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In about 15 per cent of couples in Singapore, the woman is unable to get pregnant within 12 months of trying. As infertility can be attributed to the man, the woman or both, medical investigation of the problem should involve both partners from the beginning.
In nearly all cases of male infertility, the man will not display any obvious signs and symptoms.
| Female problem |
only 39% |
| Male problem |
only 20% |
| Both male and female problems |
26% |
| No obvious cause for infertility |
15% |
Sexual intercourse, erection and ejaculation usually occur without any difficulty. The quantity and the appearance of the semen will appear normal to the naked eye. Medical tests will be needed to tell whether there is a problem in most cases.
These tests are recommended when the woman fails to conceive after regular, unprotected sexual intercourse with her partner for two years, in the absence of any known reproductive disorders.
Semen analysis
Semen analysis is the most essential part of diagnosing male infertility. It is a laboratory test of freshly ejaculated semen, and sperms are studied under a microscope to assess their number, shape and movement. These tests should be done at specialised laboratories that use methods approved by the World Health Organisation.
| Volume of semen |
More than 2ml |
| Sperm concentration (number) |
More than 20 million sperms per ml |
| Sperm motility |
More than 50%, forward progression |
| Sperm morphology (shape) |
More than 15% have a normal shape (strict criteria) |
| White blood cells |
less than 1 million cells per ml |
Based on the results of the semen analysis, physical examination and other tests can help to determine the different types of male infertility.
Types of male infertility and treatment
1. Treatable conditions
One in eight infertile men has a treatable condition that can be overcome. After appropriate treatment, the couple can try to conceive naturally without any other assisted reproductive techniques.
- Hormonal disorders
Deficiency of two hormones from the pituitary gland – luteinising hormone (LH) and follicular stimulating hormone (FSH) – can occur either congenitally or as a side effect of treatment of other disorders. Usually the patient will present with azoospermia (absence of sperm in ejaculation) and androgen deficiency. Treatment with synthetic LH and FSH readily kick-start the sperm producing function of the testes and spontaneous pregnancies are common after treatment.
- Blockage of sperm transport
This can be due to insufficient development of the genital tract, a previous bad infection or a previous vasectomy. This occurs in about six per cent of men with infertility. A bypass surgery is sometimes possible depending on the level of obstruction. Otherwise, sperm can be readily obtained by surgery for use in in-vitro fertilisation (IVF) to achieve pregnancy.
- Medical therapy such as anabolic steroids and cytotoxic therapy
Sperm production usually recovers with cessation of therapy or change of medication.
- Sperm antibodies
The reason for the occurrence is usually not obvious. Sperm antibodies interfere with fertility by reducing sperm motility and severely affecting fertilisation. Pregnancy chances increase with therapy targeted at the sperm antibodies; however, in some cases, IVF is necessary for a good result.
- Disorder of sexual function
This includes failure of sexual intercourse because of inadequate penile erection, failure of ejaculation, low sexual frequency and poor timing of sexual intercourse. Frequently, these conditions respond to treatment, including proper counselling.
2. Untreatable sterility
Men with untreatable sterility have azoospermia. The sperm producing cells in the testes either did not develop or have been irreversibly destroyed due to chromosomal or genetic disorders, inflammation of the testes or treatment with certain drugs. Couples facing this predicament can consider adoption and donor insemination.
3. Untreatable subfertility
Most men investigated for infertility have untreatable subfertility. The sperm could be of lower number, reduced motility, and lower normal forms and shapes, which affect the fertilising ability and greatly reduce pregnancy rate. Spontaneous pregnancy then depends very much on the presence of any adverse factors of the female partner, such as age being above 35 and medical conditions like endometriosis. Early recourse to assisted reproduction is therefore the key to a good outcome in fertility treatment.
At present, very little is known about the mechanisms by which sperm production and function are reduced. Many empirical treatments have not proved to be effective, which include operations for varicocoele, nutritional supplements, traditional herbs and some drugs that alter hormone levels.
There are problems in assessing the success of the treatment of infertile men:
Semen test results are very variable from day to day in the same man. An apparent improvement in the sperm quality may be a result of a chance fluctuation instead of any real effect from the treatment the man happens to be undergoing at the time. These men are subfertile, not sterile. Pregnancies occur but at a lower rate than normal. Any pregnancies occurring during treatment may not necessarily be due to the treatment.
Intracytoplasmic sperm injection
Intracytoplasmic sperm injection (ICSI) is now the method of choice for treating severe sperm problems. This technique involves the injection of a selected sperm into the body of the egg cell to enable fertilisation. It has revolutionised the treatment of male factor infertility, provided a live sperm can be found. The chances of failed fertilisation have been substantially reduced compared to when conventional IVF is used.
Male infertility deserves the same medical attention as female infertility. Any assessment of an infertile couple should include an assessment of the male partner from the outset, in view of the frequency of the male contribution to this problem. |