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Geetanjali Fertility & IVF Centre

About Department

Male Infertility

Introduction Approximately 15% of couples do not achieve pregnancy within one year of unprotected sexual intercourse. Male infertility factor is identified in about 50% of these cases and is solely responsible in 20% of couples. Male infertility has been attributed to a variety of causes including lifestyle factors, gonadotoxin exposure, hormonal dysfunction, chromosomal disorders, varicoceles, testicular failure, ejaculatory disorders, and obstruction. Evaluation of male infertility is important to identify a cause and provide treatment if the etiology is correctable. If a specific treatment is not available or the origin of the male factor infertility is not correctable, other options such as assisted reproductive techniques (ART) may exist. The pharmacist plays a vital role in identifying medications that contribute to male infertility, counseling the couple on medications used to treat infertility, and promoting healthy lifestyles that minimize infertility factors. The purpose of this article is to provide a broad overview of the etiology, evaluation, and treatment of male infertility.

Causes of Male Infertility

There are many reasons for male infertility which include:

  • Hormonal Disorders

    Certain inherited disorders can impair fertility. Examples include

    • Cystic fibrosis can cause missing or obstructed vasa deferentia (the tubes that carry sperm).
    • Polycystic kidney disease, a relatively common genetic disorder that causes large cysts to form on the kidneys and other organs during adulthood, may cause infertility as the first symptom if cysts develop in the reproductive tract.
    • Klinefelter syndrome is marked by two X and one Y chromosomes (the norm is one X and one Y), which causes low testosterone levels and abnormalities of the seminiferous tubules, although most other male physical attributes are normal.
    • Kartagener syndrome is a rare disorder that causes impaired sperm motility as well as severe respiratory infections and a reversed position of the major organs.
  • Genetic & Familial Disorders

    Genetic disorders of the testes such as Klinefelter's syndrome (male is born with two X and one Y chromosome instead of one X and one Y), microdeletion of chromosomes amongst many others cause abnormal development of the testicles.

  • Injury
    • Direct: Testicular or Pelvic Trauma
    • Indirect: Heat, Radiation, Radiotherapy, Chemotherapy, Environmental Toxins, Smoking, Drugs, Marijuana, Tobacco, Alcohol, blockage in the ejaculatory duct.
  • Previous Surgery

    Inguinal, Scrotal, Retroperitoneal, Bladder Neck, Vasectomy, Hydrocele.

  • Varicocele

    A varicocele is an abnormally enlarged and twisted (varicose) vein in the spermatic cord that connects to the testicle. Varicoceles are found in about 15% of all men and in about 40% of infertile men, although it is not clear how much they affect fertility or by what mechanisms. They can raise testicular temperature, which may have effects on sperm production, movement, and shape.

  • Retrograde Ejaculation

    Retrograde ejaculation occurs when semen enters the bladder instead of emerging through the penis during orgasm. Although you still reach sexual climax, you may ejaculate very little or no semen. This is sometimes called a dry orgasm. Retrograde ejaculation isn't harmful, but it can cause male infertility. Treatment for retrograde ejaculation is generally only needed to restore fertility.

  • Sexual Issues

    Often treatable, problems with sexual intercourse or technique may affect fertility. Difficulties with erection of the penis (erectile dysfunction), premature ejaculation, painful intercourse (dyspareunia), or psychological or relationship problems can contribute to infertility.

  • Infections

    Sexually transmitted diseases (STDs), such as chlamydia and gonorrhea, are most often associated with male infertility. These infections can cause scarring and block sperm passage. If mumps (viral infection usually affecting young children) occurs after puberty inflammation of the testicles can impair sperm production. Inflammation of the prostate (prostatitis), urethra or epididymis also may alter sperm motility.

