Male Infertility A child of my own - Andrology Australia

MALEINFERTILITYA CHILD OF MY OWNA BOOKLET IN THE SERIESOF CONSUMER GUIDESON MALE REPRODUCTIVEHEALTH FROMwww.andrologyaustralia.org

First published in May 2004by Andrology Australia3rd Edition, January 2011© Copyright 2011, Andrology AustraliaHealth information in this booklet describesMALE INFERTILITY. Diagnosis and treatmentoptions are described to help men and theirfamilies understand the health problem, makemen aware of the available treatment options,and to help make talking with their doctor easier.The information contained in this booklet isbased on up-to-date medical evidence. It hasbeen provided for educational purposes only.It is not intended to take the place of a clinicaldiagnosis or medical advice from a fully qualifi edhealth professional. Andrology Australia urgesreaders to seek the services of a qualifi ed healthprofessional for any personal health concerns.Although the information in this booklethas been carefully reviewed, AndrologyAustralia does not take any responsibilityfor any person using the information oradvice available in this booklet. Informationis given on the understanding that users takeresponsibility for checking the relevance andaccuracy of the information.Andrology Australia (The Australian Centreof Excellence in Male Reproductive Health -www.andrologyaustralia.org) is an initiativefunded by the Australian GovernmentDepartment of Health and Ageing.

MALE INFERTILITYInfertility – Not just a female problem!Men are often shocked to discover that difficulties inhaving a baby are because of reproductive problems onthe male side.Problems with the number or quality of sperm beingmade can stop many couples from becoming pregnant.It is estimated that in Australia, male infertility affectsabout one in every 20 men. Despite the popularbelief that infertility is usually because of female(gynaecological) problems, in about one in five infertilecouples, there are problems relating only to the male.Talking with yourdoctor aboutpersonal healthconcerns is thefirst step towardsimproving yourhealth and qualityof lifeCoping with male infertility can be very difficult.Men can often become stressed and frustrated as innearly half of cases, doctors can find no reason for poorsperm production.Today many infertile men become the fathers of healthychildren. Some men, when the reason for their infertilitycan be explained and fixed, have treatment and thenconceive naturally. Others use assisted reproductivetechnologies, donor sperm, adoption or foster parenting.MALE INFERTILITY 1

ContentsMale reproduction ................................ 3Signs & symptoms ................................ 13Causes ................................................... 15Diagnosis ............................................... 19Semen analysis ....................................... 28Treatment ............................................... 33Prevention ............................................... 38Having a family ..................................... 43Emotional issues ..................................... 58AppendicesHormonal problems ................................ 64Genetic & chromosomal problems ......... 66Undescended testes ................................. 70Infections ................................................. 72Torsion of the testis ............................... 75Heat ........................................................ 77Varicocele ................................................ 79Sperm antibodies ................................... 81Vasectomy ............................................... 84Absence of vas deferens ......................... 87Erection & ejaculation problems ............. 89Testicular cancer & fertility .................... 94Medicines & other drugs ....................... 98Radiation .............................................. 101Support ................................................... 103Glossary .................................................. 106Authors ................................................... 113At a glance ............................................ 114References ............................................... 116

MALEREPRODUCTIONWhat are sperm?Sperm are the male reproductive cells. To havea child, genetic material from the sperm mustcombine 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 bythe human eye. These mature sperm are highlyspecialised cells and are made up of three parts:a head, neck and tail. In the head is a structurecalled the nucleus, which contains 23 tightlypacked chromosomes (genetic material). Thehead is designed to bind to and then penetrate(enter) the egg. The neck joins the head to thetail. The part of the tail nearest the neck containsthe mitochondria, which provides the energy forthe sperm to move. The tail moves in a whippingmotion to push the sperm towards the egg.A man’s fertilityand sexualcharacteristicsdepend on thenormal functioningof the malereproductive systemHealthy, mature sperm with a normal shaped head, neck and tail.MALE INFERTILITY 3

MALEREPRODUCTIONWhere are sperm made?The male reproductive tract is made up ofthe testes, a system of ducts (tubes) and otherglands opening into the ducts. The testes (testis:singular) are a pair of egg shaped glands that sitin the scrotum next to the base of the penis onthe outside of the body. Each normal testis is15 to 35ml in volume in adult men. The testesare needed for the male reproductive system tofunction normally.The testes have two related but separate roles:• Production of sperm• Production of the male sexhormone, testosteroneAnatomy of male reproductive system.MALE INFERTILITY 4

Before birth, the developing testes move downfrom the abdomen into the scrotum. Successfuldescent of the testes is important for fertility as acooler temperature in the scrotum is needed forsperm production and normal testicular function.The location of the testes in the scrotum keeps thetestes about 2°C below normal body temperature.Sperm are made in the testes in a number of small,tightly packed, fine tubes called seminiferoustubules. These tubules have a total length of 150metres. Between the seminiferous tubules liesanother cell type, Leydig cells. These cells, whichproduce the male sex hormone testosterone, lieclose to blood vessels so that testosterone can betransported throughout the body in the blood.Cross-section of the testes showing sperm-producing tubes(seminiferous tubules) and Leydig cells.MALE INFERTILITY 5

MALEREPRODUCTIONHow are sperm made?Spermatogenesis (sperm production) is a lengthy,but continuous, process. Within the testis, spermcan be at different stages of development, withsome sperm at early stages and others at laterstages. It takes about 70 days for germ cells(in men, these are the cells in the testis thatdevelop to produce immature sperm cells) todevelop into the mature sperm found in sementhat can fertilise an egg. This means that thesperm released from the testis today started theirdevelopment weeks earlier.The germ cells in the lining of the seminiferoustubules divide over and over again to producesperm. The process of sperm production starts withthe earliest germ cell, called a spermatogonium.These dividing cells pass through many stages andundergo a major change in shape, from a roundcell (spermatid) to the familiar ‘tadpole-like’sperm. At this final stage, sperm are released fromthe lining of the sperm-producing tubes and passout 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 andspermatid, 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-coiledtube called the epididymis that lies at the backof the testes. The epididymis connects theseminiferous tubules to another single tube calledthe vas deferens. When released from the testis,the sperm spend two to 10 days passing throughthe epididymis. During this journey, the spermmature and gain the ability to become motile(swim or move). When ejaculation starts, spermare transported from the tail of the epididymis, viathe vas deferens, to the urethra (urinary tract) inthe penis. To achieve a pregnancy, sperm must beput into the vagina at the fertile time of a woman’smenstrual cycle.MALE INFERTILITY 7

MALEREPRODUCTIONSperm must then travel through the woman’suterus (sometimes called the ‘womb’) and into theuterine tubes where they meet the egg. Fertilisationof 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 thebase of the brain, control the testes. The pituitarygland releases both follicle stimulating hormone(FSH) and luteinising hormone (LH) into theblood. 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 riseduring the early stages of puberty, and under theirinfluence, the testes grow and mature. With thehelp of LH, the Leydig cells in the testis makethe male sex hormone, testosterone. Testosteroneis responsible for many of the physical changesin young boys at puberty including developmentof the genitals, facial and body hair and othercharacteristics of the adult male.Together with testosterone, FSH from thepituitary gland acts on the seminiferous tubules inthe testes to stimulate the production of sperm.How are sperm ejaculated?At the start of ejaculation, waves of musclecontractions transport the sperm, with a smallamount of fluid, from the epididymis throughto the vas deferens.At the back of the bladder, the vas deferensbecomes the ejaculatory ducts, which pass throughthe prostate gland to join the urinary tract, byentering the prostatic urethra (the section ofthe urethra that is located in the centre of theprostate). The prostate gland produces fluid thatmixes with the sperm in the prostatic urethra.Extra fluid from the seminal vesicles enters theurethra via the ejaculatory duct. The passage offluid along the urethra is further helped by thelubricating fluid made by the Cowper’s glands.MALE INFERTILITY 9

MALEREPRODUCTIONThis mixture of fluid from the testes and otheraccessory glands, travels along the penile urethra(the section of the urethra located in the penis) tothe 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 ejaculatedfrom the penis. Semen is the mixture of fluidsfrom the different organs of the male reproductivetract. About 90 per cent of the ejaculated semencomes from the prostate gland and seminalvesicles. Only a small amount of fluid, which alsocontains the sperm, comes from the epididymis.During ejaculation, usually the sperm and theprostatic fluid come out first and the seminalvesicle fluid follows.How many sperm are needed to achievepregnancy?The ejaculate of fertile men contains tens ofmillions of sperm. However, men with muchlower numbers of sperm can still achievepregnancies. Men who never produce any spermin their ejaculate are sterile and cannot get apartner pregnant without some form of treatment.MALE INFERTILITY 10

Where can sperm production go wrong?The sperm production process can be interruptedat various stages for a number of reasons:• Absence of germ cells (or Sertoli cell-onlysyndrome): The testis may completely lack thedeveloping cells (germ cells) that normally divideto become sperm. This is a severe form of spermproduction problem and makes the man sterile ifthere are no sperm in the semen or in the testes• Maturation or germ cell arrest: Sometimesgerm cells stop developing and do not becomemature sperm• Hypospermatogenesis: When the numberof sperm produced is lower than normal, onlysmaller numbers travel from the testes throughthe male reproductive system and into theejaculated fluid.How common is male infertility?Infertility is a widespread problem. For about onein five infertile couples the problem lies solely inthe male partner (male infertility). 1In about one in four couples, there are problemswith both male and female partners, and in aboutone in seven infertile couples, the cause of theproblem cannot be found (idiopathic infertility).MALE INFERTILITY 11

MALEREPRODUCTIONIt is estimated that one in 20 men have some kindof fertility problem with low numbers of sperm intheir ejaculate. However, only about one in every100 men produces no sperm in their ejaculate.Both male & female problems 27%No known cause for infertility 15%Female problems only 38%Male problems only 20%Proportion of couples with infertility problems. 2MALE INFERTILITY 12

SIGNS &SYMPTOMSWhat is male infertility?Reproduction (or making a baby) is a simpleand natural experience for most couples. However,for some couples it is very difficult to conceive.A man’s fertility generally relies on the quantityand quality of his sperm. If the number of sperma man ejaculates is low or if the sperm are of apoor quality, it will be difficult, and sometimesimpossible, for a couple to become pregnant.Male infertility is diagnosed when, after testingof both partners, reproductive problems havebeen found in the male partner.Are there any signs or symptoms ofmale infertility?In most cases, there are no obvious signs ofinfertility. Intercourse, erections and ejaculationwill usually happen without difficulty. Thequantity and appearance of the ejaculated semengenerally appears normal to the naked eye.Medical tests are needed to find out if a manis infertile.Many men will stillbe able to fatherchildren naturallyeven though theymay have a loweredsperm countMALE INFERTILITY 13

SIGNS &SYMPTOMSWhen should couples get medical advice forfertility problems?Couples not using any form of contraception, whodo not become pregnant after a year of regular (atleast twice weekly) sexual intercourse should seea doctor and have some tests. However, couplesshould seek medical help earlier if there are knownreproductive problems, or if the female partner isnearer the end of her reproductive life (older than35 years).A doctor can be asked questions about the timingof sexual intercourse and other facts about thereproductive system. Some basic answers cansometimes help couples and lower their stress andanxiety. Some couples will be worried that thingsare ‘not working’ after only a few months, and theymay find it helpful to talk about their concernswith their doctor.MALE INFERTILITY 14

CAUSESWhat are the known causes of male infertility?Male infertility can be caused by problems thataffect sperm production or the sperm transportprocess. With the results of medical tests, thedoctor may be able to find a cause of the problem.Known causes of male infertility can be:Sperm production problems: The most commoncause of male infertility is due to a problem inthe sperm production process in the testes. Lownumbers of sperm are made and/or the sperm thatare made do not work properly. About two thirdsof infertile men have sperm production problems.Blockage of sperm transport: Blockages (oftenreferred to as obstructions) in the tubes leadingsperm away from the testes to the penis cancause a complete lack of sperm in the ejaculatedsemen. This is the second most common causeof male infertility and affects about one in everyfive infertile men, including men who have had avasectomy but now wish to have more children.Sperm antibodies: In some men, substances in thesemen and/or blood called sperm antibodies candevelop which can reduce sperm movement andblock egg binding (where the sperm attaches to theegg) as is needed for fertilisation. About onein every 16 infertile men has sperm antibodies.MALE INFERTILITY 15

