Reasons for Male Infertility

 Sperm Characteristics

 Male Infertility Treatments

 Reasons for Female Infertility

 Fallopian Tube Factor

 Ovulation Factor

 Cervical Factor

 Uterine Factor

 Peritoneal Factor

 Unexplained Infertility

Infertility (being unable to conceive a child) is a problem encountered in most societies today. It is defined as being unable to conceive after 1 year of regular, unprotected sex. 

15% of couples in the world apply for assisted reproduction techniques (ART) due to infertility. In the majority of couples a reason for infertility can be found, but in 10-15 % of couples no factor can be found. Factors affecting infertility are 30-40 %  male, and 30-50 % female. Because of this, both partners are evaluated to find the infertility reason.

Reasons for Male Infertility 

In 40% of infertility cases the infertility reason is either fully or partly due to a male factor. Because of this, a semen analysis is very important in assessing infertility. The male partner is asked not to have sexual intercourse at least two days and at most five days prior to this test. On the day of the test, in the center, he will be asked to provide a semen sample by masturbating.  The semen sample's sperm concentration, motility (movement), and morphology (shape) will then be analyzed under the microscope. Since sperm quality can vary with time, it is recommended that a semen analysis be performed 2-3 times in a two to six month period. 

Hormonal Reasons: By secreting the hormones FSH and LH, the pituitary gland located in the brain stimulates testosterone secretion and sperm production in the testes. Thus, sperm production can be altered due to a hormonal imbalance.

Testicular Reasons: 6 % of infertile male also happen to have genetic anomalies. 10-15% of azoospermic men (semen without sperm) have genetic anomalies. 

Kryptorchidism (undescended testes) is another reason sperm may not be produced. Male babies' testes are generally located in the abdomen at birth and descend into the scrotum during the child's first year. If there is a delay in the descent of the testes, they  should be surgically lowered by the child's second birthday. Testes remaining in the abdomen or descending later on in life generally cannot produce sperm and these testicles might even be cancerous.

Varicoceles: a condition seen in 38 % of infertile men are varicose veins of the scrotum. The slowing down of blood flow due to these veins is thought to cause a temperature rise and sometimes irregular reproductive organ function. This reduces sperm motility, concentration and morphology. 

Chemotherapy or radiotherapy treatments to cure tumors within/out of the testes can also considerably affect sperm production. There are also some recent papers suggesting that smoking and drinking alcoholic drinks affect sperm production. Despite advanced diagnostic techniques available today, the underlying cause for 25 % of men with abnormal sperm parameters cannot be found.

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Sperm production is also affected by high fevers caused by some diseases and by liver and kidney diseases.

Diabetes, neurological diseases, lumbar spinal cord damage caused by trauma, urinary tract surgeries can all cause retrograde ejaculation where the ejaculate flows back into the bladder instead of coming out through the penis.

Sperm Characteristics

Terms frequently found on semen analysis results:

  Normozoospermia: Normal sperm count, motility and morphology.

  Oligospermia: A sperm count of less than 20 million per ml.

  Teratozoospermia: A lower than 4% normal sperm count (according to the Kruger criteria).

  Polyspermia: A sperm count of more than 250 million/ml.

  Hypospermia: An less than normal semen volume.

  Hyperspermia: An abundant semen volume.

  Asthenozoospermia: Sperm motility which is below normal.

  Oligasthenozoospermia: Sperm motility and concentration which are below normal.

  Oligoteratozoospermia: Sperm concentration and morphology which are below normal.

  Asthenoteratozoospermia: Motility and morphology which are below normal.

  Oligoasthenoteratozoospermia: Sperm concentration, motility and morphology which are below normal.

  Hematospermia: An abundance of blood cells in the semen.

  Necrospermia: An abundance of dead cells in the semen.

  Aspermia: A complete absence of semen.

  Azoospermia: A complete lack of sperm in the semen.

Normal Sperm:

Abnormal Sperm:      

Male Infertility Treatments        

In most cases the man should consult an urologist or a doctor specialized in male infertility. The treatments for male infertility include antibiotics for infection, surgery for varicoceles or channel blockage, insemination, IVF or other assisted reproductive technologies like TESE and TESA.

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Reasons for Female Infertility

Fallopian Tube Factor

If an HSG shows open healthy fallopian tubes in a young patient or if another problem has been diagnosed and is being treated, the doctor might delay laparoscopy. If pregnancy still has not occurred after 6-12 months, a laparoscopy should be recommended.

If the tubes are found to be blocked or damaged by adhesions, the problem can be solved with surgery. Despite this, since women with severe tubal damage have very low chances of getting pregnant, IVF is the preferred treatment.

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Ovulation Factor

Cervical Factor

Although a cervical factor caused by a functional problem of the cervix or problems with cervical mucus  is rarely the sole reason for infertility, it can be one of the factors causing infertility. 

During mid-cycle, the mucus produced by the cervix should be clear, colorless, watery, abundant and stretchy. When all these conditions are met, sperm can easily access the uterus and  tubes.  

The inadequacy of the mucus quality or quantity can be caused by functional problems of the cervix caused by cervical polyps, or a previous surgery to the cervix (eg. cone biopsy) or by inadequate estrogen and progesterone production. 

Cervical problems can be treated with intrauterine insemination. If pregnancy is not achieved with three or more inseminations, IVF or ICSIshould be recommended.

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Uterine Factor

A hysterosalpingogram (HSG) helps to identify defects in the uterus or tubes. The HSG is performed after the menstrual period but before ovulation. A special dye is injected through the cervix. By filling the uterus all the way to the tubes, it helps identify uterine scar tissue, polyps (attached endometrial lining), fibroids or an abnormally shaped uterus. These problems seen in about 5% of infertile women can prevent early embryo implantation or increase the chances of having a miscarriage. The HSG can also show tubal blockage. An abnormally shaped uterus and blocked tubes can also be repaired with surgery during ahysteroscopy or a laparoscopy.

Peritoneal Factor

Anomalies on the peritoneal surface of the abdominal cavity like peritoneal adhesions (scar tissue) or endometriosis (endometerial tissue located outside the uterus)  are called peritoneal factors. A laparoscophelps to identify problems in the pelvic organs like adhesions and endometriosis.  Endometriosis is found in 35% of women in whom infertility has not been diagnosed prior to laparoscopy.

Laparoscopy is performed under general anesthesia in the out-patient unit of the hospital. During the procedure, a long light telescope-like instrument is inserted  into the pelvic cavity through or below the navel. The doctor can then directly see the abdominal cavity and inspect the ovaries, tubes, uterus and peritoneum (pelvic membrane). He can also inject a dye through the cervix to determine whether the passage to the uterus and tubes is open. A few more instruments can be inserted through small incisions made above the navel for further inspection of the pelvic organs, or for treatment if a disease has been diagnosed. 

Laparoscopy is the best technique for the diagnosis of peritoneal and tubal disease such as endometriosis, adhesions, and ovarian cysts. Since most cases are treatable laparoscopically, laparotomies that require an abdominal cut and a 6-week convalescence period are not usually performed.

Unexplained Infertility

In 5-10 % of couples trying to conceive, all the above tests'  outcomes are normal and a reason for the infertility is not diagnosed.

It is thought that the number of couples who fall in this group will decrease with advances in diagnostic techniques.Inseminationis a technique used when infertility is unexplained. If a pregnancy is  not achieved after 3-6 treatment cycles, the infertility factors should be reanalyzed or other techniques likeIVF should be considered.

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