MALE INFERTILITY: CAUSES, EVALUATION AND TREATMENTS
Medically reviewed by DR. IKECHUKWU DIMANORUO
Infertility, generally, is the involuntary failure to conceive within 12 months of commencing consistent unprotected sexual intercourse between a man and a woman. Male Infertility is the inability of a man to impregnate a woman after one year of regular (at least, three times a week) unprotected sex. Studies confirm that male infertility accounts significantly on why a woman cannot get pregnant.
In this article, we outline the causes, symptoms and treatments for male infertility especially because, in the African clime, infertility is rarely discussed in reference to men. As such, barrenness is almost always seen as a burden of the woman in the African socio-cultural environment.
There are two types of infertility: primary and secondary infertility. Primary infertility is the absence of previous pregnancy while secondary infertility involves a previous pregnancy irrespective of the outcome. All over the world, about 10-15% of couples grapple with infertility in their union. Investigation is commenced after 12 months as among normal couples, 80% achieve pregnancy.
Even though infertility is not a life-threatening condition, it has been described as a radical life-changing problem because it carries significant psychological trauma for the parties involved. This is worse in Africa where childbearing is almost at the apex of the yardstick of evaluating a successful marriage. The prevalence of infertility in sub-Sahara Africa ranges from 20% – 40%. Male factor is responsible for 40–50% of all infertility cases in Nigeria with its causes varying from region to region. For instance, according to a report carried out in the various regions of the country, the male factor was responsible for 42.4% infertility cases in the South-West and 40.8% in the North-East.
Under normal circumstances, fertilization occurs when a sperm and egg meet. This usually occurs when a fertile man releases sperm through ejaculation into the reproductive carnal of a fertile woman. The causes of male infertility are numerous as a lot of factors can contribute to making a man unable to impregnate a woman. The most common cause stems from the male’s inability to produce healthy sperms in the right quantity and delivering them into a female partner’s vagina.
Problems that affect sperm production and delivery include:
Health issues such as Diabetes, Hypertension, kidney failure and sexually transmitted diseases like gonorrhea and syphilis can affect the reproductive system of men. These have been proven to affect sperm health drastically by causing permanent testicular damage and consequently result in infertility if not treated on time.
Once a man is suffering from abnormalities in his hormone system, there is a chance that these imbalances – whether over secretion or under secretion of certain hormones – can lead to infertility. Some deficiency in the Follicle Stimulating hormone (FSH) and Luteinizing hormone (LH) have a direct effect of the testes of a man. The testes are responsible for producing sperm and testosterone; hence, such deficiency will result in lower testosterone levels and low sperm count in men. Other hormone imbalances that can cause infertility are excess prolactin and pituitary problems.
Having too much weight can impair a man’s fertility as research has shown that there is a strong relationship between the degree of excessive weight and poor quality and quantity of sperm. Therefore, once a man’s Body Mass Index is >30, he is likely to have reduced fertility.
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It is no longer news that the way one lives has a great impact on their health and wellbeing. Thus, certain lifestyle and habits are proven to cause infertility or increase the chances of infertility in men. Smoking and even secondary smoking have been confirmed to significantly damage sperm production and health. Always putting on tight-fitting under-wears also affects sperm quality. Taking too much alcohol also impairs fertility in men. Drug abuse can also lead to infertility as taking body building steroids, marijuana, narcotics, cocaine and methamphetamines adversely affects sperm production.
This affects the process of making and growing sperm. It could be genetic, like having an extra sex chromosome, or it can stem from lifestyle choices. Sperm disorders ranges from Azoospermia (inability to produce sperm at all), Oligospermia (very low sperm production), Teratozoospermia (malformed sperms and oddly shaped sperms).
When a man has a problem with having or maintaining an erection sufficient enough for a successful sexual intercourse, he will most likely struggle with infertility. Premature ejaculation and impotence can lead to infertility especially with the psychological and medical impacts they have on the man.
Certain drugs used for treatment have infertility as side effects. Examples include medications for long term illnesses like kidney diseases, Diabetes management drugs, cancer drugs and chemotherapy, ulcer drugs. These medications impair sperm production thereby leading to infertility in men.
Certain measures can be taken to prevent future infertility or to drastically reduce the risks of male infertility. Some preventive practice includes but are not limited to, optimizing lifestyle factors such as sedentary lifestyle, obesity, smoking, heat exposure, stress, poor nutrition, and harmful environmental toxicants. These factors have been said to all adversely affect sperm production, delivery and quality. Others include prompt correction of cryptorchidism, testicular torsion, genital infection, and adolescent varicocele, and proper precautions to limit occupational, medical, and recreational gonadotoxins.
In evaluating male infertility, certain goals have to be outlined to guide the process of diagnosis. It is important that the fertility specialist investigates the root cause of the infertility by running necessary tests. It has been estimated that less than 50% of couples initiating an infertility evaluation will ultimately achieve fertility. Investigating male infertility, therefore, demands active participation and total cooperation of the couple to achieve the desired result as fertility is not a one-man challenge. From the onset the couple, especially the male partner, must be properly informed of steps to be taken, the need for patience and cooperation.
