Male and Female Infertility

Overview on Male Infertility

What you need to know about Male Infertility

Although infertility was once considered to be a female problem, we now know that infertility affects just as many men as women. In addition in 10% of couples, the cause of infertility remains unknown.

 

 

Male infertility is generally caused by altered sperm quality and or quantity and can be due to different causes and risk factors. Recent studies have shown that  lifestyle and diet play an important role in your fertility.

Below are some answers to the most frequent questions regarding male infertility.

1. What is Male Infertility?
2. What causes infertility in men?
3. What are the risk factors for Male Infertility?
4. What are the symptoms of Male Infertility?
5. How is Male Infertility diagnosed?
6. How is Male Infertility treated?
7. Could you prevent Male Infertility?

1. What is Male Infertility?

When a couple is not able to conceive after 12 months of  unprotected sexual intercourse and female factors have been ruled out, the probable cause could be due to the male factor. In these cases a sperm analysis will be prescribed.

The good news is that a great number of men are able to father children naturally even after being diagnosed with male infertility.

2. What causes infertility in men?

Male infertility is frequently related to problems affecting either sperm production (quantity and quality) or sperm transport.

With a medical examination, your doctor should be able to find out the cause of your fertility problem. Keep in mind that male infertility is often multifactorial and one specific cause  is identified in only about 10-20% of cases. The most frequent causes of infertility in men are listed in the figure below.

Causes of Male Infertility

3. What are the risk factors for Male Infertility?

Several risk factors are associated with infertility in men.  These include:

  • urogenital abnormalities like varicocele, the dilation of the veins (varicose veins) that regulate blood flow to and from the testicles
  • exposure to radiotherapy or chemotherapy
  • urogenital tract infections
  • steroid use
  • obesity
  • prostate surgery
  • severe illness like cancer
  • testicular injuries.

Your reproductive health can also be negatively impacted  by a number of environmental and lifestyle factors. Smoking, diabetes, psychological stress, drugs or excessive alcohol consumption as well as poor nutrition can all affect sperm quality and therefore your fertility.

4. What are the symptoms of Male Infertility?

The majority of men have no specific symptoms of infertility and the most common sign of male infertility is the inability to conceive a child, after regular unprotected intercourse. In some cases the following symptoms may be present:

  • testicle pain or swelling
  • erectile and ejaculation dysfunctions
  • small, firm testicles.

These can be related to inherited disorders, hormonal imbalances or dilated veins around the testicles (varicocele). Any changes in sexual desire should also be discussed with your doctor, especially if the problem persists.

5. How is Male Infertility diagnosed?

The first step is a clinical evaluation by a medical specialist, like an andrologist. The medical examination includes:

  • medical and reproductive history
  • physical examination
  • semen analysis
  • hormonal evaluation.

Your doctor will prescribe a semen analysis which is the standard for an initial male fertility evaluation.  The results of the semen analysis will show if you have one of the following conditions:

Spermogram

  • Azoospermia: the complete absence of spermatozoa in the ejaculate. Azoospermia can be due to a blockage in the male reproductive tract, testicular dysfunction or an impairment of the hypothalamus pituitary-gonadal axis
  • Oligozoospermia: low number of spermatozoa
  • Asthenozoospermia: reduction in motile spermatozoa
  • Teratozoospermia: spermatozoa with abnormal forms
  • Oligoasthenoteratospermia (OAT): a condition in which abnormal sperm count, sperm motility, and sperm morphology are present at the same time. Some of the most common causes associated with oligoasthenoteratospermia include hormonal alterations, varicocele, infection and drugs like anabolic steroids, antidepressants and chemotherapy.

Results from all the assessments, combined with a clinical evaluation, will guide the physician in the diagnosis of male infertility and in defining the best treatment options for you.

6. How is Male Infertility treated?

 

Male Infertility Causes Pie Chart

 

On the basis of the specific cause of your infertility, the specialist will select the best treatment option for you.

  • In case you have a varicocele your doctor may consider surgery
  • Vasectomy reversal, efficacious in 85-90% of cases
  • If your infertility is caused by ducts blockage due to an infection, then antibiotics and anti-inflammatory drugs may be required
  • Hormonal medications might be recommended if the cause is hormonal imbalances.

When the above treatments are not successful, your doctor may recommend  assisted reproductive technologies (ART) which include:

  • ICSI (Intracytoplasmic Sperm Injection): a technique that allows the introduction of a single sperm into the cytoplasm of the oocyte.
  • IVF (In Vitro Fertilization): selection and preparation of oocytes and spermatozoa. Eggs and spermatozoa are brought into contact in vitro and fertilization occurs.

In addition to medical treatments, it is important to follow a healthy lifestyle.

