Infertility is defined as the inability to achieve pregnancy after one year of unprotected intercourse. An estimated 15% of couples meet this criterion and are considered infertile, with approximately 35% due to female factors alone, 30% due to male factors alone, 20% due to a combination of female and male factors, and 15% unexplained. Conditions of the male that affect fertility are still generally underdiagnosed and undertreated.
When infertility occurs, the male and female partners are evaluated to determine the cause and best treatment options. In the past, men with infertility had few options because there was limited information about causes and even less information about successful treatment. However, new tests have made it possible to determine the causes of male infertility and treatments, and assisted reproductive techniques offer hope to many couples.
The initial evaluation of the male patient should be rapid, noninvasive, and cost-effective, as nearly 70% of conditions that cause infertility in men can be diagnosed with history, physical examination, and hormonal and semen analysis alone. More detailed, expensive, and invasive studies can then be ordered if necessary.
Treatment options are based on the underlying causes and range from optimizing semen production and transportation with medical therapy or surgical procedures to complex assisted reproduction techniques. Technological advancements make conceiving a child possible with as little as one viable sperm and one egg.
A number of things can affect sperm count, ability to move (motility) or ability to fertilize the egg. The most common causes of male infertility include:
Abnormal sperm production or function due to various problems, such as undescended testicles, genetic defects or repeated infections.
Problems with the delivery of spermdue to sexual problems, such as premature ejaculation or painful intercourse; health issues, such as retrograde ejaculation; certain genetic diseases, such as cystic fibrosis; or structural problems, such as blockage of the part of the testicle that contains sperm (epididymis).Sexually transmitted diseases and tuberculosis can cause obstruction of the vas deferens or epididymis.
General health and lifestyle issues, such as poor nutrition, obesity, or use of alcohol, tobacco and drugs.
Overexposure to certain environmental factors, such as pesticides and other chemicals. In addition, frequent exposure to heat, such as in saunas or hot tubs, can elevate your core body temperature. This may impair your sperm production and lower your sperm count.
Damage related to cancer and its treatment. Both radiation and chemotherapy treatment for cancer can impair sperm production, sometimes severely. The closer radiation treatment is to the testicles, the higher the risk of infertility. Removal of one or both testicles due to cancer also may affect male fertility.
Age. Men older than age 40 may be less fertile than younger men.
In 30-40% of cases, no male infertility associated factor is found (idiopathic male infertility). These men present with no previous history of fertility problems and have normal findings on physical examination and endocrine laboratory testing. However, semen analysis reveals a decreased number of spermatozoa (oligozoospermia), decreased sperm motility (asthenozoospermia), and many abnormal forms of sperm (teratozoospermia). Thesesperm abnormalities usually occur together and are called oligo-astheno-teratozoospermia (OAT) syndrome.Idiopathic male infertility may be explained byseveral factors, including endocrine disruption as a result of environmental pollution, reactive oxygen species, or genetic abnormalities.
A semen analysis (sperm count) is a central part of the evaluation of male infertility. This analysis provides information about the amount of semen and the number, motility, and shape of sperm.
A man should avoid ejaculation (sex and masturbation) for two to seven days before providing the semen sample. Ideally, a sample should be collected in a clinician’s office after masturbation; if this is not possible, the man may collect a sample at home in a sterile laboratory container or chemical-free condom. The sample should be delivered to the lab within one hour of collection.
Blood tests provide information about hormones that play a role in male fertility. If genetic or chromosomal abnormalities are suspected, specialized tests may also be carried out.
Treatments for male infertility include:
Surgery – For example, a varicocele( abnormal enlargement of the veins in the scrotum) can often be surgically corrected or an obstructed vas deferens can be repaired.
Treating infections–Antibiotic treatment may cure the infection of the urogenital tract, but doesn’t always restore fertility.
Treatments for sexual intercourse problems – Treating conditions such as erectile dysfunction or premature ejaculation can improve fertility. Approaches can include medication or counseling.
Hormone treatments and medications – In cases where infertility is caused by high or low levels of certain hormones or problems with the way the body uses hormones, your doctor may recommend treatment with hormone replacement or medications that change hormone levels.
Assisted reproductive technology (ART) – For blockage of the vas deferens, retrograde ejaculation or other problems with sperm delivery, sperm can be taken directly from the testicle or recovered from the bladder and injected into an egg. The most common ART treatment is in vitro fertilization (IVF). This procedure involves surgically removing an egg from a woman’s ovary, combining it with sperm in the lab, and then placing the fertilized egg into the uterus.
Sometimes male fertility problems can’t be treated, and it’s impossible for a man to father a child. If this is the case, your doctor may suggest that you and your partner consider either using sperm from a donor or adopting a child.
There are a few steps you can take at home to increase your chances of achieving pregnancy:
Having sexual intercourse every other day may increase your chances of getting your partner pregnant. However, ejaculating more often than every 48 hours may reduce your sperm count.
A woman is likely to become pregnant during ovulation — which occurs in the middle of the menstrual cycle, between periods. It is generally recommended to have sexual intercourse every two days near the time of ovulation. This will ensure that sperm, which can live several days, are present when conception is possible.
Lubricants such as Surgilube, Keri lotion, KY Jelly, and saliva are spermatotoxic, whereas egg whites, peanut oil, vegetable oil, and petroleum jelly are not known to be spermatotoxic but still should be used in only the smallest amounts possible if needed for lubrication during intercourse.
The inability to become pregnant can lead to a variety of emotions, including anxiety, depression, anger, shame, and guilt. In one study, 40% of infertility patients suffered with some type of psychiatric disorder; the most common diagnosis was an anxiety disorder (23 %), followed by major depressive disorder (17%). Both men and women can suffer from these problems, which can further hinder a couple’s ability to become pregnant. Psychological distress is associated with infertility treatment failure, and interventions to relieve stress are associated with increased pregnancy rates.
The best approach for treatment of psychological distress related to infertility treatment has not been determined. However, some experts suggest relaxation techniques, stress management, coping skills training, and group support. Evaluation by a psychiatrist may be needed for some persons with significant symptoms of anxiety or depression.
Although assisted reproductive techniques may be able to overcome genetic or chromosomal abnormalities, there is a possibility of transferring the abnormality to a child. Genetic counseling is often recommended to educate a couple about the possibility of parent-to-child transmission, possible impact of the abnormality, and treatments available to prevent parent-to-child transmission.
By: Amissah Samuel, MD
Clinic (Hospital) Combine Southwest
Dept. of Urology
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