IN­VES­TI­GAT­ING IN­FER­TIL­ITY IN MEN Tests of­ten tar­get the woman, de­spite the man be­ing re­spon­si­ble a third of the time

The Star (Kenya) - - Big Read / Reproductive Health - BY DR NJOKI FER­NAN­DES @thes­tarkenya

Kim­ber­ley and her hus­band Lionel have been mar­ried for five years. Soon after mar­riage, Lionel se­cured a schol­ar­ship to study for a Mas­ters De­gree in a pres­ti­gious Amer­i­can Univer­sity. He flew off to study, pop­ping in once in a while to see his wife. Kim­ber­ley on the other hand was en­joy­ing a high fly­ing bank­ing ca­reer, and was get­ting pro­mo­tion after pro­mo­tion.

Three years after mar­riage, Lionel fin­ished his stud­ies, and set­tled back home. After a while, it oc­curred to them that Kim­ber­ley was not con­ceiv­ing, de­spite reg­u­lar un­pro­tected coitus. After one year of try­ing, she de­cided to visit a well-known gy­ne­col­o­gist. He sub­jected her to a se­ries of tests, some painful, and all quite ex­pen­sive. Sadly, noth­ing ab­nor­mal was re­ported.

She went to an­other doc­tor, a renowned fer­til­ity expert, who put her on a cock­tail of med­i­ca­tion for six months. He did not ex­plain what was wrong with her. Six months later, and still not preg­nant, Kim­ber­ley was ready to give up. She con­vinced her­self that she would keep busy with work and so­cial projects. But deep down, her yearn­ing for a child got the bet­ter of her. It was also be­gin­ning to strain her re­la­tion­ship with Lionel.

When Kim­ber­ley ap­peared in my of­fice, I could see her dis­tress, it was clearly writ­ten on her face. I lis­tened to her story keenly and jot­ted down some notes as she spoke. I also looked at all the re­sults of her tests, all metic­u­lously filed in a neat box file. Ev­ery­thing looked good. I was puz­zled. What was miss­ing?

Of course! There was no test re­fer­ring to her hus­band. What an omis­sion.

“Kim­ber­ley, your tests look very good. You have un­der­gone every pos­si­ble test for in­fer­til­ity. I think you are ok. But where are Lionel’s tests? Did you for­get them”

“Lionel?” She ex­claimed. “Why does he need test­ing? He looks fine “I closed the file slowly. I had iden­ti­fied the miss­ing link in the chain. I faced Kim­ber­ley and tried to ex­plain the facts slowly. In cou­ples who are in­fer­tile, the man is solely re­spon­si­ble a third of the time, the woman a third of the time, and the cou­ple a third of the time. In this case, we had no clue how fer­tile the man was. Ob­vi­ously that was a prob­lem.

Kim­ber­ley be­lieved my hy­poth­e­sis. But she did not know how to con­vince her spouse to get tested. I promised to try and speak to him at their next ap­point­ment. The fol­low­ing week, the lovely cou­ple came to see me. As I had an­tic­i­pated, Lionel was up­set by the news that he could be the cause of the prob­lem. I took time to ex­plain.

CAUSES OF INFERTILTY

The av­er­age chance to con­ceive for a nor­mally fer­tile, healthy, young cou­ple hav­ing reg­u­lar, un­pro­tected in­ter­course is ap­prox­i­mately 20 per cent dur­ing each men­strual cy­cle. In most cou­ples, con­cep­tion oc­curs within about 12 months. How­ever, in­fer­til­ity af­fects about 10 per cent of cou­ples of child­bear­ing age. In­fer­til­ity is not just a woman’s con­cern.

Stud­ies in­di­cate that about onethird of in­fer­til­ity can be at­trib­uted to male alone fac­tors and about onethird to fe­male alone fac­tors. About one-third of in­fer­tile cou­ples have more than one cause or fac­tor re­lated to their in­abil­ity to con­ceive. About 20 per cent have no iden­ti­fi­able cause for their in­fer­til­ity after med­i­cal in­ves­ti­ga­tion.

So we need to in­ves­ti­gate both part­ners.

They glanced at each other un­easily as I spoke. I con­tin­ued to ex­plain

Fer­til­ity in men re­quires nor­mal func­tion­ing of the hy­po­thal­a­mus and pi­tu­itary gland (hor­mone-pro­duc­ing glands in the brain), and the testes. There­fore, a va­ri­ety of con­di­tions can lead to in­fer­til­ity.

30 to 40 per cent of cases are due to prob­lems in the testes (of which about 15 to 25 per cent are due to ge­netic causes);

10 to 20 per cent are due to a block­age in the path­way that sperm use to exit the testes dur­ing ejac­u­la­tion; this can be caused by prior in­fec­tion, surgery or ra­di­a­tion;

One to two per cent are due to con­di­tions of the pi­tu­itary gland or hy­po­thal­a­mus and

40 to 50 per cent have no iden­ti­fi­able cause, even after an eval­u­a­tion

MALE EVAL­U­A­TION

The eval­u­a­tion of male in­fer­til­ity may point to an un­der­ly­ing cause, which can guide treat­ment. We usu­ally be­gin with a med­i­cal his­tory, phys­i­cal ex­am­i­na­tion, and a se­men test. Other tests may be needed and are or­dered as re­quired.

