All About Fertility

Sterility and Infertility - "Infertility in Men"

Male fertility is less complicated than fertility in women, due to the fact that the man is responsible for fewer stages in the reproductive process. Essentially, male fertility depends to a large extent on:

  • The condition of the spermatozoa
  • The number of spermatozoa
  • Morphology and motility.

Did you know that…?

"Andrology" is the equivalent for men of what "Gynaecology" means for women. As part of our assisted reproduction laboratories, at Ginefiv we have the most advanced techniques for diagnosing andrological problems.

sterility

What are the most common causes of male infertility?

  • Inadequate sperm production: ninety percent of male fertility problems are caused by an inability to produce spermatozoa in sufficient quantities. This is called Azoospermia when there is no production of spermatozoa, whereas it is diagnosed as oligospermia when production of spermatozoa takes place, but production levels are very low.
    It must be taken into account that a low sperm count does not necessarily mean that a man is infertile. If the spermatozoa produced are healthy, well formed and motile, pregnancy may still be achieved, as only one of these is needed to fertilise the woman’s egg.
    In the most extreme scenario, a total absence of spermatozoa in the ejaculate (azoospermia), this may be due to a blockage of the epididymis or of the vas deferens, or to a problem with producing sperm in the testicles. This may be overcome by microsurgery through the surgical extraction of spermatozoa directly from the testicles, by a procedure known as TESA, and the spermatozoa can subsequently be used for the artificial fertilisation of ova in the IVF laboratory using a technique called ICSI (or sperm microinjection).
  • Varicocele: a varicose vein around one of the two spermatic cords can cause an accumulation of blood in the testicles, which in turn causes the temperature of this area to rise. The increased temperature causes a decrease in sperm production and can lead to a reduction in fertility.
  • Infections: it is common for males experiencing fertility problems to display some sign of infection of their reproductive organs. The presence of antisperm antibodies, which attack and destroy spermatozoa, is generally a good indicator of infection. Of these infections, Chlamydia trachomatis is the most common and the most serious. These diseases are transmitted sexually and can damage the epididymis and the ductus deferens in men. These infections are usually treated with antibiotics.
  • Duct obstruction: this consists of a blockage in or damage to the sperm ducts and is normally caused by sexually transmitted diseases, infections, or a congenital abnormality.
  • Ejaculatory dysfunction: these disorders are characterised by the inability of the man to achieve ejaculation in the vagina during sexual intercourse. Impotence, or the inability to maintain an erection during sex, can be caused by a diet which is high in fat (leading to fatty deposits which obstruct the arteries in the penis), by medication used in the treatment of high blood pressure, and by neurological damage resulting from diabetes.
  • Other disorders: other conditions which can cause male infertility include abnormal development of or damage to the testicles (caused by endocrine disorders or inflammation), disorders of the accessory glands, sexual disorders, exposure to diethylstilbestrol (DES), a synthetic oestrogen which was used in the 1950s and 1960s and which caused cysts in the male reproductive tract, and undescended testicles.

