What is #Male #Infertility
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MALE INFERTILITY

Male infertility refers to a male's inability to cause pregnancy in a fertile female. Infertility is a general term doctors use if a man hasn't been able to get a woman pregnant after at least a year of trying. It is a disease of the reproductive system, which makes a person unable to have children. It can affect a man, a woman, or both. Male infertility means that a man has a problem with his reproductive system.

It means the man cannot start a pregnancy with his female partner.

In about a third of all cases, infertility is because of a problem with the man. In another third, it is a problem with the woman. Sometimes too no cause can be found.

WHAT HAPPENS UNDER NORMAL CONDITIONS

The male body makes tiny cells called sperm. During sex, ejaculation normally delivers the sperm into the woman's body.

The male reproductive system makes, stores, and transports sperm. This process is controlled by chemicals in the body called hormones. The sperm and testosterone (male sex hormone) are made in the 2 testicles. The testicles are in the scrotum, a sac of skin below the penis. When the sperm leave the testicles, they go into a tube behind each testicle. This tube is called the epididymis.

Just before ejaculation, the sperm goes from the epididymis into another set of tubes called the vas deferens. Each vas deferens leads from the epididymis to behind the bladder in the pelvis. There each vas deferens joins the ejaculatory duct from the seminal vesicle. During ejaculation, the sperm mixes with fluid from the prostate and seminal vesicles. This forms semen. Semen then travels through the urethra and out of the penis.

Male fertility depends on the body making normal sperm and delivering same. The sperm go into the female partner's vagina. The sperm travel through her cervix into her uterus to her fallopian tubes. There, if a sperm and egg meet, fertilization happens.

The system only works when genes, hormone levels and environmental conditions are right.

Infertility has traditionally been thought of as a woman's problem. But as it turns out, the men do not get off that easily. About one out of every three cases of infertility is due to the man alone.

A diagnosis of male infertility can be one of the hardest challenges a man can face. For some, it could even be devastating. Not being able to father a child can make a guy feel like he's failing at one of his most primal responsibilities.

Unfortunately, some men have to cope with the fact that nothing can be done about their infertility. For other men however, advances in male infertility treatment offer real help.

UNDERSTANDING MALE INFERTILITY

Sperm are made in the testicles. They're then stored inside yards of coiled tubes called the epididymis, which lies on top of each testicle. The sperms are nourished by semen, which is made by glands along the way. During ejaculation, about 150 million sperm are ejaculated in a half-teaspoon of semen through the penis.

This whole process hinges on there being proper levels of testosterone as well as other hormones and correct signaling from the nervous system.

Women send an egg down into the uterus (ovulate) once a month. This happens about 14 days after menstruation. Unprotected sex any time in the five days before ovulation can create a pregnancy. Sex any other time, even the next day after ovulation, will not result in conception.

CAUSES OF MALE INFERTILITY

Generally speaking, infertility in men is related to issues with the following:

  • Effective production of sperm
  • Sperm count, or the number of sperm
  • Shape of the sperm
  • Movement of the sperm (including both the wiggling motion of the sperm themselves and the transport of the sperm through the tubes of the male reproductive system)

There are a variety of risk factors, medical conditions, and medications that can also affect fertility adversely.

Medications and drugs

A variety of medications and drugs can also affect male fertility, such as:

  • Calcium channel blockers used for high blood pressure
  • Chemotherapy or radiation therapy used for cancer
  • Sulfasalazine used for rheumatoid arthritis (RA) or ulcerative colitis (UC)
  • Tricyclic antidepressants
  • Recreational drugs such as marijuana and cocaine
  • Anabolic steroids used for improved athletic performance or hormonal issues such as delayed puberty

Genetic Causes of Male Infertility

  • Mutations in the genes that determine the male sex, called the Y-chromosome
  • Other irregular changes in the genes (e.g. some men have a condition called Klinefelter's XXY syndrome in which they have an extra copy of the female-sex determining genes (the X chromosome)
  • Hormonal issues, including diabetes, high levels of prolactin (the milk-producing hormone), or problems with the hormone-producing organs like the thyroid or adrenal gland.

