1. Abnormalities in the Production of
Competent Sperm
Testicular
Damage/Maldevelopment - Poor spermatogenesis / Poor sperm function.
1.
Males
may have these conditions following
mumps orchitis, cryptorchidism, or in association with Klinefelter's
syndrome. Males with the latter genetic abnormality (XXY) usually have
small testes and azoospermia. Exposure to radiation or to industrial
or environmental toxins, marijuana and alcohol use, smoking, drugs,
including cimetidine, spironolactone, nitrofurans, sulfasalazine,
erythromycin, tetracyclines, anabolic steroids, and chemotherapeutic
agents, can depress sperm quantity and quality.
Resumption of spermatogenesis has been reported to occur within 2
years following discontinuation of anabolic steroids; however, it is
not known whether all individuals will return to normal function.
Exposure to diethylstilbestrol in utero has been suggested, but not
proven, as a cause of male infertility.
2.
Approximately
20% to 40% of infertile males, depending on the zeal of the search,
have a varicocele, usually on the left side because of the direct
insertion of the spermatic vein into the renal vein. A
small-randomized trial in Germany observed a significant increase in
sperm concentration in the treated group up to 30--35% pregnancy rate.
The same change, however, was noted in the nonoperated group, and the
pregnancy rates in both the operated and nonoperated groups were the
same.
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2. Abnormalities in Male Reproductive
Tract Transport of Sperm (obstructive
abnormalities of Vas Deferens or Epididymis).
Obstructive
Azoospermia (absence of spermatozoa in the semen)
1. Previous
Vasectomy, failed vas reversal, obstruction of the vas deferens &
iatrogenic damage to the vas deferens or epididymis.
2. Congenital
bilateral absence of the vas deferens (screening for cystic fibrosis
mutations should be considered).
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3. Abnormalities in
Anterograde / Onward Ejaculation (retrograde
ejaculation, anejaculation)
1.
Retrograde Ejaculation
In retrograde ejaculation,
the part of the bladder that normally closes during ejaculation (the
bladder neck) remains open, causing the ejaculatory fluid to travel
backward into the bladder. Common causes of retrograde ejaculation
include diabetes, spinal cord injuries, certain drugsΦ, and
some surgical operations (including major abdominal or pelvic
surgery--one of the most common causes is transurethral resection of
the prostate).
A doctor makes the diagnosis
of retrograde ejaculation by finding a large amount of sperm in a
urine sample. About one third of men with retrograde ejaculation
improve after treatment with drugs that close the bladder neck (such
as pseudoephedrine, phenylephrine, chlorpheniramine, brompheniramine,
or imipramine). However, most of these drugs can increase heart rate
and blood pressure, which can be dangerous in men with high blood
pressure or heart disease. Diabetes, some neurologic diseases, or
occasionally following prostatectomy or pelvic lymphadenectomy, there
can be retrograde ejaculation into the bladder.
The presence of sperm in the
bladder can be determined by examining a post-ejaculation urine
sample.
Φ
Neurologic ejaculatory dysfunction can
be caused by β-blockers, phentolamine, methyldopa, guanethidine, and
reserpine.
2. Spinal Cord Injury, paraplegia,
quadriplegia and anejaculation
The
nerves that are responsible for carrying the signal for ejaculation
exit the spinal cord and course along the aorta at the posterior part
of the abdomen. These nerves are most commonly injured after spinal
trauma resulting in paraplegia (paralysis of both legs and often other
structures in the lower part of the body) or quadriplegia (the
inability to move all four limbs or the entire body below the neck),
major bowel or vascular surgery, or surgery for testicular cancer.
In the past, men with ejaculatory
dysfunction were considered infertile because they couldn't ejaculate
and impregnate their wives even though they did produce sperm within
their testicles. Penile vibratory stimulation (PVS) employs a custom
designed mechanical vibrator (store bought vibrators don't work for
most patients) that is applied to the underside of the glans penis and
set to vibrate at designated frequency and wave amplitude. This
technique only works in patients with an intact ejaculatory reflex arc
and the results are dependent on the level of spinal cord injury.
Electroejaculation is performed with a device known as an
electroejaculator. Electroejaculation must be performed under general
anesthesia in all patients who have abdominal and perirectal
sensation.
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4. Other conditions including Immunologic,
endocrine and infectious factors
affecting multiple components of fertility.
1. Immunology Disorders (anti-sperm antibodies):
The
presence of both IgG and IgA antisperm antibodies are measured on the
sperm surface. The results are given in terms of the number of motile
sperm affected by antisperm antibodies. Surface antibodies may affect
both movement of the sperm and the ability of the sperm to bind and
fertilize the oocyte. Results are clinically significant and positive
if more than 50% of sperm are affected by either class of antibody.
IgA antibodies are considered of greater clinical significance than
IgG. Antisperm antibodies often are associated with testicular surgery
(i.e., vasectomy, vasectomy reversal) or trauma.
2. Endocrine Disorders:
Thyroid, gonadotropins,
prolactin, and testosterone may occasionally uncover unsuspected
abnormalities. FSH levels are elevated with germ cell aplasia, and
testosterone levels are decreased in men who are hypogonadotropic.
Hyperprolactinemia is commonly associated with impotence, and in the
absence of impotence, measuring a prolactin level is unlikely to aid
in the diagnosis. Infusion of gonadotropin-releasing hormone (GnRH)
can stimulate secretion of gonadotropins, and there have been
occasional reports of the usefulness of this treatment as well as the
administration of gonadotropins in males who have an isolated
gonadotropin deficiency.
3.
Urogenital Infections, Reactive Oxygen Species, Misc.
Infection in the
genitourinary tract, including those caused by Mycoplasma, Ureaplasma,
gonorrhea and chlamydia should be treated. Increased levels of
reactive oxygen species can cause damage to the sperm membrane.
Substances such as peroxidase and hydrogen peroxide can be released by
abnormal sperm and by white blood cells, and when elevated levels of
leukocytes are present in the semen (with or without a positive
culture), treatment with vitamin E and glutathione is advocated.
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