer treatment. Cyclophosphamide, a medicine used for the treatment of some cancers and kidney disorders, can cause permanent infertility if the treatment is given for a long time. Salazopyrine, which is used to treat inflammatory bowel disease, causes short term infertility. This drug is often given for ulcerative colitis, Crohn’s disease or problems following other conditions such as rheumatoid arthritis. These health problems can often be managed with other medicines, which allow the man to remain fertile. When salazopyrine is stopped, sperm production will usually return to normal after a few months.

MALE INFERTILITY 98


Environmental and chemical agents, such as pesticides, may cause infertility. However, there is no clear scientific research as to the level to which these chemicals cause sperm production problems. Testosterone (tablets or injections), which are used to treat men with testosterone deficiency, can cause infertility problems. Testosterone stops the production of the pituitary hormones (FSH and LH), which normally trigger the testes to make sperm. Testosterone reduces the size of the testes and can lower or stop sperm production. Men who abuse the use of testosterone and more potent androgens for body building and competitive sports are usually infertile, and may also have health problems of other organs, placing other aspects of their health at risk. Recreational drugs, such as marijuana and heroin, may affect the testes and affect the long-term production of sperm in the testes.

Can anything be done before starting medical treatment? Chemotherapy for treatment of cancer can lower sperm counts temporarily or permanently. All men, and boys who have gone through puberty, who are about to have chemotherapy should talk to their doctor about the effect of treatment on their fertility.

MALE INFERTILITY 99


APPENDICES

MEDICINES & OTHER DRUGS Remember to tell your doctor if you are taking any medicines or have received any medical treatment that may have affected your fertility

It is highly recommended that men produce semen samples (through masturbation) for sperm storage. Sperm storage must take place before chemotherapy starts. Semen can be frozen and stored long-term for future use. If men want children at a later stage, the frozen semen is thawed and used in fertility treatments such as IVF. [See section: ‘Having a Family’ for more information]

How is infertility caused by medicines treated? Some medicines can leave men permanently sterile and there are no treatments that will start sperm production again. Other medicines only have a short term effect on sperm production. Once these medicines are stopped, sperm production should return. However, because sperm take a long time to develop, it may take six to 12 months for sperm counts to reach normal levels. Cancer specialists sometimes recommend that couples wait for six to 12 months after certain medicines have been taken before trying to become pregnant to make sure that possible pregnancy problems and fetal abnormalities are avoided.

MALE INFERTILITY 100


APPENDICES

RADIATION How does radiation affect sperm production? Radiation treatment for testicular or other cancers near the testes can damage the testis, leaving permanent problems with sperm production. Radiation therapy is designed to attack and destroy rapidly dividing cells, so the lining of the spermproducing tubes in the testis can easily be damaged. During radiotherapy, a healthy testis is protected from the x-rays but some exposure may happen and sometimes lowers sperm counts. This can be temporary or permanent.

What treatment is recommended for men who are having radiation therapy for cancer? All men who are about to have radiotherapy should discuss the effects of their treatment on their fertility with their doctors. Semen samples should be collected and frozen at a fertility clinic with liquid nitrogen storage facilities, before radiation treatment starts. Semen can be stored long-term for future use. If men want children at a later stage, the frozen semen can be thawed and used in fertility treatments such as IVF. [See section: ‘Having a Family’ for more information]

MALE INFERTILITY 101


APPENDICES

RADIATION Reduced fertility or sterility after radiation therapy depends on the dose received by the testis. With low doses sperm production can return to normal after some time. As radiation can cause genetic damage in the germ cell, it is advisable to avoid attempting a pregnancy for at least six to 12 months after radiation treatment.

