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Male Infertility

Male reproductive system consists of the following:

1. External genitalia: Penis is a male organ of copulation. It greatly varies in its length, measuring about 12 to 18 cm during the erectile state.

2. Internal genitalia: These include testis, vas deferens, seminal vesicles and prostate gland.

  • a. Testis: This is a pair of gonads lying in the scrotum. Each testis measures 5 cm in length, 3 cm in width and 2 cm in breadth and 10 to 15 grams. Testis contains seminiferous tubules where sperms are produced. Male hormones are produced by Leydig cells of testis. On upper pole of testis epididymis sperms mature as they pass from testis to the vas deferens.

  • b. Vas deferens: These are conducting tubes which carry the sperms from testis upto the neck of urinary bladder (prostatic urethra). It measures 45 cm in length.

  • c. Seminal vesicles: These are a pair of glands present around the neck of urinary bladder. They secrete necessary nutrients for sperm maturation.

  • d. Prostate glands: This gland is present around the neck of urinary bladder, secretes prostatic fluid in the semen that is necessary for sperm maturation and adds to the bulk of seminal fluid.

What is male factor infertility?

It is a condition where the male partner has low sperm count or sperms are non-motile or their motility is poor or they are abnormally shaped. The male may also have problem with delivering sperms in the female genital tract.

Causes of male infertility: Male infertility is caused by

1. Abnormal sperm production and function

  • A. Oligozoospermia: sperm count less than normal is called oligozoospermia.

  • B. Asthenozoospermia: decreased motility of sperms is called Asthenozoospermia.

  • C. Teratozoospermia: abnormal structure of sperms is called teratozoospermia

  • D. Azoospermia: absence of sperms in semen is called azoospermia.

Usually the above abnormalities are present in various combinations. These abnormalities are caused by following defects in male reproductive system.

2. Undescended testis: occurs when the testis fails to descend from the abdomen into the scrotum during fetal life. This leads to total absence of sperm production.

3. Varicocele: This consists of dilated and tortuous testicular veins that contain stagnated blood. This leads to impaired sperm production in testes.

4. Hydrocele: This consists of collection of fluid in coverings around the testis. This may lead to impaired sperm production.

5. Infection of testis (orchitis): This can be caused by sexually transmitted diseases, prostatitis, urethritis, etc.

6. Genetic diseases: Chromosomal disorder like Klinefelter’s syndrome having 47xxy karyotype can cause low sperm count or azoospermia.

7. Sperm antibodies: Sperm antibodies can form in individual’s blood that can lead to infertility.

8. Impaired delivery of sperm: Impaired delivery of sperms to the female genital tract can be due to:

  • Erectile dysfunction

  • Premature ejaculation

  • Retrograde ejaculation

  • Blockage of epididymis or ejaculatory ducts

  • Spinal cord problems

  • Hypospadias

  • Cystic fibrosis

  • Severe injury or major surgery involving the male reproductive system.

9. Medical conditions can be associated with infertility such as: Diabetes / Thyroid disorders / Disorders of pituitary gland / Disorders of adrenal glands / Liver or kidney failure / Genetic diseases / HIV/AIDS

10. Risk factors & life style issues:

  • Emotional stress and depression can lead to infertility.

  • Chemotherapy and radiation can severely impair sperm production and reduce their motility.

  • Smoking, alcohol, drugs & anabolic steroids can reduce sperm counts and impair sperm motility.

  • Occupational exposure to excessive heat, pesticides and other chemicals may contribute to male infertility.

Common sexual problems in men:

A) Erectile dysfunction

B) Ejaculation disorders

C) Loss or less libido

Causes: Sexual problems can be a result of physical or psychological disorder.

A) Erectile dysfunction or Impotence:

Definition: Inability to attain and or maintain an erection suitable for intercourse.

Causes:- Artherosclerosis [hardening of the arteries] affects blood flow. Nerve disorders / Psychological factors / Stress / Depression / Performance anxiety / Injury to the penis / Chronic illness / Peyronie’s disease[scar tissue in the penis]

B) Ejaculation disorders: There are 4 types of disorders:-

a. Premature ejaculation – It occurs before or soon after penetration

b. Inhibited or retarded ejaculation – Inhibited or retarded ejaculation is delayed &/or slow to occur

c. Retrograde ejaculation – At orgasm the ejaculate is forced back into the bladder rather than through the urethra and out the end of penis.

d. Anejaculation – absence of ejaculation

C) Loss of Libido: Decrease in sexual desire or interest in sexual activity.

Assessment of male infertility:

1)Semen analysis:

Semen analysis is the most important and easy investigation for male partner. You should have abstinence of at least three days before giving semen for examination.

Semen is usually given by masturbation in a sterile semen collection container in laboratory.

Analysis of semen usually includes the following components:

  • Sperm volume – is the total amount of semen in a single ejaculation.

  • Sperm concentration – is the number of sperms present in one ml of semen.

  • Sperm motility – is the ability of sperm to move.

  • Morphology – indicates the structure of sperms.

  • Minimal requirements for male fertility:

  • Semen volume: more than 1.5 ml

  • Sperm concentration: more than 15 millions/ml

  • Total sperm count: more than 38 millions/ml per ejaculate

  • Motility : more than 40% sperms having grade 3 to 4 motility( forward progression)

  • Morphology : more than 30% normal sperms

2)Evaluation of male hormones:

Testosterone, Follicle stimulating hormone (FSH), Luteinising hormone (LH),Prolactin (PRL), Dehydroepiandrosterone sulphate (DHEAS), Thyroid hormones (T3, T4, TSH)

3)Scrotal sonography & Color Doppler: this can diagnose hydrocele, hernia or varicocele.

4)Testicular biopsy: when semen analysis shows absent sperms in repeated semen samples and testicular size is normal, then testicular biopsy is usually indicated to know the cause of azoospermia. In this small piece of one or both testis is taken for histopathological examination under local or general anesthesia.

5)Genetic karyotyping: This test is done when some genetic disorder is suspected in male partner or in patients with severe sperm defects. This is also requires before proceeding for IVF or ICSI.

6)Surgical retrieval of sperms for ICSI: When semen analysis shows absent sperms but testicular biopsy shows production of sperms in testes, then various surgical sperm retrieval techniques are used to retrieve the sperms from testes or the collection system. ICSI treatment is done with these surgically retrieved sperms to achieve the pregnancy. These techniques are:

  • Testicular sperm aspiration (TESA)

  • Testicular sperm extraction (TESE)

  • Percutaneous epididymal sperm aspiration (PESA)

  • Microepididymal sperm aspiration (MESA)

  • Vas deferens aspiration (VDA)

  • Spermatocele aspiration