Dr Alex Danso Consultant Urologist
Since Biblical days, childlessness in couples has been a distressing situation and has always been considered as a female problem.
So we read for instance that “The Lord had closed the womb” of the female but today a lot more light has been shed on this problem and it is known that 30-42 percent of the problem lies squarely at the doorstep of the male.
This male problem of infertility is termed the Male Factor. The good news is that today a lot can be done to help out if you consult your doctor .
What is infertility?
Infertility or sub-fertility is defined as inability to achieve pregnancy/conception after one year of unprotected sex!
For us to understand infertility, we need to understand the simple process of fertility
Sperm are made in the testicles and are stored inside the epididymis, which lies on top of each testicle. Sperm are nourished by semen, which is made by glands along the way. During ejaculation about 150 million sperm are released in about three millimetres of semen through the penis.
This whole process is dependent on having proper levels of testosterone and other hormones as well as correct signalling from the nervous system.
Therefore, any disturbance in the process of production, in the storage and in the transport of the semen into the urethra as well as the expulsion out of the urethra can cause infertility
Women ovulate — send an egg down into the uterus — once a month. This happens about 14 days after menstruation. Sex any time in the five days before ovulation can create a pregnancy. Sex any other time, even the next day after ovulation, will not result in conception.
Causes and Contributory Factors
Here are some of the factors contributing and causing infertility:
- Varicoceles: A condition in which there is abnormal collection of bulging veins on a man’s testicles. These feel like a bag of worms and are large and cause them to overheat. (an increase in the intrascrotal temperature by 1.5 degrees for 5 weeks will render a decrease of the mean sperm count by 50 percent) The heat may affect the number or shape of the sperm. The varicocele, however, is the most common cause of correctable infertility.
- Undescended testicle: A condition where the testis has not descended into the scrotum and lies outside the scrotum resulting in the testis being exposed to different temperatures
- Testicular failure: A condition where the testis fails to manufacture the sperm.
- Trauma: When the testis is exposed to trauma
- Infections in the testicle (orchitis), the prostate (prostatitis), or elsewhere in the body that causes a fever.
- Cystic fibrosis.
- Medical conditions such as diabetes.
- Or treatment with chemotherapy or radiation.
- Heavy alcohol use.
- Testosterone supplementation.
- Anabolic steroid use, and illicit drug use.
- Environmental toxins including exposure to pesticides and lead.
- Chemotherapy for cancer.
- Medicines such as anti-seizure medicines.
- Genetic abnormalities.
- Hormone problems.
In some cases, these problems can be reversed, but for us to be certain of which one can be reversed a doctor’s evaluation is necessary .
Sometimes, making sperm isn’t the problem. The problem is getting the sperm where they need to go. Men with this type of male infertility have normal sperm in the testicles. But the sperm in the semen are either abnormal, very low in number, or not there at all. Causes of this kind of infertility include:
- Retrograde ejaculation: In this condition, semen ejaculates backwards into the bladder instead of out the penis. Usually previous surgery of the prostate gland and bladder neck surgery are the cause.
- Absence of the main sperm pipeline known as the vas deferens. This condition is a genetic problem.
- Obstruction: An obstruction can occur anywhere in the plumbing between the testicles and the penis. Infections can cause this.
- Anti-sperm antibodies: Antibodies can abnormally attack a man’s own sperm on their way to the egg.
Up to 25 percent of infertile men have idiopathic infertility. That means they have abnormal or low sperm counts for no identifiable reason.
Intercourse related causes
Diagram of the appropriate conception times in a women’s monthly ovulatory cycle.
Only about 20 percent of young men actually know the exact time to have sex during the female cycle to achieve a pregnancy. The critical period can be assessed by either basal body temperature charting or home kits that detect the LH surge in the urine immediately (24 hours) prior to ovulation.
Since sperm reside in the cervical mucus for 48 hours and are released continuously, it is not necessary that coitus and ovulation occur at the exact same time.
Another issue is how often to have sex to conceive. Ejaculation has to occur frequently enough to bracket the ovulatory period. Sex every other day around this period is recommended.
Recent evidence also suggests that most couples become pregnant from intercourse before ovulation rather than after ovulation.
The level of sexual stimulation prior to ejaculation is important to the quality of ejaculation.
Medications and Toxins
Medications are usually extensively tested for their potential as reproductive hazards before marketing. Despite this, it is wise to discontinue any unnecessary medications that can be safely stopped during attempts to conceive. .
Medications to avoid while trying to conceive.
Calcium channel blockers, Allopurinol
Cimetidine, Alpha blockers
Valproic acid, Lithium
Finasteride (Propecia, Proscar) Testosterone Supplements
Lubricants should also be avoided if possible; Surgilube, K-Y jelly and saliva should definitely not be used as they may contain antiseptics that hurt sperm. If necessary, vegetable oils such as olive oil appear to be the safest. Other toxins include heat exposure from regular saunas, hot tubs or jet tubs or baths, cigarettes, cocaine and alcohol. Marijuana can also lead to reversible depression of spermatogenesis.
