- Genetic abnormalities
- Hormonal disorders
- Structural abnormalities
- Other diseases
- Other factors
When a couple tries to conceive for at least 1 year having regular sexual intercourse without taking any protection, but still there is no successful conception, then it is considered that the couple faces a problem of infertility. Infertility increases with age. In developed countries, 33% of couples in their late 30s confront infertility problem, as a result of the vocational aspirations and targets they set. Infertility has to be treated as the couple's common problem, and not in each individual separately. Irrespective of age, it is estimated that about 1 out of 8 couples trying to have a child face some infertility problem, either of a small or great extent.
Out of 100 couples making attempts to conceive normally:
• 20 couples will conceive within the 1st month
• 70 will conceive within 6 months
• 85 will conceive within 1 year
Even though most couples will succeed in conceiving within the 1st year, there is still a significant minority (15%) encountering a conception problem. In 30-40% of these cases, the problem is due only to the male factor (male infertility).
When investigating male infertility, highly crucial is the role of a detailed medical history and thorough clinical examination. While taking the patient's medical history, the physician has to ask about any existing diseases (diabetes mellitus, mumps etc) and previous male genital surgical procedures, and also take the full sexual history. In addition, the man will be asked whether he has come in contact with any noxious environmental substances (organic solutions, oil products, dyes, heavy metals) and whether he has been receiving any pharmaceutical therapy. Some pharmaceutical agents have been proven to affect spermatogenesis; such drugs are: Spironolactone (diuretic), Calcium Channel Blockers -CCBs (antihypertensive), Anti-androgens, Nitrofurantoin (antibiotic) in high dosage, Cimetidine (gastroprotective), Cyclosporine (oncological), Colchicine (anti-inflammatory) and Erythromycin (antibiotic). During clinical examination, the physician examines the penis, scrotum (sac containing the testes), epididymis and seminal duct (the passageway of the sperm from the testes and epididymis towards the urethra). Lastly, secondary sexual elements will be examined, such as hair growth, muscle mass and voice timbre.
A basic instrument in a male fertility test is the spermiogram (sperm analysis). This has to be performed by medical experts. The primary elements detected are semen volume, spermcount per ml of semen, total spermcount and sperm motility.
It is important to underline that there are no clear borderlines between a 'normal' and 'pathological' spermiogram. Therefore, the World Health Organization (WHO) has set some reference criteria; when these criteria are not met, the man has very few chances to achieve conception by natural means. In general, semen volume should be above 2ml; spermcount >15 million per ml; total spermcount > 40 million; sperm motility>45% sperm cells with high or moderate motility; morphologically normal sperm cell> 4%.
When no sperm cells are found in semen analysis, the condition is called 'azoospermia'. Azoospermia can be due to obstructive or non-obstructive causes. In obstructive azoospermia, the sperm cells normally produced in testes are unable to exit the urethra because the seminal duct is blocked and they cannot pass through (e.g. due to inflammation) or there may be some genetic abnormality in which there is no seminal duct at all. In non-obstructive azoospermia, the etiology may involve chromosomal anomalies and syndromes or acquired conditions, such as testicular injury, torsion or tumor, problems induced by medications, toxic substances, radiation etc.
Main causes of male infertility are:
Varicocele may be caused by enlargement of blood vessels above the testes (pampiniform plexus). This can be identified either with naked eye or with palpation.
However, timely diagnosis requires scrotal color ultrasound, for measuring the width of veins and screening venous blood reflux. In most cases, varicocele is localized only on the left testis, but it can very well be bilateral as well. It occurs in 20% of men and is responsible for 40% of male infertility cases by affecting sperm quality in many ways: reducing the total spermcount, restricting sperm motility, affecting sperm morphology and impairing the DNA of the sperm. Varicocele is treated surgically and the procedure of choice is Microsurgical Varicolecelectomy of the dilated testicular veins causing the problem. On-time varicocele treatment can improve the above sperm parameters. However, once varicocele has caused significant reduction in spermcount (below 5 million per ml), then it is very unlikely that varicocele repair will resolve the male infertility problem.
The most common genetic abnormalities are mutations in the cystic fibrosis gene (resulting in agenesis of the vas deferens), chromosomal abnormalities (responsible for various syndromes, such as Klinefelter's syndrome) and small deficiencies in the Y chromosome (potentially leading to reduction of spermcount, even to azoospermia).
Hormonal disorders may be due to thyroid gland dysfunction, hormonal deficiency, distortion of hormonal action, some congenital syndromes etc.
The basic hormones controlling or affecting spermatogenesis are FSH, LH, testosterone, prolactine, TSH and inhibin B. In some cases, the treatment of the above mentioned abnormalities may restore male fertility.
Structural penile abnormalities ( e.g. epispadias, hypospadias and phimosis) may affect the proper deposition of the sperm cell into the female vagina. The surgical treatment of these disorders usually resolves the infertility problem.
Sperm quality may be affected by inflammations (prostatitis, epididymitis, testiculitis etc) that are induced by infections, such as mumps, gonhorrea, mycoplasma - ureaplasma, chlamydia, tuberculosis etc.
Inflammations are treated mainly pharmaceutically with good results in most cases.
Diabetes Mellitus plays a major role, for it affects both the erectile function and the quality of spermatogenesis. Unfortunately, once spermatogenesis or erectile function get impaired, this condition can no longer be reversed. This is the reason why tight blood sugar control is highly essential. In many cases, erectile dysfunction is treated pharmaceutically, whereas spermatogenesis disorder requires In Vitro Fertilization (IVF).
Chronic renal failure is also another major cause of male infertility. The only solution in these men is Kidney Transplantation. However, when this solution is not feasible or delays considerably, the couple may resort to In-Vitro Fertilization (IVF).
Male infertility may also be due to other causes, such as smoking, alcohol, exposure to toxic substances etc.
When the primary cause of male infertility cannot be identified (idiopathic or essential infertility), cannot be treated or is treated unsuccessfully, then the couple can resort to specialised Assisted Reproduction Centers, in order to follow some assisted conception treatment method.