Definition of Male Infertility
For a man to be fertile following requirements are essential:
- Genetically correct male gender during development: Human cells contain 46 chromosomes – 22 pairs of autosomes (non-sex chromosomes) and 2 sex chromosomes, XX in the female and XY in the male
- Normal sexual and reproductive organs
- Normal hormone function (Endocrine function) of the testis and associated organs like pituitary
- Normal sperm production (Spermatogenesis). Any abnormalities associated with these will make the person infertile
Causes of Male Infertility
- Chromosomal Causes: Common causes include Kleinfelter Syndrome (47 XXY), XX male Syndrome and XXY syndrome, Y-chromosome abnormalities
- Testicular causes: Undescended testis, Varicocele, Orchitis (inflammation/Infection of testis), Injury, Vasal obstruction, Cystic fibrosis mutation, Radiation/Chemotherapy damage to the testis, Drugs that damage testis
- Hormones: Disorders of pituitary and testicular hormone activity
- Other organs as a cause: Erectile problems, Ejaculatory problems like premature ejaculation or no ejaculation, Vasectomy, nerve injuries, penile abnormalities, coital problems
- General health: Liver and Kidney disorders, sickle cell disease
- Life style issues: Obesity, smoking, diet, exercise and psychological factors
The following investigations are done according to the information gained by clinical assessment. Semen analysis however is the basic and an essential investigation in all cases. Semen analysis: The most recommended collection technique is by masturbation. To make an objective analysis and interpretation several samples at different intervals (at least 4-6 weeks apart) are necessary. Each sample is collected after a sexual abstinence for 2-3 days prior to collection. If the first semen analysis is normal there is no need for further semen analysis or any other tests unless there is some other indication.
A typical healthy sperm is motile and has head and a tail that is 10x longer than the head.
Table 1: WHO Reference criteria for semen analysis (2000)
|Volume||2.0ml or more|
|Liquifaction Time||<60 minutes|
|Sperm concentration||≥ 20 million /ml|
|Total Sperm number||≥ 40 million/ml|
|Motility||≥50% grade a* or b** motility; ≥25% progressive motility (Grade a) within 60 minutes of ejaculation|
|Vitality||≥ 75% live|
|White Blood Cells||< 1 million/ml< 1 million/ml|
* Grade a: rapid progressive motility (moving swiftly in a straight line)
** Grade b: Slow or sluggish progressive motility
Table 2: Definitions
|a) Normozoospermia||Normal parameters as defined by WHO reference values|
|b) Oligozoospermia||Sperm concentration less than WHO reference values|
|c) Asthenozoospermia||Less than WHO reference values for motility|
|d) Teratozoospermia||Morphology less than WHO reference values|
|e) Oligo-astheno-teartozoospermia||Combination of b, c, and d|
|f) Azospermia||Absence of sperm in the ejaculate|
|g) Aspermia||No ejaculate|
Antisperm antibodies (ASA)
Sometimes sperm clump into aggregates which may be non-specific (e.g. infection or excessive debris) or in site specific manner (e.g. head to head, head to tail or tail to tail or any of these in combination). Site specific manner indicates an immunological cause and can be further investigated by immunobead test or mixed agglutination reaction test (MAR test). However this is little practical importance as the treatment is by assisted conception (IVF or ICSI).
Pituitary and testicular hormone function is assessed by estimation of Luteinising hormone (LH), follicle stimulating hormone (FSH) and testosterone. Following are the indications:
b. Impaired sexual function
c. Evidence endocrine disorder
A simple midstream urinanalysis may indicate infection, blood glucose and protein in the urine.
Ultrasound of testis
It is not necessary to carry out ultrasound in every patient presenting with infertility. It is mainly indicated to detect varicocele, to study the testis in presence of hydrocele. It is important to carry out ultrasound in patients who had history of undescended testis and atrophic testis.
Male infertility could be the first sign of genetic abnormality. A number of men with oligospermia or azoospermia have autosomal or sex chromosomal abnormalities. Karyotyping determines such genetic anomaly and can be carried out by blood test. Chromosomal analysis is indicated in presence of high FSH levels, azoospermia and small testes. Nonpalpable vas deferens indicates cystic fibrosis gene mutation and needs chromosomal analysis.
Although biopsy gives information about architecture of the testis and thereby precise infertility diagnosis arising from the testis, it is not a routine investigation of male infertility. It is mainly indicated in azoospermia to differentiate between obstruction and primary testicular problems.