Infertility

Male Infertility

Infertility is the failure of a couple to become pregnant after one year of regular, unprotected intercourse. Infertility, also known as subfertility, may be due to a single cause in either you or your partner, or a combination of factors that may prevent a pregnancy from occurring. About 8% to 10% of couples of reproductive age experience infertility, and in approximately 40% of these cases male infertility is the major factor. More than 90% of the male infertility cases are due to low sperm counts, poor sperm quality, or both. Causes of male infertility can be divided into three main categories: 1.Sperm production disorders affecting the quality and/or the quantity of sperm;
  • Affected by the raised local (scrotal) temperature,
  • Presence of varicocele,
  • Use of tight under-garments,
  • An occupational hazard where men are subjected to excessive heat
2.Anatomical
    • Incomplete development of testis.
    • Late descent or non-descent of the testis
    • Obstructions can be due to
      • Infections
      • Injury,
      • Absence of the tract (vas) from birth.
3.Other factors such immunological disorders.  Approximately a third of all cases of male infertility can be attributed to immune or endocrine problems, as well as to a failure of the testes to respond to the hormonal stimulation triggering sperm production. However, in a great number of cases of male infertility due to inadequate spermatogenesis (sperm production) or sperm defects, the origin of the problem remains unexplained. The general examination to determine a man's fertility should look at:  
  • How masculine the man is by assessing body and facial hair;
  • The presence of any breast swelling;
  • Any evidence of previous surgical scars in the groin or scrotal areas;
  • Assessment of the development of the penis should follow, together with assessing whether the testes are present in the scrotum;
  • Careful examination of the testes must take place, including a measurement of their size and texture.
  • The epididymis is carefully examined to determine whether it is enlarged, whether there is evidence of lumpy growths ('cysts') and whether the vas deferens can be felt;
  • The blood vessels entering the testis at the top of the scrotum should be examined both with the man lying down and standing up, which is one of the best ways to determine whether or not a varicocele is present;
  • If there is any suggestion of inflammation of the prostate gland, a rectal examination of the prostate should be undertaken.
Around 30 to 40 percent of men evaluated for infertility have been found to have a varicocele. Study shows that varicocele is the number one cause of male infertility. A varicocele is a condition of enlarged veins in the scrotum that causes abnormalities in the temperature regulation of the testis. Enzymes that are responsible for both sperm and hormone (testosterone) production have an optimal temperature at which they operate most effectively. If this temperature is elevated by even one degree, sperm and testosterone production are adversely affected. As explained above, male infertility is responsible for approximately 40% of all diagnosed cases of infertility. The male infertility refers to problems within the male reproductive system or the sperm. Good sperm quality is essential to male reproductive health. The five main factors that contribute to sperm quality are: 
Sperm Count  
 
Concentration
 
Motility
 
Speed 
 
Morphology
 
Many factors can interfere with optimal sperm quality in men.  The main causes are described below:
Varicocele  
Hypogonadism
Anti-sperm antibodies
Lifestyle Factors
Infections   
Medications
Cancer  
Genetic Disorders 
Retrograde ejaculation
Symptoms of male infertility are six months of unprotected intercourse with the patient’s partner unable to get pregnant while other causes have been ruled out. The doctor will ask you about the following : Sexual history such as sexual practices, timing of intercourse and sexual habits, Medical history such as illness and infections Working Conditions such as exposures to chemicals, pesticides and high temperatures Lifestyle history such as smoking, intake of alcohol and use of drugs. You will be asked to abstain from ejaculation for approximately 72 hours prior to the doctor visit. When you visit the doctor, you will be asked to provide a semen sample for analysis. The semen sample will provide valuable information. Multiple parameters are examined such as the volume of the ejaculate, the sperm density, motility percent and speed to see if the minimal standards of adequacy are attained. A physical examination will be performed and you will be evaluated for factors that may contribute to infertility, including, a varicocele. If hormone imbalance is supected, hormone levels will be drawn. The treatment plan begins with counseling regarding sexual practices. You will be informed about the optimal timing for intercourse, cautioned to avoid lubricants, since lubricants can impair sperm survival. Even saliva can impair sperm survival. You can be advised about Lifestyle changes since alcohol, tobacco, and drugs are all considered toxic to sperm. If hormonal abnormalities are found to be the cause of the infertility, hormonal replacement therapy is prescribed. This may be either in the form of an injection self-administered periodically throughout the week, or a tablet taken every day. Treatment with antibiotics may be prescribed if you show an infection or inflammation in any of the organs associated with sperm production or transportation. If you are diagnosed to have varicocele then a surgical procedure called varicocelectomy or varix ligation is recomended. Studies show that pregnancy rate in couples where men with varicoceles underwent surgery was three times higher than when men did not undergo surgery.