7. Can you prevent Male Infertility?

Adopting a healthy lifestyle can help  improve sperm quality and your chances of conceiving:

References

 

  1. World Health Organization (WHO). International Classification of Diseases, 11th Revision (ICD-11) Geneva: WHO 2018.
  2. Babakhanzadeh E, Nazari M, Ghasemifar S, Khodadadian A. Some of the factors involved in male infertility: a prospective review. Int J Gen Med. 2020; 13:29-41.
  3. Agarwal A, Mulgund A, Hamada A, Chyatte MR. A unique view on male infertility around the globe. Reprod Biol Endocrinol. 2015; 13:37.
  4. Salonia A, Bettocchi C, Boeri L et al; EAU Working Group on Male Sexual and Reproductive Health. European Association of Urology Guidelines on Sexual and Reproductive Health-2021 Update: Male Sexual Dysfunction. Eur Urol. 2021;80(3):333-57.
  5. Bisconti M, Simon JF, Grassi S, et al. Influence of risk factors for male infertility on sperm protein composition. Int J Mol Sci. 2021;22(23):13164.
  6. Barbăroșie C, Agarwal A, Henkel R. Diagnostic value of advanced semen analysis in evaluation of male infertility. Andrologia. 2021;53(2):e13625.
  7. Vander Borght M, Wyns C. Fertility and infertility: definition and epidemiology. Clin Biochem. 2018;62:2-10.
  8. Durairajanayagam D. Lifestyle causes of male infertility. Arab J Urol. 2018;16(1):10-20.
  9. Shi X, Chan CPS, Waters T, Chi L, Chan DYL, Li TC. Lifestyle and demographic factors associated with human semen quality and sperm function. Syst Biol Reprod Med. 2018;64(5):358-367.
  10. Sharma R, Biedenharn KR, Fedor JM, Agarwal A. Lifestyle factors and reproductive health: Taking control of your fertility. Reprod. Biol. Endocrinol. 2013, 11, 1-15.
  11. Jungwirth, A.; Diemer, T.; Kopa, Z.; Krausz, C.; Minhas, S.; Tournaye, H. EAU Guidelines on male infertility. Eur. Urol. 2018, 7,226-41.
  12. WHO, WHO Laboratory Manual for the Examination and Processing of Human Semen, in 5th edn. 2010.
  13. http://www.who.int/reproductivehealth/publications/infertility/9789241547789/en/
  14. Schlegel PN, Sigman M, Collura B, et al. Diagnosis and treatment of infertility in men: AUA/ASRM Guideline Part I. J Urol. 2021;205(1):36-43.
  15. Practice Committee of the American Society for Reproductive Medicine in collaboration with the Society for Male Reproduction and Urology. The management of obstructive azoospermia: a committee opinion. Fertil Steril. 2019;111(5):873-880.

Polycystic Ovary Syndrome

Polycystic Ovary Syndrome (PCOS) is one of the most common causes of infertility in woman of reproductive age. The percentage of woman with a PCOS ranges from 5% to 20%, depending on diagnostic criteria, and at least 70% of women with PCOS are not diagnosed by their primary care physician.

Although PCOS has been studied extensively for years, many aspects regarding causes, diagnosis, symptoms, complications and effective treatment remain unknown. There is evidence that a diverse set of genetic and environmental factors play an important role in the development of this syndrome. Furthermore, women with PCOS have a hormonal imbalance and other metabolic problems that could adversely affect their health. While PCOS is a frequent cause of infertility, the good news is that it can be treated with specific medications.

 

Symptoms of PCOS

Symptoms associated with PCOS typically first surface during adolescence and then worsen over time. Common problems include high testosterone levels, irregular menstrual cycles (infrequent periods, light or little bleeding, or a heavy flow), chronic anovulation, and frequently infertility.

During adolescence, the most common clinical sign of high testosterone level is male-pattern facial hair. Sometimes this symptom might be associated with other symptoms, such as moderate-severe acne and a receding hairline. Importantly, obesity is a significant risk factor associated with PCOS and also implicated in infertility in general.

 

Diagnosis and therapy

A medical evaluation should be the first course of action for any woman showing signs/symptoms of PCOS. This will usually include a physical exam, discussion of family history and laboratory tests.

Ovarian and pelvic ultrasonography may also be used to assess each ovary’s volume and antral follicle count. In addition, hormonal testing is usually required to determine the extent of ovarian problems.

Nonetheless, it can be challenging to diagnose PCOS in young girls (especially in the two years after they get their first period), since PCOS symptoms may resemble normal puberty. The medical evaluation combined with lab results can assist a physician in determining the extent of the PCOS as well as the best treatment strategy.

There is no one right way to treat PCOS. Instead, medications must be tailored to each woman’s preferences, risk profile, and treatment goals. Medications that are sometimes used to treat PCOS include Metformin, a diabetes medication, and combined oral contraceptive pills. Other frequently prescribed therapies include spironolactone as well as topical treatments for excessive facial hair and acne. For women who are planning to conceive, oral ovulatory agents (clomiphene citrate or letrozole) are often used as well.

