Male Infertility

Incidence of infertility

Humanity is remarkably fertile. Women can conceive and bear children as early as the middle of the second decade of life. In industrialised societies, women commonly conceive between the ages of 20 and 30; however, there has been a noticeable increase in the percentage of women conceiving in their 40s. Men, on the other hand, can have children well into old age.

Despite all public concern and debate, mainly in the media, the incidence of infertility over the years remains essentially at the same rates. About 15% of couples who attempt their first pregnancy fail. A couple is characterised as infertile when they have free, unprotected intercourse for at least a year without conception (many couples develop terrible anxiety after just a few months of trying). 33% of couples in their late 30s have an infertility problem — in developed countries this is closely linked to the professional goals set by the couple.

By the end of the 20th century, medical science had made significant strides in understanding the various stages of the reproductive process, allowing specialists to identify problems and take corrective measures. As a result, approximately 65% of couples who seek assistance for infertility are able to achieve childbearing.

How much is the man responsible for the couple's infertility?

It was customary to believe, not many years ago, that when a couple had a childbearing problem the woman was responsible. Nowadays statistics show that the man is at least half (50%) jointly responsible for the couple's infertility. This percentage sounds unbelievable when you consider that a healthy man releases 120–600 million spermatozoa with each ejaculation and produces about 400 billion spermatozoa during his lifetime.

So apparently the man does very well in the field of reproduction — but unfortunately this is not always true. The most common cause of male infertility is precisely the inability of many men to produce a sufficient number of healthy sperm.

What are the causes of male infertility?

Hormonal and Anatomical Causes

• • Hormonal disorders of the pituitary gland and hypothalamus — congenital or acquired (e.g. certain malignancies, radiation)
• • Incomplete descent of the testicle(s) into the scrotum
• • Acquired conditions: inflammations (orchitis, epididymitis), traumatic injuries, systemic diseases
• • Seminal antibodies

Varicocele

Varicocele deserves special mention — it occurs in about 20% of all men and is the cause of infertility in 40% of infertile men. It is caused by insufficiency of the testicular veins, resulting in venous stasis and a local increase in temperature that is thought to affect spermatogenesis. Importantly, varicocele is a surgically reversible condition with relatively simple surgery.

Medications, Substances and Lifestyle

• • Certain medications: drugs to treat stomach ulcers, cortisone, anabolic steroids
• • Nicotine and smoking (affects both sperm count and motility)
• • Marijuana, cocaine and excessive alcohol consumption
• • Certain antibiotics and vitamin C deficiency
• • Toxic drugs and chemicals used in crops and industries
• • Excessive physical activity and poor diet
• • Excessive stress, hot baths, and wearing very tight underwear (elevates scrotal temperature)
• • Multi-day abstinence from sex, erectile dysfunction, and ejaculation disorders (premature, delayed or impossible ejaculation)

How is male infertility diagnosed?

A period of at least 1 year should have passed with regular intercourse — and if possible on the fertile days of the woman's cycle — before the couple is considered infertile. After this time, if there has been no conception, both partners (not only the man) should contact an andrologist.

After taking a thorough history, the andrologist will recommend a set of tests including a complete hormonal, chromosomal and immunological assessment, and most importantly a spermiogram, which can reveal any sperm abnormalities. Depending on the results, the doctor may proceed to imaging methods, testicular biopsy, etc.

Testicular biopsies for assisted reproduction (IVF)

Intracytoplasmic sperm injection (ICSI), first used in 1992, overcame many of the barriers due solely to the male factor, allowing many men with severe fertility disorders to have children. Regardless of which technique is used to obtain seminal material, the primary goal is to preserve as much as possible the androgenic potential of the testicles. Otherwise, these men risk becoming hypoandrogenic and condemned to testosterone replacement therapy for the rest of their lives.

Testicular Biopsy (TESE)

The simplest technique, used to obtain sperm in non-obstructive azoospermia (absence of spermatozoa). It is usually performed under local anaesthesia as a day-clinic procedure.

Percutaneous Testicular Biopsy

The same technique as open biopsy, using a biopsy gun with tru-cut needles after a tiny skin incision. There is an increased risk of bleeding and injury to the epididymis compared to the open technique.

Microsurgical Sperm Collection (MicroTESE)

This is the technique that prevails over the other two, mainly in cases of non-obstructive azoospermia. Non-obstructive azoospermia is a very common cause of male infertility. MicroTESE is usually recommended when:

• • A man has adequate plasma testosterone levels
• • Testosterone levels have been corrected for at least four months and the man remains azoospermic

Sperm are found in about 70% of cases with the microTESE procedure.

In men with non-obstructive azoospermia, fine needle puncture (FNA) or standard biopsy is not recommended before microTESE, because many studies have shown that microTESE has the highest rates of sperm recovery and causes the lowest rates of testicular damage.

In 56–70% of men who had no previous biopsy, spermatozoa have been found by performing microTESE, compared to 51% of men who had undergone 1–2 biopsies and only 23% of men who had undergone 3–4 biopsies. These percentages are obviously related to the loss and damage of testicular tissue with random biopsy, in contrast to microsurgery where — with the help of the surgical microscope at a magnification of 30–40× — the seminal tubules containing spermatozoa are recognised and the collection of testicular tissue is hyper-selective.

If sperm are found during microTESE, they are extracted and frozen for future reproductive therapy such as in vitro fertilisation (IVF) with ICSI. Existing evidence suggests that frozen sperm have better rates than fresh sperm for IVF.

What determines the success of microTESE?

For a microTESE to be successful, it must be performed:

• • By a skillful, experienced surgeon
• • In combination with an excellent embryologist in a modern and specialised assisted reproduction laboratory present on site for immediate analysis of the seminal tubules

Treatment of male infertility

Surgical Treatment

The primary surgical role is the correction of varicocele, which has low morbidity and very high success rates. It can also be performed laparoscopically, with the patient leaving the hospital on the same day of surgery.

In addition, various anastomosis techniques of the vas deferens and epididymis can be applied to correct obstructive problems, as well as microsurgical procedures to obtain sperm from the testicles (microTESE).

Conservative Treatment

Conservative treatment includes endocrine (hormonal) therapy and immunological treatment where antisperm antibodies are discovered.

What a man should do to increase his reproductive ability

• • Stop smoking
• • Do not use marijuana or other drugs, and avoid excessive alcohol consumption
• • Avoid strenuous exercise
• • Eat healthily, including foods rich in vitamin C
• • Avoid chronic medication and especially antibiotics without a doctor's recommendation
• • Avoid prolonged exposure to high temperatures such as saunas and hot baths; wear comfortable, not tight, underwear and clothing
• • Have intercourse every 2–3 days — additional abstinence reduces sperm motility, while daily or very frequent intercourse weakens sperm count