CAUSESSee AndrologyAustralia’s guide onErectile Dysfunction formore informationSexual problems: Difficulties with sexualintercourse, such as erection or ejaculationproblems, can also stop couples from becomingpregnant. Sexual problems are not a commoncause of infertility.Hormonal problems: Sometimes the pituitarygland does not send the right hormonal messagesto the testes. This can cause both low testosteronelevels and a failure of the testes to produce sperm.Hormonal causes are uncommon, and affect lessthan one in 100 infertile men.[See Section: ‘Appendices’ for more information on the known causesof male infertility]Why is there no known reason for somefertility problems?Unfortunately, medical scientists do not yetunderstand all the details of sperm productionand the fertilisation process. As a result, for manymen with a sperm production problem, the causecannot be identified.Medical research continues to try and understandthe cause of male infertility problems.MALE INFERTILITY 16

Sperm productionproblemsBlockage of spermtransportSperm antibodiesSexual problems(erection and ejaculationproblems)Hormonal problemsKnown causes of male infertility• Chromosomal or genetic causes• Undescended testes (failure of the testes todescend at birth)• Infections• Torsion (twisting of the testis in scrotum)• Heat• Varicocele (varicose veins of the testes)• Medicines and chemicals• Radiation damage• Unknown cause• Infections• Prostate-related problems• Absence of vas deferens• Vasectomy• Vasectomy• Injury or infection in the epididymis• Unknown cause• Retrograde and premature ejaculation• Failure of ejaculation• Infrequent intercourse• Spinal cord injury• Prostate surgery• Damage to nerves• Some medicines• Pituitary tumours• Congenital lack of LH/FSH (pituitaryproblem from birth)• Anabolic (androgenic) steroid abuseMALE INFERTILITY 17

CAUSESWhy is timing of intercourse important?Infrequent sexual activity is a common reasoncouples do not become pregnant within the firstfew months. For the best chance of conception,sexual intercourse should take place at the timeof ovulation (i.e. when an egg is released into thefemale reproductive tract). This usually happensabout 14 days (range 12 to 16 days) after the firstday of a woman’s period, as is the most fertile timeof the month (for a woman with regular 28 daycycles). Doctors usually suggest to couples thatto improve their chances of fertility, they shouldhave sex daily or at least every second day over thisfertile period.MALE INFERTILITY 18

DIAGNOSISHow is male infertility diagnosed?If a couple has been trying to get pregnant withoutsuccess, they should go to their local doctor, familyplanning or women’s health clinic, and have someinitial tests. Both partners should be tested, even ifone has already had a child in another relationship.In many cases, both male and female problems arefound to be contributing to the difficulties couplesexperience when trying to get pregnant.What will the doctor do?A doctor will take a medical history from the manto find out whether there are any obvious healthproblems that could affect fertility.A doctor will also ask questions that include howlong the couple has been trying to get pregnant,and how often sexual intercourse happens.A physical examination is also done. This can bethe first full health check for many young men andsometimes identifies other unrelated health problems.A doctor will refer the man to a laboratory for a semenanalysis. A semen analysis will check the number,movement and shape of the sperm in the ejaculate.Blood tests may also be done to check thehormone levels that control sperm production.Genetic investigations and testicular biopsies aresometimes done.MALE INFERTILITY 19

DIAGNOSISWhat is involved in a physical examination?During the physical examination, the doctorwill check:• The amount and spread of body, pubic andfacial hair• Possible swelling in the breasts• Any sign of previous surgical scars in the groinor 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 theneck of the scrotum just above the testes• Possible varicocele development which meanschecking the blood vessels at the top of thescrotum, both while the man is lying down andstanding up• In some cases, a rectal examination is doneto check the prostate gland for signs ofpossible inflammationMALE INFERTILITY 20

Ultrasound may be used if the testes are difficult tofeel 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 freshlyejaculated semen that usually has been producedby masturbation. It is a vital part of the testingof the male partner. Specially trained laboratorypersonnel are needed to do this test accuratelyand therefore semen analysis should be done inlaboratories with this expertise. A semen analysischecks that sperm are present in the ejaculate andhelps find if there is a problem with the number orquality 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 inthe ejaculate• Sperm motility: The number of spermthat are moving and if they travel in a fast,forward movement• Sperm morphology: The number of sperm withan abnormal shapeMALE INFERTILITY 21

DIAGNOSISSemen analysischecks all thecomponents ofsemen• The presence of sperm antibodies. Sometimes,the immune system recognises the man’s ownsperm as foreign and develops antibodies againstthem which can cause fertility problems• The presence of white blood cells in the ejaculate.High numbers of white blood cells may be a signof an infection of the reproductive tractWhat hormones are tested?Testosterone and the pituitary hormones, FSH(follicle stimulating hormone) and LH (luteinisinghormone) circulate in the blood and can be easilymeasured in a blood test if hormonal problems aresuspected. Combined with results from a semenanalysis, the following diagnoses can be possiblecauses of male infertility. However, reasons forinfertility can be different for each individual man.MALE INFERTILITY 22

SpermnumbersLow orzeroLow orzeroLow orzeroFSH LH TestosteroneVeryLowVeryHighVeryHighVeryLowVeryHighVery LowLow toNormalPituitary gland problemscan cause poor FSH and LHproduction, which lead to lowtestosterone and infertilityHigh levels of FSH and LH,together with low to normallevels of testosterone, showa problem in the testesNormal Normal In many infertile men,the testosterone producingcells (Leydig cells) in thetestes are working normallyand only the sperm-producingtubules (seminiferous tubules)are a problem. The body makesmore FSH to try and overcomethe problemZero Normal Normal Normal Possible blockage to sperm flowMALE INFERTILITY 23

DIAGNOSISWhat genetic tests may be done?Chromosomes are found in each cell of thehuman body. They carry the genetic material thatdetermines growth and development of all humancharacteristics including hair colour, eye colour,height and gender. Each cell in the body normallyhas 23 pairs of chromosomes (or a total of 46).Of the 23 pairs of chromosomes, one pair are sexchromosomes which determine a person’s gender.The normal male chromosome arrangement is46XY. One of each chromosome comes from themother and the other from the father. Femalesalways pass on an X chromosome, but malescan pass on an X or a Y chromosome. The Ychromosome directs the development of the testes.Changes to chromosomes can lead to poorsperm production. Sometimes otherwise healthymen with very low sperm counts can havegenetic disorders, particularly in the numberof their chromosomes that they may not haveknown about before. A blood test called akaryotype measures the number and structure ofchromosomes in each cell. A common geneticdisorder that causes infertility is Klinefelter’ssyndrome. Men with this problem have an extraX chromosome (47XXY).MALE INFERTILITY 24

Another blood test which can be done by a fewspecialised laboratories in Australia is called theY chromosome deletion test. The Y chromosomedeletion test checks if important genetic material,which controls sperm production, is missing onthe male sex chromosome (Y chromosome). Thisgenetic problem is found in about one in 20 menwith low sperm counts.Rarer genetic causes of infertility are usuallyrecognised when the doctor does a clinicalexamination. Special tests may then be done,particularly if there is a risk of passing on a seriouscondition to the children, such as cystic fibrosis,which is a condition associated with the absenceof the vas deferens.MALE INFERTILITY 25

DIAGNOSISWhat other tests may be done?Other medical tests may be needed to identifyspecific medical conditions:Testicular biopsy: Tissue samples are sometimesremoved from the testes for testing under localanaesthetic. Sometimes this procedure is doneunder general anaesthetic. A small needle isinserted into the testes a few times and tiny piecesof testicular tissue, about half the size of a matchhead, are removed. These tissue samples are thenchecked for sperm under a microscope. A testicularbiopsy is quite safe but infection and bleeding cansometimes happen.These problems generally clear up in a few days.In a man with no sperm seen in his semen, thistest can help determine if a blockage in thereproductive tract is the problem or if sperm arenot being producedUrine analysis: Tests on urine are sometimesdone to check for retrograde ejaculation whichmeans that semen moves into the bladder duringorgasm, rather than being ejaculated out of thetip of the penis. For men with this problem, thesperm is washed out when they next urinate afterejaculation. This test is most commonly done ifthe 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 asperm production problem, a hormonal problem,a blockage to sperm transport or an ejaculationproblem and treatment can then be chosen.Unfortunately, for men with a sperm productionproblem, the cause is often not known. For othermen, everything can seem normal, including thesemen test results, and there is no clear reason whypregnancy is not happening. Infertility, where thecause is unknown, is called idiopathic infertility.Couples with this problem can seek help toconceive 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 forcouples who are having difficulty getting pregnant.However, if the semen analysis is abnormal, areferral to an infertility specialist, who may also bean endocrinologist, urologist or gynaecologist, isneeded, as the treatment is often more involved.MALE INFERTILITY 27

SEMENANALYSISA semen analysisis a vital part ofdiagnosing maleinfertilityWhat is semen analysis?Semen analysis is the laboratory testing of freshlyejaculated 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 toaccurately do a semen analysis. Therefore testingshould take place at specialised laboratories thatuse methods approved by the World HealthOrganisation (WHO).How is semen collected for testing?Semen testing should be done on a freshlyejaculated semen sample (within two hours ofbeing produced). For the test, a semen sampleis best produced into a jar by masturbating in aprivate room at the laboratory. It is important thatnone of the semen sample is lost. As sperm aremostly in the first part of the ejaculate, losing thefirst part of the ejaculate can give a false readingof a lower sperm count. It is also important thatthe man does not have sexual intercourse ormasturbate for about two (but up to five) daysbefore the test, as frequent ejaculations could alsolower the sperm count. Too long a period betweenejaculations may also lower the sperm quality.An individual’s semen quality can vary greatlybetween samples, even in fertile men. Sperm countscan be affected by illness. Fevers and infections canMALE INFERTILITY 28

temporarily lower a sperm count for several months.At least two semen analyses are needed to properlycheck fertility. These tests should be done at least sixweeks apart.What does a semen analysis report cover?A number of different items are tested andrecorded in a semen analysis report, including:Semen volume (also known as the ‘volume ofsemen’): The total amount of fluid ejaculated.Men normally produce two to five millilitres (mls)of semen when they ejaculate.Sperm concentration (commonly known as asperm count): the number of sperm in a measuredvolume of the ejaculate is counted. The spermconcentration is reported as the number of spermper millilitre (ml) of semen.Sperm output per ejaculate (also known as thetotal sperm count): This is total number of spermin the ejaculate as is calculated by multiplying thesemen volume by the sperm concentration.Sperm motility (the ability of sperm to swim ormove forward): The number of motile (moving)sperm compared to non-motile sperm is reportedas a percentage of the total number of sperm.Sperm morphology (the sperm’s shape andphysical features): The number of sperm that areimperfectly shaped (often referred to as ‘abnormal’)MALE INFERTILITY 29

SEMENANALYSISis compared with the number of normally shapedsperm. This is recorded as a percentage of the totalnumber of sperm. Defects in the shape of the spermheads or tails can affect their movement and abilityto bind to and fertilise an egg. When checked usingstrict WHO methods, this morphology result cangive an indication of the sperm’s chances of fertilisingan egg in a test-tube (in vitro). It is quite commonfor fertile men to have a small number of normallyshaped sperm however, the chance of a man beingfertile falls when the proportion of perfectly normalsperm is less than 4 per cent of all the sperm.In very rare cases, some men have sperm that allhave round heads (globozoospermia) and thesemen will not be able to get pregnant naturally.White blood (inflammatory) cells: Often foundin the semen ejaculate. Large numbers of whiteblood cells in the ejaculate can be a sign of aninfection of the reproductive tract. However, insome men, large numbers of white blood cells can‘come and go’ over time for no known reason.Semen pH: Levels are measured to determine ifthe ejaculate is acidic or alkaline. Semen should beslightly alkaline. More acidic semen, together witha low amount (volume) of semen, can mean thereis a possible blockage in the ejaculatory ducts.Sperm antibodies in semen: An importanttest, normally done in specialised laboratoriesMALE INFERTILITY 30

using methods approved by the World HealthOrganisation. Sperm antibodies can happen insome men when the immune system considers itsown sperm to be foreign and develops antibodiesagainst them. Sperm antibodies commonly happenin men after vasectomy.Antibodies attach themselves to the sperm to reducethe sperm’s movement. The sperm clump together,making it difficult to pass through the mucus in awoman’s cervix. In the fertilisation process, the spermand egg recognise each other by substances (receptors)on their surface. If antibodies are bound to sperm,these receptors are covered by the antibodies and stopthe sperm from binding (sticking) to the egg.What is a normal semen analysis result?The World Health Organisation (WHO 2010) 3published reference values to help work out howan individual semen analysis result compares to afertile population of men.A semen analysis value within the reference rangesdoes not guarantee fertility in an individual man,but gives a guide as to whether a man may befertile. Men whose semen analysis falls withinthese ranges may not be fertile as a result of otherunknown reasons. In the same way, men whohave very low counts and are not within thesereference ranges might still be able to get a partnerpregnant naturally. So for example while 15 millionsperm per ml is the new lower value for spermMALE INFERTILITY 31

