Male Infertility: Whats all the fuss about?
Male infertility is sadly on the rise.
Scientific Data indicates that male infertility also called male factor or simply infertility in men and its associated issues could affect an estimated 7% of the world population and that’s scary as hell!. This prevalence is even more than Diabetes Mellitus
Hey guys!. This is Dr. Shah, Founder of the Andrology Corner.
Today I am gonna tell you everything you need to know about a rather poorly discussed medical subject titled “Male infertility”.
Just have a quick look at the graph below……
Male fertility issues is rampantly rising around the globe,as you can clearly see infertility affects at least 15% of the world’s population which roughly translates to 70 million people!!
….and interestingly the data above clearly shows you that a male factor/infertility in men(medical jargon/garbage for any issue that could affect a man’s fertility) as a cause is ever present in at least 40% to 50% of couples as a major contributing cause leading to fertility problems.
However, the more interesting fact is that….
In countries like the Middle East, Male Fertility Problems leading to childlessness rises notoriously as high as 70%…and we do not have much data from other countries thereby actually underestimating the real threat. We are looking at just the tip of the iceberg!
Lets first discuss on Infertility in general….
now infertility is described by some BIG HEALTH AUTHORITIES as follows…
“Infertility is defined as the inability to achieve a pregnancy after one year of unprotected sexual intercourse”
But in principle this definition is fundamentally flawed, let me tell you why..
A. The definition does not take into account the pregnancies that could have happened in the second or third year of marriage
B. The definition also does not take into account or state by what is meant by regular sexual intercourse. Is it one or two times a week, once a week everyday or…?
All said and done remember one thing well…
Regardless of what science/medicine tells you from data/studies and a BLAH BLAH, natural conception can happen anytime upto a certain age!. To get a better perspective just take a look at the data table below
But here is the catch….
This data applies only to those couples who have regular intercourse at least 3 times/week and also only if the female partner’s age is less than 35 years!. and if the male partner has no other associated problems
On the other hand… the data mentioned above definitely does not apply to couples where the female age is beyond 35 years of age or if a male factor is present.
The reason is simple, their is ample evidence in the scientific literature that suggests that when women cross 35 years of age, a sharp decline in egg production takes place. Its not just the egg production though..
It is also the quality of eggs…that really matter. Look below!!!
Now let me tell you 5 events that have to happen for a pregnancy to occur. Click on the accordion to read more!
The male should produce an adequate number of sperm, these sperms should good progressive motility and at least a few of them should have a normal shape.
The female should ovulate normally once a month. If the female has irregular cycles, conception is going to be difficult. Female age is the key determining factor of the quality of egg produced. The younger the female the better the egg!
The fallopian tubes are the key conduits that allow the sperm to reach the egg. Any blocks here will prevent a natural conception from occuring.
The one sperm that reaches egg, should have the fertilizing ability to attach to the egg, penetrate it, fertilize it and allow embryo development. A complex series of molecular event signals and coordinates the sperm attachment, penetration and fertilization
If the egg fertilizes, it forms an embryo that then develops and divides sequentially from a single cell to two cell, four cell, eight cell, sixteen cells and finally a Blastocyst. This process takes about 5 days. The blast formed should migrate and attempt to implant in the endometrium (The lining of the uterus that nourishes the embryo)
If the embryo is of good quality (it has no genetic/chromosomal anomalies) and if the endometrium is sufficiently well prepped, the embryo will implant and this would result in a pregnancy.
Now before we move on please take a look at image briefly below to better understand the process of reproduction..
One thing is pretty obvious…the sperm. From a scientific view point the male gamete is key to successful fertilization, embryo development and its subsequent implantation.
Male fertility is essentially a culmination of a complex series of developmental events that is extremely well coordinated both in space and time.
Now lets move on…
Most men around the world express at least some desire to father their own biological children. But think for a moment…
How knowledgeable are men about factors that are associated with male fertility?
In an interesting Canadian study published in 2016, were 701 participated in survey on male fertility, only about 45 to 50% men had some knowledge on certain modifiable risk factors that impaired male fertility e.g (cigarette smoking, alcohol, sexually transmitted infections et cetera).
Interestingly, the younger the men..the poorer was their general awareness. Surprised?..I would be..
Causes of Infertility in Men
Male infertility causes can be broadly divided into three categories as given below
- A. A problem or disease condition that affects the Hypothalamus – pituitary – Testes axis also called Pre-testicular causes
- B. A problem or disease condition that affects the Testes or both Testis also termed as Testicular causes
- C. A problem or disease condition that affects the ducts or also termed as Post-testicular causes
Just quickly take a look at the image below..
