Male Infertility
What is Male Infertility?
Male infertility is the inability of a man to father a child. It is defined as a couple who have regular, unprotected sexual intercourse but fail to conceive after one year. In approximately half of couples experiencing difficulties conceiving, the man is found to have some form of infertility. In such cases, tests reveal that the man's sperm is abnormal.
How Does the Male Reproductive System Work?
The male body produces small cells called sperm. During sexual intercourse, ejaculation normally delivers the sperm into the woman's body.
The male reproductive system produces, stores and transports sperm. Hormones in your body control this process. Sperm and the male hormone (testosterone) are produced in the two testicles. The testicles are located in the scrotum, a pouch of skin below the penis. When sperm leaves the testicles, it enters a tube behind each testicle. This tube is called the epididymis.
Just before ejaculation, the sperm pass from the epididymis into another set of tubes. These tubes are called the vas deferens. Through these tubes, the sperm are transported to sacs behind the prostate called the seminal vesicles. During ejaculation, the sperm mix with fluid from the prostate and seminal vesicles. This mixture forms semen. The semen is then expelled through the urethra and out of the penis during ejaculation.
Male fertility depends on the body's ability to produce and transport sperm normally. Sperm enters the female partner's vagina and passes through the cervix to reach the uterus and fallopian tubes. If sperm and egg unite here, fertilisation occurs.
Types of Male Infertility:
The two main types of male infertility are:
1.Obstructive Type:
This occurs when blockages in the reproductive system prevent sperm cells from being transported from the testicles to the semen.
2.Non-obstructive Type:
Sperm quality is low.
In approximately 30-40% of cases, no specific cause can be identified; this is referred to as idiopathic or unexplained male infertility.
Causes of Male Infertility:
The production of motile, mature, and healthy sperm depends on many factors. Some problems can prevent cells from developing into sperm. Some problems can prevent sperm from reaching the egg. Even the temperature of the scrotum can affect fertility.
The main causes of male infertility are as follows:
- Sperm Abnormalities
- Varicocele
- Retrograde ejaculation
- Immunological infertility
- Hormones
- Chromosomal abnormalities
- Medications
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1.Sperm Abnormalities
The most common problem is with sperm production and maturation.
Sperm:
- May be underdeveloped.
- May have a malformed shape.
- They may have motility disorders.
- Very few may be produced (oligospermia).
- It may not be produced at all (azoospermia).
Sperm problems may be caused by congenital factors. Lifestyle choices can reduce sperm count. Smoking, drinking alcohol and taking certain medications can reduce sperm count. Other causes of low sperm count include long-term illnesses ( , kidney failure , etc.), childhood infections (mumps, etc.), and chromosomal or hormonal problems ( , low testosterone , etc.).
Damage to the reproductive system can lead to a reduced sperm count or no sperm at all. In some men with a completely low sperm count (azoospermia), there is a blockage in the ducts through which sperm pass. A congenital anomaly or infection may cause the blockage.
2.Varicocele
Varicocele is one of the most common causes of male infertility. Varicocele can be defined as the enlargement or swelling of the veins that collect blood from the testicle, resulting in a condition similar to varicose veins in the legs.
How it can affect your ability to have children:
- The swollen veins can overheat your testicles.
- This excess heat can lead to a decrease in sperm production and cause sperm to become weak or unhealthy.
- It can also affect the hormone levels necessary for healthy sperm production.
- As a result, varicocele can reduce your chances of having children.
Not all varicoceles cause problems, but if they do, treatments such as surgery can improve sperm health and increase your chances of having a baby.
3.Retrograde Ejaculation
Retrograde ejaculation is the backward flow of semen during ejaculation. Instead of exiting the penis, semen enters the bladder during ejaculation. This occurs when the nerves and muscles in the bladder do not close during orgasm (climax). The semen may contain normal sperm, but since it does not exit the penis, it cannot reach the vagina.
Retrograde ejaculation can occur due to surgery, medication, or nervous system problems. Symptoms include cloudy urine after ejaculation and less fluid or "dry" ejaculation.
