Male infertility questions answered, from the experts

Get answers to your male infertility questions, directly from the best in the business

We asked Dr Ishola Agbaje, Consultant Gynecologist and Subspecialist in Reproductive Medicine & Surgery at TFP Fertility UK for the top aspects he’d like male patients to have better information on, before starting their journey.

Watch as he covers off;

• The most common sperm concerns
• The most successful treatments for sperm-related infertility
• The lifestyle factor that has the biggest impact on male fertility
• And more of your male infertility questions

Got more male infertility questions or concerns? Catch up with Dr Agbaje for more of the facts to keep in mind, as you navigate next steps, here.

Transcript

Eloise Edington 

Hello, welcome. Today I have the pleasure of being joined by Dr Ishola Agbaje, who is a consultant gynaecologist and fertility specialist at TFP Fertility in Belfast.

Welcome.

Dr Ishola Agbaje

Hi, good morning. Thanks for having me.

Eloise Edington
Thank you so much for coming to chat with me today. We’re going to be speaking all about male fertility, subfertility, infertility. So I’m going to start with the first question: what are the most common types of male infertility you see in the clinic?

Dr Ishola Agbaje

Well, I suppose when we talk about male infertility, we’re really talking—probably from a patient’s perspective—about sperm abnormalities. So often, semen analysis is the kind of core investigation.

I guess in simple terms, people might come with a test where it shows too few sperm, sperm that aren’t moving well, or a low proportion of normally looking sperm, or sometimes no sperm at all in the ejaculate. That’s not really a diagnosis, but that’s a kind of descriptor. So that’s the kind of problems that people might come with.

I guess often we can’t necessarily define the reason why a sperm sample is abnormal from the outset, and that could be quite frustrating, I suppose, for patients.

The first thing I would probably want to stress to men is that semen, 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. Even if that does come back abnormal, that doesn’t mean to say that you’re infertile. There would be many men that will achieve a pregnancy with poor sperm quality and often don’t even know about it because they haven’t had a test done.

Obviously, if a couple come with a delay, then we do a little bit of a deeper dive into the potential reasons why that might be the case. We have to see that test in the context of that couple’s history. In other words, 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. I think that’s an important point.

Particular issues that men might attend a clinic with—again, important not to forget—are the problems with sexual dysfunction. So apart from semen analysis, we may have men with erectile or ejaculatory problems. Increasingly, we see many men who might be planning a family post-vasectomy, so they’ve been sterilised in the past.

Eloise Edington 

Which underlying health problems do you look into when making an assessment?

Dr Ishola Agbaje

Yeah, I suppose this is quite wide really, and I think history is really key. We’ve already talked about the test being quite basic, so history is really key. We would start just taking a general medical history, just looking at general health, lifestyle factors: smoking, alcohol, recreational drugs, height, weight, body mass index, that sort of thing. We would probe for some specific underlying medical issues.

There are some common medical problems that might affect male fertility, principally things like diabetes that perhaps could affect men’s sexual function, sperm quality, and their ability to produce sperm. Any chronic medical problem might affect a man’s fertility.

Common things might be things like inflammatory bowel disease—any systemic or chronic medical condition.

If they’ve had any surgery, common things could be hernia repairs, any scrotal or testicular surgery, any surgery particularly as a child.

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

We would look at things like family history. Is there a history of any genetic conditions? Things like cystic fibrosis might be relevant, or other genetic conditions, or actually specifically if there’s a history of male infertility amongst brothers or other members of the family.

Drugs—we’ve talked about recreational drugs—but prescribed drugs as well. 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 indeed some drugs like biologic drugs or cytotoxic drugs that might be used for autoimmune diseases or particular malignancies in the past.

I guess going into past significant history also—if they’ve had any major treatments in childhood or adolescence for cancers and things—you know, we would increasingly see more men that have survived childhood cancer, and they’ve had treatment that may affect their testicle and the ability to produce sperm.

Other than that, it’s just a sort of general history and then focusing in on specific things that in adult life might affect a man’s fertility—things like sexually transmitted infections.

I suppose something that is quite relevant in young men that we would see in the clinic is men that work out in the gym. They take gym supplements. The classic one is taking anabolic steroids. That’s a definite no-no. That will reduce or obliterate any sperm production.

But that can often be subtly taken in the form of powdered products, such as protein, creatine, this sort of thing. So many of these products might be contaminated by steroids, and it might be hard to actually identify that. Again, that can have an effect on the ability to produce sperm.

