About 15 per cent of the couples in Singapore do not get pregnant successfully within 12 months of trying to have a child. Infertility in 50 per cent of these couples is due to the man who may have a medical disorder. Infertility can be attributed to either the man or woman, or both (Table 1 shows the incidence of the causes of infertility). Therefore, medical investigation for infertility should involve both from the beginning.
In nearly all cases of male infertility, the man will not observe any obvious signs and symptoms. Sexual intercourse, erection and ejaculation usually occur without any difficulty. The quantity and the appearance of the semen will appear normal to the naked eye. Medical tests will be needed to tell whether there is a problem in most cases.
These tests are recommended when the couple fails to conceive after regular, unprotected sexual intercourse for 2 years, in the absence of any known reproductive disorders.
Semen analysis is the most essential part of diagnosing male infertility. It is a laboratory test of freshly ejaculated semen, of which the number, shape and movement are measured under a microscope. These tests should be done at specialised laboratories that use methods approved by the World Health Organisation.
Table 2 shows the parameters of normal semen. Based on results of the semen analysis, physical examination and other tests can help to determine the different types of male infertility.
One in eight infertile men has a treatable condition that can be overcome. After appropriate treatment, the couple can try to get pregnant naturally without any other assisted reproductive techniques.
Men with untreatable sterility have azoospermia. The sperm producing cells in the testes either did not develop or have been irreversibly destroyed due to chromosomal or genetic disorders, inflammation of the testes or treatment with certain drugs. Couples facing this predicament can consider adoption and donor insemination.
Most men investigated for infertility have untreatable sub-fertility. The sperm could be of lower number, reduced motility, and lower normal forms and shapes, which affect the fertilising ability and greatly reduce pregnancy rate.
Spontaneous pregnancy then depends very much on the presence of any adverse factors of the female partner, such as age being above 35 and medical conditions like endometriosis. Early recourse to assisted reproduction is therefore the key to a good outcome in fertility treatment.
At present, very little is known about the mechanisms by which sperm production and function are reduced. Many empirical treatments have not been proved to be effective, which include operations for varicocoele, nutritional supplements, traditional herbs and some drugs that alter hormone levels.
There are problems in assessing the success of the treatment of infertile men:
Intracytoplasmic sperm injection
Intracytoplasmic Sperm Injection (ICSI) is now the method of choice for treating severe sperm problems. This technique involves the injection of a selected sperm into the body of the egg cell to enable fertilisation.
It has revolutionised the treatment of male factor infertility; provided a live sperm can be found. The chances of failed fertilisation has been substantially reduced compared to when conventional IVF is used.
Male infertility deserves the same medical attention as female factor infertility. Assessment of an infertile couple should include the assessment of the male partner at the outset in view of the frequency of male contribution to this problem.
This will enable detection and early treatment of the many treatable conditions that can potentially negate the need for any sophisticated assisted reproduction technique. Furthermore, with the exclusion of these conditions, any unnecessary delay to assisted reproduction can be reduced, which may have a significant impact on the eventual success rate.
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