As you are reading this, it is probably because you and your spouse want to have a child but so far have not been successful. You could also be reading this for someone you know who may have this problem.

You may be reassured to know you are not alone. About one in six couples in Singapore have difficulty in having a child without medical help.

When no pregnancy occurs after one to one and half years of unprotected sexual intercourse, there is a possibility of a problem with fertility.

What are the causes of Fertility Problems or Infertility?

Fertility problems or infertility is caused by female factors in half the cases and by male factors in the other half the cases. Both male and female factors may the cause in about a third of cases  

Because fertility involves both male and female factors, we work closely with your preferred gynecologist or fertility specialist towards helping you and your spouse to achieve a successful pregnancy and birth of a healthy child.

The male factor is usually a sperm problem. It may be a problem of the testes that makes the sperm, the genitalia or with the hormones that control sperm production.

The common male fertility problems are:

1. Low sperm count
2. Poor sperm quality
3. No sperm or azoospermia

What are the tests for male fertility?

Semen Analysis
The semen analysis is the single most important test in the evaluation of a man’s fertility. It provides information about the number and quality of the sperm.

A normal semen analysis is characterized by the following:

1. Volume of semen of 1.5 to 5 mls of total ejaculate.
2. Number of live sperm of more than 20 million per ml of ejaculate.
3. More than half of the sperms is motile.
4. Adequate number of sperm with normal morphology.

If the sperm analysis is abnormal, a careful history and physical examination is carried out to determine the possible causes for the male fertility problem.

One of the causes of sperm problem is Varicoceles. 

Varicoceles

What are Varicoceles?

Varicoceles are dilated veins in the scrotum. A varicocele forms when valves inside the veins are not working properly. This causes the blood to backup, which leads to swelling and widening of the veins.

How varicoceles cause infertility or sperm problems in men is not fully understood. The simple explanation is that the pooling of blood in the swollen veins raises the temperature in the scrotum thereby affecting sperm production. Other possible effects could be the retention of toxic waste products in the veins affecting sperm production.

What can be done for varicoceles?

The anomalous veins or varicocele can be tied off with surgery. This is called varicocelectomy.

In varicocelectomy for male infertility, a small incision is made at the root of the scrotum at the lower abdomen. The leash of veins is delivered into the wound. Here each individual vein is carefully separated out from other vital structures under magnification and tied off. Varicocelectomy is performed on an outpatient basis. 

What else can be done for male fertility problems?

Every effort is made to determine the underlying cause for the sperm problem and treat it.

Mild cases may improve with the use of anti-oxidants and trace elements.

In severe cases, no sperm is found in the ejaculate. This is known as Azoospermia.

Azoospermia

Azoospermia is a state where no sperm is found in the ejaculate. This may be due to no sperm production or an obstruction to the passage of sperm from the testis. The latter situation is known as obstructive azoospermia.

Obstructive Azoospermia

Obstruction to the passage of sperm may be in the epididymis or vas.  This may be due to acquired or congenital causes.

Acquired male reproductive tract obstruction can occur as a result of infection, trauma, iatrogenic injury or previous failed vasovasostomy or vasoepididymostomy. Iatrogenic injury can occur during bladder neck, pelvic, abdominal or inguino-scrotal surgery.

Congenital anomalies of the male reproductive tract are relatively uncommon in the general population, but can occur in up to 2 percent of infertile men. 

Congenital Bilateral Absence of the Vas Deferens (CBAVD)

The most recognized congenital anomaly of the male reproductive tract is congenital bilateral absence of the vas deferens (CBAVD). This occurs in almost all men with cystic fibrosis. CBAVD is now regarded as reflecting a mild form of cystic fibrosis in which only the reproductive tract anomalies are manifest without pulmonary or digestive symptoms. CBAVD can also probably occur as a result of Wolffian duct anomalies without evidence of cystic fibrosis gene mutations. Unilateral vas aplasia can also occur and is also associated with cystic fibrosis gene mutations. Because of the association of CBAVD with cystic fibrosis mutations and Wolffian duct anomalies, all men with CBAVD should have renal ultrasounds and their wives should have cystic fibrosis gene mutation analysis prior to attempts at fertility.

In infertility, the best treatment is one that will allow the couple to conceive with minimal intervention.

When this is impossible (as in CBAVD) or has already failed (as in previous attempts at vasovasostomy or vasoepididymostomy) consideration must be given sperm retrieval directly from the epididymis or testis with assisted reproduction such as in-vitro fertilisation (IVF) with intracytoplasmic injection of sperm (ICSI). It is now possible for men with congenital bilateral absence of the vas deferens (CBAVD) or surgically unreconstructable reproductive tract obstruction to achieve pregnancies with use of these advanced techniques.

One such technique is Microsurgical Epididymal Sperm Aspiration (MESA)

Microsurgical Epididymal Sperm Aspiration (MESA)

Men suitable for sperm retrieval include men with acquired or congenital epididymal or vas obstruction and men who choose sperm retrieval as an alternative to surgical reconstruction

In microsurgical epididymal sperm aspiration (MESA) the epididymis is carefully dissected under the magnification. A tubule is incised and the sperm filled fluid aspirated. This is examined under a microscope and the sperm stored for use in fertiltisation of the oocyte from the spouse.

Non-Obstructive Azoospermia

In non-obstructive azoospermia, the cause is testicular failure. Azoospermic men with testicular failure (non-obstructive azoospermia) have Sertoli cell-only pattern, maturation arrest, or hypospermatogenesis on testis biopsy. It was previously thought that men with non-obstructive azoospermia were untreatable. The only options for these men were the use of donor spermatozoa or adoption. It was observed that testis biopsy may demonstrate sperm in men with non-obstructive azoospermia, despite severe defects in spermatogenesis. Sperm can be retrieved from the testes and used with the assisted reproductive procedure of intracytoplasmic sperm injection (ICSI) during in vitro fertilization (IVF) with a high chance of achieving pregnancies and deliveries of normal children. These findings have led to testicular sperm extraction (TESE) with ICSI.

Testicular Sperm Extraction (TESE)

In testicular sperm extraction, a scrotal exploration is performed under general anesthesia, and sperm are retrieved using an open testicular biopsy technique. In order to confirm accurate identification of the testis and to avoid any injury to the epididymis, delivery of the testis is routinely performed. Testicular blood vessels in the tunica albuginea are identified with magnification. An avascular region of the testis chosen, and an incision is created in the tunica albuginea.