Male factor infertility

"The sunrise never failed us yet."
- Celia Baxter

There is hope…………
………..for males with abnormalities in their semen.

Modern times has dragged with it the assumption (in quite a few) that just because a man is of a normal body habitus, is otherwise healthy and can function normally as a male, he is fertile! Sooner this misconception is erased; many a woman will cease to be pointlessly targeted. Infertility could be due to either or both partners and is a point well worth repeating. Since tests for infertility in a woman are many as compared to the man it is imperative that a semen analysis be advised alongside as the first measure to seeking a cause.

Semen is a viscous fluid composed of sperms suspended in a fluid called seminal fluid. Sperms are very tiny (60 m in length) specialized cells that form the male counterpart to the ovum or the egg. They are produced in millions by the cells in the testis (lying in the scrotum in the male). Seminal fluid is an admixture of secretions from the testis and the accessory sex glands such as the seminal vesicle, prostate and the bulbouethral glands. Production of sperms is continuous and requires around 72 days for maturation.

World Health Organization (WHO) criteria for a normal semen sample

Volume > 2.0ml
pH 7.2 - 8.0
Concentration > 20 x 106 / ml
Total count > 40 x 106 / ml
Motility > 50% (rapid, slow or sluggish)
Motility > 25% (rapid progressive)
Morphology > 30% normal
Viability > 75% live
Leukocytes < 1.0 x 106 / ml
Immunobead test (antibodies) < 20% sperm with beads
Mixed agglutination reaction < 10% sperm with RBC

Abnormalities in any of the semen parameters could result in infertility. The male factor is responsible for approximately 20%-30% of infertility. Combined with a female factor the contribution is 20%.

A pre-requisite before labeling a semen sample as abnormal is to rule out irregularities in the method of sample collection. For the purpose of testing, the male partner needs to collect the sample after 3 - 5 days of abstinence from sexual intercourse. The entire ejaculate should be collected in a non-toxic, sterile and wide container by direct masturbation and delivered to the laboratory within 1- 2 hours of collection. Bypassing this simple step could result in unnecessary stress to the male on account of the sample being labeled as abnormal. Two samples collected at an interval of 1- 3 weeks (as per WHO) need to show abnormal findings in order to consider the cause of infertility as being due to the male.

As a first step, certain contributing factors to the abnormality such as occupations (exposure to industrial or environmental toxins and excessive heat), stress and illnesses, habits such as smoking and alcohol need to be rectified. The presence of infection in the semen confirmed on a culture of the same, calls for antibiotic treatment. Very often these simple measures suffice to restore normalcy to the semen.

• If abnormalities in the semen persist even after these, the male needs to be examined by an urologist, preferably one who specializes in infertility. Specific tests are done to diagnose the cause. These include:
• Hormonal evaluation - Measurements in the blood of certain substances called hormones, which regulate sperm production and maturation.
• Blood karyotyping - to analyze chromosomes for the presence of genetic defects.
• Transrectal ultrasonogrphy /vasography - to visualize the testis and the male genital tact.
• Testicular biopsy - to study the cells in the testis.

Treatment then largely depends on the cause, which briefly is as follows.

• Azoospermia - The semen contains no sperms, either because they are not produced at all or they are not transported because of a block in the reproductive tract.
• Oligospermia - A low sperm count, posing a problem to fertility.

Treatment options in both the above range from administration of gonadotrophins and androgens, surgical corrections in case of obstruction, or in-vitro fertilization + micromanipulation. In oligospermia treatment with clomiphene citrate may improve sperm count.

• Presence of antisperm antibodies: These antibodies can be produced by either partner. They target the sperm and render them incapable of conception. These antibodies can be detected by specialized tests on the blood (serum) or sperm. High-dose corticosteroid regimens and ejaculating into a buffer solution have been found to be useful treatments.
• Coital disorders such as impotence, ejaculation failure or retrograde ejaculation, low libido can result in infertility. In these instances diagnosing and treating the cause (where possible) is necessary. If sexual performance cannot be improved, artificial insemination of the wife with a good quality semen sample from the husband (AIH) will help. Treatment of retrograde ejaculation is by separation of sperms from the post ejaculatory urine followed by intrauterine insemination (IUI).
• Varicocoele: This is an abnormal dilatation of the vein draining the testis. Surgical repair alleviates this problem.
• Finally there is a group of causes, which cannot be treated. To name a few they are undescended testes, Klinefelter's syndrome, and therapy for cancer, which may have damaged the testis. Undescended testis referred to, as cryptorchidism is a developmental defect where the testis remains outside the scrotum. Klinefelter's syndrome is a chromosomal disorder where the testes are small in size, the breasts are big and the male has a eunuchoid habitus. The choice is either adoption or artificial insemination donor (link) (AID). In the latter frozen sperm specimens from reputable semen banks should be used rather than fresh donor semen specimens.

Any treatment given to improve semen quality should be expected to show results roughly 3 months after it is started, as this is the time period required for a single cycle of spermatogenesis (sperm production).

It is important to bear in mind that men need psychological counseling just as much as women. As the man is less likely to verbally express his difficulty, an identification of a fertility problem could manifest as depression, denial or some other inappropriate behavior. Hence he needs to openly discuss the issues at hand with the infertility specialist.