  • Abnormal/ Sperm Count/ Motility / sperm morphology
  • Lifestyle issues: Alcohol and drugs, Tobacco smoking, Emotional stress

    Alcohol or drug dependency can cause reduced fertility. Anabolic steroids taken to stimulate muscle strength and growth can cause the testicles to shrink and sperm production to decrease. Men who smoke may have a lower sperm count than do those who don't smoke. Passive smoking may affect male fertility. Stress may interfere with certain hormones needed to produce sperm.

  • Medical conditions

    Various medical conditions that can cause infertility include Diabetes, Pituitary gland disease, Hypothalamus disorder, Multiple sclerosis, Cushing's syndrome, Hypogonadism.

Evaluation of Male Infertility

Some infertile couples have more than one cause of their infertility. In some cases, the cause of infertility may be unclear, or it may take a number of tests to determine the cause.

For a man to be fertile, the testicles must produce enough healthy sperm, and the sperm must be ejaculated effectively into the woman's vagina.

Tests for male infertility attempt to determine whether any of these processes are impaired. They include

Medical history

This includes questions about illnesses, disabilities and surgeries that could affect fertility. Medications and sexual habits are also evaluated. Sexual development as a boy and whether one has had any signs of low testosterone such as decreased body or facial hair are also looked for.

General Physical Examination

  • Semen Analysis

    A semen analysis will provide information on:

    • Amount of semen produced (volume)
    • Color(Grayish opalescent)
    • Number of sperm per milliliter of semen (concentration)
    • Total number of sperm in the sample (count)
    • Percentage of moving sperm (motility)
    • Shape of sperm (morphology)
    • Liquefaction time
    • Sperm Agglutination
  • Scrotal Ultrasound

    Ultrasound, which uses high-frequency sound waves to produce images of structures within your body, can help your doctor look for evidence of a varicocele or obstruction of the epididymis.

  • Hormone Testing

    Hormones produced by the pituitary and hypothalamus glands and the testicles play a key role in sexual development and sperm production. Your doctor may recommend a blood test to determine the level of testosterone and other male hormones that affect fertility.

  • Testicular Biopsy

    This test involves removing samples from the testicle with a needle. It may be used if semen analysis shows no sperm at all. The results of the testicular biopsy will tell if sperm production is normal.

  • Anti-Sperm Antibody Tests

    These tests are used to check for immune cells (antibodies) that attack sperm and can affect their ability to function.

  • Vasography

    In some cases, contrast dye is injected into each vas deferens to see if they are blocked.

  • Specialised Sperm Function Tests

    A number of different tests can be used to evaluate how well sperm survive after ejaculation, how well they can penetrate the egg membrane, and whether there's any problem attaching to the egg.

Treatment of Male Infertility

Treatment has to be carefully selected keeping in mind the age, health of the female partner, preference, medical history and the exact cause of infertility. The following modalities of treatment are available.

  • Medical Treatment

    This consists of the administration of certain drugs to improve semen quality. Clomiphene citrate, mesterolone, tamoxifen, gonadotropin injections, antibiotics, steroids etc. are administered as per the indications.

  • Surgical Treatment

    Obstructions in the sperm pathway, varicoceles, undescended testes etc. can be treated surgically. Modern microsurgical techniques are used for recanalisation of tubes for individuals who have undergone a vasectomy in the past or those with congenital/acquired obstruction of the vas deferens

Female Infertility

Causes of Female Infertility

For a successful pregnancy to occur, every step of the complex human reproductive process — from the release of a mature egg from the ovary to the fertilization of the egg to the implantation of the fertilized egg and growth of embryo in the uterus — has to take place right. In women, a number of factors can disrupt this process at any stage leading to difficulty in conception.

They include

  • Disorders of the Ovary

    Ovulation disorders constitute one of the most common causes. Most of them are treatable. You have an ovulation disorder if you ovulate infrequently or not at all.

