Male fertility issues – the most common cause of infertility after a woman’s age

Written by Dr Chandrika Parmar
02 Apr

Male fertility issues – the most common cause of infertility after a woman’s age

A common misconception is that infertility is a woman's problem and once that ‘problem’ is fixed the couple will be able to conceive. This couldn’t be further from the truth, as after a woman’s age the most common cause of infertility is directly attributed to a factor in the male. 

Just a decade ago treatment for severe male infertility was limited to insemination (IUI) or in vitro fertilization (IVF) using donor sperm, adoption or living a childless life. 

Fortunately, advances in male infertility have introduced innovative therapeutic options that offer most men, including those with no sperm in their ejaculate, a greatly improved chance to conceive a child.

To understand how far fertility treatment for male factor infertility has come, it helps to understand the common causes, how and what we test for and the treatment options available depending on the diagnosis. 

Sperm

What causes male infertility?

There are many reasons why men can have an abnormal sperm count

  • Problems in the testicles: a block in the path the sperm takes to reach the penis caused by a past infection or a vasectomy
  • Physical problems: Testicular trauma or undescended testes at birth 
  • Hormonal imbalances: Low levels of testosterone, follicle stimulating hormone (FSH) or luteinizing hormone (LH)
  • Genetic causes: Where the man is born with defects on the Y chromosome
  • Medical treatment: Past medical or radiation treatment can cause a low sperm count
  • Lifestyle: Smoking, excessive alcohol, recreational drugs, unhealthy diet, lack of exercise and/or being significantly overweight

How do we assess a man’s fertility?

A semen analysis is the first test your general practitioner or a fertility specialist will order to assess your fertility. This test evaluates the semen sample to check the number of sperm, motility (ability to swim) and morphology (size and shape.)

For this test, a man needs to provide a sample of his sperm either produced at home (delivered to the laboratory within one hour of collection), or onsite at a fertility clinic in a private room close to the laboratory.

The results are either normal, in which case further investigations are conducted to identify female causes or sometimes couples fall in an unexplained infertility category.

Abnormal sperm may be described as:

  • Azoospermia: no sperm at all
  • Oligospermia: not enough sperm 
  • Poor motility: sperm might move slowly 
  • Poor morphology: sperm have abnormal shapes
  • Positive sperm antibodies 

It’s often difficult to explain why a man has an abnormal sperm count. If the sperm count is low, I usually suggest repeating the test in six weeks or after three months if lifestyle modifications are recommended.

If repeat sperm counts are still abnormal, further tests may be indicated: 

  • Blood tests: for endocrine abnormality
  • Physical examination: to measure the size of your testicles
  • Ultrasound: of the genitalia to look for possible cause for abnormal sperm
  • Tests to see if there is a block in your testicles

How do we treat male infertility? 

Different treatments help men with infertility father children:

  • Hormone treatment to increase sperm count: some men have low hormone levels in the brain that can be treated with hormone injections.
  • Vasectomy reversal: ideally performed within eight years of the vasectomy as this is usually when the process is most successful.
  • Intrauterine Insemination (IUI): this can overcome some minor sperm abnormality i.e. low motility (ability to swim) by placing the pre-prepared sperm directly in the woman’s uterus.
  • In vitro fertilization (IVF): a fertility specialist takes eggs from a woman and sperm from a man and puts them together in the laboratory to fertilise. Then the fertilised egg is placed back into the woman’s uterus.
  • Intracytoplasmic Sperm Injection (ICSI): when there is a significantly low sperm count or abnormal morphology (shaped) IVF alone is not enough. ICSI together with IVF involves injecting a single sperm using fine micro manipulation equipment in the laboratory into an egg before it is placed back into the woman’s uterus.
  • Testicular biopsy: for men with azoospermia (no sperm in the ejaculate) there might be sperm in their testicles that a fertility specialist can sometimes remove from the testes. This is done during a minor surgery (open biopsy) or by using a needle to locate semen under local anesthesia. The sperm will then be used for IVF with ICSI.

How do we know what treatment will be right for us?

To choose the treatment that is right for you and your partner, you might want to think about:

  • How well your fertility specialist thinks the treatment will work for you
  • Cost of the treatment: how long your fertility specialist thinks the treatment will take to be successful
  • Consider any downsides of the treatment depending on your individual situation

When should we see a fertility specialist? 

I would recommend a man be tested if a couple cannot get pregnant after having unprotected sex for twelve months if the woman is 36 years of age or younger (or after six months if the woman is older than 36.)

Where can I get more information?

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Related Articles

Conceiving in your 40s, what are the chances?

I was recently asked to comment in a Sun Herald article on 26th August (also published online here: Sydney Morning Herald) on Collette Dinnigan, who pregnant at the age of 46, has called on women not to leave it too long to try for a baby.

It is always news when a high profile personality such as Ms Dinnigan, has a child, particularly when the personality in question is a bit older.  The difficulty is that these occasions, while very happy for the people involved, give a misleading picture of the actual likelihood of conception in these circumstances.  Remember that high profile personalities such as Ms Dinnigan, are human beings who quite rightly value their privacy and so very rarely (quite understandably) talk to the press when things aren’t going so well.  It was therefore, a particularly courageous action of Ms Dinnigan, while celebrating her own happiness, to so publicly, point out the difficulties that may face other women, seeking the same fulfilment.

What then, are the issues for women in their forties who are planning to have a child?

The main difficulty is that conceiving is simply harder at that age and, even once a woman does conceive, the risk of miscarriage is higher.  Surprisingly, although we have very good data about the effects of age on IVF conception (more shortly), we don’t have very good statistics about the effects of age on conceiving naturally. The limited available data about natural conception comes from old population studies or studies of unique populations, such as the Hutterites of North America, who do not use contraception.  Interestingly these data, such as they are, seem to be entirely consistent with the more modern and abundant IVF data.  Generally, in one year of trying, 75% of women under 30 years and 66% of 35-year-old women but only 44% of 40-year-old women will achieve a live baby naturally.

