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MALE INFERTILITY

Male Infertility refers to health issue in men which lowers chances of pregnancy in a fertile female. About 15 out of 100 couples face this problem of not getting pregnant with unprotected sex. This refers that they are not able to conceive a child after having frequent intercourse for more than a year.

Symptoms of Male Infertility

Major signs of male infertility is inability to conceive post sexual activity. Other symptoms may include:

  • Difficult ejaculation
  • Low sexual desire
  • Having issue in maintaining an erection
  • Lower sperm count ( eg., total sperm count less than 39 million per ejaculate )
  • Pain followed by swelling in testicle area
  • History of prostate problem or any testicle related problem

Causes of Male Infertility

There are various causes associated with male infertility :

  • Disorders of Sperm :
    1. Be odd shaped
    2. Not moving right way
    3. Azoospermia ( not at all moving )
    4. Not fully growing
  • Varicocele :
    1. Varicocele are basically swollen veins in the scrotum. It is present in 15% of men (normal) and about 40% of infertile men. It’s the most common causes of male infertility. It could be because of abnormal testicular temperature. Varicocele causes low and reduced quality of sperm in men. It harms sperm growth by blocking blood flow. Varicocele makes blood back to scrotum from belly and thus making testicles too warm for making sperm, thereby causing low sperm.
    2. Obstruction :
      • At times, sperms are blocked because of past infections, surgeries like – vasectomy. Having such blockage prevents sperm from testicles to leave body during ejaculation.
    3. Ejaculation Issues :
      • With retrograde ejaculation, the semen goes backwards in the bladder instead of coming out of penis. Semen might have normal sperms but unable to reach vagina. There are many health issues which can cause retrograde ejaculation, including spine injury, diabetes, bladder surgery, urethra or prostate surgery. Etc. Men with spinal cord injuries cant ejaculate sperm, even they produce sperm. Dry ejaculation and less fluid in ejaculation and cloudy urine are signs of retrograde ejaculation.
    4. Hormones :
      • Pituitary gland makes hormones which then tell testicles to make sperms. Men with low hormone levels have poor sperm growth. Male hypogonadism ( low testosterone) and hormonal problems are major causes of male infertility.
        • Men on anabolic steroids causes testicles to shrink and thereby decreased sperm production. Usage of weeds and other form of drugs, reduce quality and number of sperm count. Excessive consumption of alcohol leads to lower testosterone levels and decreased production of sperm and erectile dysfunction.
    5. Stress &Depression :

      Stress is an important factor and affects the sperm production. Prolonged and severe stress with problems of fertility may affect sperm count as well. Researches shows, male partner with severe depression have low chances of pregnancy. Depression causes reduced libido, erectile dysfunction and delayed ejaculation.

      1. Chromosome Defects. :
        • Disorders such as Klinefelters Syndrome, where a male is born with 2X chromosomes and 1 Y chromosome causes abnormal development of male reproductive organs. Changes in number of structure of chromosomes affect fertility.
      2. Medication :
        • It is observed that due to certain medications, sperm production, function and delivery is changed. Medications which are given to patients to treat health problems like :
          • Depression
          • Infection
          • Arthritis
          • High Blood Pressure
          • Cancer
    6. Past Surgeries :
      • Men with prior surgeries prevent from having sperm in ejaculate. Viz, vasectomy, testicular surgeries, hernia, rectal cancers etc.
    7. Environmental Effects :
      • Exposure to lead, heavy metals, exposure to radiation, pesticides, organic solvents, painting materials and elevated temperature of testicles impair sperm production and function. Sitting for long hours and wearing of tight clothing may slightly reduce sperm production.

DIAGNOSIS :

Causes of male infertility are really tough to diagnose, however mostly associated with sperm production or delivery. Examination and tests to be carried out to see causes of infertility.

  1. Semen Analysis : Semen analysis is the 1st choice of male infertility. Semen is collected by having the person masturbated in a sterile container and sent for studying. The reports shows sperm volume, count, movement, concentration and structure. If results shows no sperms or low no of sperms, it doesn’t mean patient is permanently infertile. It reveals problems with growth or delivery of sperms. More test may be needed.
  2. Testicular Biopsy : This involves taking samples from testicles with a needle. If biopsy shows normal sperm production, problem is likely caused by blockage. Testicular Biopsy helps find cause of infertility and at the same time sperm is collected for use in assisted production.
  3. Hormonal Profile : Hormonal profile is assessed to learn how well testicles are making sperm. Abnormality in hormonal or organ systems also contribute to male infertility. Blood tests is needed to measure testosterone levels and other hormones. FSH is the hormone which tells testicles to make sperm.
  4. Scrotal USG : A scrotal USG helps the doctor to assess if patient is having a varicocele or other problems in testicles and supporting structures.
  5. Genetic Tests : There should be a genetic cause if the sperm concentration is very low. The test reveals if there are changes in Y chromosome – its sign of genetic abnormality.

