Male Infertility, Diagnosis & Treatment

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Male Infertility, Diagnosis & Treatment:
About 15 percent of couples worldwide suffer from infertility. This means they aren't able to have a child while having unprotected sex for a year or more. In about 40 – 50% of these couples, male infertility is involved.
Male infertility is due to low sperm production, low sperm count (oligospermia), no sperm count (azoospermia), or low sperm motility (asthenospermia), abnormal sperm function or blockages inside the testicles that prevent the delivery of sperm through the penis. Sickness, injuries, chronic health problems, lifestyle choices, work habits and other factors can play a role in causing male infertility.
Sperm production (spermatogenesis):
The sperm is produced in the Testes and stored in the Epididymis. The testes and epididymis are paired structures, located within the scrotum. The testes are the site of sperm production and hormone synthesis, while the epididymis has a role in the storage of sperm. Within the walls of the tubules in the Testes, are found many randomly scattered cells, called Sertoli cells that have a function to support and nourish the immature sperm cells by giving them nutrients and blood products. As the young germ cells grow into sperm cells, the Sertoli cells help to transport them from the outer surface of the seminiferous tubule to the central channel of the tubule. Sperm cells are continually being produced by the testes. One immature germ cell takes as long as 74 days to reach final maturation, and during this growth process there are intermittent resting phases. Once the sperm has matured, it is transported through the long seminiferous tubules and stored in the epididymis of the testes until it is ready to leave the male body.
Signs of male infertility: 
The main sign of male infertility is the inability to have children. There may be no other obvious signs or symptoms. A problem such as an inherited disorder, hormonal imbalance, dilated veins around the testicle, or a condition that blocks the passage of sperm may cause signs and symptoms. 
Male infertility signs and symptoms may be: 
• Cannot have a child.
• Problems with sexual function, difficulty with ejaculation, decreased sexual desire (decreased libido) or difficulty in keeping an erection (erectile dysfunction) 
• Pain, swelling or a lump in the testicle area.
• Repeated respiratory infections.
• Abnormal breast growth (gynecomastia) 
• Decreased facial or body hair or other signs of a chromosomal or hormonal abnormality
• Low sperm count (less than 15 million sperm per milliliter or a total sperm count of less than 39 million per ejaculation)
When shall I see a doctor?
See a doctor if you: 
• Are unable to have a child after a year of regular, unprotected sex
• Have erection or ejaculation problems, diminished sex desire, or other problems with sexual function.
• Have pain, discomfort, a lump or swelling in the testicle area.
• Have a history of testicle, prostate or sexual problems.
• Have had groin, testicle, and penis or scrotum surgery.
• Unusual discharge from the penis head, or any sign of infection (burning feeling on your penis, foreskin swelling and redness, foreskin tightness, pain or itching around your genital area, sensitive, or painful genital skin). Sometimes the signs of infection might be red rash and white, shiny patches on the penis. The skin on the penis may be moist, and a thick white substance may be found under the foreskin or other folds of skin. 
Causes of male infertility:  
To make your wife pregnant, lots of factors have to work properly: 
Causes related to the semen and sperm: 
• You should produce good quality sperm. At first, the sperm is affected by the growth and formation of the male reproductive organs during puberty. At least one of your testicles must be working correctly, and your body must produce Testosterone, FSH, LH and other hormones to trigger and keep sperm production.
• Sperm have to be carried into the semen to be mixed with. When sperm are produced in the testicles, small tubes transport them to mix with semen and are ejaculated out of the penis.
• There has to be enough sperm in the semen. If the number of sperm in the semen (sperm count) is low, it decreases the possibility that one of the sperm will fertilize the egg. A low sperm count is less than 15 million sperm per milliliter of semen or less than 39 million per ejaculate.
• The sperm has to be functional and able to move. If the movement (motility) or function of your sperm is abnormal, the sperm will not be able to reach or penetrate the egg. 
  In order to fertilize the egg naturally, 50% of the sperm have to be mobile and active.
Causes related to medical treatment: 
• Chemotherapy and radiotherapy are the main medical causes of male infertility. You have to freeze your sperm before any chemotherapy or radiotherapy to be able to have children in the future.
Causes related to health problems: 
Varicocele or testicular varicosis: Is a swelling of the veins that drain the testicles. It's the most common reversible cause of male infertility. This prevents normal cooling of the testicles, causing a low sperm count and less moving sperm (low motility). Usually sperm production in men is dependent on the temperature of the testicles. Sperm is optimally produced when the testicles are 2 – 4oC below body temperature. 
