The main causes of male infertility are either linked to an alteration in the quality of the sperm, or to difficulties in achieving intercourse (erectile dysfunction and/or ejaculatory disorders).
The medical consultation
When conducting an infertility consultation, it is as important to interview and physically examine the man as the woman. Therefore, it is essential that both partners be present during the first consultation.
The interview with the man should cover issues which could explain impaired sperm production (spermatogenesis), such as present or previous occupational exposure to toxins or to heat, paternity with a previous partner, and medical or urological, genital or encephalitic (brain-related) surgical history. It is also important to consider the quality and frequency of sexual relations and to ascertain any difficulties in this regard.
The genital examination should assess the size of the testes, the presence of the vas deferens, and detect any varicocele (enlarged veins in the scrotum) and/or malformations of the penis. The only first-line examination for men is the semen analysis, which must be included in every infertility assessment, even when the cause initially appears to lie with the woman.
The semen analysis
This consists of a semen collection obtained by masturbation in a laboratory after a period of sexual abstinence (3-5 days). It is most often done by appointment and the results are usually delivered within ten days. It comprises several exams:
- The spermogram, which assesses the quantitative parameters of semen and spermatozoa, i.e. the volume and pH of semen, and the numbers, mobility, and vitality of the sperm.
- The spermocytogram, which assesses the morphology of the sperm (the percentage of normal forms) but is of little importance in clinical practice. In fact, it can cause unnecessy alarm for the patient as it is quite normal to be diagnosed as having “a large number of abnormal spermatozoids”.
- The test of migration survival (TMS), which reproduces in a gel the conditions encountered by sperm as it passes through the female genital tract, is a kind of “courage test” for sperm. Generally speaking, over a million living and mobile sperm should be collected after this test in order to ensure the possibility of a natural conception.
- Finally, a search for bacteria in the sample, or a “spermoculture”, is often requested, in order to detect the presence of any infection in the male genital tract.
It should also be borne in mind that a transitory disease, fever or infection can temporarily alter sperm parameters.
There is a medical term for each abnormality detected by the spermogram. In male cases of infertility requiring the use of Assisted Reproductive Technologies (ART), all of the sperm parameters are usually impaired, a condition defined as oligoasthenotatezozoospermia (OAT). In the extreme case known as “azoospermia”, no spermatozoids are found in the ejaculum. It is divided into the two main categories of “obstructive” and “non-obstructive” azoospermia.
The first occurs when the production of spermatozoids (spermatogenesis) takes place normally, but an obstacle or defect in the vas deferens prevents the delivery of sperm into the ejaculate. Non-obstructive azoospermia occurs when no sperm is produced (due to genetic factors or more often unknown reasons). Depending on the results, the clinician may have to prescribe other examinations, such as an ultrasound scan of the testicles or the vas deferens (effected rectally), hormonal assay tests and genetic tests.
Obstructive azoospermia may have a genetic origin or be caused by a genital infection or a vasectomy (male sterilization). If absence of the vas deferens is suspected, the patient and perhaps also his partner are tested for the genes causing cystic fibrosis.
Ejaculatory disorders are divided into the two categories of orgasmic and anorgasmic anejaculation. Orgasmic anejaculation, i.e. with an orgasm, most often has an anatomical cause, which means that during orgasm semen enters the bladder instead of emerging through the penis and is then found in the urine. This is called retrograde ejaculation, since ejaculation is effected “backwards” into the bladder. It occurs in the presence of diabetes mellitus with neurological complications or can be caused by alterations to the anatomic structures involved in ejaculation (such as the post operative effects of prostate removal).
Anorgasmic anejaculation may be due to any of several factors that can prevent orgasm during coitus, and therefore intra-vaginal ejaculation. These are usually psychogenic in origin and require the assistance of a sexologist (e.g. a low sex drive, a stressful relationship, use of antidepressants, etc.). However, it may also occur in the case of spinal cord injury, major erectile dysfunction or when the partner suffers from severe vaginismus.
Male infertility treatments
Hygiene and dietary measures
It is well-known that a healthy lifestyle can significantly improve minor abnormalities in spermatogenesis. So, it is therefore important to reduce calorie intake, keep active and, if necessary, keep any pre-existing condition of diabetes under control. It is also strongly advised to stop smoking or any substance abuse and consumption of controlled drugs. Finally, any exposure to toxins or sources of heat should be avoided as far as possible, by using protective measures, as well as limiting the amount of time spent in a sitting or sedentary position during the day.
In the case of a varicocele (similar to varicose veins) in one or both testicles, surgery should be proposed to the patient in order to stop the blood flow to it, thereby improving the vitality and mobility of the sperm. This procedure is performed either by an interventional radiologist (via the endovascular route), or by a urologist (via the inguinal route or by laparoscopy). Surgery may also be proposed in the absence of sperm abnormalities, if the condition becomes troublesome for the patient (with scrotal heaviness and pain at the end of the day).
Urological surgery may be proposed for obstructive azoospermia, depending on the location of the obstacle, a vasovasostomy in the case of stenosis of the vas deferens or a previous vasectomy, or a transurethral resection of the prostate in the case of a prostatic cyst compressing the ejaculatory ducts. However, such surgery is usually only reconstructive and only aims to extract sperm to use them for ART. It may therefore involve percutaneous epididymal punctures to take samples of testicular tissue, with a very high likelihood of sperm retrieval.
In the case of secretory azoospermia, it may be advisable to take a microsurgical sample (microTESE) of testicular tissue, which offers a 50% probability of sperm retrieval. If the testicular biopsy is negative, the couple may be advised to consider alternative solutions, such as sperm donation or adoption.
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