shattering the myths about male infertility

Shattering the myths about male infertility

Male factors play a role in up to half of subfertile couples, contrary to the myth that male factors rarely play a role. In here counters this and other myths about male infertility and suggests that primary care physicians can increase a couple's chance of conceiving by evaluating for male as well as female factors. This article will also help primary care physicians provide appropriate education and treatment, as well as determine when to make a referral to a male-infertility specialist.

In recent years, infertility has received increasing public attention. It is estimated that nearly 10% of couples are infertile (ie, unable to conceive after attempts over a span of at least 1 year) and that one of every five couples between the ages of 35 and 44 has difficulty conceiving. This article examines some of the myths associated with male infertility and subfertility and identifies the role of the primary care physician in managing the condition.

MYTHS 1 : INFERTILITY IS RARELY THE MAN'S FAULT

In fact, up to 50% of infertile couples have male factor involvement.
This group is typically split into 30% who have strictly male factors and 20% with both male and female factors. However, it is important that no blame is placed. Infertility is a problem of the couple and should be addressed as such.
We assessed the utility of evaluation for male factors in 62 couples preparing to undergo Ayurvedic treatments because of male subfertility.
The men involved were referred to our male infertility clinic for determination of the cause of subfertility.
Fifty men (81%) were found to have identifiable infertility factors, and 47 (76%) were potentially treatable.
We concluded that evaluation for male factors yields a significant, treatable cause in the majority of cases.
Thus, we advocate evaluation for and, when indicated, treatment of male subfertility factors in couples considering assisted reproductive techniques. Identifiable factors in male subfertility include excurrent ductal obstruction, hypogonadism, ejaculatory dysfunction, varicoceles, and exposure to gonadotoxins.

Evaluation consists of thorough

History taking,
Physical examination,
Laboratory tests.

History:

History taking is a crucial part of evaluation for male subfertility. Duration of infertility, number of previous pregnancies, and results of previous evaluations or treatments are key points. The sexual history, particularly with respect to potency and ejaculatory function, should be ascertained. Past medical history, including childhood history and adolescent development, should be gathered. Specifically, any history of torsion, cryptorchidism, or trauma may play a role. Systemic illness such as diabetes mellitus, neurologic disease such as multiple sclerosis, or previous cancer treatment such as chemotherapy or radiation therapy may be factors. Past surgeries may contribute to the problem, specifically retroperitoneal and bladder neck surgery. Previous hernia repair may cause vasal obstruction.

Infections can affect fertility in several ways.
Febrile episodes may decrease spermatogenesis, although usually this is self-limited and resolves within 3 to 6 months. Mumps in adolescence may lead to mumps orchitis. Sexually transmitted diseases, specifically chlamydial infection and gonorrhea, may cause ductal obstruction, as can any inflammatory condition within the testes, epididymides, or prostate. Gonadotoxins in the form of chemicals, medications (both prescription and nonprescription), tobacco, alcohol, and illicit drugs all affect spermatogenesis to some degree (table 1). The duration and amount of exposure often dictate the severity and reversibility of the spermatogenic dysfunction.

MYTH 2 : NOTHING CAN BE DONE TO IMPROVE SPERM COUNTS

Although numerous studies have demonstrated the efficacy of treatment of the male partner to increase fertility (as manifested by improved sperm counts or pregnancy), some clinicians still believe that not much can be done for male factor infertility.
Indeed, many of the causes of male infertility are progressive, and treatment is needed to halt further damage or dysfunction.
In some patients, subfertility is the first sign of systemic disease, such as pituitary tumor or testicular cancer.
Additionally, although detection of genetic aberrations associated with infertility may not cause physicians to alter the approach because these conditions are not reversible, patients should be informed about results of genetic and other diagnostic tests before proceeding to the in vitro fertilization (IVF) process.
Our previously cited study suggests that although identification and treatment of male factors in infertility do not result in pregnancy in all couples, significant improvement of the sperm count is common, resulting in increased success.
In this study, 47 of 62 men (76%) were found to have potentially correctable causes. Of these, 28 (60%) underwent corrective treatment. Spontaneous pregnancy occurred in 9 (32%) of these couples, and an additional 12 (43%) had improvement in seminal parameters.
Thus, one third of the couples were able to conceive without the use of assisted reproductive techniques, and a significant percentage was able to avoid IVF for less invasive techniques.