Sperm count

The sperm count is the total number of sperm found in semen. A normal sperm sample has at least 40 million sperm cells. If the sperm count is lower than 40 million, this does not necessarily imply that the man is infertile, however it may take longer to achieve conception. 

Concentration

The concentration is the number of sperm cells per milliliter of semen. A concentration of at least 20 million sperm per milliliter is considered "normal".

Motility

Sperm motility refers to the ability of the sperm to move or "swim". The ability of the sperm to travel through the cervical mucus and to the fallopian tubes is essential. Enough sperm should be able to move quickly enough and in a straight direction to be capable of fertilization. “Normal" sperm motility is about 50%.

Speed

Speed is sometimes referred to as "rapid linear progression". It refers to the number of sperm that are the fastest swimmers and are likely to fertilize the egg.

Morphology

Morphology is the size and shape of the sperm. Normal sperm have an oval "head" and a long tail. Defects in sperm morphology may impair the swimming strength or the ability of the sperm to penetrate and fertilize an egg. In a semen analysis, 15% or more of the sample should be normal sperm.

Varicocele

Varicocele is varicose (enlarged and twisted) veins located in the testicles. Varicocele can impair sperm production and therefore reduce sperm counts.

Hypogonadism

Hypogonadism is a condition that results in markedly decreased levels of the hormone testosterone. This deficiency negatively impacts sperm production and therefore sperm count. Typically hypogonadism is a congenital (present at birth) problem, however it can develop later in life from various brain tumors, radiation treatments, or rarely, unknown causes.

Anti-sperm antibodies

Both men and women can have anti-sperm antibodies, which are proteins in the body that "attack" sperm cells and disable them, preventing them from reaching and fertilizing a viable egg. Anti-sperm antibodies can attach to either the head or the tail of sperm, causing the sperm to stick together or preventing them from penetrating the egg. Thus, the antibodies mainly affect sperm motility and morphology.

Lifestyle factors

Alcohol

There is no question about it - alcohol consumption has been definitively linked to impaired fertility in both men and women. In men, alcohol consumption may damage the sperm or reduce sperm counts. Both sexes should reduce alcohol intake as much as possible when trying to conceive.

Drugs - recreational, anabolic steroids

Research has indicated that use of drugs such as heroin; amphetamines, cocaine, and PCP have been associated with decreased libido, erectile failure, and ejaculatory problems. Furthermore, drugs such as heroin are known to interfere with normal hormonal production, leading to decreased LH and testosterone levels. Anabolic steroids, frequently used by athletes to increase muscle mass, significantly impact sperm production, and reduce sperm counts. 

Smoking

Smoking has a negative impact on both male and female fertility. Second hand smoke (passive smoking) can be just as harmful as smoking itself. In men, smoking reduces sperm counts and impairs sperm motility. In women, smoking has been linked to impaired fertility and increased risk of miscarriage.

Heat

It is generally recommended that the male partner avoid frequent saunas and hot baths. High temperatures are believed to interfere with sperm production, and may therefore lower the sperm count. Avoiding heat does not mean that the man should not take a hot shower!

Clothing - boxers vs. briefs

Are boxers or briefs most suitable when trying to conceive? It is recommended that the man wear loose fitting clothing, which means boxer shorts and loose trousers. The reason for this is that tight clothing can increase the temperature in the scrotum and as a result, decrease the sperm production.

Timing of Sexual Intercourse

Exposure to heavy metals, particularly lead, pesticides, and anesthetic gases has been associated with potential impairments to sperm quality. Radiation treatment (perhaps for cancer) may affect sperm production, and therefore impact fertility. If you work with environmental chemicals or are exposed to radiation on a Timing sexual intercourse around the time of ovulation is one of the easiest and most effective strategies that you can take to enhance your chances of conception. The man is constantly making sperm, however the woman's fertile period only happens once a month! Therefore, it is important to time intercourse during that fertile period.

