Male Infertility

In 50% of cases, male factor is responsible for infertility.
Hence genitalia examination and good semen analysis from a trained andrologist is a must.
Along with it, thorough history and genitalia examination throw light on erectile, ejaculatory, and other problems like varicocele, etc.

Semen analysis forms the most basic evaluation for the male partner of an infertile couple.

The male partner is asked to provide a semen sample.
For a good semen analysis, one should abstain from sexual intercourse for 2-3 days. Lesser or greater abstinence may affect the report.
Intake of alcohol, caffeine, or any sort of medications should be avoided for 2-5 days.
No lubricant should be used as it affects the motility.
Ideally, the sample should be collected in a sterile, wide-mouth, labeled, tissue culture-graded container within the hospital premises. However, if collected at home, it should reach the hospital within 30 mins and should be maintained at body temperature.
Once the sample is obtained, the sample is assessed in the andrology laboratory by a trained embryologist.
There is a lot of variation in reporting from routine pathology laboratories and andrology labs, which can significantly alter the treatment plan.

1) Liquefaction: After the ejaculation, the semen sample is coagulated and needs to be liquefied in order to perform any tests. In normal conditions the semen is totally liquefied within 60 minutes after the ejaculation.

2) Viscosity: When the semen sample is very viscous, it may be a sign of a prostatic dysfunction.

3) Volume: The normal volume of an ejaculate sample after 3 or 5 days of sexual abstinence is approximately 1.5 ml. Lower volumes suggest hypospermia.

4) Colour: Semen is usually opalescent white, lightly yellow. When the color is altered, it is recommended to study possible causes.

5) pH: Values should be greater than 7.1. Lower values might be a sign of azoospermia (lack of spermatozoa) or chronic inflammatory processes.

6) Sperm concentration: Normal values are around 15 million per ml ejaculated or 39 million per complete semen sample. When these values are lower, it indicates oligozoospermia.

7) Motility: The percentage of motile spermatozoa and progressively motile is analyzed. The progressive motility value should be over 32%. If less, it indicates asthenozoospermia.

8) Vitality: The percentage of vital (live) spermatozoa must be over 58%. Lower values indicate asthenozoospermia.

9) Morphology: At least 4% or more sperm should be normal in morphology. Lower percentage indicates teratozoospermia.

10) Leukocytes: When the leukocyte concentration is over 1 million per ml of sample it might indicate an infection (leukocytosis).

Normal Semen parameters:

	4th edition (1999)	5th edition (2010)
Liquefaction	Complete in 60 min	Complete in 60 min
Volume	2ml	1.5ml
Colour	Opalescent white	Opalescent white
PH	7.2-7.8	>7.1
Concentration(ml)	20 million	15 million
Progressive motility	50%	32%
Vitality	75%	58%
Morphology	15%	4%
Leukocytes (ml)	<1 million	<1 million
Mar test	<50% sperm with bound particles	<50%sperm with bound particles

Based on the above evaluation, TMSC (Total Motile Sperm Count ) is evaluated.
Total motile sperm count is the total no of viable and motile sperm in the sample.
Based on the TMSC, further treatments are planned.
TMSC > 15 million: one can try through natural intercourse or IUI
TMSC between 5-15 Million: IUI is recommended
TMSC <5 million: IVF / ICSI – Test tube baby treatment is recommended.

Certain specialized tests like Sperm Function Test, DNA fragmentation rate and Mitochondrial assay are done in specialized circumstances so as to enhance the result.
Sperm function test gives an idea of the capacity of sperm to fertilize an egg.
DNA fragmentation rate gives an idea of genetically normal sperms. High fragmentation rate is associated with higher rates of abortion.
USG SCROTUM-Ultrasound of the scrotum is done to detect varicocele, hydrocele etc

TRANSRECTAL ULTRASOUND

In selected conditions to check if there are any poorly formed or blocked seminal vessels or ejaculatory ducts that could cause sperm blockage.

TESTICULAR BIOPSY

If the semen analysis shows azoospermia, a testicular biopsy can be performed. After administering anesthesia, a cut is made in the scrotum and a small piece of tissue from each testicle is removed and examined under the microscope. This is usually accompanied by sperm freezing if found.

HORMONAL PROFILE

Hormones that are responsible for producing the sperms are tested to learn how well your testicles make sperms and also help to rule out the major health problems.

They are helpful in giving medical management in correctable causes of male infertility.

These test include S.FSH, S.LH, Total Testosterone, S.PRL, 17-OH-P4

LOW SPERM COUNT

Low sperm count is a condition in which the sperm count is below 15 million/ml, that is oligospermia.

COMMON CAUSES OF LOW SPERM COUNT:

Genital Surgeries.
Undescended testis in adolescence.
Disease of genital tract.
Past history of mumps.
Causes leading to increased heat in genitalia: Testes are placed outside the human body as they need lower than body temperatures to survive. Excessive heat can lead to damage to sperm production. Ex: obese men (due to sagging layers of fat), truck drivers, tight underclothing, excessive sauna, etc.
Smoking, especially more than 20 cigarettes per day.
Excessive ejaculation—2 to 3 times a day.
Hormonal imbalance like Hypogonadotropic Hypogonadism, Hyperprolactinemia

Retrograde Ejaculation

It is a condition where the semen ejaculated during sexual intercourse goes backward into the urinary bladder instead of releasing out through the penis. This happens when the muscles of the bladder do not close properly during intercourse. The semen contains healthy sperms, but these sperms do not reach the vagina for the pregnancy to occur.

