Male infertility is a violation of the male reproductive function, expressed in the inability to have offspring. Most often, male infertility is a consequence of qualitative and quantitative changes in sperm in the ejaculate due to previously transferred inflammatory diseases of the genitals, infectious and chronic diseases, exposure to chemical factors on the body. In 40-50% of cases, it causes infertile marriage. It can turn into a family breakdown and a personal tragedy.
ICD 10
N46 Male infertility
General information
Male infertility is a violation of the male reproductive function, expressed in the inability to have offspring. Most often, male infertility is a consequence of qualitative and quantitative changes in sperm in the ejaculate due to previously transferred inflammatory diseases of the genitals, infectious and chronic diseases, exposure to chemical factors on the body. In 40-50% of cases, it causes infertile marriage. It can turn into a family breakdown and a personal tragedy.
One tenth of all couples are unable to conceive a child without the help of medicine. At the same time, female infertility accounts for 40%, and male infertility accounts for 45%, the remaining 15% account for cases of immunological incompatibility of spouses and rare forms of infertility.
Pathogenesis
The male germ cell is a sperm, it contains genetic information about the father. Genetic information is concentrated in the head of the sperm, and with the help of the tail, the sperm is able to move around to reach the egg. Spermatogenesis occurs in the testicles; first, the sperm passes through the convoluted tubules, which gradually turn into straight lines and then into the appendage of the testicle. The total length of the tubules is about 500 meters, thanks to the slow movement along the convoluted tubules, the sperm matures and becomes able to fertilize the egg. In the appendages of the testicles, spermatozoa go through the last stage of growth, after which they enter the seminal vesicles through the vas deferens, where they accumulate and mix with the epithelial secret, which contains nutrients for sperm. From the seminal vesicles, the seminal fluid is evacuated at the moment of ejaculation, mixing with the secret of the prostate gland, the resulting fluid is called sperm.
From the above it becomes clear that the main causes of male infertility can be either obstruction of the canal, in which sperm cannot be ejected from the urethra due to obstacles, or violations of secretory function at any stage.
Secretory form
In the secretory form of male infertility, the testicles do not produce the right amount of sperm, as a result of which fertilization of the egg is impossible. This form of infertility is also spoken of in cases when sperm motility is impaired or they have defects in structure.
A common cause of secretory male infertility is varicose veins of the testicles (varicocele). The outflow of venous blood through dilated veins is difficult, therefore, stagnation develops, blood supply is disrupted and the function of the testicles is suppressed. Basically, the left testicle is affected by varicocele, but over time the process passes to the second healthy testicle. As a result, the function of both testicles is significantly suppressed, sperm production decreases and a secretory form of male infertility develops.
Dropsy of the testicles, in which fluid accumulates in the testicles, squeezing the testicle, can also cause secretory male infertility, since prolonged squeezing of the testicles with fluid disrupts the blood supply to the sperm-producing tissue. With inguinal hernia, a similar process is observed. Cryptorchidism, that is, the non-descent of the testicles into the scrotum is less likely to cause male infertility. Treatment of cryptorchidism must be carried out before the age of seven so that the function of the testicles is preserved, otherwise the risk of male infertility increases several times.
Epidemic mumps, the virus of which affects the glandular tissue, primarily affects the salivary glands and sex glands. Therefore, epidemic orchitis with sufficiently strong inflammation and lack of treatment can significantly reduce a man’s reproductive functions, or cause male infertility.
Damage to the spermatogenic epithelium can also cause male infertility, so the effect of penetrating radiation, depending on the dose, is manifested either by a total lesion – radiation sickness, or by damage to individual tissues and organs, the spermatogenic epithelium is most sensitive to radiation radiation. Electromagnetic fluctuations often lead to the same outcome, while wearing any means of communication on a belt before scientists have not made a final verdict is also a risk factor.
High temperature has a depressing effect on the entire process of spermatogenesis and over time can lead to irreversible consequences and to male infertility. The risk group includes both people working in hot shops and abusing the bath and sauna. Any water procedures should be completed with a cool shower so that the temperature in the testicles returns to normal. Heated seats in the car on the one hand increase comfort, and on the other increase the temperature in the testicles. Squeezing the perineum with narrow underwear and clothes, frequent blows lead to testicular dysfunction and complete male infertility. Professional cycling often affects the reproductive function, male infertility in men who have been cycling for a long time is diagnosed several times more often.