LINE OF TREATMENT

NON SURGICAL TREATMENT :

  • Anejaculation : This means there’s no semen. Though, its not common but caused by various factors :
    1. Diabetes
    2. Prior surgery
    3. Spine Injury
    4. Stress or emotional problem
    • First line of treatment is to try drugs, if failed – Electroejaculation and penile vibratory stimulation is used to retrieve semen.
    • IVF and ICSI are great choice to men with anejaculation.

SURGICAL TREATMENT TO TREAT MALE INFERTILITY :

  1. Microsurgical Varicocelectomy : It helps fixing the swollen veins leading to sperm movement, numbers and structure. The surgery is performed under a operating microscope to get highest success rates with minimal side effects. Hospitalization is usually for 24 hours and patient recovery to full activity in one to two weeks time.
  2. Treatment for Azoospermia : if there is a lack of sperm in semen because of certain blockage, we have many surgical choices :
      g. Micro-Tese : In this procedure, dissecting microscope is used to pinpoint the tissue to be removed. This aims to cause less damage to the structure inside the testicles. It also appears to unease the number of sperms that can be retrieved.
    1. Microsurgical Vasovasectomy : This surgery is basically used to undo or revers vasectomy, also known as vasectomy reversal. It’s a microsurgery wherein 2 cut parts of vas deferns are joined in each testicles. Hospitalization is for 24 hours and patient can resume normal activity in weeks time.
    2. Vasoepididymostomy : In this procedure, upper end of vas-deferens is joined to the epididymis. This method is used to treat epididymal block.
    3. TURED ( Transurethral Resection of Ejaculatory Duct): This procedure is performed to treat ejaculatory duct blockage surgically. Post procedure, 65 out of 100 men gets sperms into semen. There are possibilities that 1 out 4 couples get pregnancy naturally post this treatment.
    4. TESA : The most common line of treatment to diagnose cause of azoospermia. Sperm extraction is done from testicles and used fresh or frozen (cryopreserved) for ICSI.
    5. PESA: ( Percutaneous Epididymal sperm Aspiration): This procedure involves same needle and syringe technique, but needle is placed directly into the epididymis.
    6. MESA : ( Microsurgical Epididymal Sperm Aspiration) : An open surgical sperm retrieval procedure that uses an operative microscope to locate the tubules of epididymis precisely so that large number of sperms can be extracted.
    7. Micro-Tese : In this procedure, dissecting microscope is used to pinpoint the tissue to be removed. This aims to cause less damage to the structure inside the testicles. It also appears to unease the number of sperms that can be retrieved.

LISWT ( LOW INTENSTITY SHOCK WAVE THERAPY )

LISWT has been used earlier for treating and healing fractures or inflamed tendons, but this is now being used widely in treating patients of erectile dysfunction, especially with vasculogenic ED. Andrologists suggest LISWT a better option for men with mild to moderate erectile dysfunction who had success with PDE5 inhibitors medications. Patients who wish to avoid medications, LISWT is an ideal choice.

How does LISWT works ?

  • The probe is used to deliver shockwaves on the penile area for approximately 15 to 20 minutes with approximately 2000 to 2500 shocks per sitting/session. The entire procedure is carried out in OPD and is absolutely painless and doesn’t require any anesthesia.
  • The procedure is absolutely safe and has no side effects on patient. Usually 6 to 8 sessions/sittings are prescribed by doctor for better results.
  • Two sessions are carried out in a weeks time, thereby completing the entire sessions in 3 to 4 weeks of time.
  • The energy used in LISWT leads to new blood vessel formation and improved blood flow across all vessels in penis, thereby creating a better erection than before.

WHO IS A BETTER CANDIDATE FOR LISWT ?

Men with mild to moderate vasculogenic ED along with some response to PDe5 inhibitors and ideal patients for shockwave therapy. Men with psychological disorders and those who had undergone any surgery for nerve damage don’t respond to this treatment.

“Right counselling to right candidate” -its a zero risk treatment with surprisingly good effects.

RESULTS AFTER LISWT :

Success in LISWT is defined if a person having no erection earlier is able to penetrate now. Approximately 60% of the patients do feel better erections post LISWT and the results are durable for atleast 10 to 12 months.