So, I suppose, in summary, a thorough medical history, surgical history, and drug history is important.

Eloise Edington 

And you mentioned past medical procedures as well?

Dr Ishola Agbaje

Yes, so past medical procedures principally being surgery. The important one that we would see is surgery as a child, particularly in and around testicular surgery to bring down the testicle or hernia repairs as a child. And then cancer treatment. If there’s any sort of cytotoxic chemotherapy, radiotherapy-type treatment, that may well be relevant.

Eloise Edington 

So, from count to motility, sperm concerns are a key search term for our community. What are the most common factors to cause subfertility or infertility?

Dr Ishola Agbaje

Okay, so I suppose the most important thing is just knowing what the results of that test are in context with a 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, that’s not absolute. People can still achieve a pregnancy with any number.

But if we have a couple that are coming to the clinic, and the lower limit of normal count is usually around 16 million per mL, if we see a persistent reduction in count below that level, then we would usually move forward, see if there are any reversible causes to that—hormonal causes, anything that we could potentially increase that count—and if not, then 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, such as wearing tight underwear.

There are a number of recreational sports and things that have been associated with a reduction in motility or something called varicocele, which is varicose veins within the scrotum that cause testicular heating.

Again, there’s very little one can do other than modify lifestyle to improve motility, but often treatments such as ICSI are helpful here.

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

If you look at a semen analysis for most men, you’ll find that not all of the parameters are normal. Morphology, in terms of spontaneous pregnancy, probably has less of a bearing.

However, if we have a couple that have been trying for a number of years, we haven’t had any other factors, and we’re moving towards a treatment such as IVF, then a low morphology would push us into doing ICSI. ICSI really is a treatment, a sort of final common pathway for most causes of significant male factor infertility.

Eloise Edington 

Is it possible to conceive with sperm-related subfertility?

Dr Ishola Agbaje

Absolutely. I think, as I’ve stressed, hopefully, semen analysis is a very blunt tool. It’s the best test we have, but the only real test of male fertility is trying. Unless the semen analysis result is very extreme—either no sperm or very few sperm—then I would encourage a couple to keep trying while we’re moving forward because things can still happen.

Even if there’s no sperm in the ejaculate, that doesn’t mean that there are no options. In men that haven’t got any sperm in the ejaculate, that can be for a number of reasons. It can be because there’s a blockage somewhere in the system and actually the testicles are producing sperm normally, but it’s not getting out.

Usually, that’s very easy to retrieve sperm. Or it can be that there’s perhaps a fundamental problem with the testicle, that there’s very few sperm being produced or no sperm. That again is something that one can explore with various surgical procedures to try and retrieve sperm.

Up until the 1990s, couples that had severe male factor infertility had very few options, actually. Many of them had to use donated sperm. But in the mid-1990s, ICSI treatment became available.

That is injecting the sperm into the eggs. 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 that doesn’t leave us with no options. In some cases, where there is significant male factor, we would move on with couples using donated sperm.

Eloise Edington 

What treatment options do you see as most successful where sperm is a concern?

Dr Ishola Agbaje

I think, generally speaking, the most successful treatment option is ICSI treatment.

If there’s nothing reversible—occasionally, we will have a man that has a reversible cause of male infertility—the obvious one is using anabolic steroids or having some sort of hormone deficiency that we can effectively boost and return to normal semen production.

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

Eloise Edington 

What should we know about environmental causes? For example, chemical, radiation exposure, heavy metal toxicity, overheating, etc.?

Dr Ishola Agbaje

Yeah, so there’s plenty of debate in scientific communities and the popular press about the effects of the environment on male fertility specifically. Certainly, it’s a fact that globally, male fertility is declining and sperm counts are falling. In some countries, as many as 30% of men might have a subfertile semen analysis, or 10% an infertile semen analysis.

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

Some of the common ones would be hormonal contamination of our environment. Since the advent of the oral contraceptive pill and a lot of estrogen being put into our water system and environment, this may have an effect on male reproductive function and actually male development—both in utero (as embryos) and subsequently as adults.

There’s a lot of oestrogen in the food we eat. We eat a highly processed diet, and there are many estrogens within that diet that can affect the male reproductive tract.

Certain occupations, as you mention, in terms of chemical exposure—be it pesticides, heavy metals, or whatever—but it’s very difficult to be specific about this and also very difficult to avoid everything. In everyday life, we are exposed to multiple things we’re not necessarily aware of.

