Dr Segun Afolani, a consultant physician and endocrinologist in the Department of Medicine, Federal Teaching Hospital, Ido Ekiti, Ekiti State, talks to ALEXANDER OKERE about the management of infertility in men
What is infertility generally?
We talk about infertility as the inability of a couple to achieve pregnancy after one year of unprotected regular sexual intercourse. Regular sexual intercourse means that a couple should have sexual intercourse that leads to ejaculation at least two to three times weekly on different days, at least a day in between, provided those days are not consecutive.
What is male infertility?
We talk of male infertility when the cause is connected to the male, meaning that the female has been screened and found not to have any challenge, whereas the male has been evaluated and the likely cause of that infertility has been traced to him. There are male, female, and combined and unexplained factors. Sometimes, nothing is picked up as the cause of infertility after screening the couple; that could be unexplained factors.
Is infertility the same thing as impotence?
Not exactly. Infertility is a wider term. When a person is impotent, it means that the individual, by genetic makeup, cannot father a child. On the surface, it may look like infertility but that may not be absolutely correct. Impotence means the man cannot make sperm to fertilise an egg. Infertility is a bigger term. Some people don’t have any issues with making viable sperm, yet they are infertile. For example, a man that has a weak erection does not have an erection enough to penetrate a woman to the point of orgasm but if sperm is extracted from the man, he can father a child. So, a weak erection is actually not impotence, it’s an obstruction to the flow of sperm, which could be physical and due to an infection.
What are the causes of male infertility?
The causes could be divided into four or five groups. There is something called primary gonadal failure and it means that the testes of a man have a problem but it could also be a secondary gonadal failure which means that the problem is from the brain because there are some chemicals that are secreted in the brain and inform the testes to produce sperm.
For primary gonadal failure, there could also be genital tract abnormalities, meaning though the sperm has been produced, there is an obstruction in the tract preventing it from moving to the penile end. There are also erectile dysfunction, drugs, and diseases. A common cause is Klinefelter’s syndrome. There are also what is called undescended testes, which means that the testes are inside the abdomen making the temperature (in the abdomen) too hot for the testes. Infections can cause infertility or what is known as orchitis (inflammation of the testes) and it could be due to things as small as mumps, a viral infection. Other causes of infertility are trauma (if a male is hit in the testes and the cells there are destroyed) and chemotherapy and radiotherapy because cancer drugs usually attack rapidly growing cells, and one of the fastest rapidly growing cells in the body is the testes. Secondary gonadal failure is not that common. Also, patients who have had surgery and had their urethra cut inadvertently by a doctor may not be able to father a child. Many young men that abuse drugs can have erectile dysfunction. Steroids can also suppress the production of sperm. Males with chronic debilitating diseases that affect all the organs of the body can have infertility.
Is it true that chemicals, like herbicides and insecticides, can cause infertility in men?
Yes, they can. Although it is still a new area, we have seen that such chemicals can cause infertility.
How do they affect men?
We believe that there are some things called endocrine disruptors; they are day-to-day things we see around us but they can alter the way our system functions, especially the endocrine gland, and the testes are part of the endocrine gland. What research has shown is that some of the chemicals in genetically modified foods can act as endocrine disruptors and make the testes malfunction. Females can also be affected.
What about the talk about overheating the testicles?
That is also valid. I spoke earlier about undescended testes. When a male baby is inside the womb, the testes are formed in the abdomen but go down into the final location which is seen as the scrotum. It is possible that along the line, that descent is not complete. If the testes continue to stay in the abdomen, the temperature in the abdomen is higher and can make the testes not function well. So, it is correct that people should not place laptops on their laps, and wear tight-fitting pants while travelling a long distance. So, recurrent exposure to a high temperature can reduce the viability of the sperm cells.
Can masturbation cause infertility?
Yes and no. Ordinarily, masturbation should not cause infertility. However, people who masturbate tend to have erectile dysfunction and such individuals will have infertility. Depending on the frequency of masturbation, there is a recovery period for spermatozoa to produce enough sperm cells. When we want seminal fluid analysis, which is like sperm analysis or sperm count, we tell the patient to abstain from sexual intercourse for at least three days or 72 hours before masturbating to bring to their sperm. When a man has sexual intercourse daily, the period for the recovery of the spermatozoa is not there and makes the sperm produced not viable. So, too frequent masturbation could render the cells unviable.
Can male infertility be hereditary?
Hereditary means it can be transferred from one person to the other. That may not be the right term. Although it is possible, it is not common. What we talk about is that it can be genetic, in the genes of the individual.
Is male infertility common among men in a certain age bracket?
There is really no age predilection, though what we know is that the older one becomes, the less viable the sperm cells are. The sperm cells of a man in his 20s and 30s are likely to be more viable than a man who is in his 50s and 60s whose sperm cells may be viable but abnormal, increasing the chances of abnormalities in their children. But things are changing; with the use of laptops and drugs, we can see infertility increasing in the younger age group, so it’s difficult to put an age to it.
Apart from erectile dysfunction, what are the other common signs of infertility in men?
Patients who have Klinefelter’s syndrome have an extra Y chromosome. We all have chromosomes; for a male, it is XX, and for a female, it is XY. So for patients who have Klinefelter’s syndrome, they have an extra Y chromosome – 47 XYY instead of 46 XY. The greater the number of Y chromosomes, the more likelihood of infertility. Such people have the appearance of females. Other common signs of infertility include reduced libido (urge to have sex), absence of beards, anosmia (inability to perceive smell), and small testes.
