How to Have a Baby: Overcoming Infertilityby Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD.
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 ?
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.
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.
Men with an absent vas deferens (the tube which carries the sperm from the epididymis to the urethra ) 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 deferens is absent from birth, this being a congenital defect, but one which is diagnosed only when they are trying to conceive.
This diagnosis can be suspected by analysing the semen analysis report carefully. It is easy to confirm this with a clinical examination. This needs to be done by a careful clinician, and shows that the man has normal testes; the epididymis is often full and turgid ( because it is full of sperm); and the vas (which normally feels like a hard cord like structure above the epididymis) cannot be felt at all. Unfortunately, this diagnosis is often missed, and these patients are subjected to an unnecessary testis biopsy !
For more than half of all men with this condition , the problem is genetic and they have mutations in the CFTR gene. Mutations in this gene also cause cystic fibrosis.
You can have genetic tests done to see if you have a mutation of the CFTR gene ; and if both you and your wife have the mutation, you may need genetic screening of your embryos to ensure they do not have cystic fibrosis.
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 nearly all of them to father a pregnancy with their own sperm.
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.
Immunity problems with sperm
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.
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.
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.