Definition

Male infertility is a health problem in men that can reduce the chances of a female partner getting pregnant. The female partner is fertile and does not have any problems related to infertility.

Globally, infertility affects around 13–15 percent of couples worldwide, making them unable to have children even though they have had regular sexual relations without contraception for a year or more. More than a third of infertility cases occur due to problems in men. Generally, this condition is caused by problems with sperm production or related to sperm delivery. 

Infertility problems can be an issue that causes stress and frustration. Both partners need to find out the causes of infertility and overcome them together. There are a number of therapies available to treat infertility issues in men.

Causes

Male infertility may result from a variety of factors. All of these medical conditions can prevent sperm from reaching the egg or prevent the cells from developing into sperm. The temperature of the testicles can also affect male fertility. Generally, the causes of infertility are grouped as:

• Hormonal problems
• Impaired sperm delivery
• Primary testicular defect
• Idiopathic (sperm and semen parameters are normal, and the cause of infertility is unknown)

Sperm Abnormalities

Sperm may not be fully mature, have an abnormal shape, cannot move normally, be very few in number (oligospermia), or have no sperm at all (azoospermia).

Problems with sperm can be caused by:

• An unhealthy lifestyle can reduce sperm count, such as smoking or drinking alcohol
• Chronic diseases such as kidney failure
• Infection in childhood (mumps virus infection that infects the testicles)
• Other chromosomal or hormonal abnormalities (such as low testosterone levels)
• Obstructon of the tube that carries sperm
• Congenital disease 

Varicocele

Varicocele, or enlarged scrotal veins, is a condition commonly found in infertile men. It can cause blood to accumulate in the veins. The scrotum requires optimal temperature in relation to sperm production and development. Varicocele can make the scrotum temperature hot, disrupting sperm production and development. As time goes by, it is feared that the sperm count will become low and cause male infertility.

Retrograde Ejaculation

Retrograde ejaculation is an ejaculation disorder that occurs when semen does not exit the penis and flows back into the bladder. Even though semen can contain normal sperm, because it is not released from the penis, sperm cannot enter the vagina.

Retrograde ejaculation is characterized by cloudy urine after ejaculation. Men can also experience dry ejaculation or little ejaculate fluid. This condition can be caused by:

• Diabetes
• Spinal cord injury
• Drugs
• Side effects of surgical procedures on certain organs

Reproductive Tract Obstruction

Sometimes the tube through which sperm flows can become blocked. Repeated infections, injuries arising from surgical procedures, swelling, or developmental abnormalities during pregnancy can cause obstruction. All parts of the male reproductive tract can become blocked so that sperm from the testicles cannot come out during ejaculation.

Hormonal Disorders

Hormones produced by the pituitary gland in the brain can order the testicles to produce sperm. Low levels of this hormone can affect sperm production so that it decreases. 

Chromosomal Abnormalities

Sperm carry half of the genetic material (DNA) to the egg. Changes in the number and structure of these chromosomes can affect fertility. Congenital diseases such as Klinefelter syndrome, where men are born with 2 X chromosomes and 1 Y chromosome, have developmental problems in their reproductive organs.

Risk Factor

Some factors that can increase the risk of male infertility are:

• The use of certain medications can affect sperm function, production, and delivery
• Excessive alcohol consumption
• Smoking habit
• Overweight and obesity
• History of testicles infection
• The testicles are often exposed to high temperatures
• History of injury to the testicles
• History of surgery on the genitals, abdomen, or pelvis
• History of undescending testicles or testicles that do not descend into the scrotum
• Have a family history of fertility problems
• Suffering from certain medical conditions, such as tumors and chronic diseases
• Undergoing medical therapy such as surgery or radiation related to cancer

Symptoms

The primary sign of male infertility is that a couple does not have children even though they have had regular sexual intercourse for at least one year. Routine here refers to the frequency of sexual intercourse at least 2-3 times a week without contraception for a year.

There may be no other obvious signs or symptoms. However, in some cases, symptoms can appear if there is an underlying medical condition, such as:

• Hormonal imbalance
• Enlarged veins of the testicles
• Blockage of sperm flow
• Signs and symptoms that you may notice are sexual function problems, for example, difficulty ejaculating, low volume of ejaculate fluid, decreased sexual desire, or difficulty maintaining an erection

Diagnosis

The cause of male infertility can be difficult to diagnose. To diagnose the exact cause underlying the complaint, the doctor will carry out a series of examinations.

Medical history and physical examination

The doctor will ask about your medical and surgical history to look for anything that might reduce fertility. A physical examination will reveal any abnormalities in the penis, testicles, or sperm ducts. The doctor will look at the appearance of the patient's testicles to see if there is swelling, color changes, temperature changes, or enlarged blood vessels.

Semen analysis

A semen sample will be collected and then placed in a sterile tube. This sample is analyzed:

• Volume
• Amount
• Concentration
• Movement
• Structure

The results of this semen analysis will provide an idea of whether sperm can function properly to fertilize an egg. Even though the examination shows a low sperm count or no sperm, it does not mean you are permanently infertile. This only shows that there is a problem with the growth or delivery of sperm, so further examination is still needed.

Ultrasound

Ultrasound examinations use sound waves to obtain images of organs. A probe will be placed in the rectum to look for abnormalities in the reproductive system.

Testicular biopsy

If a semen examination indicates that the sperm count is very low or there are no sperm, then further examinations, such as a testicular biopsy, can be carried out. A small sample of tissue from each testicle will be taken and examined under a microscope. The purpose of the examination is to help find the cause of infertility; it can also be used to collect sperm in assisted reproduction programs such as IVF.

Hormone profile

The doctor may check hormones to find out how capable the testicles are of producing sperm. This examination can also rule out the possibility of differential diagnosis of other diseases.

Management

Generally, doctors will recommend the patient's lifestyle modification. Common topics of discussion include:

• Quit smoking
• Limit or stop alcohol consumption
• Start consuming nutritious food
• Maintain an ideal body weight, not too much or too little
• Increase physical activity
• Reduce stress
• Avoid using lubricants with dangerous ingredients during sexual activity
• Avoid saunas and tight underwear

Treatment options for most men are generally limited to:

• Resection of the ejaculatory duct if an obstruction is found in the flow of semen
• If you have had a vasectomy, the patient can undergo surgery to reconnect the tubes that carry sperm
• Patients with varicoceles can be treated with surgical procedures to repair enlarged blood vessels in the scrotum

If the cause of infertility is not obstruction or varicocele, generally, the doctor will try to treat the disease that is the root of the problem of infertility. However, it should be noted that male infertility therapy options generally still have incomplete and inadequate research data.

Complications

Complications of male infertility include:

• Stress and relationship problems resulting from the inability to have children
• Treatment can be expensive
• Increased risk of testicular cancer, melanoma, colon cancer, and prostate cancer

Prevention

Male infertility cannot always be prevented. However, you can try to avoid some causes of infertility, such as:

• Quit smoking
• Limit or stop alcohol
• Avoid using illegal drugs
• Maintain ideal body weight
• Avoid things that can increase testicular temperature
• Reduce stress
• Avoid exposure to pesticides, heavy metals, and other toxins

When to See a Doctor?

You should consult a doctor if you are unable to have children after one year of regular sexual intercourse without contraception or if you have the following conditions:

• Erection or ejaculation problems, low sex drive, or other problems with sexual function
• Pain, discomfort, lump, or swelling in the testicular area
• History of testicular, prostate, or other sexual problems
• History of surgery on the groin, testicles, penis, or scrotum
• A couple over 35 years old

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