Dr Andris Abele – Certified Urologist & Infertility Specialist at EGV Clinic is answering the most common questions about male factor – sperm quality.
We can divide the world into two parts, and that’s the way science is looking at it. We have the Western world and the rest of the world. By the Western world, we usually understand North America, Europe, Australia, New Zealand and in a recent study that investigated sperm quality trends in the past 40 years, we can see that in the Western world sperm concentration is declining by at least 50%. It’s a huge number, a half in 40 years and this issue that this decline is not stopping so it will go on in next years and if we do not change something, it will be a dramatic burden for health care. If you’re looking at the data from another part of the world like South America, Asia and Africa, in those countries decrease is not so significant, and in some subpopulation, it’s even increasing.
Spermatogenesis is a process of developing sperm. We know that it’s happening in the testes, but it’s not only testes that are involved in this. Also, the epididymis is involved in this process. Basically, spermatogenesis lasts approximately 60 to 70 days, so by that time one generation of sperm changes. The good news is that male sperm cells are developing throughout the whole life, it’s starting from puberty, and it’s not stopping till the death. The intensity of sperm spermatogenesis is changing. The best results are in a male who reach 20-30 years old, after 35-40 years old, sperm quality is decreasing with age. After spermatozoa are developed, they are stored in the epididymis. And there the sperm undergoes further maturation and where they acquire increased motility and also enhance fertilization capacity. After that, sperm is stored in the epididymis until ejaculation. If you are looking at which hormones are regulating the spermatogenesis, there are 3 main hormones. It’s like in women FSH, follicle-stimulating hormone, LH lutein hormone and testosterone, and those hormones are impacting two main cells within the testes, its Sertoli cells which actually develops sperm and Leydig which are developing testosterone.
There are some things that we actually need to know before we go into details. If you are looking at infertility, we have to know that we are not talking about male or female, it’s a mutual inability to conceive and have a pregnancy within a one year of regular sex. It means 2 to 3 times per week without using any contraception as it is a peer diagnosis. We have to understand that not only female should be consulting in the case if natural pregnancy cannot be reached, but also a male as well needs to go to a specialist, and it’s usually an andrologist, and if the partners do it at the same time, it’s much faster, we can get a result. Approximately 15% of couple faces fertility issues, one half of them it has to do with a male factor. I believe in future there will be more and more couples facing fertility issues. If you remember we look at sperm quality issues and it’s still a problem, especially for Western countries where, and as I’ve mentioned it is also a case for Europe. One-third of all male infertility cases, we cannot say why it is so-called idiopathic male infertility, it means that a lot of it is still not clear in the field, and a lot of studies are still ongoing, and I believe in the nearest future, we will have more and more information, and therefore we can help a lot of patients to get the pregnancy.
I already mentioned the age of the partner, it’s not only female age which is important but also a male, because after the age of 35 several processes begin in the body that increases sperm DNA fragmentation for example. As well as stem cells are starting to die slowly, therefore we have to be very careful with planning our family. If we are delaying this decision the to late 30s or 40s, then there is more probability of getting some issue with natural pregnancy due to male factor. One of the cornerstones of male infertility tests is a semen analysis, and this is actually the first analysis which we are usually starting with to check the male. But not only semen analysis needs to be checked, it’s an assessment of all body, all diseases, it’s a proper physical examination that needs to be done, like a further investigation for endocrine, genetic and maybe other tests. This is something that we do during a visit case-by-case. If you are looking at the probability of natural pregnancy by looking only at semen analysis, then we can predict approximately only 60% because there’s a lot of other things that need to be taken into account besides semen analysis. Therefore I encourage not to look only at the semen analysis but to look on the whole body health as well.