Occupational Hazards

Chemicals & radiation routine basis, and are experiencing difficulty in achieving pregnancy, you should speak to your doctor. Occupational hazards are considered a risk factor for infertility.

Stress

A healthy stress free and enjoyable sex life is very important.

Infections

Viral and bacterial infections can have varying affects on current and future male fertility. This is why it is so important to provide a detailed medical history to your doctor. Mycoplasma infections can affect fertility by interfering with sperm motility, and mumps after puberty can cause testicular damage.

Medications

Calcium Channel Blockers

Medications known as calcium channel blockers can cause male infertility. These medications are typically used to control blood pressure in individuals with hypertension. If you are taking a medication for high blood pressure and are not sure if it is a calcium channel blocker, ask the doctor. He may be able to switch you to an alternative antihypertensive medication that does not interfere with your fertility.

Cimetidine

Cimetidine, also known as Tagamet®, is a medication used to treat stomach ulcers or reflux disease in both men and women. It may contribute to male infertility by causing increased levels of prolactin which results in decreased LH and testosterone levels, which in turn leads to lower sperm counts as well as decreased sexual performance.

Antibiotics

Numerous antibiotics have been associated with causing male infertility. The chart below summarizes the names of the antibiotics and their effect on sperm.


Antibiotic Drug or Class: How it affects male fertility: Comments:
Minocycline Toxic to developed sperm Toxic to bovine (cow) sperm; believed to be toxic to human sperm as well
Nitrofurantoins (nitrofurantoin, furadantin) Interfere with sperm production resulting in decreased sperm count Unknown if lower doses affect sperm to a smaller degree – recommendation is to choose an alternative antibiotic
Macrolides (erythromycin, troleandomycin) May cause reduced sperm motility or sperm death (spermicidal) Present information based on animal data, but believed to apply to humans as well
Aminoglycosides (neomycin, gentamicin) Negative affects on the production of sperm; neomycin can reduce count and motility Other aminoglycosides have not demonstrated any negative effects on sperm in laboratory studies
Sulfasalazine Can cause a decrease in sperm count, motility, and morphology Reversible after discontinuation of drug. Case reports are in patients being treated for inflammatory bowel disease (IBD)

Retrograde ejaculation

Retrograde ejaculation is a condition where sperm are forced backwards into the bladder instead of forward through the urethra. This occurs because the muscles of the urethra are not functioning properly during ejaculation (orgasm). Retrograde ejaculation is frequently associated with diabetes, multiple sclerosis, and spinal cord injury, and can significantly affect sperm count.

Chemotherapy

Chemotherapy can affect fertility in the man by reducing sperm count and/or motility. It may also cause damage to existing sperm. The impact on fertility can be temporary or permanent depending on numerous factors.

Genetic disorders

Conditions such as undescended testes or congenital malformations of any part of the male reproductive system can lead to mild to severe reduction in sperm counts, depending on the specific problem and degree of malformation.

 

Minimal Standards of Adequacy
Volume 1.5-5.0 milliliters
Sperm 20 million per milliliter
Motility over 60 percent
Speed Grade 2 or higher
Morphology Greater than 60 percent are normal shape
Fructose Present

The key test that will be performed is a semen analysis. The sample will be examined for the

  • Amount of semen
  • Consistency of semen
  • Number of sperm
  • Movement of sperm
  • Shape of sperm
  • "Clumping" of sperm
  • Presence of substances other than sperm in the semen
Investigations indicated to diagnose a case of Infertility:-
  • Testicular biopsy
  • Radio-immunoassays like FSH, LH, Prolactin
  • Agglutination tests
  • Scrotal Sonography or Colour-doppler

Management

Hormone replacement therapy or other medication, depending upon the cause.

Surgery may be indicated in case of varicocele or other obstructions.

Prevention

 

  • Infertility cannot always be prevented. But the following steps may help:
  • Avoid use of tobacco, marijuana, opiates, and anabolic steroids.
  • Avoid exposure to harmful chemicals and heavy metals.
  • Avoid excessive use of alcohol.
  • Protect yourself from sexually transmitted disease by using condoms and minimizing the number of sexual partners.