According to a research in India, where 130 men with ED were asked to stop using PDe5 inhibitors, such as Viagra etc..Out of 130, 40 patients were given PDe5 inhibitors, while rest 90 patients received LISWT sessions. Post trial, the result showed a scant improvement in patients with PDe5 inhibitors, whereas 3/4th of the LISWT men have erections sufficient enough for sexual intercourse.

WHO CAN BE BENEFITED WITH LISWT ?

  • Patients with ED
  • Patients with premature ejaculation
  • Patients with peyronies disease
  • Patients with prostatitis & pelvic pain syndrome

MALE SEXUAL DYSFUNCTION

Sexual Dysfunction can happen to men of all age groups, especially beyond 40 years of age. Sexual Dysfunction lead to many problems, viz, erectile dysfunction, ejaculation disorders and inhibited sexual desire, low libido, etc. Male Sexual Dysfunction could be because of physical or psychological problems where sexual satisfaction among couples lack.

ERECTILE DYSFUNCTION

ED is the most common sex problem, where a men have trouble to build and keep an erection firm enough to do sexual intercourse. Following reasons are listed, when ED can happen :

  • With stress or emotional reasons
  • When patient have limited flow of blood in penis or there’s a nerve damage.
  • Because of heart disease, Hypertension, Diabetes, Obesity, Clogged blood vessels etc.
  • Sclerosis
  • Peyronies Disease
  • Sleep Disorders
  • Low Testosterone
  • Due to prostate cancer or enlarged prostate

SYMPTOMS OF ED :

Patients having ED find it difficult to build and keep erection sufficient enough to have sex with partner.

Studies reveals that men with ED are prone to heart attacks, stroke, cardiovascular diseases. They have low-self esteem and distress and depression.

ED can cause various health issues, some of risk factors include :

  • Above 50 years of age
  • Smoking
  • Diabetes
  • Obesity
  • Usage of drugs & alcohol
  • Cardiovascular disease
  • Hypertension (HTN)

PHYSICAL CAUSES OF ED :

  • DIABETES – This can cause vessel disease or nerve damage in penis.
  • When penis cannot hold enough blood for erection
  • When there is not enough blood in penis
  • Cancer treatments near pelvis might affect penis functionality.

EMOTIONAL CAUSES OF ED :

  • Depression
  • Anxiety
  • Stress
  • Worry about sexual performance

DIAGNOSIS :

Diagnosis is very important in case of ED patients to rule out exact treatment options. Proper health and ED history has to be taken before proceeding for further tests and examination.

PHYSICAL EXAMINATION :

  • Physical examination of penile area and genitals is done to check ED.

TESTS :

  • Blood test for hormones & testosterone
  • Penile doppler to see blood flow in penis
  • HBA1C / Sugar tests
  • Urine tests to see sign of diabetes.

PSYCHOLOGICAL EXAM:

It is also important to screen patients having depression, stress or any other psychological problems. Treatment is started by experts depending on the cause and severity. Risks and benefits of all treatments are explained to patient.

ORAL MEDICINES ( PDE5 INHIBITORS):

  • Oral drugs helps patients in increasing blood flow in penis. Few US FDA approved drugs are used in ED treatment :
    1. Tadalafil
    2. Avanafil
    3. Sildenafil Citrate
  • - Any drugs to be used strictly under expert supervision of Andrologist / Sexologist. For better results, one can take these drugs about an hour before sexual intercourse. 70% of men perform better post drug usage and have good erections, whereas patients having diabetes and cancer respond low to such drugs. Few common side effects of such drugs ( PDE5 Inhibitors ) are : -
    1. Headache
    2. Indigestion
    3. Muscle cramps
    4. Facial flushing

TESTOSTERONE THERAPY :

Testosterone therapy is suggestive to patient with low levels of hormone (testosterone). It is also recommended to patients in combination with other therapies / treatments.

VACCUM ERECTION DEVICES :

Vaccination erection device, known as penis pumps are used to get good erection in some patients. In this procedure a tube is placed over penis and the pump is used to create vacuum which pulls blood in penis. Post erection, a plastic ring is placed at the end of penis to hold blood to maintain erection for approx. 30 minutes. Possible side effects include bruising of penis and restricted ejaculation because of ring.

SELF INJECTION THERAPY :

  • It is one of the modality to treat patients having ED issue. In this procedure, Alprostadil is injected on side of penis by Andrologist or trained physician for the 1st time and the patient is then trained to take self injections at home.
  • Erections are usually firm enough for 30 to 45 minutes. To treat ED, a combination therapy known as Biomix or Trimix is used and has become a standard treatment.
  • The erection may lasts longer in some cases post-orgasm and is one of the side effects of ICI. Prolonged erection for more than 4 hours may lead to priapism and permanent damage to penile nerves. The same has to be reversed in time by an antidote in hospital.

