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What do we know about the causes of male infertility?
Why addressing male infertility is so tremendously important

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What is infertility

According to the World Health Organization failure to get pregnant is defined as infertility if pregnancy is not established after 12 months or more of regular unprotected sexual contact. While either one or both of the partners may contribute to the reproductive challenges of the couple, male infertility, like female infertility, is a clinical diagnosis that can only be determined after formal assessment and testing.

Infertility is a common problem for males. Conception is a complicated process and there are many obstacles. Fortunately, if you have infertility issues, that doesn’t automatically mean that you won’t be able to have your own child with your partner. There are treatments and procedures that can increase the chances of conception.

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What is male infertility?

Infertility is a problem with your reproductive system that stops you from impregnating a female. If a male and a female have repeated unprotected sex for over a year and the female doesn’t get pregnant then you, she, or both of you may have infertility issues.

How common is male infertility?

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One in eight couples have trouble getting pregnant or sustaining a pregnancy. Approximately one-third of infertility is attributed to the female partner, one-third attributed to the male partner and one-third is caused by a combination of problems in both partners or, is unexplained.

Male infertility is more common in environments with high levels of environmental pollution, including water contaminants, pesticides and herbicides. Some recent population studies have suggested that sperm counts have been declining universally even though infertility has not been increasing substantially.

Is it easy to conceive?

NO. Conception is a complicated process that depends on many factors:

o          The production of healthy sperm by the male and healthy eggs by the female.

o          Unblocked fallopian tubes that allow the sperm to reach the egg.

o          The sperm’s ability to fertilize the egg when they meet.

o          The ability of the fertilized egg (embryo) to become implanted in the female’s womb.

o          Infection or inflammation in the genital tract, which can be caused by sexually transmitted bacteria like chlamydia or other microbes.

Abnormalities that result in some parts of the male reproductive system not developing at all, such as in men with congenital absence, can prevent the transport of sperm. Other men may have blockages in their reproductive system because of scarring or accidental injury during surgery or for unknown reasons.

Ejaculation problems and erectile dysfunction can be causes of male infertility.

Lifestyle factors such as alcohol and tobacco use can contribute to infertility, as can participating in high-intensity sports or activities that might expose the testicles.

Key facts Infertility is a disease of the male or female reproductive system defined by the failure to achieve a pregnancy after 12 months or more of regular unprotected sexual intercourse.

Infertility affects millions of people of reproductive age worldwide – and has an impact on their families and communities. Estimates suggest that between 48 million couples and 186 million individuals live with infertility globally.

In the male reproductive system, infertility is most commonly caused by problems in the ejection of semen, absence or low levels of sperm, or abnormal shape (morphology) and movement (motility) of the sperm.

In the female reproductive system, infertility may be caused by a range of abnormalities of the ovaries, uterus, fallopian tubes, and the endocrine system, among others.

Infertility can be primary or secondary. Primary infertility is when a pregnancy has never been achieved by a person, and secondary infertility is when at least one prior pregnancy has been achieved.

Fertility care encompasses the prevention, diagnosis and treatment of infertility. Equal and equitable access to fertility care remains a challenge in most countries; particularly in low and middle-income countries. Fertility care is rarely prioritized in national universal health coverage benefit packages.

Why addressing infertility is important

Every human being has a right to the enjoyment of the highest attainable standard of physical and mental health. Individuals and couples have the right to decide the number, timing and spacing of their children. Infertility can negate the realization of these essential human rights. Addressing infertility is therefore an important part of realizing the right of individuals and couples to found a family.

A wide variety of people, including heterosexual couples, same-sex partners, older persons, individuals who are not in sexual relationships and those with certain medical conditions, such as some HIV zero-discordant couples and cancer survivors, may require infertility management and fertility care services. Inequities and disparities in access to fertility care services adversely affect the poor, unmarried, uneducated, unemployed and other marginalized populations.

Addressing infertility can also mitigate gender inequality. Although both women and men can experience infertility, women in a relationship with a man are often perceived to suffer from infertility, regardless of whether they are infertile or not. Infertility has significant negative social impacts on the lives of infertile couples and particularly women, who frequently experience violence, divorce, social stigma, emotional stress, depression, anxiety and low self-esteem.

In some settings, fear of infertility can deter women and men from using contraception if they feel socially pressured to prove their fertility at an early age because of a high social value of childbearing.  In such situations, education and awareness-raising interventions to address understanding of the prevalence and determinants of fertility and infertility is essential.

