Male infertility is quite common these days . One third of the cases are caused by male infertility . The sperm count may be low ,nil or the sperms may have decrease motility or they may be abnormal in shape . The main cause is low sperm count .We follow WHO 2010 criteria for semen analysis (mentioned below) .
Semen analysis is the foremost simple and diagnostic investigation for male infertility.
Semen Collection is preferably to be done at IVF Centre only .
It requires
Abstinence for 2 to 3 days
Sample collection preferably by masturbation at the centre .
Keep sample at body temperature (37oC)
Avoid normal condoms or lubricants
WHO criteria for normal semen values :-
Take out from net-WHO 2010-WHO 2021
The various semen abnormalities may be-
Oligospermia -When the semen count is < 15 M/ml
Azoospemia – No sperm in the ejaculate
Aspermia – When there is no ejaculate
Asthenospermia – When the sperm motility is less
Teratospermia – When the sperms are abnormal in shape .
Oligoaesthenoteratozoospermia – When the semen count is low , the motility is less and they are abnormal in shape .
How to proceed with abnormal semen analysis ?
We perform a repeat semen anlysis 2 months after the first report . If the previous report mentions azoospermia , we confirm Azoospermia by centrifugation of a semen specimen at 3,000 g *15 min and examine the pellet under high power . Many a times we have observed sperms in centrifuged samples ,where the previous reports have mentioned azoospermia .
We have an integrated team of Urologist , Psychologist and Endocrinologist and the male partner is evaluated by an urologist who takes a detailed history and examines the male partner . Confidentiality is maintained .
A thorough history is taken ,noting occupational history or any exposue to high temperature and environmental toxins , any prolonged illness os surgery done before , history suggestive of any sexually trnsmitted diseases ,coital freequency or any ejaculatory dysfunction .
His weight and height are taken and his genitalia are exmined for Testis ,Epididymis , Vas Defrens and Prostate .
What are the tests done in case of Azoospermia or severe Oligospermia ?
In most of the cases , the history and examination is suggestive of diagnosis and tests are done according to the diagnosis . Only minimal and indicated tests are done and unindicated and unnecessary tests are not done at our centre .
To confirm the dignosis , we usually do
Hormone Testing – S.FSH ,S.Testerone ,S.Prolactin to categorize whether its pretesticular ,testicular or post testicular cause of Azoospermia .
Genetic Profile – Karyotype is done to rule out Klienfelter‘s syndrome ,Y chromosome microdeletion, Cystic Fibrosis Gene Mutation .
Imaging – Scrotal ,Trans-rectal ultrasound is done and any abnormality of testis , testicular volume ,vas defrens ,prostate is noted .
Post Orgasmic Urine analysis – It is done to rule out retrograde ejacultion . Presence of any sperms in the urine confirms Retrograde Ejaculation .
Semen Culture – To rule out any infection causing abnormal semen analysis .
What is the treatment of male infertility ?
The treatment is specific to the cause .
In general ,
Patients are advised
1.Life style modifiction
2.Medical Treatment
3. IUI
4. Assisted Reproductive techniques (ART )
5.Surgical treatment
•Lifestyle Modification
•Weigh Reduction for obesity
•Decrease alcohol &Smoking
•Loose fitted undergarments
•Avoid Occupational exposure to heat ,sauna or hot tub use and use of anabolic steroids
Medical Treatment
The drugs work in cases like
A.Hypogonadotrophic Hypogonadism.
Hypo-gonadotropic hypogonadism(HH)- It’s a condition where 2° sexual characters are absent ,testis are small and there is azoospermia . The levels of FSH, LH & Testosterone are very low.
Treatment for these patients is simple . Injectios of hCG (1,000-2,000 IU) IM are given twice or thrice weekly along with FSH injections for 6-24 months . Testicular growth occurs in almost all and spermatogenesis occurs in 80—95% of patients without undescended testes .
B.Pyospermia – Antimicrobial therapy is given in cases of pyospermia; where there are ≥106 /ml of peroxidase positive white blood cells (WBCs ). However it only eradicates microorganisms . It has no positive effect on inflammatory alterations and/or cannot reverse functional deficits or anatomic and secretory dysfunctions .
C.Coital infertility– like Anejaculation or Retrograde Ejaculation
Sympathomimetic drugs such as pseudo-ephedrine, vibrator and electro ejaculation are used
for anejaculation
Sympathomimetic drugs and recently macroplastique injection of the bladder neck are used for retrograde ejaculation .
D.Idiopathic Male Infertiliy
It occurs in ~30-45% of infertile men . There is no demonstrable cause for abnormal semen parameters . Subnormal sperm parameters include
sperm concentration < 20million /ml
motility < 50% motile sperm
normal morphology < 30%
There is low scientific evidence for the use of bromocriptine / hCG/HMG / αblockers /Systemic corticosteroids . Androgens are contraindicated. Recombinant FSH, folic acid with zinc, or antioestrogens are beneficial in some patients . Antioxidants can be given empirically for 2 months . They may work in few idiopathic cases
IUI
IUI is a suitable alternative in
Mild –Moderate Oligoasthenospermia where total sperm count is more 106/ml with motility > 30%
Antisperm Sperm Antibodies are there or there is
Ejaculatory Dysfunction
The pregnancy rates with IUI in male infertility are 9-20%. Four cycles of controlled ovarian hyperstimulation (COH) combined with IUI are superior to IVF and less expensive than single IVF cycle .
Assisted Reproductive Techniques (ART)
A.In Vitro Fertilization (IVF ) – works well in cases of Severe Oligospermia (When number of motile sperms is < 106/ml and also where no Pregnancy has occurred after 3-6 cycles of IUI in Mild-Moderate Oligospermia.
B.Intracytoplasmic Sperm Injection (ICSI)- ICSI is suitable for
Severe Astheno &Teratospermia
With surgical Retrieval of sperms
Non Obstructive Azoospermia
Obstructive azoospermia not amenable to reconstruction
as in CBAVD.
Coital infertility due to anejaculation
Fertilization failure after conventional IVF
Surgical treatment
A .Microsurgical vasectomy reversal
Vasectomy reversal may be offered to the desired patients . Low cost , good success rate makes it more effective than IVF .Overall patency in 86 %of cases and live birth rates up to 58% is reported with vasectomy .
B .Varicocelectomy
Varicocelectomy is of benefit only if there are semen abnormalities and the varicocele is clinically palpable in the absence of female factor infertility . The average spontaneous pregnancy rate after varicocelectomy is 39%
C.Surgical sperm retrieval and assisted reproduction
Indications:
Non obstructive azoospermia (NOA).
Obstructive azoospermia not amenable to reconstruction as in CBAVD.
Coital infertility due to anejaculation