What is infertility?

Infertility is absence of pregnancy within a year despite of having regular sexual life. Infertility is not a single person’s problem; it is the family’s problem. Term of the infertility, primary or secondary type, sperm analysis and woman’s age are important factors. 1/3 of infertility is due to a problem in the man, 1/3 in the woman and 1/3 is in both.

In our daily reality, in case of infertility first address is a gynecologist, however if take into take account that 30-40% of infertility is due to the man’s factor, we can feel the importance of men in this topic. We have to consider material costs, long treatments, wasted time etc. in desire of having a child. In case of an infertility complaint, both man and woman have to see a doctor: woman see a gynecologist and man an urologist-andrologist.

Physiology of the male reproductive system

Male genital system consists of the penis, prostate, scrotum, testicles and epididymis etc. and connecting ducts of semen (Vas deferens). LH (luteinizng hormone) and FSH (follicle-stimulating hormone) hormones secreted from the pituitary gland in the brain cause testosterone (male sex hormone) secretion and spermiogenesis (sperm production). 85-90% of the testicles consist of germinal cells and supporting Sertoli cells (feeder cells); germinal cells produce sperm (genesis of one sperm takes 70-75 days). Initial sperms produced in testes are not capable of fertilizing the ovum; it gains fertilizing capacity by passing via epididymis (it takes 12 days) and later goes through the seminal vesicle and mixed with prostate fluid, and becomes ready ejaculate. Therefore, it can easily move in woman’s sex organs and fertilize the ovum.

What are the factors causing male infertility?

1. EAU 2010 (European Association of Urologists)
2. Idiopathic infertility (unknown nature) - 31 %
3. Varicocele – link to varicocele page - 15.6 %
4. Hypogonadism - 8.9 %
5. Urogenital infections - 8.0 %
6. Undescended testis (cryptorchidism) - 7.8 %
7. Sexual and sperm deposition disorder- 5.9 %
8. Immune infertility - 4.5 %
9. System diseases - 3.1 %
10. Obstructions - 1.7 %
11. Other factors - 5.5 %

Other factors include:

• Toxins (some drugs, radiation)
• Trauma
• Renal insufficiency
• Liver diseases
• Testicle tumors
• Testicle traumas (injuries)
• Neurology (nerve system) pathologies
• Smoking and alcoholic beverages (decrease the sperms count and destroy its structure)

I. Absence of ejaculation

1. Drugs taken
2. Operations held
3. Diabetes mellitus
4. Psychological disorders

II. Oligospermia (decreased sperm count) (link to oligospermia)

1. Cryptorchidism (undescended testis)
2. Varicocele (enlargement of veins) Link to varicocele page
3. Drugs
4. Endocrine pathology (hormonal disorders)

III. Azoospermia (absence of sperm)

1. Genetic factors
2. Germinal aplasia
3. Maturation arrest

IV. Absence of pregnancy in case of normal sperm

1. Abnormal sexual contact habits (rare or too frequent)
2. Abnormal sperm morphology (sperm structure)
3. Immune factors
4. Unknown nature
5. Antispermal antibodies

Evaluation of the patient having complaint on infertility:

• Anamnesis - correct anamnesis collected from the patient is 70% of the diagnosis. Infertility complaint history, previous conceives (whether or not), previous treatments shall be considered. Sexual anamnesis – sexual life, libido, coitus duration, number of sexual contacts and other factors.
• Physical examination reveals varicocele, abnormalities in the scrotum, penis, prostate and secondary sexual symptoms that cause infertility. Evaluation shall be made on the short penis size (hypogonadism – diminished hormones), leaks from urethra, presense of infection, narrowed urethra, measured volume of testicles etc.
• Lab tests – initially 2 sperm analyses shall be given. If sperm count, motility, structure are abnormal then other analyses (hormonal, genetic) are made. Semen analysis shall be the first one in male infertility (first step) and given 3-5 days after sexual restraint. Sample is taken after washing hands with soap and necessarily in a designated room of the clinic. Semen analysis provide essential information on hormonal and other problems. Count, mobility, morphology (structure) of sperms are the most important indicators in semen analysis.

EAU 2010 (European Association of Urology)

Semen Analysis - normal values:

• Ejaculate volume - 1,5 ml
• Count in 1ml - 15 millions
• Motility 32%
• Morphology 4%
• Vitality 58%
• Leukocytes < 1 million

Schematic view of a normal sperm

Microscopic view of a normal sperm

2 head sperm	sperm	Sperm without tail	Multitail sperm

In semen analysis, absence of sperm is called – azoospermia, low concentration– oligospermia, low motility – astenospermia, abnormal sperm morphology – teratospermia.