Syphilis, tuberculosis, typhoid fever, taking antitumor, antiepileptic and antibacterial drugs and hormonal disorders can provoke the development of male infertility. Temporary male infertility develops as a result of prolonged stress, protein deficiency in the body, hypovitaminosis and alcohol and smoking abuse. In regions with unfavorable environmental conditions, the percentage of couples with male infertility is higher.
Diagnosis of secretory male infertility is based on a spermogram and cytological examination of testicular tissues, this helps to find out both the degree of the pathological condition and the root cause. After correction of the underlying disease that led to male infertility, a course improving spermatogenesis is carried out.
Obturation form
In this form of male infertility, the movement of spermatozoa through one or both vas deferens is impossible due to blockage. The main cause of duct obstruction is inflammatory processes in the appendages of the testicles, as a result of which the channels are glued or clogged. Untreated injuries to the testicles and inguinal region, damage during operations on the pelvic organs or compression of the vas deferens by a cyst are the second main cause of obturation male infertility after orchitis. Less often, the cause of male infertility is the absence of an appendage of the testicle or vas deferens, syphilis and tuberculosis.
During the diagnosis of obturation male infertility, it is important to determine the extent and localization of obturation. Treatment consists in excision of the obstruction site or in the formation of a new pathway for sperm by applying anastomoses.
Symptoms
10% of infertile couples do not show any pathologies, while they may have children from other marriages. A rarer cause of infertility is immunological incompatibility or hypersensitivity of a woman to the components of sperm. If the opening of the urethra is located below the tip of the penis, then at the time of ejaculation, the sperm does not fall on the cervix, so conception does not occur. Male infertility is also diagnosed in cases when a man performs no more than the 1st full-fledged sexual intercourse in a month (due to illness or because of a preference for other types of sex).
Diagnostics
After the examination and interview of the man, in order to identify diseases in the anamnesis that could lead to infertility, it is necessary to make a spermogram. The analysis should be repeated 2-3 times, while abstinence from sexual intercourse and masturbation for 2-3 days is required before the examination. You can come to the andrologist’s appointment with ready-made tests, which saves time for diagnostics. If both a man and a woman undergo an examination for infertility, it is better that the examination be conducted in the same clinic, so that doctors can more accurately determine the cause of infertility in a couple and prescribe the correct treatment.
Normally, the volume of ejaculate is 3-5 ml (about one teaspoon), if the amount of ejaculate is less than normal, then this may indicate hypofunction of the testicles. If the sperm volume is less than 2 ml, and all spermogram indicators are within the normal range, conception is unlikely due to the small volume of sperm. In 1 ml of sperm, there should normally be at least 20 million spermatozoa, if their number is below this extreme value, then they talk about oligozoospermia. Oligozoospermia can develop due to unilateral obstruction of the vas deferens or due to hypofunction of the testicles, as a result of which male infertility occurs. If the patient has bilateral obturation, then spermatozoa are completely absent in the sperm, then they talk about azoospermia. At the same time, despite the fact that only one sperm is needed to fertilize an egg, reducing the number of spermatozoa to 1 million makes conception impossible. At the moment of ejaculation, about 200 million people fall on the cervix. of spermatozoa, half of them overcome the mucous plug of the cervical canal, but only a small part reaches the mouth of the fallopian tubes. Since the egg is only in one fallopian tube, only half of the sperm will get into the tube with the egg. That is, the fewer spermatozoa are in the ejaculate, the less likely pregnancy is, therefore, a critical decrease in the number of spermatozoa in sperm is one of the signs of male infertility. Most of the spermatozoa should have a rectilinear or chaotic character of movement, if the number of motile spermatozoa is reduced, then this is called asthenozoospermia, the complete absence of motile spermatozoa is called necrosoospermia.
