Male infertility

Symptoms Of Male infertility

Male infertility is the inability to conceive a child after 1 year of regular intercourse without any birth control. Infertility by itself is a symptom. Various signs and symptoms that may be associated with male infertility include:

• Difficulty with ejaculation or small volumes of fluid ejaculated

• Reduced sexual desire

• Erectile dysfunction (difficulty maintaining an erection)

• Pain, swelling, or a lump in the testicle area

• Gynecomastia (abnormal fullness in breasts)

• Hormonal abnormality (decreased facial or body hair)

• Recurrent respiratory tract infections

• Inability to smell

• Reduced body mass

• Obesity

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Causes Of Male infertility

Male infertility is mainly caused due to anatomical abnormalities and ejaculatory disorders. Causes can be broadly classified into the following:

1. Pre-testicular causes

• Quality and quantity of semen: Over 90% of cases of male infertility are related directly to sperm numbers or poor sperm quality.

• Hormonal deficiency/imbalance: Male sex hormones exhibit a significant and focal role in the growth, improvement, and proliferation of testicles. eg. isolated LH and FSH deficiencies are linked to infertility.

• Genetics: A few chromosomal defects are directly related to male infertility. Examples include myotonic dystrophy, microdeletion, and Kallmann's syndrome amongst others.

• Oxidative stress: It is a phenomenon caused by an imbalance between the production and accumulation of oxygen reactive species (ROS) in cells. It can cause sperm dysfunction leading to infertility in men.

• Pituitary diseases: The pituitary is a small, pea-sized gland located at the base of your brain. Disorders like pituitary insufficiency, hyperprolactinemia, exogenous hormones, and growth hormone deficiency can cause infertility in men.

2. Testicular causes

• Orchiectomy: It refers to the surgical removal of both testes.

• Primitive testicular dysfunction: This may result from testosterone deficiency or impaired sperm production leading to male infertility.

• Cryptorchidism: It is a condition in which one or both of the testes fail to descend from the stomach into the scrotum (a bag of skin that holds and helps to protect the testicles).

• Atrophic testes: Small or shrunk testicles.

• Varicoceles: These are enlarged veins on the scrotum that are associated with male infertility.

• Epididymitis: It is swelling or pain in the back of the testicle caused due to sexually transmitted infections.

• Malignancies: Testicular tumors or adrenal tumors leading to an excess of androgens, radiotherapy, and chemotherapy can lead to male infertility. 

• Chromosomal disorders: Disorders like Klinefelter’s syndrome and XYY male affect the testicles and can lead to infertility.

• Sertoli- cell-only syndrome: Also known as del Castillo syndrome or germ cell aplasia, is one of the most common causes of the absence of sperm in infertile men. This syndrome affects sperm production in men.

3. Post-testicular causes

• Ejaculatory duct obstruction: It is a pathological condition that is characterized by the obstruction of one or both ejaculatory ducts. It can be present at birth or acquired later in life.

• Cystic fibrosis: It is a congenital condition that affects the lungs, heart, and other organs. Most men with cystic fibrosis are infertile because of an absence of the sperm canal, known as the congenital bilateral absence of the vas deferens (CBAVD).

• Antisperm antibodies: These are antibodies that work against the sperms. They can severely impact sperm quality, sperm count, and sperm motility. 

Risk Factors For Male infertility

Male infertility is influenced by many biological and environmental factors. The factors that can increase the risk of infertility include:

1. Local factors

• Genito-urinary infection: Infections in the male genital tract can lead to male infertility due to inflammation. These infections are generally sexually transmitted.

• Trauma to testicles: Men can experience problems with fertility after trauma to the testicles due to an injury or accident.

2. Environmental factors

• Obesity: Overweight (BMI 25–<30 kg/m2) and obese (BMI 30 kg/m2) males are associated with a low seminal discharge volume, low sperm concentration, and low total sperm count.

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• Smoking: Tobacco chewing and smoking are responsible for DNA damage and lead to lower sperm count and severely affect fertility.
  
  

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• Alcohol: Heavy consumption of alcohol can cause changes in the shape and size of the sperm. Also, damage to the liver caused by alcohol can lead to male infertility as well.

• Diet: Studies indicated that regular overconsumption of red and processed meat, fatty dairy products, refined grains, caffeine, and aerated and non-aerated sweet drinks are prone to poor semen quality.

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• Stress: Long-term stress can be detrimental to male reproductive potential. It is linked to diminished levels of testosterone leading to decreased sperm counts, altered sperm morphology, and decreased motility.