When is sperm count considered to be low or how many sperms are necessary for conception to take place?
When a seminal fluid analysis is done, the volume of the sperm a man produces should be up to 1.5 milliliters. The number of sperm per ejaculate (semen) should be at least 39 million. When that is taken per milliliter, there should be at least 15 million viable sperm cells. We also consider the number of sperm alive through a microscope; at least 58 percent of the sperm should be alive. In terms of morphology (the shape of the sperm), it should have a head, body, and tail. Also, sperms, under a microscope, should be seen moving like tadpoles in constant motion forward, called progressive motility.
Are men who have had their vasectomy reversed still at risk of infertility?
Reversed vasectomy is very uncommon. Vasectomy is almost like permanent family planning. If surgery to reverse vasectomy is successful, the patient can have infertility reversed because the reason why he cannot father a child is that his sperm cannot leave the penis
What are the psychosocial complications or challenges that come with male fertility, especially for married men?
One of them is low self-esteem. Every man has an ego even more than a woman and fertility is a sign of masculinity. So, when men are unable to get their wives pregnant, most of them (men) don’t even come for evaluation because they don’t want to be seen as being responsible for infertility. Only the women show up for tests. Infertility brings about depression and there is also the risk of suicidal ideation. Also, there is stigmatisation.
When is it appropriate for a man who cannot get his partner pregnant to see a doctor? Is it one month, six months, or one year after regular and unprotected sexual intercourse without results?
Again, there is no specific time. It will be wrong of me to say a couple looking for a child should wait for one year because I can imagine the anxiety in the family. But what I will advise is if a man has regular sexual intercourse with his wife for three consecutive months without any conception, he should seek medical care and this is personal advice, not from any book. Why wait for one year to solve a problem that can be solved in three months? Let the evaluation of the wife and the husband start; if there is any abnormality, intervention can come in, but if there is no abnormality, the couple can be advised to keep trying, pray, and be patient, believing that things will work out. If a woman is 39 years old, close to menopause, and gets married and doesn’t get pregnant within a few months, I will advise her to see a doctor because she does not have the luxury of time.
There are reports about men getting their partners pregnant for the first time after several years of marriage, even decades. What do you think is responsible for that?
There is nothing God cannot do. As I said earlier, there are unexplained causes of infertility, meaning that there is nothing wrong with the man and his wife. It can be idiopathic. If they continue to try, God can answer their prayer one day. It could take a decade or one year.
How is male infertility diagnosed?
When the patient meets a doctor, he asks when he has had sexual intercourse and was able to achieve erection and ejaculation. Once that is done, he is examined to see whether he has male sexual characteristics like a beard, cracked voice, and hair in places where he is supposed to be hairy and whether his hair pattern looks like that of a male or a female. The doctor will check whether the volume of the patient’s testes is okay. When all these are ascertained to be normal, the next thing is to tell the man to bring a sample of his sperm for analysis but ideally, he should abstain from sex for at least three days before bringing a sample. If the sperm is normal, the doctor goes ahead to investigate the woman. Of course, based on experience, women come forward easily to be examined.
If the sperm is not normal, the doctor checks the man’s hormones for the testes, called testosterone, to see whether it is low or high. The pituitary is also checked. If the testosterone and the follicle-stimulating hormone are low, then it means the problem is from the brain. So, imagery of the brain is done but if the testosterone is and the FSH is high, the implication is that though the FSH is being produced, the testes are not responding to it.
What are the common treatment methods?
It depends on what is responsible for infertility. If it is an obstruction, a surgeon can handle that. If there is an infection, the doctor looks at what the infection is and treats the patient with antibiotics or antiviral drugs as the case may be. If it is erectile dysfunction, the doctor would want to know whether it is a pathological or psychological one and later give the patient some drugs or psychotherapy. If the testes are the problem, if they produce enough sperm but the sperm cannot get out, the doctor can retrieve the sperm of the patient, usually called testicular sperm extraction, and merge it with the wife’s egg. Invitro fertilisation can as well be done. If all these do not work, the patient can be advised to adopt a child.
Are herbal mixtures effective in the treatment of this condition?
So far, we have not found them effective in the treatment of this condition, at least, not in an orthodox way because they could even cause more damage. The only way herbal mixtures can be found effective is if aphrodisiac is added to the herbs for a man with erectile dysfunction. But other than that, we have not found them effective.
What healthy habits should men adopt to reduce the risk of infertility?
Men should not wear pants that are too tight, especially if they are going to embark on a long journey. Men should not place laptops or anything hot directly on their private parts. They should not sit for too long because in a sitting position, the thighs are together and they increase the temperature around the private parts. Exercise can improve sperm production. Illnesses like diabetes, obesity, and hypertension can cause infertility, so they should be treated. Weight-enhancing medications can have a debilitating effect on a man’s reproductive health, so if he avoids such medications, he should be fine.
Does excess consumption of sugar cause infertility?
Not directly but we know that excess sugar intake can make a patient who is prone to having diabetes become diabetic.
What fruit, vegetables, and nuts are recommended to boost male fertility?
There are many of them. All the nuts are good but specifically, walnuts and tiger nuts are very good. They are very effective. Dates are also good. All these have been found to increase male libido.