The mobility and the number of spermatozoa in the ejaculate depends on the frequency of sexual intercourse, which is why a man undergoing the diagnosis of male infertility needs to refrain from sexual intercourse in order to obtain reliable spermogram results. And, with consecutive sexual acts, sperm loses fertility, so there is no need for contraception.
Infertile couples may be those who do not abstain before conception, since with frequent contacts, immature forms of sperm with low mobility and viability are present in the sperm, and the maximum number of mature and viable sperm is contained in the sperm after 2-3 days of abstinence.
Morphological analysis of spermatozoa allows us to estimate what percentage of spermatozoa has a normal structure, if more than half have a full-fledged structure, then this is the norm, a decrease in the number of normal spermatozoa is called teratozoospermia. In men who undergo examination for male infertility, sperm agglutination is often detected, which normally should not be. Normally, there should be no areas of accumulation (aggregation) of spermatozoa in the sperm, while visually such sperm looks heterogeneous, and the areas of aggregation have a higher density and a more saturated shade. Aggregation of spermatozoa often accompanies a decrease in movement speed. Such changes in sperm, which can lead to male infertility, are observed in inflammatory diseases of the pelvic organs and hormonal disorders in the male body.
A significant number of leukocytes in semen indicates an inflammatory process of the urogenital tract. And a man, in addition to examination for male infertility, should be examined by a urologist in order to detect orchitis, epididymitis, vesiculitis or prostatitis.
Since the spermogram data are labile, if necessary, the examination is repeated in order to obtain an objective assessment of the possibility of fertilization.
Male infertility treatment
Modern andrology has wide possibilities for the treatment of male infertility. First of all, it is necessary to normalize the mode of work and rest, eliminate professional and household hazards. Treatment of diseases of the urogenital sphere, vitamin therapy, normalization of nutrition and the appointment of sedatives, if necessary, is carried out in all men who are undergoing treatment for male infertility.
With impaired spermatogenesis, treatment of genitourinary infections, correction of endocrine disorders is carried out; androgen replacement therapy is indicated. The treatment regimen and the choice of drugs are selected individually in each case.
If one of the spouses has inflammatory diseases of the genitals, then the treatment of male infertility begins with the treatment of both spouses. At the same time, it is important not only to suppress microorganisms, but also to identify the original source in order to eliminate it. After etiological and pathogenetic treatment, a course of immunocorrectors and restorative drugs is recommended. Some infectious diseases of the genitourinary sphere require long-term treatment, the criteria for recovery are the absence or presence of no more than 2 leukocytes in the semen in the field of view, the absence of staphylococcal microflora and pathogens of sexually transmitted diseases and normalization of other sperm indicators.
If pregnancy does not occur within a year after the correction of male infertility due to urinary tract infections, hormone-stimulating therapy is indicated.
Artificial insemination with her husband’s sperm or donor sperm is indicated in the presence of coital disorders that prevent the ejaculate from entering the vagina. With male infertility caused by a slight violation of spermatogenesis or immunological aggression of the mucus of the cervical canal, artificial insemination with the husband’s sperm allows many couples to conceive a child. Artificial insemination with the husband’s sperm is called homologous artificial insemination, and insemination with donor sperm is called heterologous.
Artificial insemination is indicated if a woman has old perineal ruptures or anatomical obstacles from the vagina and uterus, with severe forms of vaginismus, ankylosis injuries of the hip joints and with adverse effects of the contents of the vagina on spermatozoa.
If male infertility is caused by insufficient erection or premature ejaculation, then these couples are also shown artificial insemination with their husband’s sperm. With a large hydrocele and inguinal-scrotal hernia, pronounced hypospadias and oligozoospermia of the I-II degree, artificial insemination is also resorted to. Male sperm can be cryopreserved, especially before long-term use of drugs that can cause male infertility or before the sterilization of the husband.
Insemination with donor sperm is resorted to in male infertility caused by aspermia, azoospermia, oligospermia of the III degree and other severe disorders of spermatogenesis. If the spouse has diseases in which the birth of children is not recommended, such as genetic diseases, the birth of children with severe congenital malformations or stillbirth of children with signs of severe hemolytic disease due to incompatibility of spouses by Rh factor.