We have to understand that semen analysis is individual, it’s very hard to look at them and then compare like one patient analysis with another. We have to look at the individual case, a semen analysis is changing, sometimes it’s better, sometimes it’s poor, and it’s affected by ejaculation, it’s affected by gonadal activity, by laboratory analytical errors, so, therefore, I suggest if you do a semen analysis, do it at the same laboratory and in order to get good results, you need to do at least two semen analysis with an interval of 3 months that’s obtaining by the absence of ejaculation 2 to 4 days. If you look at the semen analysis you see a lot of parameters, but basically, there are 3 main ones that you need to look for. It is sperm concentration, that’s according to WHO minimum reference values it’s 15 million per millilitre, second is progressive motility which should be at least 32%, and the 3rd is sperm morphology that needs to be at least 4%.
If you see the same analysis and you see that all the parameters are within the normal reference values or range then, unfortunately, it doesn’t mean that everything is okay. On the other hand, the semen analysis shows very well if some of the parameters are below the reference values f.e. sperm concentration is not 15, as it should be but like 13 million per millilitre, then we can say with 95% probability that there will be a problem with natural conception if those parameters are combined with like low sperm concentration or low motility and low normal sperm morphology, then there it is an even bigger chance of not getting natural pregnancy within one year. Therefore when we look at this semen analysis, you have to consider that it’s showing a probability of natural conception, but if it’s within normal ranges, it doesn’t mean that everything is okay.
So as I’ve mentioned semen analysis shows from the male perspective how much sperm we have, is it motile, or is it with normal morphology but semen analysis doesn’t show anything that happens with this sperm when it has been already in woman’s body, therefore, the science goes further and looks at the sperm functional tests. Nowadays, I would say it’s already like must-do in all fertility clinics to perform not only basic sperm or semen analysis, but we should do the sperm functional tests because the way spermatozoa are going to the oocytes in the woman’s body is quite complicated, there also a lot of things that could go wrong. We should look at it, also in more details and one of the most used sperm functional tests nowadays is DNA fragmentation assay, as well as oxidative stress assay and HBA test, there are a lot of more but those are the most common tests that are done, I believe across Europe.
We know 3 main assisted reproductive technologies which are used nowadays. The first, simplest one is the Intrauterine insemination (IUI), the second one is In vitro fertilization (IVF), the third one is Intracytoplasmic Sperm Injection (ICSI). When it comes to infertility clinics, and we deal with significant male factor, we usually use the third option ICSI, which method to choose from the male perspective depends on semen analysis and there we have to look at the 2 main factors. The first, the total sperm concentration and what part of the spermatozoa are motile, so it’s called progressive motility and if this part of spermatozoa is more than 40 million then intercourse or the natural conception is the best way. If it’s less than 40 million but not less than 5 million, then you can choose intrauterine insemination (IUI). If it’s less than 5 million or even zero, then usually we go for IVF in vitro fertilization or ICSI. I would say nowadays ICSI has shown that it has the best results, so if you are going to fertility clinics this is this will be the main procedure that will mostly be offered to you.
In case if in sperm analysis, there are no spermatozoa then we have to do a biopsy, and we have to understand that nowadays there are several biopsy types and one of them is very simple, it’s called TESA (Testicular sperm aspiration), it’s basically a needle biopsy done under the local anaesthesia or short intravenous anaesthesia. The second one is a testicle sperm extraction (TESE), which is already a small operation but I would say the best option for azoospermia, especially for non-obstructive azoospermia is that micro Tese, it’s the same sperm extraction but done under the microscope and this has shown the best results of finding the spermatozoa if there is a very low probability to fi anything, therefore, we combine open surgery with a microscope.
I would say I see quite frequently very similar couples. When it comes to the last question, I would say yes, it could be the cause. I believe this is not the only cause, there should be something more because we have two testes, and if one is not working properly then others can work perfectly. In this case, semen analysis should look much better, therefore definitely, there’s some more reason behind it. I would suggest going to a consultant or urologist, andrologist as soon as possible because he’s already over 35. So each month you will be delaying your decision to go to a specialist, the less probability to help you and therefore please do not hesitate.