 

PCOS and infertility

Since it is frequently associated with anovulation and ovulatory dysfunction, PCOS is the most common cause of infertility among women. Women suffering from PCOS may also be at risk of increased complications during pregnancy. For these reasons, women trying to conceive should consider treatment with an oral ovulatory agent, such as clomiphene citrate or letrozole. Approximately 50% of ovulating patients on clomiphene will conceive after three to five treatment cycles. If the patient fails to either ovulate or conceive after six months of clomiphene or letrozole, other solutions can be considered, such as gonadotropin ovulation induction or laparoscopic ovarian drilling. Additionally, women who do not get pregnant with ovulation induction can choose to proceed to in vitro fertilization and embryo transfer.

 

Comorbidities

In some patients, PCOS could be associated with metabolic and cardiovascular disorders and with psychological issues that adversely affect a women’s quality of life. Possible PCOS complications include insulin resistance, hyperinsulinemia, obesity, increased risk of type 2 diabetes mellitus, metabolic syndrome, hypertension, cerebrovascular accidents, cardiovascular disease and deep vein thrombosis. Moreover, depression and anxiety are common in PCOS patients. Finally, subjects affected by PCOS may be at increased risk of endometrial and ovarian – but not breast – cancer.

 

Preventive measures

Since being overweight is considered a risk factor for PCOS, lifestyle interventions are considered essential for the prevention of this syndrome. Strategies to improve lifestyle include a healthy diet (also fertility diet) and physical exercise. Moreover, behavioural interventions might be helpful in managing psychological factors – anxiety, depression, body image concerns and disordered eating – which can negatively impact the quality of life. A good lifestyle is also important for improving fertility.

In conclusion, the early diagnosis of Polycystic Ovary Syndrome and the initiation of specific treatment are essential steps not only for women trying to conceive, but also for all patients with PCOS as it could adversely affect physical and mental health.

 

References

 

  1. Teede HJ, Misso ML, Costello MF, et al; International PCOS Network. Recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome. Fertil Steril. 2018;110(3):364-79.
  2. Vander Borght M, Wyns C. Fertility and infertility: Definition and epidemiology. Clin Biochem. 2018; 62:2-10.
  3. Deswal R, Narwal V, Dang A, Pundir CS. The Prevalence of Polycystic Ovary Syndrome: a brief systematic review. J Hum Reprod Sci. 2020;13(4):261-71.
  4. Azziz R, Carmina E, Chen Z, et al. Polycystic ovary syndrome. Nat Rev Dis Primers. 2016; 2:16057.
  5. Witchel SF, Oberfield SE, Peña AS. Polycystic Ovary Syndrome: pathophysiology, presentation, and treatment with emphasis on adolescent girls. J Endocr Soc. 2019;3(8):1545-73.
  6. Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertil Steril. 2004;81(1):19-25.
  7. Infertility Workup for the Women’s Health Specialist: ACOG Committee Opinion, Number 781. Obstet Gynecol. 2019;133(6): e377-84.
  8. McDonnell R, Hart RJ. Pregnancy-related outcomes for women with polycystic ovary syndrome. Womens Health (Lond). 2017;13(3):89-97.
  9. Tomlinson JA, Pinkney JH, Evans P, et al. Screening for diabetes and cardiometabolic disease in women with polycystic ovary syndrome. The British Journal of Diabetes & Vascular Disease, 2013; 13(3), 115-23.
  10. Kshetrimayum C, Sharma A, Mishra VV, Kumar S. Polycystic ovarian syndrome: Environmental/occupational, lifestyle factors; an overview. J Turk Ger Gynecol Assoc. 2019;20(4):255-63.
  11. Ramezani Tehrani F, Amiri M. Polycystic Ovary Syndrome in Adolescents: Challenges in Diagnosis and Treatment. Int J Endocrinol Metab. 2019;17(3):e91554.
  12. Infertility Workup for the Women’s Health Specialist: ACOG Committee Opinion, Number 781. Obstet Gynecol. 2019;133(6):e377-84.
  13. Çelik Ö, Köse MF. An overview of polycystic ovary syndrome in aging women. J Turk Ger Gynecol Assoc. 2021;22(4):326-33.
  14. Al Khalifah RA, Florez ID, Zoratti MJ, Dennis B, Thabane L, Bassilious E. Efficacy of Treatments for Polycystic Ovarian Syndrome Management in Adolescents. J Endocr Soc. 2020;5(1): bvaa155.
  15. Aversa A, La Vignera S, Rago R, et al. Fundamental concepts and novel aspects of Polycystic Ovarian Syndrome: Expert Consensus Resolutions. Front Endocrinol (Lausanne). 2020; 11:516.