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Infertility is when the couple is unable to have a pregnancy in spite of trying. A better term is sub-fertility, as this implies that the condition is reversible. Whilst subfertility is not a disease, it can be the result of disease.  However, it is definitely a medical condition, best treated by medical means. Similar to taking 2 hands to clap, it takes both the man and the woman to get a baby.  When the inability to get a pregnancy is due to the man, it is then called “male infertility”.

What is it?

The male is said to be infertile if his sperm quality is below the accepted 2010 World Health Organization (WHO) norms; the sperm density should be more than 20 Million/ml, motility should be more than 50%, and normal forms should be more than 14%, amongst a few other parameters. In addition to the WHO standards, there are also sperm function tests and tests that look at where the sperm chromatin is within normal limits.

However, in a few instances, there are problems of delivery of the semen, including inability to ejaculate (“anejaculation”), retrograde ejaculation (usually after prostate surgery), and erectile dysfunction.

What is it caused by?

Over the past few decades, there has been a gradual decline in sperm quality based on the WHO sperm parameters. This conclusion was based on studies of sperm records from healthy sperm donors who gave their sperm to sperm banks. The studies also suggest that the decline is due to the exposure of men to increasing levels of pollutants and “endocrine disruptors” in the environment. The “Silent Spring” previously reported for animal life is now affecting humans.

How common is it?

It is now very uncommon to see a normal sperm test result in an infertile couple, even if the female has an obvious cause of infertility eg tubal disease or premature ovarian failure. Most studies previously state that the male is responsible for 50% of the cause of infertility. However, most times, the decrease in sperm quality is minimal, and hopefully some medical assistance is all that is required to result in a pregnancy.

Can it be treated?

So what can be done? Life-style changes are important, especially smoking, which is bad for the sperm. Simple medications, especially vitamins and anti-oxidants, should be started early. Sperm production takes 3 months, so whatever treatment that hopes to improve quality needs a minimum of 3 months before any conclusions can be made. If androgens (the male hormone) are reduced, supplementation (either oral or by injections) can be given. Rarely, the pituitary hormones that control sperm production are of low values (“hypo-pituitarism”), in which case twice-weekly injections of FSH and hCG for at least 3 months should improve the sperm quality.

Manipulation of the sperm in the laboratory can be done to improve the sperm that is processed. This is for intra-uterine insemination, which is usually done with some form of ovarian stimulation in the wife, which increases the number or quality of the follicles. That increases the number of follicles, and hence the pregnancy rates, including multiple pregnancies. The ovarian stimulation is usually with clomiphene citrate, but gonadotrophin injections can be used (ie FSH).

Finally, the best and most effective treatment is Intra-Cytoplasmic Sperm Injection (ICSI). This can even be done for patients who have no sperm in the ejaculate (“azoospermia”) as long as sperm can be collected by a small operation directly from the testes. This is known as Testicular Sperm Extraction (TESE). If azoospermia is due to obstruction (including previous ligation of the vas deferens or venereal infections) TESE will yield a fair amount of sperm. The pregnancy rate from ICSI is largely dependent on the age of the wife, with the best rates when she is younger than 35 years old.
Soon-Chye Ng, MD, FRCOG

Director, Sincere IVF Center

Professor (Adjunct), Dept of Obs/Gyn, National University of Singapore; Nanyang Technological University, Singapore.

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