Male infertility : What are the options ?

Dr Nandeibam Yohen
Introduction : Human reproduction is a very wasteful procedure. Though the women of our species can produce viable eggs almost every month in their reproductive period spanning almost 30 years, conception rates are far less, resulting in a few natural pregnancies, resulting in fewer livebirths. Though a discussion about fertility almost always veer towards women and their role, science and epidemiology have established that the men of our species have no less a role in the continuation of our species.
Definition : Inability to establish a clinical pregnancy after regular and unprotected married life of 12 months has been broadly defined as subfertility or infertility. This may be a result of any impairment or disability in either partner. In the case of males, an abnormal semen parameters or function, an abnormality of the reproductive tract (either structural or functional) or any bodily illness impairing normal cohabitation has been considered as causes for male subfertility.
Incidence : In couples with subfertility, a male factor exists along with female factor in about 30 to 40 % of the cases, while in about 8-10 % of such cases, male factor is the only identifiable reason. All in all, male factor is contributory in about 40-50% of the cases.
Normal semen parameters : According to the latest guidelines issued by WHO, semen parameters satisfying the following criteria are considered normal. Though the defining criteria is given as a range, but for easy understanding the lower limits of normal are given below:
Semen volume: 1.4 ml
Sperm concentration: 16 million per ml
Total sperm number per ejaculate: 39 million
Total motility: 42%
Progressive motility: 30%
Normal forms: 4%
Deviations from normal : The question that comes to mind, when we are given such criteria is whether these values are absolute, whether any small deviations result in infertility, or whether any men with abnormal values need treatment. Obviously, the answer is “No”. Small deviations can mean a decrease in count, motility, or normal forms, when the couple can still conceive by following fertile period and being in timely cohabitation. If at all treatment is required, then controlled ovarian stimulation followed by intrauterine insemination (IUI) can result in pregnancies in many couples. Controlled ovarian stimulation aims at the growth of more than one egg in the women using orally taken tablets or injectable hormonal preparations. IUI, otherwise known as artificial insemination, involves collection of the male partners’ semen sample, followed by a process known as washing or density gradient separation and selection of the most motile fraction of sperms to be injected directly inside the womb.
When there is a severe decrease in number, motility, or normal forms, then we need to resort to Assisted Reproductive Techniques (ART) such as in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI). But what if there is no sperm obtained in the semen, a condition known as azoospermia.
Causes for male infertility : Azoospermia or the absence of sperm in the semen sample is present in about 1% of the general male population and in 10 to 15% of infertile men. In resource limited settings and underdeveloped regions, these men are usually shown a dead end and often, given the option of undergoing a donor sperm artificial insemination or donor sperm- ART. Identifying the cause of azoospermia is the first step to management of such men. It may result from an obstruction in the male reproductive tract, a lack of production of sperms in the testes or lack of hormones responsible for stimulation of sperm production.
Treatment for pretesticular causes : When there is a defect in the production of central (brain origin) hormones responsible for stimulation of sperm production in the testes, the condition is known as pretesticular azoospermia. This is usually associated with endocrine disorders, genetic or chromosomal errors and sometimes due to use of certain medications. On laboratory testing, such men are seen to have not only low level of male hormone testosterone, but also low levels of follicular stimulating (FSH) and luteinizing hormone (LH). The accepted treatment for such men now is supplementing them with FSH, or gonadotropin releasing hormone (GnRH). Many men have benefitted from such treatment, and some have even been able to conceive naturally, without undergoing ART.
Treatment for testicular causes: Congenital absence of testes, undescended testes, injury to the testes or tumour in the testes may impair spermatogenesis. Chromosomal disorders, or deletions in genes, medications, exposure to irradiation or occupational exposure to high temperatures may result in non-production of sperms from the testes. Even in these situations there is usually focal production of sperms inside the testes, though the numbers are too small to be detected in the semen. Minimally invasive procedures using fine needles can be used to aspirate sperms from the testes. The sperm thus obtained can be used for a ICSI, an ART procedure in which one sperm is injected into one egg, thus achieving fertilization.
Treatment for post testicular cause : An obstruction in the path of the sperms from the testes to outside the body may result from an infection along the path (vas deferens), following surgical procedure near or on the vas or rarely following injury or congenital absence of the vas. Surgical correction may be possible in certain cases, and such surgeries are performed by Urologist. The other option, without having to resort surgery involves a minimally invasive procedure using fine needles, known as percutaneous epididymal sperm aspiration (PESA) where motile sperms can be obtained from a reservoir(epididymis) present alongside the testes. ISCI done using such sperms give better outcome than when sperms are obtained directly from the testes.
Conclusion : A diagnosis of azoospermia does not mean the end of options for having a child. Donor sperms have been used for achieving fertility in resource limited settings, due to lack of expertise and facilities. Those with a pretesticular cause may respond to medicines and may even father a child naturally. And with advancement in the field of reproductive medicine, testicular and epididymal sperms can be safely obtained with minimal pain and can be used for ICSI, thus giving hope of having a child with parental genes and not from an unknown donor. The writer is DNB (Obs & Gynae), Post Doctoral Fellow – Reproductive Medicine (CMC, Vellore), Consultant Reproductive Medicine, Shija Fertility Centre (a unit of Shija Hospitals) OPD Timing: Shija Urban OPD, Keishampat – 9 am to 1 om (Mon to Sun except Thursday); Shija HospitalsOPD, Langol–2 PM to 4 PM (Tuesday)