Fertility Infertility – The Male Perspective

Facts about male fertility

• Male infertility can result of physical, hormonal, genetic, or immunologic problems, a chronic illness or any condition that hinders sexual activity.
• A semen analysis is the first step to see if there is male factor infertility.
• Ideal semen sample is obtained by masturbating into a cup.
• Abstinence for minimum 3 days is recommended prior to providing semen sample. Longer than 5-6 days abstinence should be avoided.
• When trying for a baby, sex once every 2-3 days is adequate. Ejaculated sperm can five for 2-3 days.
• Having sex everyday isn’t bad either! Although the amount of living sperm drops with daily sex, the quality of the sperm seems to be better.
• We are what we eat, and breathe, and drink, inhale… Your health is tied to the quality and quantity of your swimmers.
• Alcohol intake and smoking can affect sperm health.
• Sperms are created new every day. But, it takes 72 days for a sperm to grow to a full mature sperm that can fertilize an egg.
• In infertile males sometimes genes responsible for infertility may be inherited from their father, but never they can blame their mother!
• Depending on how low your sperm numbers are, different treatments can be used to help you have a baby.

MALE FERTILITY

We all know it takes a sperm and an egg to make a baby. Then why is getting a baby so unlikely to happen when men release millions of sperm with each ejaculation?

Infertility is becoming more and more common, especially since many couples are waiting to have children later in fife. Globally, 48.5 million couples experience infertility. (Reproductive Biological Endocrinofogy, 2015) A study at the Reproduction Biology Laboratory of the University Hospital of Marseille (France) between 1988 and 2007, demonstrated declining trends in sperm concentration (1.5%/year), total sperm count(1.6%/year), total motility (0.4%/year),rapid motility (5.5%/year), and normal morphology (2.2%/year). Doctors and researchers would say that infertility is becoming an epidemic, and infertility treatments are becoming more popular as couples look for ways to start a family.

FERTILITY STATISTICS WORLDWIDE-INTERESTING FACTS

• 9 of 10 countries with the highest total fertility rate are in Africa followed by Afghanistan. (Central Intelligence Agency, 2017)
• Southern Europe, Eastern Europe, and Eastern Asia have the lowest fertility rates in the world with an average of 1.5 children per woman. (UNFPA, 2018)
• Sweden has one of the highest fertility rates in Europe (close to 1.9 children per woman). (UNFPA, 2018)
• 1in 4 couples in developing countries is affected by infertility. (WHO, 2004)

THE MALE REPRODUCTIVE SYSTEM

The male reproductive system includes a group of organs that make up a man’s reproductive and urinary system. These organs do the following jobs within your body:

• They produce, maintain and transport sperm (the male reproductive cells) and semen (the protective fluid around sperm).
• They discharge sperm into the female reproductive tract.
• They produce and secrete male set hormones.
  The male reproductive system is made up of internal (inside your body- part of vas deferens, urinary bladder, prostate and seminal vesicle) and external (outside
  your body- testicle, epididymis, part of vas deferens and penis) parts. Together, these organs help you urinate (rid your body of liquid waste materials), have sexual intercourse and make children.

THE MALE REPRODUCTIVE SYSTEMHOW DOES THE MALE REPRODUCTIVE SYSTEM FUNCTION?

The entire male reproductive system is dependent on hormones (Chemicals that stimulate or regulate the activity of your cells or organs). The primary hormones for male reproductive functioning are follicle-stimulating hormone(FSH), futeinizing hormone(LH) and testosterone. FSH and LH are produced by the pituitary gland, located at the base of your brain. FSH is necessary for sperm production (spermatogenesis). LH stimulates the production of testosterone from testis, which is necessary for spermatogenesis. Testosterone is also important in the development of male characteristics, including muscle mass and strength, fat distribution, bone mass and set drive.

MALE FERTILITY

Male fertlity is a complex process. To get your partner pregnant, the following must occur:

• • You must produce healthy sperm. At least one functioning testis & sufficient hormones are needed.
  • Sperm produced in testis have to be transported to the semen collecting chambers located behinds your prostate
  • There needs to be enough sperms in the ejaculated semen.
  • Sperm must be functional and able to move reach and penetrate your partner’s egg.

DOES MALE FERTILITY CHANGE WITH AGE?

Women have a limited fertility window, that ceases at menopause. Men, on the contrary, can produce sperm from puberty to old age and can father children as long as they do so.

In 2012, Ramjit Raghav made global headlines when he became a father at the age of 96. However, this doest mean men’s fertility is unaffected by age.

