Infertility is a condition that is often attributed to women, but the truth is not exactly what is thought. Studies have shown that in 30% of infertile couples, the male is the cause. 1 Like female-induced infertility, male-induced infertility has an extremely complex nature. Infertility can occur in men for many different reasons.
In order to better understand the occurrence of male-induced infertility, it is important to have basic information about how the pregnancy occurs.
In order for fertilization to occur, couples need to have unprotected sexual intercourse during the process of ovulation of women. Egg quality is extremely important, as is the progression of released eggs to the fallopian tubes. However, in order for the egg and sperm to meet and for the sperm to enter into the egg cell, the sperm cells must also meet various conditions.
In its simplest form, these requirements, which can be summed up as sperm quality, can be listed as ideal sperm count, the suitability of sperm morphology (sperm shape) and the presence of a forward mobility. Let's look at the journey from the production of sperm cells and their journey into the egg.
Unlike women, who are born with their egg reserves, men can produce sperm, which can vary in quality depending on the lifespan, age, and various factors. Sperm production, which is repeated approximately every 74 days, is called spermatogenesis. In order for sperm production to continue, the testes must have a temperature of 34°C.2 Sperm production is controlled by hormones. Testosterone, known as the male hormone, is one of the main hormones involved in sperm production.
The sperm produced in the testes is stored in the anatomical part called the epididymis. During sexual intercourse, just before ejaculation, sperms transfered to the main sperm transmission channel called vas deferans, merge with other fluids released from the prostate and seminal vesicles and form semen. During ejaculation, semen is excreted out of the body through the penis.3
Any disruption in the production of sperm, their combination with other fluids in the male reproductive system to form semen and/or the expulsion of semen out of the body, can be the cause of male-induced infertility. These causes may also include erectile dysfunction, the incidence of which is extremely high in men.4
There are many different reasons behind male-induced infertility. Different factors such as previous diseases, "undescended testes" (which is too late to treat), lack of sperm transmission channels, acquired varicocele disease, sexual dysfunctions that can make sexual intercourse physically impossible and testosterone deficiency are among the causes of male-induced infertility.
The main problem caused by all these risk factors is sperm disorders. The number, shape and motility of the sperms not being in ideal conditions for pregnancy or failure to produce sperm cells or failure for the sperm cells to meet with the egg cells are the main causes of male infertility.
Sperm disorders are one of the common causes of male-induced infertility. Immaturity of sperm cells, abnormally shaped sperms, sperm motility disorders or low sperm count can be shown as examples of sperm disorders.
Sperm disorders can occur as a result of many different causes;
In addition to all this, it is known that both environmental and lifestyle-related factors such as exposure to heavy metals and chemicals, occupations that increase testicular temperature, excessive weight, excessive exercise, stress, alcohol and smoking can lead to sperm disorders.5
Low sperm count is a condition in which there are fewer than normal sperms in the semen. This sperm disorder, called oligospermia, occurs when there are less than 15 million sperm in 1 milliliter of semen.
Sperm motility is one of the important criteria that allows sperm to reach the egg. When sperm motility is not sufficient, sperms cannot meet the egg by moving through the female reproductive tract. Sperms need to move forward at a speed of at least 25 micrometers per second in a straight line or in wide circles to fertilize the egg.6
Spermatozoa consist of 3 basic parts: head, neck and tail. Problems with the size and shape of sperm can hinder its ability to fertilize. Not all sperm cells are expected to be the ideal size and shape. According to the Kruger criteria applied within the scope of sperm analysis to indicate the presence of sperm deformities, if the percentage of normal shaped sperm is between 4% and 14%, it would be considered a risk factor, while if this rate is between 0% and 4%, a clear risk of infertility is considered evident.
Apart from the problems of sperm quality criteria, it is also possible for men to have other problems such as no sperm production or that the sperms produced not being able to mix with the other fluids in the semen and failure to be discharged. This condition brings up azoospermia, also called “zero sperm”.
