Male Infertilty: Investigations and Treatments

INVESTIGATIONS

Post-Coital Test

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What is the post-coital test?

The post-coital test assesses the ability of sperm to reach the canal of the cervix and survive in the mucus. One of the signs that a woman is ovulating is that there is a noticeable change in the mucus secretion. At the time of ovulation, the ovaries produce more estrogen as a result of which the mucus secreted by the cervix of the uterus becomes very profuse, clear and watery like saliva. The cervical mucus also becomes more receptive to sperm.

When should I take the post-coital test?

A post-coital test will be performed at the clinic and will be scheduled as close to the time of ovulation as possible. Previous basal body temperature charts can help to ascertain the time of ovulation. It will be necessary for you to have intercourse around eight hours before the test is performed.

Isn’t intercourse “on demand” very stressful?

Being required to schedule your sexual intercourse can put undue pressure on both you and your partner. Some couples find that they just cannot seem to go through with intercourse in such a clinical fashion. Some men have even failed to achieve an erection. This, in turn, increases anxiety and tension. Remember that the clinic has merely made a request. Men often find it easier to comply with this request if they have been involved in the investigations and other procedures right from the start.

How is the test carried out?

A speculum is gently inserted into the vagina, and a sample of mucus is taken from the canal of the cervix. It is a painless procedure that lasts for just a few seconds. The mucus sample is then transferred onto a glass slide. While this is being done the ”stretchability” of the mucus is noted. The mucus sample is then examined under a microscope. The sperm population is counted and their degree of activity assessed.

How are the post-coital test results analyzed?

A completely normal post-coital test will show very flowing ”stretchable” mucus containing a significant number of moving sperm. The sperm must be normal in appearance and moving across the slide and not simply shaking on the spot. A post-coital test of this quality implies that the sperm count is normal, that the sperm are gaining access to the canal of the cervix and that there is no major cervical mucus hostility factor.

Mucus with fewer sperm does not necessarily mean that there is a problem. However, there is a greater probability that pregnancy will occur when the sperm population is higher.

When is a post-coital test considered negative?

A post-coital test is considered negative if no sperm or only dead sperm can be found in the mucus. This does not mean that conception is impossible. It merely indicates the need for further investigation. Sometimes the mucus itself is very thick and tenacious rather than watery and flowing. A negative post-coital test may be due to:

Incorrect timing of the test 

• Cycles where ovulation is not occurring
• A low or even zero sperm count
• Antibodies preventing progressive movement of the sperm. These may be present in the mucus itself or even in the seminal fluid carrying the sperm

If your post-coital test is found to be negative, it will probably be repeated. If the repeat test should still be negative, then other tests (see below) may be necessary.

Semen Analysis

What is semen analysis?

While a positive post-coital test result will indicate that the sperm count is normal, an analysis of the semen itself is the most basic test that can be carried out on the male partner.

How is the test carried out?

A semen sample will be collected by asking the man to masturbate directly into a special sterile container. There is no point trying to collect a sample by withdrawal at intercourse as some of the initial part of the ejaculate is lost. Transferring a sample from a condom does not help either as most sheaths these days contain a potent spermicide. Some specialists recommend that you abstain from intercourse for a few days before the sample is collected. However, others feel that it is better to follow your normal pattern of intercourse. The semen sample should be kept warm and should be delivered to the laboratory for testing within one hour of production. After the sample volume has been measured, the following calculations are carried out.

• The number of sperm per milliliter (ml)
• The percentage of sperm showing normal forward progressive movements (motility)
• The percentage of abnormal sperm

What are the indications for normal semen?

A normal semen analysis will show:

• A volume greater than 2 ml.
• A count of more than 30 million sperm per ml
• A motility greater than 60% within one hour of production
• An abnormality rate of less than 25%

What if the semen analysis results are not normal?

If a man’s semen analysis falls short of the figures given above, it does not imply that a pregnancy will be unlikely. Different samples from the same person will show different results. This is why a reduced semen analysis will always be checked with one or two repeat tests. Changes in a man’s general health 10 weeks before the collection of the sample can affect the sperm count and motility. For example, if he has had an illness like ‘flu, it can reduce both the count and motility in a sample produced 10 weeks later, as this is the time taken for sperm to reach maturity. A repeat sample tested after an additional 2-3 months could very well be normal.

What will the results of the semen analysis tell me?

