from the book How to Have a Baby: Overcoming
Infertility
by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani,
MD.
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Diagnosis and Treatment for Male Infertility -- More
Confusion! (Page 1)
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Table of Contents
What
is obstructive azoospermia ?
What
surgery can be done to treat obstructive azoospermia
?
What
about men with an absent vas ( CBAVD, congenital bilateral
absence of the vas deferens) ?
What
can a man who has had a vasectomy do if he wants more
children ?
Do
sperm antibodies cause male infertility ?
Can
hormone imbalance cause male infertility ?
How
does substance abuse affect male fertility ?
What is obstructive azoospermia
?
If the passage (reproductive tract) between the penis
and testes is blocked there will be no sperm in the
semen - azoospermia. If the reason for the azoospermia
is a duct blockage, this is called obstructive azoospermia.
Blockages can be caused by infection (gonorrhea, chlamydia,
filarisias, or TB); or by surgery done to repair hernias
or hydroceles.
What
surgery can be done to treat obstructive azoospermia
?
If the passage is blocked, surgical
repair can be attempted by performing a long and complicated
2 to 3 hour micro surgery called a vasoepididymal anastomosis
(VEA) . This is highly specialised surgery which is
best done by an experienced microsurgeon, since the
tubes involved are so fine and delicate.
This is technically difficult and intricate
surgery because it needs to be done under high magnification
. The surgeon tries to bypass the block, so that the
sperm can reach the penis .
Surgical results can be poor for the
following reasons:
- Technical difficulty, because of
the minute size of the tubes; Often patency cannot
be restored, and the sperm count remains zero. The
anatomic patency rate is about 50 % for most patients
(which means that sperm can be found in the semen
after surgery).
- These sperm are often poor in quality
and are successful in giving rise to a pregnancy in
only about 25% of patients, as the sperm that make
their may out may not be mature or motile since they
have not spent enough time in the epididymis, which
functions to mature the sperms in the body.
- Secondary damage to the epididymis
and duct system may have occurred because they have
been subjected to high pressure for a long time, causing
multiple leaks and blocks, making surgery less successful.
- Damage to the functional lining of
the epididymis, either as a result of the infection
which caused the block or as a result of the high
pressure, so that it no longer works effectively and
sperms cannot mature here properly.
The best chance of success is with the
first surgical attempt - repeat surgery has a dismal
success rate and is rarely worthwhile.
One of the uncommon causes of obstructive
azoospermia is an ejaculatory duct obstruction. These
men have low semen volume, no fructose in the semen;
and an acidic semen, because their seminal vesicles
are blocked. Sometimes, this is because of an ejaculatory
duct cyst, which can be diagnosed by TRUS ( transrectal
ultrasound). This can sometimes by treated by a TURED
( transurethral resection of the ejaculatory duct) procedure,
which is performed by passing an endoscope into the
urinary bladder, but the results of surgical repair
are often very poor.
What
about men with an absent vas ( CBAVD, congenital bilateral
absence of the vas deferens) ?
Men with an absent vas deferens have azoospermia, with
a low volume ejaculate; acidic pH; and no fructose in
the semen. This is because their seminal vesicles are
also absent. The vas vas deferens is absent from
birth, this being a congenital defect, but one which
is diagnosed only when they are trying to conceive.
Conventional treatment in the past consisted of creating
a pouch surgically, into which the epididymis was made
to open. This was called a spermatocele and sperms were
aspirated from this and used for artificial insemination.
However, pregnancy rates were very poor. The technique
of PESA with ICSI has revolutionised
our approach to these men, and allows many of them to
father a pregnancy.
What
can a man who has had a vasectomy do if he wants more
children ?
Men often have this operation to render them sterile
once they have completed their family. This is safe,
easy surgery which involves cutting the vas deferens
(the sperm carrying tube) and sewing it shut , so that
sperm passage is blocked . These sperms are absorbed
into the body so that although ejaculation is normal,
there are no sperms in the semen.
If the man changes his mind after a
vasectomy, and wants to father another child, microsurgery
can rejoin the cut ends so that the sperm can once more
pass through into the semen. This reversal surgery is
called vasovasostomy or VVA (vasovasal anastomosis)
. It is expensive and only a few doctors are adequately
trained to perform the operation - and even then success
is not guaranteed. The best results are when the reversal
process is performed within 5 years after the vasectomy,
before antibodies are developed to the sperm . Good
surgeons have reported pregnancy rates of as high as
80% using meticulous microsurgical technique.