To improve sperm performance, the ejaculate is divided into fractions, separating the mobile forms by filtration, using several different portions of cryopreserved sperm. To improve the sperm indicators of a man who has been treated for male infertility, agrinin, caffeine and prostaglandins are added to it.
The effectiveness of the introduction of native sperm is several times higher than with insemination with cryopreserved sperm, but when using cryopreserved sperm, its antigenic properties decrease, which is used in the treatment of female or male infertility in couples in which women have antisperm antibodies. In this case, the sperm is injected either into the cervical canal or intrauterine every other day from the date of the expected ovulation.
Hormone therapy
Hormonal therapy of male infertility is indicated for various disorders of spermatogenesis, mainly with impaired sperm motility, as stimulation after correction of underlying diseases and less often as the main treatment.
Hormone replacement therapy for the treatment of male infertility is indicated for hypogonadism, idiopathic disorders of sperm motility (pathozoospermia) and for hypoandrogenism. With the blocking method of treatment of male infertility, a man takes drugs that suppress spermatogenesis for several months, after cancellation, the qualitative and quantitative characteristics of spermatozoa improve. Although this antifertile method for the treatment of male infertility is rarely used.
Stimulating hormone therapy for male infertility is based on the introduction of small doses of hormones that have a beneficial effect on metabolic and other processes, but do not affect the hypothalamic-pituitary system. Treatment of male infertility with hormones is long-term, at least 9 months with monitoring of the effectiveness of therapy at least once every 3 months. Dosages and the choice of the drug and the regimen depend on the type of pathology and are prescribed individually. With a sperm concentration of less than 5 million / ml of sperm, if the mobile forms of sperm are less than 20%, hormone therapy for male infertility is hopeless.
Surgical treatment
In male infertility caused by varicocele, the outflow of venous blood from the testicles is surgically improved. As a result, stagnant phenomena disappear, metabolism is normalized and spermatogenesis is restored. Testicular veins are either ligated, sclerosed, or ligated. The prognosis of surgery for unilateral varicocele is favorable, if the process is bilateral, then sometimes additional drug therapy for male infertility is required.
With cryptorchidism, the operation to lower the testicles into the scrotum is performed at an early age, but it is necessary to exclude Kallman syndrome and other congenital pathologies. The earlier the orchipexy operation is performed, the fewer irreversible changes in the spermatogenic epithelium and the less likely it is that male infertility treatment will be required in adulthood. If the reduction of the testicles was carried out after reaching the age of three, then the treatment does not give high results and many men subsequently have to undergo treatment for male infertility. Treatment of cryptorchidism with gonadotropins is ineffective.
In the surgical treatment of inguinal-scrotal hernias, it is important to minimize the risk of injury to the spermatic cord, if the operation is performed successfully, then usually no further therapy of male infertility is required, since the reproductive function is fully restored. If there are congenital anomalies of the urethra, then plastic surgery to restore the canal with the formation of an external hole on the head is enough so that at the time of ejaculation, sperm falls on the cervix. If there is a narrowing of the urethra, then surgical treatment of male infertility consists in applying anastomoses using endoscopic surgery. Operations on the vas deferens are used for obturation azoospermia, additionally eliminating the cause of obturation (cyst, site of inflammatory obstruction, etc.).
A joint visit to a psychotherapist during the treatment of female or male infertility will create a favorable atmosphere for conception. Since many couples after the news of the temporary inability to have children, there is a crisis based on reproaches, loss of tenderness during sexual intercourse and a sense of inferiority. Conversations with psychotherapists and psychologists will help to maintain normal relationships in the family and find a way out of the situation, for example, the adoption of a child or the use of donor material for conception. It is important to understand that the opportunity to be a father is an opportunity to raise a child, and not to be his biological parent. And if a man, for some reason, even after undergoing treatment for male infertility, cannot become a biological father, then this does not indicate his inferiority. A psychologist will help overcome this crisis without additional difficulties (depression, alcoholism, divorce), because often, having accepted the impossibility of conceiving a child, and using alternative methods to create a full-fledged family, a healthy and long-awaited child is born.