Infertility is a common problem of married couples. On average, ! out of every 7 couples have infertility problems. This is not just a problem for women or men. Infertility concerns both male and female couples. Therefore, these patients should be evaluated together. Urology specialist, preferably someone experienced in andrology should make the evaluation in terms of male factor. The most important causes of male infertility are low sperm count, impaired sperm functions and blockages in the ducts that allow sperm to be ejected.

Women, on the other hand, should be examined by a Gynecology and specialist experienced in infertility. In this article, I will provide up-to-date information about the causes, diagnosis and treatment of male infertility, using my own experience.

What is infertility?

The inability to have children despite being married, having regular and frequent intercourse for at least 1 year without protection is called “infertility” or “infertility”. Infertility is not just a problem that concerns women or men, it is a problem that concerns couples.

In infertile couples, the cause is 30% in men, 30% in women, 10% in men and women, the cause is unknown in 25%, and other reasons can cause infertility in 5%.

Male infertility means male infertility, that is, infertility, and this is an event in which many complex factors play a role. In order to have a child in a normal relationship, the following events must occur:

• Healthy sperm production: It is very important for the testicles to produce healthy sperm in men in order to have children. For this, hormones such as Testosterone, prolactin, FSH, LH, which are important in normal testes and sperm production, must be at normal levels.

• The sperm produced in the testicles must be transported to the semen (menis fluid) and be expelled by intercourse: In order for the sperm, which are normally performed and with normal functions, to combine with the egg and fertilize the egg, it must be expelled from the testis through the semen channels. If there is any blockage or obstruction in these sperm channels, since the sperm cannot be expelled, infertility develops even if the woman is normal.
• Sperm count should be normal: Low sperm count is one of the causes of infertility. A sperm count less than 15 million/ml is defined as a low sperm count.
• Sperm functions must be normal: Sperm movements and functions must be normal for fertility. If there is insufficient movement and dysfunction, this leads to infertility.

What are the causes of male infertility?

There are many causes of male infertility. Some causes, such as varicocele, can be treated surgically with a high success rate. In severe cases of male infertility, it is necessary to resort to assisted reproductive methods. Important factors that negatively affect sperm production, transport and maturation in men and cause infertility:

• Varicocele: It is the enlargement of the veins of the testis, that is, its varicose, especially seen in the left testis. It is a cause of infertility that can be corrected with surgery. In these patients, infertility is seen as sperm count, quality and functions will be impaired. It constitutes 37% of the causes of infertility in men.
• Infection: Infections in the genital system (male reproductive system) cause infertility in men by disrupting sperm functions or blocking the ducts carrying sperm. Infections such as epdidymitis, orchitis, gonorrhea (gonorrhea) and HIV cause infertility if left untreated.
• Ejaculation problems: Infertility is seen in cases where the semen does not come out during intercourse and escapes into the bladder or does not come at all. Prostate surgeries, bladder neck surgeries, testicular cancer surgery, urethra surgeries, use of various drugs (alpha-blockers used in the treatment of benign prostate enlargement).
• Antisperm antibody development: Immune cells called “antibodies” produced by the body against sperm perceive the sperm as a foreign body and cause infertility by preventing their functions.
• Tumors: Surgery for benign or malignant reproductive system or cancers of organs related to them, and treatment methods such as radiotherapy and chemotherapy adversely affect male fertility.
• Undescended testis: Congenital unilateral or first sided testis is not in its normal place, negatively affecting testicular functions and causes infertility.
• Hormonal imbalance: Hormones made from regions of the brain called hypothalamus, pituitary gland, thyroid and adrenal gland hormones, testosterone hormone produced from testicles play an important role in fertility. Irregularities in these hormones can lead to male infertility.
• Blockages in the sperm-carrying ducts: Obstruction of the semen ducts, which play an important role in the transport of sperm produced from the testicles, due to infection, trauma, surgery, or genetic or congenital diseases (such as cystic fibrosis) may prevent sperm transport and lead to infertility.
• Chromosomal defects: diseases such as Klinefelter (XXY) and Kallmann syndrome.
• Problems related to sexual intercourse: Causes such as impotence, premature ejaculation, anatomical causes such as hypospadias, situations that prevent regular intercourse between couples.
• Previous surgical interventions: Prior scrotal, urethral, ​​prostate, bladder neck, testicular, hernia operations, testicular cancer or colon cancer operations.
• Celiac’s disease: Celiac’s disease occurs as a result of an allergy to a protein called gluten, found in wheat. This situation improves with the removal of gluten from the diet.
• Some drugs: Testosterone therapy in patients with testosterone deficiency (hypogonadism), long-term anabolic steroid drug use, patients receiving chemotherapy for cancer, some drugs used in the treatment of stomach ulcers, some joint diseases and drugs may cause infertility in men by disrupting sperm production.
• Idiopathic (Cause of unknown infertility): 25% of male infertility cannot have a specific cause, this is called “idiopathic” (unknown cause) infertility.

