When a couple are trying for a child it is important to consider the male partner’s contribution. For many years this has been an area of limited awareness but published causes and outcomes available from the HFEA show that male factors are the most common reason for undergoing fertility treatment in the UK.
An example of how male factors have an impact on not only conception but also later events in pregnancy is evident from the increased chance of pre-eclampsia at the end of pregnancy with a first child of a new male partner. Scientific and clinical evidence is growing specifically relating to how the quality of sperm can impact on the chance of conceiving and also that of miscarriage.
Male fertility is difficult to measure and traditionally has only been performed by a semen analysis which looks at the number of sperm and how well they move and their shape. Results can be very variable and laboratories will often use different standards and criteria to describe normal. However, the predictive ability of this test is limited particularly with relation to the chance of miscarriage.
In the last decade researchers have looked more closely at the relevance of DNA damage within the sperm and how it impacts on conception and also later stages of pregnancy, including miscarriage. The DNA in the sperm is the genetic material which merges with DNA from the woman’s egg and all being well leads to the formation of a healthy embryo and pregnancy. Increased levels of DNA damage have been linked to early and late pregnancy loss even with normal sperm counts. It has also been postulated that a certain amount of DNA damage may be able to be corrected if the woman’s eggs are of very good quality.
Causes & Reactive Oxygen Species
The direct causes of DNA damage are varied but seem to have a common factor of oxidative stress. This is a type of stress caused to the sperm when exposed to certain substances called reactive oxygen species (ROS) that can damage the sperm. Treatments for excessive DNA damage are available and depend on the cause but ultimately can reduce the amount of ROS or their chance of affecting the sperm. Major causes linked to DNA damage include smoking, infection, high fevers, diet, drug use, advanced age, varicocele and exposure to environmental or occupational pollutants including increased testicular temperatures.
The results of DNA damage testing can give men and couples reassurance if normal but if elevated can help focus investigations for potential causes and even offer treatments to improve the sperm. Treatment may be removal of risk factors such as smoking cessation, treating infection or embolization of a varicocele. Lifestyle changes may also be beneficial and nutritional support or vitamin and anti-oxidant supplementation can be more directed. For couples the result may inform their decision making such as those related to continuing with natural conception or using assisted reproductive techniques such as Intra-Uterine Insemination (IUI) or In Vitro Fertilisation(IVF) or Intra-Cytoplasmic Sperm Injection (ICSI). Rarely, if IVF or ICSI are being considered then surgical sperm retrieval may be an option to use sperm that has not been subjected to the oxidative stress often found when on the prolonged journey passing through the male genital tract. If sperm quality is particularly low then consideration of using a sperm donor may be an option for some.
Rarely, if the sperm numbers and quality are particularly low or if there is particular concern about inheritable conditions then underlying genetic causes can be more specifically assessed. Specific blood and sperm genetic tests can be performed if indicated such as Karyotype, Y-Microdeletion and Cystic Fibrosis blood tests or sperm aneuploidy testing. Although rare, these tests if abnormal can have a significant impact on the male partner, any future pregnancies and offspring as well as the man’s wider family.
Wider aspects of men’s health
During the assessment of fertility concerns, it is not unusual for other conditions to be discovered or men to raise issues that they would normally prefer not to discuss. These are important to address when starting a family and they can be exacerbated in times of stress often experienced by couples in this situation. These often include concerns regarding swelling or lumps in the testicles, erection or ejaculation problems or issues related to the foreskin. In addition urinary problems or concerns regarding the prostate can arise particularly as men get older. Finally, wider issues such as obesity, diabetes, high blood pressure, cholesterol and testosterone deficiency can be assessed and addressed.
Low testosterone or libido
Testosterone is the male hormone responsible for changes during puberty and also is important for healthy sperm production and a man’s sex drive and well being. Symptoms of a low testosterone include a reduced sex drive or less strong erections. More subtle symptoms include a lack of energy, strength or endurance, loss of height, decreased “enjoyment of life”, tiredness, reduction in work performance and ability to play sports. Testosterone levels can be affected by lifestyle factors. Testosterone replacement is not recommended when a couple are planning to have children due to the negative impact on sperm production but alternative medication may be available that boosts the body’s own testosterone levels and the quality of sperm.
Lifestyle, stress, medications, age and conditions such as diabetes can all have an impact on the ability to achieve and maintain an erection. It is not unusual for men to first notice such problems related to stressful periods in their lives. With appropriate investigation and exclusion of serious medical problems most men can improve their situation with the various treatments that are now available.
Rarely men can suffer with difficulty ejaculating and may be related to diabetes or rarely testicular cancer but specific advice, medical treatments or assisted reproductive techniques can be used to overcome this problem. Premature ejaculation can also respond to counselling but if unsuccessful prescribed medication may be effective.
The testicles are easily examined and the early detection of testicular cancer now means this disease is very effectively treated. Various other causes of testicular swelling can raise significant concerns and it is important to carefully examine the testes and if uncertainty exists a simple ultrasound scan can often give further reassurance. The testicular examination performed by an Urologist is an important part of the assessment of the male partner when a couple are trying to conceive.
Urinary symptoms & prostate health
Reduced flow, frequent visits to the toilet and waking at night to pass urine are problems that can have a significant impact on a man’s quality of life. There is now greater awareness by men of the prostate and issues that may affect it. The prostate anatomically sits below the bladder and at the junction point of the tubes that transport sperm and urine. Prostate cancer is very rare under the age of 50 but men with a strong family history or Afro-Caribbean origins may be more at risk. More commonly the prostate enlarges for benign reasons but the symptoms this cause can have a significant effect on quality of life.
Infectious problems such as prostatitis can also give similar symptoms more commonly in younger men. Appropriate and prolonged antibiotic treatment may be required but consideration of effects of infection and antibiotics on sperm production must also be considered.
Often the foreskin can be inflamed or painful significantly affecting enjoyment of sexual activity. Tightness can also restrict the passage of urine or be implicated in infections.
Diabetes, High Cholesterol, High Blood Pressure
These are all common conditions that particularly when combined have a significant impact on the general health of men. Often the conditions described above can be early signs of future problems such as heart disease or strokes and so the opportunity should not be missed to consider strategies for identifying and preventing such conditions.