• Sleep disturbances: Insufficient sleep along with poor sleep quality can possibly have adverse effects on male fertility. 

• Advanced paternal age (APA): Few studies find advancing paternal age a risk factor for infertility. It is usually between 35 and 50 years of age in men.

• Exposure of the genitals to high temperatures: Excessive heat to the genital organs has a damaging impact on the testicle increasing the risk of infertility in men.

• Chemicals: Factors such as volatile organic solvents, silicones, chemical dust, air pollution, and pesticides have a negative effect on male fertility.

• Radiation: It can destroy sperm cells and the stem cells that make sperm. Radiation therapy to the brain can damage the pituitary gland and decrease the production of sperm and cause testosterone imbalance. 

3. Systemic conditions

• Diabetes: Uncontrolled diabetes can damage blood vessels and nerves, and increase the risk. As a result, it is associated with erectile dysfunction, decreased sex drive, ejaculation problems, and inflammation of the foreskin.

• Medications: Cannabinoids, opioids, and psychotropic drugs along with certain antibiotics and antifungal agents have been known to cause male infertility.

• Systemic Infection: Tissue damage and inflammation caused by bacterial infection can lead to male infertility by negatively affecting sperm production and testosterone levels.

4. Other factors

• Early or late puberty: Studies demonstrate that pubertal timing is very likely to be associated with male reproductive health as it can affect the quality of the semen.

• Hernia repair: Though extremely rare hernia surgeries can cause a narrowing of the tube and prevent the sperms from being delivered into the prostate. 

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The use of mobile phones is potentially linked to male infertility. Studies have shown that exposure to radiofrequency electromagnetic waves radiation emitted by mobile phone use may exert harmful effects on the testis. Read more on ways to increase male infertility and things to avoid for better results.

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Diagnosis Of Male infertility

Diagnosing the exact cause of infertility is important in determining the course of treatment. Most of the time, there is more than one cause of infertility. Here are a few tests the doctors at fertility clinics may conduct. They include:

1. Medical history

This consists of taking a detailed reproductive history, medical history, any history of past surgeries, and if the individual is on any medications.

2. Physical examination

This consists of examining the following:

• General appearance: It consists of seeing the hair distribution, and body habitus.

• Abdominal examination: During this examination, the abdomen is examined for any hernias or surgical scars.

• Genital examination: This examination is done in both standing and supine positions. It is done by palpating the testes, epididymis, vasa deferentia, spermatic cord, and phallus.

• Digital rectal examination: This is done in men who are over 40 years of age. Presence of lower urinary tract symptoms (LUTS) or low sperm volume.

3. Semen testing

• Semen analysis: Semen samples are sent to laboratories to measure the number, motility, and shape of the sperms present. In most cases, doctors conduct several tests to ensure accuracy.

• Semen DNA fragmentation: This test is done to evaluate lifestyle risk factors, recurrent miscarriages, and failure of IVF and IUF treatments.

• Seminal oxidative stress measures: This test is indicated in unexplained infertility, to detect varicocele, a history of genitourinary infection, and to evaluate lifestyle risk factors.

4. Blood tests

• Hormone testing: Hormones produced by the pituitary glands, hypothalamus, and testicles can affect fertility significantly. Doctors will take a blood test to measure the level of the following hormones:

  • Testosterone

  • Luteinizing hormone (LH) 

  • Follicle stimulating hormone (FSH)

  • Prolactin

  • Estradiol

• Immunobead test (IBT): This test is designed to look for the presence of antibodies (IgA) in motile sperm.

5. Genetic screening

• Sperm chromatin and abnormal DNA assays: This is a new diagnostic tool that can detect sperm samples that have a high degree of DNA fragmentation.

• Chromosome and genetic studies: This test evaluates male factors that detect signs of genetic abnormalities affecting the Y chromosome (unique to only men).

6. Testicular biopsy

It is a procedure in which a small portion of the testicle is removed for examination. The sample is then viewed under the microscope to check for any abnormalities. Bilateral testicular biopsy (TBO) is recommended while diagnosing male infertility. It is predominantly useful for the investigation of decreased or absence of sperms.

7. Imaging tests

• Ultrasound: Doctors may conduct scrotal or transrectal ultrasounds to see if there is any problem with the testicles or prostate gland that can affect fertility. In a scrotal ultrasound, the doctor will see if there are any problems in the testicles. In the rectal one, they will insert a lubed wand into your rectum to check your prostate for blockages.

• Doppler blood flow: This test is done to check for any inflammation, swelling, or torsion of testicles in the case of varicocele.