SURGICAL TREATMENT:

  • Penile prosthesis/implant surgery is a permanent solution for patients suffering from ED and who has not responded well to either oral drugs ( PDE5 inhibitors ) or by self-injection therapy.
  • There are two types of penile implants available :
    • Semi Rigid Implant :
      1. Semi Rigid or bendable penile implant is made up of silicon and the silicon rods given penis the firmness required for penetration. These implants can be bent downwards for peeing and upward to have sexual intercourse.
      2. Inflatable Penile Implants :
        • 3 Piece inflatable penile implant : It invlolves placing 2 cylinders in penis with an inflatable pump in scrotum along with fluid-filled container or reservoir in abdomen. When we squeeze the pump or button placed in scrotum few times, the fluid in reservoir moves into cylinders causing an erection. Deflate button is used post sexual activity which makes the penis flaccid.
          The main advantage of 3-piece inflatable penile implant is that it has a natural feel and erection and one feels comfortable even with penis is flaccid.
        • 2 Piece inflatable penile implant: This is very much similar to a 3-piece inflatable penile implant and works in a similar fashion. However, instated of a separate fluid reservoir, the fluid is kept within the pump in scrotum. The two-piece inflatable penile implant is not as rigid as compared to 3-piece inflatable implant on erectionbut have good erection for a satisfying sexual intercourse. Cost of treatment is also less as compared to a 3-piece inflatable penile implant.

TESTOSTERONE DEFICIENCY IN MEN

Low testosterone and testosterone deficiency is the cause when men’s testes is not able to produce enough testosterone. Testosterone is the male androgen hormone; it’s not just physical changes that happen during puberty like the development of the penis and testicles, growth of body hair, but it builds sex drive,muscles etc. Testosterone levels are high between the ages 20 or 30 andstarts declining as one grew older. It also decreases because of obesity and other medical problems. Its symptoms are not similar in all persons and might differ as per age or lifestyle factors.

Symptoms of low testosterone (Low-T):-

  1. Difficulty in erection:- During sexual activity men are not able to build and maintain erection because of physical problems, injury to penile nerve, loss of blood supply to penis etc.
  2. Low volume of semen: Sometimes due to high or low level of testosterone, volume of semen become less, which is one of the most important indicators of testosterone deficiency in men.
  3. Hair loss: Hair loss is one of the common problem in males and females both. Specially in men,its a symptom of testosterone deficiency.
  4. Loss of muscle mass Deficiency of testosterone hormone cause loss of muscle mass which cause saggy or loose body.
  5. Fatigue Fatigue / lack of energy (including sexual energy, tiredness, sleep and lethargy body) may be due to less of vitamins, but testosterone is one of the major factors.
  6. Depression:- Depression may happen because of low testosterone. Now a days it’s very common among men. It affects the sexual ability and other physical things as well.
  7. Work performance down:- Low testosterone may decrease work performance as well.
  8. Less exercise Less exercise is a factor of low blood supply in penis which causes erectile dysfunction, hence exercise is must to boost your testosterone levels.

Causes of Low Testosterone:

As we all know, the levels of testosterone gradually decreases after 30 yrsof age. Other causes include :

  1. Injury, low blood supply in testicles.
  2. Chemotherapy
  3. Haemochromatosis
  4. Tumors of pituitary gland.
  5. Alcohol abuse
  6. Liver cirrhosis
  7. Chronic Renal failure
  8. HIV/ AIDS
  9. Obesity
  10. Diabetes
  11. Congenital Defect

Treatment of Testosterone Deficiency:-

  1. MEDICINE:-
    In medicine, oral tablets are not only the part of it, it can be in part of injections, supplements, hormonal pills etc which can be prescribed by only Andrologist /Sexologist. It can be short term treatment as well as long term. It is easily treatable through experts at Diyos Hospital. Medicines are the beginning of the treatment and other treatments might require if this isn’t working for a patient.
  2. TESTOSTERONE REPLACEMENT THERAPY (TRT) :-
    When the testosterone deficiency is not curable through medications, we move on to second step that is called “Testosterone Replacement Therapy”. TRT is helpful to increase the energy levels, sex drive etc. TRT is usually done with the help of injections, Gels. Etc. Our Andrologists will make a complete line of treatment best suited for an individual.