The male fertility truths you should know

With the clinic who know. Because for 101s and the latest in fertility treatment, TFP Fertility are one of our instant go-tos. Infertility in men is pretty common – read our male biological clock updates for more – but with varying degrees and severity. Many types of male infertility are treatable, and the key is getting support, with a team you trust. 

We asked Dr Ishola Agbaje, Consultant Gynecologist and Subspecialist in Reproductive Medicine & Surgery at TFP Belfast Fertility, for the top aspects of male fertility he’d like patients to have better information on, before beginning their journey. And, the treatment options available, to tackle each one. 

Here are the facts to keep in mind, as you navigate. 

Ready to talk tests and treatment? Skip straight to TFP Fertility, find a clinic and get started on a plan that’s completely dedicated to you.  

Over to Dr Agbaje (and catch our infertility in men Q&A once you’re done).

What are the most common types of male infertility you see in-clinic?

When we talk about male infertility, we’re really talking, probably from a patient’s perspective, about sperm abnormalities. So often, this is the core investigation. 

Sperm abnormalities

So I guess, in simple terms, people might come with a test showing too few sperm, sperm that aren’t moving well, or a low proportion of normal-looking sperm, or sometimes no sperm at all in the ejaculate. But this isn’t really a diagnosis, more a kind of descriptor. 

Often we can’t necessarily define the reason why a sperm sample is abnormal from the outset, and that can be quite frustrating for patients. The first thing I want to stress to men is that semen analysis, as I said, isn’t a diagnosis. So having an abnormal semen test doesn’t mean that you’re infertile or subfertile. 

In fact, semen is a biological fluid, and it changes frequently. So we never rely on one test. And even if that does come back abnormal, that doesn’t mean you’re infertile. Many men will achieve a pregnancy with poor sperm quality and often don’t even know about it, because they haven’t had a test done. 

But obviously, if a couple come with a delay in conceiving, then we do a little bit of a deeper dive into the potential reasons why that might be the case, and we have to see that test in the context of that couple’s history. 

So principally, how long they’ve been trying to achieve a pregnancy, because really, the best test is actually trying, no matter what the semen analysis says. 

Sexual dysfunction

I should add that there are other particular issues that men might attend a clinic with. For example, problems with sexual dysfunction. So, apart from semen analysis, we may have men with erectile or ejaculatory problems. And increasingly we see many men who might be planning a family post vasectomy, where they’ve been sterilised in the past.

What about underlying health problems?

This is quite wide, really, and I think history is key. 

We’d start by taking a general medical history, looking at general health, lifestyle factors, smoking, alcohol, recreational drugs, height, weight, body mass index, that sort of thing. The aim would be to probe for specific underlying medical issues. 

There are some common medical problems and procedures that might affect male fertility, principally things like: 

• diabetes, which could affect sexual function, sperm quality and their ability to produce sperm 
• inflammatory bowel disease
• other systemic or chronic medical conditions 
• sexually transmitted infections
• surgery, for example hernia repairs, any scrotal or testicular surgery, or particularly surgery as a child

There might be a history of having, say, undescended testis as a child. So this is something that their parents might tell them is long-forgotten, but actually they’ve had a testicle brought down into the scrotum, so that’s often very relevant. 

We’d also look at things like family history and genetic conditions. Cystic fibrosis might be relevant, or other genetic conditions, or specifically, if there’s a history of male infertility amongst brothers or other members of the family. 

Meds, drugs & supplements

I want to talk quickly about medications and drugs, too, because these can be important. if men are on any sort of hormonal drugs, particularly things like testosterone replacement, that might well be relevant. Some general medical drugs could also be relevant. 

Things like antihypertensives in relation to sexual function, or biologic drugs, cytotoxic drugs that might be used for autoimmune diseases or particular malignancies, going into past significant history. 

There are also gym and workout supplements which some may take, the classic one being anabolic steroids, which is a definite no-no for male fertility – it will reduce or obliviate any sperm production – and can often be subtly taken in the form of powdered products such as protein, creatine, this sort of thing. 

So many of these might be contaminated by steroids, and it’s often hard to actually identify what’s in the product. And again, this can have an effect on the ability to produce sperm.

Also, if they’ve had any major treatment in childhood or adolescence for cancers and other diseases, this could be relevant. So for men who’ve survived childhood cancer and had treatment, it may affect their testicles and the ability to produce sperm. 

