FERTILITY IN MEN
INTRODUCTION
Fertility is often thought of as a predominantly female issue. This simply is not true. Data have suggested that the incidence of male infertility ranges from 2.5% to 12% between different regions. Let's first start by considering what infertility is:
​
Infertility: the inability of a couple to achieve pregnancy following at least 12 months of unprotected vaginal sexual intercourse.
​
When a couple decides to embark on the journey to have a child, nobody considers that this may become difficult. That is unless they are aware of the potential factors that may make it more tricky to achieve pregnancy. When they realise that pregnancy is not happening as quickly as they hoped, the couple will normally go to their GP to ask for help. The journey from this point forward has many similarities for men and women, but on this page, we are going to look at the pathway for men, whilst considering how this joins in with their partner.
​
Pathway summary:
STEPS EXPLAINED:
GP Review 1: the GP will most likely ask you how long you have been trying for a child if you have a child from a previous relationship, lifestyle questions and maybe some other personal questions such as how often you have sex or if you suffer from erectile dysfunction. The aim is to get an idea of whether there is a fertility issue or another underlying cause.
​
Semen Analysis: Your GP is most likely going to start by referring you to have a semen analysis. Semen analysis aims to look at the quality of sperm in a laboratory. This will sound daunting for most men. You will be expected to ejaculate and allow the laboratory to look at this sample. They will look at numerous things, which is covered in this section (click here). Once this has been done, the laboratory will send the results back to your GP who will review this alongside your history. They will contact you about these results.
GP Review 2: As mentioned, the GP will discuss your results with you. They may suggest a repeat semen analysis, blood tests, referral to a specialist or a combination of these. In some cases, they may explain some things that may help you improve results. This will depend on your initial consultation or the results of the laboratory test.
​
Blood Tests: If blood tests are requested, these may be due to an abnormality in your semen analysis or if the GP wants to make sure everything is functioning normally. Blood tests for fertility generally will start with follicle-stimulating hormone (FSH), Luteinising hormone (LH) and Testosterone (T). These are really important hormones produced in the body for producing testosterone and sperm. The image on the left shows the cycle of spermatogenesis (producing sperm).
The hypothalamus is a small area at the base of the brain near the pituitary gland. It has several functions, including releasing hormones (otherwise known as endocrines), controlling appetite and sexual behaviours. In the context of male-specific functions discussed here, the main role is the production of gonadotropin-releasing hormone (GnRH). The release of GnRH takes place in 'bursts' and acts on an area of the brain called the pituitary gland. GnRH stimulates the secretion of two hormones from the pituitary gland; luteinising hormone (LH) and follicle-stimulating hormone (FSH). LH acts on cells (small structures in the body that contain DNA) in the testes. These are called Leydig cells. Leydig cells in turn synthesise the hormone testosterone (T). This hormone is responsible for developing male secondary sexual characteristics (puberty), impacting libido, increasing muscle mass and the production of sperm (not a complete list). FSH acts on cells called Sertoli cells. These cells support the production of sperm in the seminiferous tubules within the testicle, act as a barrier to protect the developing sperm cells and produce inhibin. The increase in T leads to the start of spermatogenesis. This pathway is complicated but essentially involves cells developing from an immature cell (germ cell), dividing, multiplying and then maturing. All this occurs within the testicles. Endocrine production is ceased by a negative feedback loop. This means that as LH and FSH increase, the rise in their levels leads to the slowing down of the pituitary. This is coordinated by the increase in T and oestrogen (from the production of T) and inhibin (from Sertoli cells).
The results of the blood tests can sometimes aid in diagnosing the potential cause of infertility. This is quite complex and is also dependant on the semen results, clinical picture and blood tests.
Referral to Specialist: once you and your partner have been reviewed, the next step is that a GP will refer you both to a specialist. This may depend on whether something has been identified during routine tests or not. If there are male-related issues identified, then you may be referred to a Urology Consultant that deals with men's issues (Andrologist). If there are no identifiable reasons or it's an issue with both of you, your partner or neither (not every fertility problem is diagnosed), then you may be referred to a Fertility Consultant. Most GP's will refer you and your partner to a Fertility Consultant to be investigated. If this is the case, an appointment will come through, often under your partner's name for you both to attend. Please ensure that if you are both asked to attend that you do too, even if the letter is under your partner's name. This is a particular issue in Fertility (one the author of this page would love to change) where correspondence is done via the female on behalf of the couple. Remember; your test results are only for you to know unless you disclose them or give permission for them to be disclosed. You are part of the pathway. Do not feel alone or unimportant.