MALE INFERTILITY 102


SUPPORT This booklet gives information about male infertility and may be helpful when talking with your doctor. Couples wanting to get pregnant who are unsure about intercourse timing, any aspect of the normal reproductive system or are anxious about not conceiving, should talk firstly with a doctor. The doctor may provide a referral to a specialist for tests. Professional societies, such as the Fertility Society of Australia (FSA), and national consumerbased organisations also offer men and their partners additional support and information about male infertility. Infertile men are encouraged to talk with doctors and counsellors at the many infertility clinics throughout Australia. These clinics are able to provide professional counselling and referrals to other private practitioners who also work with infertile couples. AccessAustralia’s National Infertility Network is an independent, non-profit organisation, which provides whole of life support for women, men and their families suffering from infertility. ACCESSAustralia also strives to raise community awareness about the social and psychological effect of infertility. Email: info@access.org.au

MALE INFERTILITY 103


SUPPORT Donor Conception Support Group provides support to couples considering accessing donor sperm, eggs or embryo programs. It also helps families who already have children conceived on donor programs, adult donor off spring and donors. Phone: (02) 9793 9335 Fertility Society of Australia (FSA) is the peak body representing scientists, doctors, researchers, nurses, consumers and counsellors in reproductive medicine in Australia & New Zealand. It aims to determine, oversee and improve the standard of fertility service offered in Australia and New Zealand. Infertility patient support groups are associated with many fertility clinics. Contact your nearest IVF clinic for more information. A list of IVF clinics can be found on the FSA website at www. fertilitysociety.com.au/patients-information/.

MALE INFERTILITY 104


Websites of relevance AccessAustralia www.access.org.au Andrology Australia www.andrologyaustralia.org Australian Infertility Support Group www.nor.com.au/community/aisg Fertility Society of Australia www.fsa.au.com

Please note that websites developed overseas may describe treatments that are not available or approved in Australia . Any questions that you have from information found on these or other sources should be talked about with your doctor.

Donor Conception Support Group www.dcsg.org.au Urological Society of Australia and New Zealand www.urosoc.org.au

MALE INFERTILITY 105


GLOSSARY abstinence No sexual activity such as intercourse or masturbation acute bacterial prostatitis (ABP) An infection in the prostate gland that causes fever, severe pain in the lower back and genital area and burning, urgent and frequent urination. It is quite rare and can usually be successfully treated with antibiotics anabolic steroid A hormone that causes muscle and bone growth and is sometimes used illegally by athletes competing in sports competitions anaesthetic/anaesthesia A medicine that stops pain being felt androgen A male sex hormone such as testosterone responsible for the development of male characteristics antibodies Proteins made by the body’s immune system in response to foreign substances; attacks foreign substances and protects against infection aspiration Use of a thin needle to take small samples of tissue from the body asthenozoospermia Less than the normal number of moving sperm in the semen biopsy An operation to remove a small sample of tissue or cells from part of the body for testing and examination under a microscope catheter A thin flexible tube used to take fluids in or out of the body MALE INFERTILITY 106


chromosomes Structures in each cell in the body, which contain genetic material congenital Any condition that is present at birth (See Undescended Testes) culture To grow cells, tissues or organisms, often in a sterile dish, for scientific purposes cyst A closed sac or capsule, usually filled with fluid or semi-solid material DNA The genetic code of the individual Down Syndrome A chromosome disorder that causes mental retardation and a range of other physical problems, including infertility ejaculation Release of semen from the penis during orgasm (sexual climax) ejaculatory duct The part of the male reproductive tract where the vas deferens joins with the seminal vesicle and passes through the prostate embryo An early stage of development as a result of successful fertilisation, up to the eighth week of pregnancy endocrine system The system of glands (including the pituitary, thyroid, adrenals, testes) which secrete their products (hormones) into the blood endocrinologist A doctor who specialises in problems in the endocrine system (hormones and hormonal function)

MALE INFERTILITY 107


GLOSSARY epididymis A highly coiled tube at the back of the testes in which sperm are stored and mature. All sperm must pass along this tube to reach the vas deferens fertilisation The penetration of the egg by the sperm to create a zygote follicle The fluid-filled sac on the ovary in which the egg develops gynaecologist A doctor who specialises in the treatment of women’s diseases of the reproductive organs human chorionic gonadotropin (hCG) A hormone made by chorionic cells (in the fetal part of the placenta). It is a very similar hormone to LH but it has a longer time of action hypospermatogenesis Low sperm production within the testis infertility Failure to achieve a pregnancy within one year of regular, unprotected sexual intercourse ICSI (intracytoplasmic sperm injection) A form of IVF used to treat male infertility in which a single sperm is injected directly into the cytoplasm of an egg IVF (in vitro fertilisation) A form of assisted reproduction in which sperm collected from the male is mixed with the female partners eggs outside the body karyotype A blood test to check for the number and appearance (size and shape) of chromosomes in cells (used in AHW module) MALE INFERTILITY 108