A deficiency in any of these hormones can lead to infertility.
Okay…I know you are bit overwhelmed, so let me try to make things easy for you by splitting the above images as below…Don’t think.!. Keep Reading…
Causes of infertility in men can be easily understood if you divide the various disease depending on which part of the male reproductive axis they affect..
Part A: Diseases or conditions that lead to infertility by specifically affecting key Brain structures namely the Hypothalamus and/or the Pituitary
Now you should understand a few points.
First of all, the hypothalamus and the pituitary are key structures involved in normal male reproductive function.
First when you are somewhere around 12 to 14 years of age, the hypothalamus produces GnRH (Gonadotrophin releasing hormone), the cyclical release of this hormone in turn stimulates the release of FSH and LH, which are key hormones needed for initiating sperm production at that age.
Male infertility can be caused by diseases that affect key brain structures like the Pituitary and/or Hypothalamus
Do you remember the first time you felt attracted to a women? or the the first time you had erections?.
That’s your reproductive hormones kick-starting into action!. FSH and LH have two crucial functions
A.FSH acts on a specific cell type in the male testes, called the Sertoli cells.
The sperm production completely takes place over these supporting cells. The sertoli cells also secrete numerous complex growth factors to coordinate the development of a germ cell into a sperm cells.
The sertoli cell also produces something called Androgen Binding Protein and this substance carries and binds the testosterone and concentrates it within the tubules (hair like structures that make up the bulk of the testes).
- LH on the other hand acts on a different cell type, these cells are called the Leydig cells of the testis, and these cells produce testosterone, the male sex hormone that kick starts and is responsible for all your sexual feelings/sexual fantasies/interests et cetera.
Its what makes a male a male!….. Of course their are a few other sex organs, but testosterone is indeed very important both for male fertility and sexual function.
Given below are a few diseases that can specifically affect these complex hormones and their functions
Now lets discuss part B
Part B: Diseases or conditions that lead to infertility by specifically affecting the Testis (Testicular causes of infertility in men)
The testis is THE SITE of sperm production.
Thus if a disease specifically affects your testis, ultimately your sperm production is gonna take a hit!. Sperm production involves four facets as below
- A male has to produce an optimal number of sperm
- The sperm produced has to be motile
- The sperm produced has to have a normal shape
- The sperm DNA should be reasonably intact
The diseases shown in the image below can affect either sperm count and/or sperm motility and/or sperm shape by affecting the testis.
In all of the conditions mentioned above, in the image a diagnosis of primary testicular failure is made.
however in some of these conditions the leydig cell compartment needed for sperm production may be spared…
Hence, in theses conditions, a diagnosis of Seminiferous tubular failure is made. What this means in essence is that, the testis is probably doing only one of its two functions.
Quickly look at the image below…
Some conditions affect only a mans sperm output by directly damaging the Sertoli Cell compartment in the testes, but a few other conditions for example…Klinefelter’s Syndrome affects both a mans sperm output and his testosterone production (that is by affecting both the Sertoli cell and Leydig cell compartment. In this case a man is diagnosed with total testicular failure).
Now on to Part C…..
Part C: Diseases or conditions that lead to infertility by specifically affecting the ducts beyond the Testis
This is were things become really interesting…
A sperm once produced in the testis has to travel swim out or be pushed out into the ductular system, which comprises namely of the rete testis, the epidydimis, the vas and the ejaculatory duct.
Look at the image below and see the labels to gain a better understanding..
Image: See Clockwise from above. Sperms are produced over the Sertoli cells. They then move sequentially through the rete testis (1), efferent ducts (2), epidydimis (3) and then vas (4).
A few conditions can lead to a male infertility by obstructing the sperm transit pathway. The table below gives brief outline of all possible disease states that can affect the sperm transport into the semen.
Now let me tell you a bit about fertility testing in men..
Male Fertility Testing
Fertility test for men is best done by doing a semen analysis.
“The semen analysis remains the gold standard test for male infertility testing”
A detailed semen analysis gives both the patient and the doctor the following information that helps in assessing male fertility or male infertility.
Point 1: It tells the patient about the volume of semen he is producing along with information about the semen’s pH, the semen’s color it’s consistency, viscosity and its general appearance
Point 2: A semen analysis gives important information about how much sperm a man is producing and also important information about the sperms motility and sperm shape also commonly referred to as sperm morphology
Point 3: A semen test if properly reported and interpreted gives the doctor the expert ability to find out the cause of a male infertility.
As per the WHO 2010 Andrology laboratory guideline values (see below!) a man if and if he has intercourse at least three times a week regularly from the time of his marriage and if he has semen values that are close to or above the number mentioned below should have no problem in fathering a child within a year or two of marriage.