What to expect when you visit the doctor with a problem of infertility .
Initially there will be a discussion between you and the doctor in which the doctor will try and elucidate the cause of the problem. This is only a conversation (History Taking)
In the physical examination the doctor will find out whether the man has:
- Varicoceles — bag of worms in the scrotum.
- Testicular agenesi-absence of testes.
- Undescended testes.
- Presence/absence of vas deferens.
- Klinefelter’s syndrome — the hair distribution , stature tall and thin , with enlarged breast (gynaecomastia) small rubbery testes.
Among further investigation may be:
Spermanalysis: Will describe the sperm production describe the number of sperms produced and the stage of their maturation, their shape and motility
Testicular biopsy: Will describe the stage of maturation, sperms develop in an average of 74 days from Spermatogonia to Spermatocytes to spermatids and to spermatozoa (which we call sperms). Biopsy will describe maturation arrest.
Hormonal profile: Will describe the normal and abnormal hormonal levels
Genetic profile: Will indicate genetic abnormalities like (Klinefelter’s syndrome — in which a male is born with two X chromosomes and one Y chromosome (instead of one X and one Y) — cause abnormal development of the male reproductive organs
Today a lot can be offered to deal with the male factor of infertility .
- Surgical treatment for varicocele . This is not a new treatment.
- Assisted reproductive technology. Today, assisted reproductive techniques (ARTs) offer powerful new options.
These high-tech and expensive male infertility treatments give sperm an artificial boost to get into an egg. ARTs have made conception possible even for men with very low or abnormal sperm.
First, sperm are collected either from ejaculated semen or by a needle from the testicle. They are then processed and introduced to eggs by different methods.
- Intrauterine insemination (IUI.)At the time of ovulation, sperm are injected directly up into the uterus. Medicines are usually given to the woman first to increase the number of eggs she releases.
- In-vitro fertilisation (IVF.) Sperm are mixed with multiple eggs collected from the woman in a “test tube” (actually just a plastic dish.). Fertilised eggs are then placed in the uterus. IVF requires at least some viable sperm.
- Intracytoplasmic sperm injection (ICSI.)A single sperm is injected through a tiny needle into an egg. The fertilised egg is then implanted in the uterus. ICSI can be performed when sperm counts are extremely low or abnormal.
- Hormonal Treatments: Specific Hyperprolactinemia
The normal role of prolactin in men is not clear, but it may keep testosterone levels high in the testis and help the growth and secretions of the sex glands.
Normal prolactin levels are important for normal sex drive and fertility as well. Hyperprolactinemia occurs when prolactin levels rise above normal and this is a medical condition that is routinely treated. Other reasons for elevated prolactin include stress during the blood draw, obtaining the blood test too soon after awakening (prolactin levels rise during sleep), illness in the body and medications.
Both high and low levels of thyroid hormone can affect sperm production. Thyroid issues account for 0,5 percent
of infertility but are very treatable. Because of their rarity, routine thyroid screening is not recommended for infertility patients.
Congenital Adrenal Hyperplasia
This congenital condition where there is a abnormal growth of the adrenal gland is known to cause infertility. in this condition the testes fail to mature and there is low production of Cortisol. A treatment with cortiscosteroids is appropriate in this condition.
There are conditions in which no or low testosterone is present due to abnormal hormone signalling in the brain (Kallman Syndrome). Infertility associated with these conditions can be effectively treated by replacing pituitary hormones. On the contrary, anabolic steroid use, commonly taken by college and professional athletes(pro-health young men), impairs sperm production and leads to zero sperm counts in most men. In this case, the steroids should be discontinued to reverse the problem.
Other Specific Medical Treatments
Elevated white blood cells in semen is termed pyospermia or leukocytospermia and is associated with (a) silent genital tract infection, (b) elevated reactive oxygen species, and (c) poor sperm function and infertility.
Sperm can be damaged by oxidative stress from leukocytes because the sperm have little inherent protective antioxidant activity.
The treatment of leukocytospermia is controversial without an obvious bacterial infection. When appropriate, the use of broad-spectrum antibiotics such as doxycycline and trimethoprim-sulfamethoxazole in combination with frequent ejaculation has been shown to durably reduce seminal leukocyte concentrations. Generally, the female partner is also treated.