oligozoospermia (or oligospermia) A very low number of sperm present in the seminal fluid ovulation The process by which an egg is released from the ovary primary seminiferous tubule failure The sperm producing cells in the testes either did not develop or have been permanently destroyed. It is an untreatable condition prostate cancer A condition in which cells within the prostate grow and divide abnormally so that a tumour grows in the prostate puberty The period in both males and females in which changes occur in reproductive organs/ovaries/testes so that reproduction is possible retrograde ejaculation A health problem where semen flows backwards into the bladder rather than out of the penis during orgasm scrotum The skin pouch that holds the testes semen Fluid that is ejaculated (released) from the penis during sexual activity; contains sperm and other fluids from the testes, prostate and seminal vesicles seminal fluid The thick white fluid mainly produced by the prostate and seminal vesicles containing sperm that is ejaculated by the penis seminal vesicles Sac-like structures in the male, found near the prostate gland, which produce fluid that is part of the semen ejaculate MALE INFERTILITY 109


GLOSSARY seminiferous tubules The sperm-producing tubules in the testes in which sperm are produced sertoli cells Cells in the testes that are responsible for nurturing the spermatids (immature sperm) sperm Mature male sex cell sperm bank Facility where sperm are kept frozen in liquid nitrogen for later use in artificial insemination sperm morphology A semen analysis factor that indicates the number or percentage of sperm in the sample that appear to have been formed normally sperm motility The ability of sperm to swim. Poor motility means the sperm have a difficult time swimming toward their goal, the egg sperm retrieval The doctor removes sperm from a man’s reproductive tract (testis or epididymis) using a fine needle, biopsy gun, or other instrument spermatic cord The spermatic cord is made up of the vas deferens, nerves and blood vessels and attaches the testes to the body spermatids Immature sperm spermatocele A spermatocele is (usually) a small cavity, filled with watery liquid, in the epididymis spermatogenesis Production of sperm in the testes

MALE INFERTILITY 110


spermaturia Spermaturia is the release of sperm into the urine. This can happen in men with long periods of sexual abstinence. This is quite normal and is a way of discharging sperm from the body teratozoospermia High percentage of sperm with an abnormal shape testicle/testis (plural: testes) The male reproductive organ that produces sperm and the male sex hormones testosterone Male sex hormone torsion Abnormal twisting of a testis in the scrotum ultrasound Medical process, which takes images or pictures using special sound waves, that are used to examine organs inside the body without the need to make cuts or incisions undescended testicles (cryptorchidism) Health problem in which one or both testicles do not move from the abdomen (where they develop before birth) into the scrotum urethra (urinary tract) The tube that leads urine from the bladder out of the body via the penis. In men, secretions from accessory glands also empty into the urethra urologist A doctor who specialises in diseases of the urinary tract in men and women, and the genital organs in men uterus The part of a woman in which a baby develops before birth, often referred to as the ‘womb’ MALE INFERTILITY 111


GLOSSARY vagina The lower part of the female reproductive tract that connects the cervix to the outside varicocele A collection of the enlarged (dilated) testicular veins in the spermatic cord vas deferens Duct that transports sperm from the epididymis to the ejaculatory duct vasectomy sterilisation procedure in which the vas deferens is cut

MALE INFERTILITY 112


AUTHORS Professor Robert McLachlan MMBS FRACP PhD Professor Robert McLachlan is currently Principal Research Fellow at Prince Henry’s Institute and Director of Andrology Australia. He is also a practicing andrologist and endocrinologist at Monash IVF and Monash Medical Centre, Melbourne. Contributions by: Dr HW Gordon Baker Royal Women’s Hospital, Melbourne and University of Melbourne (retired)

This booklet has been reviewed by a panel of experts in male reproductive health. Andrology Australia gratefully acknowledges the expert panel and consumers with infertility who have provided valuable assistance and input into the production of this guide.