Steps in evaluating male infertility include detailed history of the male to note down speculative tendencies that may have resulted in infertility. Elements to consider include; coital practices, developmental history, medical history, (genital disorders, genital trauma, infections, chronic illness), medications (alternative, orthodox), potential STIs exposure (urethral discharge, dysuria), previous fertility, recent high fever, substance use, surgical history and toxin exposures.
Physical examination includes general and specific (system) examinations. System examinations include genital infections (discharge, prostate tenderness), hernia or scar of previous repairs, presence of vas difference, signs of androgen deficiency (increased body fat, decreased muscle mass, decreased facial and body hairs, small testes), testicular mass and varicocele.
The processes should be thoroughly explained to the man, and the wife if present. The rationale behind each investigation should be fully explained in simple language. Investigation should be based on findings from the history and physical examinations.
Relevant investigations include Full Blood Count, urinalysis (post-ejaculatory), seminal fluid analysis (SFA) ± culture, VDRL, urethral swab for culture and sensitivity, chlamydia cultures, kidney and liver function tests. Hormonal profile tests include FSH, testosterone, scrotal ultrasonography, transrectal ultrasonography and specialized sperm studies.
A normal sperm cell under a light microscope typically has one big head, one smaller body and a long tail. It will also be ‘alive’ and swimming, usually similar to how tadpoles behave. If your first test is normal, a second test is not required. Otherwise, a repeat confirmatory test is undertaken three months after the first to allow for a full sperm cycle development. Depending on findings from patient history, a semen analysis may be required as the initial investigation to assess a man’s fertility profile.
Arrangements on how a sample is received at the Laboratory may differ in settings, but the underlying denominators include:
1. Abstinence from sexual intercourse for 3 days prior to collection. The logic behind this is that the ejaculate volume and sperm quality may decrease with the increasing frequency of sexual activity.
2. Specimen must be kept warm and ideally submitted within 45 minutes to 1 hour from production, so the sperms do not die.
3. The specimen must be produced by masturbation and not into a condom. This is because most condoms contain special lubricant that may be spermicidal.
To help with 2) and 3) above, most facilities may have a sample room with audiovisual enhancers for easy masturbation. While physical parameters like the color of the semen may be assessed, acceptable parameters by the World Health Organization are:
1. Semen Volume (>2 mL)
2. Total sperm count (> 40 million/ejaculate)
3. Sperm concentration (>20million/ml)
4. Total sperm motility (>50%)
5. Progressive motility (25%)
6. Vitality (live spermatozoa, %)
7. Sperm morphology (>14% normal forms)
Treatments for male infertility are expected to be individualized and may involve one or more of the following.
This could be employed to correct a varicocele or an obstructed vas deferens repaired. Prior vasectomies can be reversed. In cases where no sperm is present in the ejaculation, sperm can often be retrieved directly from the testicles or epididymis using sperm retrieval techniques.
As has been noted earlier, infertility can be caused by certain sexually transmitted infections. Thus, correct treatments for underlying STIs can enhance fertility. Also treating intercourse problems with the appropriate medication or counselling can help improve fertility in conditions such as erectile dysfunction or premature ejaculation.
In cases where the root cause of infertility is deficiency in hormones, hormone revamp treatments and medications such as hormone replacement are used to tackle infertility. Hormone-induced infertility is caused by high or low levels of certain hormones. So, balancing the right hormones can prove a lasting solution.
This involves obtaining sperm through normal ejaculation, surgical extraction or from donor individuals, depending on the specific case and choice of the couple. The sperms are then inserted into the female genital tract or used to perform in-vitro fertilization (IVF) or Intra-cytoplasmic sperm injection.
In mapping out a solution path for couples tackling the challenge of infertility, it is pertinent that both the male and female are evaluated. Treating only one party as the culprit can be misleading as studies have shown that male infertility is fast becoming extremely common among couples who are trying to conceive (TTC). For a lot of couples dealing with infertility, the semen analysis is the single highest yield test performed during a comprehensive fertility evaluation. However, it is worthy of note that relying only on the results of a semen analysis is often inadequate to determine an optimal treatment path. Therefore, it is advised that further targeted testing may be necessary.
The good news is that, more often than not, the right treatment is able to sufficiently solve the issues of male infertility. This is especially true for men whose major reproductive challenge emanates from sperm production abnormalities. Speak to a Fertility Doctor to kick-start your assisted reproduction treatments. Remember that a timely referral to a Reproductive endocrinologist or a Fertility specialist can save a couple years of needless delay.
Dr. Ikechukwu Dimanoruo is a Family Medicine Resident who firmly believes that patient care should be a physician’s first priority. He is currently a Registrar in the Department of Family Medicine, National Hospital Abuja.
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