4.Immunological Infertility
Sometimes the male body can produce antibodies that attack its own sperm. Antibodies are mostly produced due to injury, surgery or infection. Antibodies prevent sperm from moving and functioning normally. How antibodies reduce fertility is not yet fully understood. Antibodies can make it difficult for sperm to swim through the fallopian tube to reach the egg.
5.Hormonal Problems
Hormones produced by the pituitary gland tell the testicles to produce sperm. Very low hormone levels cause a decline in sperm cell production and development.
6.Genetic Disorders or Chromosomal Abnormalities
Sperm carries half of the DNA to the egg. Changes in the number and structure of chromosomes can affect fertility. For example, some parts of the male Y chromosome may be missing.
7.Medications
Some medications can alter sperm production, function, and transport. These medications are most commonly prescribed to treat the following health conditions:
- Arthritis-like joint diseases
- Depression
- Digestive problems
- Infection
- High blood pressure
- Cancer
Male Infertility Diagnosis:
1.Medical history and physical examination
Your doctor will discuss your health and surgical history with you and will want to know about anything that could reduce your fertility. These may include disorders of the reproductive system, low hormone levels, illnesses or accidents. They will ask questions about childhood illnesses, current health problems or medications that could impair sperm production. Factors such as mumps, diabetes and steroids can affect fertility. They will also ask about alcohol, tobacco, cannabis and other recreational drug use. They will ask whether you have been exposed to radiation, heavy metals (such as mercury, lead, arsenic) or pesticides. All of these can affect fertility.
During the physical examination, the entire urogenital system (penis, epididymis, vas deferens, testicles) is evaluated in detail. Your doctor will examine your testicles to check for varicocele. Varicocele can be easily detected through physical examination.
2.Sperm Analysis
A sperm sample is the fluid a man ejaculates during orgasm. It is analysed under a microscope to check how healthy the sperm are.
The test is performed at least twice if the sperm count is abnormal. Sperm is collected in a sterile container through masturbation. The sperm sample is examined. Factors that help or hinder conception (fertilisation) can be checked.
Your doctor will examine your semen volume, count, concentration, motility, and sperm morphology. The results of semen analysis tests provide important data indicating how well you can initiate pregnancy.
Even if a sperm test shows a low sperm count or no sperm at all, this may not necessarily mean permanent infertility. It may simply indicate a problem with the growth and movement of the sperm. Further testing may be required. Treatment may still be possible even if the sperm analysis shows no sperm.
3.Hormonal Profile
Your doctor may check certain hormone levels through a blood test. This is to find out how well your testicles are producing sperm. For example, follicle-stimulating hormone (FSH) is a pituitary gland hormone that tells the testicles to produce sperm. High levels may mean that your pituitary gland is trying to get your testicles to produce sperm, but they are unable to do so.
4.Transrectal Ultrasound
Your doctor may request a transrectal ultrasound if they suspect obstruction-type male infertility. Ultrasound uses sound waves reflected from an organ to produce an image of that organ. An ultrasound probe is inserted into the rectum. Transrectal ultrasound can reveal any malformations or obstructions in structures such as the ejaculatory ducts or seminal vesicles.
5.Testicular Biopsy
If the sperm count is very low or no sperm is found in the sperm test, a testicular may be necessary . This test can be performed under general or local anaesthesia. It is performed by making a small incision in the scrotum. A small piece of tissue is taken from the testicle and examined under a microscope. The biopsy has two functions. It helps to determine the cause of infertility and sperm cells can be obtained from it for use in assisted reproductive techniques (such as IVF, also known as in vitro fertilisation).
Male Infertility Treatment:
Treatment depends on the cause of infertility. Many problems can be resolved with medication or surgery. This makes it possible to conceive normally through sexual intercourse. Treatments for male infertility are divided into three categories:
1.Non-surgical treatment for male infertility
Surgical treatment for male infertility
Treatment for unknown causes of male infertility
1.Cases where treatment for male infertility is administered without surgery:
Many male infertility problems can be treated without surgery. Some of these conditions are as follows:
- Anejaculation (dry ejaculation)
Anejaculation is the failure of semen to be expelled during sexual climax. It is not a common condition, but it can occur due to the following reasons:
- Spinal cord injury
- Previous surgeries
- Diabetes
- Multiple sclerosis
- Other mental, emotional, or unknown issues
Medication is usually tried first to treat this condition. If medication does not work, there are many other options. Ejaculation can be achieved with penile vibratory stimulation (PVS) or rectal probe electroejaculation.
