Introduction

Infertility is usually defined as the inability of a couple to conceive even after one year of unprotected, frequent sexual intercourse.[1] It affects about 15% of all couples in the United States and at least 180 million worldwide.[2] Male infertility is defined as the inability of a male to make a fertile female pregnant, also for a minimum of at least one year of unprotected intercourse. The male is solely responsible for about 20% and is a contributing factor in another 30% to 40% of all infertility cases.[3] As male and female causes often co-exist, it is important that both partners are investigated for infertility and managed together. Overall, the malefactor is substantially contributory in about 50% of all cases of infertility.
There are several reasons for male fertility to occur, including both reversible and irreversible conditions. Other factors that could influence each of the partners could be their age, medications, surgical history, exposure to environmental toxins, genetic problems, and systemic diseases. The key purpose for evaluating a male for infertility is to identify his contributing factors, offer treatment for those that are reversible, determine if he is a candidate for assisted reproductive techniques (ART), and offer counseling for irreversible and untreatable conditions.[4] In rare cases, male infertility could be a herald to a more serious condition. This is an additional reason to do a comprehensive evaluation of the male partners of infertile couples; so that any significant, underlying medical conditions can be identified and treated.[5]

Problems with sperm production

The most common causes of male infertility are called:
In Azoospermia, no sperm cells are produced
Oligospermia, where few sperm cells are produced
Teratospermia, where a high proportion of sperm is abnormally shaped
Blocked or absent vas deferens:
The Vas deferens is the tube that transports the sperm from the testes
Genetic conditions such as cystic fibrosis or chromosomal abnormality
High sperm DNA fragmentation can affect a sperm’s ability to fertilize an egg
Sperm antibodies that can interfere with sperm motility and fertilization
It’s usually a good sign if you have ever conceived a baby with any partner in the past, but this may not mean that your sperm is compatible with your current partner.

What affects sperm quality?

Health & lifestyle factors such as smoking, excessive drinking, drugs including steroids and recreational use, and weight and Body Mass Index
Past medical conditions such as undescended testes, hernia, STD, or severe trauma.
Acute viral illness can also temporarily affect sperm health.
Sports injuries to the groin will only have an impact on sperm production in extremely severe cases.
While the effect of age on a man’s fertility is not as significant as it is with women, there is a decline in the quality of sperm after the age of 45. After this age, sperm volume, motility, and morphology decline, and damage to sperm DNA increases.

Retrograde ejaculation

Retrograde ejaculation is a condition in which some or all semen flows backward into the bladder rather than out through the urethra during ejaculation. Symptoms include producing little or no semen during ejaculation and can be diagnosed with a urine sample and semen analysis. If you are trying to conceive, retrograde ejaculation can be treated using assisted reproductive technology such as intrauterine insemination, IVF, or ICSI procedures. Sperm can be collected from the urine or surgically retrieved from the testis. A fertility specialist can explain your options and help you choose the best path for you.

Immunological infertility

Male immunological infertility occurs when a man develops antibodies against his own sperm. These anti-sperm antibodies attach to the sperm affecting the way they move and their ability to penetrate a woman’s cervical mucus and fertilise the egg. The presence of anti-sperm antibodies is commonly the result of vasectomy, injury, or injection but it does not mean a man won’t be able to conceive a child. Intracytoplasmic Sperm Injection (ICSI) can be used to help achieve a pregnancy.

Hyperprolactinemia

Hyperprolactinemia refers to elevated levels of the prolactin hormone in the bloodstream. In men, this can cause infertility by affecting the function of the testicles, decreased testosterone levels, decreased sex drive, and abnormal sperm production. If hyperprolactinemia is affecting your fertility there are treatments available and your fertility specialist will guide you on the one most appropriate for you.

Occlusion

Occlusion refers to a blockage in a man’s reproductive system, often in the epididymis or vas deferens, which prevents sperm from reaching the urethra. Occlusions in men could be a result of injury, vasectomy, or a congenital condition. It can be treated using a Vasovasectomy which is a surgical procedure that reconnects the ends of the vas deferens together or a testicular biopsy to surgically retrieve sperm from the testis for use in IVF or ICSI treatment.

How is male infertility diagnosed?

Potential male infertility will be assessed as part of a thorough physical examination. The examination will include a medical history regarding potential contributing factors.
Your healthcare provider may use one or more of the following tests to assess fertility:
Semen analysis to determine the number and quality of sperm.
A blood test to check for infections or hormone problems.
Making a culture of fluid from the penis to check for infections.
Physical examination of the penis, scrotum, and prostate.

What are they looking for in the testing?

When a semen analysis is done, your healthcare provider will be looking for some specific markers to access fertility.
The total amount or volume of semen – 2 milliliters is considered normal. A lower amount may indicate an issue with the seminal vesicles, blocked ducts, or a prostate gland issue.
Sperm count – 20 million to 300 million per milliliter is considered in the normal range for sperm counts. Below 10 million is considered “poor.”
Morphology – the size and shape of the sperm affect the sperm’s ability to reach and fertilize an egg. 30% is considered a good amount of sperm that is shaped “normal.” And “strict” testing shows an even lower percentage than normal.
Motility – movement and number of active cells. Movement is rated from 0-4, with a score over 3 considered good. The amount of active cells is rated in percentages from 1-100%, with 50% considered the minimum.

Compiled using information from the following sources:
The National Infertility Association (RESOLVE) https://www.resolve.org
American Society for Reproductive Medicine (ASRM) https://www.asrm.org
World Health Organization (WHO) https://www.who.int
American Urology Association https://www.urologyhealth.org