Other than that, it’s about taking a general history and then focusing on specific things that in adult life might affect fertility. 

In summary, a thorough medical history, surgical history and drug history is important.

Focusing on sperm concerns, which are the most common that you see?

It’s actually really difficult because semen analysis is such a blunt tool, and it’s very varied in terms of what it actually means. It’s very difficult to cover it all. 

The most important thing is knowing what the results of that test are in context, with a particular couple. There are certain parameters or lower limits of normal that we look for, such as count, motility and morphology. I think it’s important to remember that no matter what the numbers are, it’s not absolute. 

People can still achieve a pregnancy with any number. But for example, the lower limit of normal count is usually around 16 million per millilitre. So if we have a couple that are coming to the clinic, and we see a persistent reduction in count below that level, then we’d usually want to check any reversible causes of that – hormonal causes, for example – and if not, move forward to treatment like ICSI. 

Similarly, motility levels can be affected by a number of things. In terms of medical problems, often cited are perhaps lifestyle factors that cause scrotal heating. So wearing tight underwear, for example. We’d also look into something called varicocele, which is varicose veins within the scrotum that cause testicular heating. 

There’s very little one can do other than modifying lifestyle to improve motility. But often treatments such as ICSI are helpful. 

Morphology, which is the proportion of normal looking sperm, is subtly different. If that’s the only abnormality in a semen analysis, then often that doesn’t have any particular bearing on the chance of a spontaneous pregnancy, unless it’s extreme. 

ICSI for morphology

If for example a couple has been trying for a number of years, we haven’t found any other factors and we’re moving towards a treatment such as IVF, then a low morphology may lead us to try ICSI. 

If you look at a semen analysis for most men, you’ll find that not all of the parameters are normal. ICSI is often thought of as a final common pathway for most causes of significant male factor infertility. 

Is it possible to conceive with sperm-related subfertility?

Absolutely. As I’ve stressed (hopefully!) semen analysis is a very blunt tool, but the best test we have. 

The only real test of male fertility is trying to conceive. So unless a semen analysis result is very extreme, so either no sperm or very, very few sperm, then I would encourage a couple to keep trying whilst we’re moving forward with other investigations. 

For men that haven’t got any sperm in the ejaculate, we still have options. This may be due to a blockage somewhere in the system and actually the testicles are producing sperm normally, but it’s not getting out and usually it’s then very easy to retrieve sperm. 

Or, it can be that there’s perhaps a fundamental problem with the testis, where very few sperm are being produced, or no sperm. Again, we can explore this with various surgical procedures to try and retrieve sperm. 

Up until the 1990s, couples that had severe male factor infertility had very few options, and many of them had to use donated sperm. But in the mid 1990s, ICSI treatment became available, where we inject the sperm into the egg. This revolutionised the treatment of most male factor infertility and allowed us to treat these couples successfully. 

So the answer is, yes. Even with significant male factor infertility, one can achieve a pregnancy. Unfortunately, that’s not the case for everybody, but even then, we still have options. And in some cases, where there is a significant male factor issue, we’d work with couples to look at using donated sperm.

Which treatment is most successful for sperm-related infertility?

Generally speaking, the most successful treatment option is ICSI. 

Occasionally a man will have a reversible cause of infertility, for example use of anabolic steroids or some sort of hormone deficiency, and in these cases we can effectively treat and support normal semen production. 

But by and large, if there is a significant male factor in a couple’s infertility, ICSI really is the core of our treatment. 

What should we know about environmental causes?

There’s plenty of debate in scientific communities and the popular press about the effects of the environment and male fertility, specifically. And certainly it’s a fact that globally male fertility is declining and sperm counts are falling. 

In some countries, as many as 30 per cent of men might have a subfertile semen analysis or 10 per cent may see results showing infertility.

It’s very hard to be specific when we talk about environmental factors because there are so many. And if you pick up the tabloids every day, whether it’s a lifestyle factor, an environmental factor, or something else, there are so many newly proposed factors that might affect male fertility. 

Some of the common ones would be hormonal contamination of our environment – oestrogens in the food we eat, for example. In general as a population, we eat a highly processed diet. And there are many sorts of oestrogens within that diet which can affect the male reproductive tract. 

