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Male factor infertility Factors
  1. Defective spermatogenesis
  2. Obstructive azoospermia
  3. Failure to deposit sperm high in the vagina
  4. Errors in the seminal fluids.
  5. Iimmunological cause
Defective spermatogenesis
1. Congenital causes
Undescended
Some genetic abnormalities like Klinefelter’s Syndrome (47XXY) can lead to incomplete development of the testes. The other chromosomal abnormalities could lead to nonfunctioning testes or functioning testis with poor quality sperm production.
2. Acquired causes
  • Optimum production of spermatozoa takes place when the testes is  slightly cooler than rest of the body, as in scrotum.In some cases the temperature of the testes is increased like in varicocele
  • Big hydrocele
  • Tight undergarments
  • Working in hot atmosphere thus adversely affecting spermatogenesis.
  • Trauma to testes like accident
  • Torsion
  • post operative scarring may adversely affect the spermatogenesis.
3. Infections
Infection causes testicular tissue damage which might be irreversible like in Mumps, Influenza, TB, Gonorrhoea, Filariasis, Syphilis, Brucellosis, Chlamydia infection.
4. Endocrinologic factors
The secretion of gonadotrophins directly or indirectly affects spermatogenesis. Hyperprolactnemia, thyrotoxicosis, diabetes mellitus
5. Toxins
Some drugs like cimentidine, spironolactone, colchicines, hormones, anabolic steroids can cause depression of sperm production. Radiations, Cytotoxic drugs like alkylating agents-cyclophosphomide, busuphan, chlorambucil can directly and irreversibly affect the spermatogenesis in testes.

OBSTRUCTION
Congenital causes
In some patients like those suffering from cystic fibrosis or carriers of cystic fibrosis genes the vas deference or seminal vesicles fail to develop while the spermatogenesis in testes is normal as the sperms cannot be transported to the ejaculatory duct and urethra, so the ejaculate shows azoospermia.
Acquired causes
Surgical trauma like herinoraphy , vasectomy or infections like Gonorrhea and tuberculosis, here again the production of spermatozoa is normal and because of obstruction, the ejaculate will show azoospermia
Failure to deposit sperms in vagina

  1. Infrequent sexual intercourse
  2. wrong timing of intercourse
  3. Impotence, erectile dysfunctions
  4. Premature ejaculation
  5. Failure of ejaculation.
  6. Retrograde ejaculation (can occur even in normal men)
  7. Abnormality of penis
  8. Psychosexual causes
Some of couple could be having delay in conception as they might not be having regular intercourse at fertile period, there by not ensuring the availability of enough spermatozoa in the genital tract to fertilize the egg at the time of ovulation.
Immunologic cause
Couple may have circulating antibodies against spermatozoa, in the semen and or blood. These antibodies are produced when there is damage to the testes or infections of the testes and surrounding tissues. IgGantisperm antibodies are found in the serum while IgA are found in cervical mucus; both classes of antibodies are found in seminal fluids. These antibodies binds to the sperm and immobilizes them or can cause clumping or agglutination of spermatozoa. Usually anti sperm antibodies causes sub fertility than frank infertility.

Treatment of the male partner
The treatment of male part is usually done by andrologist.
Role of empirical therapy?
Empirical treatment for 2-3 months if the man has OAS
  • anti-oxidants like Vit. E or herbal medicines
  • zinc-containing multi-vitamins
Dos and Don’ts for male with suboptimal sperm parameters
  • Discontinue any adverse drug use or Drug abuse
  • Avoid any exposure to X-RAYS, Radiations ,excessive heat or chemicals like pesticides, plastics etc
  • To stop smoking and any use of tobacco in any form
  • To avoid alcohol intake
  • Avoid tight under garments, tight clothing
  •  saunas, steam and very hot baths
  • Stress /irregular diet
  • Obesity
Repeat SA after  3 months. If no improvement, one can try a wide variety of drugs like clomiphene, oral testosterone, cell energizers, etc. Some patients seem to benefit, though controlled studies have not been able to prove benefit. These drugs can be tried for some time, but too much time should not be wasted.