- Genital System Infection
Genital system infections are rarely associated with infertility. In such cases, the problem is usually detected in a semen test. White blood cells are found in the test. White blood cells cause the release of excessive free oxygen radicals. This can damage sperm cells and reduce the sperm's ability to fertilise the egg. Infections of the epididymis and testicles can cause the testicles to shrink and the epididymal duct to become blocked. Previous infections often cause blockages.
Antibiotics are usually prescribed to treat newly diagnosed infections. However, some antibiotics can damage sperm production or function. In some cases, non-steroidal anti-inflammatory drugs (such as ibuprofen) may be used instead.
- Hyperprolactinemia
Hyperprolactinemia is a condition in which the pituitary gland produces too much prolactin hormone. It can cause male infertility and erectile dysfunction. Treatment depends on the cause of the prolactin increase. If there is a tumour in the pituitary gland, medication or, more rarely, surgical treatment may be used.
- Hypoprolactinemic Hypogonadism
Hypo-gonadotropic hypogonadism is the inability of the testes to produce sperm due to insufficient secretion of pituitary hormones. This stems from a problem in either the pituitary or hypothalamus regions of the brain. It may be the cause of a small number of infertility cases in men. It may be congenital or develop later in life.
The congenital form, also known as Kallmann syndrome, occurs due to a decrease in gonadotropin-releasing hormone (GnRH) levels. GnRH is a hormone produced by the hypothalamus.
The acquired form may arise due to other health issues, such as:
- Pituitary tumours
- Head trauma
- Use of anabolic steroids
If hypogonadotropic hypogonadism is suspected, your doctor may request that you undergo an MRI scan of your pituitary gland. This will provide an image of your pituitary gland. A blood test will also be performed to check prolactin levels. Pituitary tumours can be detected through MRI and blood tests. If prolactin levels are high but there is no tumour in the pituitary gland, your doctor may first try to lower your prolactin levels. The next step would be gonadotropin replacement therapy. During treatment, blood testosterone levels and semen will be monitored. The chances of pregnancy after these treatments are very high.
- Genetic Conditions.
Genetic abnormalities causing male infertility are most commonly detected in men with no sperm in their semen (azoospermia). (e.g., Klinefelter syndrome – an extra chromosome in males or Y chromosome microdeletion – a small part of the genetic material is missing). In addition, some genetic conditions can affect the development of the male reproductive system that carries sperm, causing abnormalities in the formation of the ducts responsible for transporting sperm, which can lead to infertility.
- Retrograde ejaculation
Retrograde ejaculation, which is when semen flows backwards into the bladder instead of out of the penis, can have many causes:
- Prostate or bladder surgery
- Diabetes
- Spinal cord injury
- Antidepressants
- Certain antihypertensive medications
- Certain medications used to treat prostate enlargement
Retrograde ejaculation is diagnosed by checking whether there is sperm in your urine. This is done by analysing your urine under a microscope immediately after ejaculation.
Medications may be used to correct retrograde ejaculation.
If medications are ineffective and you require assisted reproductive technology (ART), your doctor may attempt to obtain sperm from the urine provided after ejaculation.
2.Surgical Treatment for Male Infertility:
- Microsurgical Varicocele Surgery
Varicoceles can be corrected with a procedure called varicocelectomy . Correcting these swollen veins improves sperm motility, count and structure. This procedure is often performed using microsurgical techniques.
- Microsurgical Vasovasostomy
When a reversal is desired after a vasectomy performed as a permanent method of birth control in men, the micro-surgical vasovasostomy method is used to reconnect the two severed parts of the vas deferens in each testicle.
- Microsurgical Vasoepididymostomy
Vasoepididymostomy connects the upper end of the vas deferens to the epididymis. It is the most common microsurgical method used to treat epididymal blockages.