SEMENANALYSISconcentration, this does not mean that men with2 million sperm per ml are always infertile. About30 per cent of such couples will have a spontaneouspregnancy over a 2 to 3 year period. Other majorfactors that can affect a couple’s chance of gettingpregnant, 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 interpretedwith other clinical information by a doctor. Itis also important to remember that a couple’schance of getting pregnant and the time it takesto become pregnant is also affected by the femalepartner’s fertility.Are other tests done as part of a semen analysis?In some instances, men may need to provide a urinesample after ejaculation if the doctor thinks there isan ejaculation problem (retrograde ejaculation). Theurine is checked for sperm.In severely infertile men, sperm DNA may bedamaged which reduces the chance of the spermproducing a healthy embryo and live birth.Different methods for testing sperm DNAdamage are available; however, more researchis needed to decide if these tests have a role inroutine clinical practice.MALE INFERTILITY 32

TREATMENTCan male infertility be treated?The results of medical tests help doctorsdecide whether the male infertility problemcan be treated.Treatable conditions: One in eight infertile menhas a treatable condition, and after treatmentcouples can become pregnant naturally.Untreatable sub-fertility: Three quarters ofinfertile men have sperm present in the semen,but in lower numbers than normal. The problemcausing the poor production or function oftheir sperm is often not able to be identified andcured. These men are often referred to as being‘sub-fertile’ as pregnancies may happen but atlower rates than usual. On average, more monthsof trying are needed for conception to happen,however it still may never happen. Assistedreproduction or in vitro fertilisation (IVF) canhelp some of these men to become fathers.Untreatable male sterility: About one in nineinfertile men have no sperm in their semen or intheir testes and cannot often be treated. Spermproducing cells in the testes either did not developor have been irreversibly destroyed. Adoption ordonor insemination are the only possibilities forcouples in this group who wish to have a family.IVF does not cureinfertility, but itmay help a coupleachieve a pregnancyMALE INFERTILITY 33

TREATMENTHow is the best treatment decided?Using the results of physical examinations andthe laboratory tests, a doctor can usually work outif difficulties in becoming pregnant are becauseof a problem with the male partner and if thecondition is treatable. Possible treatments maythen be explained. Doctors will also discuss thechances of becoming pregnant naturally, whencertain male infertility problems exist.Many men will still be able to father childrennaturally even though they may have a loweredsperm count.In some cases, the doctor will recommend thatthe couple seek assisted reproductive technologies(such as IVF) in order to become pregnant. Thesetechniques do not cure or treat the cause of themale infertility problem, but they may help thecouple conceive even if the man’s sperm count isvery low.[See Section: ‘Appendices’ for more information about specific infertilityconditions and their treatment]What causes of male infertility can be treated?In some cases, the cause of the male infertilityproblem can be treated and a couple can try andbecome 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, problemswith getting and keeping an erection)• Some reversible conditions (for example, useof anabolic steroids)When is male infertilitycompletely untreatable?Male infertility is completely untreatable when aman has no sperm in his semen (azoospermia) orin the testes, because the sperm producing cellsin the testes either did not develop or have beenpermanently destroyed.Azoospermia may be caused by chromosomal orgenetic disorders, inflammation of the testes orcertain medicines (especially cancer treatments). Itmay also be because the testes did not descend intothe scrotum at the time of birth (undescended testes).The only options for such couples who want tohave a family are to think about adoption, fosterparenting or donor insemination.[See section: ‘Having a Family’ for more information]MALE INFERTILITY 35

TREATMENTSee AndrologyAustralia’s guide onAndrogen Defi ciencyfor more informationSome men with testicular damage and failureof sperm production do not produce normalamounts of the male sex hormone, testosterone,resulting in lower levels in the blood. Lower levelsof testosterone can lead to lower libido (interest insex) and lower energy levels, hot flushes and othersymptoms. The general health and sexual interestof such men can be improved through testosteronereplacement therapy, but sperm production doesnot improve with such treatment.Can natural therapies improve spermproduction?There have been many natural products marketedto improve unexplained sperm productionproblems, such as vitamins, antioxidants and zincsupplements, antibiotics (even when no infection ispresent) and various other natural therapies. At thisstage, there is no good medical research that suchtherapies improve the chance of having a child.Men should talk to their doctor when thinkingabout using natural therapies that are marketed asproducts 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 asIVF) can greatly increase the couple’s chance ofbecoming pregnant. It is important to realise thatwith all medical treatments, including IVF, thereare some risks. Even when the fertility problemrelates only to the man, IVF procedures place thefemale partner at risk of side-effects and problems.Deciding on treatment needs careful thought andshould be talked about with the doctor.[See section: ‘Having a Family’ for more information]MALE INFERTILITY 37

PREVENTIONLifestyle behaviourscan affect fertilityCan male infertility be prevented?Cigarette smoking, alcohol, sexually transmitteddiseases, heat stress from tight fitting underwear,and anabolic steroids (taken for body buildingor sporting purposes) can be harmful to theproduction of sperm and should be avoided.How does cigarette smoking affectmale fertility?Research on the effect of smoking on semenquality is unclear. However, it is generallyrecommended that men quit smoking for theirlong term health. Quitting smoking is particularlyimportant if a man is trying to have childrenbecause of the passive smoking effects on theirpartner and children.How does alcohol affect fertility?Moderate alcohol intake (one to two standarddrinks per day) does not affect sperm production.However, a large amount of alcohol may causeliver damage, which could have an effect ongeneral and reproductive health.What sexually transmitted infections canaffect fertility?Sexually transmitted infections (STIs), suchas gonorrhoea and chlamydia, can damage theepididymis and stop sperm passing from thetestes into the ejaculate. Genital herpes, whileMALE 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 stagesof the disease.It is important for men who think they may havea STI to get immediate treatment from a doctor.This can stop the spread of the disease to a partnerand also reduce the chance of blockages developingin the male reproductive tract. For men notwanting a family, safe sex practices using condomsare recommended outside stable monogamousrelationships. Both partners may want to be testedfor STIs before trying to have a family. This may stopany disease being passed on to partners or children.Do underwear styles really affect fertility?Whether looser (cooler) boxer shorts are betterthan tighter (warmer) briefs is unclear. Someresearch has suggested that wearing tightunderwear can decrease sperm counts, althoughother studies have not found this to be the case.Doctors usually suggest that men reduce thechances of heat stress on sperm production byavoiding tight-fitting clothing before and whiletrying to conceive.There is ongoingdebate about theeffect of underwearstyles on spermproductionMALE INFERTILITY 39

PREVENTIONHow do spas and saunas affect fertility?It is generally recommended that men avoid spas,saunas and hot baths if trying to father a child. Raisingbody temperature, and particularly the temperaturearound the testes when sitting in hot water for a longperiod of time, can reduce sperm production.How do vaginal lubricants affect the chancesof becoming pregnant?Many vaginal lubricants kill sperm. If couplesare trying to become pregnant, vaginal lubricantsshould not be used during the fertile time in thefemale partner’s menstrual cycle.Do recreational drugs affect fertility?Androgens (anabolic steroids), taken for bodybuilding or sporting purposes, reduce spermproduction by stopping the hormones madeby the pituitary gland. Androgens can also beharmful to general health if men who have normaltestosterone levels take them. These drugs shouldbe stopped straight away, particularly if a couple istrying to have a baby.Other illegal use of drugs, such as marijuana andheroin, may also affect fertility.What work environments affect fertility?Although there is no clear scientific researchthat some work environments affect fertility, itis generally recommended that couples trying toMALE INFERTILITY 40

ecome pregnant avoid exposure to any possibleharmful chemicals.Pesticides, heavy metals, toxic chemicals andradiation may affect the quality and quantity ofsperm produced.For men who work in occupations that may affectfertility, it’s important to wear protective clothing andfollow all occupational health and safety guidelines.Is age important when trying to have a family?Healthy men in their 70s and beyond can stillfather children, however the time taken to cause apregnancy is longer from middle-age onward. 4Reasons for this may include a decrease insexual activity, semen volume, sperm motility(movement), the total number of motile spermand possibly sperm function and DNA quality. 5Some genetic and chromosomal problems inoffspring also increase as the male age increases.Can storing sperm prevent loss of fertilitywith some treatments?Sperm storage is the collection (through masturbation)and freezing of semen. Men about to start treatmentthat could make them infertile, such as treatment forcancer, may want to consider storing sperm beforestarting treatment. If and when a couple want to havea family this semen can be thawed and used in fertilityMALE INFERTILITY 41

PREVENTIONInfertilitycentres, whichprovide assistedreproductivetechnologies,usually offer longtermsperm storagefacilitiestreatments such as vaginal insemination at the timeof ovulation or, in some cases, through IVF.All men and teenage boys who have started orpassed puberty and who are about to receivechemotherapy or radiotherapy should considersperm storage before their cancer treatmentstarts. Men who need to take medicines for otherhealth reasons when they are also trying to starta family, should check with their doctor to makesure that the medicine does not cause infertility.If medicines cause infertility, such as Salazopyrin®(used to treat inflammatory bowel disease), mencan also store sperm before starting treatment.Men who have taken pituitary hormone treatments inorder to improve sperm production, but wish to stopthis therapy after their first child has been born, maywish to store some sperm for possible later pregnancies.Men planning a vasectomy should think aboutstoring sperm before having this procedure.Semen storage may remove the possible need fora vasectomy reversal or IVF at a later stage.[See section: ‘Appendices’ for more information on vasectomy]For more information on semen storage, contactthe nearest IVF or fertility clinic, or talk to aninfertility specialist.[See Section: ‘Support’ for more information and contact details]MALE INFERTILITY 42

HAVINGA FAMILYWhat are the chances of natural conception?It can often take up to a year, even for healthyfertile couples, to become pregnant. In a study 6of the time it took women who were planningfamilies to become pregnant:• About one third (38%) conceived in the firstmonth of tryingFertility drops withfemale age from themid 30s onwardsand rapidly fromage 40, so thisshould be takeninto account whenplanning 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 yearAbout three to four per cent of couples who wantto have children, remain childless at the end oftheir reproductive life phase.A small number of men who are sub-fertile andhave at least some moving sperm in their semen,father children naturally whether or not theinfertility problem is treated. However, it can takelonger and possibly a number of years before menwith sub-fertility conceive.About one third of sub-fertile couples get pregnantnaturally in the first year after investigation forinfertility, with almost half (45%) by two years.MALE INFERTILITY 43

HAVINGA FAMILYEven men with azero sperm countmay produce spermin their testes thatcan be collectedand used in assistedreproductivetechnologiesWhat are the options if natural conception isnot possible?If an infertility problem cannot be treated, ortreatment is unsuccessful, and it is not possible tobecome pregnant through sexual intercourse, thereare several options available to couples wishing tohave a family. These options include:• Assisted reproductive technologies (ART) suchas IVF• Donor insemination• Adoption, foster parenting or permanent care• Deciding not to have childrenWhat are assisted reproductivetechnologies (ART)?Assisted reproductive technologies (ART), suchas IVF, do not treat the cause of male infertility.However, they can help couples become pregnant.Assisted reproductive technologies are now oftenused to help infertile men father children. InAustralia, about four in every 10 infertile couplesuse ART because of a male infertility problem.Originally, IVF was developed as a medical techniqueto overcome female infertility. In 1993, theintroduction of a technique called intracytoplasmicsperm injection (ICSI) greatly helped men withMALE INFERTILITY 44

very low sperm counts who previously could not betreated by standard IVF procedures.What is in vitro fertilisation (IVF)?In vitro fertilisation (IVF), developed in thelate 1970s, is a form of assisted reproductivetreatment where sperm collected from the male ismixed with the eggs from the female partner. Thefemale partner is given fertility drugs to producean increased number of eggs that are removedsurgically from the woman’s ovary.Sperm is collected by masturbation (or a frozensample) and mixed with the eggs in a dish or tube.After fertilisation, the resulting embryos are thenplaced back into the woman’s uterus.This form of IVF works for many couples, butthe pregnancy rates for couples with severe maleinfertility are generally quite low.What is intracytoplasmic sperminjection (ICSI)?ICSI is a form of IVF where a single sperm isinjected directly into each egg by piercing theouter covering of the egg, and is particularlyhelpful for men with poor sperm production.ICSI can achieve pregnancies even when onlya few sperm are produced.MALE INFERTILITY 45

