Male Infertility and Andrology in Jaipur

What Male Infertility and Andrology Is

Male infertility is a condition that affects men and interferes with the ability of their reproductive system to impregnate a female. It means you have repeated unprotected sexual intercourse for over a year but your female partner does not get pregnant. Infertility is defined as the inability to achieve pregnancy after 1 year of regular unprotected sexual intercourse.

A male factor is a primary or contributing cause in approximately 50% of couples. Male infertility is a multifactorial pathological condition affecting approximately 7% of the male population. The global prevalence of infertility varies between 2.5% and 15%, correlating to at least 30 million infertile men worldwide.

Conception is a complicated process that depends on many factors in the male and female reproductive systems. For the pregnancy to continue to full term, the embryo must be healthy, and the female's hormonal environment must be adequate enough for the embryo to develop.

Spermatogenesis refers to the process wherein germ cells known as spermatogonia develop into spermatozoa or sperm through a complex process involving mitosis, meiosis, and spermiogenesis. This process takes approximately 75 days to complete. The majority of spermatogenesis occurs within the seminiferous tubules of the testis. Additional maturation occurs in the epididymis, where spermatozoa are stored until ejaculation.

Spermatogenesis is regulated by intra-testicular testosterone and dihydrotestosterone, which is in turn influenced by the signalling hormones from the pituitary gland. In response to gonadotropin releasing hormone secreted by the hypothalamus, the anterior pituitary gland secretes both luteinising hormone (LH) and follicle stimulating hormone (FSH). Luteinising hormone acts on Leydig cells within the testes to promote testosterone production.

FSH acts at the level of the Sertoli cells to promote spermatogenesis. This complex signalling network is referred to as the hypothalamus-pituitary-gonadal axis. Derangement of one or more of these hormones can lead to fertility problems.

Semen is the whitish-grey liquid that releases from a penis upon orgasm (ejaculation). Semen contains sperm, as well as fluids that help deposit sperm toward the back of the vagina, and proteins, vitamins and minerals that help nourish the sperm.

Spermatozoa are highly vulnerable to oxidative stress owing to limited levels of antioxidant defence and a single, limited DNA-damage detection and repair mechanism. High levels of oxidative stress result in damage to sperm DNA, RNA transcripts, and telomeres. Oxidative stress refers to an imbalance in levels of reactive oxygen species (ROS) and antioxidants.

High levels of ROS can cause infertility through lipid peroxidation or DNA damage. High levels of ROS can cause infertility through inactivation of enzymes and oxidation of proteins in spermatozoa. A new term has been proposed, Male Oxidative Stress Infertility (MOSI).

Symptoms and Warning Signs of Male Infertility

The primary symptom of male infertility is being unable to have a biological child. There aren't any obvious signs of unhealthy sperm. The only way to accurately determine the health of your sperm is to get a semen analysis. Typically, semen is thick and sticky. Runny or watery semen may indicate a low sperm count, which may cause male infertility.

Male infertility can also lead to many psychological and emotional symptoms, including feelings of depression, grief or inadequacy. In this case, symptoms such as tiredness, impotence, depression, weight gain and apathy may occur. If you or your partner experiences these feelings, it's a good idea to talk to a therapist or psychiatrist.

Talking to a therapist or finding a support group may help you cope with your feelings. Be kind to yourself and your partner.

Varicoceles may also cause testicular pain or discomfort. Many varicoceles are completely asymptomatic and many patients with varicoceles have entirely normal semen analyses. Patients who experience retrograde ejaculation where the semen preferentially enters the urinary bladder rather than being expelled antegrade through the urethra at the time of ejaculation may notice low semen volume or cloudy urine after orgasm.

This is not harmful from an overall health perspective but is a potential cause for male factor infertility. If you have cancer, talk to a healthcare provider about banking your sperm before you start treatment.

Causes and Risk Factors for Male Infertility

Causes of male subfertility vary highly, but can be related to congenital, acquired, or idiopathic factors that impair spermatogenesis. Many health conditions can affect male fertility, which underscores the need for a thorough evaluation of patients to identify treatable or reversible lifestyle factors or medical conditions.

