Male Infertility

Male Infertility

We may observe male infertility in one out of every five men. We also quite frequently observe female infertility. However, do we know enough about male infertility? Are men tested adequately? We will give you brief information on these issues…

Sperms which have the ability to fertilize mature eggs are produced in the testicles. This production cycle is completed in 80 to 90 days. Sperms that are mature and have the ability to fertilize are produced from premise sperm cells.

There are not only sperms in the semen as a result of ejaculation. A large portion of this fluid is a special liquid named seminal vesicle fluid. The remaining parts are prostate fluid, other fluids and sperm cells. In the sperm analysis, sperm numbers, motility and shapes in the semen as a total and in 1 ml are checked initially. Following sexual abstinence of 3 to 5 days, normal values would be as follows:

  • Total count 40 million
  • 15 million in 1 ml
  • Total motility at least 40%
  • Advance movement (A+B) at least 32%
  • Normally shaped ones at least 4%

If we observe a problem about these numbers, we mention male infertility. If the number is below 5 million in 1 ml or if motility is low or there are no normally shaped sperms, medical treatment might be required following various tests or intrauterine insemination/IVF may be considered.

We may sort reasons of male infertility as follows: issues regarding hormones secreted from the brain, production malfunction in the testicles, issues due to the seminal duct regarding ejaculation of produced sperms or unknown causes.

Reasons of male infertility that are most frequently observed in our daily lives are as follows:

Hypothalamic-Pituitary Disorders

Idiopathic isolated gonadotropin defi ciency

Kallmann syndrome

Single gene mutations (e.g., involving the GnRH receptor, FSHb, LHb, or transcription factors involved in pituitary development)

Hypothalamic and pituitary tumors (e.g., craniopharyngioma, macroadenoma)

Infiltrative diseases (sarcoidosis, histiocytosis, transfusion siderosis, hemochromotosis)

Hyperprolactinemia

Drugs (GnRH analogs, androgens, estrogens, glucocorticoids, opiates)

Critical illness or injury

Chronic systemic illness or malnutrition

Infections (e.g., meningitis)

Obesity

Primary Gonadal Disorders

Klinefelter syndrome

Y chromosome deletions

Single gene mutations and polymorphisms (e.g., involving the androgen, estrogen, or

FSH receptor)

Cryptorchidism

Varicoceles

Infections (e.g., viral orchitis, leprosy, tuberculosis)

Drugs (e.g., alkylating agents, alcohol, antiandrogens, cimetidine)

Radiation

Environmental gonadotoxins (e.g., heat, smoking, metals, organic solvents, pesticides)

Chronic illness (renal insuffi ciency, cirrhosis, cancer, sickle cell disease, amyloidosis,

vasculitis, celiac disease)

Disorders of Sperm Transport

Epididymal obstruction or dysfunction

Congenital bilateral absence of the vas deferens (relating to CFTR mutations)

Infections causing obstruction of the vas deferens (e.g., gonorrhea, chlamydia, tuberculosis)

Vasectomy

Kartagener syndrome (primary ciliary dyskinesia)

Young syndrome

Ejaculatory dysfunction

If the given sperm sample does not include live sperm cells, we call it azoospermia. In such cases, we repeat the sperm analysis a few days later. We must request additional tests if azoospermia is detected once again. These tests include:

  • Testicular ultrasound
  • Chromosome analysis
  • Hormones
  • Microdeletion testing (AZF-a,b,c)

We generally observe azoospermia in 1% of the society and 20% in patients who apply to a hospital for possible infertility. If there are no live sperm cells in the semen, we must definitely do the second test. We make the diagnosis if we are unable to find live sperm cells once again. So, is it possible to have children even if there is azoospermia? Which tests should be performed?

In cases of azoospermia, we observe around 40% congestion in the channel. In such cases, tests related to the cause are required. Congenital absence of channels or congestion of channels due to infections may cause azoospermia. In these cases, we are able to obtain mature sperm cells. It is possible to have children, by retrieving sperms through congested vessels or if there is no channel, microinjection could be performed by obtaining sperms from the testicular tissue.

In cases of azoospermia, we observe around 60% of production malfunction in the testicles. In such cases, it might be harder to obtain mature sperms. These cases include:

  • Hypogonadism; that is congenital problems in brain hormones
  • Undescended testicle
  • Production malfunction following chemotherapy/radiotherapy
  • Individuals with Klinefelter’s syndrome
  • Individuals with Y microdeletion
  • Those who have had testicular infection called orchitis
  • Those who have had testicular surgery

In these cases, live-mature sperm cells might not be obtained in sperm analysis. After this phase, hormones should be monitored and if necessary hormone therapy could be initiated. In cases of azoospermia, several techniques are used to obtain sperms.

TESE: sperm search under microscope by taking tissue samples from testicles

TESA: getting sperms from testicular channels through a needle. We are able to find approximately 30-40% live sperm cells in men by using these methods.

Sperm DNA Damage in Male Infertility

In various cases, although the best sperm is selected as a result of the IVF treatment, embryo development may be slow or it may be difficult to get pregnant even if embryo development is good. In those cases where no problems are encountered, it should be investigated why pregnancy does not occur or the embryo development is slow.

Researches show that some sperms produced in the testicles of the father-to-be can be exposed to DNA damage during the process from the urethra to the penile glans i.e. ejaculation. DNA damage can be detected via special methods. If the damage is more than 30%, no matter how quality and normal the sperm is, the pregnancies obtained with that sperm cell may fail. In that case, some antioxidant medications may be needed. However, the most effective method in such cases is the Micro TESE method. In this method, sperm cells are taken from the testicles through a special process. The sperms obtained from the testicles are examined via the IMSI method and the best sperm cells among them are selected and then the microinjection method begins.

The reasons of sperm DNA damage:

  • Certain diseases
  • Use of medication
  • High fever
  • Elevated testicular temperature
  • Air pollution
  • Smoking
  • Advanced age
  • Varicocele

The higher the sperm DNA damage rate, the less chance of being naturally conceived. Men with infertility problems are observed with a higher rate of sperm DNA damage. The rate of DNA damage is higher in men with fewer sperm counts, motility or normal sperm morphology. Sperm functions are very important for DNA investigation in unexplained male-oriented infertility. Even in males who cannot have children and whose sperm analysis is normal, abnormal results may occur due to sperm DNA analysis. The rate of damaged sperm in sperm DNA analysis test is expected to be below 15%. The rate between 15-30% is intermediate level and men with semen that contains more than 30% abnormal sperms are regarded at risk.

Sperm DNA Fragmentation test should be applied in such cases:

  • Unexplained infertility
  • Couples experiencing slowdown of embryo development
  • Those with abnormal embryo development in IVF

Recurrent IVF failures