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Infertility
What is infertility?
Infertility is a significant problem in the community - roughly one quarter of couples will experience it at some point during their reproductive lives. Fortunately the introduction of technology such as IVF has made successful treatment more likely. In medical terms, infertility is defined as the inability of a couple to initiate a pregnancy after a year of unprotected sexual intercourse.
The problem can lie either with the male partner (1/3 of the time), the female partner (another 1/3) or a combination of factors may be involved (the remaining 1/3). In some instances a cause cannot be found.
Causes of infertility
Quite simply there are a multitude of causes of infertility.
To know what can go wrong, it's a good idea to know what's required for the conception of a new human life. Successful fertilisation of a female egg by a male sperm depends on:
- The timing of intercourse;
- The production and transport of sperm in the male;
- The number and quality of sperm;
- The production of an egg by the female;
- Fusion of the egg with a sperm; and
- Transfer through the female reproductive tract so that implantation and pregnancy can occur.
Upsetting just one of these factors may result in infertility.
When infertility is found to be mainly due to the male partner the most common reasons are low sperm concentration and reduced sperm motility (or what may be thought of as sperm swimming ability). Other causes include:
- hormone imbalance;
- injury to the testicles;
- ductal obstruction - a blockage somewhere in the male reproductive system;
- retrograde ejaculation - where sperm are forced backwards into the bladder rather than through the penis;
- sperm autoimmunity - where the body's immune system attacks sperm;
- undescended testicles as a child - where boys are born with their testicles located in their abdomen;
- a varicocoele - where there is swelling of the veins located near the testicles.
Infertility may also result from certain medications, infections, drugs and from environmental causes such as radiation and excessive heating. Even a very hot bath can alter a man's sperm quality! The causes of infertility are numerous - so it's best to have the problem investigated to see what treatment may help.
How is it investigated?
The first step in overcoming infertility is to have the cause(s) of the problem investigated so that the likelihood of the couple being able to have children may be assessed. From here the couple will be provided with information on either further tests or on the treatments available to them.
The specialist is likely to begin the investigation with a questionnaire followed by separate examinations of both partners. Here only the tests specific to the male partner will be described. The doctor will take an extensive medical and sexual history, and then will perform a physical examination which will include inspection of the genitals. One or more semen analyses are likely to be required, along with a blood test which is used to look at the levels of certain hormones.
Possible Treatments?
There are a variety of treatments used to combat infertility. They generally target the different causes of the problem and thus won't be appropriate in every case.
Below are some of the approaches used to manage infertility in males due to different causes. It should be noted that these techniques vary in their success rates and that pregnancy may occur without treatment.
- Severe infertility - in about 1 in 8 men with infertility there is an absence of sperm and unfortunately there is little that can be done. The major options are the use of donor sperm for artificial insemination (where sperm are placed into the female's reproductive tract so that fertilisation can occur) or adoption.
- Hormone imbalance - there are a number of drugs that may be used to correct hormone levels, this is termed endocrine therapy.
- Obstruction - when there's a blockage somewhere in the male reproductive system then surgery may be appropriate. It can also be used to reverse vasectomy. If surgical measures fail then the use of reproductive technologies may be considered. These include in vitro fertilisation (IVF), where recovered sperm are used to fertilise one or more eggs in the laboratory. The embryos formed in this process are then transferred into the female's uterus. Another technique that appears to be useful in cases of low sperm motility is called intracytoplasmic sperm injection (ICSI). It involves the direct injection of a sperm into the middle of an egg in order to achieve fertilisation.
- Sexual dysfunction - although an uncommon cause of infertility, problems such as impotence are usually treatable. The sperm of patients with retrograde ejaculation may be recovered for insemination.
- Sperm autoimmunity - this is where the body attacks its own sperm. Reproductive technologies such as ICSI may be helpful.
- Varicocoele - this may be overcome with surgery (varicocoele ligation) or if unsuccessful, with the use of reproductive technologies.
- Low sperm count or reduced motility - first it's important to make sure intercourse is taking place near the middle of the female's monthly cycle. It is also necessary to correct any factors in the female partner that may be contributing to the infertility. If pregnancy is not achieved then the use of reproductive technologies can be considered - IVF may be possible, as may a technique called gamete intrafallopian transfer (GIFT). This quite invasive procedure involves placement of sperm and eggs in the female's fallopian tubes. A disadvantage of this procedure when used to treat male infertility is that it is not possible to ensure that fertilisation occurs. In treating very low sperm counts, ICSI may be the most promising technique.
Important information concerning reproductive technologies
Before making the decision to attempt this form of treatment it's important to know all the pros and cons. It is an expensive and often difficult process and there is no guarantee of pregnancy. The likelihood of success is about 20-30% per attempt which is roughly the same as the natural fertility rate. There are some health risks associated with these techniques, for instance a genetic defect may be passed on to the male infants of men with low sperm counts.
The female partner should be aware that there are increased rates of ovarian and breast cancers in women that have used reproductive technologies to become pregnant - this is thought to be related to the drugs that females must take to stimulate increased release of eggs by their body. Also, ICSI is a relatively new procedure and there is a lack of long term information on its safety. Bearing this information in mind, it's important for any couples considering the use of reproductive technologies to discuss the various issues with their doctor before reaching a decision.
What can I do to enhance my fertility?
Take note of the following tips to help keep your sperm in top notch condition!
- Stop smoking
- Avoid marijuana and other illicit drugs
- Keep alcohol consumption to moderate levels
- Learn about your medications - some drugs can adversely affect sperm
- Keep your scrotum cool - whether due to a sauna, underwear or intense exercise, excessive heat can affect sperm production
- Avoid coming into contact with toxic substances, e.g. pesticides
- Eat a healthy diet with lots of fruit and vegetables
- Abstain occasionally - periods of sexual restraint (of about three to six days) may improve sperm numbers and motility
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