Prof. Dr. Mustafa SOFİKERİM | Urology

Male Infertility

Infertility is a complex health problem with a high rate of approximately 15% of couples who want to have a child. Approximately 50% of the couples suffering from the problems of pregnancy are stricken with the problem of male reproductive system. In spite of unprotected and regular sexual intercourse, all conditions in the male preventing the pregnancy to occur in the spouse for 12 months, is called male infertility. Generally, the problem causing male infertility is either in sperm production or maturation or in the transfer of mature sperm.

Male fertility (reproductive capacity) involves the transmission of the sperm produced in the testicles (eggs) through the reproductive channels and the delivery of the sperm to the female reproductive canal. Male fertility begins with the stage of maturation of the crude sperm in the very small ducts (seminiferous tubules) in the testicles at a mean period of 69 days. The maturing sperms leave the testicle and are stored in a section called epididymis where the movement gains and completes its development. Once stored, it is transferred to just before ejaculation to the “ejaculatory duct” and “urethra”, surrounded by the prostate, through the sperm canal called “vas deferense” when necessary. During ejaculation, it is ejected through the urethra from the penis end. There is a need for a genetic structure working perfectly for the formation, maturation, storage, transfer of sperm as well as healthy organs and their environment and hormonal effect.

• Sperm disorders

Sperm production or sperm development problems are one of the most common causes of male infertility. Sperms are either inadequate mature and cannot reach their mature form and mobility. Or, as normal sperms in the testis may be produced less than necessary amount (oligozoospermia), there may be no sperm production (azoospermia).

• Varicocele

Usually seen in the left testis. It is more than normal expansion of the veins of the testis. Due to varicocele, the feeding of the testis and the decrease in the transfer of oxygen in the testis emerges and this can lead to developmental disorders of sperm production. Varicocele is seen in 16-20% of males and the rate of varicocele in men with infertility is 40%. Varicocele is the most common cause of male infertility.

The treatment of male infertility is also the specific treatment for its cause. In some severe cases, treatment may not be possible. Combined therapies are usually applied as mixed therapy.

Treatment Options

In the presence of varicocele, especially when varicocele grade is high and testicular development is impaired, the chance of getting benefit from varicocele surgery increases. Varicocele surgery is called varicocelectomy. Today, varicocelectomy should be done either under optical magnification or under the microscopic image at the level of the groin channel. The patient is taken out of the hospital on the same day or the next day after this operation which lasts about 1 hour. Semen analysis is performed at postoperative 6th and 12th months for improvement in sperm quality.

Drug treatments:

Depending on the specific condition of the disorder causing infertility, the treatments also vary.

Sperm production may be affected by the deficiency in the level of hormones required. Sperm production can be gained by replacing these hormones. However, it should be kept in mind that the desired response in such treatments may emerge at least 9-12 months after long-term treatment.

There are many therapeutic approaches to increase the quality of sperm (without specific cause). However, there are very few studies that show that their scientific activities are significant. The efficacy of the drugs (kallikrein, L-arginine, E-vitamins, pentoxifylline) given in these cases is not different from the placebo (active substance-free substance).

Varicocele is the expansion and varicosity of the veins draining the blood in the eggs in men.

The veins that regulate the blood circulation on the inner surface of these varicose veins have lost their function and cannot drain the blood. Excess and abnormal expansion of the valves in the testis, the testicle heat effect and malnutrition result in the fact that sperm producing cells are exposed to toxic substances. This affects the formation of sperm because the substances in the testis are badly influenced.

Approximately 40% of men with infertility have varicocele. This rate is higher than 80% in males with previous children who have a secondary infertility complaint. Varicocele can be seen in both testes. However, the incidence of left testicle is 85% and 15% for the right testis due to their anatomical neighborhood. Varicocele on one side usually affects the other testicle.

Varicocele often gives no symptoms. However, sometimes the following symptoms can be seen: Pain in the testes Depression in the testicles, Fullness in the testicles, Infertility, Visibly enlarged veins, Expanded veins. The patients come to the doctor because of enlarged veins in the egg they see while they are standing. The diagnosis is usually manually made by the doctor. Ultrasonography / Doppler should be performed. Sperm analysis, sperm count, motility and shape should be investigated after 3-4 days of sexual abstinence in all patients with varicocele. About 60% of the patients had decreased sperm density and motility, and their shape deteriorated. In men with varicocele who have a complaint of infertility, surgical treatment is recommended in men with very severe pain and in one of the testicles with varicocele. To switch to treatment, varicocele may not necessarily have impaired sperm values. If there is varicocele identified in unmarried males and the sperm have begun to deteriorate, treatment may be recommended. If the male is at adolescent age, that is not yet in mature age, and he can not provide sperm, then it is checked if there de-growth in the testis. If there is a volume loss of 10% or more, the operation is recommended.

Its Treatment Is Operation

Surgical microscope is recommended during surgery. It is performed with a small incision made in the groin area. Varicose veins are connected. The success rate of varicocele surgery is variable. Microscopic surgeries have a higher chance of success than others. It takes about 45 min. During this process, care should be taken not to damage the other formation related to the testis. If varicocele surgery is not performed carefully, complications such as hydrocele (fluid around the testes) and atrophy may be seen. However, in recent years, these complications are much less common due to the progress in the surgical technique. The people who will be operated on should know this and the doctor who will perform the surgery should get information about it. After 3-6 months after surgery, sperm production starts to improve. Sperm examination should be performed at 6 months after surgery. Improvement in sperm production is seen in 60-70% of patients who undergo surgery. The effect on pregnancy is also very positive. Although varicocele surgery is recommended in special cases in azoospermia, it should be stated that its success will be lower. However, it should be kept in mind that the success of assisted reproductive techniques may increase after varicocelectomy in some of these patients.

It is also possible to increase the success of the tube infant after the varicocele surgery. In some of the operated patients, sperm values can be increased and tube baby application can be started.