Most common courses of male sub fertility
- Nature and Duration of Infertility
- Testicular Symptoms
- Family History
- Coital Adequacy and Timing
- Childhood and Pubertal Development
Nature and Duration of Infertility
Previous pregnancies and time taken to conceive each pregnancy and duration of infertility are important prognostic factors. - The couple may be aware of an infertility-related problem, such as past undescended testes or orchitis.
- Some who present with a short duration of infertility may be unaware of the normal human pregnancy rates.
- The plan for investigation depends on the possibility of finding remediable abnormalities and on the age of the female partner.
Family History
The family history should be considered but may not be known because infertility is often not discussed openly.
- Increasing numbers of chromosomal and genetic causes for male infertility are being discovered.
- The most important genetic causes include Kallmann syndrome, myotonic dystrophy, androgen receptor defects, gonadotropin and gonadotropin receptor defects, cystic fibrosis and bilateral congenital absence of the vasa (BCAV) and Yq microdeletions.
- While some of these cause sterility and are recessive disorders or denovo mutations, others may only affect fertility slightly.
- There are many paediatric syndromes which involve hypogonadism or undescended testes in association with ambiguous genitalia, multiple malformations or mental retardation but patients with these generally do not present for management of infertility.
- Other genetic diseases may be associated with infertility for example haemoglobinopathy, Huntington disease, polycystic kidneys, and mitochondrial disorders.
- Predispositions to certain conditions may also have a genetic basis such as the anatomical variant of the tunica vaginalis which predisposes to testicular torsion, the association of Young syndrome to mercury poisoning in infancy and the familial aspects of sperm autoimmunity.
- Men with sperm autoimmunity have increased frequencies of both family histories of organ-specific autoimmune diseases and autoantibodies to thyroid and gastric parietal cells in their serum.
- Furthermore, brothers of men with poor semen analysis results are more often infertile than expected.
Thus it is postulated that genetic causes or predispositions will be found for most male infertility. However, genetic factors are not clear for the common types or associations of male infertility: idiopathic oligospermia, asthenospermia, teratospermia or varicocele and past undescended testes.
Coital Adequacy and Timing
Information on impotence and ejaculatory disturbances is important because intravaginal deposition of semen near the time of ovulation is crucial for fertility. - Infrequent coitus is common in couples seen for infertility.
- Low libido may result from androgen deficiency, general illness, or a psychological reaction to the infertility.
Childhood and Pubertal Development
Treatment in childhood for penile or scrotal disorders (e.g. hypospadias, epispadias, urethral valves, undescended testes, inguinal hernia, or hydroceles) could be relevant. - Sexual maturation may be delayed and incomplete with primary or secondary hypogonadism. There may have been associated growth problems that required treatment. Early puberty and growth resulting in short stature suggest congenital adrenal hyperplasia.
General Health
Any illness, acute or chronic, can impair sperm production in a nonspecific manner.
- Acute critical illness such as severe trauma, surgery, myocardial infarction, burns, liver failure, intoxication, or starvation, is often accompanied by suppression of gonadotropin secretion and secondary hypogonadism.
- N contrast, a primary testicular disorder with elevated gonadotropin levels may occur with chronic illnesses.
- Increased peripheral conversion of androgens to estrogens may produce some features of feminization such as gynecomastia.
- The association of hypogonadism and feminization with chronic liver disease is well known.
- Similar hypogonadism may occur with other chronic illnesses such as chronic anemia, chronic renal failure, rheumatoid arthritis, chronic spinal cord injury, thyroid diseases, Cushing's syndrome, obesity, HIV infection and neoplasia.
- Sex hormone binding globulin levels are increased with some conditions such as cirrhosis and thyrotoxicosis but suppressed with others such as obesity, hypercortisolism and hypothyroidism.
- Numerous drugs have side effects on the reproductive system.
- Heroin addiction and intrathecal narcotic infusions to control chronic pain suppress LH secretion.
- Fever can cause transient declines of a few months' duration.
- Diabetes mellitus may be associated with impotence in early uncontrolled stages, ejaculatory disorders with autonomic neuropathy, and sperm autoimmunity.
- Men with renal disease may have infertility of multifactorial origin, including testicular failure from chronic illness, cytotoxic drug exposure, zinc deficiency, and damage to the vasa or penile blood supply during kidney transplantation. However, as with cirrhosis, provided that metabolic decompensation is not severe, semen quality often is adequate for fertility.
- Epididymal obstruction associated with chronic sinopulmonary disease (Young syndrome) was diagnosed frequently in Australia and the United Kingdom in the past yet is rare elsewhere.
- Some cases of Young syndrome may have been caused by mercury poisoning in childhood from calomel containing teething powders. These were withdrawn from the market in the mid 1950s when it was found that they caused Pink disease and Young syndrome is seen less commonly.
- Bronchiectasis and sinusitis are common in men with immotile sperm from cilial defects.
- Situs inversus may also be present.
Testicular Symptoms
Previously undescended testes are common in men being investigated for infertility.
- Undescended testes may be associated with other congenital malformations and disorders of testicular hormone production or action during fetal development, such as Kallmann syndrome, insulin-like factor 3 mutations, androgen receptor mutations or defects of androgen metabolism, and diethylstilbestrol exposure in utero.
- In Western countries this condition is usually treated in early childhood but whether early surgery reduces the severity of the subsequent spermatogenic disorder is unclear.
- A testicular dystrophy may cause both the failure of descent and defective sperm production in adult life despite early surgery.
- It is difficult to explain otherwise how men with unilateral undescended testes are so frequent in the infertile population.
- Bilateral undescended testes carry a worse outlook for fertility than unilateral undescended testes.
- Infertility after bilateral treatment was about six times more common than in the general population and occurred in about half the men whereas after unilateral treatment infertility was increased by a factor of two and affected about 10%.
- Rarely, the testes atrophy after surgery because of interference with the blood supply or coincidental torsion.
- Episodes of severe testicular pain and swelling may result from torsion, orchitis, or epididymo-orchitis and may be followed by loss or atrophy of the testis. Postinflammatory atrophy is particularly frequent with mumps orchitis but rare with other illnesses such as glandular fever and brucellosis.
- Epididymo-orchitis of bacterial origin is commonly associated with urethritis or urinary tract infections and may follow straining with heavy lifting.
- Sexually transmitted diseases are important, particularly if there was associated epididymal pain or swelling.
- Some patients have postgonococcal obstructions in the tails of the epididymides without clear or admitted histories of epididymitis.
- Failure of development and a decrease in size of one or both testes are important symptoms of spermatogenic defects.
- Torsion of the testes may cause atrophy.
- The vasa may be damaged during hernia repairs and kidney transplantation.
- Testicular biopsy may inadvertently damage the epididymis especially if retroversion of the testis is not recognised and the biopsy is performed without taking the testis out of the tunica.
- Similarly, surgery for torsion, hydroceles or epididymal cysts may result in the obstruction of the epididymis.
- Hematomas in the scrotum and infarction of the testes may follow interference with the vascular supply of the testes.
- Rarely, autoimmune orchitis results from testicular injury or inflammation.
- Testicular tumors and carcinoma in situ occur with increased frequency in infertile men even without a history of undecided testes.
INFERTILITY – LIST OF ARTICLES
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