A UK study showed after adjusting for female age,fertility potential was 30% less for men over the age of 40 Compared with younger men.

Although sperm is stiff being produced, the quantity of sperms produced and their quality (both motility and morphology) decline with age.

A recent study in the British Medical Journal (BMI) reported, men above 45 years have higher risk of infants born premature, of low birth weight, and with a low apgar score (a health score for the newborn). Moreover, babies born to fathers older than 55 are more likely to require assisted ventilation and admission to a neonatal intensive care unit.

MALE INFERTILITY

Male infertility is a condition where a man is not able to achieve pregnancy with his female partner despite 1 year regular sex without any birth control.

About 85% couples usually conceive in their first year of trying. Additionally, 7% of couples conceive in their second year of trying.

How common is Infertility?

According to American Society Of Reproductive Medicine (ASRM), amongst couples with infertility, roughly 20% of the time it’s completely due to male issues. Male partner’s problems may also be a contributing factor in an additional 30-40% of infertile couples.

• • • An estimated 15% of couples will have trouble conceiving. (UCLA Health, 2020)
    • About 9% of men and 10% of women aged 1s to 44 reported infertility problems in the United States. (CDC, 2013 and Office on Women’s Health, 2019)

Common Causes 0f Male Infertility

The main causes of male infertility are:

• • Sperm Disorders: Disorders of sperm production or maturity are the most common causes of male infertility and may be inherited. Lifestyle practices like smoking, drinking alcohol, and taking certain medications can lower sperm numbers. Long-term sickness (such as kidney failure), childhood infections (such as mumps) can also be culprits.Damage to the reproductive system can cause low or no sperm. About 4 out of every 10 men with total lack of sperm (azoospermia) have an obstruction (blockage) within the tubes that transport sperms. A birth defect or a previous infection can also cause blockage.
  • Varicoceles: Varicoceles are swollen veins in the scrotum. They’re found in 16 out of 1oo of all men, but more common in infertile men (4o out of 100). They hinder proper blood drainage back to the body from the scrotum. The testicles are then too warm and sperm motility and sperm numbers are affected.
  • Retrograde Ejaculation: Retrograde ejaculation is a condition where ejaculated semen goes backwards into your bladder instead of out the penis. This happens when nerves and muscles in your bladder don’t close during orgasm (climax). Despite having normal sperms, semen may cannot reach the vagina.
    This condition can be caused by previous surgery, certain medications or neurological diseases. Men may notice cloudy urine after ejaculation and less fluid or “dry” ejaculation.
  • Immunologic Infertility: Sometimes a man’s body makes antibodies that attack his own sperm. These may arise from previous injury, surgery or infection. These antibodies affect sperm movement and function. This condition is not common though.
  • Obstruction: Repeated infections, surgery (such as vasectomy), swelling or developmental defects can cause blockage of the tubes that transport sperms and thereby, sperm from the testicles can’t leave the body during ejaculation.
  • Hormones: Hormones made by the pituitary gland tell the testicles to make sperm. Very low hormone levels cause poor sperm growth.
  • Chromosomes: Sperm carry half of the DNA to the egg. Changes in the number and structure of chromosomes can affect fertility. For example, the male Y chromosome may be missing parts.
  • Medication: Certain medications can change sperm production, function and delivery. These medications are most often given to treat health problems like
  • arthritis
  • depression
  • digestive problems
  • anxiety or depression
  • infections
  • high blood pressure
  • cancer
  • skin conditions like psoriasis

  • ARETHERE ANY SYMPTOMS OR SIGNS OF MALE INFERTILITY?

    The main sign of male infertility is the inability to conceive a child. There may be no other obvious signs or symptoms.

    Occasionally, men may notice the following signs and symptoms that may be associated with infertility:

    • Problems with sexual function – difficulty with ejaculation or small volumes of fluid ejaculated, reduced sexual desire, or difficulty maintaining an erection (erectile dysfunction)
    • pain swelling or a lump in the testicle area
    • Recurrent Respiratory infections
    • Inability to smell
    • Abnormal breast growth (gynecomastia)
    • Decreased facial or body hair or other signs of a chromosomal or hormonal abnormality

    WHEN TO SEE A DOCTOR

    See a doctor if you have been unable to conceive a child after a year of regular unprotected or sooner if you have any of the following

    • Erection or ejaculation problems, low sex drive, or other problems with sexual function
    • Pain, discomfort, a lump or swelling in the testicle area
    • A history of testicle, prostate or sexual problems
    • A groin, testicle, penis or scrotum surgery

    SEMEN ANALYSIS:SAMPLE COLLECTION TECHNIQUES

    In males, semen analysis is the initial investigation. Ideal semen sample is obtained by masturbating into a cup. Alternatively, (if one has personal or religious prohibitions against
    masturbation), sample can be produced during sex, using a special type of condom, but the sample quality may be inferior.

