One-third of couples are unable to conceive with one of the reasons being the drastic decrease in sperm count in the past 100 years, gynaecologist and fertility specialist Dr Mark Sant said.

In 1930, there would be 130 million sperm cells per millilitre of semen but today the count has gone down to 15 million sperm cells in the same volume, a staggering 88.5 per cent drop.

Sant blames the modern diet for this, saying that processed food contains high levels of oestrogen, a hormone which opposes sperm production. Partially for this reason, the old-fashioned mentality of inadvertently blaming the woman for infertility by testing her first may safely said to be over, Sant said. Today, couples struggling to conceive undergo respective tests together.

Additional problems to male fertility can be due to trauma to the male reproductive system. Indeed, Sant said, that should such a trauma have happened the man will undergo a sperm count if unable to conceive in under 1 year, showcasing technical issues with the WHO’s general definition of infertility.

As of April 2023, the WHO defined infertility as follows: “Infertility is a disease of the male or female reproductive system defined by the failure to achieve a pregnancy after 12 months or more of regular unprotected sexual intercourse.”

Sant said that though as a baseline it serves its purpose, this is only part of the picture and omits to state that it only the case for women with regular periods. The main problem lies with the timeframe stated: 1 year.

Sant said that 1 in 6 couples cannot conceive after a year but that doesn’t automatically categorize them as infertile. For example, in women whose periods last 35 days, the timeframe required to conceive increases and they would still be healthy and fertile. Even if the timeframe exceeds a reasonable interval, infertility is not immediately placed like a label. Rather, it would be a time to begin tests to investigate any problems hindering conception: infertility is only a final diagnosis, Sant said.

From the female perspective, there is a decrease in fertility due to an increasing age of family planning, Sant added. In nature, a woman may begin to procreate age 15 with the ideal time for procreation being 18 to 25. That said, for many reasons such as the readiness of a woman depending on her life situation this ‘ideal’ age simply cannot be adhered to.

Unfortunately, nature works against the woman and is the chief cause for the declining fertility in the female sex. With age, the number of eggs the woman decreases, said Dr Sant.

To begin with, by puberty, a woman has lost half the eggs she possessed whilst still in her mother’s womb. Fertility then starts declining at age 30 until age 36 when fertility takes a “nosedive”.  The ultimate end of fertility in a woman is then menopause.

At this point one must keep in mind that due to drastically different physiology a woman is given a set amount of eggs in utero and expends them with each menstrual cycle. The supply of eggs is finite and prone to aging. Men, on the other hand, are capable of producing new and functional sperm cells potentially until very late in life.

Problems to not only the eggs but also to the embryo itself arise as the woman ages, Sant said. At age 40, the probability of a healthy embryo is 27%, however this dips to 8% by age 43. Other embryos would simply not implant in the uterus to continue normal development.

That said, at such an age, even if implanted successfully, the risk of miscarriage is serious due to potential abnormalities caused by the aged egg. This deterioration of eggs with age carries over even to problems with egg storage such as cryopreservation. By this process, eggs are frozen rapidly, to avoid cells bursting.

This is essential to young women who are about to undergo intense therapy, for example to treat breast cancer, whose drugs and treatments would destroy their healthy eggs, Sant said. Cryopreservation does have its drawbacks and “fresh [not cryopreserved] eggs are always better” but at least it gives the patient a chance to procreate, said Sant.

Age remains an important factor even in freezing. He said that if eggs are donated to be preserved at age 36, eight eggs would be sufficient to give an 80% chance of conception. Above 36 years however, 25 eggs are required for a reasonable chance of a good embryo, but it is highly impractical.

20% of perfectly healthy couples with “normal fertility” cannot conceive and the reason why still eludes us, Sant said, but in the case of diagnosed infertility there are a number of treatments that can be done; from advice on the time to copulate to artificial insemination.

IVF is only utilised “if all else fails,” he added. He called for increased investment in the IVF process due to the rising population and concurrently rising infertility. Though it is currently provided by government as part of free Maltese healthcare, a waiting list does exist.

When questioned what may be done to make amends to the crash in sperm count, he said that whilst diet remains an important factor, one cannot forget the effects of a sedentary lifestyle and the effects of tobacco smoke.