Male Infertility
NATIONAL JOURNAL OF HOMOEOPATHY 2003 Mar / Apr VOL V NO 2.
Dr CH Asrani

INFERTILITY: THE Family Physician’s approach
Infertility (and sterility) is the inability to conceive after one year of regular, unprotected sexual activity (ie without any contraception).
In the male dominated Indian society, the female partner is generally blamed for infertility and faces social wrath for her barrenness. Even though times are changing and many parents plan to be DINK (double income no kids), infertility does lead to unhappiness and marital disharmony, which may even end in divorce. A family physician can play an important role in initial screening.

Infertility may be
- Primary, where conception has never occurred and
- Secondary (acquired) where conception has failed to occur after a period of fertility.

CAUSES
To understand the causes of Infertility one must understand necessary pre-requisites for conception:
Testis must produce healthy motile sperm which should travel through the vas and be successfully ejaculated (Fig1; 1-5) Sperm has to be deposited at the external os through satisfactory intercourse This has to be transported through cervical mucus, uterine cavity and fallopian tubes;
On the other hand, the ovary must produce healthy ovum by ovulation this ovum should be picked up by the fallopian tube à Fertilization to occur at the tubal lumen and the fertilized egg to be transported through the tube to be implanted on the healthy endometrium. The embryo grows to healthy baby in uterine incubator and baby is safely delivered.

One or multiple of the following factors may interfere in the above process:

• Physiological, it is not possible to conceive before puberty, after menopause, during pregnancy and sometimes during lactation, as ovulation does not occur during these periods.
• Pathological.
• Faulty male factors are responsible in about one-quarter cases.
• Faulty female factors are responsible in another one-half cases.
• Faulty combined male-female factors are responsible in remaining one-fourth cases.

We must know that in 10 per cent of cases, no obvious abnormality can be found to explain infertility even with the current diagnostic facilities. This is unexplained infertility. In practice when we approach the complaint of infertility, we must understand that both the partners share the responsibility, as fertility is the function of husband-wife unit.

WHEN TO START INVESTIGATION & TREATMENT OF INFERTILITY?
With unprotected intercourse, about 90% of normally fertile couples conceive within 1 year, therefore, no couple should be subjected to rigours of infertility work up until they have tried to conceive for at least 1 year without success. But, if history or examination reveals some obvious defect in either partner or obvious sexual dysfunction, there is no need to wait.

Modern "Couple Friendly" approach to infertility diagnosis & management involves inexpensive and less invasive tests first, which can be handled by the family physician. Only later is the need to proceed to the more expensive & invasive procedures, if required.

Complete Medical and Reproductive History:
Past history including:
- past contraceptive methods.
- induced and spontaneous abortion.
- still-birth & live birth and
- previous conception with other partner in case of 2nd marriage or pre/extra marital relations.

Menstrual history with reference to
- regularity.
- length
- frequency
- flow and
- pain if any.
Ask for any lubricants used. Get details of any pre-existing illness and treatment thereof.
Any systemic disease contraindicating pregnancy/impairing fertility should be ruled out. Both the partners should be evaluated system by system.

IDENTIFYING THE MALE FACTOR:
Male Partner.
Detailed medical history should be asked with special reference to
Mumps in the testicles.
Scrotal swelling-varicocoele. hydrocoele, hernia.
General illness.
Drugs.

PHYSICAL EXAMINATION
Physical examination for male infertility is quite simple. The most important things to look for, are the size of the testicles, scrotal swelling due to hydrocoele, hernia or varicocoele. Palpate the vas and perform a per rectal examination to rule out any prostatic abnormality. Detailed medical history should be asked with special reference to Mumps in the testicles. Scrotal swelling-varicocoele. hydrocoele, hernia, general illness and drugs.

Normal parameters for Semen as per WHO criteria are as follows:

• Volume of ejaculate 2.0 ml or more.
• Sperm concentration 20 million spermatozoa/ml or more.
• Total sperm count 40 million or more.
• Motility; 50% or more with forward progression, within 60 minutes of collection.
• Fructose-present.
• Morphology; 50% or more with normal morphology.
• White blood cells: Fewer than 1 million per ml.
• Reliquefication within 30 mins.

SEMEN ANALYSIS:
The semen analysis is only a screening test. It does not provide a definitive diagnosis. It ONLY tells us about the volume of semen and the concentration of sperm. We obtain information about quality, quantity and the motility or movement of a patient’s sperm. Simply put it tells us if he is producing the right amount of good quality sperm and semen.