As a result of two different spermiogram tests performed in at least two different time periods, if no live or inanimate mature sperm cells are found in the semen, this condition is called azoospermia.7 Azoospermia is observed in 10% of men diagnosed with infertility. In order for there to be no sperm in a man's semen, we can either talk about faulty sperm production or the failure of the produced sperm to meet with the semen. These two different conditions bring up different types of azoospermia.
Obstructive azoospermia: Azoospermia due to blockage occurs when sperm production occurs, but the sperm and other fluids that make up the semen do not merge, or the semen cannot be excreted out of the body. Blockages in the male reproductive system can be caused by congenital duct deficiencies and retrograde ejaculation. Congenital or acquired obstructive azoospermia can be treated surgically, as well as other sperm harvesting techniques can be used for assisted reproductive treatments.8
Non-obstructive azoospermia: In the event of no sperm production in the testes, non-obstructive azoospermia can be considered. In this group of patients, the testes may not be able to produce any sperm cells or mature sperm cells. This could be due to a number of reasons such as the absence of testes, the history of undescended testes, hereditary diseases and hormonal problems.9 Depending on the cause, it could be possible to treat with hormone therapy. The most advanced surgical method for the treatment of non-obstructive azoospermia is MICROTESE. MicroTESE is based on the harvesting of tissue from the tubules with the possibility of finding spermatozoa in the testicles. The probability of finding spermatozoa in patients with sufficient testosterone levels is about 50%-65%. 10
The first step in the diagnosis of male-induced infertility is to obtain information about the patient's overall health and conduct a comprehensive physical examination. After the completion of the physical examination, a semen analysis called a spermiogram is performed.
This is the test that allows the evaluation of the number of sperms, their motility, shape, in short, their ability to fertilize the egg cell. Since sperm values may vary, it is recommended to repeat the spermiogram test twice in different time periods. Before the semen analysis, patients may need to practice sexual abstinence for 2-3 days, and if they are regularly taking medications, they may need to take a break from these medications by consulting with their physicians.
With semen analysis, information is obtained about sperm count, motility, shape, semen volume, chemical structure of semen, liquefaction time of semen and fructose level in it. According to the results obtained, additional tests such as sperm antibodies, sperm penetration test (SPA), Hemizona test may also need to be performed. 11
Semen analysis is an important guide in the process of diagnosing male-induced infertility. Detailed examinations can be applied in accordance with the results obtained: 12
When the cause of male infertility is determined, treatment is planned in accordance with the cause. In this context, treatment methods such as hormone treatments, surgical correction of obstructions, varicocele surgery and closure of varicose veins in the scrotum and opening up the functional ones, can be considered as treatment methods.
In the treatment of male infertility, couple-specific planning should be considered and the overall health and expectations of the couples should also be evaluated. Today, effective alternatives to infertility treatments can be offered thanks to the developing assisted reproductive techniques.
Intrauterine insemination and IVF treatments can ensure highly successful results in selected couples, and the variety of sperm collection techniques can eliminate the need for the surgical interventions for men. As always, comprehensive treatment planning is of decisive importance.
1 https://www.ncbi.nlm.nih.gov/books/NBK562258/
2 https://www.merckmanuals.com/professional/gynecology-and-obstetrics/infertility/sperm-disorders?query=male%20infertility
3 https://www.webmd.com/men/features/male-infertility-treatments
4 https://www.urologyhealth.org/urology-a-z/m/male-infertility
5 https://www.mayoclinic.org/diseases-conditions/low-sperm-count/symptoms-causes/syc-20374585
6 https://www.medicalnewstoday.com/articles/320160#causes-of-low-motility
7 https://www.hopkinsmedicine.org/health/conditions-and-diseases/azoospermia
8 https://www.fertstert.org/article/S0015-0282(08)03512-7/fulltext#relatedArticles
9 https://www.healthline.com/health/infertility/azoospermia#symptoms
10 https://healthcare.utah.edu/fertility/conditions/sperm-production-azoospermia.php
11 https://www.webmd.com/men/features/male-infertility-treatments
12 https://www.mayoclinic.org/diseases-conditions/male-infertility/diagnosis-treatment/drc-20374780
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