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October 2018

Is Male Fertility Declining?

In the 1940s, a physician would consider the sperm count to be abnormal when the concentration of sperm fell below 60 million per millimetre. By today’s standard, only a sperm concentration of less than 20 million per millimetre is viewed to be abnormal. This offers the impression of a declining sperm quality that has been occurring over the past decades. Despite Macleod’s conclusion that there was no decline of sperm quality from his 10 year study of 15000 men in the 1970s, the debate was re-ignited by the “landmark” finding of Carlsen in Denmark when she published her analysis in 1991. Her meta-analysis of 61 studies between 1938 and 1991 that included 15000 men found a significant decrease in average sperm count from 113 million per millimetre in 1940, to 66 million per millimetre in 1990. This stirred up many years of research across the world to determine if male fertility has and is still declining.

The hypothesis has been that the changing world environment, contributed by the industrial pollution has altered sperm quality. The rising trend of increasing testicular cancer and abnormal male genitals seen in some north European societies added strength to the argument.

In the ensuing years, data spewing up from North America and East Asia gave new insight to what is becoming a very complex issue. Although sperm quality reflects male fertility, the assessment of sperm quality has not shown consistency across time and geography.

What Is Infertility?

To a couple who is happily married and geared up to start a family, to be suspected or be told of either one or both suffers from infertility is extremely distressing and ego-damaging. If you are age twenty and twenty-five years old, you have the best fertility potential; on average, 70% of you will become pregnant within three months, and 85% within six months and 95% at the end of one year. Fertility declines with age. If you are age thirty and thirty-five years old, then your chance of being pregnant at end of three, six and twelve months are 40%, 60% and 80% respectively. Regardless of age, for a couple who are having regular unprotected sexual intercourse, there is an 80% chance of conception after 12 months and a 90% chance of conception after 18 months. A couple therefore should seek medical attention if they are unable to conceive within one year of unprotected regular intercourse. For those women who are more than 35 years old, they should see a doctor within 6 months of active trying.

Prevalence Of Infertility

About 15% of couples of reproductive age find difficulty in conceiving. It is estimated that about a third is due to problem affecting the woman, about a third is due to problems affecting the man, and the rest involving both parties. In brief, to be pregnant successfully, the woman needs to have eggs, mature and release them regularly at the middle of menstrual cycle, and able to traverse the Fallopian tube into the womb cavity. The man needs to produce mature sperm of the right quality and quantity, able to be deposited in the vagina and travel upward, overcoming the resistance at the neck of the womb. The egg and the sperm have to meet at the right site of the tube, move into the womb cavity at the right pace and be well implanted into the womb lining. About 25% of infertility is due to a lack of eggs, about 25% is due to a problem with the sperm, about 25% is due to tubal problems and in the remaining 25%, the reason for infertility is never discovered (so called unexplained infertility).

Common Causes Of Infertility

When you have regular monthly menstruation, it strongly suggests that you are ovulating. In fact, majority of healthy women in the reproductive age group ovulate regularly. You may be able to tell if you are ovulating when you notice thin and runny cervical mucus or short sharp pelvic pain at the time of ovulation. Monthly release of the egg is under very tight hormonal control, and many conditions disturb this control at the level of the brain, the mid-brain or the ovary itself. As expected, you will most likely present with irregular or absent menstruation when this hormonal control is deranged. One very common condition that we see is polycystic ovarian syndrome. Lifestyle factors, such as work stress, extreme dieting, excessive physical training, can lead on to hormonal imbalance and failure to ovulate. Other serious medical disorders involving the pituitary and thyroid glands may also be implicated. If you have previous pelvic surgery for whatever reason, or suffered from previous pelvic infection, you are at risk of having damage to the fallopian tubes. Another common cause of tubal damage is endometriosis. We recognize that the tubes may be damaged structurally or functionally. To date, we do not have an easy reliable assessment of tubal function, the only being successful spontaneous intrauterine pregnancy. Nevertheless we can determine if the tubes are blocked by ultrasound imaging (sono-hysterography), X-ray imaging (hysterosalpingogram) or laparoscopic hydrotubation. In all these tests, some form of dye (contrast) has to be infused into the womb and observe for easy spillage of the dye (contrast) through the other end of the tube.

Every man starts to produce sperm when he reaches puberty, and is expected to release at least 20 million sperm per millilitre of semen. The standardized way to appreciate sperm quality is through its count, whether they are alive, whether they moves well and whether they are well formed structurally. Abnormal sperm quality may exist from birth, or come about later in life – having suffered from an illness, infection or injury affecting the male testes. It is important to unveil any history of trauma or surgery to the male gonads. Alcohol and drugs (coccaine, marihuana) can temporarily reduce sperm quality. Environmental toxins like pesticides and lead compounds may also impact sperm quality. Use of chemotherapy for cancer treatment, radiation exposure or long term drug treatment for chronic childhood conditions has to be looked into.

Fertility Treatment Need NOT Cost A Bomb

Treatment of infertility depends on the defects in the conception pathway, be it single or multiple causes. On one hand, some couples require a mere discussion on the mechanics of conception and advice on lifestyle changes to facilitate pregnancy. On the other hand, many couples have to handle the hard fact that either one or the other will never be able to participate in the child-bearing process and are left with adopting a child. Managing infertility is emotionally distressing to most. Conveying the facts and prescribing treatment is only the beginning. Understanding the needs, allaying the fears and anxieties, dispelling the reservations and supporting the couple through the downs and ups complete the management. Lifestyle changes to both partners may be highlighted; weight loss, smoking cessation, and avoidance of certain activities. A discussion on diet may also be helpful. When you have blocked tubes on both sides, surgery may be initiated to unblock or re-join segments of the tubes. Surgery may also be indicated in women with large ovarian cyst, fibroids that are affecting fertility and abnormally formed uterus. If the infertility is due to poor ovulation, various medications may be used to trigger the maturation and release of the eggs. The success and timing of this induction of ovulation may be tracked by ultrasound imaging. When sperm abnormality is encountered, a trial of improving the count may be offered. Further advice and counseling regarding assisted conception may become necessary when simple measures do no achieve pregnancy.
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