Addressing challenges

Availability, access, and quality of interventions to address infertility remain a challenge in most countries. Diagnosis and treatment of infertility is often not prioritized in national population and development policies and reproductive health strategies and are rarely covered through public health financing. Moreover, a lack of trained personnel and the necessary equipment and infrastructure, and the currently high costs of treatment medicines, are major barriers even for countries that are actively addressing the needs of people with infertility.

While assisted reproduction technologies (ART) have been available for more than three decades, with more than 5 million children born worldwide from ART interventions such as in vitro fertilization (IVF), these technologies are still largely unavailable, inaccessible and unaffordable in many parts of the world, particularly in low and middle-income countries (LMIC).

Government policies could mitigate the many inequities in access to safe and effective fertility care. To effectively address infertility, health policies need to recognize that infertility is a disease that can often be prevented, thereby mitigating the need for costly and poorly accessible treatments. Incorporating fertility awareness in national comprehensive sexuality education programmers, promoting healthy lifestyles to reduce behavioral risks, including prevention, diagnosis and early treatment of STIs, preventing complications of unsafe abortion, postpartum sepsis and abdominal/pelvic surgery, and addressing environmental toxins associated with infertility, are policy and programmatic interventions that all governments can implement.

In addition, enabling laws and policies that regulate third party reproduction and ART are essential to ensure universal access without discrimination and to protect and promote the human rights of all parties involved. Once fertility policies are in place, it is essential to ensure that their implementation is monitored, and the quality of services is continually improved.

Diagnosis of male infertility

Many infertile couples have more than one cause of infertility, so it’s likely you will both need to see a doctor. It might take a number of tests to determine the cause of infertility. In some cases, a cause is never identified.

Infertility tests can be expensive and might not be covered by insurance — find out what your medical plan covers ahead of time.

Diagnosing male infertility problems usually involves:

General physical examination and medical history. This includes examining your genitals and asking questions about any inherited conditions, chronic health problems, illnesses, injuries or surgeries that could affect fertility. Your doctor might also ask about your sexual habits and about your sexual development during puberty.

Semen analysis. Semen samples can be obtained in a couple of different ways. You can provide a sample by masturbating and ejaculating into a special container at the doctor’s office. Because of religious or cultural beliefs, some men prefer an alternative method of semen collection. In such cases, semen can be collected by using a special condom during intercourse.

Your semen is then sent to a laboratory to measure the number of sperm present and look for any abnormalities in the shape (morphology) and movement (motility) of the sperm. The lab will also check your semen for signs of problems such as infections.

Often sperm counts fluctuate significantly from one specimen to the next. In most cases, several semen analysis tests are done over a period of time to ensure accurate results. If your sperm analysis is normal, your doctor will likely recommend thorough testing of your female partner before conducting any more male infertility tests.

Scrotal ultrasound. This test uses high-frequency sound waves to produce images inside your body. A scrotal ultrasound can help your doctor see if there is a varicocele or other problems in the testicles and supporting structures.

Transrectal ultrasound. A small, lubricated wand is inserted into your rectum. It allows your doctor to check your prostate and look for blockages of the tubes that carry semen.

Hormone testing. Hormones produced by the pituitary gland, hypothalamus and testicles play a key role in sexual development and sperm production. Abnormalities in other hormonal or organ systems might also contribute to infertility. A blood test measures the level of testosterone and other hormones.

Genetic tests. When sperm concentration is extremely low, there could be a genetic cause. A blood test can reveal whether there are subtle changes in the Y chromosome — signs of a genetic abnormality. Genetic testing might be ordered to diagnose various congenital or inherited syndromes.

Testicular sampling. This test involves removing samples from the testicle with a needle. If the results of the testicular biopsy show that sperm production is normal your problem is likely caused by a blockage or another problem with sperm transport.

Specialized sperm function tests. A number of tests can be used to check how well your sperm survive after ejaculation, how well they can penetrate an egg, and whether there’s any problem attaching to the egg. These tests aren’t often used and usually don’t significantly change recommendations for treatment.

Watch the Paradise TV Health Talks every Monday from 8 to 9PM.

Dr Hassan Azadeh MD, senior lecturer at the University of The Gambia, Clinical Director at the Medicare Health Services.

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