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INFERTILITY
Primary infertility is defined as the inability to conceive after one year of unprotected intercourse, which affects approximately 20% of couples.
At least 30-50% of couples with primary infertility will have male related problems as the sole or partial reason for their infertility.
CAUSES OF INFERTILITY
Systemic diseases that directly or indirectly affect sperm production include ulcerative colitis, sickle cell disease, mumps orchitis, viremia, uremia, hypo-gonadotrophic hypogonadism, diabetes, multiple sclerosis/spinal cord injury, and testicular malignancy, among others.
Ulcerative colitis (inflammation of the colon) may require treatment with various drugs that can suppress normal sperm production. Mumps infection in post-pubertal males can result in swelling of the testicles in 22-30% of affected individuals. Such swelling may then lead to marked atrophy (shrinkage) of the testicle with poor sperm production as the result.
Viremia or systemic illness with or without fever may damage sperm production. Uremia or build up of waste products due to renal failure can cause abnormal sperm production, which may be reversed by a kidney transplant.
Failure of pituitary gland to balance various hormones including testosterone produced in the testicles may also affect sperm production. Approximately 30% of long term diabetics can have problems with ejaculation. This problem may also be seen with other neurologic defects such as Multiple Sclerosis or spinal cord injury.
Cancer of the testicles and subsequent treatment may cause problems with both sperm production and ejaculation. Also these men often have pretreatment impairment of fertility.
There are genetic syndromes, which can affect sperm production and/or reproductive structural abnormalities. Several surgical procedures may cause problems with ejaculation such as trimming of prostate and lymph node dissection or pelvic surgeries.
Substances, which can affect sperm production deleteriously are called gonadotoxins. These can include medication, illicit drugs, nicotine, caffeine, and alcohol among others. Also, environmental exposure to certain fertilizers and fumigants may also impair sperm production.
Chemotherapies and or drugs, which can cause damage directly to the testicle or affect hormone balance, can indirectly affect sperm production. Also radiotherapy (treatment with radiation) for Hodgkin's disease and seminoma can damage sperm production from scatter to the testes or pelvic organs.
WHEN TO SEEK MEDICAL CARE
Male conditions may be the cause of infertility in up to 50% of affected couples. Also, medical evaluation of the male partner is relatively easy and noninvasive. Therefore, men should be evaluated early on when there is suspicion or evidence for infertility among any couple.
DIAGNOSIS
Typically, the male partner of an infertile couple will undergo evaluation early on because his evaluation tends to be easier and less invasive than the female's evaluation. The evaluation of men with possible infertility includes a complete history and physical examination, urinalysis, and semen analysis (assessment of sperm production). The outcomes noted on these exams and/or tests then may guide your physician to do other tests. For instance, a finding of decreased movement of sperm on the semen analysis may lead to a test for antisperm antibodies. Also, blood test may be performed to rule out hormone imbalance as a cause for abnormal semen analysis results.
TREATMENT
Treatment of male infertility is not uncommonly multifaceted. If a patient is being exposed to substances, which damage sperm production we will recommend that he do his best to limit or reduce such exposures. Some of these toxins, however, may have caused lasting damage despite the fact that the exposure to these substances has ended (i.e. radiotherapy or chemotherapeutic damage).
In cases of hormone imbalance, replacement therapy may be implemented to try to normalize that balance. Also, if patients have evidence of an infection in the reproductive tract, then these men will be treated with antibiotics. There may be instances where toxins are in the form of excess heat to the testes (i.e. frequent use of hot tubs). The testicles are located in the scrotum (outside of the abdominal cavity) so as to be 1-2º cooler than normal core body temperature.
There are surgical treatments, which may be required for various conditions that may exist. One such condition is presence of a varicocele, which are dilated veins above one or both of the testicles. These veins can be surgically interrupted through a small incision above the scrotum. Care must be taken to avoid injury to important structures which exist in the spermatic cord such as the sperm duct, arteries, (carrying blood to the testis), and lymphatic channels (which clear waste products from the scrotum). This surgery is done as an outpatient.
Another condition that is corrected surgically is an obstructed vas (from a previous vasectomy, surgery, or trauma). This obstruction is reversed by removing the scarred segment and reattaching the two ends of the vas with multiple layers of suture. This is performed using an operating microscope in a four-hour operation, which is also done on an outpatient basis.
Another obstructive condition has to do with the ejaculatory duct (or the last portion of the male reproductive tract before the ejaculate enters the urethra, which is the common duct for urine and/or sperm to leave the body). This is treated telescopically by incising the obstructed ducts in the prostate bed thus reopening the passage for sperm. These cases may occur from scar tissue resulting from previous surgeries to open the prostate and improve urinary stream.
Other surgical procedures include biopsies of the testicles in men who have no sperm in the ejaculate. This is done as an outpatient to determine whether there is no sperm being produced or whether the sperm that is produced is just trapped in the testicle. If sperm are produced but are trapped in the testicle then there are procedures to retrieve sperm such as aspiration of sperm from the testicle. Also tissue can be removed from the testicle with sperm in the tissue that can then be microdissected from the testicular tissue. These sperm are then usually used for injection into eggs to result in fertilization. These fertilized eggs can then be replaced in the female's reproductive tract.
Cryptorchidism is the condition where one or both testicles are not fully descended into the scrotum. This condition is most successfully treated early in life (before the age of three). This condition is treated by surgically exploring the affected side and lowering the testicle back into the scrotum. Treating this early in life will give the patient the best chance of preserving ultimate fertility and sperm production.
PREVENTION
Stopping or reducing use of cigarettes or marijuana will usually result in improvement of sperm production. The improvement will not be seen on the semen analysis until the changes has been made for three months. This is because of the delay of 90 days from the time a sperm is produced in the testicle to the time that sperm is present in the ejaculate. Also, semen production may be deleteriously affected by extreme fatigue, stress, and malnutrition. For this reason, treatment may be in the form of avoiding these stressors, getting more rest, and eating a more balanced diet. Some nutritional supplements may be helpful in improving sperm production.
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