Do sperm antibodies
cause male infertility ?
If varicoceles are controversial, immune sperm problems
are even more so. However, while the controversy surrounding
varicoceles is now quite old, the immune problem is
a relatively newer area, which means we have even more
questions about this, and even fewer answers !
In one of Nature's quirks , men can
develop antibodies to their own sperm; or the wife can
develop these against the husband's sperm . What happens
is that the body's defense mechanisms destroys its own
sperm ; or the wife's hostile cervical mucus does so,
as though the sperm were enemy bacteria or virus. This
can happen after problems of inflammation, injury to
the testes, surgery, infection, or blockage.
Problems start with making a diagnosis.
Antisperm antibodies are suspected when the sperms clump
to one another (agglutinate) on a sperm test. A poor
postcoital test, which shows all immotile sperms in
the mucus is also a tip-off, because one of the reasons
for this is cervical mucus hostility because of antibodies.
There are many tests available to detect
sperm antibodies. Blood tests for antipserm antibodies
can be done for both the wife and husband using ELISA
methods. This is an easy test to do but interpreting
it is hard - what does a positive test mean? Could it
be responsible for infertility? Most doctors don' t
think so, because they argue that the presence of these
antibodies in the blood is of little clinical importance
- but the debate goes on ! These older tests are now
considered to be obsolete. The newer antibody tests
which are more reliable, are done on the sperm itself,
using immunobead testing, and these can tell the doctor
whether the antibodies are on the sperm head or tail.
However, interpreting the significance of a positive
result remains a vexed issue!
Treatment is equally confusing - and
included testosterone injections in the past in order
to suppress sperm production - the rationale being that
if there are no sperm there will be no further formation
of the battling antibodies ! Corticosteroids have also
been used successfully to stop a person from making
antibodies, but these drugs can have significant side
effects , as a result of which they are not considered
standard therapy today.
Today, washing the sperm in the lab
to clean away the seminal fluid which contains the antibodies
, along with timed intrauterine insemination ( IUI)
, is the first-line treatment. For other patients, where
the antibodies are tightly bound to the sperm head,
IVF or ICSI may be needed.
Can hormone imbalance
cause male infertility ?
Unlike the woman, hormone imbalances in the man are
not a common cause of fertility problems . These problems
can stem from organs as far apart as the brain or the
testicles, and can show up in blood tests. They can
arise because of:
- Head injury
- A tumour in the pituitary gland at
the base of your brain
- A tumor in the adrenal gland, above
the kidneys.
- Malfunctioning of the pituitary gland
- Cirrhosis of the liver
- Conditions present from birth, such
as and Klinefelter's syndrome (47, XXY syndrome)
- A thyroid problem
One problem is that of hyperprolactinaemia
(a high prolactin level). This is usually caused by
a pituitary malfunction or tumour; and can be detected
by a blood test. Patients with hyperprolactinemia often
also have decreased libido and may be impotent. Treatment
with bromocryptine to suppress the high prolactin levels
is highly successful in achieving pregnancy.
Another problem is that of hypogonadotropic
hypogonadism (poor function of the testes because of
inadequate stimulation of the testes by the gonadotropic
hormones, FSH and LH produced by the pituitary). Most
hypogonadotropic patients are hypogonadal - that is,
they have low levels of the male hormone, testosterone.
This means they have poorly developed secondary sexual
characters ; an effeminate appearance; scanty hair;
decreased libido , and small flabby testes. This can
be confirmed by blood tests which show low levels of
FSH and LH. This can be treated by replacement therapy
with the gonadotropin hormones - HCG and HMG. These
are expensive injections and a fairly long course of
treatment is needed for them to work , but they are
effective in enhancing sperm production in these men.
How does substance
abuse affect male fertility ?
As Shakespeare said "Alcohol increases the desire
but takes away the performance." Not only are alcoholics
unable to perform, but their liver function also deteriorates
, resulting in excessive levels of the female hormone,
estrogen , which has a severe sperm suppressing effect.
Drugs of abuse can also create malformed
sperm with poor motility ; they also alter hormonal
balance and testicular function ; and cause impotence
and erection problems.
Tobacco is a potent toxin. It attacks
the tail of the sperm so that it is unable to swim to
its goal. The testicular artery can go into spasm because
it is choked with nicotine. Prolactin levels in smokers
tend to be higher so sexual desire disappears in smoke.
continued
. . .
Next page: Diagnosis
and Treatment for Male Infertility -- More Confusion!
(Page 3)
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