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Male Infertility
Prof. (Asso.) Dr. M.A.Bashed Ph.D (Italy)
MBBS, FCGP, FIAGP,
Embryologist.
Objectives: The aim of this paper is to assertion the male factors infertility in the community and the role of male partners for Infertility. This will help the Government to formulate the policy to overcome the serious infertility problem in Bangladesh. Fertility has been the main study of civilization since time immemorial but not infertility. The diagnosis of infertility in couple changes the dynamics of the family attached to the female partner, it is known that male partners responsible either wholly or partially in almost 50% of the infertile couples. Treatment of male infertility is a challenging problem of reproductive biology and more challenge to the infertility specialist.

Methods: Since July 2004 about 4000 couples have been recorded and evaluated in Infertility Treatment and Research Centre (ITRC).Three semen analysis have been made with a interval of one week. Analysis have been made as per WHO2 schedule. Special care was taken for collection, preservation and analysis in respect of macroscopic, microscopic and biochemical analysis. In some cases repeated microscopic examination have been made in a particular sample to avoid any error. In azoospermic cases – fructose test was done in and every sample at ITRC laboratory by the same andrologist.
 
Results: About 60% male patients were found wholly and partially responsible for Infertility. Of them 40% were azoospermia 34 % were oligospermic and the rest 5% were asthenospermia and teratospermia 1% case was due to non descendent and mal development of testes rest per cent was design as unexplined infertility. The main cause of azoospermia was due to small pox, measles, mumps, tuberculosis, STD, trauma etc reveled from history.

Key wards: Asthenospemia, Terratospermia, Color Doppler, Varicocele, Hydrocele, Agglutination, Autoimmunity, Post Coital Test, Spin Barket Test. Endometrial thickness, Follicular measurements.

Abbreviation: ITRC (Infertility Treatment & Research Center (ITRC), IUI (Inter Uterine Insemination), ICSI (Intra-cytoplasm Sperm Injection), IVF (In Vito Fertilization), PESA (Per-cutennous Epididymal Sperm Aspiration), MESA (Micro Surgical Epididymal Sperm Aspiration), TESA (Testicular Sperm Aspiration), TESE (Testicular Sperm Extraction) TFNA (Testicular Fine Needle Aspiration)


     
Introduction: With 60% of infertility wholly or partially attributed due to male factors. It is incumbent on the family physician to be knowledgeable in this field. After the initial semen analysis it is the responsibility of doctor to determine whether specialist consultation is required or not. There are still a great deal of confusion concerning what factor contribute for not forming normal semen. It is now established that the 50% of pregnancies decrease when the sperm count drops below 20 million per cc. The technique of sperm count has an inherent error of approximately 20 % even performed by expert technician. It is advice to repeat the count on another specimen if it is below 30 million per cc.

 Abnormal semen: Abnormal semen is more important than it's number and movement At least 50% of the sperm should be motile for 2 hours after ejaculation into a clean jar. Plastic and rubber jar may affect the sperm motility and should not be used. The entire specimen must be collected because there are variations in both sperm count and movement between the first and second ejaculation. All collection must be made in a very hygienic condition at a well ventilated clean room with good environment Collection at toilet bears the risk of psychological agony and infection .Attempt to collect by withdrawal during intercourse run the risk of missing rich portion. Collection in a condom decrease the motility due to spermicidal agents incorporated into the material. Frequent coitus may degrade motility and count of sperm. 48 hours abstinence for collection is advised. Normal human semen contain a great variation in number and verity of abnormalities in sperms shapes and even motility than most of the mamalian species. In general up to 40% of sperm may show abnormal morphology without being a basis for infertility. It has been emphasized that abnormal morphology is more important in diagnostic sense than in its questionable affect on infertility. Normal ejaculate has a volume between 1 to 6 CC. Lower volume associated with absence of sperm in the post coital test suggest the need of artificial insemination. IUI gives batter result than any other ART methods. which is simple, cost effective and high success rate.

 

Semen is ejaculated in liquid form and then quickly becomes a jell which again liquefies within 20 minutes. Failure to liquify produces a thick sperm which may entrap sperm. Spontaneous agglutination may caused by E coil infection or sperm antibodies. Agglutination due to sperm auto– immunity is seen rarely. It is more common to a person who have testicular injury or had vasectomy followed by re-anatomists. The semen quality is affected by factors other then local infection and antibodies. Heat has been shown to depress spermatogenesis.