Dr Roger Cook Swinburne University of Technology, Melbourne Professor Gab Kovacs Monash IVF, Melbourne Professor David M de Kretser, AC Monash University, Melbourne Associate Professor Doug Lording Cabrini Health, Melbourne

MALE INFERTILITY 113


AT A GLANCE Prevalence Infertility is a widespread problem. For about one in five infertile couples the problem lies solely in the male partner (male infertility). Causes Male infertility can be caused by problems that affect sperm production or the sperm transport process. With the results of medical tests, the doctor may be able to find a cause of the problem. Diagnosis Both male and female partners should have medical tests when infertility is suspected. Diagnosis can involve a medical history from the man and a physical examination along with a semen analysis to check the number, movement and shape of the sperm in the ejaculate. Treatment Many treatments, both surgical and medical, are available to improve sperm production and enable natural conception. However, in some cases the doctor will recommend the couple seek assisted reproductive technologies (ART).

MALE INFERTILITY 114


Assisted reproductive technologies (ART) Assisted reproductive technologies do not cure or treat the cause of the infertility, but they can help couples become pregnant. ICSI (intracytoplasmic sperm injection), where a single sperm is microinjected into an egg, is a form of ART for couples when male infertility is a problem. Emotional issues An emotional response to infertility is normal. Talking with a doctor and if needed a sexual therapist or counsellor to work through these feelings can help some men at this difficult time.

MALE INFERTILITY 115


REFERENCES

MALE INFERTILITY 116

1

De Kretser DM. Male Infertility. Lancet 1997; 349: 787-90

2

WHO Task Force on the Diagnosis and Treatment of Infertility 1987: Towards more objectivity in diagnosis and management of male infertility. Int J Androl [Suppl] 7

3

World Health Organization. WHO laboratory manual for the examination and processing of human semen, 5th ed. Geneva: WHO Press, 2010.

4

Hassan MA, Killick SR. Effect of male age on fertility: evidence for the decline in male fertility with increasing age. Fertil Steril. 2003; 79 (Suppl 3): 1520-7

5

Eskenazi B, Wyrobek AJ, Sloter E, Kidd SA, Moore L, Young S, Moore D. The association of age and semen quality in healthy men. Hum Reprod. 2003; 18: 447-54

6

Gnoth C, Godehardt D, Godehardt E, FrankHerrmann P, Freundl G. Time to pregnancy: results of the German prospective study and impact on the management of infertility. Hum Reprod. 2003; 18: 1959-66


7

Halliday, JL, Ukoumunne OC, Baker HWG, Breheny S, Jaques AM, Garrett C, Healy D and Amor D. Increased risk of blastogenesis birth defects, arising in the first 4 weeks of pregnancy, after assisted reproductive technologies. Hum Reprod. 2009

8

Holden CA, McLachlan RI, Pitts M, Cumming R, Wittert G, Agius P, Handelsman DJ and de Kretser DM. Sexual activity, fertility and contraceptive use in middle-aged and older men: Men in Australia, Telephone Survey Human Reproduction 2005; 20: 3429-3434

MALE INFERTILITY 117


Andrology Australia (The Australian Centre of Excellence in Male Reproductive Health) gives free independent and evidence-based information and education to the community and health professionals on disorders of the male reproductive health system and associated problems. Andrology Australia’s resources and information are provided at no cost and are available to be downloaded or ordered online at www.andrologyaustralia.org or ordered by phone 1300 303 878. The booklets available in the Andrology Australia Consumer Guides Series on men’s health include: • Erectile Dysfunction: Impotence and related health issues • Androgen Deficiency: A guide to male hormones • Male Infertility: A child of my own • Testicular Cancer: Lumps and self-examination • Prostate Enlargement: A guide to urinary symptoms The information in this consumer guide on Male Infertility has been reviewed by:


Postal address: Andrology Australia Monash Institute of Medical Research PO Box 5418, Clayton, Victoria, 3168, Australia Street address: 27–31 Wright Street, Clayton, Victoria, 3168, Australia Phone: 1300 303 878 Fax: +61 3 9594 7156 Email: info@andrologyaustralia.org Website: www.andrologyaustralia.org Andrology Australia is supported by a grant from the Australian Government Department of Health and Ageing.

MALE INFERTILITY 122


Male Infertility