The genetic landscape of male infertility is highly complex as semen and testis histological phenotypes are extremely heterogeneous, and at least 2,000 genes are involved in spermatogenesis. Anomalies in sex chromosomes have major roles in severe spermatogenic impairment.

Autosome-linked gene mutations are mainly involved in central hypogonadism, monomorphic teratozoospermia or asthenozoospermia, congenital obstructive azoospermia, and familial cases of quantitative spermatogenic disturbances.

Oxidative stress is predominantly caused by a host of lifestyle-related factors, the majority of which are modifiable. Oxidative stress is caused by various modifiable factors, and the use of simple interventions can decrease levels of oxidative stress. Immature spermatozoa are a main source of ROS. Inflammatory factors are a main source of ROS.

Genetic mutations are a main source of ROS. Altering levels of sex hormones are a main source of ROS. Spermatozoa are highly susceptible to the deleterious effects of ROS due to the large amounts of unsaturated fatty acids found in their cell membranes. Increased ROS along with decreased antioxidant defence result in redox imbalance, reduced sperm motility and sperm DNA damage.

Varicocele, the most common etiology of male infertility, has been linked with the increased oxidative burden and ROS-induced sperm DNA damage. Varicocele has been linked with increased scrotal temperature. Increased temperature has been related to increased ROS production and negative effects on other seminal fluid parameters.

The exact etiology of how a varicocele can cause infertility is still debated, but it is most likely due to thermal dysregulation. The dilated veins cause blood to pool around the testis which causes the intratesticular temperature to increase.

Since optimal spermatogenesis occurs at a temperature lower compared with internal body temperature, the increased blood pooling will cause a decrease in sperm production and quality. Varicocele adversely affects semen parameters. Varicocele results in decreased testosterone secretion, impaired spermatogenesis, and testicular atrophy. Varicoceles are seen in a large number of males in the general population with a prevalence around 20%.

Varicocele is a common finding in infertile couples, affecting 15% to 40% of men with primary infertility and 5% to 10% of men with azoospermia.

Smoking has been associated with reduced sperm concentration, motility, and altered morphology. Smoking also elicits a chronic inflammatory response which recruits leukocytes to the genital tract and causes a substantial increase in seminal ROS levels. Alcohol abuse results in increased production of acetaldehyde which promotes the generation of ROS due to its interactions with proteins and lipids.

Altered sperm function and increased DNA damage have been associated with industrial exposure to heavy metals such as lead, cadmium, iron, and copper, as well as exposure to phthalates, pesticides, and pollution. Malignancies are another important extrinsic source of ROS, along with the accompanying exposure to radiation and chemotherapy.

Men treated with chemotherapy medications such as cisplatin, doxorubicin, or cyclophosphamide have been linked to increased oxidative stress. Radiotherapy has also been associated with increased oxidative stress. Hyperprolactinemia results in suppression of the pituitary secretion of gonadotropins (LH, FSH). Causes of hyperprolactinemia include different types of medications such as anti-psychotics, chronic kidney disease, hypothyroidism, and even pituitary tumours (prolactinomas).

Retrograde ejaculation may occur as a result of bladder neck incompetence – this can be congenital or acquired such as occurs after transurethral resection of the prostate. If the bladder neck function is altered, semen may flow through the path of least resistance towards the urinary bladder.

Sometimes, male infertility can be associated with a low production of testosterone from the testicles. Despite such efforts, the aetiology of infertility remains unknown in about 40% of patients. No underlying cause can be identified for primary or secondary infertility in approximately 25% of couples which is termed idiopathic infertility.

Your chances of having male infertility may be higher if you have known hypogonadism, history of orchiopexy or other testicular surgery, prior chemotherapy or pelvic radiation, or family history of male factor infertility. Men with risk factors for infertility should undergo more expeditious evaluation. Any male may have infertility.

How Male Infertility Is Diagnosed

Workup for male factor infertility is indicated for any couple who has been attempting to conceive via unprotected sexual intercourse for one year or longer without success. Infertility work-up can also be considered for any man who has concerns regarding his baseline fertility status, regardless of risk factors or active attempts at conception.

See a healthcare provider if you and your partner haven't been able to get pregnant after a year of trying. A primary care physician can diagnose male infertility. Or they may refer you to a urologist who specialises in male infertility or a reproductive endocrinologist.

