Infertility

Male infertility suggests infertility in male humans. Male infertility is involved in a sexually paired couple\’s inability to conceive after one year of unprotected sex in a considerable number of cases, ranging from 40-50%. It is recorded that about 15% of couples in North America and Europe trying to conceive are infertile in any given year.

The fertility of a couple depends upon several factors of both male and female partners. Females are found to rank higher than males in case of being infertile. Among all cases of infertility, about 20% can be traced to male factors, 38% to female factors, 27% can be traced to factors in both the male and female partners, and 15% cannot be traced to obvious factors in either partner.

If a couple has been found to be infertile, they are evaluated thoroughly and are offered the best possible treatment. Earlier, men with infertility had few options owing to lack of information about causes and more precisely about successful treatment. However, new tests have come up with the possibility to determine the causes of male infertility and treatments. Assisted Reproductive Techniques (ART) offer hope to many couples.

Causes behind male infertility: Fertility in men depends on normal functioning of the hypothalamus, pituitary gland, and testis variety of factors can cause infertility. The evaluation of male infertility is required for a right treatment. Evaluation generally begins with assessing the medical history, physical examination, and a semen test. Other tests may also be required depending upon the case.

• 30 to 40% of cases indicate problems in the testes (called primary hypogonadism)
• 10 to 20% are due to problems with the transport of sperm from the testes to the urethra (usually caused by a blockage)
• 1 to 2% of cases are based on the conditions of the pituitary gland or hypothalamus (called secondary hypogonadism)
• In 40 to 50% of cases no such causes are found even after an evaluation.

Factors affecting male fertility:

• Environmental pollutants
• Exposure to high heat for prolonged periods
• Genetic abnormalities
• Addicted to alcohol, marijuana, or cocaine
• Hormone deficiency or taking too much of a hormone
• Impotence
• Infections of the testes or epididymis
• Older age
• Previous chemotherapy
• Previous scarring due to infection (including sexually transmitted diseases), trauma, or surgery
• Radiation exposure
• Retrograde ejaculation
• Smoking
• Surgery or trauma
• Use of prescription drugs (cimetidine, spironolactone, and nitrofurantoin)

Treatments: Infertility in men may be treated following the methods mentioned below:

Fertility History – This is the primary stage of treating infertility. Patients are asked to provide detailed history of medical and sexual factors that might affect one’s fertility. The information to be delivered is as follows:

Frequency and timing of sexual intercourse.
Duration of infertility and any previous fertility events.
Childhood illnesses and any problems in growth.
Any serious illness such as diabetes, respiratory infections, cancer, previous surgeries etc.
Sexual history, including any sexually transmitted diseases.
Exposure to toxins, such as chemicals or radiation.
History of any medications and allergies.
Any family history of reproductive problems.

Physical Examination – A fertility specialist (urologist) performs a physical examination of the scrotum, including the testes. It is useful for detecting large varicoceles, undescended testes, and absence of vas deferens, cysts, or other physical abnormalities.

Examination of the scrotum may find large Varicoceles that can interfere with fertility. These extra large Varicoceles are described as feeling like \”a bag of worms.\” They disappear or are greatly reduced when the patient lies down, so the patient is examined for varicoceles while standing.

Checking the size of the testicles is also necessary. Smaller-sized and softer testicles along with tests that show low sperm count indicate problems in sperm formation. However, normal testicles accompanied by a low sperm count, suggest possible obstruction. The temperature of the scrotum may also be considered (scrotal thermography).

The doctor can also examine the prostate gland to detect abnormalities.
The penis is checked to find if there are warts, discharge from the urinary tract, and hypospadias (incorrect location of the urethra opening).

Post-Ejaculatory Urine Sample – A urine sample is tested to detect sperm after ejaculation. It may either rule out or indicate retrograde ejaculation. It is also helpful to detect any infections.

Semen Analysis – The common test to evaluate a man\’s fertility is a semen analysis. The sperm collection test for men who can produce semen involves the following steps:

A man should keep away from ejaculation for several days before the test because each ejaculation can reduce the number of sperm by as much as a third. Therefore most doctors recommend abstaining from ejaculation for at least 2 days for a better result, but not more than 5 days, prior to semen collection.

A man has to collect a sample of his semen in a collection jar during masturbation either at home or at the doctor\’s office. Proper collection procedure is essential, to contain highest concentration of sperm. Specially patented condoms are also useful to collect a sample during sexual intercourse. But remember that regular condoms are not useful, since they often contain substances that kill sperm.

The sample should be kept in body temperature and delivered quickly because if the sperm are not analyzed within 2 hours or kept reasonably warm, a large proportion may die or lose motility.

A semen analysis should be repeated at least three times over several months.
The sperm count test is performed if a man\’s infertility is suspected . It is helpful in determining the problem related to sperm production or quality of the sperm as a cause of infertility. The test may also be performed after a vasectomy to make sure there are no sperm in the semen.

The presence of both man and woman is necessary when the doctor discusses the results of this analysis so that both partners understand the implications. The analysis report contains results of any abnormalities found in sperm count, motility, and morphology as well as any problem in the semen. However, semen analysis alone may not be a definitive indicator of either infertility or fertility.

A semen analysis provides information on:

Amount of semen produced (volume)
Number of sperm per milliliter of semen (concentration)
Total number of sperm in the sample (count)
Percentage of moving sperm (motility)
Shape of sperm (morphology).