• MRI pituitary: Indicated to detect true prolactinoma (noncancerous tumor of the pituitary gland that produces a hormone called prolactin).

• MRI pelvis/scrotum: This test is done to check for undescended testes and suspicious testicular lesions.

• Vasography: It is mainly done to rule out any kind of obstructions, especially before surgery.

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Prevention Of Male infertility

Consume a healthy diet

A healthy, balanced, and wholesome diet plays a pivotal role in the prevention of male infertility. Here are some food items that you should prefer and the others you should avoid in your diet. 

Foods to prefer

• Green leafy vegetables
• Legumes 
• Whole fruits
• Whole grains like wheat, brown rice, jowar, ragi and bajra
• Low-fat or fat-free milk or yogurt
• Eggs, fish, seafood, lean poultry

Foods to limit or avoid

• Refined grains like white flour or white bread
• Table sugar
• Sugar-sweetened beverages
• Packaged foods
• Red and processed meats

Shed those extra kgs

A healthy weight can keep infertility at bay. Regular exercise and a healthy diet are the cornerstones of attaining and maintaining a healthy weight.

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Stay away from recreational drugs

Drugs like marijuana, cocaine, anabolic–androgenic steroids (AAS), opiates (narcotics), and methamphetamines are examples of illicit drugs that can have a negative influence on male fertility. Say no to drugs not just for boosting fertility but also for overall health.

Quit smoking

Tobacco can harm your health, and it can affect fertility as well. Heavy smoking also increases the risk of erectile dysfunction. People who have been trying should try quitting to optimize their chances of conceiving.

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Be mindful while consuming alcohol

Drinking too much can alter sperm count, shape, size, and motility. It can lower testosterone levels and affect ejaculation. So try to avoid or limit drinking alcohol.

Keep calm and manage stress

Everyone suffers from stress from time to time. However, too much stress is an important risk factor affecting male infertility. You can de-stress by working out, reading, meditating, or doing what you love. 

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Give importance to sleep

Research shows that lack of sleep time may reduce sperm quality in men. Getting adequate sleep of at least 7-8 hours is vital to maintaining your reproductive health.

Avoid heat around your testicles

Heat near the testicles can kill sperm cells and result in the production of abnormally shaped sperm. Avoid keeping your laptop on your lap while working, take cold showers, and wear loose clothes.

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Specialist To Visit

If you have failed to conceive for a year or if you are 35 or above, you may consider going to the following doctors:

• Reproductive endocrinologist
• Urologist
• Andrologist
  
  

Reproductive endocrinologists are specially trained gynecologists that focus on fertility-related problems in both men and women. They are typically the primary consultants through the entire fertility testing and treatment process. If a male fertility specialist is needed, patients may be referred to a specialized type of urologist called an andrologist.

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Treatment Of Male infertility

There are several treatment options available for infertility in men. They include:

1. Medications

• Antioxidants: These are used to reduce oxidative stress, which can be causing male infertility. Pharmacological management includes antioxidants that can help combat the problem. The most commonly used ones include:

  • Vitamin C

  • Vitamin E

  • Zinc

  • Clomiphene

  • Carnitines

• Dopamine antagonists: These are indicated for the treatment of infertility and the pituitary tumor. The drugs used are:

• Bromocriptine

• Cabergoline 

• Selective estrogen receptor modulators (SERMs): These are SERMs compounds that act on the estrogen receptor as agonists or antagonists. Before These were used earlier to treat infertility for unknown reasons. They increase sperm production by increasing LH and FSH levels. Drugs used are:

• Clomiphene citrate (CC)

• Tamoxifen

• Toremifene

• Aromatase inhibitor (AI):  It is prescribed for treatment of men with idiopathic azoospermia (no sperms).  Anastrozole is the most commonly used drug in this category. However, treating male infertility is an off-label use of this medication.

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2. Hormonal therapy

When infertility is due to a decrease in the levels of hormones, doctors may suggest replacements or medications such as hormone replacement therapy. These include:

• Testosterone replacement therapy
• Human chorionic gonadotropin (rec-hCGrecombinant)
• Recombinant LH (rec-hLH)
• Recombinant FSH (rec-hFSH)
• Purified urinary gonadotropins (GTs)
• The combined therapy of (hCG), LH, FSH, GnRH and human menopausal gonadotropin (HMG).
  
