Male Infertility : A Silent Dilemma


Male infertility is on the rise. ‘Male biological clock’ is ticking faster than before.

The incidence of male factor infertility has risen from about 10-15% to about 40-50% in the last 10 years.

Are the men doing something wrong or are they not doing something right that give rise to male infertility in recent years.

Worldwide statistic and from my own experience managing male infertility, the majority of men have problems of either sperm production or sperm transport blockage or a combination of both.

1. Sperm Production Problems

Problems with sperm production can either be non-inherited or inherited.

Most common non-inherited causes are lifestyle related.

Cigarette smoke contains numerous chemicals that are harmful to sperm . The chemicals reaches the sperm production 'factory' (testicles) via blood stream and affects the balance of certain proteins that are required for optimal sperm production and integrity. This process damages the genetic of sperm via oxidative stress. Thus, a smoker may have a normal sperm count but the quality of his sperm is very much reduced.

Alcohol abuse also reduces sperm production by lowering the level of male hormone called testosterone. Testosterone is needed for optimal sperm production. Many health organisations recommend men to avoid habitual or binge drinking. Research could not conclusively identify the amount of alcohol that affects sperm quality but as little as 5 units of alcohol per week has been shown to have a negative effect on sperm.

Besides alcohol, testosterone replacement or abuse can reduce or completely stop sperm production. Testosterone that are consumed can halt the natural production of hormones that are essential for sperm production. The reversal back to normality sometimes can take years.

Obesity is a well known risk factor for heart disease. Obesity affects sperm production by lowering testosterone. This can happen because fat cells can turn testosterone into female hormone called oestrogen. High levels of oestrogen can reduce sperm production. Other possible reason, is the insulating fat increases scrotal temperature thus reducing the optimal environment for sperm production. Obesity also can cause erectile dysfunction.

male infertility

The incidence of male factor infertility has risen from about 10-15% to about 40-50% in the last 10 years. (Image source from:

Stress affects a man's fertility health. Men with high level of stress has lower sperm quality. The mechanism on how stress affects sperm quality is not fully understood but it could be related to release of steroids called glucocorticoids which lowers the testosterone level. It is also proposed that stress damages sperm by oxidative-stress.

Sexually Transmitted Infection (STI) can also reduce sperm production by directly damaging the site of sperm production in the testicles. Any man suspected to have STI should seek appropriate consultation and treatment to avoid long term fertility health consequences.

Varicocele (dilated veins around the testicle) has long been proposed to reduce sperm production. However, only a moderate to large varicocele may impair sperm production by increasing the scrotal temperature. Mild varicocele do not lessen sperm production.

Failure of the testicles to descend into scrotum during childhood (cryptorchidism) can lead to permanent damage of sperm production. Testicles which failed to descend are in a more 'hotter' environment compared to its natural position in the scrotum . If treated surgically in early childhood, long term sequelae can be avoided.

Other less common causes are injury to the genitals and medical treatment such as chemotherapy. Sometimes, the cause is unknown.

Inherited sperm production problems are rare. Conditions such as Klinefelter's Syndrome, Y-Chromosome micro deletion and Down's Syndrome can lead to either low sperm production or no sperm production (azoospermia).

2. Sperm Transport Blockage (Azoospermia)

male infertility

Sperm count for Azoospermia (Image source from South India Institute for urology and Transplantation)

In this condition, the sperms that are produced are unable to be ejaculated. The ejaculate is a combination of semen and sperm. So, a man could still ejaculate out semen without any sperm (azoospermia).

Most common cause of a blocked sperm pathway is infections , especially sexually transmitted infection (STI). The inflammatory process damages the structure of sperm transport pathway within and outside of the testicle. However, most of the infections are asymptomatic and difficult to diagnose.

Prostate-related problem such as infection (Prostatitis) or prostate surgery can lead to blockage. Other pelvic surgery such as for inguinal hernia can, in some cases,contribute to this problem.

In rare cases, the sperm transport channel is absence in a condition called Cystic fibrosis. Fortunately, it is more prevalent in Western countries.

3.Sexual Problems

Sexual problems lead to improper deposition of sperm in the vagina. Failure of ejaculation , erectile dysfunction and retrograde ejaculation are some common examples.

Sexual problems can be due to an underlying medical condition such as an uncontrolled Diabetes Mellitus. Trauma to spinal cord and pelvic or prostate surgery complicated by nerve damage can also lead to erectile dysfunction.

4. Hormonal and Sperm Antibody

Diseases of pituitary , congenital lack of hormones (FSH & LH) and Kallmann Syndrome can reduce the hormones needed for sperm production . FSH (Follicle Stimulating Hormone) and LH (Luteinising Hormone) are produced in the pituitary and they drive sperm and testosterone production in the testicle.

Vasectomy ( male sterilisation) , injury or infection in the epididymis can lead to sperm antibody production. This sperm antibodies wrongly identify the sperms as a foreign body and destroys the sperm.

How Male Infertility is Diagnosed?

Diagnosis is based on a combination of clinical history , physical examination, semen analysis and additional hormonal tests.

The first line test is semen analysis (sperm test).
Sperm concentration :
The lower range of normality is when at least 15 millions sperms
for every millilitre (ml) of semen is found. Sperm concentration above this value is
considered “normal”.

Vitality :
This is the percentage of life sperms in the sample. It should be at least 58% ( at
least 58 out 100 sperms are alive).

Motility :
This parameter looks at the movement of the sperm. At least 40% of the sperms
should be moving. The movements are further graded according to how fast it moves and
direction of the sperm movements.

Morphology :
This parameter looks at how normal a physical shape of a sperm looks
like. This is done under high powered microscope. At least 4% ( you read it correctly!) of
the sperms should be normal-looking to be considered “normal”.

Additional hormonal tests are needed when there is no sperm (azoospermia).

Physical examination to look for any signs of testosterone (male hormone) deficiency followed by blood tests for hormones ( i.e. FSH,LH,testosterone) are done. The results will generally guide the fertility specialist as to the cause of azoospermia.

Treatment Options

Sperm quality can be improved by lifestyle changes. The focus should be on reducing / stopping cigarette smoking , if consuming alcohol aim for moderate alcohol intake , weight reduction, healthy diet and reducing daily stress level.

Men should also consider adding anti-oxidants in the daily meal plan. Anti-oxidants pills such as Vitamin C, selenium and zinc are easily available in retail pharmacies. Anti-oxidants potentially lowers the level of oxidative stress on the sperm and thus may improve sperm quality.

However, any lifestyle modifications will not show an immediate effect. It takes at least 2-3 months before any improvement is seen because sperm production takes 72 days to complete. Any improvement will be reflected in the new batch of sperm.

If azoospermia is due to vasectomy or obstruction , sperm can be obtained directly from the testicles. This requires a minor surgical procedure under sedation. The severity of azoospermia will determine the type of surgical procedure required.

Dr Agilan Arjunan

by Dr Agilan Arjunan

Dr Agilan graduated as a doctor from University Malaya in the year 2004. Since very early in his career, he found his passion in treating couples with Infertility. Upon being conferred his specialist degree from UK, he pursued his extensive training in Laparoscopic Surgery, aiding him to treat many gynaecological conditions. View all articles by Dr Agilan Arjunan.


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