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What is Male Infertility?



What is Male Infertility?

Fertility Enhancing Endoscopic Surgeries 0

 What is male infertility? How common is it? Male infertility refers to a male's inability to cause pregnancy in a fertile female.

In India it accounts for 40-50% of infertility. It affects approximately 7% of all men. With lifestyle changes and stress, the problem of male factor infertility is on the rise and thus has taken attention of many researchers and infertility specialists with increasing need of public awareness.

What are the common causes of male infertility?

Normal male reproductive system functions as shown in the following diagrams.

Normal male reproductive system Normal male reproductive system

 The causes of male infertility can be commonly divided into 3 factors-

  1. Pre-testicular factors: Inadequate hormonal support of the testes by the hypothalamus or pituitary, thus producing poor quality or quantity of sperms.
  2. Testicular factors: Testes produce semen of low quantity and/ or poor quality despite adequate hormonal support
  3. Post- testicular factors: These affect the male genital system after normal testicular sperm production and include defects of the genital tract as well as problems in ejaculation
 

The common causes of each of the above are highlighted in the table below:

 
Pre-testicular factors Testicular factors Post- testicular factors
Hypogonadotropic hypogonadism due to various causes Genetic defects- Y chromosome microdeletions, Abnormal set of chromosomes (eg. Klinefelter syndrome)   Vas deferens obstruction (blocked tubes) Absence of Vas deferens, often related to genetic markers for Cystic Fibrosis (CBAVD)
Obesity alters the release of gonadotropin-releasing hormone (GnRH) which is important for production of reproductive hormones. Cancers e.g. seminoma Infection, e.g. prostatitis
Drug abuse, alcohol intake Cryptorchidism (undescended testes) Varicocele (dilated vessels of testes) (14% in one study) Hydrocele Retrograde ejaculation (ejaculation in a reverse direction, i.e. inside bladder)
Strenuous exercise (bicycle riding, horseback riding) Trauma Ejaculatory duct obstruction
Medications- chemotherapy, anabolic steroids, cimetidine, spironolactone, phenytoin, sulfasalazine, nitrofurantoin. Exposure to toxic chemicals and dyes. Infections such as mumps, malaria Hypospadias  
Genetic abnormalities such as Robertsonian translocations Radiation therapy Impotence
Idiopathic oligospermia - unexplained sperm deficiencies account for 30% of male infertility
  How does tobacco smoking affect fertility?

Male smokers also have approximately 30% higher odds of infertility. There is increasing evidence that the harmful products of tobacco smoking kill sperm cells. Smoking tobacco increases intake of cadmium. Cadmium, damages the function of DNA polymerase in testes, which plays a critical role in sperm production. Nicotine and tar in the cigarettes are also shown to cause impotence.

  What are the important factors in the history of the male partner of a couple with infertility?

The diagnosis of infertility begins with a medical history of any prior testicular or penile insults (torsion, cryptorchidism, trauma), infections (mumps orchitis, epididymitis), environmental factors, excessive heat, radiation, medications, and drug use (anabolic steroids, alcohol, smoking).

Sexual habits, frequency and timing of intercourse, use of lubricants, and each partner's previous fertility experiences are important.

The past medical or surgical history may reveal thyroid or liver disease (abnormalities of spermatogenesis), diabetic neuropathy (retrograde ejaculation), radical pelvic or retroperitoneal surgery (absent seminal emission secondary to sympathetic nerve injury), or hernia repair (damage to the vas deferens or testicular blood supply).

A family history may reveal genetic problems.

How important is the physical examination of the male partner?

The physician usually performs a thorough examination of the penis, scrotum, testicles, anus and rectum. An orchidometer can measure testicular volume, which in turn is tightly associated with both sperm and hormonal parameters. A physical exam of the scrotum can reveal a varicocele, but the impact of detecting and surgically correct a varicocele on sperm parameters or overall male fertility is debated.

 What is the role of semen analysis?

