Surgery for Male Infertility
Causes of Male Infertility
Male infertility is very common. About one in twenty men is sub fertile and a male factor is present in half of all infertile couples. About one third of all IVF procedures are performed for male factor infertility.
It must be remembered that the testis has two distinct roles. The first is to produce the male sex hormone, testosterone, which is important for providing sex drive, erections, strong muscles. The second function of the testis is to produce millions of sperm every day, a process which occurs inside the approximately 150 metres of fine tubes in each testis. For most infertile men it is only this process which is at fault and a reduced number or poor quality of sperm are produced.
Why does this problem develop? We now believe that most cases are genetic. In other words, these men are born without the genetic information which would allow sperm production to occur normally. Small pieces of the Y, or so called male chromosome are often missing in men with severe infertility. Presumably these missing pieces of genetic information are the cause for the poor sperm production. But we need much more research before we can point to particular genes. Without that knowledge no treatment for men to improve sperm counts is likely to become available. IVF techniques offer hope now as they require very much fewer normal sperm than does Nature.
In the remaining one third of infertile men, we can find a likely cause for their infertility including:
• Obstruction to the passage of sperm from the back of the testis to the outside can result from blockage or absence of the vas deferens. Common causes include, obviously, vasectomy, but any history of injury, and other surgery or sexually transmitted disease may be important.
• Men can make antibodies to their sperm following vasectomy or other trauma or infection. These antibodies are a common cause of infertility and prevent sperm swimming or sticking to the egg. The testis can be damaged by a wide number of treatments including chemotherapy or X-Ray therapy.
• Some men have difficulties obtaining an erection, or in ejaculating due to a wide range of problems such as diabetes, MS, or previous prostate surgery. In these cases sperm can be found and used for IVF.
• Rarely, a deficiency in the brain pituitary hormones may result in low sperm counts. Its detection is important as it is readily treated with hormone injections.
• Finally there remains great controversy as to whether sperm counts have declined worldwide. The alleged change is quite small (about 15%) and no cause has been confidently identified.
• In conclusion while the causes of infertility are uncertain in many men, certain conditions can be identified and treated. These facts make it essential that all infertile men have their situation thoroughly investigated.
The basic male investigation begins with a detailed history and physical examination by our andrologist. Semen analysis and serum hormonal profile (FSH, LH, Testosterone, Prolactin and TSH) represent the first line investigations. History of hernia surgery or mumps in childhood, lifestyle (excessive exercise or steam/sauna), sexually transmitted infections or trauma will all be noted. Use of medication, alcohol, drugs and occupational and environmental exposure to toxins such as heat and other chemicals will also be recorded.
The semen analysis is the first basic investigation. The sample should be collected by masturbation after 2-7 days of abstinence (no sexual intercourse or masturbation). In exceptional circumstances, semen may be produced at home or during sexual intercourse using a special condom. The sample must be submitted within an hour after ejaculation.
Sperm counts of > 15 million/ml with >40% motility and > 4% normal morphology forms are considered normal.
The andrologist might suggest further investigations such as a color Doppler of the scrotum or certain dye tests such as vasography for accurate diagnosis.
Some conditions can be treated medically (such as hormone deficiencies) or surgically (varicocelectomy). If these fail to result in pregnancy you would be advised further treatment with IUI or finally ICSI which is the most successful treatment for almost all types of male factor infertility.
Very rarely, in some cases of primary testicular failure with elevated FSH levels where even microdissection TESA fails to yield sperm you might have to resort to a semen bank and avail of donor sperm for pregnancy.