Beyond Stigma: Understanding Male Infertility and Its Treatment - Dr Jyothi C Budi

Conception, a seemingly natural phenomenon, can present significant challenges for some couples. It is essential that both partners are investigated for infertility and managed together. Overall, the male factor substantially contributes to about 50% of all cases of infertility.

Male infertility is defined by the World Health Organization (WHO) as the inability of a male to make a fertile female pregnant for a minimum of at least 1 year of regular unprotected intercourse. The male is solely responsible for about 20% of cases and is a contributing factor in another 30% to 40% of all infertility cases.

Prevalence and Considerations

Infertility is a prevalent concern, affecting approximately one in six couples attempting conception. It's crucial to recognize that male and female factors often coexist, necessitating a comprehensive evaluation of both partners.

Etiological Landscape

A multitude of influences can contribute to male infertility. Here's a breakdown of the primary categories:

• Spermatogenic Disorders: This encompasses issues directly impacting sperm production or quality. It can manifest as low sperm count (oligospermia), abnormal sperm motility (asthenozoospermia), or atypical sperm morphology (teratozoospermia).
• Obstructive Defects: Blockages within the male reproductive tract can impede sperm transport. Common culprits include epididymal obstructions, congenital absence of the vas deferens, or prior vasectomy.
• Endocrinopathies: Chronic stress can affect hormone levels. Hormonal imbalances can disrupt spermatogenesis. Hypogonadism, characterized by insufficient testosterone production, is a frequent endocrine culprit.
• Medical Conditions: Various medical conditions, both acute and chronic, can negatively impact fertility. Some sexually transmitted infections (STIs) can damage the reproductive organs and reduce fertility.
• Examples include genitourinary infections, chronic illnesses like diabetes, and even childhood illnesses such as mumps orchitis.
• Certain medications: Some medications, such as chemotherapy drugs and steroids, can impair sperm production.
• Age is a factor: Men's fertility also declines with age, although not as dramatically as women's.
• Environmental factors: Exposure to toxins, pesticides, and heavy metals can reduce sperm quality.
• Lifestyle Factors: Certain lifestyle choices can adversely affect sperm health. Smoking, excessive alcohol consumption, illicit drug use, and obesity are all potential contributors.
• Undescended Testicles: Cryptorchidism can impair sperm development.
• Genetic problems: Chromosomal abnormalities or genetic diseases can cause infertility.

Diagnostic Approach

A thorough evaluation is paramount in identifying the underlying cause of male infertility. The workup typically involves:

• Detailed Medical History: A comprehensive inquiry into the patient's medical history, including past illnesses, surgeries, medications, and lifestyle habits, is crucial for pinpointing potential etiologies.
• Physical Examination: A focused physical exam of the genitalia assesses for any anatomical abnormalities like varicoceles or undescended testicles.
• Semen Analysis: This is the cornerstone of male infertility evaluation. Semen analysis measures various parameters like sperm count, motility, morphology, and volume, providing valuable insights into sperm health.

Treatment

1. Sperm issues (low count, poor motility, abnormal morphology):

• Medications: Hormonal imbalances can sometimes be corrected with medications to regulate testosterone levels.
• Lifestyle changes: Quitting smoking, reducing alcohol consumption, maintaining a healthy weight, and avoiding certain medications or toxins can all improve sperm health.
• Varicocele repair: Varicoceles are enlarged veins in the scrotum that can impair sperm production. Surgery can be performed to correct them.

2. Blockages:

• Surgery: Depending on the location of the blockage, surgery may be an option to clear the pathway for sperm transport.

3. Medical conditions:

• Treating the underlying condition: For example, managing chronic illnesses like diabetes can improve sperm health.

When the cause is untreatable

Although not all causes of male infertility have a direct fix, there are still options for couples to achieve pregnancy:

1. Assisted reproductive technologies (ART): These techniques involve combining sperms and eggs to facilitate fertilization. ICSI stands for intracytoplasmic sperm injection; a procedure used in conjunction with in vitro fertilization (IVF) to help couples conceive. Here's a breakdown of ICSI:

• Purpose: ICSI is typically used when there's male infertility, such as low sperm count, poor sperm motility, or blockages preventing sperm from reaching the egg.
• Process: During ICSI, a single sperm is injected directly into the cytoplasm (the inner part) of a mature egg in a lab setting. This bypasses the natural process of sperm fertilizing the egg on its own.
• Part of IVF: ICSI is a specialized technique within ART, ICSI involves stimulating the female to produce multiple eggs, retrieving the eggs, fertilizing them with sperm in a lab dish, and implanting the resulting embryos into the uterus.
• PICSI: Physiological intracytoplasmic sperm injection (PICSI) is a technique used to select mature and healthy sperm to use in Intracytoplasmic sperm injection (ICSI) treatment. It involves placing sperm with hyaluronic acid (HA), a natural compound found in the body. PICSI identifies sperm that can bind to HA and then these sperm are selected for use in treatment.

2. Sperm retrieval techniques: In some cases, sperm can be retrieved directly from the testicles or epididymis using surgical procedures like TESA (Testicular sperm aspiration), PESA (Percutaneous Epididymal Sperm Aspiration), TESE (Testicular sperm extraction) & Micro-TESE (microsurgical testicular sperm extraction) for use with IVF/ICSI. 

Important to Remember

• A doctor can help create a personalized treatment plan based on the specific cause of infertility.
• Consulting an andrologist or specialist in male infertility is recommended for diagnosis and treatment options.
• Even if the cause is untreatable, there are still ways to achieve pregnancy with the help of ART.
• Open communication with your doctor and partner is essential throughout the process.
• Men diagnosed with infertility experience a variety of psychosocial problems due to infertility. These psychosocial problems can include:

• A different perspective on the world
• Emotional turbulence
• Difficulty finding ways to contribute
• Changes in their relationship with their partner
• Selective sharing of their experiences with infertility

• Men often carry the weight of these psychosocial problems with them in their daily lives. Healthcare professionals need to acknowledge the impact of infertility on men and create space for them during ICSI treatment.