The most important investigation for any male factor infertility is semen analysis. The volume of the semen sample, approximate number of total sperm cells, sperm motility/forward progression, and percentage of sperm with normal morphology are measured. This is the most common type of fertility testing. Semen deficiencies are often labeled as follows:

There are various combinations of these as well, e.g. Teratoasthenozoospermia or oligoasthenoteratozoospermia.

 How is semen analysis done?

For an ideal semen sample, the male partner is required abstinence of 3-5 days. The sample is collected by masturbation. The man is provided a clean private room within the premises of the testing laboratory, and he is required to wash his hands properly. He then cleans the prepuce with water after retracting the foreskin. A wide-mouthed sterile container is provided to him, into which he ejaculates. The embryologists then analyse the sample provided according to the WHO 2010 guidelines, and provide a detailed report to the patient.

This is the easiest and simplest non-invasive test which provides the maximum information.

  Are there any other tests on the blood or ultrasonography required?

In certain cases, a semen analysis might not suffice alone, and certain other tests may be required. Common hormonal tests include determination of FSH and testosterone levels. Karyotyping can reveal genetic causes of infertility.

Ultrasonography of the scrotum is useful when there is a suspicion of some particular diseases like testicular dysgenesis, which is often related to an impaired spermatogenesis and to a higher risk of testicular cancer; dilation of the head or tail of the epididymis, unilateral or bilateral congenital absence of the vas deferens (CBAVD). Doppler ultrasonography useful in assessing venous reflux in case of a varicocele or in the diagnosis of testicular torsion.

In patients with a low sperm count, sometimes, another test called as sperm DNA fragmentation assay may be advised which tells us about the fertilization potential.

 How can one prevent male infertility? Some strategies suggested for avoiding male infertility include the following:
  • Avoiding smoking as it damages sperm DNA
  • Avoiding heavy marijuana and alcohol use.
  • Avoiding excessive heat to the testes. (Tight clothing, working in high temperature environment, using laptop over lap, sauna bath etc)
  • Sperm counts can be depressed by daily coital activity and sperm motility may be depressed by coital activity that takes place too infrequently (abstinence 10–14 days or more).
  • When participating in contact sports, wear a Protective Cup and Jockstrap to protect the testicles to prevent injuries.
 What are the various treatment modalities available for male infertility?

The treatment modalities vary according to the underlying disease and the degree of the impairment of the male fertility. Further, in an infertility situation, the fertility of the female also needs to be considered.

Pre-testicular conditions can often be addressed by medical means or interventions.

Testicular-based male infertility tends to be resistant to medication. Usual approaches include using the sperm for intrauterine insemination (IUI), in vitro fertilization (IVF), or IVF with intracytoplasmatic sperm injection (ICSI). With IVF-ICSI even with a few sperm pregnancies can be achieved.

Obstructive causes of post-testicular infertility can be overcome with either surgery or IVF-ICSI. Testicular sperm aspiration (TESA) can help retrieve viable sperms even with males having azoospermia. Ejaculatory factors may be treatable by medication, or by IUI therapy or IVF.

The use of Clomiphene citrate, an anti-estrogen drug designed as a fertility medicine for women, is controversial. Vitamin E helps to counter oxidative stress, which is associated with sperm DNA damage and reduced sperm motility. A hormone-antioxidant combination may improve sperm count and motility. The Low dose Estrogen Testosterone Combination Therapy may improve sperm count and motility in some men.

Oral antioxidants given to males in couples undergoing in vitro fertilisation for male factor or unexplained subfertility result in significantly higher live birth rate.

IMSI is the latest technology in which morphological normal sperms can be selected under very high magnification (7200 times) microscope and followed by ICSI to improve fertilization rate.

We, at Ruby Hall Clinic, Pune have a solution for almost all of the causes of male infertility. We have a state-of-the–art ART centre with all the latest modalities including ICSI and IMSI (the first in Pune) and in-house embryologists who are trained at semen analysis and processing. Our team works relentlessly in helping many childless couples realize their dreams of parenthood.

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