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Male infertility: often overlooked possibility

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Infertility is the inability to achieve pregnancy after one year of unprotected intercourse. (WHO –ICMART glossary). But, according to the American Society for Reproductive Medicine (ASRM) and recently at a WHO expert meeting, we revised the definition to encourage earlier evaluation in the highest risk group. Now, any man or woman >35 years should seek fertility evaluation or treatment after six months of trying. Conditions of the male that affect fertility are still generally underdiagnosed and undertreated.

In our society, the burden is placed more on the female partner when it comes to conception. When a couple can’t conceive after a year, the community automatically blames the woman. This assumption many times is false male infertility accounts for about 40% of infertile couples. About 7% of men are infertile, but a lot of men with fertility problems are reluctant to come for further testing and treatment.
The male partner can be evaluated for infertility or subfertility using a variety of clinical interventions, and also from laboratory evaluation of semen.” (WHO-Semen manual, 5th Edition).
A man’s fertility generally relies on the quality of his sperm. If the sperm concentration in a man’s ejaculates is low or if the sperm is of poor quality, it will be difficult and sometimes impossible for him to achieve pregnancy.
The words ‘low sperm count’ and ‘no sperm’ are terrifying terms to hear for many men and couples alike, especially when there is a history of infertility.
Oligozoospermia or ‘low sperm count’ refers to semen with a low concentration of sperm cells, and is commonly associated with male infertility.
Based on recent WHO criteria, a concentration of less than 20 million sperm/ml of semen is oligozoospermia. There are also different classes of oligozoospermia (mild to severe).
While it requires only one sperm to fertilize the ovum, the odds of conception are such that it takes millions of sperm per milliliter of semen actually to achieve the goal of fertilization. A “normal” sperm count is about 20 million or more sperm per milliliter of semen. Over 4% of the sperm in each sample should exhibit normal morphology and indicate normal motility – the forward swimming movement.
Azoospermia (no sperm) is the complete absence of sperm in an ejaculate, a well-known cause of male factor infertility.
Cryptozoospermia means the sperm is not observed in a fresh semen sample but later found after extensive centrifugation and microscopic search.
Male infertility is usually caused by problems that affect either sperm production in the testes or sperm transport.

The production of sperm is a complicated process and requires normal functioning of the testicles (testes) as well as the hypothalamus and pituitary glands — organs in your brain that produce hormones that trigger sperm production. Once the sperm is produced in the testes, delicate tubes,(epididymis) transport them until they mix with semen and are ejaculated out of the penis via the urethra. Problems with any of these systems can affect sperm production.

A detailed history and physical examination are done by a clinician to check for possible causes like varicocele, testicular atrophy, undescended testis and other abnormalities. A seminal fluid analysis (SFA) is done to assess the sperm parameters accurately, usually, patients are advised to abstain from intercourse for between 2 to 7 days before doing this test for optimal results. Further testing including hormone profile, scrotal ultrasound may be done primarily to check for other underlying causes.
The other causes related to the male lifestyles include; alcohol consumption which can lower testosterone levels and cause decreased sperm production.
Weight/ Obesity can impair fertility in several ways, including directly impacting sperm and by causing hormone changes.
Occupation such as welding or those associated with prolonged sitting, such as truck driving might be linked with a risk of infertility. However, the data to support these associations are inconsistent.
Tobacco smoking in men can result in lower sperm count than in those who don’t smoke.
Drug use, such as anabolic steroids taken to stimulate muscle strength and growth can cause the testes to shrink and cause a decrease in sperm production. Use of cocaine or marijuana might reduce the number and quality of your sperm as well. Medical conditions are also associated with infertility such as mumps, tuberculosis, sexually transmitted diseases, like gonorrhea and syphilis amongst others are responsible for male infertility.
Sperm testing is not without its attending issues, lower than average sperm counts can result from testing a sperm sample that was taken too soon after the last ejaculate, too shortly after an illness or stressful event, or didn’t contain all of the semen you ejaculated due to spillage during collection. Therefore the results are generally based on the selection of several samples over a period.
Treatment of male infertility is possible through assisted reproductive techniques (ART), and sometimes surgery for varicocele and undescended testes.
Assisted reproductive techniques are the advanced methods of achieving conception.
The techniques could be invasive or non –invasive.
The non-invasive techniques are the medical treatment with drugs for patients with hormonal imbalances such as anti-estrogens, e.g., clomiphene citrate, tamoxifen, gonadotropins such as HCG, dietary supplements, e.g., coenzyme Q10, aromatase inhibitors like Anastrazole and cyclic steroids (for immunosuppression). It is important to note that these drugs can be combined to get better results. The clinician has to identify the underlying causes and appropriate medications to use.

Patients with mild and even moderate oligozoospermia can benefit from Artificial Insemination (AI)/Fallopian Tube Sperm Perfusion (FTSP) which is also a non-invasive treatment for the men.
Patients with severe oligozoospermia can benefit from Intra-cytoplasmic Sperm Injection (ICSI) which involves the direct injection of sperm into the oocyte (eggs). For this to be done the oocytes have to be retrieved from the female partner while semen is collected from the male partner and processed.
The invasive techniques are advanced sperm retrieval methods involving minor surgical procedures using local anaesthesia. It can be used to collect sperm in patients with azoospermia. Many patients with absence of sperm in their ejaculate (semen), still have some sperm in their testes (organ where sperm is produced) and epididymis (stores mature sperm). These techniques include:
TESA (Testicular Sperm Aspiration)
TESE (Testicular Sperm Extraction)
Micro-TESE (Micro-Testicular Sperm Extraction)
PESA (Percutaneous Epididymal Sperm Aspiration)
They all involve the direct collection of sperm from the testes and epididymis.
Pregnancy rates according to the above treatment varies: In Artificial insemination; pregnancy rates are about 20% per trial, and multiple births are common when combined with superovulation; it could be as high as 35% to 45% and can go up to 60% with numerous trials using intracytoplasmic sperm injection (ICSI) techniques. We have also reported many pregnancies and babies born through the TESA/TESE/PESA techniques.
When all else has failed, we counsel couples on the use of third party reproduction such as the use of donor sperm. There is a process of matching and evaluation of the third party to enable the suitability of the sperm for the said purpose.
Antibiotics use has also been proven to be effective in treating infections such as gonorrhea and syphilis.
Lifestyle modifications, such as stopping cigarette smoking and psychoactive substances. Stress relief, weight loss, dietary change, avoidance of toxins has also shown a significant improvement in the sperm qualities
Total body medical detoxification in a medical spa helps to remove toxins, such as food preservatives, drugs, cosmetics which has a propensity for vital organs in the body; thereby improving fertility and overall patient wellbeing.
In summary, the diagnosis of male infertility is not the end of the road for the couple, and we encourage that they should seek treatment together which has a higher preference for successful therapy.


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