    The best sample is produced after three days of abstinence from sexual activity.

    rationale: sperm is continuously made fresh however daily ejaculation results in samples with lower amounts of sperm in each. This could make the results of the analysis look
    abnormal even though you are making enough sperm.

    Waiting too long is not great though. Longer than 5-6 days abstinence for most men results in the number of living sperm to seem low.

    The specimen should be kept warm and sent to the laboratory for examination, ideally within an hour from production. Best option is to produce the sample in the laboratory if facilities exist.

    NORMAL SEMEN PARAMETERS

    Normal results based on latest World Health Organization (WHO, 6th edition, 2021) criteria are given below. Figures shown are lowest acceptable result (5th percentile) and 95% confidence limits
    in brackets:

    • Parameter : Normal(range)
    • Semen volume (ML) : 1.4(1.3-1.5)
    • Total sperm number (10° per ejaculation) : 39(33-46)
    • Sperm concentration (10°per mL) : 16(15-18)
    • Total motility(%) : 42 (40-43)
    • Progressive motility(%) : 30(29-31)
    • Vitality (Iivespermatozoa,%) : 54(50-56)
    • Sperm morphology(normaI forms,%) : 4 (3.9-4.0)

    FEW TERMS USED TO DESCRIBE ABNORMAL SEMEN RESULTS

    • Azoospermia: absence of sperms in your semen
    • Oligozoospermia: sperm concenttration <16 million spermatozoa/ml.
    • Asthenozoospermia: sperm progressive motility <30% motile spermatozoa.
    • Teratozoospermia: sperm morphology <4% normal forms.
    • Polyzoospermia: sperm concentration >208 million/ml.

    WHAT TO DO IF THE SEMEN ANALYSIS RESULT CAME ABNORMAL

    If the first test is normal, a second test is not required. Repeat semen test should ideally be undertaken three months after the initial analysis, to allow time for the cycle of spermatozoa formation to be completed. However, if a gross spermatozoal deficiency (azoospermia or severe oligozoospermia) has been detected, the repeat test should be undertaken as possible.

    OTHER INVESTIGATIONS WHEN SEMEN PARAMETERS ARE ABNORMAL

    Further investigations are indicated if two semen tests are abnormal.

    • Hormone analysis FSH, Total & Free Testosterone, LH and Prolactin may be checked. Impaired sperm production is often associated with elevated FSH levels.
    • Genetic testing. Common tests performed are Y-chromosome microdeletion assay, karyotyping, Cystic fibrosis gene assay.
    • Ultrasound.Scrotal ultrasound detects abnormalities in the testis, epididymis, spermatic vein(varicocele) and proximal vas deferens. Transrectal ultrasound identifies pathologies at pros-tate, vas ampulla, seminal vesicles (SVs) and ejaculatory ducts (EDs).
    • Sperm DNA Fragmentation Test. In couples with recurrent pregnancy loss or in men with unexplained infertility
    • Testicular biopsyis the best procedure to define the histological diagnosis and the possibility of finding sperm. It is also called Testicular Sperm Aspiration/ Extraction (TESA/ TESE). About 60% cases of Non-obstructive azoospermia (NOA) may show sperms in TESA/ TESE.
    • Viral screening. Infertile men should undergo testing for HIV, hepatitis B and hepatitis C. If tested positive, specialist advice and counselling and appropriate clinical management is offered.
    • General.Men with ejaculatory disorders should have their fasting glucose performed to exclude diabetes mellitus.
    • Post-ejaculation urinalysis.Sperm in your urine can indicate retrograde ejaculation (sperm traveling back to the bladder instead of out your penis during ejaculation).
    • Specialized sperm function testsA number of tests can be used to check how well your sperm survive after ejaculation, how well they can penetrate an egg, and whether there’s any problem attaching to the egg. These tests are used only in special circumstances of unexplained infertility.

    WHAT TREATMENT OPTIONS ARE AVAILABLE

    Lifestyle changes

    • Get and maintain a healthy body weight by exercising and eating a healthy diet.
    • Stop smoking.
    • Stop drinking.
    • Stop using marijuana.
    • Stop any illegal drug use.
    • Avoid heat and radiation exposure to testicles.

