Chapter 6c
Diagnosis and Treatment for Male Infertility -- More Confusion!

from the book How to Have a Baby: Overcoming Infertility
by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD.

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Undescended testes

Undescended testes are a tragic cause of male infertility, since often it is preventable. Some babies are born with one or both testicles up in their bellies instead of hanging down in the scrotum. Sometimes the condition might correct itself by the time the toddler is around 2 years old. (Don't worry unduly if you find the testes "disappearing occasionally " from the scrotum of a young boy. These are called "retractile " testes, and are very common.) However, if left unattended , the undescended testes tend to get damaged by the heat in the abdominal cavity ; and they can even because cancerous in adult life. The child should be operated before two years of age or else fertility can be lost forever. Treatment with hormonal injections (HCG injections) to cause testicular descent is another alternative.

Torsion

If one of the testicles has undergone torsion, (the doctor's word for twisting) , it could be damaged since it is starved of blood.

Signs of torsion are an excruciating pain and swelling of the testicle. Sadly, it is often misdiagnosed as a testes infection, and left untreated. This causes the testis on that side to shrivel up and die (atrophy). The best way to make the diagnosis of torsion is with a Doppler ultrasound ; and emergency surgery is needed right away, to untwist and fix the testis. The other testis must also always be fixed surgically to prevent it from undergoing torsion . Unfortunately, often, sperm antibodies are produced which decrease sperm production in the other testis .

Infections

The commonest reason for azoospermia in India used to be smallpox - the virus attacks and damages the epididymis, causing ductal obstruction. Tuberculosis also damages the epididymis, causing azoospermia. However, making a specific diagnosis of tuberculous epididymitis can be very difficult, because it is often a silent and indolent disease. Gonorrhea, chlamydia , syphilis and other STDs can also play havoc with the male genital tract; causing irreparable damage to its epithelium (internal lining).

Mumps can also cause orchitis (inflammation of the testis) - especially when it affects young men. This can cause severe damage to the testes, resulting in testicular failure.

What about other genital tract infections? Many doctors will do a semen culture, to look for a treatable cause of infertility, if the semen sample shows many pus cells. If the test is positive treatment with antibiotics is instituted. Male reproductive tract infections (such as prostatitis) are often chronic, and may require many weeks of antibiotic treatment. It is therefore important to recheck the semen culture after therapy, to ensure that treatment has been adequate. However, the relation between the presence of bacteria in the semen and male infertility is still unclear . Do the bacteria really cause the infertility? Does treating the infection help to improve fertility? More questions than answers, once again !

Medication and its effects

Some medications can play havoc with the sperm count or with the sex drive. These include :

Drugs for high blood pressure like reserpine, methyldopa, guanethidine, and propranolol; nitrofurantoin for urinary infection; corticosteroids; anabolic steroids for muscle building; and anti psychotic drugs.

A rare problem is that of anti cancer drugs and radiation therapy - used to treat young men with Hodgkin's disease, lymphoma, leukemia and testicular tumours. In these men, the chemotherapy and radiation therapy used to treat the disease also wipes out sperm production, rendering them sterile. An option available today is to store the sperms (sperm banking) which can later be used for inseminating the wife to achieve a pregnancy.

Detrimental effects of heat

The testicles are in the scrotum because they can't make sperm at body temperature - they need a cooler environment so they hang outside the body where the temperature is 0.8 degrees centigrade cooler. Tightly encased groins because of jock straps, tight jeans, lungottis, and nylon briefs cause the testicles to be pressed back into the warmth of the body and literally cook the sperm to death - especially when combined with hot tub baths and saunas . Working in hot sedentary jobs for long periods like foundries, boiler plants and engine rooms, may also cause a lower sperm count as your testicles get too hot.

This damage can be prevented by wearing loose fitting cotton trousers and cotton boxer shorts; and applying a cold ice water soaked towel around the scrotum at least two or three times a day.

Occupational hazards

These affect fertility by upsetting the hormonal balance; and suppressing sperm production.

Dangerous chemicals include: heavy metals, like lead, nickel, mercury; insecticides, petrochemicals, pesticides, benzene, xylene, anaesthetic gases , and X- rays.

Ejaculation problems

Very often a perfectly fertile man may not be able to ejaculate. Since he can't make love he can't make babies. Some men can't have an erection (impotence) and some cannot achieve an erection sufficient for intravaginal penetration or ejaculation in the vagina.

