Fatherhood has always been important in Indian society, but male infertility is surprisingly common . 1 in 6 couples is infertile , and in 50% of these, the problem is with the man . To put this in perspective, remember when you are watching the Indian cricket team playing the next time , that at least one of the men on the field is likely to have a fertility problem , whether they know it or not!

Most young men are obsessed with their virility, but few worry about their fertility. Most Indian men still believe that making babies is a woman’s job, and expect that if they can have sex, they can also get their wives pregnant. However, this is simply not true ! While it is true that you need to be able to perform sexually in order to get your wife ( or girl friend) pregnant, this is not enough ! You also need to have enough active sperm in your semen to be able to fertilise her eggs, and there is no relationship between your sperm count and anything else - your sexuality, virility , your performance in the bed, or the size of your penis. What this effectively means is that you can never be sure of your fertility – until you have actually got your wife pregnant !

Some men may suspect they have a fertility problem. Thus , men who have low levels of testosterone (poorly developed secondary sexual characters ; an effeminate appearance; scanty hair; decreased libido) may have a fertility problem; as may men whose testes are small or absent. Men who have had testicular inflammation ( a swollen and painful swelling of the testis called orchitis) after an attack of mumps; and those whose testis have been injured are also at risk for infertility. Children who have had hernia surgery in childhood are also at risk; as are young men who have chemotherapy for treating leukemia and lymphoma. Men who have erectile dysfunction may also need infertility treatment; as may those with diseases such as diabetes, which cause them to have problems with ejaculating semen properly.

Isn’t there a test for measuring male fertility ? The basic test is a semen analysis, which allows the doctor to measure the number of sperm ( sperm count) you have, how active they are ( motility) and whether they look normal ( morphology). However, while it is true that a man with no sperm ( a condition called azoospermia) cannot get his wife pregnant, many men ( and even many doctors ) still do not appreciate the limitations of the semen analysis. After all, the sperm count is not like a bank account, and the key question is not – What is the sperm count, or motility ? They key question is – are the sperm capable of working ? are they capable of fertilizing the egg ? And there really is still no test which can answer this reliably for the individual man. While it is true that men with a low sperm count have lower fertility, there are also men with an absolutely perfect sperm count who cannot get their wives pregnant, because their sperm do not work properly – in effect, they are shooting “blanks”.

What if the sperm count is zero ? This is called azoospermia, and requires evaluation by a specialist, so that the doctor can determine if the problem is a result of the failure of the testes to produce sperm properly; or if the passageway is blocked or absent.

Men with a low sperm count present the most frustrating problem in reproductive medicine today. This condition is called oligoasthenospermia ( low sperm count with weak sperm) and in the vast majority of cases, we simply cannot determine what the reason for the low sperm count is. This is labeled as being idiopathic , which is just a Latin term to disguise our ignorance ( or as my patient poetically phrased it, means that the doctor is an idiot and the condition of the man is pathetic !) In many cases, we are now learning that the reason for the low sperm count is genetic, and is due to a microdeletion on the Y-chromosome. These men typically have a very low sperm count, because some of the genes on their Y-chromosome which code for sperm production are absent. Since we cannot determine the reason for the low sperm count in many men, it is hardly surprising that we have very little effective therapy to offer them. This is the reason why there are hundreds of medicines to treat men with low sperm counts – because none of them work ! We do know that a low sperm count is not related to physique, general state of health, diet, sexual appetite or frequency. While not knowing the cause can be very frustrating, medicine still has a lot to study and understand about male infertility, which is a relatively neglected field today.

The good news is that modern assisted reproductive technology can help practically every man to have a baby with his own sperm, using an advanced technique called ICSI ( intracytoplasmic sperm injection), in which the doctor injects a single sperm into each egg to fertilise it. However, because this is so expensive, many men end up wasting a lot of time and money on ineffective treatment options in a futile attempt to improve their fertility.

The diagnosis of a low sperm count can be a major blow to a man’s ego --- it is so totally unexpected, because it is not associated with other symptoms or signs. Men react differently - but common feelings include anger with the wife and the doctor; resentfulness about having to participate in infertility testing and treatment since they feel having babies is the woman's "job"; loss of self-esteem; and temporary sexual dysfunction such as loss of desire and poor erections. Many men also feel very guilty that because of "their" medical problem, they are depriving their wife the pleasures of experiencing motherhood. Unfortunately, social support for the infertile man is practically non-existent, and he is forced to put up a brave front and show that he doesn't care. Since he is a man, he is not allowed to display his emotions. He is expected to provide a shoulder for his wife to cry on - but he needs to learn to cry alone. However, remember that the urge for fatherhood can be biologically as strong as the urge for motherhood - and we should stop treating infertile men as second class citizens.

The Reproductive System of a Man – A guided tour

Even though a man’s reproductive system hangs out in the open, most men are so obsessed with their penis, that they know surprisingly little about their own reproductive organs. The male reproductive system begins in the scrotum, the sack behind the penis. This contains two testicles, which make men's sex cells, called sperm; and the male sex hormone, called testosterone. The testicles feel solid, but a little spongy, like hard boiled eggs without the shell. They hang from a cord called the spermatic cord. It's normal for one testicle to hang lower than the other; and for one testicle to feel slightly larger than the other. The testicles make sperm best at a temperature a few degrees cooler than normal body temperature. This is why nature designed a scrotum - so that the testes can hang outside the body to keep them cool.

