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Male factor in infertility cases on rise

SINGAPORE — First-time father Paul Koh (not his real name) dubs the birth of his baby girl last month “a miracle”. He and his wife had waited four years before successfully conceiving their first child via in vitro fertilisation (IVF).

In some male fertility cases, Intracytoplasmic Sperm Injection in which a single sperm is injected directly into an egg to achieve fertilisation, is used. Photo: Thinkstock

In some male fertility cases, Intracytoplasmic Sperm Injection in which a single sperm is injected directly into an egg to achieve fertilisation, is used. Photo: Thinkstock

SINGAPORE — First-time father Paul Koh (not his real name) dubs the birth of his baby girl last month “a miracle”. He and his wife had waited four years before successfully conceiving their first child via in vitro fertilisation (IVF).

The gynaecologist found nothing wrong with Mrs Koh, who is in her late 30s. But Mr Koh, who is in his early 40s, was dealt a hard blow. Tests found virtually no sperm in his semen, a condition known as azoospermia.

Men with this condition make up about 10 to 15 per cent of the total number of male infertility cases globally, said Dr Roland Chieng, medical director of Virtus Fertility Centre.

“The diagnosis was a shock. We stopped trying for a baby for over a year to discuss our next step. I tried alternative therapy such as traditional Chinese medicine but that did not work out,” said Mr Koh, who works in the financial industry.

MORE MEN WITH SPERM ISSUE

Mr Koh’s case is not unique. Doctors say they are seeing more men with poor sperm quality, which is either the main or contributing cause of couples struggling to conceive.

Fertility expert Professor William Ledger, who spoke at the Singapore International Congress of Obstetrics and Gynaecology last month, said that data from global studies has shown that the proportion of couples with male fertility issues in developed nations has risen from about 30 to 40 per cent of infertility cases in the past decade.

Prof Ledger is head of Obstetrics and Gynaecology at The Royal Hospital for Women in Sydney and advisor to Virtus Fertility Centre in Singapore.

In Singapore, Dr Chieng, who focuses on male infertility cases, sees about 30 male patients each month. They form about half of all infertility cases he sees at his clinic.

“Women with tubal damage seemed more common 20 years ago. Now, we see more men with poor sperm quality, among other fertility problems.”

From 2004 to 2014, the number of Intracytoplasmic Sperm Injection (ICSI) procedures performed at National University Hospital (NUH) Women’s Centre has gone up by about 4 per cent. NUH Women’s Centre carried out about 700 IVF cycles last year.

ICSI is a procedure in which a single sperm is injected directly into an egg to effect fertilisation. It is typically used as part of an IVF cycle in cases of male fertility problems, such as a low sperm count or low sperm motility, said Dr Chieng.

Sperm health depends on several factors, including quantity, motility (movement) and shape, said Prof Ledger. “An infertile man can have a high sperm count but the sperm might not move well or have an abnormal shape. However, the most common problem we see is that these men have all three problems — low count, poor movement and shape.”

Dr Lim Min Yu, consultant at the NUH Women’s Centre, said poor sperm quality may not be the sole cause of male factor infertility. “Some men are unable to have or maintain erections and some cannot ejaculate,” he said.

A relatively newer fertility treatment, dubbed Intracytoplasmic Morphologically-selected Sperm Injection (IMSI), is also available for men with poor sperm quality.

Using magnification of up to 4,000 times, good quality sperm without structural defects can be selected to fertilise the eggs, said Dr Chieng. In ICSI, sperm are usually selected at around 400 times magnification.

However, the use of IMSI is selective, said Dr Chieng. The treatment has been found to be useful in instances where the couple experiences recurrent miscarriages, previous poor embryo quality and IVF failure.

SPERM HEALTH SABOTEURS

With more couples waiting longer before starting a family, age might be one culprit for flagging fertility.

Dr Lim noted that most couples seeking treatment are in their mid to late 30s. Each month, he sees about 70 cases, which include couples with male and/or female factor infertility.

Prof Ledger said: “The ‘sell-by date’ is later for men than women, but male fertility declines with age too. In women, it starts to go down from the age of 35. For men, the decline starts from the age of 45.”

Lifestyle factors and poorer health, such as having a chronic disease at a younger age, may also reduce fertility.

“For example, it is clear that men with diabetes have poorer sperm quality. They’ll also have a higher risk of erectile dysfunction,” said Prof Ledger.

Some medications, including those used for severe asthma, inflammatory bowel disease and digestive problems, may affect male fertility, he added.

A 2013 study published in the British Journal of Sports Medicine has linked a sedentary lifestyle with poorer sperm quality. Men who led sedentary lifestyles and watched over 20 hours of TV per week were found to have nearly half the sperm count of people who did not watch much TV.

Another hypothesis links declining male fertility to the modern environment, including exposure to certain chemicals found in every-day products, said Prof Ledger.

A study published online in the journal Fertility and Sterility found that female partners of men who have high concentrations of phthalates in their bodies take a longer time to become pregnant than women paired with men with low concentrations.

Phthalates are chemicals found in many consumer products, including plastic film, plastic containers, and even shampoos and fragrances.

There are currently not many treatment options to treat poor sperm quality, said Dr Lim.

If a man has a significant varicocele (a swelling of the veins in the scrotum), which is thought to lower sperm quality, he might be advised to correct it through surgery, said Dr Lim.

Studies show that some supplements can improve sperm health. For instance, Vitamin C supplementation has been shown to improve sperm quality in heavy smokers, while Vitamin E improves sperm motility and pregnancy rates, said Dr Lim.

While certain issues, such as lifestyle changes and the proper management of diseases, can be fixed, Prof Ledger said that usually works only if the man has mild sperm health issues.

“If the problem is severe, you’ll need to talk to a fertility expert about your options, especially if the woman is over the age of 30, and you’re hoping to have at least two children,” he said.

WHEN TO SEEK HELP

Male infertility signs are often hard to detect. “Unlike women, who might have more clear-cut symptoms such as irregular menses, men with sperm abnormalities usually do not show obvious symptoms,” said Dr Chieng.

He urged couples who have been trying to conceive naturally for a year without success to seek medical advice. If the woman is aged 35 years or older, the couple should see a doctor if they are unable to conceive naturally after trying for six months.

In Mr Koh’s case, a sperm needle biopsy retrieved sperm for IVF from the sperm-producing areas inside his testes. To increase the chances of fertilisation, the ICSI procedure was used to inject the sperm directly into each egg harvested from Mrs Koh.

“Previously, for men with severe sperm quality issues, we could only offer donor sperm,” said Prof Ledger.

According to Dr Chieng, ICSI is widely used in many fertility centres in Singapore.

“Previously, IVF relied on sperm with good fertilising factor. Out of 10 eggs, maybe only seven will be fertilised. ICSI has nearly eliminated fertilisation failure. Data on its outcomes has also been reassuring in the last 20 years.”

The Kohs’ IVF cycle successfully produced three embryos.

“One of them became our baby girl. The other two are now frozen until we are ready for a second child,” said Mr Koh.

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