Semen Volume and Concentration: The seminal fluid (semen) itself is analyzed in order to find out abnormalities. The color is checked and it should be preferably whitish-gray.

The amount of semen ejaculated is important. Most men ejaculate 2.5 – 5 milliliters (ml) (1/2 – 1 teaspoon) of semen. Significantly higher or lower amounts may indicate prostate problems, blockage or retrograde ejaculation.

The semen will be tested to ensure how long it takes to achieve its liquid state. (Normal semen is liquefied within 20 minutes after adding certain enzymes.) Abnormal results may occur due to prostate gland problems or lack of sperm.

The amount of sugar (fructose) in sperm will be measured: In the epididymis, fructose is added to the semen. Therefore, an absence of fructose indicates obstruction either in the vas deferens or in the epididymis. But If there is only fructose in the semen and no sperm, then it indicates a defect in sperm production even though the channel from the epididymis is open.

Other factors may also be measured: White blood cell counts are taken to detect infection.

Low levels of a substance (inhibin B), produced only in the testes, and may indicate blockage or other defects in the seminiferous tubules.

Low levels of another compound called alpha-glucosidase, may also hint at blockage in the epididymis.

Sperm Count: A low sperm count is not a definitive diagnosis of infertility; rather only an indicator of a fertility problem.Generally, a normal sperm count reads 20 million per milliliter of semen.

Sperm Motility: Motility (the speed and quality of movement) is graded on a 1 – 4 ranking system. For fertility, motility should be greater than 2.

Grade 1 sperm wriggles sluggishly and progresses little slowly. (Sperms that clump together may indicate that antibodies to the sperm are present.)

Grade 2 sperm moves forward either very slowly or does not move in a straight line.

Grade 3 sperm moves in a straight line at a reasonable speed and can home in on an egg accurately.

Grade 4 sperms are as accurate as Grade 3 sperms, but they advance rapidly.

More than 63% of the sperm are required to be motile for normal fertility. Even men whose motile sperm constitutes only about a third of the total sperm count should not rule out conception. Testing for sperm motility is essential to predict the success of artificial insemination and which men might be candidates for the intracytoplasmic sperm injection (ICSI) fertilization technique, in which the sperm is inserted directly into the egg and motility plays almost no role.

Sperm Morphology: Morphology means shape and structure of the sperm. Importance of determining the morphology of sperm can’t be negated as the success of the fertility treatments in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) depend on it.

Blood Tests: Blood tests are done to measure several factors affecting fertility.

Hormonal Levels: Tests for certain hormone levels are suggested if semen analysis is appears abnormal (especially if sperm concentration is less than 10 million per milliliter) or in case, other indications of hormonal disorders are found.Blood tests for testosterone and follicle-stimulating hormone (FSH) levels are usually done first.
If testosterone levels are low, then luteinizing hormone (LH) is measured.
Low levels of FSH, LH, and testosterone indicate hypogonadotropic hypogonadism.
Very high FSH levels with normal levels of other hormones indicate abnormalities in initial sperm production. Usually this happens only if the testicles have some serious defects, causing Sertoli cell- only syndrome, in which sperm-manufacturing cells are absent. Other hormones, such as prolactin, estrogen, or stress hormones may be measured if there are symptoms indicating other problems including low sexual drive or the presence of breasts.

Infections: Blood tests are also helpful in determining the presence of any other serious infections that might affect fertility, including HIV, hepatitis, and Chlamydia.

Ultrasound: Ultrasound imaging helps to determine the size of the testes or to detect cysts, tumors, abnormal blood flow, or varicoceles that are too small to find in physical detection (remember, such small veins may have little or no impact on fertility). It can also be done to detect testicular cancer.

Sperm Penetration Tests: Cervical Mucus Penetration Test. This post-coital test is useful to examine the effect of a woman\’s cervical mucus on a man\’s sperm. Typically, a woman is instructed to contact their physician within 2 – 24 hours after intercourse at mid-cycle (when ovulation should occur). A small sample of her cervical mucus is examined under a microscope. If the doctor observes no surviving sperm or no sperm at all, the cervical mucus is then cultured to detect the presence of infection. It is not possible to evaluate sperm movement from the cervix into the fallopian tubes or the sperm\’s ability to fertilize an egg with the help of this test.

Micro-Penetration Assay Test: This test is done to find if sperm can penetrate hamster eggs that have had their covering removed. If less than 5 – 20% of the eggs are penetrated, infertility is diagnosed.

Genetic Testing: Genetic testing may be highly recommended to men who are severely deficient in sperm and who show no evidence of obstruction, particularly in men undergoing the intracytoplasmic sperm injection (ICSI) procedure. Genetic testing is able to identify DNA fragmentation, chromosomal defects, or the possibility of genetic diseases that can be passed on to their next generation. Genetic abnormalities suspected in either partner, need counseling.

Prevention: Prevention is better than cure. Then why not follow these simple guidelines?

Sexually transmitted diseases (STDs) often cause infertility. So it is wise enough to indulge in practicing safer sex behaviors that may minimize the risk.

Gonorrhea and Chlamydia are the two most common causes of STD-related infertility.

STDs often don\’t have symptoms at first, until PID or salpingitis develops. These can cause scar to the fallopian tubes and decrease fertility or may increase the risk of ectopic pregnancy.

Getting a mumps vaccine in men has been shown to prevent mumps and its complication, orchitis. The vaccine is useful to prevent mumps-related sterility.