Role of antibiotics in treatment of ‘pus cells’ in semen analysis.?
Do not give antibiotics for “pus cells” without confirming pyospermia by stained smear examination - there are 3 types of round cells in the semen: leucocytes, macrophages and spermatocytes; only leucocytes indicate infection; most labs do not distinguish between these cell types and erroneously label all round cells as pus cells, leading to a false diagnosis of infection and unnecessary antibiotic therapy.
Anti-filarial Therapy
Chronic filarial epididymo-orchitis is a common tropical problem that can cause infertility. Treatment with anti-filarial and anti-inflammatory medications can produce dramatic improvement in some cases
Antisperm antibodies in men
The treatment of Anti sperm antibody in cases of infertility is disappointing.
Various methods from steroid therapy to immunomodulators have been tried without much success. Suppressing the immune system with corticosteroids may decrease the production of antibodies but can result in serious side effects, including severe damage to the hipbone.
Intrauterine insemination, with or without the use of fertility medications, has been used for the treatment of antisperm antibodies. It is believed to work by delivering the sperm directly into the uterus and an easier access to fallopian tubes, thus bypassing the cervical mucus.
In vitro fertilization appears to be the most effective treatment for antisperm antibodies, especially when antibody level is very high.
Varicocele
The treatment of varicocoel is very controversial. Varicocoel is common finding among fertile men. The surgical option is only considered in couples who are infertile with abnormal semen parameters, with no other apparent reason.
Some facts
  • Affects 15% of all men
  •  Many men with varicoceles are fertil
  •  A varicocele in an infertile man may be coincidental
  • After varicocele surgery, only some men will have improved semen
  • Some infertile men with varicoceles, may improve on medical therapy alone
  • Hence, not every infertile man with a varicocele needs surgery
Approach to therapy  Varicocele with normal SA no surgery  is required ,operation will only be beneficial if semen parameters deteriorates ,  if sperm function tests are abnormal or there is  testicular atrophy
  • Varicocele with abnormal SA
  • Initial trial with medical therapy : 25% will improve
  • If no improvement,  surgery  : 60% will improve
  • If no improvement then  IUI or ICSI
Clinical impression can be misleading, USG should be done when surgery is being considered which will  reconfirm diagnosis (differentiate from lymphangiocele) and Will help decide whether right side needs surgery when varicocele is clinically obvious only on left side
Hypogonadotropic Hypogonadism
Once the diagnosis is made, the treatment would include hormone replacement therapy.
Hormone injections
HMG and HCG injections mimic the action of natural FSH and LH. They are specifically indicated for treatment of hypogonadotropichypogonadism where hormone levels are well below normal. Gonadotropin injections are expensive .The role of empirical gonadotropin therapy in men with normal hormone levels is unproven.
Azoospermia
once the  diagnosis of azoospermia is made, after ruling out psudoejaculation., effort should be made to check if there are any precursors cells  of sperm that are found in the sample. If the sperm precursors are found it rules out an obstructive cause of azoospermia and confirms the pathology to be testicular failure.
Next attempt is to find out vas aplasia or ejaculatory duct obstruction in fructose positive patients. Obstructive azoospermia or primary testicular failure present as fructose negative.
Vas aplasia: this diagnosis is made clinically. There is a mutation in Cystic fibrosis gene and the mutation can be of variable degree, spermatogenesis in these patients is normal and azoospermia is only because of the inability to come out during ejaculation because of vas aplasia . The treatment would be surgical sperm retrieval like percutaneous epididymal sperm aspiration (PESA) using insulin syringe and fine needle. The obtained epididymal fluid contains sperm which can be used for Intra Cytoplasmic Sperm Aspirations (ICSI)
Ejaculatatory duct obstruction
It can be congenital or acquired. A diagnostic PESA can be done to confirm the presence of sperm and this can be cryo preserved and used for ICSI cycle Or PESA can be done with ICSI cycle itself.
Surgical correction or anastomosis can be done, vaso-epididymal or vaso-vasal in selected cases of obstructive azoospermia is successful.
Testicular failure
In Primary testicular failure can be reversible following high fever, chemotherapy or radiation.
