April 9, 2020
Author Name: Dr. Jyoti Pandey Mentor Name: Dr. Rinoy on April 09, 2020
Infertility is common health issue with about 13% of couples not getting pregnant after unprotected sexual intercourse. There can be many causes and in 33% of cases the problem lies in male. There can be problem due to low
sperm production or any obstruction in sperm pathway leading to inadequate delivery of sperms.
Normally the sperms are produced inside testis from where they travel through epididymis to vas deferens which joins the ejaculatory duct with secretions of seminal vesicle into prostatic urethra. Semen deposited in urethra combined with prostatic gland secretions are released into female vagina during ejaculation from where it travel into fallopian tube via cervix and uterus and meet female egg thus resulting in fertilization. The whole process needs appropriate levels of hormones and adequate environment.
An event causing either decreased production of sperms or obstruction in sperm passage can lead to infertility. This can be by birth or acquired due to environmental factors,smoking ,alcohol, infections, trauma. Given below is the list of low sperm count in males
1. Varicocele 27%
2. Immunological 2%
3. Ejaculatory duct obstruction 15%
4. Cryptorchidism 3%
5. Failure to ejaculate 2%
6. Hormonal imbalance 2%
7. Drugs/Radiation 2%
8. Genetic 2%
9. Systemic disease/infection/ 5%
10. Idiopathic(cause not known) 40%
History and Physical Examination –
Any h/o childhood illness such as mumps, intake of drugs that can harm sperm production like tobacco, alcohol, marijuana, steroids or recreational drugs. Any h/o of exposure to ionizing radiation, heavy metals (mercury, arsenic, lead) or pesticides.
Examination of testis (size, consistency, location any signs of infection), epididymis, vas deferens (presence or absent), penis.
Semen analysis –
Semen analysis is a routine laboratory test that is used to know the cause of male infertility. Parameters studied in semen analysis are sperm count, concentration, motility, physical properties of semen, volume or any abnormal forms. Low sperm count also known as oligozoospermia is sperm concentration less than 15 million/ml.
Hormonal assessment –
Pituitary hormone FSH guide the testis to make adequate sperm production. Any abnormal increase in FSH signals failure of testis to produce adequate sperms.
USG of testis can be used to make the diagnosis of varicocele and transrectal USG can be used to look for any blockage in ejaculatory duct.
Management of male infertility depends on the cause of it. The treatment starts with behavioral modification. Cessation of smoking, alcohol, any recreational drugs including steroids. Daily exercise, healthy diet rich in antioxidants. Good control of diabetes, Hypertension or any chronic diseases and treatment infection if any. Varicocele as the cause of low sperm count and low sperm motility needs correction with Varicocoelectomy. Any obstruction in the passage of sperms may needs to be corrected and may require surgery in the form of vasovasostomy, vasoepididymostomy or ejaculatory duct resection depending on the level of blockage. But the results are poor and require high degree of surgical precison and skill.
Even after this around 45% of causes are idiopathic and may not respond to any of treatment and may require Assisted reproductive techniques. These techniques require sperm retrieval in the form of-
1. PESA – Percutaneous Epididymal Sperm Aspiration.
2. TESE – Testicular Sperm Extraction.
3. TFNA – Testicular fine needle aspiration.
Once sperm are retrieved they can be either deposited inside female reproductive tract and the process is known as Intrauterine Insemination or sperms can be fused with egg outside in petridish and can be transferred later on after 2-5 days the process known as In Vitro Fertilization (IVF). ICSI (Intracytoplasmic sperm injection) is a form of IVF in which a single sperm is injected into egg and later on transferred into uterus. Even with all these the sperm may not be able to fertilize the egg or in cases in which there is no sperm production we may resort to IUI or IVF with Donor sperm.
To end our discussion there are many treatable causes of low sperm count. Maintaining healthy lifestyle, good diet with physical activity and antioxidants can help. Certain cases need surgical treatment in the form of varicocelectomy,vasovasostomy,vasoepididymostomy, Ejaculatory duct resection. Rest of cases may need IUI or IVF.
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