The provider will perform a complete physical examination to help determine your overall health and identify any physical problems that may affect your fertility. They may also ask you and your partner questions about your sexual habits and health history.

The cornerstone of a male infertility workup is the semen analysis. A semen analysis is one of the primary tests healthcare providers use to help diagnose male infertility. It's a lab test of a semen sample that examines the volume and quality of your sperm.

The most current guidelines for this are published by the WHO (World Health Organization) and are on their 6th edition. It should be examined under the microscope within one hour of collection and the sample should be given after 2-3 days of abstinence.

If abnormalities are seen on an initial semen analysis, it is often recommended to repeat the test approximately one month later to confirm the original findings. The World Health Organization (WHO) has published reference values for seminal fluid analysis parameters. Decreased sperm concentration – defined as < 15 ×106 sperm/ml – is termed oligozoospermia.

Asthenozoospermia corresponds to progressive sperm motility of <32% or total sperm mobility under 40%. Teratospermia is defined as normal sperm motility of <4% using Kruger's strict criteria. The combination of all these abnormalities is termed oligoasthenoteratozoospermia. Other semen analysis parameters that may be reported include serum pH, presence/absence of fructose, and the presence/concentration of leukocytes.

Over-the-counter (OTC) at-home semen analysis tests are available to purchase. However, these products aren't as thorough and may not be as effective as a lab test.

Blood testing for male factor infertility is used to evaluate for hormonal and genetic causes of infertility. The 2020 AUA-ASRM infertility guideline panel recommends that patients with alterations in sexual desire (libido), sexual dysfunction (erectile dysfunction), small testes, signs of hypogonadism, and those with abnormal semen analysis should undergo laboratory testing with serum testosterone and FSH.

LH and prolactin are indicated for patients with hypogonadism (i.e. low circulating testosterone levels). If elevated prolactin levels are seen, an MRI of the pituitary gland is indicated to rule out a tumour. Genetic testing (karyotype and Y-chromosome microdeletion) should be performed on any patient with severe oligospermia or azoospermia.

According to the updated AUA/ASRM infertility guideline, karyotype testing is indicated for patients with sperm concentration < 5 million / mL in the setting of elevated FSH or testicular atrophy. Y-chromosome microdeletion testing is indicated for patients with primary infertility who have azoospermia OR sperm concentration < 1 million / mL with elevated FSH or testicular atrophy.

Patients with non-palpable vas deferens bilaterally should undergo cystic fibrosis testing (CFTR testing), as should those with unilateral absent vas deferens and obstructive azoospermia. More advanced testing such as sperm DNA fragmentation can also be done.

For patients with aspermia or low semen volumes (< 1.5 cc), a post-ejaculatory urinalysis can be used to assess for the presence of sperm within the urine.

Scrotal ultrasound is not recommended in the routine evaluation of a patient with infertility. It may be considered for patients with an abnormality identified on physical examination such as a testicular or extra-testicular scrotal mass. Scrotal ultrasound can be used to identify a varicocele but is not necessary to make the diagnosis in most cases.

The presence of clinical varicocele was diagnosed by physical examination and, in some cases, was confirmed by scrotal ultrasonography. Physical examination was performed in an upright position by the same examiner. Patients were asked to perform the Valsalva manoeuvre when the varicocele was not clearly palpable.

For patients with low semen volume and abnormalities in semen pH, transrectal ultrasound can be used to evaluate for ejaculatory duct obstruction. Patients with absent unilateral or bilateral vas deferens should undergo a renal ultrasound to rule out a kidney abnormality. Genetic screening is relevant for its diagnostic value, clinical decision making, and appropriate genetic counselling.

Non-Surgical Treatment and When Surgery Is Advised for Male Infertility

In most cases, male infertility requires treatment. Just because you have male infertility, it doesn't mean you'll never be able to have a biological child. Because of modern technology, many couples have the potential to conceive a biological child.

The purpose of evaluation is to identify potentially treatable causes of male factor infertility or to identify non-treatable causes that may require alternative treatment pathways such as assisted reproductive techniques or even the use of donor sperm or adoption.

