Male Derived Causes of Infertility
Male causes can occur at any point in the male reproductive system. There may be a problem in any area that extends from the pituitary gland, which provides sperm production and the release of the male hormone called testosterone, to the canals that produce sperm in the testicles and the semen containing the sperm from the testicles to reach the penis.
GnRH, FSH and LH hormones secreted from the hypothalamus and pituitary gland in the brain provide sperm production from testicles and the release of male hormone called testosterone. In the hormone deficiencies resulting from this, there will be insufficiency in sperm production.
There may be congenital causes such as Kallmann Syndrome in hormonal problems or tumoral causes such as prolactin producing pituitary adenoma. For this reason, the pituitary gland should be evaluated by pituitary MR and prolactin levels in the blood should be evaluated.
In these cases, which are called hypogonadotropic hypogonadism, the necessary treatment of adenomas in the pituitary gland should be regulated after the tests performed to determine the cause, or if there are indications, the semen parameters should be checked and the treatment should be adjusted accordingly.
The absence of sperm in the semen is seen in 1% of men and 15% of infertile men. It is necessary to distinguish the case of zero sperm, called azoospermia, from cases where a small number of sperm, called heavy oligospermia, can be found. For this, it would be appropriate to evaluate two separate sperm samples after a good centrifuge. In the absence of any sperm, genetic tests, urological research and surgery may be required to obtain sperm from the testicles, while if there is a small amount of sperm in the semen, these sperms can be used directly for microinjection.
There may be two reasons for azoospermia cases where no sperm can be found in the semen. Either no sperm is produced from the testicle (nonobstructive azoospermia) or there is obstructive azoospermia in the ducts that carry the produced sperm to the penis.
In nonobstructive forms, there is a problem in sperm production from testicles, and FSH and testosterone should be examined first, whether the problem is caused by the deficiency in hormone stimulation (hypogonadotropic hypogonadism) or whether the testicle is caused by the primary testicular failure. Genetic examinations should then be carried out. The most common anomalies in this group are sex chromosome anomalies (47 XXY: Kleinfelter Syndrome). This is followed by Y chromosome deletions. When these anomalies are detected, a very good evaluation should be made and the chance of finding sperm should be calculated well. It will be possible to give the right consultation to the couple in this direction. Testicular history of undescended testicles in the testicles, late-performed testicles, surgeries due to testicular tumours, radiotherapy and chemotherapy history due to cancer, severe infection and traumas, and testicular torsions may also affect sperm production from the testicle.
In obstructive forms, sperm production from hormonal stimuli and testicles is normal. However, in azoospermia, in 40% of cases, the channels may be blocked at some point in the transportation of sperm from the testicular area to the penis. Vas deferens, the channels that carry sperm, should be examined manually during physical examination. There may be unilateral or bilateral absence of vas deferens and in this case, cystic fibrosis must be investigated. In the absence of bilateral vas deferens, cystic fibrosis can be seen in 50-80% of cases. If the cystic fibrosis gene is found to be positive in the male, the woman must be evaluated in this respect and genetic counselling must be given before microinjection application. Sperm production is normal in the absence of vas deferens, and sperm can be obtained from the testicle with PESA, TESA or TESE. These channels are normal and channels closer to the penis may be blocked. This obstruction can be determined by rectal ultrasound and sperm can be easily obtained by aspiration.
While the probability of obtaining sperm in obstructive forms of azoospermia is almost 100%, the rate in nonobstructive forms is around 65%.
In the presence of Kleinfelter Syndrome or in women with cystic fibrosis, caries can be genetically evaluated before embryo transfer is performed during IVF applications and it is aimed to transfer healthy embryos.
After extensive pelvic surgery and lymphadenectomy, such as diabetes, neurological diseases, surgical procedures in the lumbar spine, and bladder and urinary tract, prostate surgery, semen can escape from the penis instead of coming out of the penis. It is seen in 14-18% of men who do not have ejaculation, that is, ejaculation, and the diagnosis is made by the presence of sperm in the urine sample taken after masturbation. In this case, the ejaculated sperm can be obtained with urine and used for microinjection.
Varicocele is perhaps one of the most controversial issues in the field of infertility. We call the expansion of veins called pamphiniform plexus, which carries dirty blood from the testicles, varicocele. There is no evidence to show that there is a correct ratio between the presence of varicocele and semen parameters in terms of number, movement or structural problems.
When the varicocele is visible by hand, it becomes a clinical varicocele. In this group, if there is a groin pain and pressure sensation or if the patient is adolescent, surgical treatment can be considered. However, most of the time, only Doppler ultrasonography is diagnosed with varicocele and there may not be any clinical findings or complaints. In this case, surgery is not required to correct the semen parameters. Because, it has been shown that there is no significant difference between the rates of conception of the spouses of men who had surgery and those who did not.
If the female age is young, the ovarian reserve is good and the couple’s infertility period is short and the sperm count is over 5 million per milliliter, clinical varicocele surgery can be treated and supported to achieve a double natural pregnancy. In azoospermia cases where the number of sperms are zero and oligospermia cases in which there is less than 1 million per milliliter, the diagnosis of varicocele and the surgery performed for this purpose are not useful.