HAVINGA FAMILYSperm are collected from the semen or removedcarefully from the testis or epididymis.A skilled medical scientist (embryologist) injects asingle sperm directly into each egg by piercing theouter covering of the egg.As for IVF, after fertilisation the resulting embryosare then placed back into the woman’s uterus.The intracytoplasmic sperm injection technique where a sperm is placed directlyinto the egg.Pregnancy rates for ICSI are the same as thosefor standard IVF with normal semen. Pregnancysuccess largely depends on other factors, such asthe age and reproductive health of the female.MALE INFERTILITY 46

What issues need to be thought about whenhaving ICSI?Research has shown that the quality of spermcollected for ICSI is often quite poor. Some menwith low sperm counts have a change in thenumber of their chromosomes (aneuploidy) intheir individual sperm. Such extra, rearrangedor missing chromosomes do not allow normalembryo development to happen.Some genetic disorders may be passed on to thechild and may not appear until after birth orlater in life. Male children may be at greater riskof inheriting fertility problems, especially thosewhose fathers have been shown to have pieces ofthe Y chromosome missing.What are the risks with ART?If a couple decides to go ahead with ICSI, it shouldbe remembered that these assisted reproductivetechnologies expose women to risk, such as thoseassociated with surgical collection of eggs, andswitches the focus from the man to the woman.Is there a higher rate of birth defects inchildren born through IVF and ICSI?Current research is looking at whether childrenborn through IVF/ICSI are at a greater risk ofbirth defects or other health problems when adults.MALE INFERTILITY 47

HAVINGA FAMILYSome things a couple may want to discuss with aninfertility specialist in more detail include:Congenital abnormalitiesResearch has shown a significant increase in reportedcongenital abnormalities (birth defects) in babiesborn as a result of IVF or ICSI compared with thosefor babies born in the general population.Research shows that the number of babies bornwith birth defects increases from three to four inevery 100 live births, to five to six in every 100after IVF.There does not appear to be a difference betweenbabies born from IVF and ICSI procedures.Congenital abnormalities do not appear to be dueto the IVF or ICSI procedure but rather to theoriginal problems in the infertile couple.Genetic problemsEarly studies showed a small increase inchromosomal defects in IVF or ICSI children, buta recent Australian study 7 did not find a higherrisk of such chromosomal defects when conceivinga child through ART.Genetic diseases in some parents can be passedto offspring, such as inherited infertility inmale children from men with part of their Ychromosome missing (Y chromosome deletions).MALE INFERTILITY 48

Childhood developmentLarge studies have not found any major differencesin the development or abilities of children bornafter IVF or ICSI, when compared to those fromnatural conception.Premature birthMultiple pregnancies are common in IVF andICSI when more than one embryo is transferred,which increases the chance of babies being bornpremature and with low birth weight. Single babiesare also more likely to be premature, which seemsto be related to factors in the woman not the IVFor ICSI procedures.Long term adult diseaseLow birth weight and premature birth is linkedwith an increased risk of diabetes and heart diseasein later life, in both babies conceived naturallyand those born through IVF or ICSI It is not clearwhether IVF and ICSI babies are at any otherincreased risk of health problems as adults. Someresearch has shown that the rates of cancer in IVFchildren are the same as the general population.What if there is no sperm in the ejaculate touse in ICSI?Men who have azoospermia (produce no spermin their ejaculate) because of a sperm productionproblem or a blockage in the reproductive tract,MALE INFERTILITY 49

HAVINGA FAMILYcan sometimes have sperm collected from thesperm-producing tubes in the testis or other partsof the genital tract. A needle biopsy (an operationto remove a small sample of tissue or cells frompart of the body for testing and examination undera microscope) is sometimes done for these men.A fine needle is inserted into the testis under localanaesthetic. A biopsy can also help determine thetype of problem. If mature sperm can be foundin the tissues of this small sample, these cansometimes be frozen or more needle biopsies canbe 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 smallneedle biopsy sample, it still may be possible toget sperm from an open biopsy of the testis whichis done under general anaesthetic. More tissuesamples can be collected from several sites in thissurgical procedure, which increases the chance offinding some usable sperm for ICSI.What are the chances of finding sperm bytesticular biopsy?Success rates for both needle and open testicularbiopsies vary and depend on the reason for theinfertility problem.The chance of finding sperm using a needle biopsyis excellent in all cases of azoospermia caused by ablockage of the reproductive tract.MALE INFERTILITY 50

Chances of finding sperm are low for menwho have sperm production problems, such asgerm cell arrest or Sertoli cell-only syndrome.However, the chances are better for men withhypospermatogenesis.Many couples decide that a small chance offinding sperm in an open biopsy is not worth therisk and may want to use donor sperm instead.Others may wish to take every opportunity to havetheir own child.What are the risks with a testicular biopsy?A needle biopsy has an excellent safety record.Sometimes, infection and bleeding can happenand the testis can swell and be sore for several days,but these problems generally clear up easily. Lessthan one in 100 men has bleeding or infectionafter a biopsy.Discomfort is common for a few days after anopen biopsy procedure. Supportive underwearmay help.In some men, removal of larger biopsy samplesmay damage the testis and lower its ability tomake the male sex hormone, testosterone. Thismay lead to a life-long need for testosteronereplacement therapy.See AndrologyAustralia’s guide onAndrogen Defi ciencyfor more informationMALE INFERTILITY 51

HAVINGA FAMILYWhat should be expected at an infertility clinic?If a couple chooses to have assisted reproductionsuch as IVF, the infertility clinic will explain allthe procedures and success rates for the type ofinfertility problem. Some things couples need tothink about before starting treatment include:Possible setbacks and failureWhen making a decision to take part in an assistedreproduction or IVF program, it is important toknow that the chance of success depends on manyfactors. The success of the treatment depends onthe type of fertility problem, the age of the femalepartner and the type of treatment used. Manycouples have a number of treatment cycles beforeconceiving while some still may never have children.Female focusMost attention during assisted reproduction isgiven to the woman as she has more medicalprocedures and the infertility specialists aregynaecologists. Men are encouraged to supporttheir partners and to have an active role in theprocess. Men also have concerns such as thepressure of producing sperm when needed or aboutthe testis biopsy procedure. It is important thatmen ask for help or information when needed.Staff at infertility clinics recognise the importanceof men’s concerns and will try to provide supportwhere they can.MALE INFERTILITY 52

Semen collectionFor most types of IVF procedures, men will needto produce a semen sample on the day of theirpartner’s egg collection. In some men with verylow numbers of sperm, ejaculates may be frozenbefore treatment as a back-up in case not enoughsperm are produced on the day of IVF treatment.Private rooms at infertility clinics are available formen to produce semen samples by masturbationinto the sterile containers provided. Many menhave difficulty producing a semen sample underpressure. Clinics can sometimes arrange for thefemale partner to join the man in the room andcan also provide special condoms for the collectionof semen by sexual intercourse. Standard condomscannot be used to collect semen for IVF as theyusually have lubricants and spermicides in themthat kill sperm.Blood testsBoth male and female partners may need tohave blood tests to check for infectious diseasessuch as HIV and hepatitis, before starting on anIVF program.MALE INFERTILITY 53

HAVINGA FAMILYLegislativeguidelines on ARTdiffer betweenstates and territoriesLegislation and Code of PracticeMost clinics offering assisted reproductivetechnologies operate under legislative guidelineswhich may differ between each state and territory.When deciding to start infertility treatment, coupleswill be fully informed of any legislation that mayaffect treatment, donation and storage procedures.The treating doctor and counsellors speciallytrained in infertility problems are available todiscuss any legislative issues and help couplesmake informed decisions about their treatment.The Reproductive Technology AccreditationCommittee (RTAC), established by the FertilitySociety of Australia, also provides a Code ofPractice for clinics offering IVF and relatedtechnologies. Clinics offering assisted reproductivetechnologies must be accredited by RTAC.CounsellingSpecialised counselling services are provided inclinics offering assisted reproductive technologies.The services of a professional counsellor may helpindividuals and couples at times of stress, such asat initial diagnosis, and also provide informationand support at any stage of treatment. In somestates in Australia, counselling is compulsorybefore treatment starts.MALE INFERTILITY 54

What are the success rates with ART?ICSI can result in pregnancy rates up to 50 percent per treatment cycle. This is a major increaseon traditional IVF techniques for the treatmentof male infertility, which were used before ICSIwas developed. A number of factors, such as theage and fertility of the female partner, need to beconsidered when reviewing a couple’s chance ofgetting pregnant by different assisted reproductivetechnologies. Infertility clinics can often providemore detail about pregnancy outcomes for thedifferent treatment options they offer.The Fertility Society of Australia supportsand funds the collection of the data used inthe provision of overall success rates of ARTthroughout Australia and New Zealand. Thisdata is collated by the Perinatal and ReproductiveEpidemiology 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 havebeen unsuccessful with ICSI, donor inseminationusing sperm donated by another anonymous orknown male may be an option. About one in14 infertile couples need to use donor sperm tobecome pregnant.MALE INFERTILITY 55

HAVINGA FAMILYWith donor insemination, the child receives halfits genetic material from the mother. The donor isthe biological father, however, in all other ways themale partner will become the legal parent. Couplesusing donor insemination can still share theexperience of pregnancy, birth and child-rearing.Men who donate sperm go through a majorscreening process before becoming a donor.Legislation about the amount of informationmade available about the donor varies aroundAustralia. The National Health and MedicalResearch Council (NHMRC) Ethical Guidelineson Assisted Reproductive Technology stipulatesthat procedures must be in place to allow childrenborn from the use of donor sperm to contact theirdonor when they reach 18 years of age.What other options are available to bea father?Some infertile couples, who have either beenunsuccessful when trying ART or do not want tohave medical treatment, choose to adopt, foster orprovide permanent care to children. Adoption is apermanent legal appointment of another person asthe parent of a child, whose biological parents forsome reason cannot care for them. There are very fewbabies available for adoption in Australia, however,there are some older children in need of families.MALE INFERTILITY 56

Adoption of babies and children from overseasis sometimes chosen by couples who are unableto conceive naturally. There are many children,especially in war torn or developing countries,who are in need of families. State governmentbodies are normally responsible for adoptions.For more information contact the localcommunity or family services department.Foster parenting is also a legal arrangementbut normally only short-term. Many babiesand children are in need of families who cancare for them for varying lengths of time.More information can be obtained from localgovernment agencies.Permanent care is a long-term arrangement wherecouples or single people are given legal custodyand guardianship of a child unable to live withtheir own family. However, the child’s name, birthcertificate and inheritance rights do not change.More information can be obtained by contactingstate community services departments.MALE INFERTILITY 57

EMOTIONALISSUESAn emotionalresponse toinfertility is normalWhat emotions can a man experience whendiagnosed with infertility?Most men are shocked when they find out theyare infertile. There is still a common but incorrectbelief that infertility is a female condition.Therefore when men are told that there is a spermproblem, they are often quite unprepared.It is not unusual for men to feel stressed about aninitial diagnosis of infertility.They may also find it difficult to deal with theirstress, particularly if they do not feel comfortabletalking to others about their emotions. Men donot usually express their feelings in the same wayas women, but the anger, guilt and anxiety felt canappear in many ways.Stress often comes from feelings of vulnerability.Being told that there is a sperm problem can havea major impact on a man’s sense of masculinity.Most infertile men at some time struggle with theidea that they are not able to do what other mencan. This may lead men to confuse their infertilitywith their sense of masculinity, sexuality, virilityand potency.It is not unusual for these men to experienceerection difficulties while they try to come to termswith their diagnosis, which can sometimes affecttheir relationship with their partner overall.MALE INFERTILITY 58

Most men also feel the need to understand whythey are infertile. Sometimes no reason can be given,which can lead to feelings of frustration. Wherepossible, knowing the cause can help men acceptthe problem, but it can also leave them with a senseof injustice. Men and women often have differentresponses to a diagnosis of infertility. Womenmay commonly feel a sense of loss or bereavementwhereas men often sense that their infertility exposesthem to potential ridicule and humiliation fromothers. Men may then feel added stress as they try tofind ways to manage this perceived situation.An emotional response to infertility is normal.Talking with a doctor and if needed a sexualtherapist or a counsellor to work through thesefeelings can help some men at this difficult time.What part do partners play?Female partners can play many roles in helpingmen cope with infertility. Many men rely heavilyon their spouses or partners to talk through theirconcerns and uncertainties. It is common for mento be concerned about the effect of their infertilityon their partners, as it is the women who mustgo through most of the often invasive treatmentto achieve a family. These men feel it is unfairthat women should be inconvenienced when theinfertility treatment is not needed because of thewoman’s reproductive problem.MALE INFERTILITY 59

