New Delhi: Infertility is on the rise and is reaching epidemic proportions. It is a burning problem affecting young couples who are at the prime time of their life and career with social and economic implications. According to the World Health Organization, around 60-80 million couples worldwide suffer from infertility, and the male factor accounts for 40-50% of the cases.
Basis of male infertility
Medical literature shows that sperm quality is clearly declining over the past 30 years and the reasons are not completely understood. Causes of male infertility include low sperm counts (oligospermia), azoospermia (absent sperms in semen) or problems with sperm motility (asthenospermia) and poor quality sperms. Low sperm counts happen due to varicocele (enlarged veins around testis), lifestyle diseases, obesity, testosterone and male reproductive hormone deficiency and also some men have a genetic cause for low sperm counts. There can also be a block in the sperm passage which leads to either absent or very low sperm output from the testes. Erectile or ejaculatory issues can also contribute to infertility. Couples may face difficulty in penetration and there are occasions where successful penetration has not happened.
Couples who are unable to conceive are extensively evaluated and this is usually centred around the female partner. The male undergoes a semen analysis and is often the only test widely practised to test the man’s reproductive potential. It is also important to understand that couple evaluation approach is important and sometimes both partners are completely normal yet infertile.
How to go about male fertility evaluation?
This starts with a thorough history and physical examination of the male partner and also in the presence of the female partner which gives new insights about the problem. History involves important questions like duration of marital life, the frequency of intercourse, the couple’s knowledge and understanding about the concept of fertile period and mating during this period, any issues related to erection or ejaculation and also regarding any issues in the female partner during a sexual intercourse. History also dwells deep into past medical and surgical history, habits, work shifts, prior exposure to radiation and chemicals and non-communicable diseases like diabetes mellitus and hypertension.
During physical examination of the male partner, attention is paid to the penile anatomy, penile foreskin related issues, testis size, any pain or inflammation of the spermatic passage and presence of a varicocele. Examination also includes assessing the body mass index, body habitus, hair pattern and markers of metabolic syndrome.
Semen analysis: This is by far the most important and commonest test performed for fertility assessment in the male. Semen analysis requires preparation and clear instructions should be given to men who take this test. Period of abstinence, method of semen collection, attending to queries and difficulties during collection and allaying their anxiety go a long way in giving a good semen sample for the test. Reports may fluctuate and be a source of confusion in case of sampling errors. The semen volume, pH, consistency, sperm counts, motility and shape and the presence of infection in the form of pus cells give an idea about the male’s sperm parameters.
Male hormones: It includes testosterone and follicle stimulating hormone most importantly, and screening for diabetes mellitus. Other blood tests include luteinising hormone and estradiol levels. These reports give us an idea about the ability of the testis to respond to signals from the brain which controls sperm production by the testis.
Imaging tests: There is limited role for use of ultrasound imaging in male fertility. It includes performing a scrotal scan (doppler) to see for the testicular anatomy, varicocele and specific abnormalities. The other scan which is prescribed for men with infertility, especially with azoospermia or ejaculatory issues is a transrectal ultrasound and sometimes a MRI to look for the sperm passage, that is, the ejaculatory ducts and the vas deferens.
Genetic evaluation: The next step is to perform a genetic evaluation especially in men with azoospermia or very low sperm counts. The tests are different for men with non obstructive and obstructive types. In non obstructive type of azoospermia where sperm production is defective, the tests include karyotyping, Y chromosome microdeletion and more recently a genetic panel (includes 200+ genes) is performed in select men. In men with obstructive azoospermia, genetic evaluation includes testing for cystic fibrosis.
Treatment options: This includes medical and surgical options. Medical treatment is based on the male hormone levels and sperm counts. Surgical treatment is useful in men with varicocele. The most successful surgical option for varicocele is microsurgical varicocelectomy where an operating microscope is used to identify the enlarged veins and interrupt the flow. The operating microscope aids in preventing damage to vital structures like the vas deferens (sperm passage) and the testicular artery that supplies the testis. An intraoperative Doppler can be used to confirm the testicular artery.
For non obstructive azoospermia, sperms can be retrieved using a needle (testicular sperm aspiration) or by a special operation called micro dissection testicular sperm extraction (microTESE). MicroTESE is the most sophisticated operation to obtain sperms from the testis in men with non obstructive azoospermia where the production is defective. This operation can be successful even in men where sperms were not available during retrieval with a needle. Here the testis is opened under the operating microscope (as mentioned above) and the probable sperm containing areas are identified and these tubules are picked and given to the embryologist, who extracts sperms and uses it for ICSI. In ICSI, the sperm is injected into the egg retrieved surgically from the wife and an embryo is formed.
For men with obstructive azoospermia, if there is a block, it can be corrected by microsurgical vasoepididymal anastomosis which is a highly complex operation connecting the sperm passage from the testis (epididymis) to the vas deferens, In men who had undergone vasectomy, vasectomy reversal is possible using the operating microscope (microsurgical vasovasostomy) and can lead to successful appearance of sperms in the semen in most cases.
Male sexual dysfunction: Medical or hormonal therapy, intrapenile injections and penile prosthesis are operations which can help in improving the erection and successful pregnancy especially when the husband and wife are otherwise normal and have normal sperm counts. Some men are otherwise normal, but have difficulty in performing during the period of ovulation. They should be comforted, counselled and optimal medical therapy should be initiated to overcome the situation. This itself can be the cause for infertility in some couples.
All things considered: Finally it is important to note that both partners need to be evaluated, and the treatment is tailored according to the age of the partners, duration of married life and the male’s treatment plan is decided based on the female partner’s reproductive status. Reducing stress and anxiety about conception, appropriate management of diabetic status and correction of non-communicable diseases, proper understanding of both partners’ parameters and careful detailed discussion with the couple regarding treatment options including assisted reproduction as appropriate would be the key to success in couples with infertility. Whenever genetic, a thorough genetic counselling with experts is mandatory. With the advent of preimplantation screening and rigorous first trimester screening, the incidence of congenital anomalies can be kept to a minimum in these couples.