What is Male Infertility?

Male infertility is quite common these days . One third of the cases are caused by male infertility. The sperm count may be low ,nil or the sperms may have decrease motility or they may be abnormal in shape. The main cause is low sperm count. We follow WHO 2010 criteria for semen analysis (mentioned below).

Semen analysis is the foremost simple and diagnostic investigation for male infertility.

Semen Collection is preferably to be done at IVF Centre only. It requires:

  • Abstinence for 2 to 3 days
  • Sample collection preferably by masturbation at the centre .
  • Keep sample at body temperature (37oC)
  • Avoid normal condoms or lubricants

WHO criteria for normal semen values :-

The various semen abnormalities may be:

  • Oligospermia – When the semen count is < 15 M/ml
  • Azoospemia – No sperm in the ejaculate
  • Aspermia – When there is no ejaculate
  • Asthenospermia – When the sperm motility is less
  • Teratospermia – When the sperms are abnormal in shape
  • Oligoaesthenoteratozoospermia – When the semen count is low, the motility is less and they are abnormal in shape

How to proceed with abnormal semen analysis?

We perform a repeat semen analysis 2 months after the first report. If the previous report mentions azoospermia, we confirm Azoospermia by centrifugation of a semen specimen at 3,000 g *15 min and examine the pellet under high power. Many a times we have observed sperms in centrifuged samples, where the previous reports have mentioned azoospermia. We have an integrated team of Urologist and Psychologist and Endocrinologist and the male partner is evaluated by an urologist who takes a detailed history and examines the male partner. Confidentiality is maintained. A thorough history is taken, noting occupational history or any exposure to high temperature and environmental toxins, any prolonged illness or surgery done before, history suggestive of any sexually transmitted diseases, coital frequency or any ejaculatory dysfunction. His weight and height are taken and his genitalia are examined for Testis, Epididymis, Vas Defrens and Prostate.

What are the tests done in case of Azoospermia or severe Oligospermia?

In most of the cases, the history and examination is suggestive of diagnosis and tests are done according to the diagnosis. Only minimal and indicated tests are done and unindicated and unnecessary tests are not done at our centre.

To confirm the diagnosis, we usually do

  • Hormone Testing – S.FSH, S. Testerone, S.Prolactin to categorize whether its pretesticular, testicular or post testicular cause of Azoospermia
  • Genetic Profile – Karyotype is done to rule out Klienfelters syndrome, Y chromosome microdeletion, Cystic Fibrosis Gene Mutation
  • Imaging – Scrotal, Trans-rectal ultrasound is done and any abnormality of testis, testicular volume, vas defrens, prostate is noted
  • Post Orgasmic Urine analysis – It is done to rule out retrograde ejaculation. Presence of any sperms in the urine confirms Retrograde Ejaculation
  • Semen Culture – To rule out any infection causing abnormal semen analysis

What is the treatment of male infertility?

The treatment is specific to the cause. In general, Patients are advised:

  • Lifestyle Modification
  • Weigh Reduction for obesity
  • Decrease alcohol and Smoking
  • Loose fitted undergarments
  • Avoid Occupational exposure to heat, sauna or hot tub use and use of anabolic steroids

2. Medical Treatment
The drugs work in cases like

A. Hypogonadotrophic Hypogonadism (HH) – It’s a condition where 2° sexual characters are absent, testis are small and there is azoospermia. The levels of FSH, LH & Testosterone are very low. Treatment for these patients is simple. Injectios of hCG (1,000-2,000 IU) IM are given twice or thrice weekly along with FSH injections for 6-24 months. Testicular growth occurs in almost all and spermatogenesis occurs in 80—95% of patients without undescended testes.

B. Pyospermia – Antimicrobial therapy is given in cases of pyospermia; where there are ≥ 10 M/ml of peroxidase positive white blood cells (WBCs ). However it only eradicates microorganisms. It has no positive effect on inflammatory alterations and/or cannot reverse functional deficits or anatomic and secretory dysfunctions.

C. Coital infertility – like Anejaculation or Retrograde Ejaculation

  • Sympathomimetic drugs such as pseudo-ephedrine, vibrator and electrojaculation are used for anejaculation
  • Sympathomimetic drugs and recently macroplastique injection of the bladder neck are used for retrograde ejaculation .

D. Idiopathic Male Infertility – It occurs in ~30-45% of infertile men. There is no demonstrable cause for abnormal semen parameters. Subnormal sperm parameters include:

  • sperm concentration < 20 million/ml
  • motility < 50% motile sperm
  • normal morphology < 30%

There is low scientific evidence for the use of bromocriptine / hCG / HMG / α blockers / Systemic corticosteroids. Androgens are contraindicated. Recombinant FSH, folic acid with zinc, or antioestrogens are beneficial in some patients. Antioxidants can be given empirically for 2 months. They may work in few idiopathic cases.

IUI
IUI is a suitable alternative in:

  • Mild – Moderate Oligoasthenospermia where total sperm count is more 10 M/ml with motility > 30%
  • Antisperm Sperm Antibodies are there or there is
  • Ejaculatory Dysfunction

The pregnancy rates with IUI in male infertility are 9-20%. Four cycles of controlled ovarian hyperstimulation (COH) combined with IUI are superior to IVF and less expensive than single IVF cycle.

Assisted Reproductive Techniques (ART)

A. In Vitro Fertilization (IVF ) – works well in cases of Severe Oligospermia (When number of motile sperms is < 10 M/ml and also where no Pregnancy has occurred after 3-6 cycles of IUI in Mild-Moderate Oligospermia.
B. Intracytoplasmic Sperm Injection (ICSI)- ICSI is suitable for

  • Severe Astheno & Teratospermia
  • With surgical Retrieval of sperms
    – Non Obstructive Azoospermia
    – Obstructive azoospermia not amenable to reconstruction as in CBAVD
  • Coital infertility due to anejaculation
  • Fertilization failure after conventional IVF

Surgical treatment

A. Microsurgical vasectomy reversal: Vasectomy reversal may be offered to the desired patients. Low cost , good success rate makes it more effective than IVF. Overall patency in 86 %of cases and live birth rates up to 58% is reported with vasectomy.

B. Varicocelectomy: It is of benefit only if there are semen abnormalities and the varicocele is clinically palpable in the absence of female factor infertility. The average spontaneous pregnancy rate after varicocelectomy is 39%

C. Surgical sperm retrieval and assisted reproduction:

  • Non obstructive azoospermia (NOA)
  • Obstructive azoospermia not amenable to reconstruction as in CBAVD
  • Coital infertility due to anejaculation

WHO Criteria for Normal Semen Values

Parameter Lower Reference Limits (WHO)2010
Volume(ml) 1.5
Total Sperm Number(106 per ejacuate) 39
Sperm Concentration(106 per ml) 15
Total Motility(%) 40
Progressive Motility(%) 32
Vitality(live spermatozoa, %) 58
Sperm Morphology(normal forms, %) 4
pH >7.2
Peroxidase-positive leukocytes(106 per ml) < 1.10