Semen Analysis

  • A. Routine diagnostic tests
    • Seminogram: the seminogram test, also known as the spermiogram, aims to evaluate parameters for semen which is obtained through masturbation. These parameters are established on two levels, macroscopic and microscopic. The macroscopic parameters are: appearance, liquefaction, viscosity, Ph, volume and colour. The microscopic parameters are: concentration and total number of spermatozoa, motility and vitality of sperm, sperm morphology and any presence of agglutination (antisperm antibodies).
      In 1980, the World Health Organisation (WHO) produced a manual for carrying out analyses on semen, establishing the guidelines for these and dictating the criteria for what is normal. This guide was revised in 1999 and updated in 2002 by the European Society of Human Reproduction and Embryology (ESHRE). These values are summarised in the following table:
      It is important to emphasise the fact that these do not imply that couples who do not meet the criteria cannot get pregnant. It only means that the chances of conceiving are reduced.
    • Survival test: the test of sperm survival or capacitation evaluates, in addition to the parameters already mentioned in the seminogram, the survival of sperm and the movement of spermatozoa after they have been capacitated. Additionally the presence or absence of bacterial contamination in the capacitated sample is evaluated.
      What is sperm capacitation?
      Sperm capacitation is defined as the physiological changes which spermatozoa undergo in order to acquire the ability to fertilise an ovum. Spermatozoa achieve this capacity for fertilisation in the female reproductive system, when they pass through the cervical mucus. Sperm capacitation can also be achieved artificially in a laboratory via two different techniques: the swim-up technique and the density gradient method. These techniques are used to separate spermatozoa from the seminal liquid, obtaining those with the best motility and morphology. The result of capacitation using these methods is known as TMSC (the Total Motile Sperm Count) and the unit of measurement for this is the number of spermatozoa with rectilinear motility per millilitre of ejaculate.
  • B. Advanced diagnostic tests
    • The Fragmentation test: this is a test which analyses breaks or lesions in the genetic material of the spermatozoa. The greater the level of fragmentation, the worse the prognosis will be for getting pregnant. The main reason why this treatment is recommended is because the DNA in the spermatozoa normally fragments after leaving the testicles as it passes through the epididymis, which is where spermatozoa are stored before being ejaculated. This test would be recommended in the following cases:
      • Low fertility rate, low quality embryos, repeatedly failing to become pregnant, repeatedly miscarrying.
      • Varicocele.
      • Genitourinary infections.
      • People over 45, smoking, exposure to environmental toxins.
      • Smokers and people exposed to environmental toxins.
      • Exposure to high temperatures (fever).
    • When the sperm DNA fragmentation test indicates a disorder, the use of spermatozoa from the testicles rather than from the ejaculate is recommended for IVF. This involves carrying out a technique called TESE or TESA which consists of a small aspiration directly from the testicle.
    • The FISH test on spermatozoa: any somatic cell (non-reproductive cell) in the human body has 23 pairs of chromosomes, in other words, 2 copies of each chromosome. On the other hand, in order for human gametes (spermatozoa and ova) to be normal in terms of their chromosome content they must have 23 chromosomes, that is to say a single copy of each chromosome. Using FISH (fluorescence in situ hybridisation) on spermatozoa enables the number of chromosomes contained in the spermatozoa in a semen sample to be studied, indicating whether or not they present the correct chromosome set, and assessing the risk of transmitting anomalies to offspring. Its main disadvantage is that in cases of severe Oligoasthenozoospermia it is difficult to perform due to the low sperm concentration. This test would be recommended in the following cases:
      • Failure of implantation.
      • Repeated miscarriages.
      • Previous pregnancy with a chromosomal disorder.
      • Patients who have undergone chemotherapy or radiotherapy.
      • Patients suffering from severe Oligozoospermia or Teratozoospermia.
    • The Meiosis test: meiosis is the process by which spermatozoa mother cells (or spermatogonia) reduce their chromosome count by half; in other words, they pass from having 46 to 23 chromosomes, which are those that form each spermatozoon. A problem in this process leads to a greater or lesser number of chromosomes than normal, which can give rise to embryos with anomalies which may not be capable of becoming implanted, or lead to a miscarriage in the first trimester, or to the birth of a child with some sort of irregularity. The disadvantage of this test is that it is performed on spermatozoa obtained from a testicular biopsy.
    • Y chromosome Deletions: evidence exists that spermatogenesis is controlled by certain genes which are located in the euchromatic region of the long arm of the Y chromosome. Microdeletions from these regions, which are divided into three non-overlapping loci, such as AZFa, AZFb, AZFc, are related to severe azoospermia and oligozoospermia. Due to its cost, the limitations of the technique, and the fact that the frequency of microdeletions in infertile males is estimated at around 7%, the usefulness of the test is debatable as a method of diagnosis for IVF patients. In addition, the information provided does not enable us to alter how it behaves; it only helps to explain the cause of azoospermia or cryptozoospermia.
    • Microbiological tests: when there is reason to suspect an infection of the seminal tract or of the urinary tract, a semen culture test can confirm the infection, identify the germ responsible, and indicate the treatment to be followed. In any case this examination should be routine, as subclinical infections are frequently found which are caused by mycoplasmas and by Chlamydia, as well as by non-specific bacteria, the involvement of which in fertility is arguable. These bacteria are often found stuck to the membranes of the heads and mid-pieces of spermatozoa, where they may affect sperm motility, or the integrity of the genetic material in the head of the spermatozoon.
    • Antisperm antibodies (ASA): this is an uncommon phenomenon (found in just 4% of males in sterile couples) and it is directly related to sterility, although there is no evidence that treating the condition improves fertility. Secretory IgA antibodies combine with cervical mucus, meaning that the presence of IgA on spermatozoa causes a reduction in their ability to penetrate the cervical mucus. The methods for studying ASA in the seminogram are the MAR Test and the Immunobead test (IBT).

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