An older theory held that 80% of impotency problems, (which are very common) were rooted in psychological inhibition and fears which could respond to sex therapy and counselling. However modern research has lowered this figure and estimates that 50% are due to physical causes ranging from inadequate blood flow to the penis, diabetes, neurologic defects, and hormonal problems.

How does the doctor suspect a physical problem? By asking a simple question - Do you have wet dreams? If men have nocturnal ejaculations (wet dreams) this would suggest that the physical apparatus is sound, and that the problem is psychological.

Testing, includes nocturnal penile tumescence (NPT) testing, which monitors for normal night-time erections; and measuring blood flow through the arteries of the penis (using Doppler methods).

Treatment that may be prescribed includes:

• Viagra ( sildenafil citrate), to induce an erection
   
• Injections of papaverine and prostaglandins , (chemicals which cause blood vessel to dilate)can be self- injected into the penis under medical supervision These substance increase the blood flow to the penis, thus creating an erection.
   
• A surgical implant or penile prosthesis to give an artificial erection.
   
• Microsurgery to plug leaks in the veins of the penis, thus preventing the loss of turgidity of the erect penis.

The sperms can also be collected by masturbation and used for artificial insemination. This has a very high success rate, because there is really no fertility problem as such for these patients.

Retrograde ejaculation

This means that the semen goes backwards into the bladder instead of coming out of the penis, so that very little or no semen is ejaculated at the time of orgasm, and the urine looks cloudy after having sex. This occurs when the bladder sphincter muscle does not contract properly during orgasm, as a result of which the semen leaks back from the urethra into the bladder. This could be caused by prostate surgery, a spinal injury, diabetes, high blood pressure medication and congenital problems.

A simple way to diagnose retrograde ejaculation is to examine a man's urine after he ejaculates. If there are sperm in the urine, this confirms the diagnosis.

Self-help includes trying to have sex with a full bladder and while standing up, because this makes the muscle around the opening of the bladder more likely to stay closed . Some medications like decongestants can also help the sphincter muscle to close. Surgery can also be performed on the opening of the bladder to prevent it from misbehaving but this is not very successful.

An effective treatment option is to collect the sperm and use it for artificial insemination . After passing urine, the man alkalinizes his urine by drinking sodium bicarbonate; and then urinates immediately after ejaculation. The recovered sperm in the urine are processed and used for insemination. Pregnancy rates with insemination are usually low because the recovered sperm are often of poor quality , and sometimes IVF needs to be done with these sperm to give a reasonable chance of pregnancy.

Anejaculation

Some men find that they can get an erection, but they are unable to ejaculate. This is an uncommon problem, and is often not diagnosed correctly. Most of these men can be helped by teaching them to use a vibrator in order to ejaculate. A vibrator is a simple devise, which is easily available at most chemists’ shops, and is often called a body massager. The surface of this vibrates rapidly, and it is used to provide prolonged mechanical stimulation to the penis , until ejaculation occurs.

Electroejaculation for spinal cord problems

Men with spinal cord problems who cannot ejaculate can now be helped to father a pregnancy with the help of a new technique called electroejaculation. A probe is inserted into the man's rectum ( under general anesthesia ) and electrical stimulation delivered to the prostate in a gradually increasing fashion to induce an ejaculation. The man usually attains an erection and ejaculates in about five minutes. The recovered sperm can then be used for IUI, IVF or ICSI, depending upon their quality (which is usually poor).

Treating the couple

If the man has a low sperm count, since so little can be done with conventional therapy to improve the sperm count, today we usually offer them one of the assisted reproductive technologies. This might seem unfair , since the wife is being treated for what is essentially the husband's problem, but the fact of the matter is that there is very little effective therapy for a low sperm count. Since the fertility of the couple is the sum of the fertility potential of both the partners, a male factor problem can often be treated by treating the wife !

Conclusion

Conventional treatment of male infertility has poor success rates and leaves a lot to be desired. However the availability of assisted reproductive technology in recent times has revolutionised our approach to male infertility, and using techniques such as IVF and ICSI, most men can be helped to have their own babies. This is a rapidly developing area , and the spectacular advances which have occurred in recent times are described in the chapters to follow.

by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD.

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