EMOTIONALISSUESMen areencouraged totalk to a doctoror a counsellorabout anyemotional issuesSome women try to ‘protect’ their partners bytelling others that the infertility problem is solelytheir problem. They are concerned people mightjudge their husbands to be less masculine, andwant to avoid unwanted curiosity from those whoare 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 canrely on to be supportive. For some men, familiesprovide this support. Some men have continuedclose relationships with both or either parents andsome have brothers or sisters they can talk to.How important are men’s friends or matesfor support?Australian men are known for their mateship.Many infertile men have close male friends (mates)with whom that they can talk to and discusspersonal matters. The important point is that thesemates are trustworthy. The conversations that thesemen have with each other are valuable in helpingmen to come to terms with their problem.What strategies help men cope?Many men see infertility problems often publishedin women’s magazines, usually with a positiveoutcome. There is usually no detail about the painor 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 samedilemmas and distress and it helps to talk withmen who are experiencing or have experienced thesame situation.Acknowledging that infertility can create feelingsof stress and anxiety is an important step towardscoping with the health problem. A common stressmanagement technique used by men is to look fora solution to the cause of the stress. In the case ofinfertility, this often means searching for availabletreatments and putting aside emotional responses.Many men see emotions as distractions.In some cases, men want solutions for theirinfertility, but rely on their partner to organise thedetails and the appointments. It is usually helpfulfor men to take responsibility for these mattersthat directly affect them.Does knowledge and understandinghelp emotionally?Understanding the problem and ideally finding areason for their infertility can help men accept theirhealth problem. For some, knowledge can give themback a sense of control. Therefore searching theInternet, reading journal articles and finding othersources of information can be quite useful.Local patientsupport groups existto help and supportcouples dealingwith the emotionalaspects of infertilityMALE INFERTILITY 61

EMOTIONALISSUESIs it healthy to laugh about infertility?Men often cope with the stress of their infertilitythrough humour. It is typical for Australian mento respond to a problem with a joke. By laughingat their condition, men make themselves lessvulnerable in a way that is socially acceptable.Ironically, by making themselves the butt of jokes,men can feel more confident and in control ofdifficult situations. A sense of humour often helpsand can be a way of being optimistically motivatedto do whatever has to come next.Is counselling worthwhile?Infertility can be a distressing condition, which isdifficult to accept for many couples. Many men arereluctant to seek psychological counselling, fearingit is an admission of weakness. However, whenpartners set up counselling consultations, theyoften find such conversations surprisingly helpful.An emotional response to infertility is normal andgetting expert help to work through these feelingsis strongly recommended.All infertility clinics provide psychologicalcounselling and support with counsellorsspecially trained in infertility problems.MALE INFERTILITY 62

APPENDICESMALE INFERTILITY 63

APPENDICESHORMONAL PROBLEMSSee AndrologyAustralia’s guide onAndrogen Defi ciencyfor more informationWhat hormonal problems cause infertility?Low levels of pituitary hormones is a rare cause ofinfertility. Low production of follicle stimulatinghormone (FSH) and luteinising hormone (LH)by the pituitary gland can affect testosterone levelsin the testes and reduce sperm production. Themost common hormonal problems are pituitarytumours or problems with the development of thepituitary 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 aboutone in 100 infertile men having this problem.However, it is vital that these men are properlydiagnosed because effective treatments cansometimes be given. FSH and LH treatments canusually improve sperm production.Human chorionic gonadotrophin (hCG)injections (which is similar to LH) once or twicea week can stimulate the Leydig cells to producetestosterone. After four to six months of treatment,FSH may also be given if sperm productionhas not improved using just hCG. Testosteronetreatment does not boost sperm productionand should not be given to men seeking fertilitywithout specialist review.MALE INFERTILITY 64

What are the risks of hormonal treatment?There are very few risks associated with thesehormone medicines, but breast tenderness andswelling sometimes happen.What are other considerations for men withhormonal problems?Sperm production is a long process (about threemonths for mature sperm to be produced), sotreatment with these hormones is usually over avery long period of time, sometimes two or moreyears. Sperm production usually stops when thesehormone treatments are withdrawn. Thereforefreezing some sperm at the end of treatment forlater pregnancies should be considered.Some men with zero or very low sperm countscan have low testosterone levels. Such menwith poor semen quality should always have aserum testosterone level measured and if theirtestosterone is low, careful consideration shouldbe given to treatment.Men who are clinically diagnosed with lowtestosterone (androgen deficiency) will needtestosterone treatment for life, even if nothaving infertility treatment.MALE INFERTILITY 65

APPENDICESGENETIC &CHROMOSOMAL PROBLEMSEach cell in the bodynormally has 46chromosomesWhat are the genetic and chromosomal causesof infertility?Changes to chromosomes and genes can causeabnormal sperm production or blockages to spermflow. Chromosomes are the structures in cells thatpass on genetic information.Genetic and chromosomal disorders that affectfertility include:• Klinefelter’s syndrome• Y Chromosome deletions• Congenital absence of vas deferens (CAVD)• Other genetic problems, such asDown SyndromeIt is likely that other genetic disorders will befound in the future, which can help explain othersperm production problems that currently have noknown cause.What is Klinefelter’s syndrome?Klinefelter’s syndrome is the most commonchromosomal disorder in men. About one in 650men, have an extra X chromosome, so instead ofhaving the normal 46XY chromosomes, there are47XXY or similar abnormalities.MALE INFERTILITY 66

Most men with Klinefelter’s syndrome (about95%) do not produce sperm in their ejaculateand are sterile. However, recent scientific researchsuggests that in up to half of men with Klinefelter’ssyndrome, sperm can develop in small areas of thetestes, which never get into the ejaculate.In many men with Klinefelter’s syndrome, as wellas poor sperm production, testosterone productionby the testis is less than normal. Most men withKlinefelter’s syndrome will need testosteronetreatment at some time in their life.What are Y chromosome deletions?Some men have some genetic material missingfrom their Y chromosome. This has recently beenshown to be the cause of infertility in about one in20 men with low sperm counts (less than 5 millionsperm per millilitre. Tests are now available thatcan pick up these changes on the Y chromosome.What is congenital absence of the vasdeferens (CAVD)?Congenital absence of the vas deferens (CAVD)is a rare genetic problem that causes infertilityin about one in 2500 men. Many men withCAVD have a mutation (genetic change) in thecystic fibrosis gene (cystic fibrosis transmembraneregulator, CFTR).See the AndrologyAustralia guide onAndrogen Defi ciencyfor more informationMALE INFERTILITY 67

APPENDICESGENETIC &CHROMOSOMAL PROBLEMSIn most men withcystic fibrosis, thevas deferens isabsentSeveral parts of the reproductive tract (includingthe vas deferens) are missing from birth. Thisstops sperm moving from the testes out intothe ejaculate.[See section: ‘Appendices’ for more information on the absence of the vasdeferens and seminal vesicles]What is Down syndrome?Down syndrome can affect both men and women.People with this condition have an extra copy ofchromosome 21 and have a range of disabilities.They have distinctive physical features and varyingdegrees of mental disability. Men with Downsyndrome also have abnormal sperm productionand are usually infertile.How are genetic problems treated?At this stage there are no treatments that can fix thegenetic problems that cause poor sperm production.While some men with these problems cansometimes father children naturally, IVF or otherforms of assisted reproduction is the most likelychance of these men having biological children.[See section: ‘Having a Family’ for more information]MALE INFERTILITY 68

What are other considerations for men withgenetic problems?Some genetic problems, such as Y chromosomedeletions, will be passed onto any male child bornthrough the use of sperm in IVF/ICSI procedures.The investigation of men with low sperm counts(less than 10 million sperm/ml) should include aY chromosome deletion test.Men with CAVD (congenital absence of the vasdeferens) have a high risk of carrying a geneticchange 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 andfemale partner are tested for the gene mutation ifthe couple decides to start IVF. If both the maleand female are found to carry this gene mutation,there is an increased risk that children will beborn with cystic fibrosis. The couple may thenneed to think about genetic counselling and preimplantationgenetic diagnosis (PGD) and embryoselection before starting IVF/ICSI procedures.MALE INFERTILITY 69

APPENDICESUNDESCENDED TESTESRemember to tellyour doctor if youhave had hormonetreatment or hadsurgery as a babyto move your testesinto your scrotumWhat is an undescended testis?Before birth the testes develop in the abdomen(where they develop before birth) and thendescend (drop down) into the scrotum at orshortly after birth. In a condition known asundescended testes (cryptorchidism), the testesof some boys remain in their abdominal cavity orgroin after birth. As the testes normally descend inthe eighth month of pregnancy, about one in threepremature baby boys have undescended testes.About three in every 100 full-term baby boys canalso have this problem.In most boys born with undescended testes, thetestes drop naturally into the scrotum before theyare six months old. About one in every 100 boyswill need an operation (orchidopexy) to bring thetestes down into the scrotum when the child isbetween six and twelve months of age.Why do undescended testes at birth causelater fertility problems?Testes need to be kept cool to produce sperm. Thetemperature in the scrotum is usually a few degreeslower than normal body temperature. It is believedthat the warmer temperature in the abdomendamages the sperm-producing tubes in the testes.The longer the testes spend in the abdomen, thegreater the effect on sperm production.MALE INFERTILITY 70

Even when this problem is surgically corrected inearly childhood, ideally before the age of one, menwho have had this problem as a child have a muchhigher chance of being infertile.Men born with undescended testes have agreater chance of developing testicular cancerand bringing the testis down into the scrotumdoes not reduce this risk. Men with a history ofundescended testes need to be checked regularlythroughout life for testicular cancer.How is infertility from undescendedtestes treated?Sperm output is variable for men with undescendedtestes. If the testes have remained undescended for along time, they do not produce sperm.If small numbers of sperm are present, IVF orother forms of assisted reproduction are usuallyneeded if the man wishes to have a family.[See section: ‘Having a Family’ for more information]Regular testicularself-examinationis recommendedfor men born withundescended testesto check for anylumps or changes inthe testisSee the AndrologyAustralia guide onTesticular Cancer formore informationMALE INFERTILITY 71

APPENDICESINFECTIONSWhat types of infection causefertility problems?Orchitis (infection in the testes) can damage thesperm-producing tubes (seminiferous tubules)and stop sperm production. Although theinfection is often only temporary, severe damagecan leave men permanently infertile. Mumps isthe most common infection of the testes but isless likely to happen since the introduction ofimmunisation programs for children. Infectionsin the reproductive tract caused by sexuallytransmitted infections, particularly untreatedgonorrhoea and chlamydia, may cause blockages inthe tail of the epididymis or other parts of the malegenital tract. Non-specific epididymo-orchitis orprostate infections may sometimes cause blockagesalong the reproductive tract.How does mumps cause infertility?Mumps that spreads to the testes is called mumpsorchitis. This can cause major swelling and painin the testes. It can also totally destroy the spermproducingtubes (seminiferous tubules) andpermanently stop sperm production. Mild cases ofmumps orchitis may only stop sperm productionfor six to twelve months.Mumps vaccine is available and boys should beimmunised in infancy to avoid infection andpossible infertility in adult life.MALE INFERTILITY 72

How do sexually transmitted infectionsaffect fertility?Sexually transmitted infections, such as gonorrhoeaand chlamydia, can damage or block the epididymisso that sperm cannot pass from the testis into theejaculate. Because the testis only contributes a smallpart to the ejaculate, these blockages do not obviouslychange the amount of fluid ejaculated but no spermwill be found in the ejaculate (azoospermia).What is epididymo-orchitis?Epididymo-orchitis is caused by viral or bacterialinfections of the testes and epididymis. Pain andswelling usually last for several days. Epididymoorchitissometimes happens with urinary tractinfections and can cause permanent blockages andtesticular damage but this is rare. Early treatmentwith antibiotics is recommended to preventtesticular damage becoming too severe.How do prostate infections cause infertility?Infections of the prostate can cause swelling andblock off part of the reproductive tract that passesthrough the prostate. This can also stop spermfrom being ejaculated.Because the prostate and seminal vesicles contributemost of the fluid to the ejaculate, blockage nearthe prostate can sometimes reduce the volume ofejaculate. Infections of the prostate and seminalMALE INFERTILITY 73