    • Polycystic ovary syndrome (PCOS): It occurs due to overproduction of male hormone: androgen which adversely affects ovulation. Infertility is just one of the symptoms. Other symptoms include menstrual irregularities, acne, excess facial and body hair, obesity to name a few.
    • Hormonal Imbalances: Production of appropriate amounts of hormones: FSH (Follicle Stimulating Hormone) and LH (Lutenizing Hormone) through the month is essential for ovulation. Any abnormality due to endocrine gland disorders, stress, and excessive weight loss/gain amongst many other factors can adversely affect their production leading to ovulation disorders. Some women produce excess amounts of prolactin, (a hormone that stimulates production of breast milk) which prevents ovulation.
    • Luteal phase defect: It occurs due to insufficient progesterone levels, which again maybe due to a variety of causes. This leads to the uterine lining being inadequately prepared for implantation of the fertilized egg. Such women usually have normal periods and hence, remains undetected till being investigated for infertility.
    • Premature ovarian failure: This occurs when the ovary fails to produce eggs. It can be genetic (Turner's syndrome) or acquired (following radiation or chemotherapy for cancers; surgery to remove the ovaries for treating ovarian cancer or severe endometriosis or autoimmune ovarian failure) or unexplained reasons.
    • Un-ruptured follicle syndrome: A normal follicle, with an egg inside of it is produced every month yet the follicle fails to rupture. The egg, therefore remains inside the ovary and ovulation does not occur.
  • Disorders of the Fallopian Tubes

    Tubal diseases vary widely, ranging from mild adhesions to complete tubal blockage. Tubal damage occurring through pelvic infection is called pelvic inflammatory disease (PID). It can occur due to numerous causes such as,

    • Sexually transmitted diseases (e.g. Gonorrhea, Chlamydia)
    • Infection after childbirth, miscarriage, termination of pregnancy (MTP) or IUD (intrauterine device) insertion
    • Post-operative pelvic infection (e.g. perforated appendix, ovarian cysts)
    • Severe endometriosis
    • Tuberculosis: It can manifest as tuberculous endometritis (infection of uterus) or/and salpingitis (infection of tubes).
    • Other reasons for tubal damage include: Tubal Surgery, Abdominal Surgery; and Previous Tubal or Pelvic Pregnancy.
    • More often than not, PID is a silent disease.
  • Endometriosis

    Endometriosis occurs when inner lining of the uterus grows outside the uterus, usually on the surfaces of organs in the pelvic and abdominal areas, in places that it is not supposed to grow. When the ovaries are involved, it leads to formation of "chocolate cysts". The symptoms include heavy, painful and long menstrual periods, urinary urgency, rectal bleeding and premenstrual spotting and infertility. Sometimes, however, there are no symptoms at all, owing to the fact that there is no correlation between the extent of the disease and the severity of the symptoms.

  • Uterine Causes

    Benign tumors (fibroids or myomas) in the uterus, common in women in their 30s, can impair fertility by blocking the fallopian tubes or by disrupting implantation.

  • Unexplained Infertility

    In some instances, a cause for infertility is never found. It's possible that combinations of minor factors in both partners underlie these unexplained fertility problems.

  • Miscellaneous Causes

    Other than the common causes mentioned above, infertility can occur due to vast number of medical and surgical abnormalities. In many cases, it may be due to abnormalities in both the partners to some extent. Some of the causes include:

    • Congenital abnormalities, such as septate uterus, unicornuate uterus
    • Abnormalities of Cervical mucus
    • Adverse lifestyle and behavioral factors

Evaluation of Female Infertility

Some infertile couples have more than one cause of their infertility. In some cases, the cause of infertility may be unclear, or it may take a number of tests to determine the cause.

They include

Medical history

This includes questions about illnesses and surgeries that could affect fertility. Medications, menstrual history and sexual habits are also evaluated. Sexual development and whether one has had any signs of hormonal imbalances are also looked for.

