Male fertility problems

Written by Dr John Dean, specialist in sexual medicine, South Devon Healthcare NHS Trust

Problems with erection and ejaculation

Problems with sex are the principal cause of infertility in about 5% of couples. This can be due to:

erectile dysfunction (inability to attain or maintain an erection adequate for intercourse)

premature ejaculation

failure to ejaculate

inability to achieve vaginal penetration for other reasons.

Hormonal problems

Testosterone deficiency can reduce fertility and may be caused by problems with testicular testosterone production, or problems with the pituitary gland or hypothalamus in the brain, which control testosterone production. Overproduction of prolactin (hyperprolactinaemia), a hormone produced by the pituitary gland, may also reduce fertility.

General medical disorders that reduce fertility

There are several conditions that may reduce fertility:

Fever: influenza, pneumonia, or even a severe cold can cause a high fever, which will adversely affect sperm production and quality. These changes usually recover over a few weeks.

Diabetes: in the longer term, diabetes can cause problems with erection and ejaculation through causing damage to the function of the 'automatic nervous system'.

High blood pressure: hypertension (high blood pressure) can cause problems with erection, either directly or as a side effect of medication.

Coronary artery disease: coronary artery disease can cause problems with erection. This could be due to generalised hardening of the arteries, in the penis as well as the heart, or to drugs used in the treatment of heart problems.

Neurological disorders: multiple sclerosis, stroke, and spinal cord injury and disease can all cause problems with erection and ejaculation.

Kidney disease: chronic renal failure, which results in a build up of waste products in the body, can adversely affect sperm quality and fertility. It can also cause erection problems.

Cancer: cancers that affect the genital tract or endocrine (hormone-producing) systems may directly reduce fertility. Otherwise, drugs and radiation used to treat cancer may severely reduce sperm production or even stop it altogether. Stress (see below) may also have an effect.

Alcoholism: alcohol is toxic to sperm and overuse of alcohol can reduce sperm quality and fertility.

Stress: stress causes several hormonal changes in the body that can affect fertility. Stress can have many causes, including anxiety over fertility problems.

Drugs that reduce fertility

Many drugs, both prescribed and those used recreationally, can reduce fertility. Any fertility concerns related to prescribed drugs should be discussed with your GP - do not just stop taking them yourself.

Recreational drugs that may affect fertility
Recreational drug	Effect
Alcohol	Reduces sperm count and quality
Tobacco	May reduce sperm motility
Marijuana	May affect hormone production
Opiates (heroin, morphine)	Affect hormone production
Anabolic steriods	Affect hormone production

Prescribed drugs that may affect fertility
Prescribed drug	Effect	Main use
Amiodarone	Inflammation of the testicles and epididymis (epididymo-orchitis) leading to problems with sperm production	Abnormal heart rhythm
Cancer chemotherapies	May severely reduce sperm count, quality and motility. Effects may be permanent	Cancer
Cimetidine	Affects hormone production and reduces sperm count	Peptic ulcer and acid reflux disease, indigestion
Colchicine	May severely reduce sperm count	Gout
Digoxin	Affects hormone production	Heart failure; abnormal heart rhythm
Erythromycin	May reduce sperm count	Chest infections
Gentamicin	Reduces sperm count	Bacterial infections
Hormonal therapies	May disrupt other hormone production	Various
Ketoconazole	Reduces sperm count	Fungal infections
Methotrexate	Reduces sperm count	Some cancers; arthritis
Nitrofurantoin	Reduces sperm count	Urinary tract infection
Phenytoin	Reduces sperm quality and motility	Epilepsy
Spironolactone	Affects hormone production	Fluid retention
Sulphasalazine	Reduces sperm count and quality	Ulcerative colitis

Environmental toxins and radiation

Several media reports have highlighted research studies showing that sperm counts are falling and that male fertility is declining, possibly because of environmental pollution. A similar number of studies have shown no change whatsoever, but these do not make such good headlines and often fail to be reported in the media.

Is male fertility in decline? Because evidence exists both one way and the other, the answer must be 'maybe'! One thing is certain, and that is that many more environmental toxins that might affect fertility exist now than 50 years ago.