APPENDICESINFECTIONSvesicles can also cause inflammatory cells to passinto the ejaculate, which may damage the sperm.Can surgery repair blockages?Some couples become pregnant naturally aftersurgery to remove blockages caused by infections.The success of surgery depends on the amount ofdamage and where the blockage is located in thereproductive tract. Blockages near the testes areparticularly hard to fix. Sperm antibodies are alsooften a problem for men with these blockages andmay 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 isneeded, has some risks that need to be discussed withthe doctor. The risks with surgery to repair blockagesare small, however, sometimes bleeding and infectioncan happen at the site of the operation.Are there other ways to treat sperm blockages?IVF or other forms of assisted reproduction maybe done if men wish to have a family and do notwish to have surgery, or surgery was unsuccessful,to remove the blockage. A biopsy, or sample of thetestis, is taken to find sperm that can be used forIVF/ICSI procedures.[See section: ‘Having a Family’ for more information]MALE INFERTILITY 74

APPENDICESTORSION OF THE TESTISWhat is torsion of the testis?The spermatic cord, which is made up of the vasdeferens, nerves and blood vessels, attaches thetestes to the body. Torsion of the testis happenswhen the testis rotates (twists) in the scrotumaround the spermatic cord, blocking blood flowto the testis. This causes severe pain and swelling.Testicular torsion, which normally affects teenagersor young adults, happens when there are structuralproblems that make it easier than normal for thetestis to twist. Testicular torsion can be triggeredby hard, physical activity and can happen in oneor both testes. Sometimes, torsion of the testis isconfused with an infection.How does torsion of the testis affectsperm production?The twisting of the testis cuts off the blood supplyto the testis, causing damage to the tubes thatproduce sperm. If the blood supply is stopped,even for a short period of time, the testis doesnot recover and stops producing sperm.A diagnosis of aninfection shouldNOT be made unlesstorsion of the testisis ruled outMALE INFERTILITY 75

APPENDICESTORSION OF THE TESTISTorsion of thetestis should betreated as a medicalemergencyHow is torsion of the testis treated?This condition is a medical emergency andimmediate surgery is needed to not only relievethe pain, but also to ‘save’ the testis. It is also usualto fix the other testis during surgery to preventtorsion happening in the other testis. If thisproblem only happens in a single testis, the othertestis should continue to produce sperm, whichwould make natural conception possible.MALE INFERTILITY 76

APPENDICESHEATHow does temperature affectsperm production?A cooler temperature in the testis is necessaryfor sperm production. Outside the body, in thescrotum, the testes are a few degrees below normalbody temperature.Illness with fever can temporarily reduce spermproduction in the short term. Men who have hadundescended testes can also experience spermproduction problems because their testes wereexposed to higher temperatures inside the body.Regular immersion of the testes in hot waterthrough hot baths, spas and saunas can also affectthe testes and sperm production.Some research has suggested that wearing tightunderwear may also decrease sperm counts,although this finding has not been proven inother studies.MALE INFERTILITY 77

APPENDICESHEATHow can problems with over-heating of thetestis be overcome?Doctors usually suggest that patients with lowerthan normal sperm counts keep away from hotbaths and tight-fitting clothing. Wearing boxershorts may be recommended.The number of sperm produced will generallyincrease once the temperature of the scrotum staysat its normal lower level, which is a few degreeslower than body temperature. However, as it takesabout 70 days for sperm to develop, it may takea few months of keeping the testes cooler for thenumber of sperm produced to improve.MALE INFERTILITY 78

APPENDICESVARICOCELEWhat is a varicocele?A varicocele is a swelling of the veins above thetestis. It usually happens on the left side and iscaused by a lack of normal valve function whichwould normally stop the backward flow of blood.Blood pools in the veins around the testis, whichforms a varicocele.These ‘varicose veins of the testes’ are quitecommon. About three in 20 men who have nofertility problems have varicoceles.To check for varicoceles, the man has to beexamined standing up. The testis below avaricocele is usually smaller than a testis wherethere is no varicocele.How does a varicocele affectsperm production?Men with varicoceles often have a lower thanaverage number of sperm, poorer spermmovement and an increase in the number ofabnormally shaped sperm. Even so, some menwith varicoceles can also have normal spermcounts and many men with varicoceles havefathered children. There is some scientific researchthat shows that the temperature of the testes witha varicocele is higher.How are varicoceles treated?Varicoceles can be surgically removed undergeneral anaesthetic by a urologist. This is oftenMALE INFERTILITY 79

APPENDICESVARICOCELEdone as a day procedure but at the most may needan 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 veinin the groin and guided through a network of veinsand into the left testicular vein. A small coil or aplug is passed through the catheter to block theblood flow and stop the varicocele from forming.Dye may also be injected into the testicular vein toclearly show the location of the varicocele.Is treatment for varicoceles helpful?The benefits of both these varicocele operations arenot clear. Improved semen quality and increases inpregnancy rates after varicocele surgery have notbeen proven.What are the risks with varicocele treatment?Both procedures have a small number ofrisks. Sometimes the wounds bleed after theoperation. The blood supply to the testis can alsobe affected in these procedures, which can causepermanent testis damage and increase the chancesof infertility.In some men, a hydrocele (collection of fluid ina sac around the testis) can happen as a result ofsurgery but this does not affect testicular function.MALE INFERTILITY 80

APPENDICESSPERM ANTIBODIESWhat are sperm antibodies?Antibodies are proteins made in the body by theimmune system to fight infection or disease. Theyattack anything in the body that is foreign (that isnot naturally part of the body). Sperm antibodies,also known as sperm autoimmunity, affect aboutone in every 16 infertile men.As sperm are produced at puberty, well after theimmune system has developed, the body willmake antibodies against the sperm (antispermantibodies). Normally, there are systems in thetestes that limit the response of the immunesystem to sperm and stop the production of spermantibodies. When these systems breakdown, forreasons that are not clear, the immune systemdevelops antibodies against sperm.Sperm antibodies are commonly found in twothirds of men who have had a vasectomy, injuryor infection in the epididymis. However, in manycases, the presence of sperm antibodies cannotbe explained.Sperm antibodiesare common in menwho have had avasectomyMALE INFERTILITY 81

APPENDICESSPERM ANTIBODIESHow do sperm antibodies affect fertility?Sperm antibodies can reduce fertility in a numberof ways, by:• Reducing the number of sperm in the semen• Coating sperm, causing them to clump togetherand reduce the motility (movement) of sperm.This stops the sperm from swimming throughthe fluid in the female cervix and reproductivetubes, when ejaculated into the vagina• Preventing sperm binding to and penetrating theegg during the fertilisation processThere are usually no other effects on a man’sgeneral health and no signs that might mean thatsperm antibodies are present. Some men withgenital tract blockages also have sperm antibodies.How are sperm antibodies treated?Prednisolone, a cortisone-like medicine, can beused to lower the levels of sperm antibodies. Aboutone in four couples become pregnant while theman is taking this medicine.MALE INFERTILITY 82

What are the risks of medicine treatment forsperm antibodies?High doses of prednisolone can cause weightgain, a rise in blood pressure, mood swings, acne,diabetes or peptic ulcers. Some of these side-effectsdisappear after treatment stops.However, high doses of prednisolone can severelyaffect the blood supply to the femur (head of thethigh bone) and about one in 200 men using thistreatment will have permanent hip damage andneed a hip replacement.Are there other ways to treat men withsperm antibodies?Today, ICSI is almost always used if men withsperm antibodies wish to have a family. The useof ICSI can overcome problems related to thepresence of sperm antibodies. By directly placingthe sperm into the egg, there is no need for thesperm to move to or to bind to the egg.[See section: ‘Having a Family’ for more information]MALE INFERTILITY 83

APPENDICESVASECTOMYVasectomy shouldNOT be consideredreversible. Spermstorage (banking)however, doesoffer an ‘insurancepolicy’ to couplesconsideringvasectomyWhy is a vasectomy considered afertility problem?Vasectomy is a safe and effective way to stopcouples becoming pregnant. It should beconsidered permanent contraception. Almost onein three Australian men aged between 40 and 49years of age have had a vasectomy. Men planningto have a vasectomy should think about storingsperm before having this procedure. This mayremove the possible need for a vasectomy reversalin the future.Vasectomy involves cutting and removing asection of the vas deferens, the tube that carriessperm from the testis to the urethra at the base ofthe bladder.Only a small percentage of the large number ofmen having had a vasectomy each year will, atsome time, want to have more children. However,this still means that each year many hundreds ofthese men will think about surgical reversal of thevasectomy or fertility options such as IVF.Vasectomy reversal surgery can be difficult due tothe small size of the tubes that need to be joinedback together and often does not enable couplesto become pregnant naturally. If sperm have beenstored before the vasectomy, a female partner canbe inseminated at the time of ovulation (the fertiletime of a woman’s menstrual cycle).MALE INFERTILITY 84

Alternatively, sperm can be collected from theman’s epididymis by a needle puncture aspiration.Or in another approach, in a small operationcalled a biopsy, sperm can be taken from the testesof a man who has had a vasectomy. 8 These spermcan be used in ICSI treatment cycles, as for thosemen with naturally occurring fertility problems.The choice of surgical vasectomy reversal versussperm aspiration/ICSI, including costs, risks andbenefits, should be carefully talked about withthe doctor.[See section: ‘Having a Family’ for more information]What happens with a vasectomy reversal?Vasectomy reversals involve rejoining the cut endsof the vas deferens using microsurgery. Factorsfrom the original vasectomy can affect the chancesof a vasectomy reversal being successful. Theoutcome is reduced by:• Diathermy (the use of burning to close eitherend of the vas deferens)• A larger amount of the vas deferens havingbeen removed• The increasing time between the vasectomyand reversal• Sperm antibodiesMALE INFERTILITY 85

APPENDICESVASECTOMYIf 10 years or more has passed since the vasectomy,the chance of having a normal sperm count after avasectomy reversal is lower.The development of other blockages in theepididymis can also reduce the chance of success.An epididymal blow-out may happen, where theepididymis bursts because of pressure from spermbuild-up. As the blow-out heals, scarring can createan extra blockage.Sperm antibodies are present in four in everyfive men after a vasectomy. These can still stoppregnancy happening, even if the vas deferens issuccessfully joined back together.[See section: ‘Appendices’ for more information on sperm antibodies]MALE INFERTILITY 86

APPENDICESABSENCE OF VAS DEFERENSWhat is absence of the vas deferens?Men who have an absence of the vas deferensare missing part of the tube that sperm travelalong after they leave the testes. These tubes eitherdo not grow as a child or they degenerate at anearly age so that the men are infertile, as spermcannot pass from the testis into the ejaculate. Menborn with this problem, known as congenitalabsence of the vas deferens (CAVD), are usuallymissing both their vas deferens and two-thirds oftheir epididymis.How does CAVD happen?CAVD is a genetic problem. The most commoncause is a genetic change or mutation in thegene called the ‘cystic fibrosis transmembraneregulator’ (CFTR). Men with CAVD do not havecystic fibrosis even though they have the geneticchange linked with this disease. Cystic fibrosis is aserious condition that causes breathing and bowelproblems from early life and premature deathbefore the age of 40 years. Most men with severecystic 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 congenitalabsence of the vas deferens, as the seminal vesicledevelops from the vas deferens. The prostate andseminal vesicles provide about 90 per cent of theMALE INFERTILITY 87

APPENDICESABSENCE OF VAS DEFERENSfluid in the ejaculate, so absence of the seminalvesicles can cause a smaller amount of ejaculate(usually about 0.5 ml, compared with a normalman of more than 2 ml). The seminal vesicles alsomake the ejaculate alkaline, so when they are notthere the ejaculate is more acidic.How is absence of the vas deferens andseminal vesicles treated?At this stage there are no surgical treatments thatwill cure CAVD. ICSI is usually needed if menwish to have a family. When the vas deferens andseminal vesicles are missing, it is usually possible tocollect sperm directly from the testis or from thesmall remaining part of the epididymis.[See section: ‘Having a Family’ for more information]What are other considerations for menwith CAVD?Due to the genetic basis of this problem, boththe man and his partner must have a blood testto check for changes in the CFTR gene, beforestarting assisted reproduction treatments. If bothpartners have CFTR mutations, then there is aone in four chance of severe cystic fibrosis in theirchildren. It may be possible to test the fertilisedeggs, using a technique known as pre-implantationgenetic diagnosis (PGD). Only the embryos thatare not affected by the CFTR mutations aretransferred to the woman’s uterus.MALE INFERTILITY 88