In all cases, I always suggest using fresh sperm because it shows much better results even if the patient is getting older when we’re talking about male patients. In this case, I would say it is best to try and improve the sperm, and I believe your doctor can help, so try to conceive a child with fresh sperm. If you see that this is not possible and you have to use a frozen sample, then you have to do the frozen sample, and there is not another possibility. And the age is not a problem, the male can be 60 or 70.
The short answer is that yes, ICSI overcomes this issue. I would suggest doing ICSI if this is the only problem. From another aspect, if other parameters are good, then to do the best you can increase motility and therefore again you need to visit your urologist or an andrologist to try to find a reason why your motility is affected. There should be some reasons behind this.
Yes, DNA fragmentation affects the quality of not only embryo but how pregnancy is developing, especially in the first weeks. It has been proven with many studies that patients with high sperm fragmentation as you’ve mentioned here, there’s less probability of natural conception and a much greater probability of having a miscarriage, as it already happened. My advice is again to look for the reasons why DNA fragmentation is so high, cause definitely there are reasons behind this and you should avoid those reasons. About the alcohol consumption during the weekend, I always suggest my patients drinking alcohol as little as possible because it’s not only the alcohol that is the problem, it’s a lifestyle problem. If we are drinking alcohol, we are moving less, we are not doing sports at that time, we are usually pitting, and also, smoking is also a problem, eating habits all of those can impact the quality. Therefore I see that it’s a complex way that you have to look at and you have to encourage your partner to visit a doctor. If we are looking at the doxycycline course, then if the problem was an infection because antibiotics are usually given if the problem is some kind of bacterial infection, then definitely it will improve it. You have to take into account that doxycycline will actually decrease sperm quality for the first 3 months, and it will get better only starting from the 4th or 5th months, so please do not be patient and do not wait for your pregnancy 3 months after finishing antibiotic courses.
In general, supplements are beneficial for male infertility, but if you are looking at the big clinical trials, then it has not been proven that by using only supplements it will help to overcome male infertility. You have to be very careful with that, it’s big business nowadays for supplements, and you know if you go to the pharmacy you can find supplements basically for everything including male infertility. It’s important not only to take those supplements, but it’s important to change your lifestyle, and you have to move, you have to quit smoking, you have to do sports, you have to reduce your alcohol consumption, you have to look at the way you eat you can’t eat more vegetables, more fruits, less meat, more fish. Do not wait and think that this one tablet will be a magic trick, it will do very little for you. Sometimes it can help, but every case is individual, when it is prescribed by a doctor, it can help you.
It’s 3 to 4 units of alcohol per week that is maximum. If you drinking more than this, then it will decrease sperm quality and not only the sperm quality, it could actually affect the offspring as well, so be careful with alcohol, especially if you are planning a family.
Yes, it is true. In the first part of my speech I’ve mentioned that it’s important to have a regular sex life and it means 2 to 3 times per week, and it actually means that it’s like every 40, over 48 hours. In real life, it can be changed, it could be 74 or 24 hours it depends on the couple. To my patients, I always say the frequency of your sex life is your private matter, but if you are planning a child, you need to do it at least 2 to 3 times per week, therefore please do not be afraid and if you want to do it like more frequently, like every day, no problem because there will be good spermatozoa even if there will be 24 hours gap in between. In the majority, it should be 2 to 3 days.
No, I would say no. Because the quality is not measured by the thickness. You have to look at the concentration, you have to look at the motility, you have to look at the morphology, those are parameters that show the real quality. The spermatozoa are in a liquid and this liquid is produced by the prostate. The thick sperm could be the result of some prosthetic issues like inflammation, therefore, it’s not the only reason that shows the quality.
No, the fastest sperm is much better because that gives much more probability that spermatozoa will get to oocyte much faster than the slowest one. The fastest spermatozoa and it’s called category A you have, the more probability that natural conception will happen sooner. The slowest sperm you have, the longer you will have to wait for the pregnancy.