Male Infertility

What is Male Infertility?

Male Infertility is defined as the inability of a male to contribute to pregnancy in a fertile female even after 1 year of unprotected sex. A number of factors can contribute to Male Infertility and in roughly about 1/3^rd of the cases of couples who don’t conceive, male fertility is discovered to be the cause.

Is Male Infertility condition a Medical emergency?

Male Infertility is not a medical condition.

Causes

Male Infertility can be caused by a number of factors including genetic, environmental, and medical causes. They may also be broadly categorized as obstructive and non-obstructive causes.

Some of the common causes of Male Infertility include:

• Abnormal sperm production: This may include aspermia (complete lack of semen), Hypospermia (reduce the volume of semen), oligospermia (low sperm production), azoospermia (absence of sperm production), teratospermia (presence of abnormal sperm in semen), asthenozoospermia (low motility of sperms in seme), necrozoospermia (all sperms in the semen are dead), leucospermia (high levels of white blood cells in the semen):
  • Genetic defects: Klinefelter syndrome, Y chromosomal infertility
  • Undescended testicles
  • Infections such as mumps, HIV, gonorrhea, chlamydia, malaria
  • Varicocele
  • Hydrocele
  • Trauma
  • Testicular tumors
  • Endocrine disorders such as hypopituitarism
• Abnormal or dysfunctional delivery of sperm:
  • Vas deferens obstruction
  • Ejaculatory duct obstruction
  • Cystic fibrosis with absence of vas deferens
  • Prostatitis
  • Retrograde ejaculation
  • Hypospadias
• Environmental and medical causes:
  • Presence of anti-sperm antibodies
  • Smoking
  • Alcohol
  • Recreational drugs like marijuana
  • Anabolic steroids
  • Exposure to pesticides and toxic chemicals
  • High blood pressure
  • Uncontrolled Diabetes
  • Depression disorders
  • Chemotherapy
  • Radiotherapy

Risk factors

Factors that increase the risk of Male Infertility include:

• Obesity
• Smoking
• Alcohol and recreational drug abuse
• Uncontrolled high blood pressure and diabetes
• Frequent exposure to high temperatures
• Trauma
• Certain medications such as chemotherapeutic agents, cimetidine, spironolactone, nitrofurantoin, sulfasalazine, and phenytoin
• Celiac disease
• Strenuous activities such as bike riding, horseback riding
• Family history of infertility

Symptoms & signs

The main sign of Male Infertility is the inability to induce pregnancy in a fertile female even after 1 year of unprotected intercourse. Other symptoms related to underlying conditions may or may not be apparent.

Investigations

Some investigations that are done to evaluate Male Infertility include:

• Laboratory tests:
  • Semen Analysis: Which includes:
    • Ejaculate volume: Normal is 1.5 – 5ml
    • Semen quality: Normal coagulation and sperm agglutination is checked
    • Sperm density: Normal density is greater than 15 - 20 million sperm/ml
    • Sperm motility
    • Sperm morphology
    • The presence of white blood cells in the semen may suggest infection
    • Levels of zinc, acid phosphatase, citric acid, and alpha-glucosidase are checked to evaluate gland failure or obstruction
  • Antisperm antibody test
  • Complete hormonal assay: Including FSH, LH, Testosterone, and Prolactin
• Imaging Tests:
  • Transrectal Ultrasonography (TRUS): In individuals with oligospermia and azoospermia
  • Scrotal Ultrasound: To evaluate the testis, epididymis, and the spermatic cord
  • Vasography: To assess the different ducts
• Other tests:
  • Post-coital test: Examination of the female cervical mucus for the presence or absence of sperm
  • Hypoosmotic Swelling Test: To differentiate between viable, immotile sperm versus dead sperms
  • Vitality stains
  • Inhibin B test
• Testicular biopsy

Diagnosis

A diagnosis of Male Infertility is established based on medical history, clinical evaluation, and results of the investigations done.

Treatment options

Treatment of Male Infertility depends on identifying the underlying cause and treating it. Medical management and surgical interventions may be required depending on the cause of infertility.

Medical management

Medical management of Male Infertility may include:

• Hormonal Therapy: For the management of endocrinal causes:
  • Pulsatile GnRH therapy: For hypogonadism with intact pituitary function
  • Estrogen modulators: Useful in individuals with low testosterone levels
  • Clomiphene citrate: Useful in individuals with hypogonadotropic hypogonadism
  • Tamoxifen: Useful in improving sperm motility, sperm concentration, and pregnancy rates in men with infertility of unknown cause
  • Dopamine agonists: Treatment of individuals with high levels of prolactin
  • Imipramine: For retrograde ejaculation
  • Pseudoephedrine: For retrograde ejaculation
  • Zinc, Vitamin C, Vitamin E and Folic Acid supplementation

Interventional including surgery and indications for surgery

Surgical interventions may be needed for the management of Male Infertility under for the treatment of certain conditions and the procedures may include:

• Varicocelectomy: For the management of varicocele
• Varicocele embolization: For the management of varicocele
• Vasovasostomy or Vasoepididymostomy: If there is obstruction of the vas deference or the epididymis
• Tranurethral Resection of the ejaculatory ducts: If there is an obstruction of the ejaculatory ducts
• Sperm retrieval techniques and assisted reproduction techniques include:
  • Testicular sperm extraction
  • Electroejaculation
  • Artificial insemination
  • In vitro fertilization
  • Gamete intrafallopian transfer (GIFT) and Zygote intrafallopian transfer (ZIFT) procedures
  • Intracytoplasmic sperm injection (ICSI)

Role of diet/ Exercise/ Lifestyle changes/ Preventive measures

Some measure that can be taken to manage and prevent Male Infertility include:

• Cessation of smoking
• Limiting or moderating the consumption of alcohol
• Avoiding the use of recreational drugs
• Avoid high-temperature exposure to the groin area
• Eating a good balanced diet
• Maintaining an ideal body weight
• Consuming a diet high in antioxidants and vitamins C & E
• Adding zinc, and selenium to the diet
• Avoiding the use of spermatotoxic lubricants during intercourse
• Maintaining a good frequency of intercourse and engaging in intercourse every 2 days during mid-cycle can increase the probability of conception
• Using protective gear when engaging in sports or physical activities that increase the risk of injury to the groin area

Complications

Complications associated with Male Infertility include:

• Inability to induce pregnancy in partner
• Depression

Prognosis

The prognosis for Male Infertility depends on the underlying cause and varies between individuals. Some underlying causes of infertility have a better scope of management and better prognosis.

When to contact the doctor or hospital? / How to identify the emergency or complications?

It is advisable to seek medical attention if there is an inability to conceive even after 1 year of unprotected sex.

Indications for hospitalization if required

Brief hospitalization may only be required for the management of some causes of Male Infertility when surgical interventions are advised.

Suggested clinical specialist/ Departments to consult for this condition

• Urology
• Endocrinology