What are the environmental factors that can cause male infertility?

Today, environmental factors that emerged as a result of industrialization negatively affect the male reproductive system and lead to infertility. In this regard, care should be taken not to damage the testicles too much from environmental factors.

• Industrial products and wastes: Today, as a result of industrialization, various chemicals, pesticides used in agriculture, paint industry wastes, etc. have negative effects on sperm counts.
• Heavy metals: Heavy metals such as mercury have adverse effects on the reproductive system.
• Radiation exposure: Low doses of radiation can temporarily lower sperm counts, but high doses of radiation cause permanent reductions in sperm counts.
• Exposure of testicles to excessive heat: High temperature adversely affects testicular functions and reduces sperm count and function. Frequently, hot environments such as saunas are harmful for the testicles and such hot environments are not recommended for those who want to have children.
• Medications: Anabolic steroids used by athletes to build muscle cause reduction in testicular size and decrease in sperm production. Cocaine and morphine use can also temporarily reduce sperm count and quality.
• Alcohol use: Alcohol use reduces testosterone levels, resulting in decreased sperm production and erectile dysfunction. In addition, excessive alcohol use causes liver disease, resulting in impaired testicular functions and infertility.
• Smoking: Active and passive cigarette smoking (being in smoking environments) causes infertility by lowering the sperm count.
• Obesity: Obesity, that is, obesity, can cause male infertility by directly affecting sperm and negatively affecting hormonal balance. In this care, overweight patients are recommended to lose weight and be at an ideal weight.
• Diabetes, high cholesterol, hypertension: It has a negative effect on sperm count and functions as well as on the general health system.

What are the risk factors for male infertility?

In married couples, some important risk factors increase the risk of infertility in men. It is possible to prevent infertility by paying attention to these. We can summarize the conditions that pose a serious risk for infertility in men as follows:

• Smoking
• Alcohol use
• Drug purchase
• Excess weight (obesity)
• Past or current genital infections
• Exposure to various toxins
• Exposing the testicles to excessive heat
• Testicular trauma
• Previous abdominal, pelvic surgery
• Vasectomy (connection of the semen duct for birth control)
• Undescended testis (unilateral or bilateral)
• Previous hernia operation
• Those with infertility problems in the family
• Those born by in vitro fertilization method
• Those with cancer or chronic disease
• Those who receive surgery, radiotherapy, chemotherapy due to cancer

What should be considered to protect male infertility?

Some of the risk factors are factors that can be prevented by following the recommendations of experts. Paying attention to these lifestyle-related issues is extremely important in order to have quality sperm and children. Important points to consider in this regard are:

• Quitting smoking
• Cut down or quit alcohol
• Quitting if taking drugs
• A healthy weight
• Not having a vasectomy (may be difficult to reverse)
• Testicles are not exposed to excessive heat
• A life free from stress
• To stay away from pesticides, heavy metals, etc. industrial wastes.

What are the complications of male infertility?

Infertility is an important social problem for couples. Couples who cannot have children despite their desires are faced with many problems, including domestic problems, social life and work environment. These issues can vary from culture to culture. Complications (problems) encountered in couples who want to have children but cannot due to male or female factors are as follows;

• Not being able to have children causes stress and difficulties in marital life.
• Families may face serious economic difficulties in order to have children.
• Treatment methods applied for infertility treatment cause some diseases and unwanted effects in the body.
• Depending on the problems caused by infertility, people may have problems in their social and business life.
• It may cause the termination of the marital relationship between the couples.

In summary; infertility is a common problem that concerns couples. Male infertility is a problem that should be evaluated by a urologist. Varicocele in male infertility is a disease that can be treated with surgery. Microsurgery is the most effective treatment method. Environmental factors and lifestyle significantly affect fertility in men. Paying maximum attention to these adversely affecting situations significantly increases the chances of conceiving a child. It is recommended that the woman from the couple be evaluated by a Gynecologist who is experienced in infertility. Couples who cannot have children may experience some complications (negativeness) that negatively affect their social life, family and business life. Couples who cannot have children in the normal way can have children with assisted reproductive methods.

Prof. Dr. Emin ÖZBEK

Urology Specialist

Istanbul- TURKEY