A mans semen report is considered to be in the normal range if every parameter fits within the values as mentioned below
Normal values range from 1.4 to 1.7 ml
Normal color of semen is usually whitish grey
Normal semen pH ranges from 7 to 8
Normal semen liquefaction is usually complete within an hour of collection
Normal semen will fall drop by drop after liquefaction is complete. Viscous semen will not.
Normal sperm count for a man ranges from 13 to 16 million/ml. The cut off value is 15 million/ml
Normal sperm motility for a man ranges from approximately 32% to 40%
Normal sperm morphology refers to the number of sperm that have a normal shape. This ranges from 3% to 4%
Normal sperm vitality refers to the number of sperm that are alive in the semen sample. This is usually 63%
Moreover remember their is no point taking a single semen analysis and then coming to a conclusion based on that single report. For any patient suspected with a fertility issue, the WHO recommends a minimum of at least 2 semen analysis
The reason for this is not too difficult to understand because, for a man of normal fertility his semen analysis report can fluctuate from hour to hour. This is because sperm production in a man is rather a continuous process that starts from puberty!
On an average a man produces at least 2500 sperm/minute. This sperm production process begins from puberty and goes on till death..
Male Fertility Testing can also be done by checking a man’s hormones.
The hormones are FSH, LH, Free Testosterone and total testosterone. An optimal balance of these hormones is key for normal male fertility, as these hormones play a key role in sperm production as discussed earlier.
Male Fertility Testing can also be done by checking the sperms DNA
We now know from numerous studies that sperm with damaged DNA do not do their job of meeting and interacting with the egg leave alone fertilizing it. Although this test is not routinely done in an Andrology Clinic, this particular test may give the consultant and the patient a better understanding of the problem in hand. Strategies can then be put in place for reducing the percentage of DNA fragmented sperm in the semen.
Okay…lets move on to the next section
Treating male infertility
Treatment of male infertility requires a specialized approach from someone trained to manage such issues…
Interestingly this is were most of us fail!. Over 85% of ivf clinics in India, do not employ qualified professionals trained to treat male infertility!. Men never…or seldom get the expert care they deserve. This is also the cardinal reason as to why male infertility is so poorly diagnosed at levels of the healthcare system especially in our country.
Their are four cardinal treatment approaches for male infertility, decisions are made depending on the blood test reports, semen analysis and other ancillary investigations.
Approach 1: Natural is better for him…
No one treats male infertility better than nature. Today obesity is one of the leading causes of male infertility as well. A simple weight loss program, going back to eating fresh home cooked food, a fruit and fiber rich diet free of added sugar goes a long way in improving a mans fertility potential
Approach 2: Medical management of male infertility…
This is typically done when their is documented hormonal deficiency affecting a mans sperm output. Suitable hormonal injections are administered depending on the problem at hand. Medications are added on if required.
Approach 3: Surgical management of male infertility…
Surgical retrieval of sperm is done in case men present with Azoospermia (no sperm in the semen). A decision is only made after finding out the cause of Azoospermia in the first place.
Approach 4: ART management of male infertility…
This globally involves two different procedures as mentioned below..
IVF (In-vitro fertilization)
In an IVF procedure approximately 100,000 sperms are kept close to the egg. The sperm has to do the Herculean task of swimming to the egg, attaching to the egg, penetrating the egg and ultimately fertilizing it.
ICSI (intra-cytoplasmic sperm injection)
In an ICSI procedure a single best appearing sperm is taken and is directly injected into the egg. Here a few natural selection barriers are bypassed as compared to ivf. The sperm is spared of all its headache to attach, bind and or penetrate the egg. The sperm has to only fertilize the egg after injection. ICSI is best suited for treating men with very low sperm counts.
ivf or icsi as a treatment for male infertility remains an expensive treatment option..
The one thing you need to remember…
“The success rate of both ivf or icsi in terms of taking a baby home after the procedure never exceeds 35% to 40% world over”
To conclude, fertility treatments for most couples remains a difficult journey. This is partly because a lack of time is spent tying to understand or make the patient understand the whole complexity of the problem. Most people just cannot accept that their fertility potential is impaired.
Proper guidance and counseling goes a long way in helping patients through their fertility journey.
"Your fertility is your right"
Meet Dr. Shah at the Male Infertility & Sexual health Clinic
Dr. Shah is Consultant Andrologist and Sexologist in Chennai. His passion for helping men facing infertility issues stems from the fact that “Men never ever get the care they deserve as far as fertility treatments is concerned”