Part III of the five-part series on ‘Infertility' deals with the problems faced by males
Approximately half the cases of infertility are caused by a male factor, either as the main cause or as a contributory cause. It is absolutely important that the couple is seen together when it is a question of infertility. Very often, the mother or mother-in-law takes a woman to the doctor, to find out why she has not become pregnant yet. This is an unacceptable practice and it is the gynaecologist's duty to ask the husband to be present at the initial evaluation. The couple should be seen without the rest of the relatives so that they have the opportunity to discuss, without embarrassment, any problems they may be having.
What causes infertility in men?
There are two main reasons for male infertility. One is due to abnormalities in the sperm count, motility or shape. The other is due to erectile dysfunction. In this situation, the male partner is unable to achieve or maintain an erection. This requires consultation with a urologist who has special training in treating these problems.
Investigating the male factor
As mentioned earlier, a semen analysis should be the first investigation in a couple's infertility work-up. It is unfortunate that we sometimes find a woman being put through many investigations, including surgical procedures, without the husband having had a sperm count done. When compared to the invasive nature of many female infertility tests, semen analysis is certainly easier.
Semen analysis, or sperm count testing
One needs to abstain from intercourse for at least four days prior to taking the test. According to the American Society of Reproductive Medicine, a semen sample should be taken no less than two to three days after sexual intercourse, and no more than seven days.
The semen sample is collected into a sterile container. If collecting the sample at the diagnostic centre or the doctor's clinic does not seem possible, the container can be taken home and the sample can be collected there. If you live very far from the diagnostic centre, it might be necessary to give the sample at the lab. A semen sample should be evaluated within two hours for best results.
What does a semen analysis tell us?
A semen analysis report gives us important information. It starts with the sperm count i.e. the total number of sperm in the sample and also the number of sperm per millilitre. The motility of the sperm is also observed. The shape of the sperm is analysed and the number of normally shaped sperms is mentioned.
According to the World Health Organization, a sperm concentration of 20 million per millilitre, and a total of at least 40 million per sample, is needed for optimum fertility. In some cases, however, the number of sperm may be normal, but other factors may play a part in preventing pregnancy. The motility of the sperm i.e. their ability to swim forward at a fast rate is also very important in ensuring fertility. At least 40 per cent of the sperm should be actively motile for fertility. Similarly, at least 40 per cent of the sperm should have a normal shape and should not be deformed.
What causes abnormal sperm counts?
Smoking and drinking (more than 2 alcoholic drinks per day) can cause low sperm counts. Childhood illnesses like mumps or measles may impair the ability to make sperm. Some hormonal or genetic conditions may also result in poor sperm production. Physical examination may reveal that the man has a varicocele. In this condition there is increased blood flow around the testicles, causing poor sperm production. Sometimes there is normal sperm production but because of a block, the sperm may not be able to leave the testes.
What can be done for an abnormal sperm count?
If the report is abnormal, then your doctor will ask you to repeat the count after 4 weeks. If the report is abnormal twice, your doctor will counsel you for further treatment.
Smoking and consumption of alcohol should be stopped. If there is a varicocele, a minor surgery may be offered which might improve the count and motility of the sperm. If there is a complete absence of sperm, a biopsy of the testes will be done to determine whether there is complete absence of production or if there is a block.
There are assisted reproductive techniques for low sperm counts that may help a couple achieve a pregnancy.
Treatment options for infertility will be discussed in my next two columns.
The author is an obstetrician and gynaecologist practising in Chennai and has written the book 'Passport to a Healthy Pregnancy'.