What is male subfertility?

Subfertility is the inability to conceive following 12 months of regular unprotected intercourse. Definitions of subfertility vary widely. These range from not conceiving a child after a year of regular unprotected sex, to more precise measures such as those used by the World Health Authority (WHO). The WHO defines a man as being at risk of subfertility if he has a sperm count of less than 15million per millilitre of semen. However, men with a lower sperm count than this may still be fertile, while men with a higher sperm count may not.

How common is male subfertility?

Male subfertility is increasing and is thought to contribute to around 30-40% of all subfertility problems in couples.

What are the types of male subfertility?

There are four main reasons for male subfertility:

• Azoospermia – no sperm is present in the semen
• Oligozoospermia – low number of sperm are present in the semen ‍
• Low sperm quality – the sperm is malformed or the DNA carried by the sperm is abnormal ‍
• Low sperm motility – the sperm lacks the ability to swim the distance required to reach the egg  

What causes a low sperm count?

Lack of sperm or low sperm count may be caused by:

• A blockage between the testicles and the prostate (obstructive azoospermia), or
• A lack of sperm production within the testicle itself (non-obstructive azoospermia)  

In rare cases, the sperm may travel the wrong way up the urethra and into the bladder. This is called retrograde ejaculation and is normally related to medications (such as alpha blockers), or after major lymph node surgery due to testicular cancer.  

What are the risk factors in male subfertility?

Both quality and quantity of sperm production has been seen to fall over recent decades. This is thought to be due to a number of factors, including:

• Heavy drinking – with alcohol more widely available and the binge drinking culture amongst young men
• Sedentary lifestyle  
• Smoking – although smoking has reduced, it is still a significant factor in male subfertility
• Stress – due to the demands and expectations of modern life  

What are the diagnostic tests to check for male subfertility?

The main test for male subfertility is the analysis of a semen sample. The analysis will check the quantity, appearance and motility of sperm within the sample.

If fertility treatment is to be considered, further tests may be undertaken, such as genetic and hormone tests.

Keep in mind that sperm is constantly being made in the testicles, and takes around 3 months to produce and mature. It is common for someone to have an abnormal result during the first semen test to then have a normal result when repeating the test 3 months later.

Which lifestyle changes can impact male subfertility?

If you have a low sperm count with no obstruction present, there may be number of lifestyle changes you can make to improve your fertility and chances of conceiving. Naturally, these echo the risk factors discussed above, including:

• Stopping smoking
• Reducing alcohol consumption
• Wearing loose fitting underwear
• Taking regular breaks from a sedentary job or watching TV
• Taking regular exercise
• Losing weight
• Avoiding hot baths and showers

What are the surgical treatment options?

Options for patients with obstructive azoospermia

If you are producing normal, healthy sperm, but there is a blockage that is preventing this from reaching the ejaculate, then surgery may be an option. This may involve opening the blockage (such as prostate surgery), or reconstructive surgery to repair or rebuild the correct pathway. If this is successful, then conception can continue in the normal way.

Rather than undergo surgery, some men prefer to try assisted reproduction treatment commonly known as IVF. If there is no sperm due to a blockage, one of three methods are used to harvest (surgically retrieve) sperm:  

• Percutaneous epididymal sperm aspiration (PESA) – in which sperm is harvested from the epididymis via a fine needle
• Testicular sperm aspiration (TESA) – whereby sperm is aspirated from the testicles
• Microdissection testicular sperm extraction (mTESE) – in which sperm is extracted directly from tissue taken from the testes

Sperm retrieved using PESA, TESA or mTESE is then used to fertilise eggs harvested from your partner (or a donor) using a process called intracytoplasmic sperm injection (ICSI). This involves injecting a single, carefully selected sperm into each egg and growing the embryos in the lab for several days. The healthiest looking embryo(s) are then transferred back into the uterus.  

Options for patients with non-obstructive causes of azoospermia

If there is a problem with sperm production in the testes, it may still be possible to conceive via ICSI, as long as sufficient sperm can be found using mTESE. In this case, expert embryologists will examine the testicular tissue in great detail to identify even the smallest quantities of usable sperm. Generally the success rate in finding sperm in the testicles is about 55-60%.

Every person or couple has a different experience when it comes to trying for a baby. Some people get pregnant quickly, and for others it can take much longer. If you’ve been trying for a baby for a year or more and your partner is not pregnant, it’s a good idea to speak to your Fertifa Patient Advisor who can help you with the next steps.

If you're not part of Fertifa, but you're interested in getting fertility support and benefits in place at work, get in touch here to book a call with our team. We'd love to speak 💜

Read our guide to male fertility

In our guide, we'll answer the questions our doctors and nurses get asked the most about male fertility:

• What is male infertility and what causes it
• How to optimise and improve your fertility as a man
• How do I find a sperm donor
• How can I become a solo parent as a man
• The best fertility tests for men