Management

Management of male factor infertility is directed toward treating reversible causes and assisting in advanced reproductive techniques. From the primary care physician's perspective, the most effective way to improve sperm counts is through patient education.
The mainstay of primary care involves addressing issues such as the ovulatory cycle and timing of intercourse and exposure to gonadotoxins that may interfere with spermatogenesis, erection, and ejaculation.
Primary care physicians may also be instrumental in diagnosing potentially correctable disorders, such as genital tract infections, erectile dysfunction, and hormonal abnormalities.
Therefore, it is imperative that primary care physicians be involved in the process of evaluating for male factors. The treatment of endocrinopathy can have a huge impact on the outcome of a couple's quest for children. Endocrinopathy may be a harbinger of more serious medical problems.
Once such problems have been ruled out, treatment may be undertaken. In almost all men with hypogonadotropic hypogonadism--in which little or no gonadotropin-releasing hormone is present, thus leading to nearly nondetectable levels of luteinizing and follicle-stimulating hormones--injection of gonadotropins results in the return of spermatogenesis, with the majority of couples achieving pregnancy.
Success rates after treatment of the male partner include improved seminal parameters in up to 70% of men, with a 35% to 40% pregnancy rate.
Correction of obstructions, or other factors, results in return of sperm to the ejaculate in 50% to 95% of men.
Pregnancy rates as high as 65% have been obtained, although a more realistic value is probably closer to 30% to 50%

MYTH 3 : VARICOCELES DON'T CAUSE INFERTILITY

The most common cause of male infertility is varicocele.
A varicocele is an abnormal dilation of the pampiniform plexus of the internal spermatic vein and is typically identified on the left side.
This condition has been found to be a contributing factor in up to 40% of cases of primary and up to 80% of cases of secondary male subfertility. Varicoceles have also been identified in up to 15% of the general population.

Diagnosis and treatment
Diagnosis of a clinical varicocele is usually made by physical examination, with or without the aid of Doppler ultrasound. Diagnosis and treatment of subclinical varicoceles (those identifiable only by radiographic means) remain controversial.

Laboratory tests:
Selective use of laboratory studies may be a cost-effective adjunct to history taking and physical examination. All patients should have at least two seminal fluid analyses.

Myth 2. Nothing can be done to improve sperm counts

Although numerous studies have demonstrated the efficacy of treatment of the male partner to increase fertility (as manifested by improved sperm counts or pregnancy), some clinicians still believe that not much can be done for male factor infertility. Indeed, many of the causes of male infertility are progressive, and treatment is needed to halt further damage or dysfunction. In some patients, subfertility is the first sign of systemic disease, such as pituitary tumor or testicular cancer.

Additionally, although detection of genetic aberrations associated with infertility may not cause physicians to alter the approach because these conditions are not reversible, patients should be informed about results of genetic and other diagnostic tests before proceeding to the in vitro fertilization (IVF) process. Our previously cited study suggests that although identification and treatment of male factors in infertility do not result in pregnancy in all couples, significant improvement of the sperm count is common, resulting in increased success.

In this study, 47 of 62 men (76%) were found to have potentially correctable causes. Of these, 28 (60%) underwent corrective treatment. Spontaneous pregnancy occurred in 9 (32%) of these couples, and an additional 12 (43%) had improvement in seminal parameters. Thus, one third of the couples were able to conceive without the use of assisted reproductive techniques, and a significant percentage was able to avoid IVF for less invasive techniques.

Management

Management of male factor infertility is directed toward treating reversible causes and assisting in advanced reproductive techniques. From the primary care physician's perspective, the most effective way to improve sperm counts is through patient education.

The mainstay of primary care involves addressing issues such as the ovulatory cycle and timing of intercourse and exposure to gonadotoxins that may interfere with spermatogenesis, erection, and ejaculation.
Primary care physicians may also be instrumental in diagnosing potentially correctable disorders, such as genital tract infections, erectile dysfunction, and hormonal abnormalities. Therefore, it is imperative that primary care physicians be involved in the process of evaluating for male factors.

The treatment of endocrinopathy can have a huge impact on the outcome of a couple's quest for children. Endocrinopathy may be a harbinger of more serious medical problems. Once such problems have been ruled out, treatment may be undertaken. In almost all men with hypogonadotropic hypogonadism--in which little or no gonadotropin-releasing hormone is present, thus leading to nearly nondetectable levels of luteinizing and follicle-stimulating hormones--injection of gonadotropins results in the return of spermatogenesis, with the majority of couples achieving pregnancy.

Success rates after treatment of the male partner include improved seminal parameters in up to 70% of men, with a 35% to 40% pregnancy rate. Correction of obstructions, or other factors, results in return of sperm to the ejaculate in 50% to 95% of men. Pregnancy rates as high as 65% have been obtained, although a more realistic value is probably closer to 30% to 50%

Myth 3. Varicoceles don't cause infertility

The most common cause of male infertility is varicocele. A varicocele is an abnormal dilation of the pampiniform plexus of the internal spermatic vein and is typically identified on the left side. This condition has been found to be a contributing factor in up to 40% of cases of primary and up to 80% of cases of secondary male subfertility. Varicoceles have also been identified in up to 15% of the general population.

Diagnosis and treatment

Diagnosis of a clinical varicocele is usually made by physical examination, with or without the aid of Doppler ultrasound. Diagnosis and treatment of subclinical varicoceles (those identifiable only by radiographic means) remain controversial.