ENVIRONMENTAL CAUSES OF MALE INFERTILITY

Excess heat, sometimes due to the male's occupation, such as truck driving, welding, or firefighting, or habits like excessive use of hot tub or tight clothing.

  • Certain antibiotics and prescription medicines, anabolic steroids, alcohol, marijuana.
  • Toxicants (e.g. pesticides, herbicides, heavy metals, lead, mercury, or paints)
  • Diseases of the male genital tract (infections, cancer, trauma, or retrograde ejaculation)
  • Stress
  • Obesity
  • Excessive exercise
  • Chronic diseases, such as anemia, malnutrition, cancer, neurological disease, or diabetes
  • Dietary deficiencies (e.g. zinc, vitamin C, folic acid)
  • Varicocele, (when the veins enlarge inside the scrotum)
  • Surgery on the male genitals (e.g. treatment of undescended testicle, or hernia)

SYMPTOMS

The main sign of male infertility is the inability to conceive a child. However, other underlying problems such as an inherited disorder, a hormonal imbalance, dilated veins around the testicle or a condition that blocks the passage of sperm may cause the signs and symptoms.

Although most of the men with male infertility do not notice symptoms other than the inability to conceive a child, signs and symptoms associated with male infertility include:

  • Problems with sexual function - Difficulty with ejaculation or small volumes of fluid ejaculated, reduced sexual desire, and/or difficulty maintaining an erection (erectile dysfunction)
  • An abnormally low sperm count
  • Swelling, Pain or a lump in the testicle area
  • Repeated respiratory infections
  • Abnormal breast growth (gynecomastia)
  • Loss of smell
  • chromosomal or hormonal abnormality (e.g. decreased facial or body hair)

RISK FACTORS

Risk factors linked to male infertility include:

  • Being overweight
  • Tobacco Smoking
  • Using alcohol
  • Using certain illicit drugs
  • Being severely depressed or stressed
  • Having certain past or present infections
  • Exposure to toxins
  • Certain medical conditions, including tumors and chronic illnesses, such as sickle cell disease
  • Overheating the testicles
  • Trauma to the testicles
  • A prior vasectomy or major abdominal or pelvic surgery
  • Having a history of undescended testicles
  • Having been born with a fertility disorder or having a blood relative with a fertility disorder
  • Certain medications or undergoing medical treatments, such as surgery or radiation used for treating cancer

WHEN TO SEE A DOCTOR

People should see their doctors if they have been unable to conceive a child after a year of regular, unprotected intercourse but perhaps sooner if they have any of the following:

  • Problems with erection or ejaculation
  • 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

DIAGNOSIS

Many infertile couples have more than one cause of infertility, so it's likely both partners will need to see a doctor. It might take more than one test to determine the cause of infertility. In some cases, a cause is never identified.

Diagnosing male infertility problems usually involves:

General physical examination and medical history. The doctor may examine the genitals and ask questions about any inherited conditions, chronic health problems, illnesses, injuries or surgeries that could affect fertility. Other questions could be about sexual habits and about sexual development during puberty.

Semen analysis. Semen samples can be obtained in different ways. It could be by masturbating and ejaculating into a special container. But because of religious or cultural beliefs, some men prefer alternative methods of semen collection.

The semen is then sent to a laboratory to measure the number of sperm present and look for any abnormalities in the motility (movement) and shape (morphology) of the sperm. The lab will also check the semen for possible infections.

Sperm counts fluctuate significantly from one specimen to the next. In most cases, semen analysis tests are done over a period of time to ensure accurate results. If the sperm analysis is normal, your doctor will likely recommend thorough testing of the female partner before conducting any more male infertility tests.

To help identify the cause of infertility the doctor might recommend additional tests.

These can include:

Genetic tests.

When sperm concentration is extremely low, there could be a genetic cause. A blood test can reveal whether there are signs of a genetic abnormality (changes in the Y chromosome).

Scrotal ultrasound.