General Physical Examination

  • Hysterosalpingogram (HSG)

    During this X-ray procedure, a speculum is used to open the vagina, a liquid is injected into the cervix (opening into the uterus) so that it flows into the uterus. The extent to which the liquid comes out of the tubes is used to determine if one or both of the tubes are open.

  • Laparoscopy

    In this minimally invasive procedure, a laparoscope is inserted through a small incision below your belly button. The surgeon can determine if one or both of tubes are open. The laparoscope can also be used to look for other problems that may affect fertility, such as adhesions (scar tissue) ,endometriosis, PCOD,Fibroids etc

  • Hysteroscopy

    In this procedure, a small scope is inserted into the uterus through the vagina to look inside of the uterus. This test is done if uterine abnormalities are seen during the HSG (tubogram),for suspected scars , polyps, PCOD, Ffibroids,Septal uterus.

  • Hormone Testing

    for FSH, LH, Prolactin,T3,T4,TSH

  • Endometrial Biopsy

    It involves scraping and examining a sample of tissue from the lining of the uterus. One can then determine if ovulation has occurred, any infection, whether the lining of the uterus has undergone the changes necessary for the implantation of a fertilized egg and support of an early pregnancy. An endometrial biopsy can also detect an infection or inflammation of the endometrium (endometriosis).

  • Pelvic Ultrasound

    Ultrasound is the standard technique for evaluating the uterus and ovaries, detecting fibroids/polyps, ovarian cysts and tumors. Transvaginalsonohysterography uses ultrasound along with saline infused into the uterus, which enhances the visualization of the uterus.

  • Other Tests

    These include tests for Infections (tuberculosis, syphilis or other sexually transmitted infections),genetic testing (Turner syndrome, testicular feminization syndrome) may also be required to be conducted.

Treatments Available

  • IUI (Intra Uterine Insemination)
  • IVM (In vitro maturation)
  • IVF (In vitro fertilization)
  • ICSI (IntraCytoplasmic Sperm Injection)
  • IMSI (Intracytoplasmic morphologically selected sperm injection)
  • laser assisted hatching
  • Embryo Freezing
  • Donor Eggs
  • Donor Embryos
  • Computer-assisted sperm analysis
  • Sperm Morphology
  • Sperm - DNA
  • Donor Sperm
  • Sperm Aspiration (TESA)
  • Sperm Freezing
  • Surrogacy
  • Other infertility treatments

Intrauterine insemination (IUI)

Intrauterine insemination has been shown to increase the chance of pregnancy in women undergoing induced ovulation. During this procedure, the partner's sperm is placed directly into the uterus near the time of ovulation. IUI is often performed in the case of a low sperm count, abnormalities of ejaculation (retrograde ejaculation, impotence,), when the cervix prevents sperm from entering the uterus, or with donor sperm. Because sperm are inseminated into the uterus, it is important that the female partner has no other obvious fertility problems. Investigations should ideally show that the female is ovulating normally, has open fallopian tubes, and has a normal uterine cavity. IUI has been found useful in couples with no obvious cause of infertility.

Assisted Reproductive Techniques

In vitro fertilization (IVF)
IVF is the most effective form of assisted reproductive technology. The procedure can be done using your own eggs and your partner's sperm. Or IVF may involve eggs, sperm or embryos from a known or anonymous donor. In some cases, a gestational carrier — a woman who has an embryo implanted in her uterus — might be used.

Intracytoplasmic sperm injection (ICSI)
In Intracytoplasmic sperm injection (ICSI)a single healthy sperm is injected directly into each mature egg. ICSI is often used when semen quality or number is a problem or if fertilization attempts during prior in vitro fertilization cycles failed.

Blastocysts
At Geetanjali IVF we prefer to transfer embryos five days after egg retrieval, when the embryo is at the blastocyst stage. Not all embryos have the ability to reach the blastocyst stage which is usually because there are inherent issues within the embryo, however if the embryo can become a blastocyst by day 5 or 6 it is more likely to result in a pregnancy.

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