Hormonal Treatments — Empirical
Empirical therapy can also be offered to men with infertility. These treatments are not necessarily disease-based, but tend to push the hormone axis harder than normal to make more sperm or add something that infertile men may be missing to improve fertility. As a rule, empirical therapy does not work as well as specific therapy in the treatment of infertility. Several examples of empirical therapy include:
This is a synthetic, non-steroidal drug that acts as an antiestrogen and binds to estrogen receptors in the brain. This blocks the action of the normally low levels of estrogen on the male hormone axis and causes increased output of reproductive hormones that increases testosterone production and (hopefully) sperm production.
Clomiphene is given for low sperm counts and is much less effective as a treatment for low motility. After starting, testosterone and FSH levels should be monitored at 2-4 weeks and the dose adjusted to keep the testosterone level within the normal range. Higher than normal testosterone levels may result in a decrease in semen quality.
A semen analysis is obtained at 3 months and at regular intervals thereafter. Therapy should be discontinued if no semen quality response is observed in 6 months.
Clomiphene therapy is relatively safe with the following side effects occurring in less than 5 percent of patients: breast tenderness, upset stomach, weight gain, dizziness, visual complaints, change in sex drive (more) and skin reactions.
Gonadotropins (hCG, FSH)
This treatment concept is simply the idea that “if some is good, more is better.” Human chorionic gonadotropin (hCG), human menopausal gonadotropin (hMG) or pure forms of FSH are most commonly used. They tend to increase the hormonal drive to the testicle to make testosterone (hCG or LH) or sperm (FSH). Serum testosterone levels and semen analyses are monitored and drug doses adjusted accordingly.
These medications are safe, but can be very expensive and are all taken as injections. Therefore, there is a risk of scarring and infection at injection sites. Mood and libido changes and acne can occur. There is evidence to suggest that sperm concentration may rise with treatment.
From an evidence-based viewpoint, this therapy is useful in limited situations.
There is evidence that up to 40% of infertile men have increased levels of reactive oxygen species (“oxidants”) in the reproductive tract. These are reactive molecules (OH, 02 radicals and hydrogen peroxide) that are thought to cause damage to sperm membranes and hurt fertility.
Treatment with scavengers of these radicals may protect sperm from oxidative damage. This kind of treatment may be useful for cases of unexplained low motility on the semen analysis. They are also used to reduce levels of fragmented DNA in sperm.
Generally, antioxidants are found in vitamins and other nutritional supplements, which, although expensive, have minimal side effects. The best-studied fertility supplements are vitamins E and C, acetylcysteine and glutathione. Folic acid is an important micronutrient well studied for its effects on preventing neurologic problems in the embryo.
It is involved with RNA and DNA synthesis during spermatogenesis and has antioxidant properties. Folic acid supplementation may benefit certain groups of infertile men, especially tobacco users.
The trace element zinc plays an important role in testicular development, sperm production, and sperm motility. In fact, the zinc level in male genital organs is considerably higher than that in other tissues. It is made by the prostate and is also found in maturing sperm.
Zinc deficiency has been linked to low sperm counts in men, but large randomized studies of zinc supplementation in infertile men are lacking. L-Carnitine and acetyl-L-carnitine are highly concentrated in the epididymis and are important for sperm maturation.
In studies of infertile men, there have been significant improvements in sperm quality (sperm concentration and forward motility) in men taking this supplement relative to men taking sugar pills. What has not been significant are improvements in pregnancy rates.
Chinese and Japanese herbal therapy has been used for centuries for a variety of maladies, including female infertility. Their application to treat male infertility, however, is very recent. There have been recent attempts to study these medications more scientifically to demonstrate exactly how they might improve male fertility.
How to preserve male fertility status. Is there something I can do or must not do?
Life Style Modifications
- Stress reduction
- Weight loss
- Quit smoking, drug
- Avoid environmental toxins
Exercises are good for sperm production . Modern literature confirms that exercises are good for increasing testosterone level and semen parameters. sedentary lifestyle leads to obesity and to low testosterone levels and to poor sperm parameters.
So Why Not Just Take Testosterone Tablets Or Injection?
Just giving testosterone is harmful . Exogenous testosterone will lower the spermproduction through the lowering of the gonadotropin hormones.
Effects of tobacco on fertility include testicular atrophy, poor and abnormal semen quality and quantity, elevated prolactin and oestrogen some IVF programs restrict smoking for 3months before sperm collection
Marijuana and cocaine impair spermatogenesis and reduce testosterone production.
Alcohol: Social alcohol intake does not affect fertility but chronic alcohol abuse reduces testosterone production, sperm production and induces erectile dysfunction, decreases libido and increases feminsation
Increase in intrascrotal temperatures do harm spermatogenesis A 1.5 degree Celsius increase of intrascrotal temperature for five weeks decreases the spermcount by 50 percent
So what should we be telling our patients?
Please please please avoid tight underpants. Avoid tight jeans!!
- Bibliography: Peter chan; Assisted reproductive technologies, The role of urologists. www.webmd/com/men www.mayoclinic.org