This uses high-frequency sound waves to produce images inside the body. A scrotal ultrasound can help the doctor see if there is a varicocele or other problems in the testicles and supporting structures.

Testicular biopsy.

In this test, samples are removed from the testicle with a needle. If the results of the testicular biopsy show that sperm production is normal, the problem is likely caused by a blockage or another problem with sperm transport.

Hormone testing.

Abnormalities in other hormonal or organ systems also might contribute to infertility. Hormones a blood test measures the level of testosterone and other hormones produced by the pituitary gland, hypothalamus and testicles. These play a key role in sexual development and sperm production.

Post-ejaculation urinalysis.

Sperm in your urine can indicate retrograde ejaculation (sperms are traveling backward into the bladder instead of out the penis during ejaculation).

Specialized sperm function tests.

Some tests can be used to check how well the sperm survives after ejaculation, how well they can penetrate an egg and whether there is a problem attaching to the egg. However, these tests are rarely performed and even when they are, they often do not significantly change recommendations for treatment.

Transrectal ultrasound.

A small, lubricated rod is inserted into the rectum. It allows the doctor to check the prostate and look for blockages of the ejaculatory ducts and seminal vesicles (tubes that carry semen).

TREATMENT

Treatment depends on the cause of infertility. Many problems can be fixed with drugs or surgery. This would allow conception through normal sex.

The treatments below are broken into 3 categories:

  1. Non-surgical therapy
  2. Surgical Therapy
  3. Treatment for Unknown Causes

Non-Surgical Treatment for Specific Male Infertility Conditions

Many male infertility problems can be treated without surgery.

Anejaculation

When there's no semen. This is not common, but can be caused by:

  • Abnormalities present at birth
  • Diabetes
  • Spinal cord injury
  • Prior surgery
  • Multiple sclerosis
  • Other mental, emotional or unknown problems

Often, drugs are tried first to treat this condition. If they fail, there are 2 other steps remain.

  • Rectal probe electroejaculation (RPE), is one.
  • Penile vibratory stimulation (PVS) is the other.

Rectal probe electroejaculation is most often done under anesthesia. RPE retrieves sperm in 90 out of 100 men who have it done. But movement of sperm and their shape may still lower fertility.

Penile vibratory stimulation vibrates the tip and shaft of the penis to help get a natural climax. This is non-invasive, except that it doesn't work as well as RPE.

Assisted reproductive techniques like in vitro fertilization (mature eggs are retrieved from ovaries and fertilized by sperm in a laboratory) and intracytoplasmic sperm injection (when a single sperm cell is injected directly into the cytoplasm of an egg) are of absolute importance to men with Anejaculation.

Infections of Genital Tract

This is also rare as it is only found in about two percent (2%) of 100 men with fertility problems. this problem is often diagnosed from a semen test. During this test, white blood cells that make too much reactive oxygen species (ROS) are found. This, naturally will lower the chances of sperm being able to fertilize an egg. For example, an infection of the epididymis and testes may cause shrinking of the testicles and block the epididymal duct.

Antibiotics are often given only for full-blown infections as they can sometimes harm sperm production. Non-steroidal anti-inflammatories (such as ibuprofen) are often used instead.

Inflammation from other different causes can also affect fertility.

Congenital Adrenal Hyperplasia (CAH)

A rare cause of male infertility, it involves flaws in certain enzymes from birth. It causes abnormal hormone production. CAH is most often diagnosed by looking for too much steroid in the blood and urine. This condition can be treated with hormone replacement.

Hyperprolactinemia

This is when the pituitary gland makes too much of the hormone, prolactin. It's a recognized factor in infertility and erectile dysfunction. Treatment will depend on what's causing the increase. In case medications are the cause, the doctor may stop them and give drugs to bring prolactin levels down to normal. If a growth in the pituitary gland is found, the patient may be referred to a neurosurgeon.

Hypogonadotropic Hypogonadism

This is due to a problem in the pituitary or hypothalamus. The testicles don't make sperm due to poor stimulation by the pituitary hormones. A small percentage of infertility in men can be attributed to this. It can be congenital (exist at birth), or it can be acquired (show up later).

