MALE INFERTILITY

male infertility
Male Infertility

General Information

Male infertility accounts for 15% of infertility cases. Also male infertility may contribute to 30-40% of all infertility instances.  Because of this, couples who cannot get pregnant should apply to the clinic together. 
Couples who are unable to get pregnant after 1 year of unprotected, timed intercourse are regarded as infertile.  When one partner is over 35, then they can consider being evaluated for infertility sooner than one year.

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Male Infertility Reasons
  • Genetic
  • Hormonal
  • Environmental – working conditions. Wearing tight pants, truck drivers, window workers, bakers.  In working environments where the testes are subjected to high heat, the testes’ sperm production may be compromised.
  • Undescended testis.  Men who have bilateral undescended are infertile.
  • Immunological
  • Sexual and psychological
  • Infections: Gonorrhea, Tuberculosis, Chlamydia micoplasma and ureoplasma infections usually cause blockage in the sperm collecting ducts causing infertility.  Irreversible infertility is often caused by viral infections like Mumps that affect both testes.
  • Systemic infections (kidney and liver disease)
  • Trauma (physical injury)
  • Tumors in testes.  Drugs used for cancer therapy and radiotherapy will decrease sperm production.

 

When evaluating for infertility, semen analysis is the first test that must be done.  In order to standardize the results, 2-4 days sexual abstinence is recommended.

In the event that the results of the semen analysis are sub-normal, the test must be repeated one month later.  If the second test also shows sub normal results, then a physical exam and blood tests will be required.

The doctor will examine the penis, opening of the urethra, testes, epidydimis, and prostate. The patient’s body type, hair growth, genitalia will be examined in detail.  Sexual functions, erection – ejaculation and other habits that might result in infertility will also be evaluated.  Items below are also shown to cause infertility.

  • Smoking
  • Drinking excessive alcohol
  • Medications
  • Illegal drug use
  • Chemotherapy ( cancer drugs)
  • Radiation
  • Testes being exposed to heat for prolonged periods of time

 

  • The doctor can discern the congenital absence of the vasa deference (CAVD) during the physical exam.  Vasa deference is the sperm carrying tube that moves sperm from the testes to the urethra. The possibility of a genetic disease called Cystic Fibrosis must be investigated in patients when CAVD is observed.
  • If testes are smaller than normal then genetic diseases maybe the cause. Kleinfelter’s syndrome is a genetic condition where there genetic composition is 47, XXY and is characterized by small testicles.  These patients do not have sperm in their ejaculate but tissue biopsied from the testicles can contain sperm. When there are abnormalities in secondary sexual characteristics such as body hair, sexual dysfunction, hormonal problems such as hypogonatrophic hypoganadism should be investigated.
  • Cryptorchidism (undescended testicles):  Testicles descend into the scrotum at birth or one year after the birth at the latest.  The condition where one or both testicles have not descended into the scrotum is called Cryptorchidisim.  Testicles that remain in the abdomen are exposed to prolonged heat which breaks down sperm production.  Infertility is only caused by bilateral cryptorchidisim.
  • Varicocele: Caused by incompetent valves in the blood vessels around the testicles and like varicose veins in the legs, the veins in the testicles expand.  Sperm production is negatively affected by the reduced blood circulation and increased heat in the testicles.  Some people may need surgery to correct the condition.

Hormone tests are required if semen analysis is sub normal or if the patient has other endocrinological disorders such as diabetes. FSH and Testosterone are the most commonly tested hormones.  More detailed tests will be done if necessary.

FSH may appear to be normal in some patients with abnormal spermatogenesis. But an increased level of FSH in the serum is a sign of abnormal spermatogenesis.

Some patients may have their urine checked for the presence of sperm right after ejaculation.  Ultrasonography, the antisperm antibody test, cervical mucous interaction test are some of the more detailed tests they may be done on semen and sperm.

When looking at semen under a microscope, leukocytes and immature germ cells are difficult to tell apart.  These cells are labeled round cells. Many laboratories evaluate all the round cells as leukocytes and report them as such.

In such cases, doctors will evaluate the genital tract for infection.  Immunological tests also need to be done to determine whether the round cells observed are immature germ cells or leukocytes.

 

 

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Azoospermia

Azoospermia is the condition describing a complete lack of sperm cells in the ejaculate.  There is a 1% incidence in all men and 10-15% incidence in infertile men.  Azoospermia is divided into three categories: pre-testicular, testicular and post testicular.

  • Pre testicular azoospermia usually has endocrinological causes which affect spermatogenesis.  Hypogonadotrophic hypogonadism can cause azoospermia but can be treated with hormone replacement therapy.
  • Primary testicular failure applies to problems relating to the testicles specifically.
  • Post testicular problems usually relate to ejaculation dysfunction or obstruction in the ducts. Incidences of this nature are found in 40% of the cases.

