Dear Dr G

My wife and I have been trying for a baby for five years.

We went to a fertility specialist a year ago and discovered that I am not producing healthy sperm.

Fortunately, doctors are optimistic as both of us are under 40 years old and reckon we will have a good chance of having at least one baby through IVF.

I am absolutely over the moon at the prospect of being a father but I am terrified of the surgical procedure I must undergo to achieve parenthood.

I would like to put Dr G on the spot for some clarification.

How common is male factor infertility? What exactly is happening down below that is causing the depletion of sperm?

How are the doctors supposed to know if there’s something “still in the bag” before doing the surgery?

How will the sperm be extracted and what complications could I potentially face?

My wife says I need to man up and just face the knife.

However, I am simply too scared at the prospect of someone messing with me down below and need to know all the facts before signing on the dotted line.

Yours truly

Terrified Tim

The World Health Organisation (WHO) has estimated that one in ten couples has fertility issues. With the trend of couples trying for a baby only later in life, the incidence of infertility is likely much higher compared to two decades ago.

Another statistic which could have changed is the ratio of female to male factor infertility. It was previously thought female-derived infertility accounted for half of all cases; a quarter due to the man; and the remaining quarter of combined causes. Recent research, however, reveals that male factor infertility is a lot higher than previously estimated.

Male factor infertility occurs mainly if there is depleted or no sperm production in the testicles. When an analysis of sperm quality demonstrates less than 15 million sperm with less than 4% normal morphology and less than 40% active, the likelihood of male-oriented infertility is high.

In some cases, not even a single sperm is detected in the ejaculate, and this condition is termed azoospermia. It is believed to affect up to 5% of men, many of whom are completely oblivious of this.

The causes of depleted sperm quality are essentially unknown. However, several intrinsic and extrinsic factors are observed to be related.

Inborn errors such as undescended testicles or varicocele (dilated veins of the testicles) are well recognised to cause higher temperatures in the scrotal sac, resulting in poor sperm quality. External factors such as diabetes, smoking, mumps, obesity and occupational hazards are also known to result in the rapid decline in semen quality. As sperm production is a delicate process, even surgical correction and lifestyle changes may not be enough to regain fertility in men.

However, Assisted Reproductive Technology (ART) has essentially changed the landscape of the treatment of couples with infertility, but sperm retrieval is still an essential part of the process. For men facing issues with poor sperm quality, this requires providing ejaculate from which the embryologist can select the healthiest sperm.

For men with azoospermia, however, this will involve sperm retrieval. The procedure is usually a small operation and sperm can be retrieved by direct access to the scrotum through percutaneous epididymal sperm aspiration (Pesa).

If this fails, direct access to the testicles may be necessary with anther minor operation. During the procedure, either microscopic epididymal sperm aspiration (Mesa) or testicular exploration sperm extraction (Tese) using a microscope is carried out. The names of the procedures may sound complex but patients are usually under local or general anaesthesia with minimal risk of complications. Like most operations, the resulting small wound needs proper care to heal. Therefore, most doctors advise patients to refrain from strenuous exercise and take a course of antibiotics to prevent infection.

It is natural for men to be afraid when they learn that the cause of infertility lies with him and not the wife. If the man is terrified of potentially facing the knife for sperm retrieval, Dr G says they should divert their attention to the poor wife facing the pain of multiple hormonal injections, followed by an operation to retrieve the eggs, the emotional roller-coaster due to a fear of miscarriage and finally, the trauma of bearing the child for nine months and the eventual childbirth! Obviously, there is no comparison at all.

On that note, Dr G’s advice is: “The only thing men have to fear is bearing the cost of fertility treatment and fatherhood in the years ahead!”

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