What is infertility?
Infertility is a very emotional and often heartbreaking subject. To be trying for years to start a family and be unable to conceive a child is very stressful and difficult for both the man and the woman.
Infertility is a common condition but generally speaking we do not consider there to be a problem unless a couple has been trying to conceive a child for 12 months or more with regular unprotected intercourse. After this point it is worthwhile investigating both partners to make sure there isn’t a reason behind it.
About 25% of infertility cases are due to male factor problems alone and a further 25% due to a combination of male and female problems. The remaining 50% is due to female factors alone.
Why do men have problems with fertility?
Infertility may be due to the male partner either having reduced numbers of sperm in the semen (called oligozoospermia) or even no sperm at all (termed azoospermia). Provided that there are at least some sperm in the semen, men still have the option of undergoing IVF treatment to father their own offspring.
However treating azoospermia is a little more difficult and it is important to determine the cause. Azzospermia may be caused by an obstruction (obstructive azoospermia, OA) or due to impaired sperm production within the testicle itself (non-obstructive azoospermia, NOA).
Why see a specialist?
Being diagnosed with infertility can be devastating for the individual and the couple. However the good news is that in the vast majority of cases of male infertility the underlying cause is treatable. It is important though that you see a specialist if you are having trouble conceiving: as with all these things it is important to make the correct diagnosis so that the correct treatment can be started and so maximise the chances of a successful pregnancy. Often a combination of lifestyle changes together with an assessment of specific risk factors is all that is needed.
What does an assessment involve?
I always start by taking a detailed history, looking into how long you have been trying for a family and if you have had any conceptions along the way. I will also enquire about your general health as well as aspects of your lifestyle as these can all have an impact on your likelihood of conceiving.
I will then examine you and arrange for blood tests to look at (among other things) the level of various hormones. An examination of your semen will also allow me to determine if you have oligozoospermia or azoospermia.
The critical thing is to determine if you have obstructive azoospermia (OA – in other words no sperm in the semen due to a blockage somewhere) or non-obstructive azoospermia (NOA – in other words a lack of sperm without a blockage).
In OA this is potentially treated with surgery to relieve the blockage, as you might expect, and this will allow you to try to start a family with your partner naturally.
If you have NOA we will need to see if we can find any sperm cells within the testicles which can then be retrieved and used to help you start a family using IVF techniques.
How can you tell the difference between OA and NOA?
From the clinical history and examination together with additional hormonal blood tests, the two conditions can be differentiated.
What is the treatment for men with OA?
If the cause of obstruction is a blockage to the transport of sperm from the testicle then reconstructive surgery can be performed. The blockage can be anywhere from the testicle to the prostate and the operation involves finding the blockage and reconstructing the tube.
However, some people with OA prefer to undergo IVF treatment in which case sperm can be retrieved directly from the epididymis using a technique called PESA or directly from the testicles using a technique called microdissection TESE. IN both cases sperm are retrieved and can be used in IVF
What if there has been a previous vasectomy?
Some men have OA due to a previous vasectomy. If they wish to try for a natural pregnancy then a microsurgical vasectomy reversal can be performed in order to connect the two ends of the vas deferens together.
This involves a general anaesthetic and is performed as a daycase procedure. As there is often some discomfort and swelling after the procedure. After surgery you will feel some discomfort and bruising so I advise raking a week off from work to recover.
How is ejaculatory duct obstruction (EDO) treated?
EDO is a condition which is treatable using endoscopic (“keyhole”) surgery. If there blockage is at the level of the prostate gland, tissue can be removed at the prostate level and this opens the ducts up.
This procedure involves a general anaesthetic and an overnight stay in hospital to recover. Again taking a week off from work is advisable.
How is NOA treated?
In NOA there is a problem with sperm production within the testicles. There are many causes for this problem, for example Sertoli Cell Only syndrome or Maturation Arrest.
This is treated by surgical sperm retrieval, but before going down this route I usually advise special chromosome tests (including a “Y deletion” screen) to make sure there isn’t a deeper genetic problem behind the infertility such as Kilnefelter’s syndrome or other problems which are associated with NOA.
If the genetic tests are satisfactory I will recommend a microdissection TESE (microTESE) procedure in which I use an operating microscope to analyse the tissue within the testicle and dissect out the tubules which are likely to contain sperm. The procedure is performed in conjunction with embryologists in theatre who analyse the tissue until sperm is found. I work closely with a number of specialist embryologists who also provide facilities for the storage and transport of sperm. Once the sperm has been identified, it is transported and frozen until required for fertility treatment, usually intra-cytoplasmic sperm injection (ICSI). The sperm can be transported to any fertility unit of the patients’ choice.
How is a low sperm count with a varicocoele treated?
For sperm to grow, mature and function successfully in the testicle it is important that the temperature is a little lower than in the rest of the body. That is why the testicles lie in the scrotum which because it hangs outside the body keeps them cooler.
In men with a varicocoele – an enlarged collection of veins in the scrotum – this can reduce fertility; we think this is because the testicles are at a higher temperature than they should be.
In these cases a treatment I sometimes recommend is to perform a microsurgical varicocoele ligation or radiological embolization. This helps shrink the veins in the varicocoele and improve the number and effectiveness of the sperm.
Arranging a consultation
As a recognised expert in the field I offer a holistic approach to male infertility. It is a sensitive subject and one that many men and their partners find difficult to come to terms with.
In cases where there is a reduction in the sperm count I can offer lifestyle advise together with supplements in order to improve the likelihood of conception.
In cases where there are no sperm present, I will perform a full assessment to identify the underlying cause together with the most appropriate treatment options in your case. I perform all of the surgical procedures myself and can offer a whole package of care and support, with an expert team of embryologists as well as psychological support for patients who have to make this difficult journey.
A 35 year old patient had pain after ejaculation in the scrotum and perineum. His wife had also failed to conceive after 2 years. Having been treated with multiple antibiotics and even been referred to a psychiatrist he eventually underwent an MRI scan which showed that the pain was probably due to a prostatic cyst blocking his ejaculatory duct. This was opened up using endoscopic surgery which required an overnight stay. Following the procedure he had a normal sperm count and a healthy baby girl.
What patients say
“My testicles were affected due to mumps and I was told that I would remain infertile. Fortunately our fertility clinic did suggest that there was a chance to find sperm in the testicles by undergoing a microTESE procedure. Mr Muneer performed the procedure for us and we were lucky that he managed to find a small amount of sperm that we could use for fertility treatment. We have a lovely baby boy!”
“I had a vasectomy whilst in a previous marriage. Having got remarried we wanted to start a family. I knew the chances were slim but I was prepared to take a chance rather than put my new partner through IVF treatment. Mr. Muneer performed my vasectomy reversal using microsurgery and this was successful. My sperm count was well over the normal range and I was back at work after a week.”