In cases of irreversible testicular failure, these patients might have small pockets of spermatogenesis in the testis, so ejaculate may show few motile sperms as it is a total collection from all the seminferous tubules in both testis which can be used for ICSI. A multiple needle aspiration biopsies or single seminferous tubule biopsy can be done and material scanned under microscope for any sperm and that can be used for ICSI procedure.
Testicular Biopsy
Indications:
  • DiagnosticIn azoospermia with normal FSH to distinguish between obstructive and non-obstructive azoospermia.
  • In azoospermia with elevated FSH (testicular failure) to see whether there is focal spermatogenesis so that TESE-ICSI can be done,
  • TherapeuticFor sperm retrieval in azoospermic men
What is new?
Needle biopsy - this avoids the need for open biopsy.
Multiple diagnostic biopsies - we now understand that in some men with testicular failure, there may be a few areas of focal spermatogenesis. If these sperm can be recovered they can be used for ICSI. To diagnose such men, multiple biopsies (testicular mapping) are needed since a single biopsy may not identify the area of sperm production.
Erectile dysfunction (ED)
Impotence is the repeated inability to achieve and sustain erection long enough for a sexual intercourse to take place. In older men, erectile dysfunction usually has an organic cause like injury to the nerve, smooth muscles, fibrous tissues, or impaired blood flow. Diseases such as diabetes, renal disease, chronic alcoholism, atherosclerosis, vascular disease, and neurologic disease account for large percentage of erectile dysfunction patients. The other reason for ED can be iatrogenic, related to medicines that these men could be taking like antihypertensive drugs, some antihistamines, antidepressants, tranquilizers, Cimetidine. The third category is psychological factors such as stress, anxiety, guilt, depression, low self-esteem, and fear of sexual failure.
Treatment would start with life style modification like quitting smoking, losing excess weight, increasing physical activity, Cutting back on any drugs with harmful side effects may help some men regain sexual function. Psychotherapy and behavior modifications will also benefit these men.
Drug Therapy
Oral -oral medicines improve the response to sexual stimulation, they do not trigger an automatic erection.Phosphodiesterase (PDE) inhibitors, Viagra has to be taken an hour before sexual activity. These drugs work by enhancing the effects of nitric oxide, a chemical that relaxes smooth muscles in the penis during sexual stimulation and allows increased blood flow. This group of drug is contraindicated in men who take nitrate-based drugs such as nitroglycerin for heart problems.
Injectable drugs
Drugs such as papaverine hydrochloride, phentolamine, and alprostadil can be injected into penis this causes widening of blood vessels causing it to become engorged with blood.
A system for inserting a pellet of alprostadil into the urethra, erection will begin within 8 to 10 minutes and may last 30 to 60 minutes. The most common side effects are aching in the penis, testicles, warmth or burning sensation in the urethra, redness and minor urethral bleeding or spotting.

 Mechanical vacuum devices
Mechanical Vacuum devices cause erection by creating a partial vacuum, which draws blood into the penis, engorging and expanding it.
Surgical therapy
Implanted devices, known as prostheses, can restore erection Ejaculatory dysfunctions
  • Premature ejaculation
  • Delayed ejaculation
  • Retrograde ejaculation
  • Anejaculation/anorgasmia
The etiologies of these ejaculatory dysfunctions are numerous and multifactorial; psychogenic, congenital, anatomic, neurogenic, infectious, endocrinological, and iatrogenic factors secondary to medications.
Premature ejaculation, if it does not take place outside vagina will not result in infertility.
Retrograde ejaculation is caused by diabetes, antihypertensive medication, and mood elevator drugs or by urethral / prostate surgery.
The condition can be partial or complete and diagnosis is made by urine analysis obtained soon after ejaculation, which will reveal large number of sperms.
Treatment would be to stop or substitute the offending drug. In post surgical cause such as post genito urinary surgery or as in diabetes, they are usually irreversible but some improvement might be seen with imipramine or pseudephedrine like drugs.
Untreated Retrograde ejaculation with no neurologic problem would require the patient to go through a process of IUI to achieve pregnancy.