- Transurethral resection of the ejaculatory duct (TURED)
This is a method in which ejaculatory duct obstruction is treated with endoscopic surgery. A cystoscope is inserted into the urethra (the tube inside the penis) and the narrowed or closed opening of the ejaculatory duct is opened with a small incision.
Assisted Reproductive Techniques
If the infertility treatments mentioned above are unsuccessful or not possible, there are other ways to achieve pregnancy without natural means. These methods are called assisted reproductive techniques. Depending on the type and cause of infertility, your doctor may recommend the following:
- Intrauterine Insemination (IUI): This involves placing healthy sperm into the woman's uterus via a tube. IUI is generally effective for low sperm count and motility issues, retrograde ejaculation, and other causes of infertility.
- In Vitro Fertilisation (IVF): This is the process of combining the female partner's or donor's egg with sperm in a laboratory environment in a Petri dish. For IVF, the ovaries must be stimulated to produce multiple eggs (ova). This is usually done with daily injections of medication. This allows for the retrieval of multiple mature eggs. After a three to five-day growth period, the fertilised egg (embryo) is transferred back into the uterus. IVF can be used in women with various hormonal disorders, blocked fallopian tubes, or idiopathic infertility (where there is no apparent cause for the fertility problem). In men, it is increasingly used in cases of azoospermia (absence of sperm) and oligospermia (low sperm count).
3. Intracytoplasmic Sperm Injection (ICSI): This is a type of IVF. A single sperm is injected into the egg using a small needle. After the egg is fertilised, it is placed in the woman's uterus. ICSI may be used if your sperm quality is very low, or if there are no mature spermatozoa due to an uncorrectable blockage or testicular failure. For this method, spermatozoa can also be surgically retrieved from the testicles or epididymis.
Sperm Collection for Assisted Reproductive Techniques:
TESE (Testicular Sperm Extraction)
A small tissue sample is surgically removed from the testicle to find sperm. This procedure is performed under local or general anaesthesia.
TESA (Testicular Sperm Aspiration)
Sperm is gently extracted from the testicle using a needle and syringe. This procedure is performed under local anaesthesia.
Micro-TESE
This is a more detailed version of TESE that uses a special microscope to find sperm in men with very low sperm counts. It requires general anaesthesia.
MESA (Microsurgical Epididymal Sperm Aspiration)
Sperm is collected directly from the epididymis (a small tube where sperm mature) using a microscope. This can be performed under local or general anaesthesia.
What is Sperm Freezing (Cryopreservation)?
Sperm freezing is the process of storing sperm samples for long periods under special conditions to preserve male fertility. It is particularly preferred before situations that may damage sperm, such as cancer treatment (chemotherapy, radiotherapy).
How is the procedure performed?
- The sperm sample is collected into a clean container.
- It is immediately frozen using special solvents to preserve its viability.
- This process halts metabolic activity to prevent cellular damage.
- When needed, the sperm is slowly thawed in water at 37–° °C to prepare it for use.
- Not all samples may remain viable after thawing, but most can be successfully used in fertility treatments.
Living with Male Infertility
A diagnosis of infertility can be a challenging process not only medically, but also psychologically and socially. However, you do not have to go through this process alone.
Emotional Effects:
Infertility can lead to intense emotions such as disappointment, guilt, and shame. These feelings are quite natural. Consulting with mental health professionals or support groups can help you cope with these emotions.
Communicating:
It is very important to talk openly and honestly with your partner. Infertility can create pressure in a relationship; however, sharing this process together can strengthen your relationship. Sharing your feelings with trusted friends and family can also make it easier to find support.
Parenting Options:
Infertility does not prevent parenthood. Assisted reproductive techniques such as IVF/ICSI, or alternative routes such as adoption, are available. You can find out which options are suitable for you by consulting a urologist specialising in reproductive medicine.
Stigma and Feelings of Isolation:
Male infertility is not discussed enough in society, so you may feel alone. However, millions of men worldwide are going through the same process. Joining support groups, seeing that you are not alone, and sharing your experiences with others can make this process easier.