APPENDICESERECTION &EJACULATION PROBLEMSHow do erections and ejaculation problemsaffect fertility?For semen to be placed in the vagina, an erectionmust be hard enough to allow penetration. Manyfactors can affect a man’s ability to get and keep anerection, causing erectile dysfunction and failure ofpenetration. Often two or three factors are presentat one time. At other times there may be no clearreason for the erectile dysfunction.Sometimes even with a satisfactory erection,problems may happen with ejaculation so thatsperm is not deposited appropriately.Problems with ejaculation that can causeinfertility include:See AndrologyAustralia’s guide onErectile Dysfunction formore information• Retrograde ejaculation - a problem where semenflows backwards into the bladder rather than outof the penis during orgasm• Premature ejaculation - ejaculation that occurssooner than desired• Failure of ejaculation - ejaculation does nothappen at allAbout one in every 100 infertile couples has troublegetting pregnant because of erection, ejaculation orother sexual problems.MALE INFERTILITY 89

APPENDICESERECTION &EJACULATION PROBLEMSMALE INFERTILITY 90Causes may include:• Nerve damage following prostate or otherabdominal surgery, spinal cord injury or diabetes• Poor blood supply into the penis and poorfunction of the blood vessels in the penis (suchpoor blood vessel function is more common inmen with cardiovascular problems like heartdisease, stroke and diabetes)• Interactions with other medicines• Psychological or relationship problemsHow is erectile dysfunction orimpotence treated?Most often erectile dysfunction is due toconditions affecting the blood flow to the penis orthe nerves which supply the blood vessels. Theseare not usually reversible but medicines, whichrelax blood vessels in the penis, can help men geterections. Tablets such as Viagra®, Cialis® andLevitra® (PDE5 inhibitors), work well for manymen with erectile dysfunction. Injections for thepenis, such as Caverject Impulse®, can be used ifthese oral medicines don’t work or can’t be used.Erectile dysfunction can be caused bypsychological problems, and even if a physicalcause is found, psychological problems may stillhappen. Counselling can often help overcomeperformance anxiety and other concerns.

What are the risks with erectiledysfunction treatments?The PDE5 inhibitor tablets are not recommendedfor men with serious heart disease or men takingnitrate medicines for a heart condition. Thesemedicines must only be used when prescribed by adoctor who understands the man’s medical history.How is premature ejaculation treated?Men with premature ejaculation sometimesejaculate before the penis has entered thevagina (vaginal penetration). Medicines calledserotonin reuptake inhibitors (SSRIs) may helpdelay ejaculation.Other non-medicine treatments include couplecounselling, pelvic floor exercises, methods ofreducing sensation and psychotherapy. Talking toa doctor or experienced sex therapist is importantand is recommended.How is retrograde ejaculation treated?During normal ejaculation, a ring of musclearound the opening of the bladder closes to stopsemen from entering the bladder during orgasm.This muscle does not close in men with retrogradeejaculation, allowing semen to flow back into thebladder. Retrograde ejaculation can be caused by anumber of problems, and is common after surgeryon the prostate.MALE INFERTILITY 91

APPENDICESERECTION &EJACULATION PROBLEMSSome men with retrograde ejaculation can be treatedwith medicines like pseudoephedrine or imipramine,which help improve the muscles in the bladder neck.These medicines are not recommended for men withheart or blood pressure problems.For men who wish to have a family, sperm maybe collected for use in ART. Sometimes sperm canbe taken directly from the testes in a biopsy orremoved from urine samples in the laboratory.[See section: ‘Having a Family’ for more information]How are erectile and ejaculation problems dueto spinal cord injury treated?Medicines, like Viagra®, Cialis® and Levitra®, orinjections into the penis, like Caverject®, usuallyhelp 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 bedone at home. Electro-ejaculation is another optionfor men with spinal cord injury. An electrical chargeis given to the back of the penis via the rectum.Sperm is then ejaculated and collected for use inART. A qualified health professional experienced inthese techniques must perform electro-ejaculationtreatment. Alternatively, sperm can be isolatedfrom 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 orelectro-ejaculation treatments for men with spinalcord injuries may not be good and the proceduremay need to be repeated several times to collectenough quality sperm.There are several risks linked with the electroejaculationprocedure, which should be discussedwith a doctor. These can include severe rises inblood pressure and internal bleeding in the brain(cerebral haemorrhage). There is also a small riskof rectal burns.General anaesthesia is sometimes needed if theman has some sensation or feeling in the lowerpart of the body.Why is treating erectile problems alone notalways enough?Erectile dysfunction is a common health problemoften caused by other more serious life-threateninghealth problems such as heart disease, diabetes,hypertension, high cholesterol, obesity anddepression. Treating the erectile difficulties alonewill not fix the underlying health problem, whichif left untreated can have serious health outcomes.This is why men with erectile dysfunction needto see their doctor and be properly checked. Itis important that any underlying problems areidentified, and also treated, as a priority.MALE INFERTILITY 93

APPENDICESTESTICULARCANCER & FERTILITYSee AndrologyAustralia’s guide onTesticular Cancer formore informationDoes testicular cancer affect the chances ofhaving children?Cancer in a single testis may not affect the chanceof having children. In many men, after a canceroustestis is removed, the remaining testis continuesto produce of sperm and amounts of testosterone,the male sex hormone, that is important forreproductive and general health.Men who are diagnosed with testicular cancerare more likely to have reduced fertility beforeany treatment starts as it seems they have a preexistingtendency to poor sperm production.Fertility can be further affected by the followupcancer treatments such as radiotherapy andchemotherapy. It is therefore possible that somemen who have had testicular cancer may havetrouble having children.How does radiotherapy affect fertility?During radiotherapy, the other non-affected testisis shielded from the x-rays but some exposure mayhappen, which sometimes lowers sperm countsfor a short-time afterward. As radiation can causegenetic damage in the early development stages ofsperm (germ cells), it is best to avoid attempting apregnancy for six months after radiation treatment.MALE INFERTILITY 94

How does chemotherapy affect fertility?Chemotherapy can temporarily or permanentlydestroy developing sperm cells. Most patientswill return to the level of fertility they hadbefore chemotherapy, but this can take up tofive years. In some cases, fertility is permanentlyreduced or eliminated.Why is sperm storage important?Even though surgical removal of one testisdoes not affect the sperm-producing ability ofthe remaining testis, both radiotherapy andchemotherapy can lower sperm counts for ashort-time or permanently after treatment. Menwith testicular cancer often have lower fertilitybefore treatment starts. Treatment can reduce theirfertility further.All men who are going to have chemotherapy orradiotherapy should talk to their doctors abouttheir fertility before treatment begins. It is highlyrecommended that men produce semen samples(through masturbation) for sperm storage (alsoknown as sperm banking). Sperm storage must takeplace before chemotherapy or radiotherapy starts.Semen can be frozen, using special equipment,and stored long-term for future use. If men wantchildren at a later stage, the frozen semen is thawedand used in fertility treatments ranging frominsemination of their partners to IVF.MALE INFERTILITY 95

APPENDICESTESTICULARCANCER & FERTILITYFor moreinformation onsperm storage speakto your specialistor contact a localinfertility clinicWhen should sperm be stored?To avoid having to delay treatment for testicularcancer, it is important to think about spermstorage early and before treatment starts. Somemen may have poor sperm counts and may needto visit the sperm-banking unit on two or threeseparate occasions. Even if the sperm quality beforetreatment is poor, sperm storage is recommendedas advances in reproductive technologies, just a fewmoving sperm can be used successfully to producechildren at a later stage.Should teenage patients be encouraged tostore sperm?Sperm storage for teenagers with testicularcancer can be a difficult issue and needs carefuland delicate management. It can be extremelydifficult for young males to come to terms withthe diagnosis of cancer at a young age and possiblebody image problems they may have followingsurgery. Fatherhood is therefore not likely to bea priority concern. Producing a semen sample bymasturbation can also be stressful for a very youngmale in these circumstances.Family support and encouragement withoutpressure can be extremely valuable to teenagerswith testicular cancer. Parents may need tohelp communicate future fertility problems totheir child.MALE INFERTILITY 96

Where can sperm be stored?Sperm is frozen using special technologies andthen kept in liquid nitrogen (-196˚C) for longtermstorage. Specialist reproductive centresproviding IVF and other ART usually also offerlong-term sperm storage facilities.MALE INFERTILITY 97

APPENDICESMEDICINES &OTHER DRUGSWhat medicines and other drugs affectsperm production?There are a number of commonly used medicinesthat may have a negative effect on spermproduction and function.Medicines used in the treatment of cancer aredesigned to attack the multiplying or dividingcells. The cells in the lining of the spermproducingtubes in the testis are continuallymultiplying to produce the new cells neededto make sperm. These cells are thereforeopen to attack during cancer treatment.Cyclophosphamide, a medicine used for thetreatment of some cancers and kidney disorders,can cause permanent infertility if the treatment isgiven for a long time.Salazopyrine, which is used to treat inflammatorybowel disease, causes short term infertility. Thisdrug is often given for ulcerative colitis, Crohn’sdisease or problems following other conditionssuch as rheumatoid arthritis. These healthproblems can often be managed with othermedicines, which allow the man to remain fertile.When salazopyrine is stopped, sperm productionwill usually return to normal after a few months.MALE INFERTILITY 98

Environmental and chemical agents, such aspesticides, may cause infertility. However, there isno clear scientific research as to the level to whichthese chemicals cause sperm production problems.Testosterone (tablets or injections), which areused to treat men with testosterone deficiency, cancause infertility problems. Testosterone stops theproduction of the pituitary hormones (FSH andLH), which normally trigger the testes to makesperm. Testosterone reduces the size of the testesand can lower or stop sperm production. Menwho abuse the use of testosterone and more potentandrogens for body building and competitivesports are usually infertile, and may also havehealth problems of other organs, placing otheraspects of their health at risk.Recreational drugs, such as marijuana and heroin,may affect the testes and affect the long-termproduction of sperm in the testes.Can anything be done before startingmedical treatment?Chemotherapy for treatment of cancer can lowersperm counts temporarily or permanently. Allmen, and boys who have gone through puberty,who are about to have chemotherapy should talkto their doctor about the effect of treatment ontheir fertility.MALE INFERTILITY 99

APPENDICESMEDICINES &OTHER DRUGSRemember to tellyour doctor if youare taking anymedicinesor have receivedany medicaltreatment thatmay have affectedyour fertilityIt is highly recommended that men producesemen samples (through masturbation) for spermstorage. Sperm storage must take place beforechemotherapy starts. Semen can be frozen andstored long-term for future use. If men wantchildren at a later stage, the frozen semen is thawedand 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 sterileand there are no treatments that will start spermproduction again. Other medicines only have ashort term effect on sperm production. Once thesemedicines are stopped, sperm production shouldreturn. However, because sperm take a long timeto develop, it may take six to 12 months for spermcounts to reach normal levels.Cancer specialists sometimes recommend thatcouples wait for six to 12 months after certainmedicines have been taken before trying to becomepregnant to make sure that possible pregnancyproblems and fetal abnormalities are avoided.MALE INFERTILITY 100

APPENDICESRADIATIONHow does radiation affect sperm production?Radiation treatment for testicular or other cancersnear the testes can damage the testis, leavingpermanent problems with sperm production.Radiation therapy is designed to attack and destroyrapidly dividing cells, so the lining of the spermproducingtubes in the testis can easily be damaged.During radiotherapy, a healthy testis is protectedfrom the x-rays but some exposure may happenand sometimes lowers sperm counts. This can betemporary or permanent.What treatment is recommended for men whoare having radiation therapy for cancer?All men who are about to have radiotherapyshould discuss the effects of their treatment ontheir fertility with their doctors. Semen samplesshould be collected and frozen at a fertility clinicwith liquid nitrogen storage facilities, beforeradiation treatment starts. Semen can be storedlong-term for future use. If men want children ata later stage, the frozen semen can be thawed andused in fertility treatments such as IVF.[See section: ‘Having a Family’ for more information]MALE INFERTILITY 101

APPENDICESRADIATIONReduced fertility or sterility after radiation therapydepends on the dose received by the testis. Withlow doses sperm production can return to normalafter some time. As radiation can cause geneticdamage in the germ cell, it is advisable to avoidattempting a pregnancy for at least six to 12months after radiation treatment.MALE INFERTILITY 102

