The inability of a couple to achieve pregnancy after one year of regular, unprotected
intercourse or the inability of a woman to carry a pregnancy to a live birth.
Over 15% of couples experience difficulty in conceiving a child after attempting for
one year. Although in the past infertility problems were attributed to the woman, we now
know that a male factor plays a role in almost one half of cases. Since a male fertility
problem is much more common that initially thought, any infertility evaluation should
include a thorough male history and physical examination and two semen analyses. The
optimal evaluation should recognize and treat the couple as a unit.
Although men are often not as expressive about the impact of infertility as women,
husbands contribute just as much to the causes of infertility as do their wives. It can't
be assumed, if a wife doesn't get pregnant, that it's her problem and that her husband's
reproductive system is normal. The male side of the fertility issue must also be examined,
from the beginning of sperm production through the release of sperm into the
ejaculate.
The glands, organs, and tubes that comprise the male reproductive system are located in
three parts of the body - the scrotum, abdomen, and penis. The scrotum is the sac that
holds a man's testicles. Sperm leave the testicles bathed in testicular fluid, enter a
cluster of microscopic tubules at the top of each testicle, and then move into a tightly
coiled, fifteen-footlong tube called the epididymis. From the epididymis, sperm enter the
vas deferens, a fifteen-inch-long tube about as thick as a Venetian blind cord, that rises
into the abdomen. From the vas, sperm and testicular fluid enter the ejaculatory duct,
formed by the end of the vas and the exit duct of the seminal vesicle, a gland that
produces approximately 65 percent of the semen. The ejaculatory duct empties into the bulb
of the urethra. Here, sperm from each testicle combine with a mixture of fluid produced in
the prostate gland, which empties into the bulb of the urethra through a separate duct.
Muscles surrounding the urethra contract rhythmically to cause ejaculation, the sudden spurt of semen from the penis.
The most common reason for infertility in the male is the inability to produce adequate
numbers of healthy sperm. Infertility in men may also be caused by problems delivering
sperm into the vagina, as occurs in impotence or in disorders affecting ejaculation,
including inhibited ejaculation and retrograde ejaculation (when ejaculate is forced
backward into the bladder). It may also be caused by failure of the testes to descend into
the scrotum, by diseases or severe physical injuries which damage the sperm-producing
structures, or by antibodies to the sperm found in either the male or the female.
About 25% of all infertility is caused by a sperm defect and 40-50% of infertility
cases have a sperm defect as the main cause, or a contributing cause.
It is sometimes hard to know whether the sperm problem is the only cause, or just a
contributing cause to the infertility. Part of the problem is that numbers are just
numbers:
We know that men with very low sperm counts can sometimes have children.
We know that some men with normal sperm counts can be infertile.
What matters is not really how many or how fast they swim - but whether they can
fertilize the female partner's eggs.
The semen analysis is the cornerstone of testing for male infertility problems. This
test provides important information about the quality and quantity of the sperm. The semen
sample is analyzed for volume, viscosity (thickness), pH and color of the ejaculate, sperm
concentration, motility, morphology, and forward progression of the sperm. The sample is
also examined for the presence of white or red blood cells which may indicate infection or
inflammation. A minimum of two semen analyses provided several weeks apart and collected
in a similar manner is recommended because sperm counts tend to fluctuate.
Occasionally due to religious reasons, the sample may have to be obtained during
intercourse. A special condom designed for this purpose will be provided.
Anejaculation and ejaculatory dysfunction are the terms used to describe the inability
of a man to have an ejaculation. This condition typically results from neurologic diseases,
traumatic injury, or as a complication of surgery. The nerves that are responsible for
carrying the signal for ejaculation exit the spinal cord and course along the aorta at the
posterior part of the abdomen. These nerves are most commonly injured after spinal
trauma resulting in paraplegia or quadriplegia, major bowel or vascular surgery, or
surgery for testicular cancer. Other conditions that can result in ejaculatory failure
include diabetes, multiple sclerosis, syringomyelia, psychological disorders and
peripheral neuropathies. In the past, men with ejaculatory dysfunction were considered
infertile because they couldn't ejaculate and impregnate their wives even though they did
produce sperm within their testicles.
Electroejaculation and vibratory stimulation have enabled many men who suffer from
ejaculatory failure to conceive children of their own.
For those couples experiencing infertility due to a man's vasectomy, there are the
alternatives of T.D.I. (therapeutic donor insemination) or IVF/ICSI (in-vitro
fertilization with intracytoplasmic sperm injection), but restoration of a man's fertility
by reconnecting the tubes at the site of the previous vasectomy appears to provide couples
with the most optimal and least expensive option for a family.
There are two main reasons why sperm may be absent from the semen (necessitating sperm
aspiration). Obstructive azoospermia is the result of a blockage in the male reproductive
tract. Sperm production in the testicle is normal but the sperm are trapped inside the
epididymis. Non-obstructive azoospermia is the result of severely impaired or non-existent
sperm production. It is precisely these situations that require advanced reproduction
technologies such as intracytoplasmic sperm injection to establish a pregnancy.
Four different techniques can be used to obtain sperm. The procedures have clear cut
advantages and drawbacks and not all are applicable to every situation. A thorough
knowledge and understanding of the cause of the patient's infertility and pathophysiology
of the disease process are essential prior to recommending and performing any
procedure.
Varicocele is a dilation (enlargement) of the internal spermatic veins that drain the
testicle. It is a very common condition present in 15% of the general male population and
40% of men evaluated for infertility. A varicocele develops because of defective valves
that normally allow for one-way blood to flow away from the testicle toward the abdomen.
Testicular injury occurs due to abnormal back flow of blood form the abdomen into the
scrotum and this creates a hostile environment for sperm development. The significance of
this condition has been known for a thousand years. The first century Greek physician
Celcius originally described the varicocele: "The veins are swollen and twisted over the
testicle, which becomes smaller than its fellow in as much as its nutrition has become
defective".
Numerous theories postulate how a varicocele can affect fertility:
temperature increases due to abnormal blood flow in the veins draining the testicle and in
the artery entering the scrotum. Prolonged elevated testicular temperature has detrimental
effects on sperm production.
may impede development of normal sperm.
increases metabolic waste products and decreases the availability of of oxygen and
nutrients required for sperm development.
testosterone concentration, which in turn can interfere with sperm production. The long
term effects of compromised circulation may interfere with normal male androgen
production.
Depending on the individual circumstances and the severity of the sperm abnormalities,
multiple approaches to this problem can be taken. Surgical correction, intrauterine
insemination and clomid therapy can be used simultaneously to achieve a pregnancy. The
most severe cases may require in-vitro fertilization. The varicocele remains the most
treatable cause of poor semen parameters and male infertility.
Myth or fact: If a couple is having trouble conceiving a child, the man should try wearing loose underwear?
That's a fact, according to a study on "Tight-fitting Underwear
and Sperm Quality" published June 29, 1996, in the scientific journal The Lancet.
Tight-fitting underwear--as well as hot tubs and saunas--is not recommended for men trying
to father a child because it may raise testes temperature to a point where it interferes
with sperm production.
