Wednesday, 26 September 2018

MALE INFERTILITY


In this edition, I am going to deliberate on the various causes of male factor infertility.

In our series, “Answers to frequently asked questions” we defined male infertility as a situation where the quality of the sperm produced by the male partner is either abnormal, inadequate or with no sperm cells at all. Such that his normal female partner is unable to get pregnant.


The reasons for such abnormalities or inadequacies would now be discussed in more detail.

It has been variously estimated that the source of problems in a couple with fertility is approximately:
Ø Solely 30% in the female
Ø Solely 30% in the male
Ø Solely 20% in both male and female combined and in about 20%, no recognizable cause (unexplained infertility) is found.

The experience in our Clinics is not significantly different from the above male contribution to subfertility is therefore not less than 40% overall.

A     GENERAL FACTORS INFLUENCING MALE INFERTILITY

1.    AGE

In men, the probability of conception (fecundability) is maximal at age 24-25 years and tend to fall after the age of 40 years. Although sperm production usually continues to some extent until old age. One of our recent pregnancies belong to a 76 year old male partner.

2.    General health and Nutrition

Good General health is associated with fertility but bad health is not an absolute barrier to conception.

Excessive alcohol consumption, prolonged cigarette smoking and drug addiction, all are harmful to sperm production and to a less extent to sexual ability.

3.    Psychological Factors
Anxiety, stress, and tension are common features in modern life and are adverse factors for fertility in both male and female while they predispose to reduced erection ability in male, they may cause irregularity in the menstrual cycle of the female partner. Also anger, depression and even grief may be generated as a result of delay in getting pregnant thus a vicious cycle is established.

Intercourse schedule by prescription from doctors may remove desirable spontaneity in love-making.

Post-coital test used to determine the viability of sperm deposited into the vaginal during intercourse. Sometimes, the knowledge that a subsequent post-coital examination would be preformed on a woman may result in loss of erection in the male partner.

4.    Timing and frequency of Intercourse.
Eggs are released (ovulation) approximately 14 days before a woman’s menstruation irrespective of the cycle length.

A woman is most fertile around this time (the fertile period). Therefore intercourse outside if this period may not result in pregnancy.
NB: - It should be noted that only about 80% of women would menstruate following ovulation. On the other hand about 20% of women would experience and abnormal period without a preceding ovulation.

BASIC KNOWLEDGE OF MALE PHYSIOLOGY
Sperms are produced inside some tiny tubes in the innermost part of the testis. They move from there to be matured and stored in an area called the Epidydimis. The whole process of sperm production to maturity takes about 3 months.

During intercourse, the sperms are transported from the epidydimis through another tube called the vas deferens, to the tube (urethra) of the male organ (penis). During its passage, the raw sperms are mixed with fluid produced by other glands as they pass to the outside resulting in the final ejaculate which is deposited in the vagina during intercourse.

B.    SPECIFIC FACTORS CAUSING MALE INFERTILITY

1.  (a)     Previous Infections:-   Infections affecting any part of the testis or its tube may lead to permanent damage to the sperm producing cells. The commonest example is caused by mump virus. This infection is common in childhood and result in damage to the testis. Also other parts of the tube and glands may be so adversely affected.
Another common type of infection is that caused by        Gonorrhoea and Chlamydia.

PLEASE NOTE THAT STAPHYLOCOCCUS AUREUS DOES NOT CAUSE INFERTILITY contrary to widely publicised information given by quack “doctors”and questionable laboratories
The staphylococcus aureus bacteria at best could only be contaminants in any sperm specimen submitted for examination. They are usually skin germs, not sperm germs.
A carefully taken specimen of sperm, preferably by masturbation would never grow staphylococcus, but other germs that are relevantly present in the sperm itself

(b) Surgery
Accidents can occur during surgery for example during hernia repair, or other pelvic operation/resulting in injury to the tubes that carry sperm from the testis.

(c) Excessive Smoking/Drinking can lead to reduction in sperm production, decrease in their ability to move and a reduction in the number of normal forms.

(d) Certain drugs and chemical agents such as steroids can have a serious effect on sperm production.
Men who suffer chronic alcoholism with a Liver disease called liver cirrhosis could experience complete failure of the functions of their testis.

(e) Radiation and radiotherapy can lead to irreversible damage to sperm production ability of the testis.

(f) A common cause of low sperm count is called VARICOCOELE. A Varicocoele is the presence of engorged veins around the testis. This dilated veins cause unduly high temperature around the testis, which in turn lowers the ability of the testes to produce sperms in adequate number and of good movement.

2.    Antisperm Antibodies
Sometimes, some substances inside the semen produced can attach to the sperm cell (spermatozoa) and disturb their movements and ability to fertilise egg.
These substances are sometimes found after some previous genital infections and operations.

3.    Azospermia & Oligospermia
Azospermia simply means complete absence of spermatozoa in the semen produced. Oligospermia means significantly reduced number of such sperms. These are terms that our readers commonly come across daily.

The above two problems can be caused by obstruction to the flow of sperm in the sperm tube as a result of operation such as hernia operation. Sometimes such obstruction can be in-born. It could also be due to infections by gonorrhoea, tuberculosis.

Such absence of spermatozoa can also be due to the following:
Ø Chromosome problem as in some disorders which affect males called Klinefelter’s syndrome
Ø Previous infection by mump virus mentioned above
Ø When the testes does not descend into the testis at birth or for a long time.
Ø Generally, during ill-health such as that of long term illness of the kidneys requiring blood cleaning (dialysis).
Ø Some rare abnormally where the hormones from the brain that normally enable sperm production are absent.
4.    Failure to Deposit Spermatozoa in the Vagina
this problems collectively would contribute to failure to get sperm into the vagina. Examples are
Impotence:-         This is lack of erection

Premature ejaculation:- This results when the man releases sperm even before penetration into the vagina. The result is that little or no sperm gets into the vagina.

Hypospadia and phimosos:- Hypospadia is a condition in which the opening on the penis opens not at the tip but way back-under the penis shaft.

Phimosis is an abnormal curvature of the penile shaft. In all these cases, semen is usually unable to be deposited into the vagina at ejaculation.
Retrograde ejaculation:- In this unusual condition, semen is ejaculated backwards into the urine bladder instead of into the penis hole (penile urethra). This could be the case in males who have had prostate operation.

5.    Problems associated with the semen fluid
(1)        Examples of these are: -
(a)  Low fructose content of semen
(b)   Higher than normal level of prostaglandin level in the semen and
(c)    Unusually thick (viscous) semen.

(2)        Usually small or high volume of semen produced is associated with low fertility potential.

Readers are encouraged to generate questions on the issues discussed in this edition. Answers to questions would be provided in the next edition.