  Surgical treatment of the varicocele can improve sperm number and function, and may improve pregnancy success when using assisted reproductive techniques such as in vitro fertilization     (IVF). The surgical treatment of testicular varicosis is successful in 30 - 35% of cases only. 
Infection. Some infections can change sperm production or sperm quality and count, or can cause scarring in the testicles which blocks the passage of the sperm. These include sexually transmitted diseases (STDs), such as chlamydia and gonorrhea; inflammation of the prostate (prostatitis); and inflammation of the testicles due to mumps (mumps orchitis). Even though some infections can do permanent testicular damage, most often sperm can still be retrieved by aspiration when needed.
Ejaculation. Retrograde ejaculation happens when semen enters the bladder during orgasm instead of going out of the penis. Several health problems can cause retrograde ejaculation, including diabetes, spinal injuries, medications, and surgery of the bladder, prostate or urethra. Some men with spinal cord injuries or certain diseases can't ejaculate semen, although they still make sperm. In such cases sperm can still be retrieved to be used in assisted reproductive techniques (ART).
Antibodies that attack sperm. Anti-sperm antibodies are immune system cells that mistakenly identify sperm as harmful and try to eliminate them.
Cancers and nonmalignant tumors can affect the male reproductive organs directly or can affect the glands that release hormones related to reproduction, such as the pituitary gland. Surgery, radiation or chemotherapy to treat tumors will affect male fertility.
Undescended testicles. In some males, during fetal development one or both testicles fail to descend from the abdomen into the sac that normally contains the testicles (scrotum). Decreased fertility is likely in men who have had this problem.
Hormonal imbalances. Infertility can result from disorders of the testicles themselves or an abnormality affecting other hormonal systems including the hypothalamus, pituitary, thyroid and adrenal glands. Low testosterone (male hypogonadism) and other hormonal problems of the FSH, LH, prolactin and free Testosterone have a number of possible underlying causes.
Sperm duct defects. The tubes that carry sperm (sperm ducts) can be damaged by sickness, infection or injury. Some men experience blockage in the part of the testicle that stores sperm (epididymis) or a blockage of one or both of the tubes that carry sperm out of the testicles. Men with cystic fibrosis and some other inherited problems may be born without sperm ducts (congenital bilateral absence of the vas deferens). In this case the sperm never make it into the semen, making it impossible for them to reach and fertilize an egg through intercourse. 
Chromosome defects. Genetic Inherited disorders: such as Klinefelter's syndrome where a male is born with two X chromosomes and one Y chromosome (instead of one X and one Y). This will result in abnormal development of the male reproductive organs. Other genetic syndromes associated with infertility include cystic fibrosis, Kallmann's syndrome and Kartagener syndrome.
Problems during sex. Problems in maintaining full erection enough for sex (erectile dysfunction), premature ejaculation, painful intercourse, anatomical abnormalities such as having a urethral opening under the penis (hypospadias), or psychological or relationship problems related to sex.
Celiac disease. A digestive problem caused by sensitivity to gluten. Celiac disease can cause male infertility. Fertility may improve after having a gluten-free diet.
Certain medications. Testosterone replacement therapy, long-term anabolic steroid use, cancer medications (chemotherapy and radiotherapy), some antifungal medications, some ulcer drugs   can impair sperm production and decrease male fertility.
After surgeries. Certain surgeries may prevent sperm presence during ejaculation, including vasectomy, inguinal hernia repairs, scrotal or testicular surgeries, prostate surgeries, and large abdominal surgeries performed for testicular and rectal cancers. In most cases, we can retrieve sperm directly from the epididymis and testicles by special techniques (TESA, TESE, PESA, MESA….)
Causes related to environment: 
Overexposure to heat, toxins and chemicals can reduce sperm production or sperm function. 
Specific causes include: 
Industrial chemicals. Extended exposure to benzenes, toluene, xylene, pesticides, herbicides, organic solvents, painting materials and lead will lead to low sperm counts.
Radiation or X-rays. Exposure to radiation can reduce sperm production, though it will often eventually return to normal later. In case of high doses of radiation, sperm production can be permanently decreased.
Overheating the testicles. Frequent use of saunas or hot tubs may temporarily lower your sperm count. Sitting for long periods, wearing tight clothing or working on a laptop computer for long   period of time also may increase the temperature in your scrotum and slightly reduce sperm production.
  The type of underwear doesn’t make a significant difference in male fertility.