The testicles start making sperm when a young man reaches puberty. This is in response to the male sex hormone, testosterone , which starts being produced at this time. The testes keep making sperm for the rest of the man's life. Most of the testis is composed of the tightly coiled microscopic seminiferous tubule, which if uncoiled would reach a length of 70 cm. The sperms are produced inside the seminiferous tubule, from where they are carried to the outside through the male reproductive passage, which consists of the epididymis , a finely coiled tubule, which leads to the vas deferens , - a thin cord like muscular tube, which is part of the spermatic cord and which ends at the ejaculatory duct in the prostate. Here is joined by the seminal vesicle ducts and they all open into the urethra . During ejaculation, the epididymis and vas deferens muscles contract to propel the sperm into the ejaculatory duct. Here the sperm is joined with the secretions of the seminal vesicles and prostate gland (which contribute the bulk of the seminal fluid) to form the semen. The powerful muscles surrounding the base of the urethra then cause the semen to squirt out of the penis at the time of orgasm.

Mature sperm take about 75 days to develop in a process called spermatogenesis which takes place in the seminiferous tubules. This can be a very "temperamental" assembly line - things often go wrong, causing low sperm counts. When the sperm leave the testis, they are not yet able to swim on their own. They acquire the capacity to do so in their passage through the epididymis - which is like a swimming school for the sperm.

During ejaculation, about one teaspoon of semen spurts out of the penis. Semen is a milky white color, the consistency of egg white. Sperm account for only about 2 to 3% of semen. Most of it consists of seminal fluid - the secretion of the seminal vesicles and the prostate gland, which provide a vehicle for the sperm into the vagina.

A normal ejaculation contains 200 to 500 million sperm. Sperms are the smallest living cells in the human body , while their female counterpart , the egg , is the largest. Basically, sperms are designed so that they can deliver their contents - the male genetic material - to the egg. This is why they are designed like projectiles - the male DNA is in the chromosomes in the sperm head nucleus, and the tail propels the sperm up towards the egg.

What happens to the sperms if you don't have sex for many days? Unfortunately, you cannot "store up" sperms. If ejaculation does not occur for many days, the sperms in the reproductive ducts simply die. But just like you cannot store your sperm, you cannot run out of sperm either - masturbation and sex cannot use sperm up. The body keeps making sperm as long as a man has even one normal testicle.

Preventing male infertility

Often preventing infertility is much easier and better than treating it! What can you do to reduce the risk of being infertile ? The biggest preventable danger to male fertility is due to uncontrolled sexually transmitted diseases (STDs) such as syphilis, gonorrhea and chlamydia which can cause irreparable damage to the reproductive tract . Another important preventable cause of testicular damage in men is uncorrected undescended testes. Undescended testes should be surgically treated at an early age to prevent damage - preferably before the age of 2 years. This requires educating mothers of young boys; and doctors as well. It may also be a good idea to immunise boys against mumps in childhood, thus preventing the ravage which mumps can cause to the testes in later life.

Drugs - including alcohol, cocaine and marijuana - are all poisons. They can reduce sex drive; damage sperm production; and interfere with ovulation - and sometimes this damage is irreparable. Smoking tobacco also affects reproductive function - by depleting egg production; increasing the risk of PID; and lowering sperm counts. Often, the adverse effect is temporary, so that when these are stopped, the harmful effects on reproductive function are likely to be reversed. However, since abstinence is easier than moderation, the best option is not to smoke, drink or use drugs!

Occupational hazards can also decrease sperm counts. Many toxic drugs - including radiation, radioactive materials, anesthetic gases, and industrial chemicals such as lead, the pesticide DBCP and the pharmaceutical solvent ethylene oxide can reduce fertility by imparing sperm production. Intense exposure to heat in the workplace (for example, long-distance truck drivers exposed to engine heat; and men working in furnaces or in bakeries) can cause long-term and even permanent impairment of sperm production. You should be aware of these hazards and may need to control your exposure if fertility is a concern.

Interestingly, many researchers have observed that sperm counts the world over are declining. Whether this is due to exposure to toxic chemicals such as dioxins ( formed as a result of environmental pollution) , which cause disruption of the endocrine system; or to the stresses of modern day life remains unclear.

What can you do to improve your sperm count ? Stop smoking, drinking or abusing drugs. Most doctors will advise that you take vitamins ( such as Vitamin E, Vitamin C); and others prescribe antioxidants and selenium, though the effect of these on male fertility is still a contentious issue. Traditional advise included taking cold water showers and wearing loose underwear, to help keep the testicular temperature low and “ sperm friendly “, but the results can be unpredictable. Certain drugs ( for example, salazopyrine which is used for treating ulcerative colitis) can suppress sperm counts, so if you are taking prescription medicines, ask your doctor about what their effect on sperm counts it. One simple way of increasing your chances of getting your wife pregnant is to have sex frequently – the more the sperm you deposit, the better your chances of hitting the jackpot !