Male Infertility

Problems causing infertility in males are very common. Male infertility accounts for 25-50% of infertility cases.

The problems that can cause male infertility can be divided into two main groups: problems affecting the production of sperm by the testicles and problems affecting the transport of sperm outside the male genital tract.

Problems with sperm production can be related to the testicle itself or to the signals the testicle receives (or does not receive) from the brain. In problems related to the testicle itself, we can mention those caused by various infections such as orchitis (testicular infection mainly as a complication of mumps in childhood), varicocele (expansion of veins that cause damage to spermatogenesis), various testicular tumors, congenital anomalies in which the testicle does not produce spermatozoa because it does not have the proper structure for spermatogenesis (fragile Y chromosome).

Problems in ejaculate can be caused by blockages (obstructions) of the ejaculatory system at different points. Such blockages can be a consequence of various infections, traumas, past surgeries, etc.

Analysis and diagnosis

The main analysis recommended for an infertile man is the spermiogram, which analyzes the patient's sperm by comparing it with globally accepted normal values. It is the spermiogram that diagnoses whether a man has a fertility problem or not. The spermiogram is a very simple, inexpensive, and necessary analysis in evaluating the fertility potential of a man.

The normal parameters of the spermiogram are as follows:

Depending on the result of the spermiogram, the need for other analyses in men will also be determined. In cases with normal spermiograms, it usually is not deemed necessary to seek other analyses. In cases with very poor spermiogram results, e.g., when the concentration of spermatozoa is very small (oligospermia, azoospermia), additional scrotal ultrasound, hormonal profile analyses, and genetic analyses may be sought.

The scrotal ultrasound will determine the dimensions of the testicles and epididymides, the presence or absence of masses, tumors, or cysts as well as vascular abnormalities (varicocele).

From the hormonal profile analyses, it will be possible to understand if there is any problem with the signals that the testicle should receive from the center (central nervous system) in order to produce sperm. The hormonal profile includes:

• FSH
• LH
• Total Testosterone
• TSH
• Prolactin.

Genetic analyses will show if the sperm problems are related to congenital genetic defects that make it impossible to produce sperm (Klinefelter syndrome, fragile Y chromosome) or cause or with defects that make it impossible to transport sperm from the testicles to the ejaculatory ducts of the penis (cystic fibrosis causes absence of the vas deferens which connect the testicles with the ejaculatory ducts of the penis).

The genetic analyses are:

• Karyotype,
• Cystic fibrosis
• Fragile Y chromosome

In cases with azoospermia (total absence of spermatozoa in the testicles) the only way to learn if there are spermatozoa in the testicles (and potentially use them for In Vitro Fertilization) remains the surgical extraction of sperm from the testicles.

TREATMENT

The treatment of mild cases includes improving the hormonal profile, eliminating factors that harm spermatogenesis (quitting smoking, not wearing very tight underwear). For the treatment of mild forms of male infertility, intrauterine insemination (IUI) is also reserved.

As for varicocele, surgical treatment is only recommended in cases where varicocele causes severe sperm abnormalities, pain, enlargement of the testicle. However, it should be emphasized that the majority (6 out of 7 individuals) of those who undergo surgery for varicocele do not benefit from this treatment.

The treatment of severe cases of male infertility varies from classic In Vitro Fertilization to In Vitro Fertilization (IVF) with intracytoplasmic sperm injection into the egg's cytoplasm (ICSI – intracytoplasmic sperm injection).

Why ICSI for severe cases? Because in severe cases, besides the very reduced number we may also have problems with motility or even with morphology. So, we are not satisfied only with placing the spermatozoon near the egg but we inject the spermatozoon directly inside the egg.

In severe cases, surgical extraction of sperm from the testicles (Testicular sperm extraction – TESE) may also be required to obtain the necessary spermatozoa for IVF – ICSI. In cases where even through surgical extraction spermatozoa cannot be found, sperm donation is recommended to the couple.