Hormonal analysis - taken in case of finding a pathology in semen analysis and alleged special hormones pathology. FSH and testosterone are the first ones to look at. In FSH analysis, if there is azoospermia (lack of sperm) then biopsy is conducted on the testis.

Bacteriological - Depending of the results of clinical and lab findings bacteriological (cultural) tests are made.

Immunological –Having ASA (antispermal antibodies) decreases the fertilizing ability. In man and woman, ASA exists in blood, sperm and cervical fluid. ASA has to be checked in partners having abnormality in post-coital tests (ASA – reduces sperm motility and the live sperms count, causes infertility by preventing acrosome reaction, sperm and ovum union)

Systemic diseases - diseases with high fever reduce sperm formation, and in liver and kidney diseases disruption of the hormonal balance affects spermatogenesis. Diabetes mellitus, hypertension also cause infertility.

Genetic - If sperm count is less than 5 mln., genetic analysis is recommended. Usually Karyotype (46XY) and AZF division and other genetic examinations are made.

Cryptorchidism – (link to cryptorchidism) undescended testis to the scrotum (one or both), in 1% of newborn undescended testis is present and it is more common in premature birth. If they do not descend normally within a year after the birth, one needs to descend within 12-18 months, initially with treatment, and if unsuccessful, with surgical operation. Later they are descended higher the risk of infertility. Undescended tests cannot normally grown in abdomen or inguinal area due to the exerted pressure.

Previous diseases and operations – certain diseases in childhood like parotitis damage the testicles. Presence of cryptorchidism (late descend of the testis) before, some previous operations and other factors negatively affect the spermiogeneis.

Environmental causes – change in the environment, pollution, high radiation (for example, mobile phones and other electronic devices) negatively affect the spermiogenesis. Some medicines also delay spermatogenesis.

Testicles - chemical and radiation treatment mainly applied in testicle swellings significantly reduces spermiogenesis; it is recommended to have semen analysis before and after such treatment. It is recommended to have semen freezing before starting this treatment.

Treatment: 1.Drug treatment 2. Surgical treatment

In complaint about infertility, physical examination, at least 2 semen analysis and other analysis requested by the doctor (at his discretion) are reviewed. If any problem is observed, relevant treatment is selected. If sperm count, motility and normal morphology (structure) is below the normal values (15 mln. per 1ml, motility 32%) then relevant treatment shall be conducted to increase the count and motility.

If sperm count decreased, number of motile sperms is more than 5 mln. then insemination, and if below 5 mln. ICSI (Intracytoplasmic Sperm Injection) – in vitro fertilization is recommended (EAU 2010 – European Urology Association). Insemination is an injection of the prepared ejaculate (after cleaning from leukocytes and other harmful factors) into the uterus. The aim here is to shorten the way of sperm and remove obstacles on the way.

If there is no sperm in the sample, it is azoospermia (link to azoospermia). Azoospermia occurs when spermoduct is blocked, spermiogenesis in the testis decreased or not realized at all. Azoospermia is observed in 5% of all patients complaining on infertility.

There are two forms of azoospermia:

1.Obstructive azoospermia

2.Non-obstructive - this condition occurs during hormonal secretion disorders in the brain or inability of testis to accept (intake) these hormones

Obstructive azoospermia occurs when there is an obstruction (obstacle) in any part of spermoducts. Here hormones are found in normal range. In this case, the obstruction is eliminated. There is no obstruction in the second form and FSH (follicle-stimulating hormone) level rises there.

In azoospermia, there is a necessity to conduct genetic and hormonal analyses and check volume of the testes.

Is azoospermia treatable?

Methods of getting sperm in azoospermia: if there is no semen in the ejaculate then semen is taken from the testes by PESA, MESA, TESA, TESE (micro) methods and decision is made by the urology-andrology doctor based on the patient’s condition.

PESA (Percutaneous Sperm Aspiration): Semen presence is checked by taking a piece from the testis using a needle. If enough sperm is shown then procedure stops.

MESA (Micro Epididymal Sperm Aspiration - getting sperm from the epididymis): Aspiration is done from the epididymis through a micro incision under the microscope, and stopped after finding sufficient semen.

TESE - is a method of extracting a piece from the testicles.

Micro-TESE (Testicular Sperm Extraction): micro-TESE is the latest method successfully implemented in all over the world in serious male infertility cases. Under 15-25X magnification microscope vision, samples taken (at least 50) from all expanded ducts in the testes and sent to the lab. Operation stops after finding semen.

Recommendations - It is recommended to timely identify any problem and look for the treatment, if testis are undescended then see a doctor (they have to descend between 12-18 months). Examination is necessary in delay of secondary sexual characteristics (growth of hair, voice change etc.), past urogenital infections, trauma and other cases. The most important is to be examined and be certain before marriage (both man and woman).