If the man has a good quality semen sample with a count of 10 million per ml and the woman’s fertility is normal, then statistically it will take up to 6 years for the woman to become pregnant. If the count is 20 million per ml and of good quality it will take up to 3 years, and at 30 million per ml a pregnancy should occur within a year. But keep in mind that these are generalizations that cannot be blindly applied to every couple. The quality of the semen is always more important than the quantity of sperm per ml.

Treatment of the Infertile Male

Oligospermia

In cases of oligospermia, the man should first try to control the known environmental causes of the problem. Cutting down on heavy smoking and drinking and reducing work pressures are a few steps that you can take. Obese men should go on a weight loss programme. Do not have baths in scalding hot water. If intercourse is very frequent, a reduction in the frequency of ejaculation is very advisable.

Absence of Testicles

There is no treatment for men who do not have testicles or whose vas deferens is absent from both testicles. The tying off of varicoceles by high ligation and the surgical removal of hydroceles can bring about dramatic improvement in spermatogenesis, but there is no guarantee that these operations will be successful. If the testicles tend to lie in the groin region, the operation of orchidopexy that keeps them in the cooler environment of the scrotum can also be beneficial.

Retrograde Ejaculation

Intercourse on a full bladder can solve the problem of retrograde ejaculation. This will force the sperm to move in the right direction. The alternative is to remove the sperm from the urine that is passed immediately after ejaculation, and then by artificial insemination introduce the sperm into the cervix.

Obstruction in Sperm Flow

If tests have shown that there is an obstruction to the outflow of sperm from the epididymis of the testicles, the operation of epididymovasostomy can be performed. This procedure removes the blocked portion of tube and rejoins the open healthy tubes to each other. Unfortunately the success rate of this form of microsurgery is poor.

Bacterial Infection

Any infection indicated by a high white cell count in the semen may be due to a chronic infection of the prostate gland. Treatment with a long course of antibiotics can be very beneficial.

Antibodies

When there is severe agglutination of sperm in the semen sample due to antibodies in the sperm, the prognosis is not good. Theoretically, it is possible to remove antibodies from the sperm to prevent them from sticking together. Some doctors prescribe special steroid therapy to reduce the sperm antibodies, but there are potential risks to this form of treatment.

Hormone Disorders

Save in the case of a hormone deficit, hormone therapy in the male generally has disappointing results. Treatment with clomiphene, Pergonal, H.C.G. and testosterone are associated with a limited success rate. A weak male hormone, mesterolone, is frequently prescribed to men with oligospermia, but here too the results are poor.

Sperm Dilution

If split ejaculate semen analysis shows that there is a considerable increase in the sperm count in the first part of the ejaculate, then the technique of split ejaculate intercourse carried out only at the time of ovulation can be helpful. In split ejaculate intercourse, the man will have to withdraw after the first part of the ejaculation has occurred. This will ensure that a higher than usual sperm population is deposited in the vagina. This is not the most comfortable and satisfying way of having intercourse, but to do it this way just once a month is surely not too much to ask if you want a child. The alternative is to use the first part of the ejaculate for artificial insemination.

Various Male Fertility Disorders

Azoospermia

Azoospermia, characterized by the absence of sperm, is either due to an obstruction in the outflow system from the testicle, in the epididymis or vas deferens, or due to a failure in sperm production (spermatogenesis). If a biopsy of the testicle showed that spermatogenesis was normal, this would then indicate that an obstruction was the cause of the azoospermia. Vasograms, which are X-rays of the vas deferens, can then be performed to identify the location of the obstruction.

Presence of Antibodies

Sometimes, a semen sample when seen under a microscope will show sperm clumping. This may indicate the presence of sperm antibodies that are causing the sperm to stick together. A blood sample can be tested for the presence of agglutinating and other sperm-inhibiting antibodies.

Klinefelter’s Syndrome

Very small testicles may be the manifestation of Klinefelter’s Syndrome. This is caused by a chromosomal aberration. Thus, a chromosome investigation will show the presence of an extra X (female) chromosome.

Hormone Disorders

Hormone disorders are rare causes of male infertility, but it may sometimes be helpful to check the man’s F.S.H., L.H., testosterone (male hormone), prolactin and thyroid hormone levels.

Bacterial Infection

The existence of an excessive amount of white blood cells in the semen sample may indicate that an infection may be reducing the ability of the sperm to fertilise an egg. The semen sample should then be cultured to determine the type of infecting bacterial organism.