Lifestyle interventions including yoga and meditation can substantially improve the integrity of sperm DNA by reducing levels of oxidative DNA damage, regulating oxidative stress and by increasing the expression of genes responsible for DNA repair, cell-cycle control and anti-inflammatory effects.

Antioxidant regimens and lifestyle modifications could both be plausible therapeutic approaches that enable the burden of oxidative-stress-induced male factor infertility to be overcome. Oral antioxidants can be helpful in coping with oxidative stress in male infertility. You may benefit from a more balanced diet that incorporates certain foods and drinks.

Some studies suggest that certain foods and drinks may affect your sperm quality. Lifestyle changes may be able to prevent infertility, and surgeries and procedures can treat the causes.

Hormone therapy can regulate hormone levels that are too high or low and affect your sperm quality. You may also need to stop using, or find alternatives to, certain medications. Assisted reproductive technologies such as intrauterine insemination (IUI) and IVF can overcome many potential causes of idiopathic infertility.

This is also the treatment of choice for unexplained infertility which is infertility despite a completely normal workup of both the man and female partner. Assisted reproductive technology (ART) procedures involve removing an egg from your partner's ovaries and combining it with your sperm in a lab.

Surgical treatments may include varicocele repair and sperm retrieval procedures. Varicocele is highly treatable. Effective treatments are available. What Are the Different Types of Varicocele Surgery in India? Open Surgery is a traditional surgical approach with an incision made in the groin area or abdomen. Microsurgical varicocelectomy uses an operating microscope to repair the veins with precision.

Laparoscopic Surgery uses a camera-assisted laparoscope with small incisions. Varicocele repair was performed using a microsurgical subinguinal approach by the same operator. A standard operating microscope with a dual ocular system was used in all procedures. Incisions were made at the level of the external inguinal ring until the subcutaneous tissue was reached. Enlarged veins were identified and ligated.

Patients who underwent varicocele repair showed higher testicular histopathological patterns. Men with nonobstructive azoospermia and clinical varicocele who underwent varicocele repair before the sperm retrieval procedure had higher sperm retrieval rates compared to those who did not undergo varicocele repair.

In one study, motile spermatozoa were found in 69.1% of patients who had undergone varicocele repair before the sperm retrieval procedure and 27.4% of those who had not undergone the repair.

Sperm retrieval procedures include Micro-TESE, PESA, and TESA for azoospermia (obstructive/non-obstructive). All sperm retrieval procedures were conducted using TESE. TESE was performed by making a small incision on the testis, followed by the collection of a small portion of the testicular tissue.

The collected tissue was then placed in medium containing human serum albumin and was examined using a standard laboratory microscope. The SRR was defined as the number of successful sperm retrievals, i.e., retrievals showing the presence of viable spermatozoa, in relation to the total number of sperm retrievals.

Testicular biopsies were performed during the sperm retrieval procedure using a standard procedure for each testicle. Testicular histopathology was reported in terms of five patterns based on the Johnsen scoring system.

The five testicular histopathological patterns based on spermatogenesis are:

• Sertoli cell-only
• Early maturation arrest with spermatocyte cells
• Late maturation arrest with spermatids
• Hypospermatogenesis
• Normal spermatogenesis

The decision of each patient's treatment, i.e., whether the patient underwent varicocele repair before sperm retrieval or sperm retrieval procedure without varicocele repair, was based on the patient's preference after discussion with the urologist. Your surgeon will advise which technique suits you.

Preparing for male infertility surgery at Jaipur Hospital

Before any procedure, your surgeon will review the results of your semen analysis, hormonal profile and any genetic tests you have already done.

If you are taking regular medicines — for blood pressure, diabetes, thyroid or any other condition — bring the prescription list to the pre-operative visit so the anaesthesia team can advise which ones to continue and which to pause. Blood thinners and certain supplements are usually stopped a few days before surgery; your surgeon will give you the exact timing.

You will be asked to fast for six to eight hours before the procedure, which means no food or water after midnight for a morning slot. Wear loose, comfortable clothing and bring an attendant who can stay with you at the hospital and take you home afterwards. If you use a CPAP machine or have any allergy, tell the nursing staff when you arrive.