Certain occupations, in terms of chemical exposure, from heavy metals to pesticides, can also impact. But it’s very difficult to be specific about this and also very difficult to avoid everything. In regular everyday life, we’re exposed to multiple things that we’re not necessarily aware of. 

All we can do is be aware of things that come with definite evidence and try to avoid these, whether it’s exposure to particular chemicals, lifestyle factors or something different.

What about overheating?

Overheating has long been cited as a negative thing for testicular function. And there is certainly truth in that. It’s why the testicles hang outside the body in the scrotum, about one degree below core body temperature. 

Some factors would increase the risk of testicular heating – particularly obesity, and occupations where, for example, you drive or travel long distances. And medical conditions like a varicocele, can also have an effect.

In terms of saunas, hot baths and tight underwear, these are things that we can do in moderation. I think you’d have to be doing a lot of it to have a significant effect. But again, it’s just sensible advice to avoid, and probably just try to wear sort of loose underwear generally!

Taking a hot bath is absolutely fine – just maybe not too many of them.

Which lifestyle factor has the biggest impact on male fertility?

Probably the biggest lifestyle factors we might see generally, day to day, are things like body mass index (BMI). So obesity, both male and female, adverse lifestyle factors like smoking and particularly vaping. 

People might see vaping as a ‘lesser evil’. However, I think there’s very little research done in terms of vaping, in terms of chemicals involved and what negative effects there might be. 

Recreational drugs – particularly things like cannabis – certainly have a documented effect on sperm motility. And as we’ve talked about previously, anabolic steroids, protein creatine, can also impact. 

Other factors would be things like excessive alcohol consumption and perhaps sexually transmitted infections. Again, these would be common things we’d see day-to-day. 

I think a lot of infertility, both for men and women, often comes associated with uncertainty and guilt, and it’s a very difficult journey to be on. For example, if you have an abnormal semen test, you’re suddenly thinking, this is the reason and it’s my lifestyle, and there’s a lot of shame and guilt associated with that. 

But I think in general, probably most people who are coming to a fertility clinic try to adjust their lifestyle, and probably most of these things, within that context don’t have a big impact. 

Can nutrition have an impact?

I think this is really about common sense, and always say to patients, it’s the sorts of things that your granny would have told you! 

So we’re talking about having a good diet, exercising, managing stress, all of these things. For example, stress doesn’t necessarily directly affect your semen quality, but it can affect how you experience the journey with infertility. 

In terms of supplements, there are no specific supplements that we recommend for male fertility. For women, folic acid and vitamin D are the core supplements. 

My practice is generally to advise men to have a good, balanced diet. And if you’re eating all the colours of the rainbow, then you’re getting all the sort of trace elements and nutrients that you need. If you feel you want to take a broad multivitamin, then that’s probably okay. 

What about penis size, versus form?

Size of penis definitely isn’t important, but function is. 

As long as a man can have penetrative intercourse, it doesn’t really matter what size the penis is. Men aren’t always too forward in terms of discussing these details, but it’s a very important part of the fertility assessment. And sometimes these can be signs of other underlying health issues which require being addressed, such as diabetes. 

There can also be a significant psychological component to infertility, and I think the pressure of having to perform on command can present a vicious cycle. So it’s important to break that, because it can be a subtle contributor. 

In summary, yes, size isn’t important, but function is. 

Testicular health – what should we look out for?

I think good general health and good sexual health. 

Those are two good starting points. In terms of testicular health, one important thing we do know is that men that have lower sperm counts or semen abnormalities are at slightly increased risk of having other problems, such as testicular cancer, later on in life. 

So that’s a really important message, that when they’re being assessed in the clinic, they’re examined for these risk factors. And, that they continue to examine themselves throughout their life because they are a group not at high risk, but higher risk than the general population for having these types of problems. And if they’re picked up early, then they can be sorted out more easily. 

Checking for lumps and bumps regularly is important. And also, just as I’ve mentioned, male fertility can be a sign of other health issues, so it’s important to be assessed properly. Things like erectile dysfunction can be a sign of diabetes or other neurological problems, varicocele can be a sign of another pathology. Your general practitioner or health fertility specialist should be looking for these things. 

Keen to dive deeper into male fertility? Head to TFP Fertility or call 0808 2234128 to connect with the amazing team, and build a plan that’s dedicated to your fertility journey.