The congenital form is known also as Kallmann's syndrome. It is caused by lower amounts of gonadotropin-releasing hormone (GnRH), a hormone made by the hypothalamus. The acquired form can be triggered by other health issues such as:

  • Use of anabolic steroid
  • Pituitary tumors
  • Head trauma

The doctor may recommend an MRI If Hypogonadotropic hypogonadism is suspected. This will show a picture of the pituitary gland. Blood test may also be ordered to check prolactin levels. These two put together, an MRI and blood test can rule out pituitary tumors.

In the case of high levels of prolactin without tumor on the pituitary gland, the doctor may try to lower the prolactin first, and then Gonadotropin replacement therapy would be the next step in the treatment. During treatment, blood testosterone levels and semen will be checked. Chances for pregnancy are very good since the sperms resulting from this treatment are normal.

Retrograde Ejaculation

Retrograde ejaculation, semen that flows back instead of going out the penis, has many causes. It can be caused by:

  • Surgeries for prostate or bladder
  • Diabetes
  • Injuries to the Spinal cord
  • Anti-depressants
  • Some medications used to treat prostate enlargement (BPH)

Retrograde ejaculation is diagnosed by checking the urine for sperm. This is done under a microscope right after ejaculation. Retrograde ejaculation can be corrected with Drugs.

It is often treated first with over-the-counter medications (e.g. Sudafed®).

Surgical Therapy for Male Infertility

Varicocele Treatments

Varicoceles can be fixed with minor outpatient surgery called varicocelectomy. Fixing these swollen veins helps sperm movement, its numbers, and structure.

Azoospermia Treatments

If the semen lacks sperm (Azoospermia) because of a blockage, there are many surgical options.

  • Transurethral Resection of the Ejaculatory Duct (TURED) - Ejaculatory duct blockage can be treated with surgery. A cystoscope will be passed into the urethra (the tube inside the penis) and a small incision is made in the ejaculatory duct. This normally would get sperm into the semen in about sixty-five percent (65%) of men. however there can still be problems because blockages could recur. Incontinence and retrograde ejaculation from bladder damage are other possible problems but are rare. Also, only a quarter of couples get pregnant naturally after this treatment.
  • Microsurgical Vasovasostomy – This is used to undo a vasectomy. It uses microsurgery to join the 2 cut parts of the vas deferens in each testicle.
  • Vasoepididymostomy – This is a procedure that joins the upper end of the vas deferens to the epididymis. It's the most common microsurgical method to treat epididymal blocks.

Treatment for the Unknown Causes of Male Infertility

Often times it's difficult to tell the cause of male infertility. This is called non-specific or idiopathic male infertility. The doctor may use empiric therapy (experience to help figure out what works), because infertility problems are often due to hormones, empiric therapy might balance hormone levels. It could even be difficult to tell how well empiric treatments will work. Each case is different.

Intrauterine Insemination (IUI)

The doctor will place the sperm into the female partner's uterus through a tube. IUI is often used for low sperm count and movement problems, retrograde ejaculation, and other causes of infertility.

Assisted Reproductive Techniques

If infertility treatment fails or isn't available, there are ways to get pregnant without sex. These methods are called assisted reproductive techniques (ARTs). Based on the specific type of infertility and the cause, your health care provider may suggest:

  • In Vitro Fertilization (IVF) - The egg of a female partner or donor is joined with sperm in a laboratory Petri dish. For IVF, the ovaries are overly stimulated with drugs. This allows many mature eggs to be retrieved. After 3 to 5 days of growth, the fertilized egg (embryo) is put back into the uterus. This procedure is used mostly for women with blocked fallopian tubes.

But it's also being used more and more in cases where the man has very severe and untreatable low sperm count (oligospermia).

  • Intracytoplasmic Sperm Injection (ICSI) – this is a different variation of IVF. It has revolutionized treatment of severe male infertility. A single sperm is injected into the egg with a tiny needle. Once the egg is fertilized, it's put in the female partner's uterus. Doctors use ICSI for men who have very poor semen quality. It is also used for patients with Azoospermia (if there is no sperm in the semen) caused by a block or testicular failure that can't be fixed. Sperm may also be taken from the testicles or epididymis by surgery for this method.

