The UK discovery of in vitro fertilisation (IVF) in the 1970s, led the way for our current system. IVF (also known by the blanket term “Assisted Reproductive Technology” or ART), tends to be the first and only treatment offered to couples in cases of involuntary infertility, says Imperial College Consultant Urologist, Jonathan Ramsay. “The male is seldom considered in his own right”.

This is a situation that is finally beginning to change, he says, partly because of more awareness around the issue. There is emerging research evidence that male fertility levels are declining and, whether couples have access to NHS-funded IVF, go private or do a mix, money is increasingly an issue at both individual and national levels.

“Couples can be paying between £4,000 and £15,000 per cycle of IVF, with a success rate of about 30 per cent. If we run the entire known battery of male tests it’s not going to be more than £1,500,” says Ramsay. Most of his patients have undergone at least three IVF cycles, but that trend is beginning to change. “Now, couples are beginning to come to a urologist with specialist male fertility knowledge, before undergoing IVF.”

 

How did the dominance of IVF develop?

 

The technique of intra-cytoplasmic sperm injection (ICSI) was discovered almost by mistake, when somebody injected an egg with a sperm in the early 1990s. It was then realised that men with only a very few sperm could undergo this process of ICSI (clearly a refinement of the IVF process), “and that reinforced the idea that ICSI was the only treatment for such men”, says Ramsay. 

Undoubtedly, our colleagues in reproductive gynaecology did a huge service, together with the embryologists, in finding a procedure that allowed many more infertile men to have children, but clearly this process, although sometimes a solution to the problem, was not really a ‘treatment’.  “The agenda was set by gynaecologists who suddenly had the answer to infertility and, through nobody’s fault, this just became a self-fulfilling prophecy”.

However, this means that IVF, and ART in general, is the only area in medicine “where we do not even attempt a diagnosis of 50 per cent of the issue, which could be the male-factor”, he says.  “If we can identify that 50 per cent and manage it with accurate diagnosis, specific treatments and lifestyle changes, then we might reduce the need for IVF and ART. By improving sperm quality, we could improve natural conception rates and also IVF outcomes, which would mean savings to the public purse”. 

 

Poor sperm quality - the usual suspects

 

Factors like smoking, stress, obesity, poor diet, drugs, steroids, infection, over-heated testicles, or abnormal hormones in the male are not taken sufficiently seriously, says Ramsay. It is unusual for a man even to have a simple physical examination in the IVF clinic. The message is that if you have poor sperm quality, there is very little you can do – a GP will recognise a low sperm count, and refer the couple for IVF. The female partner is usually reassured that, despite the low sperm count (even when the sperm is a bit ‘dodgy’), the solution is to inject the sperm by the ICSI technique. The man’s role in this is merely to produce specimens, often in difficult circumstances, only to be told that his efforts have only been rewarded with sub-optimal sperm, which may negatively impact the outcome.

Jonathan believes that many of the issues affecting sperm quality can be identified and treated with lifestyle changes over a three-month period. “A typical case for us might be a big, heavy-drinking, 32-year-old trader who works in the City and eats on the hoof. Three months of cutting back on the alcohol and improving his lifestyle can double the quality of his sperm, just in those few weeks. I can say this, and I know we can make men better, because we do see a lot of people who are beginning to make their way to urologists before they go to the IVF clinic”.

An increasingly common reason for poor quality sperm are microorganisms, says Ramsay. “These might be bacteria that we have yet to discover, or an undetected but diagnosable infection. These may not be producing any symptoms but they will show up on specialised tests and can usually be improved with a short course of antibiotics”.

Other factors can be over-heated or undescended testicles. “Over-heated testicles are a common side-effect of modern life, ‘competitive’ commuting on bicycles and tightly fitting sports-wear, but approximately 12 per cent of men do have the equivalent of varicose veins around one of their testicles, which has a heating effect. Undescended testicles may be present in many men with poor sperm counts, and prevalence is increasing. When I started in the profession, it was very rare to see a man with undescended testes because there were regular school medicals”.

 

Advice for couples?

 

Before rushing into IVF, if you’ve been unable to get pregnant for a couple of years, Ramsay advises couples to be aware of the issues that can affect the male and to approach their GP for a referral to a urologist for basic tests.

“Patients need to lobby. It’s been hard to get evidence of male factors, because sperm count varies from one day to the next and because IVF and/or ICSI has become the single treatment for infertility. If you want to prepare for pregnancy, stop smoking, reduce alcohol and caffeine intake, and lose weight if you’re overweight - both of you.

“And men, stop all this mad spinning on bikes in the gym - your testicles are up inside you, getting too hot for too long,” says Ramsay.

 

Learn more

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