The main explanation for this, is that women are born with a finite number of eggs, and from that moment onwards, the number of eggs is declining all the time, until women go through their menopause at around 50-51.  Nonetheless, women in their 40s do still ovulate each month.  What is it about their eggs that cause all these problems?

A common misunderstanding with some women is that the fact she looks and feels young, and leads a healthy lifestyle, means that her eggs will be healthier. I regularly see women who have taken enormous care with their fitness and their health.  The rest of their body is in great shape, completely fit and ready to carry that longed-for pregnancy.  Sadly, despite this, the eggs still can’t do it.  The effects of time are remorseless and, sadly, there is no wonder drug to fix it.

Scientists have shown that eggs from older women are more likely to have an abnormal makeup making pregnancy less likely, miscarriage more common and increasing the risk of Down Syndrome, a condition where a child is born with an extra chromosome number 21.

Nor is IVF a cure for this problem. For women, in their early 40s, IVF is still a good thing to try and gives significantly higher success rates than trying naturally.    However, IVF success rates fall sharply after the age of 40 and by the time a woman is 45 are close to zero.

So, what’s the good news?  Well despite all of the above, many women do conceive in their forties, either by IVF, or naturally, and have very happy healthy families.  It is obviously better to have your family earlier, if you can, but all hope is not lost, just because you’re past 40.  Conception and early miscarriage are the big problems but, if you do conceive and get past the first few weeks, by far the most likely outcome will be a healthy child.  While the risk of Down Syndrome is increased, most of the other problems that affect young children are not increased by being conceived a later maternal age.

Finally, many women worry that by having their children later, their long term health and emotional development may be affected.  On the contrary, we now know that the children of older mums grow up to be as healthy and bright as any other child.

Snapshot of Fertility in Australia

There have been a number of happy and high profile stories in the press recently about older celebrities giving birth to healthy children. Stories like this used to be extraordinary, but they certainly seem to be on the increase. While this trend is supported by data that shows the fertility rate and numbers of births are increasing for women over 30 and especially for women in their early 40s, women and couples should understand the risks associated with having children later in life.  IVF Australia, Melbourne IVF and Queensland Fertility Group, have teamed up to create their latest infographic - “Fertility and Age in Australia” which explores some of these issues.
 Fertility in Australia infographic

Paternity, Maternity, Equality

Conceiving a baby in a same sex relationship

IVFAustralia, and its partner clinics Melbourne IVF, Queensland Fertility Group and TasIVF, are proud supporters of ‘rainbow families’. IVFAustralia were an Official Supporter of Sydney’s Gay and Lesbian Mardi Gras this year, and we’ve seen the number of same sex couples accessing our donor program double in the last year.
 
In 2011, a survey of 3,835 LGBT people found 33% of women and 11% of men had children1 - but close to 40% reported wanting to have children or have more children. This so-called ‘gayby’ boom is thanks to changes in community attitudes and laws, including better access to Assisted Reproductive Treatments for lesbian and single women.
 
So, if you’re hoping to experience the joy of starting a family within a gay or lesbian relationship, what do you need to consider?

How long will it take to conceive?

Generally speaking, we’d expect a healthy woman with no fertility issues to fall pregnant through IVF or Artificial Insemination within six months. You can prepare for pregnancy by improving your diet, doing regular exercise and other lifestyle factors.
 
When you access the donor program there are a few extra decisions you need to make.
 
Do you choose a known donor, or an anonymous donor? In a lesbian relationship, do you want to implant an embryo with eggs from one mother into the other? Should you store some sperm from the same donor for later, in case you’d like a related sibling? For two dads, the process of finding a surrogate can also be complex.

How do we choose a donor?

Our fertility clinics offer access to both Australian and US* donor sperm. The access fee for US donor sperm is higher, but the waiting list is also shorter as there is a shortage of local donors (gay men, we’d love to hear from you!)
 
When you’re using donor sperm or eggs, there are a few legal, emotional and ethical factors to consider and a counsellor will help you work through these concerns so you can make the best decisions for your family’s future.

Are there any legal issues?

Each state has different laws about parental recognition and access, so it’s worth seeking specialist advice before you start.
 
For example, in Victoria, the Victorian Assisted Reproductive Treatment Act (2008) removed discrimination against lesbian and single women with regard to fertility treatment, recognised parenting status for non-birth mothers and also effectively legalised ‘altruistic’ surrogacy. It also recognises lesbian couples as equal parents of their child or children as long as they were in a de facto relationship.

What else should we be prepared for?

30 years of research2 has shown that the children of same-sex parented families do just as well as the children of heterosexual parents socially, educationally, physically and emotionally.

The issues your children will face as they get older are just the same as the issues facing any children conceived using donor sperm or eggs: Where did I come from? Should I contact my donor? You need to be prepared for these questions at some point.
 
In the meantime, we hope we can help you fulfil your dream of having a baby, and that you will experience the joys of pregnancy, birth and parenthood.

What should be my next steps?

If you would like to learn more about the fertility treatments available for same-sex couples in your regions, visit one of our websites. 


 * IVFAustralia and Queensland Fertility Group patients only.

1 Leonard et al. (2012) Private Lives 2: The Second National Survey of the Health and Wellbeing of GLBT Australians, The Australian Research Centre in Sex, Health and Society, Melbourne
2Rainbow Families Council of Victoria (2010) Rainbow Families and the Law, RFC, Melbourne, http://www.rainbowfamilies.org 

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