Environmental toxins that may affect fertility
Potential toxin	Origin	Effect
Alkylphenols	Industrial and domestic detergents	Hormonal disrupter
Lacquers to coat foods; dental treatments	Lacquers to coat foods; dental treatments	Hormonal disrupter
Dioxins	Paper production; transformer disposal	Hormonal disrupter
Organochlorine pesticides (Lindane, DDT, etc,)	Lindane used on cereals, soft fruits, cabbage	Hormonal disrupter
Phthalates	Some soya products	Hormonal disrupter, testicular toxin
Phyto-oestrogens (found in certain types of plant products)	Some soya products	Hormonal disrupter
Vinclozolin	Hormonal disrupter, testicular toxin	Hormonal disrupter

When should I seek advice?

Although fertility is affected by many factors, particular a woman's age, the chance of a young couple conceiving following regular intercourse is about one in five (20 per cent) in each menstrual cycle. The odds remain the same in each cycle and you are not guaranteed conception after five menstrual cycles. However, most couples can expect to conceive within six months.

Do not be too concerned if you fail to conceive after only two or three of your partner's menstrual cycles, even if friends seem to conceive straight away.

Although it is affected by many factors, particular a woman's age, the chance of a young couple conceiving following regular intercourse is about one in five (20 per cent) in each menstrual cycle. The odds remain the same in each cycle and, although it might sound likely, a couple are not guaranteed conception after five menstrual cycles. However, most couples can expect to conceive within six months.

Seeking some initial advice after six months or so is reasonable and you should not feel that you must wait for a year. Most doctors are very understanding and may not insist on a year's failure to conceive, just in order to fulfill an arbitrary medical definition.

How are the causes of fertility problems diagnosed?

The first place to seek advice regarding a conception problem is your GP. You and your partner should be assessed as a couple, at the same time, rather than one after the other. It is very important not to attach blame to yourself or your partner, even if one of you has an obvious problem.

Both of you are reasonably likely to contribute problems that affect your chance of conception. Trying to conceive and undergoing medical assessment is stressful enough without putting additional strain on your relationship through mutual antagonism.

What else could it be?

n some couples, no cause can be found for their failure to conceive, despite very intensive investigation. Both partners seem quite healthy, but they simply do not conceive together. This can be very distressing and seem quite incomprehensible, but it does happen reasonably frequently.

Self-help

There are a number of things that men can do to help preserve and promote their fertility.

Eat a healthy, balanced diet.

Take regular exercise.

Try to maintain their weight in the ideal range.

Don't smoke.

Keep alcohol consumption within recommended limits.

Don't use recreational drugs.

Try to reduce stress.

Two other actions have been suggested. They may improve sperm quality parameters, but evidence that they improve the successful pregnancy rate is poor or non-existent.

Avoid tight underwear or wear boxer shorts - the evidence for benefit from this is very poor. One study from the Netherlands showed that tight leather trousers and tight plastic underpants affected sperm quality when worn together, but not alone! Y-fronts probably do not make much difference.

Cold showers or scrotal soaks - while these might take the mind off fertility concerns for a few moments, there is no evidence of their effectiveness.

What can your doctor do?

Your GP should be able to identify many of the common causes of male fertility problems, or refer you to a fertility specialist (usually a urologist, gynaecologist or specialist in reproductive medicine) for advice.

Surgery, including vasectomy reversal, may be helpful for some men with obstructive problems.

However, success is not guaranteed, and assisted conception techniques, including in-vitro fertilisation ('test-tube' babies or IVF), may offer a better chance of a pregnancy.

Although assessment and initial investigation is available within the NHS, vasectomy reversal, assisted conception and some other fertility treatments are either not available or have very limited availability in most health districts. Private treatment may cost several thousand pounds, again with no guarantee of success.

Prognosis

Sadly, most disorders affecting sperm quality and production either cannot be cured or do not respond well to treatment. However, assisted conception techniques, including use of donated sperm, can help affected couples achieve a successful pregnancy, even if there are very severe sperm production problems.

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