Causes related to lifestyle
Illegal drugs. Anabolic steroids to stimulate muscle strength and growth cause the testicles to shrink and sperm production to decrease. Use of cocaine or marijuana can temporarily reduce the number and quality of the sperm also.
Alcohol use. Drinking alcohol lowers testosterone levels, cause erectile dysfunction and decrease sperm production. Liver disease caused by excessive drinking can also lead to fertility problems.
Work or occupation. Certain occupations can increase the risk of infertility, including those associated with car or house painting because of the toxins found in the paints.
Tobacco and smoking. Men who smoke have a lower sperm count than those who don't smoke.
Emotional stress. Stress can interfere with certain hormones needed to produce sperm. Severe or prolonged emotional stress, can affect your sperm count.
Depression. Research shows that pregnancy rate may be lower if a male partner has severe depression. In addition, depression in men may cause sexual dysfunction due to reduced libido, erectile dysfunction, or delayed or inhibited ejaculation.
Over weight. Obesity can cause hormonal changes that decrease male fertility.
Prolonged bicycling or horseback riding. Prolonged cycling is a cause of decreased fertility due to overheating of the testicles. In some cases, bicycle seat pressure on the area behind the   testicles (perineum) can cause numbness in the penis and erectile dysfunction.
Certain occupations including welding or those involving prolonged sitting, such as truck driving, may be associated with a risk of infertility.
All men who have life styles or a kind of risk that might lead to infertility have to freeze their sperm to have a semen backup in a specialized center in case they would like to have kids in the future.
Tests and diagnosis of male infertility:
Many infertile couples have more than one cause of infertility, so it's better to go both to see a doctor. They will need several tests to determine the cause of infertility. In some cases, cannot be identified.
Diagnosing male infertility problems: 
•    General physical exam and medical history. This includes examining your genitals and questions about any inherited conditions, chronic health problems, sickness, injuries or surgeries that could affect fertility. The doctor will also ask about your sexual habits and about your sexual development during puberty.
•    Semen analysis. Semen is generally obtained by masturbating and ejaculating into a special container at the clinic in a private room. Your semen is then examined in the laboratory to measure the number of sperm present and look for any abnormalities in the shape (morphology) and movement (motility) of the sperm. The lab will check your semen for signs of problems or infections. Often sperm counts change from one specimen to the next. In most cases, several semen analysis tests are done during a period of time to have accurate results. If the sperm analysis is normal, the doctor will start testing the female partner before asking to do any more male infertility tests.
The doctor may recommend other tests to help find the cause of infertility.
•    Scrotal ultrasound. This test uses high-frequency sound waves to produce images inside your body. A scrotal ultrasound can help see obstructions or other problems in the testicles and supporting structures.
•    Trans-rectal ultrasound to check the prostate. A small, lubricated sonde is inserted into the rectum to check your prostate, and look for blockages of the tubes that carry semen (ejaculatory ducts and seminal vesicles).
•    Hormone testing. Hormones produced by the pituitary, hypothalamus and testicles play an important role in sexual development and sperm production. Abnormalities in other hormonal or organ systems may also lead to infertility. A blood test is recommended that measures the Testosterone and other hormones.
•    Post-ejaculation urinalysis. Sperm in your urine indicates that the sperm is going backward into the bladder instead of out of the penis during ejaculation (retrograde ejaculation).
•    Genetic tests. When sperm concentration is extremely low, genetic causes could be involved. A blood test can reveal whether there are changes in the Y chromosome (signs of a genetic abnormality). Genetic testing such as the karyotype may be done to diagnose various congenital or inherited syndromes.
•     Anti-sperm antibody tests. Those are the tests that are used to check for immune cells (antibodies) that attack the sperm and affect their ability to function.
•    Testicular biopsy, TESA or TESE. This test is to remove samples from the testicle with a needle or after a small incision. The results of the testicular biopsy will tell if sperm production is normal. If sperm is found, that means that the problem is caused by a blockage or another problem with sperm transport.
Medical treatment for male infertility: 
The doctor will try to improve your fertility by either correcting an underlying problem (if it is found) by tablets or hormonal injections or trying treatments that seem to be helpful. Often, the cause of infertility can't be treated medically and Assisted Reproductive Technologies will be needed (IUI, conventional IVF, IVF + ICSI, TESA, TESE, PESA, or MESA). Even if an exact cause isn't clear, your doctor may be able to give treatments that work. In many cases of infertility, the female partner also will need to be checked and may need treatment.
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