 

Pre and post testicular abnormalities are treatable.  Testicular failure is irreversible.  Varicocele is excluded from this group however.

Another way of categorizing azoospermia is by dividing up groups based on whether or not the ducts are blocked.

  • Obstructive azoospermia: Although there is sperm production in the testes, the ducts which move the sperm are blocked (e.g. due to a previous infection). These patients can have cells removed from their testes or surrounding ducts with the help of an injector and fine needle.
  • Non-Obstructive Azoospermia:  In this case there is no sperm production, or tissue biopsy indicates immature cells do not complete the maturation process. This type of azoospermia maybe due to several reasons: undescended testicles, genetic or environmental reasons are some.  Doctors take small samples of tissue from the testicles by making small incisions or using a fine needle to aspirate.  The samples are then examined for sperm cells.

TESA: TEsticular Sperm Aspiration
TESE: TEsticular Sperm Ekstraction
PESA: PErcutaneousr Sperm Aspiration
MESA: Microsurgical Epydydimal Sperm Aspiration

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Normal semen analysis values
Volume: between 1.5-5ml
Concentration: 15 million /ml
Motility:  over 50%.
Morphology: over 30% according to  WHO or 14% and over according to  Kruger’s Strict Criteria.
Progressive motile: must be over 20 %

 

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Varicocele

The veins surrounding the testicles expand and result in an increased temperature which is believed to negatively affect sperm production.  Surgery may be required to correct the condition.

Men who have varicocele are not infertile but 1/3 of infertile men have varicocele.

Normally varicocele is seen in 15% of the general population whereas 40% of infertile men have varicocele.  The doctor will examine the patient both in an upright position and while the patient is lying down. Palpation done when the patient standing will feel like a sack of worms but this feeling will decrease or disappear when the patient is lying down.

Varicocele can only be treated surgically.

Indications for varicocele surgery:

If sperm parameters are normal then surgery is performed if it causes discomfort or for cosmetic reasons (if it is large).

Young men should have yearly examinations even if their sperm parameters are normal to monitor any changes and operate before the problem progresses.

When children are diagnosed with varicocele:

  • If there is asymmetry in testicular size,
  • Abnormal semen results accompanying clinical findings,
  • If the child complains of swelling, feeling of heaviness or testicular pain,
  • Or if varicocele affects both sides then it should be operated on.

When the male partner is infertile then his female partner’s age gains importance.  If the woman’s age is close to 40 then the couple may not have time to wait for the results of varicocele surgery.  If the varicocele is not painful, artificial reproductive technology might be a quicker solution.

Young infertile patients may also benefit from varicocele surgery.

If the female partner is also infertile then the couple will need treatment for infertility which obviates the need for varicocele surgery except for cosmetic reasons.

Some of the possible complications of varicocele correction surgery are: infection, hydrocele, varicocele persistance and recurrance.

Semen analysis must be done every three months after varicocele correction surgery for one full year minimum or until the couple achieves pregnancy.

Surgical Techniques:

There are a varieties of procedures for varicocele treatment. Retroperitoneal, inguinal (an incision is made in the groin area), microsurgical, making sub inguinal cut near the scrotum, laparoscopic ligation or blocking the veins with radiation (embolization) are some of the methods.  The ultimate goal is to perform the treatment that best fits varicocele type and has the least chance of reccurrence.  Ligating veins near the scrotum with the aid of a microscope (microsurgical varicocelectomy) appears to be the most successfull treatment.  This method also has less post operative pain.

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Surgical Technique

Incidence of hydrocoele

Recurrence

Cost

Retroperitoneal

%7-10

%9-11 (artery preserved)
<%3 (artery not preserved)

Low

Inguinal

%3-7

%9-12

Low

Inguinal Microscopic

<%1

%0,6-2.1

Modarete

Laparoscopic

%1.25

%9
%1.25 in young patients

Expensive

Embolisation

 

%19

Expensive


Varicocele and Azoospermia:

Some studies suggest that azoospermic men with clinical type varicocele might benefit from varicocele surgery.  According to research results 50% of patients show resumption of spermatogenesis and 20% report spontaneous pregnancy.  Testicular biopsy done before or during surgery will give the doctors an idea of the sucess of the procedure.  Men who have immature sperm cells may start sperm production but patients who had no spermatogenesis, previously, do not start producing sperm after varicocele treatment.  Consequently azoospermic patients with varicocele who have begun infertility treatment, and have sperm cells found in testicular biopsy, should be treated for varicocele even if they get pregnant through IVF.

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