    Medicine

    Antioxidants

    Vitamin and mineral supplements are sometimes recommended for their “antioxidant” properties (they prevent damage to the sperm-making process).

    Hormones

    Hormone treatment may help you if you have a hormone disorder causing your infertility. Treatment may include gonadotropin therapy or antiestrogens.

    Antibiotics

    Antibiotic treatment might cure an infection of the reproductive tract.

    Treatments for sexual problems

    Medications can help improve fertility in conditions such as erectile dysfunction or premature ejaculation.

    Surgery

    Varicocele surgery

    Can improve sperm quality. Different surgical techniques (Microsurgery, Open, Laparoscopy, Embolisation) are available. Currently, Microsurgery claims to provide best results. Patients with previous Vasectomy desirous of fertility may opt for Microsurgical Vas Reversal.

    Assisted Reproductive Technologies (ART)

    If tests show that the male partner’s semen contains no or few normal sperm, ART can help. This may be through:

    Artificial insemination (lntrauterine Insemination, lUl).

    This method puts many healthy sperm at the entrance of the cervix or right into the partner’s uterus. The sperm can then make their way to the fallopian tubes.

    IVF, GIFT, and other techniques.

    In vitro fertilization (IVF) and gamete intra-fallopian transfer (GIFT) work like artificial insemination. Your provider collects your sperm. Then he or she mixes your partner’s eggs with a lot of high-quality sperm. He or she may mix the eggs and sperm in the tab or in your partner’s fallopian tube.

    lntracytoplasmic sperm injection (ICSI).

    Your provider injects a single sperm into an egg. Fertilization then takes place under a microscope. Your provider puts the fertilized egg in your partner’s uterus.

    Semen Cryopreservation

    Semen cryopreservation (commonly called sperm banking or sperm freezing) is a procedure to pre-serve sperm cells. Semen can be used successfully indefinitely after cryopreservation. For human sperm, the longest reported successful storage is 24 years.

    WHEN INFERTILITY CANNOT BE TREATED

    Sometimes, infertility treatments are not successful, or treatment is not an option. If this is the case, there may be other ways to start a family. This is a very personal decision based on a
    couple’s values and preferences.

    • Artificial insemination with donor sperm – Some couples may choose artificial insemination of the female partner with donor sperm. Donor sperm may be obtained from a l‹nown donor or from a sperm bank, which screens for infections and genetic problems. The decision to use donor sperm can be complicated and difficult for a couple.
    • Adoption – Some couples consider adopting a child.
    • Childlessness – Some couples affected by infertility decide to remain childless.

    FREQUENTLY ASKED QUESTIONS ON MALE INFERTILITY

    What health problems can cause male infertility

    Many health problems–from kidney disease to testicular cancer–can result in male infertility. “Whole-body” health problems and metabolic disorders, and ordinary fevers and infections can harm sperm growth. Diseases passed through sex can lead to blocks and scars in the reproductive tract.

    Genetic health problems, such as cystic fibrosis can cause the vas deferens or seminal vesicles to be absent leading to no sperm in the semen. Many illnesses can cause infertility. It’s important that you and your partner tell your family and personal health histories to your health care provider.

    Can cigarette smoke affect sperm?

    Yes. Research shows that routine smoking affects sperm in many ways. It causes sperm cells to be smaller and slower. It harms their DNA. Smoking can also affect the seminal fluid ejaculated with sperm.

    Can using steroids for body building cause infertility?

    Yes. Steroids tal‹en by mouth or shot can cause your body to stop making the hormones needed to make sperm.

    Do abnormal semen analyses or sperm lead to children with birth defects?

    Not necessarily. For most couples seel‹ing fertility treatment, the risk of conceiving a child with a birth defect is the same as for the general population. Some problems (chiefly genetic
    problems) that cause infertility may also cause a greater riskof conceiving a child with birth defects. So cou- ples need thorough exams and advice before beginning some forms of ARTs.

    What’s the main thing I should l‹now about male infertility?

    Infertility is not your or your partner’s fault. The American Society of Reproductive Medicine (ASRM) estimates that in about a third of infertility cases it is due to the male. Another third is the female.

    In the fast third of infertile couples, the problem is caused by either a combination of reasons, or, in 20 out of 100 cases, it can’t be explained.

    In men, few or no sperm is the biggest problem. In women, the common problems are ovulation problems and blocked tubes. But today, technology and surgical tools exist to address many of
    these problems.

    The best Male Infertility Treatment in Bahrain is provided by Dr Das Urology Hospital.