Sperm Retrieval for Assisted Reproductive Techniques

There are many microsurgical methods that can be employed to retrieve sperm that is blocked by obstructive Azoospermia. The goal is to get the best quality and number of cells. All of this will be done while trying not to harm the reproductive tract.

These methods include:

Microsurgical Epididymal Sperm Aspiration (MESA)

This method uses a surgical microscope. MESA yields high amounts of motile sperm from the epididymal tubes. The sperm can be frozen and thawed later for IVF treatments. This method limits harm to the epididymis and keeps blood out of the fluid. Even though MESA calls for general anesthesia and microsurgical skill, it has a lower problem rate. It's also able to collect larger numbers of sperm with better movement.

Testicular Fine Needle Aspiration (TFNA)

This was first used to diagnose Azoospermia. It is used sometimes used to collect sperm from the testicles. A needle and syringe is used to puncture the scrotal skin to pull sperm from the testicle.

Percutaneous Epididymal Sperm Aspiration (PESA)

PESA, like TFNA, can be done many times at low cost. Totally on-invasive, there is no surgical cut. More urologists can do it because it doesn't call for a high-powered microscope. PESA is done under local or general anesthesia. The urologist sticks a needle attached to a syringe into the epididymis, and gently withdraws fluid. Sperm may not always be gotten this way. You may still need open surgery afterwards.

NATURAL TREATMENTS

Acupuncture

Acupuncture involves the insertion of small, thin needles into various points of the body. It's believed that these points can help stimulate the body's energy flow.

There's no definitive evidence to support acupuncture as a treatment for infertility.

A recent study of multiple clinical trials found limited evidence that acupuncture could improve both ovulation and menstruation in women with Polycystic ovary syndrome (PCOS).

Yoga

Yoga incorporates postures and breathing techniques to promote relaxation and decrease stress levels.

Studies on yoga as an infertility treatment are limited. However, it's believed that if practiced, yoga can be beneficial in relieving the stress that can be associated with undergoing fertility treatments.

Vitamins

A host of vitamins and minerals can be beneficial in promoting fertility.

Some to look out for include:

  • Zinc
  • Iron
  • Folate
  • Vitamin C
  • Vitamin E

Tea

A variety of fertility teas are commercially available for purchase, but their levels of efficacies are in doubt. However, investigations into the effects of these tea formulations found that antioxidant compounds found in green tea may help fertility by improving parameters such as sperm count and motility.

Essential oils

Essential oils are derived from plants, typically from their roots, seeds, or leaves. They may be utilized in aromatherapy to promote relaxation and reduce stress levels. Aromatherapy can involve massaging with, bathing with, or burning essential oils.

Fertility diet

Some dietary recommendations for boosting fertility include:

  • Choosing carbohydrates wisely by focusing on fiber-rich foods (e.g. vegetables and whole grains)
  • Avoiding refined carbohydrates that are high in sugar
  • Avoiding trans fats, which is found in many fried and processed food products
  • Swapping animal protein for vegetarian sources of protein
  • Selecting high-fat dairy (like whole milk)
  • Avoiding low-fat products

Following the above recommendations, and generally eating a nutrient-rich diet, can also help men improve the health of their sperm.

Implementing dietary changes along with lifestyle changes including being more active can help promote fertility.

OUTLOOK

Being diagnosed with infertility doesn't mean that a person's dreams of having a child have come to an end. It may take some time, but a number of couples who experience infertility will eventually be able to have a child. Some will do so on their own, while others will need medical assistance.

The appropriate treatment individuals and their partners will depend on many factors, which may include age, the cause of infertility, and personal preferences. Similarly, whether a specific infertility treatment will result in pregnancy can depend on a lot of factors.

Depending on the circumstances some fertility problems may not be able to be treated. Couples might have to consider as alternatives, the donation of sperm or eggs, surrogacy, or adoption.

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