Specimen collection is of significance. We have all heard the frequent errors in collection and misinterpretation that can have tragic consequences. For these reasons we, the family physicians, should explain in full detail the process of collecting a sample.
5 days of abstinence before an analysis is attempted. Best is to co-incide with the menstruation cycle. If the lab does not offer facility of collection or patient is comfortable doing it at home, it should be carried immediately to the lab preferably in the hip pocket, so as to keep as near normal body temperature. Under NO circumstances should it be refrigerated.

Sperm Count
WHO guidelines say a normal sperm count consists of 50 million sperm per ejaculate with 50% motility and 60% normal morphology. We now know that concentrations of below 20 million sperm/ml of ejaculate in order to impair fertility. In practice it is seen that if sperms show adequate forward motility and good egg penetration, concentrations as low as 5 to 10 million can produce a pregnancy. It’s interesting to note that only twenty-five years ago counts of 100 million sperm per ejaculate were the norm. With time, the effects of our toxic environment and/or lifestyle seem to be gradually decreasing male sperm counts.

Sperm motility, ie the speed and the quality of their movement. There are always a certain number of dead, non motile sperm in the ejaculate. These non motile sperm are incapable of fertilization. The motility is recorded as follows:

• Grade I motility-sperm are only wriggling sluggishly in place with very little, if any, forward progression. These sperms are incapable of fertilizing the egg.
• Grade II motility-the sperm are moving forward, but either the speed is very slow or they do not move in a straight line. Such sperms will simply never make it in the female genital tract.
• Grade III-motile sperms are able to move at a reasonable speed with straight forward progress and accurate homing.
• Grade IV-sperm not only advance straight, but do so at an extraordinarily rapid speed.

SEMEN VOLUME: Most men ejaculate 2.5 cc to 5 cc of semen. Low ejaculate volumes may mean a very high concentration of sperm, but very little seminal fluid. On the other hand, patients with very high volume of ejaculate, in spite of adequate sperm production will have low sperm concentration as the sperm are diluted in relatively large amount of fluid. The total number of sperm ejaculated into the vagina is probably not as important as the concentration of sperm.
LIQUEFACTION: Within a minute of ejaculation, the semen should normally turn into gel. This change is referred to as clumping. The sperm cannot be adequately counted or examined while the semen is in this state. The main function of clumping is probably to prevent early leakage of sperm out of the vagina. Within 10-30 minutes after ejaculation, the blob should ideally liquefy. Failure of semen to reliquefy could indicate subtle infections of the prostrate and seminal vesicles, but sometimes it is simply a normal variant and subsequent semen collections on different days might present no problem. But in a panicky couple this often leads to all sorts of false notions.
FRUCTOSE: The sugar provides instant energy for rapid movement.
ALKALINITY: The sperm appear to be relatively safe in the vas deferens and epididymis prior to ejaculation, and thereafter have a decent prospect for survival only after they penetrate the cervical mucus of the wife. It is in the precarious moment, when the sperm are ejaculated into the vagina that time is of the essence. The semen’s alkalinity protects against the acidic medium of the vagina. The gelatine like blob prevents early leakage out of the vagina
ABNORMAL SPERMS: there is no relationship between abnormal sperm and abnormal pregnancy. Abnormally shaped sperm CANNOT fertilize the egg.
The normal sperm has an oval head with a long tail. Abnormal sperm may either have a very large round head or an extremely small, pinpoint head or have two heads. The sperm may be bent at the neck and misshapen, and the tails may have kinks and curls in them. There is a strong relationship between structure of the sperm and their motility. In general, abnormal sperm exhibit poor motility and normal sperm exhibit good motility. The female cervical mucus tends to filter out the misshapen sperm and those with poor motility.
Clumping or Sperm Agglutination
Microscopic examination tells if sperm are clumping together (agglutinating). It is seen very often that the sperm orient themselves tail-to-tail or head-to-head instead of swimming in a straight line. This clumping prevents them from swimming through the cervical mucus to the egg and attaching if they get there. This finding indicates a problem with sperm antibodies or the presence of a bacterial infection.
Debris and Infection
Too many underdeveloped or immature sperm in semen indicate testicular stress from illness or infection. Finding leukocytes in semen, suspect an infection. It is mandatory to check both (all) sexual partners for infection, since these diseases are easily passed back and forth. Doxycycline treatment may be continued upto 4-6 weeks. Prostatitis can be especially stubborn to treat and may take longer.
Antisperm Antibody-Some cases of infertility may be due to the wife developing an immune reaction to the husband’s sperm. This antibody destroys the sperms.
FSH-a case of zero sperms on at least 2 occasions should be subjected to either a testicular biopsy or FSH to confirm/rule out Primary testicular failure.

Continue Reading...

Back