​
Specialist Review 1/Further Tests: as mentioned, if it is a Fertility appointment (most likely) you will attend with your partner. A doctor will meet you both and ask some key questions. This will include looking at past history of surgery, drug use, sexually transmitted infections (STI), illnesses, medication and lifestyle choices such as smoking/alcohol consumption. Try to be as honest as possible. There will also be questions on sexual habits and any issues with that (see the section on sexual dysfunction on this website). Sometimes, patients may feel a little embarrassed or have not disclosed these issues with their partner. At this point, consider you call up the healthcare nurse/Consultant after the appointment and ask to speak with an Andrologist or discuss personal aspects that you could not in front of your partner. Once all the history has been discussed, further tests are most likely going to be arranged. This may include more (or initial) blood tests and semen analysis. On occasion, this may also include referral to another specialist such as a Urologist. The Urologist may initiate a specialist examination. This will often involve a physical examination of your genitals or further tests such as an Ultrasound (US).
​
Treatment: once everything has been gathered, investigations and tests are done, management will be decided. This will depend on the reasons for infertility (if any can be found) and also how things may be funded. Unfortunately, there may not always be funding for fertility treatment. It will depend on you and your partner's circumstance and where you live.
MALE RELATED ISSUES CAUSING INFERTILITY
This topic is actually quite complicated and therefore needs to be split into sections.
​
See the slide show below for some causes:
ANABOLIC STEROID, TESTOSTERONE AND hCG USE
There are various reasons why steroids or testosterone may be used. In some patients, testosterone is used when they are deficient in this hormone. Low testosterone can cause low mood, low libido, infertility and impact other key metabolic activities within the body. this is often seen in patients with type-2 diabetes of men with hypogonadism. Treatment involves the administration of testosterone in either a gel-form or injections.
​
Some athletes, particularly in body-building, will use anabolic steroids, or testosterone to improve the workout and build on muscle. Anabolic steroids are synthetic (man-made) hormones that mimic testosterone. These compounds can be taken in the following ways:
​
-
Oral: Androl-50; Anavar; Dianabol; Winstrol; Restandol
-
Injection: Deca-durabolin; Durabolin; Depo-testosterone; Retandrol
-
Cream or gel
​
Athletes or those that wish to enhance performance, may take these steroids in cycles, also in conjunction with other compounds to counteract the negative impact of taking them. These compounds are either LH surrogates such as human chorionic gonadotropic hormone (hCG) or oestrogen blockers such as Clomid (clomiphene citrate). The use of this drug in conjunction with T therapy is to minimise the impact on the body of the flood of T. There are many side-effects to taking exogenous T:
​
-
Increase risk of cardiovascular complications such as hypertension (high blood pressure), thrombosis (clots), stroke and artery damage
-
Liver damage including cholestasis and jaundice
-
Hormonal changes in men leading to decreased sperm production, male-pattern baldness and gynecomastia (increase in breast size)
-
Mood swings, aggression and decreased libido
-
Shrinking of testicle size
​
The unknown side-effect to many men is that the administration of Testosterone causes the testes to sperm production (as mentioned in the list above). This is often a surprise to many men as they see Testosterone as what is needed for male function. The truth is that it is required but, by taking it, the body thinks that it has had enough and shuts down the testicle produced hormone production. Taking Clomid or hCG may help prevent many of the negative side-effects but in reality, these medications are not advised for self-administration and should always be given under the supervision of a medical professional.
​
The good news is that in most cases, once the steroid use has stopped most men will have a return to a functioning endocrine system. The trouble is that many times nobody would know what they were like before this. If patients could produce sperm before, this is likely to resume. It is important to understand that although this happens for many men, it will depend on:
​​
-
Duration of steroid use
-
Regime used
-
Strength of T and if any counteracting drug was used
-
Their pre-drug levels
-
Side-effects resulting from damage and subsequent treatment
​
If you are wishing to start a family, go to your doctor. Be honest and explain to them what you are doing/or have done. This is the only way to begin to manage you properly and help you achieve your goal. Most will understand it is not as simple as 'just stopping'. Many men will struggle with additional mood swings, feeling that they have 'lost who they are and may be tempted to re-start'. Help is there...see some of the other pages if you begin to feel depressed, anxious or dislike your body.
SUPPORT FOR MEN AND COUPLES
The support network for men alone during fertility is limited, although it will depend on what you feel you need as a person and how to deal with the emotions you feel. As a couple, there are many networks available to help you both deal with this. You may find the contacts or websites below useful:
​
If you want to talk to someone on your own, try looking at counselling which can be arranged through your doctors or local services (example includes 'Healthy Minds' in Birmingham). The Hospital that is dealing with you may have access to a specialist who can listen to your problems and either help support you or flag you to a service that can.
REFERENCES:
Agarwal, A., Mulgund, A., Hamada, A. and Chyatte, M. A unique view on male infertility around the globe. Reproductive Biology and Endocrinology, 13(1). 2015.
​
Stewart, J. Subfertility, Reproductive Endocrinology And Assisted Reproduction. 1st ed. Cambridge: Cambridge University Press. 2019.
​
​
Gunasekaran, K. and Pandiyan, N. Male Infertility. 1st ed. New Delhi: Springer. 2017.
