Male infertility in modern society
Infertility
Infertility is the inability of a sexually active couple to achieve pregnancy within one year of unprotected sexual intercourse.
It is divided into primary infertility (no history of pregnancy) and secondary infertility (when there is a history of a previous pregnancy).
Diagnosis and treatment of course concern both partners, so the couple should see both an andrologist and a gynaecologist.
Causes - Diagnostic work-up
The causes of male infertility can be divided into three broad categories:
- disorders of hypothalamic and pituitary function (pre-testicular causes),
- disorders of testicular function (testicular causes), and
- abnormalities of the ducts that carry sperm, as well as disorders of sperm motility and sperm count (post-testicular causes).
The urologist-andrologist should take a very detailed history from both partners and focus on conditions that may have affected sperm production (spermatogenesis), even at a young age (undescended testicles, past infections such as orchitis, epididymitis or mumps, injuries, a history of testicular torsion, use of alcohol, tobacco, recreational drugs, or medicines that affect spermatogenesis).
This is followed by a clinical examination and palpation of the male genitals, and an assessment of any signs of hypogonadism: poor development of secondary sexual characteristics, abnormal skeletal and body proportions, abnormal muscle development, absence of a male hair distribution, eunuchoid development of the external genitals, gynaecomastia. The penis is checked for micropenis, hypospadias, congenital curvature or phimosis (which make it difficult to deposit semen in the vagina). Examination of the testicles assesses their size and consistency. Small testicles may indicate damage to the sperm-producing tissue (the seminiferous epithelium), while very small testicles are found in men with Klinefelter syndrome. It is also essential to palpate the epididymides and the vasa deferentia and to perform a digital rectal examination of the prostate, to detect any congenital underdevelopment or acquired abnormalities caused by previous infections. Examination of the scrotum is completed with an ultrasound scan (looking for abnormalities of the testicular tissue, and colour Doppler for a possible varicocele).
A semen analysis gives us important information, mainly about sperm concentration, motility and morphology. It is important to stress that there are no clear boundaries between a “normal” and an “abnormal” semen analysis. The World Health Organization has therefore set certain reference values; when a semen analysis does not meet them, the man has a reduced chance of achieving conception naturally, although it is not ruled out. Spermatogenesis is a complex process influenced by many factors. A simple viral infection, for example, can affect sperm production for up to 3 months. For this reason, infertility should be assessed with at least 2 semen analyses taken one month apart.
This is followed by blood tests for hormones, to assess pre-testicular causes of infertility. Hormone testing includes measurement of FSH, LH and testosterone.
The treatment of infertility depends on the test results. It ranges from simple advice (avoiding things such as heavy smoking, alcohol misuse, anabolic steroid use, strenuous sports, and raising the temperature of the scrotum through saunas, hot baths and underwear, or occupational exposure to heat sources), to surgical treatment (for varicocele, obstruction of the ejaculatory ducts, testicular biopsy with sperm retrieval for insemination or in vitro fertilisation), and oral treatment (vitamin preparations to improve sperm motility, antibiotics in cases of inflammation, gonadotrophins in hypogonadotropic hypogonadism).
If, despite efforts to improve the semen, the desired result is not achieved, we should encourage the couple to move on to assisted reproduction techniques: first insemination (up to three attempts) and, if that fails, in vitro fertilisation (IVF), especially when the partners are over 40 years of age.