Courtesy of Singapore General Hospital  
 
 
Male Infertility  
 
   
     
 

Male infertility on the rise.

After trying to get pregnant for two years, a woman who wanted to be known only as Ms Lim went to a doctor to find out why she could not.

It turned out, after some tests, that there was nothing wrong with her. Her husband, on the other hand, had very few viable sperm, a condition known as oligospermia and a common cause of male infertility. “

It was a shock to us,” she said.

Though her husband is older – she is in her mid-30s and he is in his late 40s – he had had children from his first marriage. Both are in the finance industry.

Like many women, Ms Lim had always thought she was the one “at fault”.

But doctors here say they are seeing more cases of male infertility, partly because more men are seeking help, but also because more men are suffering from it.

Age is thought to be one of the main factors behind the rise.

Dr Michael Wong at the International Urology, Fertility & Gynaecology Centre at Mount Elizabeth Medical Centre has noted a four-fold increase in male infertility treated at his practice in the past five years.

Aside from greater awareness leading to more cases being diagnosed, more people are delaying marriage or getting married again, which means the men are older and sperm quality is poorer, he said.

Based on international studies, female factors account for 55 per cent of infertility cases while male factors account for 45 per cent of cases, said DrWong.

Both female and male factors are present in 25 per cent of cases. Thus, in general, male factors contribute to about 60 per cent of all infertile couples.

“In many second marriages, where the man is in general older and the woman is younger, the male factor is expected to be much higher,” he said.

In fact, the in-vitro fertilisation (IVF) centre at the KK Women’s and Children’s Hospital (KKH) has noticed the incidence of male infertility going up from 62per cent in 2001 to 73per cent in 2005, and 77per cent last year.

At the National University Hospital (NUH) Women’s Centre, the number of couples seeking fertility treatment at the centre has risen by about 10percent in the last one to two years.

Professor P.C. Wong, head and senior consultant at the division of reproductive endocrinology and infertility in the department of obstetrics and gynaecology at National University Hospital (NUH), said that male infertility is brought up only when couples seek fertility treatment at the centre.

Men do not seek fertility treatment independently, he said.

Many men still do not feel they are the primary cause of infertility though, increasingly, they may be.

A man’s “biological clock” is not as obvious as that of a woman, as age-related decline in fertility in males is more gradual, he said.

LOWER TESTOSTERONE LEVELS
Although it is possible for men to father children well into their later years, there is such a thing as a male “biological clock”.

The male hormone, testosterone, is required for sperm production and development of the male reproductive organs.

Levels of testosterone in men, produced by the testes and adrenal glands, decline at 1 per cent per year after the age of 30. After the age of 40, it drops by 1.5 per cent a year.

Lower testosterone levels have sometimes been associated with decreased sperm production.

Though that may not sound like much, by the age of 50, about 8 per cent of men have sub-optimal hormonal levels, said Dr Wong.

By the age of 70, about 30 per cent have low hormonal levels.

He added that lower testosterone levels also give rise to poor sexual drive and poor erections, which all affect fertility.

Dr Tay Kae Jack, a registrar at the department of urology at Singapore General Hospital, agreed that ageing in men is linked to a decrease in testosterone and fertility.

In a British study of 8,515couples, after controlling for the age of the female partner, it was found that couples where the man was more than 35years of age were half as likely to conceive within a year, compared with men less than 25 years of age.

 

Dr Tan Heng Hao, head and consultant at the department of reproductive medicine at KKH, said there is also increasing evidence of a decline in sperm quality with age.

Ageing is thought to reduce sperm quality, in terms of semen volume, sperm motility (movement) and normal sperm concentration.

It is now believed that ageing is also a factor in damage to the sperm’s genetic material or DNA.

A study done in Northern Ireland of 239 couples with unexplained infertility found that 80 per cent could not conceive because of poor sperm quality, known as high sperm DNA damage.

HIGHER CHANCE OF MISCARRIAGE
Scientists suspect a wide range of environmental causes for the abnormal sperm – from smoking to exposure to pesticides and heavy metals and electromagnetic radiation.

Abnormal sperm is also more evident in older men.

The study, by Professor Sheena Lewis of the School of Medicine, Dentistry and Biomedical Sciences at Queen’s University Belfast, found that tiny breaks and tears in the sperm’s DNA damage it and make it less likely to impregnate a woman.

Furthermore, if she does conceive, she is more likely to miscarry.

KKH has in fact found that advanced paternal age increases the risk of miscarriage.

A study from November 2010 to March last year of 139 expectant mothers facing a threatened miscarriage found that a father-to-be aged more than 40 was eight times more likely to see his wife miscarry than a younger man.

“Men aged older than 40 years old contribute to the reduced fertility of a couple,” said DrTan.

The reduced fertility is even more pronounced when the woman is also older.

In addition to sperm DNA damage, the sperm of older men is also shown in aneuploidy (an abnormal number of chromosomes), said DrTay.

Increased rates of birth defects have also been associated with increased male age, he said.

Children, whose fathers were aged 40years or older were 5.75 times more likely to have autism spectrum disorder compared to those born to men younger than 30, he said.

INFECTIONS ON THE RISE
Another possible reason for male infertility to be more common here is that sexually transmitted diseases are also on the rise, Dr Wong said.

Undiagnosed and untreated, such infections can lead to damage to the testes and scarring of the sperm delivery tubes, leading to obstruction.

The figures from the Ministry of Health show that the number of sexually transmitted infections has increased from about 11,000 in 2006 to 12,300 in 2008. Seventy per cent of the cases involved young adults in their 20s or 30s – the prime of their reproductive years.

Some infections, such as chlamydia, cause symptoms that are much more subtle than those of gonorrhoea and syphilis. Chlamydia is now one of the most common sexually transmitted infections here, Dr Wong said.

“Compared with the previous decade, where disease presentation is more ‘in your face’ with purulent discharge in gonorrhoea and penile ulcers in syphilis, chlamydia tends to go unnoticed,” he said.

A BABY AT LAST
Fortunately for Ms Lim and her husband, medical advances came to their help.

Their doctor recommended an intracytoplasmic sperm injection.

This meant her husband’s sperm and her eggs were harvested so that sperm could be injected directly into each egg to fertilise it.

After two tries, she became pregnant and successfully delivered a baby girl two years ago.

“We are very happy to have a child, though we are not sure if we would want to do it again.

“In this case, medical intervention helped so that we could have a child despite my husband’s age and low sperm count. But we may not be so lucky the next time,” she said.