What is Male Infertility  ?

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