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Impotency & Infertility

Infertility

 

Male Factor infertility is one of the most common reasons why couples do not become pregnant.

There are many different causes of male infertility. There may be a shortage of sperm, or a blockage preventing the sperm from being ejaculated, or the sperm may not swim properly, they may stick together, or there may be no sperm produced at all.

If your partner is to become pregnant, several things have to happen. The man must produce millions of healthy, active sperm which pass into the womans vagina during intercourse. Then the sperm must swim through the womb and into the Fallopian tube to fertilise the egg. The resulting embryo travels on and embeds itself into the womb.

Problems can exist at all stages in this process. Until fairly recently, there was little that could be done to help - but new advances mean that men who would not have been able to father a child can now do so, and even the most severe types of male infertility can be treated. There are a number of different types of treatment available. The type you are offered will depend on the cause of your infertility.

Remember that male infertility problems are very common, remember also that you are not on your own - we are here to help and you should talk and share how you are feeling with your partner.

We also understand much more today about the impact of lifestyle on male infertility - and smoking, heavy alcohol consumption, overeating, lack of exercise and stress can all contribute to the problem.

 

CAUSE
INVESTIGATION
TREATMENT OPTION
Failure of sperm production

Initial semen analysis
Hormone assessments / Testicular biopsy

Donor sperm Testicular sperm extraction and IVF / ICSI

Blocked/absent
vas deferens
Scrotal examination Screen for Cystic Fibrosis

Unblock microsurgically
MESA with IVF / ICSI

Low sperm numbers

Semen analysis RCA

IUI, IVF or ICSI Poor sperm movement Semen analysis RCASperm
stimulants with IUI / IVF or ICSI

High numbers of abnormal forms

Semen analysis RCA

IVF or ICSI
Antisperm
antibodies
Antisperm antibody screen
Sperm preparation with IUI, IVF or ICSI
Vasectomy
 

Vasectomy Vasectomy Reversal
PESA / TESE



Causes and Investigations of Male Infertility

Male infertility (or sub-fertility) as it is often known) is defined by a sperm count of less than 20 million per millilitre of semen, compared with the average of around 62 million.

There are many reasons why a mans sperm count is low, usually related to health and hormone balance and these issues are discussed in the Lifestyle section of this site.

Sperm count is not the only issue - and sperm quality and motility (the ability to swim within the female reproductive system) are important issues too.

There may also be psychological reasons. The male sex organs are complex and delicate and blockages can occur at several points which prevent the effective release of sperm on ejaculation.

It is unfortunately the case that many of the tests available to assess sperm counts and motility are inaccurate and out-of-date and you may be getting misleading information - see the next section Infertile? Dont be so sure.

A total absence of sperm in the ejaculate is known as azoospermia. There are two main reasons for this occurrence:

1. A blockage, or congenital abnormality, which prevents movement of the sperm between the testis (where sperm is produced) and the penis.

  • A blockage can be the result of a previous vasectomy or infection.
  • Congenital abnormality presents as an absence of the tubes which carry the sperm from the testis to the penis. Some men are born with this congenital absence of the vasa. This condition is likely to be associated with an abnormal gene for Cystic Fibrosis
2. A poorly-functioning testis, resulting in low sperm production.

  • This may happen when the testis has been affected by conditions such as mumps, infections, trauma, testicular torsion or undescended testes
OR
  • genetic abnormalities may be the cause. It is now recognised that up to 15% of men with azoospermia may carry abnormal genes responsible for their infertility. It is, therefore, important to perform a genetic screen to check this, not only to understand the problem, but also to assess the risk of transmission to the child. However, in many cases, the reason for azoospermia will remain unknown.

 

Semen analysis
The next step is a semen analysis which will enable us to assess your condition with accuracy.

Production of semen samples Semen samples should be produced by masturbation at Bridge so that the analysis can take place immediately after production. However, if you feel you are unable to produce a sample on-site, please speak to one of our laboratory staff to discuss alternative arrangements.