How male infertility surgery is done at Jaipur Hospital

The operation you have depends on the cause found during your workup. For a varicocele, the usual approach is microsurgical varicocelectomy: a small cut is made just above the groin, an operating microscope is used to see the tiny veins clearly, and the enlarged veins are tied off while the arteries and lymphatics are preserved.

This technique is described in studies as the subinguinal microscopic approach. If no sperm are found in the ejaculate (azoospermia), sperm retrieval is planned.

Options include:

• PESA, where a fine needle is passed through the skin into the epididymis
• TESA, where a needle takes tissue directly from the testis
• Micro-TESE, where the testis is opened under the microscope to search for small pockets of sperm production

The retrieval method is chosen by your surgeon based on whether the blockage is obstructive or non-obstructive. On the day of surgery you are admitted to the daycare unit, the anaesthesia team gives local, spinal or general anaesthesia as discussed beforehand, and the procedure takes 30 to 120 minutes. Most patients go home the same day; a few stay one night for observation.

Risks and possible complications of male infertility surgery

All surgery carries some risk. With microsurgical varicocelectomy the main risks are infection at the wound, a collection of blood (haematoma) in the scrotum, and a hydrocele (fluid around the testis) which may need drainage if it does not settle. The microscope and fine sutures keep these rates low.

There is a small chance the varicocele comes back or that sperm parameters do not improve. For sperm retrieval procedures the risks include bleeding, infection, and temporary pain or swelling in the testis. In micro-TESE there is a theoretical risk of injury to the testicular artery, which could affect testosterone production; this is uncommon with microscopic technique.

Anaesthesia risks are the same as for any short procedure — nausea, sore throat from a breathing tube, or rare allergic reactions. Your surgeon will discuss the risks that apply to your specific operation before you sign the consent form.

Recovery and aftercare after male infertility surgery

After the operation you will rest in the recovery area until the anaesthesia wears off. You will be given pain tablets and, if needed, a short course of antibiotics. An ice pack applied to the scrotum for the first day helps reduce swelling. Wear supportive underwear or a scrotal support for one to two weeks.

You can shower after 24 hours; keep the wound dry and pat it gently. Avoid heavy lifting, strenuous exercise and sexual activity for two weeks. Desk work can usually be resumed in two to three days. A follow-up appointment is scheduled after one week to check the wound.

For varicocele surgery, a repeat semen analysis is typically done after three months because the sperm cycle takes about 75 days. If you had sperm retrieval, the laboratory will tell you whether sperm were found and whether they have been frozen for future IVF or ICSI cycles.

Call the hospital or visit the emergency department if you develop:

• Fever above 38°C
• Increasing pain not relieved by tablets
• Heavy bleeding from the wound
• Sudden swelling of the scrotum

Results of male infertility surgery in studies

In studies of men with non-obstructive azoospermia and a clinical varicocele, those who had varicocele repair before sperm retrieval had higher sperm retrieval rates than those who went straight to retrieval. In one trial of 104 men, motile sperm were found in 69.1 percent of the repair-first group compared with 27.4 percent of the no-repair group.

Testicular histology also showed better patterns of spermatogenesis after repair. For obstructive azoospermia, sperm retrieval rates with PESA or TESA are generally high because sperm production is normal. Success of varicocele surgery is measured by improvement in semen parameters and, ultimately, by pregnancy rates with or without assisted reproduction.

Recurrence of a varicocele after microsurgical repair is reported as low in the literature. Your surgeon will explain what the published numbers mean for your situation and will not promise a specific outcome.

Cost and insurance for male infertility treatment in Jaipur

The typical cost range in India is ₹2,000 to ₹5,000 for a semen analysis, ₹50,000 to ₹1,50,000 for varicocele surgery, and ₹30,000 to ₹80,000 for a sperm retrieval procedure.

The final amount depends on the type of surgery (microsurgical, laparoscopic or open), the anaesthesia used, whether you stay as daycare or overnight, the room category you choose, and any additional tests or medicines needed before or after the procedure. Jaipur Hospital is empanelled under RGHS, MAA Yojana, CGHS and a panel of private insurers and TPAs.

If you are covered under one of these schemes, bring your card and any pre-authorisation letter at admission. The billing team will help you understand what is covered and what you may need to pay out of pocket. Ask for an estimate before you are admitted so you can plan accordingly.