10-15% of all married couples face a problem in conceiving a child. Abnormalities in the male partner are responsible in about half of these cases. Infertility is defined as the inability to conceive after one year of unprotected intercourse.
When should evaluation start?
- All couples who have failed to conceive after one year of trying
- Evaluation may begin earlier in:
- Men with a known reason for possible problems such as a history of mumps, chemotherapy, radiation, testicular tumors
- Couples with advancing age
Evaluation of an infertile couple should always be done for both partners together. In fact, since the evaluation of the male partner is simpler, non-invasive and inexpensive, it should be done at least simultaneously if not before that of the female partner.
The basic evaluation of the male partner involves a detailed history, physical examination and a semen analysis. A number of treatment decisions can be based on just these three things while advanced investigations are required in a small proportion of patients.
The semen analysis forms the cornerstone of male fertility evaluation. Semen values can vary tremendously in the same individual on different occasions. Therefore it is important to get at least three semen reports on three different days. There should be a 2-3 day abstinence period before the test and preferably, the sample should be evaluated within an hour of collection.
Common causes of abnormal semen reports are recent illnesses, medicines including most antibiotics, fever, heat and stress. Incomplete and improper collection of the sample may also be responsible. It is also important to be aware that the ‘normal’ values of a semen report include: > 2mL volume, > 20 million sperm/mL, > 50% total motility and > 30% normal forms.
Based on the semen report, problems in the man are categorized into two major classes:
- Oligo/astheno/teratospermia (OATS) when the total number of sperms, the number of motile sperms or the number of normal sperms is lower than normal.
- Azoospermia when there are no sperms in the sample
The commonest report of a semen analysis in male factor infertility is an abnormal sperm count/ motility or morphology. There are a number of reasons for these problems.
- Varicoceles are an abnormal set of veins near the head of the testis. These are considered the commonest correctable cause of male infertility. They are diagnosed through a clinical examination by the urologist and a Doppler ultrasound may be ordered only to confirm their presence. Patients with OATS, infertility and a clinical varicocele may benefit from a varicocelectomy. This is a day-care procedure wherein the abnormal veins are tied. Ideally, this procedure is done using an operating microscope (microsurgical varicocelectomy) to magnify the tiny veins and thus avoid injury to other structures nearby.
- Recent illnesses, stress, medications and heat exposure may also cause OATS and their correction may help improve the semen reports.
- Hormonal/ genetic factors are an infrequent cause of OATS and a hormonal analysis (FSH/ LH/ Testosterone/ Prolactin) does not need to be routinely done.
- A large number of cases will have no clear cause for their problem. Unfortunately, there are no drugs that clearly help improve the semen quality. Testosterone/ hCG and other androgens must not be taken without a clear deficiency as these may actually further decrease the semen values.
Azoospermia is the total absence of any sperms in the semen. This must be confirmed on two or three separate examinations in a centrifuged semen sample. There are two basic categories of azoospermia: obstructive (OA) and non-obstructive (NOA).
- Obstructive azoospermia: The hallmark of this condition is that there is a normal production of sperms within the testis but they are not present in the semen due to an obstruction in their normal pathways of secretion. Except in cases with a previous vasectomy or absent vas, it requires confirmation of testicular sperm production through a testis biopsy or FNAC.
- Vasectomy is an obvious cause of OA because the vasa deferentia that carry the sperms from the testis have been surgically cut. Bilateral hernia/ hydrocele surgery or injuries may also lead to injury to the vas deferens resulting in OA.
- Absent vas deferens is a congenital condition wherein the vas deferens are not present since birth. It results in OA if both vasa are absent. It can be diagnosed through a clinical examination and a semen analysis. It cannot be surgically corrected.
- Vaso epididymal junction obstruction also results in OA. It occurs on both sides and usually there is no clear cause. This is surgically correctable by a vaso-epididymal anastomosis (VEA) operation with a return of sperm in about 30% of patients. This operation involves bypassing the site of obstruction. The operation is extremely delicate and is performed under an operating microscope using stitches that are barely visible to the naked eye. Microsurgical single tubule VEA is the best procedure for this problem and has the best possible results.
- OA may also be due to an obstruction near the ejaculatory ducts that can be treated by an operation called TURED.
- Non-obstructive azoospermia is said to exist if there is decreased or absent production of sperm in the testis. This is confirmed through hormone analysis (FSH) and a testis biopsy or FNAC. This is surgically not correctable.
Surgical options are useful in cases that have been outlined above. Medications are not very effective except in cases with a clear hormonal abnormality. However, they may be tried for a limited period of time in patients with mild to moderate OATS.
Recent advances in science have made it possible to father a child through just one sperm. Some of the techniques used in assisted reproduction are:
- IUI: Intrauterine insemination involves collection and processing of semen and its injection directly into the female partner’s uterus. This needs a certain basic sperm count and motility and is suitable for a limited number of patients.
- IVF: in-vitro fertilization involves retrieval of the egg from the female and sperms from the male and their fertilization in a laboratory before reimplantation of the embryo back into the female. It is feasible with very poor quality semen that is not azoospermic.
- IVF with ICSI is an advanced form of IVF wherein one single sperm is injected into the female egg. This may be possible even in patients with NOA where a single or few immature sperms may be extracted from the testis.
Things to remember:
- The male and female partners should be evaluated simultaneously.
- A trained Urologist/ Andrologist should evaluate the male since a number of diagnosis and treatment decisions are based primarily on the examination.
- At least three semen reports should be assessed.
- Hormone tests/ semen culture/ anti-sperm antibody tests are not routinely required.
- Varicoceles should be diagnosed clinically.
- Surgical treatment exists for varicoceles and a number of cases with obstructive azoospermia.
- VEA and varicocelectomy have the best results if performed using a microscope by an experienced surgeon since these are highly delicate operations. Even in the best hands, the results are often less than 50%.
- Few drugs are of benefit in treating OATS. These should be taken with caution. Hormones should not be taken unless clearly deficient.
Assisted reproduction techniques (ART) offer a hope to almost all categories of patients. However, they are expensive and have limited success. Patients whose condition can be treated either surgically or through medication should first be treated with these rather than going straight for ART.