A man’s past health and med­i­cal his­tory are im­por­tant in the process of eval­u­a­tion. We will ask about child­hood growth and de­vel­op­ment; sex­ual de­vel­op­ment dur­ing pu­berty; sex­ual his­tory; ill­nesses and in­fec­tions; surg­eries; med­i­ca­tions; ex­po­sure to cer­tain en­vi­ron­men­tal agents (al­co­hol, ra­di­a­tion, steroids, chemo­ther­apy, in­dus­trial chem­i­cals)

A phys­i­cal ex­am­i­na­tion usu­ally in­cludes mea­sure­ment of height and weight, as­sess­ment of body fat and mus­cle dis­tri­bu­tion, in­spec­tion of the skin and hair pat­tern, and ex­am­i­na­tion of the gen­i­tals and breasts.

Spe­cial at­ten­tion is given to fea­tures

A SE­MEN ANAL­Y­SIS IS KEY TO EVAL­U­AT­ING MALE IN­FER­TIL­ITY. IT PRO­VIDES IN­FOR­MA­TION ON THE AMOUNT, NUM­BER, MOTILITY, AND SHAPE OF SPERM.

of testos­terone de­fi­ciency, which may in­clude loss of fa­cial and body hair and de­crease in the size of the testis.

A se­men anal­y­sis (sperm count) is a cen­tral part of the eval­u­a­tion of male in­fer­til­ity. This anal­y­sis pro­vides in­for­ma­tion about the amount of se­men and the num­ber, motility, and shape of sperm. A man should avoid ejac­u­la­tion for two to seven days be­fore the se­men sam­ple is col­lected. It is usu­ally done by a clin­i­cian. The sam­ple should be de­liv­ered to the lab within one hour of col­lec­tion.

If the ini­tial se­men anal­y­sis is ab­nor­mal, the clin­i­cian will of­ten re­quest an ad­di­tional sam­ple; this is best done one to two weeks later.

Blood tests pro­vide in­for­ma­tion about hor­mones that play a role in male fer­til­ity. If sperm con­cen­tra­tion is low or the clin­i­cian sus­pects a hor­monal prob­lem, the clin­i­cian may or­der blood tests to mea­sure to­tal testos­terone, luteiniz­ing hor­mone (LH), fol­li­cle-stim­u­lat­ing hor­mone (FSH), and pro­lactin (a pi­tu­itary hor­mone).

If ge­netic or chro­mo­so­mal ab­nor­mal­i­ties are sus­pected, spe­cialised blood tests may be needed to check for ab­sent or ab­nor­mal re­gions of the male chro­mo­somes (Y chro­mo­some). Some men in­herit genes as­so­ci­ated with cys­tic fi­bro­sis that can re­sult in male in­fer­til­ity due to a low sperm count. How­ever, these men do not have the other usual signs of cys­tic fi­bro­sis, such as lung or gas­troin­testi­nal dis­ease.

Although in­fer­til­ity treat­ments may be able to over­come ge­netic or chro­mo­so­mal ab­nor­mal­i­ties, there is a pos­si­bil­ity of trans­fer­ring the ab­nor­mal­ity to a child. In this case, ge­netic coun­sel­ing is of­ten recommended to in­form a cou­ple about the pos­si­bil­ity of par­entto-child trans­mis­sion and the pos­si­ble im­pact of the ab­nor­mal­ity.

If a block­age in the re­pro­duc­tive tract (epi­didymis or vas def­er­ens) is sus­pected, a tran­srec­tal ul­tra­sound test may be or­dered.

If ret­ro­grade ejac­u­la­tion (move­ment of se­men into the blad­der) is sus­pected, a post-ejac­u­la­tion urine sam­ple is needed.

A tes­tic­u­lar biopsy (col­lec­tion of a small tis­sue sam­ple) may be recommended in men with no sperm on the se­men anal­y­sis. The biopsy can be done by sur­gi­cally open­ing the testis or by fine-nee­dle as­pi­ra­tion (in­sert­ing a small nee­dle into the testis and with­draw­ing a sam­ple of tis­sue). An open biopsy is usu­ally done in an op­er­at­ing room with gen­eral anes­the­sia, while a fine-nee­dle as­pi­ra­tion may be done with lo­cal anes­the­sia in an of­fice set­ting. The biopsy al­lows the physi­cian to ex­am­ine the mi­cro­scopic struc­ture of the testes and de­ter­mine if sperm are present. The pres­ence of sperm pro­duc­tion in the testes when there are none in the ejac­u­late sug­gests block­age in the re­pro­duc­tive tract.

Lionel looked very stressed as I con­cluded my nar­ra­tive. Clearly he had never en­coun­tered this in­for­ma­tion be­fore.

“One step at a time guys.....one step at a time. All will be well” I as­sured them, pray­ing to God that in­deed all would be well.

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