Male infertility is either due to a problem making good quality sperm, or a problem with delivery of the sperm to the outside world.

In 75% of infertile men, the cause remains unexplained (this is termed “idiopathic infertility”). It may, however, still be possible for couples to conceive naturally, provided some sperms are present.

Typical causes of delivery problems can range from issues with erections or ejaculation, to physical blockages, which can occur at any step from where the sperm is made in the testicle, to its point of delivery at the tip of the penis. Some blockages can be more easily overcome, such as a previous vasectomy. Others, such as multi-level obstruction due to infections, or being born without a vas tube cannot.

Issues that can cause problems with how sperm are made include:

The damage associated with some of these situations may be reversed to allow a return to normal fertility. Genetic problems cannot be reversed, but may be overcome using direct surgical sperm retrieval from the testicle.

In cases where the obstruction cannot be reversed, direct surgical sperm retrieval (SSR) from the normal but blocked testes carries a 100% success rate in finding sperm for use with assisted conception. The choice to reconstruct or obtain sperm surgically depends on a number of factors, including;

In this type of in vitro fertilisation (pictured) a single sperm is injected directly into an egg to fertilise it. It is useful if you have a very low sperm count or in cases of surgically retrieved sperms. As with any IVF technique it carries risks for the female partner due to the drug stimulation required in the egg retrieval process. It has a pregnancy rate of approximately 30-40% per cycle.

CAH is a rare cause of male infertility. It involves flaws from birth in certain enzymes. This causes abnormal hormone production. CAH is most often diagnosed by looking for too much steroid in the blood and urine. CAH can be treated with hormone replacement.

Hyperprolactinemia is when the pituitary gland makes too much of the hormone prolactin. It’s a factor in infertility and erectile dysfunction. Treatment depends on what’s causing the increase. If medications are the cause, your health care provider may stop them. Drugs may be given to bring prolactin levels to normal. If a growth in the pituitary gland is found, you may be referred to a neurosurgeon.

Ejaculatory duct blockage can be treated surgically. A cystoscope is passed into the urethra (the tube inside the penis) and a small incision is made in the ejaculatory duct. This gets sperm into the semen in about 65 out of 100 men. But there can be problems. Blockages could come back. Incontinence and retrograde ejaculation from bladder damage are other possible but rare problems. Also, only 1 in 4 couples get pregnant naturally after this treatment.

PESA, can be done many times at low cost. There is no surgical cut. More urologists can do it because it doesn’t call for a high-powered microscope. PESA is done under local or general anesthesia. The urologist sticks a needle attached to a syringe into the epididymis. Then he or she gently withdraws fluid. Sperm may not always be gotten this way. You may still need open surgery.

What options are available if no sperms can be found?

– Donor insemination (DI)

Donor semen is carefully screened for infections and a donor selected to have similar attributes to you. This is the only viable option if you have no sperms at all and you do not have obstruction which can be relieved surgically.

– Adoption

If no success is gained with other treatments, you may wish to consider adopting a child. Your GP and local / national adoption agencies can help with this process.

Dr Rahul Yadav is specialised in PESA, MESA, Micro TESE, Testicular Biopsy, Penile Prosthesis/Implant, Priapism Surgeries, Bilateral Vasectomy, Microsurgical Varicocelectomy, Microsurgical Vasovasostomy /Vaso-epididymostomy and Vasectomy.