  

3. Surgery

Surgery may be advised in the case of a varicocele or an obstruction. Surgical techniques are classified into microsurgical, laparoscopic, and conventional open methods. These include:

• Laparoscopic varicocelectomy: It is surgery to repair a varicocele. It has a significant improvement rate with lesser complications.
• Vasoepididymostomy (VE) and Vasovasostomy (VV): These two are procedures that are used to bypass any obstruction in the male genital tract.
• Microsurgical epididymal sperm aspiration/testicular sperm extraction (MESA/TESE): These procedures are used to retrieve sperm-containing fluid from optimal areas.

4. Assisted Reproductive Technology (ART) 

This is a range of treatments that involve getting sperm from a man by normal ejaculation or surgical extraction to insert it into the female genital tract. They include:

• Artificial insemination: This method puts healthy sperm at the entrance of the cervix or right into the female’s uterus.
• IVF, GIFT, and other techniques: In vitro fertilization (IVF) and gamete intra-fallopian transfer (GIFT) work like artificial insemination. In these techniques, your doctor collects your sperm, then mixes your partner’s eggs with a lot of high-quality sperm. These are then planted into the female fallopian tube.
• Intracytoplasmic sperm injection (ICSI): In this procedure, a single sperm is injected into an egg. Fertilization then takes place under a microscope. Once fertilized, your doctor puts the fertilized egg in the female uterus.

Did you know? 

There is a biological clock ticking for men as well. Studies show plummeting sperm counts and declining sperm quality is seen in men after the age of 40. To tackle the female and male biological clock men can consider freezing their sperms.

Home Care For Male infertility

Male infertility can sometimes be due to poor lifestyle choices. Follow all the points mentioned in the prevention section along with these important home care remedies:

Avoid certain prescription medications

Certain prescription medications like anti-androgens, anti-inflammatories, antipsychotics, opiates, antidepressants, and steroids can potentially decrease healthy sperm production. Talk to your doctor about their replacement.

Try the fenugreek (methi) supplement

Studies show that fenugreek can be used to improve sperm count and overall sperm quality.

Get your daily dose of vitamin D

Studies suggest that Vitamin D increases sperm motility and supports sperm health. Try to maintain optimum levels of vitamin D by basking in morning sunlight or through foods or supplements.

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Take ashwagandha

Also known as Indian ginseng, which is a traditional medicine that acts as a remedy for several forms of sexual dysfunction. Studies show that oral intake of Ashwagandha roots has been found to improve sperm count and motility.

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Load your plate with antioxidant-rich foods

Several vitamins and minerals act as antioxidants, for example, Vitamin C, Vitamin E, selenium, zinc, etc. Make sure to add food items that are rich in these antioxidants to boost fertility.

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Keep your cell phones at bay

Cell phones emit electromagnetic radiation and especially when kept in pant pockets or near the groin region can have a negative effect on the testis.

Complications Of Infertility in Males

Complications of infertility in men are generally related to emotions and mental health as the treatment itself can be a long journey. These complications can include:

• Issues with the marital relationship: Infertility can often lead to issues in communicating, frustration, or in extreme cases, depression.
  
• Psychological distress: Continuous trying and treatment can lead to feelings of stress, depression, guilt, or anxiety in men. This can cause psychogenic impotence, which gives feelings of inadequacy.

Alternative Therapies For Male infertility

Although the treatment options may work for you and your partner, some people may have to look at other options. Here are some alternative options:

Acupuncture

Acupuncture works by putting tiny, delicate needles into particular body locations. Research shows that acupuncture can help restore fertility in patients, by improving sperm quality and balancing the endocrine system and hormones.

Sperm donation

A sperm donor is a man who donates his semen to help an individual or couple trying to conceive. The donated sperm can be injected into women’s reproductive organs or used to fertilize mature eggs through IVF. Before going on with the procedure, the donor has to go through a series of tests to ensure there are no risk factors. 

Living With Male infertility

There are a lot of treatments available for infertility, all you need to do is embrace this journey with grace. Some tips that might help include:

1. Get your facts right

If you have been trying for a long time, and are unable to conceive, don’t jump to any conclusions. Go to an expert, get your sperm tested, ask questions, and read as much as you can. There is no point in just being disheartened and giving up, understanding what your particular issue is, and what you can do to improve your chances of conception. 

2. Set your expectations 

Before you decide on any procedure, consider your and your partner’s expectations, your financial situation, and your recovery time.

3. Know all your options

Talk through all the options like adoption, IVF, or donor sperm before deciding anything. Talking about potential avenues will help you prepare for any setbacks and you will be ready with other options that you and your partner may want to try.

4. Talk about it

Communicating with your partner and doctor can be the key to managing the stress and anxiety around infertility. Your doctor can help you understand how each procedure works, and it can help you suggest methods that will meet your expectations.

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