What should I do if I have fertility problems?

If you have been trying unsuccessfully to produce a pregnancy for 1-2 years, without using any form of contraception, you should contact your GP for further advice.

Your GP will normally wish to review both of you initially. Further investigations may reveal that only one partner has a problem contributing to the infertility. As a general rule, most urologists only deal with problems affecting the male partner. Investigations in the female partner are not considered on this website.

What are the facts about male infertility?infer

• 10% – 15% of couples in Kenya are unable to have a child.
• In 60% of these couples, the problem lies wholly or partly with the male partner
• Urological investigation may reveal a reversible underlying cause for male-factor subfertility and full assessment by a urologist is recommended
• In many cases, no underlying cause is found, in which case assisted conception may offer the best chance of pregnancy
• Infertile couples are often assessed in gynaecology gepartments and, therefore, subfertile men may wish to seek a urology assessment from a urologist specialising in andrology

What should I expect when I visit my GP?

Your GP should work through a recommended scheme of assessment for men with infertility. This will normally include some or all of the following:

1. A full history

Your GP will enquire about lifestyle factors (e.g. your job, work pressures, smoking habits, alcohol intake and drug consumption) as well as asking whether you have previously fathered children. Your past medical history may also be relevant in identifying a reason for your infertility, especially if you have had previous testicular infections or operations. You will be asked about when you have been having sexual intercourse. Ideally, this should be timed to coincide with your partner’s ovulation (approximately 7-10 days before the next menstrual period).

2. A physical examination

A general physical examination will be performed, paying particular attention to the development of your male sexual characteristics. Your blood pressure will normally be measured as part of this examination.

Special attention is paid to your genitals – shape, size and consistency of your testicles, and the presence or absence of all the structures which attach to the testicles and carry sperms. Your GP will also look for evidence of enlarged, varicose veins (a varicocele) in your scrotum, usually above the left testicle but, very occasionally, on the right.

3. Additional tests

The usual tests performed are:

a. Sperm counts

You will need to provide at least two semen specimens for analysis. Click here for information on how to do these specimens (opens a PDF file in a new browser window). A sperm count of more than 15 million normal, motile (active) sperms per ml should be sufficient to allow pregnancy by natural means

b. General blood tests

The actual tests performed will be left to your GP’s discretion. It is common to measure kidney function & liver function and to check the blood cells for anaemia or other problems

c. Hormone measurements

Blood levels of testosterone, prolactin, FSH (follicle-stimulating hormone), LH (luteinising hormone) and thyroid hormones will normally be measured. Anti-sperm antibodies are not routinely measured during assessment of male infertility

d. Other specific tests

Other tests, usually performed by specialists, may include chromosomal studies, ultrasound of the scrotum and, possibly, the prostate area.

What could have caused my infertility?

In 75% of infertile men, the cause remains unexplained (this is termed “idiopathic infertility”). It may, however, still be possible for couples to conceive naturally, provided some sperms are present.

Physical abnormalities

Absence or blockage of the tubes that carry sperms (vas deferens) is uncommon but may be treatable. The best-known cause of blockage is, of course, vasectomy which, like scarring due to infection, may be treatable surgically by reconstruction or bypass.

A Varicocele is seen in 20% of infertile men (and in 10% of the normal male population). Surgical treatment has little effect on natural pregnancy rates and is usually reserved for those with symptoms (aching discomfort) or to improve semen quality in couples undergoing assisted conception.

Childhood surgery, especially for undescended testicles or hernias, may be associated with reduced fertility in later life.

Genetic causes

10% of infertile men have an underlying genetic problem. Typically they have very poor sperm counts or no sperms at all. In men with no sperms, hormone measurements help to determine whether this is genetic (primary testicular failure) or associated with obstruction. The former is untreatable whilst the latter can usually be treated successfully.

Other factors

All of the following can have harmful effects on sperms:

• smoking
• excess alcohol consumption
• tight-fitting clothing
• prolonged sitting
• drugs, both prescribed (e.g. steroids) and recreational (e.g. cannabis, cocaine)

What treatments are available for this problem?

Many couples produce a pregnancy whilst undergoing investigations or treatment for infertility (85% within the first year) but, for those who do not, a number of treatments are available

General Measures

If you have poor sperm counts, you should wear loose-fitting trousers and boxer shorts. You should stop smoking, reduce your drug consumption and endeavour to adopt a “healthy” lifestyle. Spraying or splashing the scrotum with cold water 2-3 times a day may also be beneficial.

Drug treatment

Many drugs have been used to improve sperm counts. None has been found to be beneficial although steroids may be useful if you have anti-sperm antibodies after vasectomy reversal.

Surgery

Surgical bypass may be possible for obstruction caused by infection or surgical injury. There is, however, an increasing tendency to avoid surgery in this situation and to use sperm retrieval with assisted conception.

Vasectomy reversal is 75-90% successful in restoring sperm production. Unfortunately, restoration of sperms does not guarantee a pregnancy if your sperm count is low or if your sperms are of poor quality.

Intrauterine insemination (IUI)

Selecting out the most motile sperms and injecting them directly through the cervix at the time of ovulation, whilst employing drug-induced ovarian stimulation in the female partner, results in a 7-8% pregnancy rate for each cycle of treatment.

Intracytoplasmic insemination (ICSI)

In this type of in vitro fertilisation (IVF) a single sperm is injected directly into an egg to fertilise it. It is useful if you have a very low sperm count. It may be necessary to extract useful sperms directly from the testicle or from the epididymis (sperm-carrying mechanism). The procedure carries risks for the female partner and has a pregnancy rate of 20-30% per cycle.

Donor insemination (DI)

Donor semen is carefully screened for infections and a donor selected to have similar attributes to you. This is the only viable option if you have no sperms at all and you do not have obstruction which can be relieved surgically.

Adoption

If you are unfortunate and do not to have any success with other treatments, you may wish to consider adopting a child. Your GP and local / national adoption agencies can help with this process.