Description

• Infertility is the inability of a sexually active, non- contracepting couple to achieve spontaneous pregnancy in one year
• An estimated 15% of couples meet this criterion and are considered infertile, with approximately 35% due to female factors alone, 30% due to male factors alone, 20% due to a combination of female and malefactors, and 15% unexplained

Types

• Depends on the underlying condition 
• Diabetes may cause autonomic neuropathy, neurogenic impotence, and retrograde ejaculation
• Obesity alters hormonal metabolism, leading to increased peripheral conversion of testosterone to oestrogen and decreased luteinizing hormone (LH) pulse amplitude, and has been linked with reduced sperm concentration 
• Patients with sickle cell disease or thalassemia may have infertility due to haemosiderosis from multiple blood transfusions
• Almost all males with cystic fibrosis have a congenital bilateral absence of the vas deferens 
• Chronic kidney disease leads to hypogonadism and feminization
• Liver disease may result in decreased male secondary sexual characteristics, testicular atrophy, and gynecomastia due to increased oestrogen levels
• Haemochromatosis leads to hypogonadism and signs of androgen deficiency without gynaecomastia and is associated with decreased estradiol levels
• Postpubertal mumps may lead to testicular atrophy
• Sexually transmitted diseases and tuberculosis can cause obstruction of the vas deferens or epididymis
• Prostatitis, orchitis, seminal vesiculitis, and urethritis may lead to obstructive azoospermia
• Anesthesia, surgery, starvation, myocardial infarction, hepatic coma, head injury, stroke, respiratory failure, congestive heart failure, sepsis, and burns are associated with a suppression of gonadotropin release, possibly through an increase in dopamine and opiate levels
• Chronic medical illnesses may directly suppress sex hormone production and sperm production, leading to end-organ failure

Investigation

• Medical history – General & Sexual history
• Physical examination – Thorough Examination of Body habitus, Penis, scrotum, Testes, Epididymis
• Semen Analysis 
• Hormone Assay - GNRH, Testosterone, Free Testosterone, FSH, LH, Prolactin, 17 OH progesterone, Thyroid Hormones 
• Scrotal Doppler ultrasound – To detect Varicocele, Spermatocele, Epididymal lesions
• Transrectal Ultrasound (TRUS) – Provides clear images of Seminal vesicles, Vas deferens, Prostate, ejaculatory ducts
• MRI
• CT
• Venography – to diagnose varicocele
• Anti sperm antibodies 
• Karyotype ( genetic testing)
• Testicular biopsy - In cryptorchidism, Testicular histology typically reveals a decreased number of Leydig cells and decreased spermatogenesis

Treatments

The following causes of infertility, if identified, can often be treated by medical means: 

• Endocrinopathies 
• Antisperm antibodies 
• Retrograde ejaculation 
• Poor semen quality or number 
• Lifestyle issues 
• Infections 

Surgical interventions to be considered include: 

• Varicocelectomy 
• Vasovasostomy or vasoepididymostomy 
• Transurethral resection of the ejaculatory ducts 
• Sperm retrieval techniques 
• Electro ejaculation 
• Artificial insemination 
• Assisted reproduction techniques 
• In vitro fertilization 
• Gamete intra fallopian transfer (GIFT) and zygote intra fallopian transfer (ZIFT) 
• Intra cytoplasmic sperm injection 

Department

Male Infertility