Male infertility is out of the closet

Dr S S Vasan

Male infertility is not a very well perceived topic in the Indian society and there is little awareness of the magnitude and importance of the male factor infertility. Despite the relative importance of infertility due to the male factor, infertility evaluations have traditionally focussed on women, because women tend to seek gynaecological care and because men often are reluctant to seek advice or do not know where to look for it. Male infertility refers to the failure of a couple to achieve conception due to problems specifically related to the man’s sperm, seminal fluid, or reproductive organs which can be effected by a number of factors. Andrology (study of male reproductive system and urological problems that are unique to men) has only been studied as a distinct speciality since the late 1960s but unfortunately has not received its due in the medical field. Andrology remains a sub-speciality area within urology around the world except in a few developed countries. In India, widespread practice of andrology is not prevalent, with few specialists. However, some private specialised andrology clinics have been birthed in India and are making an effort to bring the issue to the forefront. Dr S S Vasan, Andrologist and Managing Director, Ankur Healthcare, Bangalore speaks to M Neelam Kachhap about the importance of andrology and advances in the field.

What is the incidence of male infertility in India?

According to a report conducted by the International Institute of Population Sciences, infertility is growing at an alarming pace, especially in the cities. Out of around 250 million individuals estimated to be attempting parenthood at any given time, 13 to 19 million couples are likely to be infertile.

Although the national census does not head count infertile couples, this study, which takes into account the national census reports of the past three decades, viz, 2001, 1991 and 1981, showed that infertility has risen by 50 per cent in the country.

The report said that in India, 13 per cent of ever-married women aged 15-49 years were childless in 1981 (rural 13.4 per cent and urban 11.3 per cent) which increased to 16 per cent in 2001 (rural 15.6 per cent and urban 16.1 per cent). Over half of married women aged 15-19 years were childless in 1981, which increased to 70 per cent in 2001.

Nearly 30 million couples in the country suffer from infertility, making the incidence rate 10 per cent. Earlier, childlessness in a couple used to be talked about in hushed tones, with the problem, without doubt, being attributed to the women.

Today, infertility is no longer recognised as only a female problem. In fact, the term infertility is a broad term, often loosely used. It actually refers to a range of disorders, some of which affect the male, and some the female, and contribute to childlessness in a couple. 

What are the main causes of male infertility that you see in your practice?

Some of the problems that frequently come to us are due to varicocele, infections: Acute: smallpox, mumps, other viral infections; Chronic: TB, leprosy, prostatitis. Other than these we also see patients with idiopathic – cause unknown or injury related. Then there are direct causes like testicular or pelvic trauma, heat, irradiation and indirect causes like radiotherapy, chemotherapy, environmental toxins, drugs, marijuana, tobacco, alcohol. Undescended testes (cryptorchidism) and obstructions like congenital (aplasia), vasectomy, post-infective ejaculatory disturbances and sexual dysfunctions are also common.

What are the treatment options available?

There are some tests done to find the cause of infertility. Physical examination is the basic test done by a doctor. Any male with infertility problem will have to go through semen and sperm analysis to test the size and shape of the sperm, mobility, and number of sperms. Hormone testing is done to test the level of testosterone. Ultrasound is often done to check whether the patient has retrograde ejaculation or obstruction in the tube.

Many male infertility treatment options are also available – both nonsurgical and surgical. Treatment options vary depending on the problem. Non-surgical options including counselling, education and/or prescription of medications to improve semen quality. Physical therapy and acupuncture are also available as male infertility treatment options. Spinal cord injury treatments and electro ejaculation therapy can help infertility. Electro ejaculation therapy is very successful and is used in patients with ejaculation problems. It is a noninvasive and pain-free procedure. In patients with varicocele, ligation surgery is done to construct the dilated veins. There are minimally invasive procedures to retrieve the sperms. This is effective even in azoospermia and also in patients who have had vasectomy. If infertility is due to obstruction, then trans urethral resection of the ejaculatory duct or seminal vesicles can be done. If other treatments are not useful, then intra-cytoplasmic sperm injection can be done to overcome all the problems causing male infertility. With the use of these male infertility treatment options, infertility in men can be treated.

Kindly comment on the sociological effect of male infertility?

According to research, men and women differ in their psychological responses to infertility. Men undergo various battles like anxiety concerning potency, masculinity, and sexual adequacy. The male partner is either the sole cause or a contributing cause of infertility in 49 per cent of couples. Throughout history men have recognised the desire for paternity and the possibility for male infertility; however, women are typically the subject of fertility studies and hence the number of studies conducted on male infertility is limited. What is reassuring is that in the last decade importance accorded to male infertility research has increased substantially.

What is the latest research in this area?

A new study published in the journal ‘Cell’ reveals that researchers at Stanford School of Medicine have managed to decode the full genetic blueprint of a single sperm cell. The researchers revealed that there were 23 recombination events in every sperm, wherein the DNA inherited by a sperm is shuffled, thus mixing up the genes passed on by a man’s mother and father. Each sperm also had 25 to 36 new mutations which are not seen in any other cells. 

In older men, intake of micronutrients is strongly associated with improved sperm DNA quality, finds the study. In an analysis of 80 healthy male volunteers between 22 and 80 years of age, the scientists found that men older than 44 who consumed the most vitamin C had 20 per cent less sperm DNA damage compared to men older than 44 who consumed the least vitamin C. The same was true for vitamin E, zinc, and folate. Older men are also more likely to have increased frequencies of sperm carrying certain gene mutations, such as those leading to dwarfism. These findings help explain why aging men are less fertile and are predicted to have more chromosomally defective pregnancies and a higher proportion of offspring with genetic defects. But until now, researchers haven’t understood whether diet can protect against the detrimental effects of aging on the sperm genome.

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