So I suppose all one can do is be aware of things that have definite evidence and try to avoid those—whether those be particular chemicals—and just in terms of lifestyle, try to maintain a healthy lifestyle and healthy diet.

Eloise Edington 

What about overheating—like baths, saunas, and heated seats in the car?

Dr Ishola Agbaje

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

Some factors in patients would increase the risk of testicular heating. These would particularly be things like obesity, or some occupations—where you’re, for example, a long-distance driver.

You might be obese, and the testicles have a heating effect. Or some medical conditions like a varicocele, which is the varicose vein we talked about around the scrotum. These things certainly potentially do have an effect.

I guess in terms of saunas, hot baths, and tight underwear—these are things that we can do in moderation. I think you would have to be doing a lot of it to have a significant effect. But again, it’s just kind of sensible advice—probably just trying to wear loose underwear generally—and I think taking a hot bath 

Is absolutely fine, but just not maybe taking too many of them.

Eloise Edington 

We see a lot about lifestyle factors. Which do you most commonly see in clinic which make a profound effect?

Dr Ishola Agbaje

I think probably the biggest lifestyle factors that we might see generally day-to-day are things like body mass index—so obesity, both male and female.

Adverse lifestyle factors like smoking, vaping—vaping particularly, compared to smoking—people might see that as a lesser evil.

However, I think there’s very little research done in terms of vaping, in terms of chemicals that are in it, and what negative effects there might be.

We would see recreational drugs, particularly things like cannabis, which certainly has a documented effect on things like sperm motility.

Drugs such as anabolic steroids, protein, creatine that are used in gym work—these things are probably things that we would see day-to-day.

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

I think a lot of fertility—both in male and female sides—is associated with a lot of uncertainty and guilt. It’s very difficult because it’s a difficult journey to have. For example, if you have an abnormal semen test, you’re suddenly thinking, “This is the reason,” and, “It’s my lifestyle,” or 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 in that context don’t have a big impact.

Eloise Edington 

What about positive things that people can do such as supplementation and healthy diet?

Dr Ishola Agbaje

Yeah, I think it’s really common sense. I always say to patients, it’s sort of things that your granny would have told you—so it’s kind of good diet, exercise, managing stress. All of these things, for example, stress, don’t necessarily directly affect your semen quality but affect how you experience the journey with infertility.

In terms of supplements, there are no specific supplements that we recommend for males. For females, it’s important to supplement folic acid and vitamin D—those are the core supplements. There’s quite a bit out there on the internet in terms of a panoply of different supplements, and not all that’s backed up with robust scientific evidence.

So my practice is generally to advise men particularly to have a good, balanced diet. If you’re eating all colours of the rainbow, then you’re getting all the sort of trace elements and nutrients that you need.

There are some commercially available basic supplements that, if you feel you want to take a broad vitamin, then that’s probably okay.

Probably not much evidence of any harm, but certainly a lot of these things can be very expensive, and one wouldn’t necessarily recommend that you must go on these types of things.

Eloise Edington 

Our community often ask about penis size versus form. Can you clear up any confusions or myths here, please?

Dr Ishola Agbaje

Yeah, so 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.

I suppose I would see erectile and ejaculatory difficulties commonly in the clinic. Men aren’t always too forward in terms of discussing that or admitting to that, but clearly that’s a very important part of the fertility assessment.

Sometimes these can be signs of other underlying health issues which require being addressed, such as diabetes.

There can also be a large psychological component, and I think the pressure of infertility and having to perform on command—often people are tracking cycles and that sort of thing—can be a vicious circle.

So it’s important to break that, because that can be a subtle contributor. So in summary, yes, size isn’t important, but function is.

Eloise Edington

Testicular health is another key concern for our audience. What should we know, and is there any action that we can take?

Dr Ishola Agbaje

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.

That’s a really important message: that when they’re being assessed in the clinic, that they’re examined, and actually that they continue to examine themselves throughout their life.

They are a group not at high risk, but at higher risk than the general population for getting these types of problems. If they’re picked up early, then they can be sorted out more easily.

So checking for lumps and bumps regularly is important. Also, 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 other pathology or problems. So again, your general practitioner or fertility specialist should be looking for these things.

Eloise Edington 

Thank you.

Well, thank you so much, Dr. Isola, for your time today and for these thorough answers around male infertility.

If anyone is looking for personalised treatment plans or support, please do follow the link to get in touch today with the team at TFP Fertility, who are more than happy to help with a consultation and discuss next steps.

Dr Ishola Agbaje

Thank you.

Eloise Edington 

Thanks so much.

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