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Male Infertility: A guidance to symptoms, diagnosis and treatment





What is male infertility?


Male infertility is any health issue in a man that lowers the chances of his female partner getting pregnant. It is defined as the failure to conceive despite one year of regular unprotected intercourse.


Approximately 15% of couples will experience infertility, and of these, 20% will have a male factor that is solely responsible;

In general, male infertility is identified by abnormalities on a semen analysis; however, other issues can contribute to infertility despite normal semen.

In 30-40% of cases, no male-associated factor is found to explain impairment of sperm parameters and it is referred to as idiopathic male infertility.


These men present no previous history of diseases affecting fertility and have normal findings on physical examination, endocrine, genetic and biochemical laboratory testing, although semen analysis may reveal pathological findings.


Risk Factors


Advanced paternal age has emerged as one of the main risk factors associated with the progressive increase in the prevalence of male factor infertility.





Environmental and lifestyle factors such as smoking, excessive alcohol intake and obesity can also affect fertility


Etiology


Male fertility can be impaired as a result of:




  • congenital and acquired urogenital abnormalities(Cryptorchidism, Varicocele)

  • gonadotoxic exposure (e.g., radiotherapy or chemotherapy use of (anabolic drugs);

  • malignancies (Testicular germ cell tumour (TGCT))

  • urogenital tract infections(urethritis, prostatitis, orchitis and epididymitis, STDs, VPH)

  • Obstructions ( infratesticular, epididymal, vas deferens, ejaculatoty duct obstruction)

  • increased scrotal temperature ( as a consequence of varicocele);

  • endocrine disturbances ( dysfunction of the hypothalamus-pituitary-gonadal axis. Hypogonadism)

  • genetic abnormalities;

  • immunological factors


Diagnostic evaluation:


The full evaluation for male infertility should include a complete medical and reproductive history, a physical examination by a urologist or other specialist in male reproduction and at least two semen analyses.



Based on the results of the full evaluation, the physician may recommend other procedures and tests to elucidate the etiology of a patient's infertility.These tests may include additional semen analyses, endocrine evaluation, post-ejaculatory urinalysis, ultrasonography, specialized tests on semen and sperm, and genetic screening.



Reproductive history:


Typical findings from the history of a patient with infertility include:

  • cryptorchidism (uni- or bilateral);

  • testicular torsion and trauma;

  • genitourinary infections (urethritis, prostatitis, orchitis and epididymitis, STDs, VPH)

  • exposure to environmental toxins;

  • gonadotoxic medications (anabolic drugs, chemotherapeutic agents, etc.);

  • exposure to radiation or cytotoxic agents.


Physical Examination:


Typical findings from the physical examination of a patient with characteristics suggestive for testicular deficiency include:




  • abnormal secondary sexual characteristics;

  • abnormal testicular volume and/or consistency;

  • testicular masses (potentially suggestive of cancer);

  • absence of testes (uni-bilaterally);

  • gynecomastia (enlargement of the breast tissue in men or boys “Man Boobs”)

  • varicocele (swollen veins in the scrotum)

  • Pain, swelling or a lump in the testicle area

  • Problems with sexual function :

  • Difficulties with ejaculation

  • Reduces sexual desire(libido)

  • Erectile dysfunction


Semen analysis:


Semen analysis is the cornerstone of the laboratory evaluation of the infertile male and helps to define the severity of the male factor.


A defined period of abstinence of two to three days is advised before the sample collection. Semen can be collected by masturbation or by intercourse using special semen collection condoms


It is important to differentiate between the following:

  • oligozoospermia: < 15 million spermatozoa/mL;

  • asthenozoospermia: < 32% progressive motile spermatozoa;

  • teratozoospermia: < 4% normal forms.


None of the individual sperm parameters (e.g., concentration, morphology and motility), are diagnostic per se of infertility.


Hormonal determination:


Hormonal abnormalities of the hypothalamic-pituitary testicular axis are well-recognized, though not common causes of male infertility.


An initial endocrine evaluation should include at least a serum testosterone and FSH. It should be performed if there is:

  • an abnormal semen analysis, especially if the sperm concentration is less than 10 million/ml;

  • impaired sexual function

  • other clinical findings suggestive of a specific endocrinopathy.


Post-ejaculatory urinalysis


A post-ejaculatory urinalysis should be performed in patients with ejaculate volumes of less than 1 ml, except in patients with bilateral vasal agenesis or clinical signs of hypogonadism.


Ultrasonography

Transrectal ultrasonography is indicated in azoospermic patients with palpable vasa and low ejaculate volumes or in oligospermic patients with low volume ejaculates, palpable vasa and normal testicular size to determine if ejaculatory duct obstruction exists.


Scrotal ultrasonography is indicated in those patients in whom physical examination of the scrotum is difficult or inadequate or in whom a testicular mass is suspected. It may be helpful in:

  • measuring testicular volume;

  • assessing testicular anatomy and structure in terms of US patterns

  • finding indirect signs of obstruction (e.g., dilatation of rete testis, enlarged epididymis with cystic lesions, or absent vas deferens)


Treatment:


The treatment of male Infertility should be specific to the condition responsible (non invasive management, hormonal therapy management, surgical management), however there are some general recommendations and lifestyle changes that may improve male Infertility such as:

  • Weight loss

  • Increase physical activity

  • Reduce smoking and alcohol consumption( can reduce testosterone levels)

  • Antioxidant treatment (Oxidative stress is considered to be of the most important contributing factors in the pathogenesis of idiopathic infertility)






References:

  • Smith & Tanagho’s General Urology. Chapter 44. Male Infertility

  • European Association of Urology. Guideline of Sexual and Reproductive Health 2021. Chapter 10: Male Infertility

  • American Urological Association. Guideline Infertility-Optimal Evaluation of the Infertile Male 2011.

  • Urology Care Foundation. Male Infertility. www.urologyhealth.org

  • Mayo Clinic. Male Infertility. www.mayoclinic.org

  • World Health Association. Fertility. www.who.int

  • Dimitriadis F., Adonakis G., Kaponis A., Mamoulakis C., Takenaka A., Sofikitis N. (2017) Pre-Testicular, Testicular, and Post-Testicular Causes of Male Infertility. In: Simoni M., Huhtaniemi I. (eds) Endocrinology of the Testis and Male Reproduction. Endocrinology. Springer, Cham. https://doi.org/10.1007/978-3-319-29456-8_33-s2


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