Medications

Some medications can cause a change in sperm production, function, and delivery. Medications for common health problems that cause infertility are:

Cancer
Arthritis
Depression
High blood pressure
Infections

Varicoceles

This is a condition where there is dilatation of pampiniform plexus of the scrotum. They are more common in infertile men. They block the proper blood drainage which harms sperm growth.

Few patients of varicocele have normal sperm count and motility but higher Fragmented DNA in their semen sample

Idiopathic- when the cause is not known

TREATMENT OPTIONS FOR LOW SPERM COUNT:

Treating Infections with antibiotics: Infections if present should be treated with the help of antibiotics. This is not always helpful.
Medications can be given to correct hormonal issues.
Correctable surgeries- Varicocele may be repaired
In persistent oligospermia, IVF treatment offers good pregnancy results. To attain pregnancy via IVF treatment, even low sperm counts are sufficient.

AZOOSPERMIA-NO SPERMS IN SEMEN

When there are no sperms in the sample, it is called Azoospermia.
Azoospermia can be obstructive or non-obstructive.
Obstructive azoospermia is due to a block in the passage that the sperm has to travel. Ex -Absence of Vas deferens.
Non-obstructive azoospermia is due to very low production or non-production of sperms.

Causes of Non -Obstructive Azoospermia

Genital surgeries
Urogenital Infections
Genetic causes like Y chromosome microdeletion, etc need to be ruled out in patients of azoospermia.
Testicular Cancers
Chemotherapy or Radiotherapy secondary to testicular cancers.
Hormonal imbalance like Hypogonadotropic Hypogonadism

Causes of Obstructive Azoospermia

CBAVD (Congenital Bilateral Absence of Vas Deference)
Ejaculatory duct obstruction (EDO)- (low vol, acidic ejaculate with normal hormone profile, palpable vas)
Vasal obstruction (vasectomy )
Scarring caused by previous infection
Iatrogenic injury from previous inguinal surgeries especially in children

TREATMENT FOR AZOOSPERMIA:

In Azoospermia, sperm can often be retrieved directly from the testicles or epididymis using sperm retrieval techniques.
Chances of sperm retrieval are very good is obstructive azoospermia
Chances of sperm retrieval vary in cases of non-obstructive azoospermia.
In PESA (Percutaneous Epididymal Sperm Aspiration), sperms are usually recovered from the epididymis by puncturing it with a fine needle. This is in cases of obstructive azoospermia.
In TESA or testicular sperm aspiration (also known as TESE, or testicular sperm extraction), testicular tissue is sucked out through a fine needle, under local anesthesia. The sperm are then liberated from tissue and used for ICSI.
In MicroTESE- healthy testicular tissue is extracted from the testis under higher magnification like 20x. This is usually done in cases of non-obstructive azoospermia.
In case no sperms can be extracted through surgical procedure, semen samples from a matched donor can be used for IUI or ART treatment after couple’s consent.

LOW SPERM MOTILITY

Sperm motility treatment refers to the movement of sperm.
Poor sperm motility means that the sperm do not swim properly, which affects their ability to reach the fallopian tube for fertilization and leads to infertility.
Normally at least 32% of the sample should show forward progressive motility.

Causes of low sperm motility:

Disease of genital tract
Causes leading to increased heat in genitalia: Testes are placed outside the human body as they need lower than body temperatures to survive. Excessive heat can lead to damage to sperm production. Ex: obese men (due to sagging layers of fat), truck drivers, tight underclothing, excessive sauna etc.
Smoking, especially more than 20 cigarettes per day.
Excessive alcohol intake
Stress
Varicoceles

This is a condition where there is dilatation of pampiniform plexus of the scrotum. They are more common in infertile men. They block the proper blood drainage which harms sperm growth.

Few patients of varicocele have normal sperm count and motility but higher Fragmented DNA in their semen sample

Idiopathic- when the cause is not known

TREATMENT OPTIONS FOR LOW SPERM MOTILITY

• Lifestyle Modifications:

Reduce chemical exposure.
Improve diet.
Exercise regularly.
Take nutritional supplements—antioxidants—to reduce stress.
Stop smoking, tobacco, alcohol, and marijuana.
Stop using any anabolic steroids, including any testosterone supplements.

• IUI (Intrauterine Insemination):

Intrauterine insemination (IUI), also known as artificial insemination, is a process in which the washed/processed semen is placed into the uterine cavity with the help of a catheter in and around the time of ovulation (release of egg from the ovary).
The purpose of IUI treatment is to introduce the best and the most motile sperm high up in the uterine cavity, i.e., as close to the ovum as possible so that the sperm have to travel the least distance.
Procedure and details are described separately.

• IVF/ICSI:

IVF with ICSI treatment has delivered the most promising results in male infertility.

ERECTILE AND EJACULATORY DYSFUNCTION

Erectile and ejaculatory dysfunction require detailed history taking and counseling. At times, it can be corrected with the help of medications or the use of a vibrator.
If not correctable, sperms can always be obtained by surgical procedures and ICSI treatment done to attain pregnancy.

WE HAVE THE MOST EXPERIENCED UROLOGISTS WHO ARE EXPERTS IN PROVIDING MALE INFERTILITY TREATMENT IN THANE.