Infertile men wear jockey shorts should switch to boxer shorts. Prolonged sitting such as truck driving may be responsible for depressed sperm counting should be discontinued. Febrile illness, virus infections, severe drug allergy and drug like furdentin can produce mark depression of counting even may change sperm morphology and motility. Cigarettes, alcohol, heard work may contribute to sperm count . Alcohol is more potent among them for causing infertility. Male history should be reviewed very seriously for precipitin factors when poor result is obtained. If no such history is obtained and a report of semen examination is also abnormal the male should be sent to infertility center. In a series of infertile male study in ITRC it is reported that 8% to 10 % of the cases compromise some of ducal obstruction and common site is epididymal area due to gonorrhea and tuberculosis. In a case of congenital obstruction or absence of duct, fructose will not be found in the semen because it is normally produced in the seminal vesicles. Mucus plugs may occlude the execratory duct. Testicular damage may be found following mumps, orchids and crypto orchidism.

Finally men with Klinefilter syndrome usually have small testis and azoospermic. Varicocele, hydrocele, hearnia are most important factors for impotency and in turn influencing semen quality and fertility. Speculation concerning the effect of them on a possible elevation in testicular temperature and local pressure. If the physical examination of the male dose not uncover the abnormality, testicular biopsy PESA, MESA, TESA TESE may reveal the causes of abnormality and infertility. Azoospermia associated with normal spermatogenrsis indicate ductile obstruction. If the biopsy, reveals complete hyalinization and fibrosis of the seminal tubules, there is almost no chance of fertility.

Hormone Therapy: Testosterone therapy once was popular one- but recently it has been proved no or minor use 7 Some embryologist, andrologist suggest the use of Human Chronic Gonadotropin (HCG). It is reported to increase the sperm count but to have only a limited effect on sperm motility which is more important for fertility. In the study of Mattock and Nilsson 8 injection to normal males with large doge of (HCG) resulted severe damage to the somniferous tubules. Recently Human Gonadotropin preparations which have follicular stimulating hormone (FSH) as well as Leutinising Hormone (LH) have become available. Use of these can established spermatogenesis. A number of European investigations have reported improvement in the semen quality of oligospermic cases who have normal pituitaral function. Treatment for a number of months may be needed but cost involvement is high.

Frequency of exposure: A major question in the mind of infertile couples concerns the optimum frequency of expose to achieve desire pregnancy. It is true that the frequency of sexual relation may have bearing with fertility. In males with border line sperm numbers daily exposure may depress the counts to a level where chances for pregnancy are diminished. Persistence and infrequent coitus or premature ejaculation may require sexual counseling.

Artificial Insemination (IUI): Two questions that often arise in cases where the males have poor sperm quality are–

1] Use of husband semen for insemination or
2] Possibility of freezing the ejaculate and pooling a number of samples.

It would be logical to do IUI with poor quality and motility sperm into the uterus after washing with media and to save the part of journey.

Insemination can be place in the Uterus, Cervix or Vagina. A cervical cap used some specialist dose not appear to enhance the success rate. Intrauterine (IUI) gives better and satisfactory result than any methods Chance of pregnancy is more than 60%. Certainly no more then 0.5cc can be safely installed into the uterus. In ITRC we prefer to insert very highly repeated washed motile sperms to the uterus by means of Teflon polyethylene tube. The patient remains on the table in a modified Trendelenburg position for at last 20 minute. This may bring invaluable smile at lips of parents to about 60 p.c cases.

Conclusion: Per condition for treating the infertile couples is to find out the real cause of infertility through repeated clinical and physical examination. IUI should be done which is the safest and easy method of treatment male factor infertile couples. Considering the fact that the treatment of male infertility does not only mean treatment of sperm parameters but ultimately birth of a healthy child. It is up to the embryologist to decide the optimal management in a particular couples considering not only the clinical factors but also the socio economic factor. In clinical statistics hardly anything is absolute. With time older studies give way to newer studies proving and disproving merits and demerits of drugs. What is not effective today in one study becomes effective tomorrow in another study. In a country like ours conservative management of male infertility definitely has got a big role to play.

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