SUPPORTThis booklet gives information about maleinfertility and may be helpful when talking withyour doctor.Couples wanting to get pregnant who are unsureabout intercourse timing, any aspect of the normalreproductive system or are anxious about notconceiving, should talk firstly with a doctor.The doctor may provide a referral to a specialistfor tests. Professional societies, such as the FertilitySociety of Australia (FSA), and national consumerbasedorganisations also offer men and theirpartners additional support and informationabout male infertility.Infertile men are encouraged to talk with doctorsand counsellors at the many infertility clinicsthroughout Australia. These clinics are able toprovide professional counselling and referrals toother private practitioners who also work withinfertile couples.AccessAustralia’s National Infertility Networkis 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 communityawareness about the social and psychologicaleffect of infertility.Email: info@access.org.auMALE INFERTILITY 103

SUPPORTDonor Conception Support Group providessupport to couples considering accessing donorsperm, eggs or embryo programs. It also helpsfamilies who already have children conceivedon donor programs, adult donor off springand donors.Phone: (02) 9793 9335Fertility Society of Australia (FSA) is the peakbody representing scientists, doctors, researchers,nurses, consumers and counsellors in reproductivemedicine in Australia & New Zealand. It aimsto determine, oversee and improve the standardof fertility service offered in Australia and NewZealand.Infertility patient support groups are associatedwith many fertility clinics. Contact your nearestIVF clinic for more information. A list of IVFclinics can be found on the FSA website at www.fertilitysociety.com.au/patients-information/.MALE INFERTILITY 104

Websites of relevanceAccessAustraliawww.access.org.auAndrology Australiawww.andrologyaustralia.orgAustralian Infertility Support Groupwww.nor.com.au/community/aisgFertility Society of Australiawww.fsa.au.comDonor Conception Support Groupwww.dcsg.org.auPlease notethat websitesdeveloped overseasmay describetreatments thatare not availableor approved inAustralia .Any questions thatyou have frominformation foundon these or othersources should betalked about withyour doctor.Urological Society of Australiaand New Zealandwww.urosoc.org.auMALE INFERTILITY 105

GLOSSARYabstinence No sexual activity such as intercourseor masturbationacute bacterial prostatitis (ABP) An infection in theprostate gland that causes fever, severe pain in the lowerback and genital area and burning, urgent and frequenturination. It is quite rare and can usually be successfullytreated with antibioticsanabolic steroid A hormone that causes muscle andbone growth and is sometimes used illegally by athletescompeting in sports competitionsanaesthetic/anaesthesia A medicine that stops painbeing feltandrogen A male sex hormone such as testosteroneresponsible for the development of male characteristicsantibodies Proteins made by the body’s immune systemin response to foreign substances; attacks foreignsubstances and protects against infectionaspiration Use of a thin needle to take small samples oftissue from the bodyasthenozoospermia Less than the normal number ofmoving sperm in the semenbiopsy An operation to remove a small sample of tissueor cells from part of the body for testing and examinationunder a microscopecatheter A thin flexible tube used to take fluids in or outof the bodyMALE INFERTILITY 106

chromosomes Structures in each cell in the body,which contain genetic materialcongenital Any condition that is present at birth(See Undescended Testes)culture To grow cells, tissues or organisms, often in asterile dish, for scientific purposescyst A closed sac or capsule, usually filled with fluid orsemi-solid materialDNA The genetic code of the individualDown Syndrome A chromosome disorder that causesmental retardation and a range of other physical problems,including infertilityejaculation Release of semen from the penis duringorgasm (sexual climax)ejaculatory duct The part of the male reproductive tractwhere the vas deferens joins with the seminal vesicle andpasses through the prostateembryo An early stage of development as a result ofsuccessful fertilisation, up to the eighth week of pregnancyendocrine system The system of glands (including thepituitary, thyroid, adrenals, testes) which secrete theirproducts (hormones) into the bloodendocrinologist A doctor who specialises in problems inthe endocrine system (hormones and hormonal function)MALE INFERTILITY 107

GLOSSARYepididymis A highly coiled tube at the back of the testesin which sperm are stored and mature. All sperm mustpass along this tube to reach the vas deferensfertilisation The penetration of the egg by the sperm tocreate a zygotefollicle The fluid-filled sac on the ovary in which the eggdevelopsgynaecologist A doctor who specialises in the treatmentof women’s diseases of the reproductive organshuman chorionic gonadotropin (hCG) A hormonemade by chorionic cells (in the fetal part of the placenta).It is a very similar hormone to LH but it has a longer timeof actionhypospermatogenesis Low sperm production withinthe testisinfertility Failure to achieve a pregnancy within one yearof regular, unprotected sexual intercourseICSI (intracytoplasmic sperm injection) A form of IVFused to treat male infertility in which a single sperm isinjected directly into the cytoplasm of an eggIVF (in vitro fertilisation) A form of assistedreproduction in which sperm collected from the male ismixed with the female partners eggs outside the bodykaryotype A blood test to check for the number andappearance (size and shape) of chromosomes in cells(used in AHW module)MALE INFERTILITY 108

oligozoospermia (or oligospermia) A very low numberof sperm present in the seminal fluidovulation The process by which an egg is released fromthe ovaryprimary seminiferous tubule failure The spermproducing cells in the testes either did not developor have been permanently destroyed. It is anuntreatable conditionprostate cancer A condition in which cells within theprostate grow and divide abnormally so that a tumourgrows in the prostatepuberty The period in both males and females in whichchanges occur in reproductive organs/ovaries/testes sothat reproduction is possibleretrograde ejaculation A health problem where semenflows backwards into the bladder rather than out of thepenis during orgasmscrotum The skin pouch that holds the testessemen Fluid that is ejaculated (released) from the penisduring sexual activity; contains sperm and other fluidsfrom the testes, prostate and seminal vesiclesseminal fluid The thick white fluid mainly produced bythe prostate and seminal vesicles containing sperm that isejaculated by the penisseminal vesicles Sac-like structures in the male, foundnear the prostate gland, which produce fluid that is partof the semen ejaculateMALE INFERTILITY 109

GLOSSARYseminiferous tubules The sperm-producing tubules inthe testes in which sperm are producedsertoli cells Cells in the testes that are responsible fornurturing the spermatids (immature sperm)sperm Mature male sex cellsperm bank Facility where sperm are kept frozen in liquidnitrogen for later use in artificial inseminationsperm morphology A semen analysis factor that indicatesthe number or percentage of sperm in the sample thatappear to have been formed normallysperm motility The ability of sperm to swim. Poormotility means the sperm have a difficult time swimmingtoward their goal, the eggsperm retrieval The doctor removes sperm from a man’sreproductive tract (testis or epididymis) using a fineneedle, biopsy gun, or other instrumentspermatic cord The spermatic cord is made up of the vasdeferens, nerves and blood vessels and attaches the testesto the bodyspermatids Immature spermspermatocele A spermatocele is (usually) a small cavity,filled with watery liquid, in the epididymisspermatogenesis Production of sperm in the testesMALE INFERTILITY 110

spermaturia Spermaturia is the release of sperm intothe urine. This can happen in men with long periods ofsexual abstinence. This is quite normal and is a way ofdischarging sperm from the bodyteratozoospermia High percentage of sperm with anabnormal shapetesticle/testis (plural: testes) The male reproductive organthat produces sperm and the male sex hormonestestosterone Male sex hormonetorsion Abnormal twisting of a testis in the scrotumultrasound Medical process, which takes images orpictures using special sound waves, that are used toexamine organs inside the body without the need tomake cuts or incisionsundescended testicles (cryptorchidism) Healthproblem in which one or both testicles do not movefrom the abdomen (where they develop before birth) intothe scrotumurethra (urinary tract) The tube that leads urine from thebladder out of the body via the penis. In men, secretionsfrom accessory glands also empty into the urethraurologist A doctor who specialises in diseases of theurinary tract in men and women, and the genital organsin menuterus The part of a woman in which a baby developsbefore birth, often referred to as the ‘womb’MALE INFERTILITY 111

GLOSSARYvagina The lower part of the female reproductive tract thatconnects the cervix to the outsidevaricocele A collection of the enlarged (dilated) testicularveins in the spermatic cordvas deferens Duct that transports sperm from theepididymis to the ejaculatory ductvasectomy sterilisation procedure in which the vasdeferens is cutMALE INFERTILITY 112

AUTHORSProfessor Robert McLachlanMMBS FRACP PhDProfessor Robert McLachlan is currently PrincipalResearch Fellow at Prince Henry’s Institute and Directorof Andrology Australia. He is also a practicing andrologistand endocrinologist at Monash IVF and Monash MedicalCentre, Melbourne.Contributions by:Dr HW Gordon BakerRoyal Women’s Hospital, Melbourne and Universityof Melbourne (retired)This booklet hasbeen reviewed by apanel of experts inmale reproductivehealth. AndrologyAustralia gratefullyacknowledges theexpert panel andconsumers withinfertility who haveprovided valuableassistance and inputinto the productionof this guide.Dr Roger CookSwinburne University of Technology, MelbourneProfessor Gab KovacsMonash IVF, MelbourneProfessor David M de Kretser, ACMonash University, MelbourneAssociate Professor Doug LordingCabrini Health, MelbourneMALE INFERTILITY 113

AT A GLANCEPrevalenceInfertility is a widespread problem. For about onein five infertile couples the problem lies solely inthe male partner (male infertility).CausesMale infertility can be caused by problems thataffect sperm production or the sperm transportprocess. With the results of medical tests, thedoctor may be able to find a cause of the problem.DiagnosisBoth male and female partners should havemedical tests when infertility is suspected.Diagnosis can involve a medical history fromthe man and a physical examination along witha semen analysis to check the number, movementand shape of the sperm in the ejaculate.TreatmentMany treatments, both surgical and medical, areavailable to improve sperm production and enablenatural conception. However, in some cases thedoctor will recommend the couple seek assistedreproductive technologies (ART).MALE INFERTILITY 114

Assisted reproductive technologies (ART)Assisted reproductive technologies do not cure ortreat the cause of the infertility, but they can helpcouples become pregnant. ICSI (intracytoplasmicsperm injection), where a single sperm ismicroinjected into an egg, is a form of ARTfor couples when male infertility is a problem.Emotional issuesAn emotional response to infertility is normal.Talking with a doctor and if needed a sexualtherapist or counsellor to work through thesefeelings can help some men at this difficult time.MALE INFERTILITY 115

REFERENCES1De Kretser DM. Male Infertility. Lancet 1997;349: 787-902WHO Task Force on the Diagnosis and Treatmentof Infertility 1987: Towards more objectivity indiagnosis and management of male infertility.Int J Androl [Suppl] 73World Health Organization. WHO laboratory manualfor the examination and processing of human semen,5th ed. Geneva: WHO Press, 2010.4Hassan MA, Killick SR. Effect of male age on fertility:evidence for the decline in male fertility with increasingage. Fertil Steril. 2003; 79 (Suppl 3): 1520-75Eskenazi B, Wyrobek AJ, Sloter E, Kidd SA, Moore L,Young S, Moore D. The association of age and semenquality in healthy men. Hum Reprod. 2003; 18: 447-546Gnoth C, Godehardt D, Godehardt E, Frank-Herrmann P, Freundl G. Time to pregnancy: resultsof the German prospective study and impact on themanagement of infertility. Hum Reprod. 2003; 18:1959-66MALE INFERTILITY 116

7Halliday, JL, Ukoumunne OC, Baker HWG,Breheny S, Jaques AM, Garrett C, Healy D andAmor D. Increased risk of blastogenesis birth defects,arising in the first 4 weeks of pregnancy, after assistedreproductive technologies. Hum Reprod. 20098Holden CA, McLachlan RI, Pitts M, Cumming R,Wittert G, Agius P, Handelsman DJ and de KretserDM. Sexual activity, fertility and contraceptive usein middle-aged and older men: Men in Australia,Telephone Survey Human Reproduction 2005;20: 3429-3434MALE INFERTILITY 117

Andrology Australia (The Australian Centre of Excellencein Male Reproductive Health) gives free independent andevidence-based information and education to the communityand health professionals on disorders of the male reproductivehealth system and associated problems.Andrology Australia’s resources and information are providedat no cost and are available to be downloaded or orderedonline at www.andrologyaustralia.org or orderedby phone 1300 303 878.The booklets available in the Andrology Australia ConsumerGuides 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 symptomsThe information in this consumer guide onMale Infertility has been reviewed by:

Postal address:Andrology AustraliaMonash Institute of Medical ResearchPO Box 5418, Clayton,Victoria, 3168, AustraliaStreet address:27–31 Wright Street, Clayton,Victoria, 3168, AustraliaPhone:1300 303 878Fax:+61 3 9594 7156Email:info@andrologyaustralia.orgWebsite:www.andrologyaustralia.orgAndrology Australia is supported by agrant from the Australian GovernmentDepartment of Health and Ageing.MALE INFERTILITY 122