Please make sure that you do not ejaculate for three days prior to producing a semen sample for analysis. This is important as it will ensure that the sample you produce on the day is at its optimum in terms of numbers and quality.

The Analysis

The following parameters will be assessed in the semen analysis:

  • the number of sperm present within the ejaculate (the sperm count)
  • the number of sperm that are moving (the motility)
  • the number of sperm that are normally formed (the morphology)
  • whether or not there are anti-sperm antibodies present
  • the ability of sperm to survive over a 24 hour period
  • xwhether or not there is any infection present within the sample.

What is a normal semen analysis result?
A normal semen analysis will show the following

  • a semen volume of between 2 and 3mls
  • a sperm count of significantly more than 20 million sperm per ml
  • at least 45% of the sperm will be motile
  • at least 30% of the sperm will be normally formed
  • less than 10% of the sperm will be affected by antisperm antibodies

Repeated Centrifugal Analysis (RCA)
Some men with infertility problems are told that it is not possible to find any sperm in the ejaculate following routine semen analysis. This condition is called azoospermia. If these men wish to father a child using their own sperm it is then usually necessary to undergo a surgical procedure to try and extract sperm directly from the epididymis or from the testis. (PESA or TESE)

However, this surgery may not always be necessary. In some cases, men who have been told that they have azoospermia do in fact produce some sperm that can be found in the ejaculate. The sperm is produced in very minute quantities and, as a result, can be missed during a routine semen analysis. Using advanced analysis techniques it may be possible for the embryologist to recover a few sperm from the ejaculate, which can then be cryopreserved. This procedure can be carried out on several occasions and it may be possible to store enough sperm to be used in a treatment cycle. If sperm is collected using this method there will not be sufficient sperm to be able to fertilise eggs in the normal way and Intra-cytoplasmic sperm injection (ICSI) will always be required.

Th non-surgical recovery technique is called Rapid Centrifugal Analysis (RCA). Firstly, the man will need to give several ejaculates for analysis over a period of weeks. Each of these ejaculates is then prepared by spinning in a centrifuge at very high speed. This concentrates all the cells, including any sperm cells in the sample, into a very small volume. It may then be possible for the embryologist to identify a few sperm using a very powerful microscope. If any sperm are seen then the ejaculate will be cryopreserved for future use.

Not all men who undergo this procedure will be successful, however we see it as an important first step in the process and expect that, for about 25% of men treated, we will be able to collect enough sperm for use in an ICSI treatment cycle.

If these sperm are used during ICSI then around 65% of the eggs will fertilise following the injection of a single sperm. Pregnancy rates following IVF/ICSI vary for many reasons and your consultant will discuss his with you.



Premature Ejaculation and Psychogenic Impotence

Premature Ejaculation

The definition for premature ejaculation in terms of time varies from 30 seconds up to 4 minutes1. Therefore the best definition is an inability to control ejaculation sufficiently to permit both partners to enjoy sexual intercourse.

Epidemiology
  • The prevalence of premature ejaculation varies according to definition and is difficult to assess in view of many men not wanting to seek help or even discuss the problem.
  • One random survey of in the United States found that about 30% of men had ejaculated prematurely in the past year


Risk factors Underlying causes include
Premature ejaculation may be anxiety related.
It is therefore more common in young men and early in a relationship. In these situations, the problem usually resolves with time.
Iatrogenic causes include amphetamine, cocaine and dopaminergic drugs. Although effective for the treatment of premature ejaculation in some men, sildenefil may also be a cause of premature ejaculation in others4.
Urological causes, e.g. prostatitis.
Neurological causes, e.g. multiple sclerosis, peripheral neuropathies.

Psychogenic Impotence
Only about 10-20% of patients with erectile dysfunction are believed to have a solely psychogenic cause, but psychogenic factors are often present in those who are diagnosed as having a physical cause.

Features suggestive of psychogenic cause for erectile dysfunction include:
Sudden onset.
Early loss of erection.
Better erections when masturbating or on waking in the morning.
Premature ejaculation or inability to ejaculate.
Problems or changes in the relationship.
Major life events.
Psychological problems.
 

 
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