Male Infertility
The diagnostic criteria for male infertility have not been fully standardized. Currently, most scholars use the criterion of cohabitation, unprotected, regular sexual intercourse without obtaining a pregnancy within 1 year of marriage. the 12-month period is consistent with the fact that most couples (85%) conceive naturally, but it does not mean that testing for infertility must wait until the 12-month period expires, especially if infertility is suspected in either partner due to family history.
I. Prevalence and etiology
In 2001, the European Reproductive Society estimated that 25% of couples of childbearing age fail to conceive within a year. Of these, 15% sought treatment, and male factor causes 50% of infertility.
The causes of male infertility are.
Varicocele (12.3%)
Reproductive tract infections (6.6%)
Immunological factors (3.1%)
Acquired diseases (2.6%)
Congenital developmental abnormalities (2.1%)
Sexual dysfunction(1.7%)
Endocrine disorder(0.6%)
Other abnormalities (3%).
However, up to 60%-75% of patients have no known cause, called idiopathic male infertility, and they only present with abnormal sperm quality such as oligospermia, weak sperm and/or teratozoospermia. Unexplained male infertility may be due to a variety of factors, such as endocrine disruption due to long-term stressful environmental factors, reactive oxygen elements and genetic defects.
Second, reasonable assessment of male infertility
The purpose of male infertility evaluation is to distinguish different causes of infertility and give different treatment measures, so that patients can spend less time and money to obtain a more accurate diagnosis and reasonable treatment. We can broadly classify male infertility into the following categories
① fertility can be achieved through treatment;
②Fertility can be achieved through assisted reproductive technology if conventional treatment fails;
(3) Children can only be obtained through adoption or AID;
④Diseases that cause infertility and affect health and require other treatments;
⑤ Diseases with a high risk of passing abnormal genes to the offspring using assisted reproductive technology.
These diseases should be treated differently.
The main prognostic factors affecting infertility are
① Duration of infertility;
(ii) primary or secondary infertility;
③ Semen analysis results;
(iv) the age and fertility of the female partner.
Assessment points
①Both partners should be examined at the same time;
②The relationship between the age of the female partner and fertility: the fertility of women at the age of 35 is only about 50% of that at the age of 25. At age 38, it drops to 25%, and over 40, it drops to less than 5%;
③ Semen analysis should be performed in accordance with the WHO Manual of Human Semen and Sperm-Cervical Mucus Interaction Laboratory (4th edition);
④Do the necessary physical examination and special examination to clarify the causes of abnormal semen quality, such as reproductive tract infection, varicocele, endocrine, immunological and genetic examination, etc.
Third, the treatment of male infertility
The pregnancy rate of normal couples is 25% per month, 75% in 6 months, 85% to 90% in 1 year, and 10% to 15% for infertility. Infertile couples without treatment had pregnancy rates of 25% to 35%, including 23% within 2 years and 10% after 2 years, and assessment after 1 year was not required for advanced couples. Baseline pregnancy rates should be considered in the assessment of success rates for all treatments.
Both infertile couples should be treated together.
① Absolutely infertile men:i.e. those who cannot obtain fertility without treatment, such as non-ejaculation and azoospermia, should also be checked for fertility in the female partner before the male partner undergoes treatment.
②Reduced male fertility: such as idiopathic or secondary oligospermia, hypospermia and aberrant spermatozoa, according to the WHO multicenter clinical study, about 26% of female spouses also have fertility problems at the same time.
Prophylactic treatment. In order to prevent future causes of male infertility should focus on the following points.
① Prevention of sexually transmitted diseases;
②Incomplete testicular descent should be treated accordingly in early childhood;
③Safe environment, avoid exposure to harmful factors and chemicals to the testes;
④ Use treatments that impair testicular function, including certain drugs such as chemotherapy for lung tumors, and refrigerate the patient’s semen before using the drugs (reproductive insurance).
Non-surgical treatment.
①Specific treatment. The etiology of the disease is clear, there is a definite effect of treatment measures, such as HCG and HMG or FSH treatment of hypogonadotropic hypogonadism caused by oligospermia, azoospermia infertility;
② semi-specific treatment: there is a definite disease trap, but the pathogenesis and pathology of infertility has not been elucidated, evidence-based medicine has proved that clinical treatment is effective
(iii) Non-specific treatment: empirical treatment, treatment of idiopathic oligospermia and azoospermia of unknown etiology, etc.
Surgical treatment
①Surgery to improve spermatogenesis in the testes: such as high spermatic cord vein ligation for infertility of varicocele and surgery for incomplete testicular descent;
(2) Removal of obstruction of the vas deferens, including epididymal-vas deferens anastomosis, vas deferens-vas deferens anastomosis, ejaculatory duct dilatation, transurethral ejaculatory ductotomy, etc. The rate of recanalization after vas deferens anastomosis reached 77% in 217 cases during 5 years of DOHLE analysis, and the pregnancy rate reached 42% 1 year after the operation, and recanalization was related to the preoperative condition (especially the number of years of obstruction) and intraoperative findings, accompanied by testicular abnormalities, epididymal The success rate of recanalization is lower in patients with testicular abnormalities, no sperm in the tubular fluid, and extensive fibrosis of the epididymis; the effect of vas deferens-vas deferens anastomosis is generally better than that of vas deferens epididymal anastomosis, and the recanalization rate after vasectomy is higher than that of inflammatory obstruction of the epididymis, and the choice of microsurgery or assisted reproductive technology for treatment should be carefully decided according to the efficacy-price ratio;
③ Surgery to remove other factors that cause semen not to enter the female reproductive tract normally (e.g. hypospadias);
④Surgery for male infertility caused by other systemic diseases (such as pituitary, thyroid, adrenal diseases, etc.).
Assisted reproductive technology
As of 2004, the global assistedreproductivetechnology (ART) births have reached 1 million (excluding AID), with a clinical pregnancy rate of 25%-60% per cycle of transplantation, a spontaneous abortion rate of 18%, an ectopic pregnancy rate of 1%-2%, and a multiple pregnancy rate of 37% (US) and 29% (Europe). 0.83% increase in sex chromosome abnormalities, mild increase in congenital anomalies in ART-born infants (hypospadias), low neonatal weight, and increased perinatal complications (multiple births)
ICSI technology has been widely used to treat severe male infertility since the birth of the first ICSI IVF in 1992, with fertilization rates and clinical pregnancy rates of 65%-85% and 30%-50% of cycles.
Its features are:
(1) Only one viable sperm is needed for a mature egg;
(ii) Deformed sperm can also be fertilized, as ICSI bypasses many of the steps required for natural pregnancy to achieve direct sperm-egg union;
③Obstructive or non-obstructive azoospermia can be treated by ICSI through percutaneous puncture and surgical extraction of sperm from the epididymis and testes.
④Indications for ICSI: absolute indications are 2 failed conventional IVF fertilization attempts, use of epididymal or testicular sperm, severe oligozoospermia, acrosome deficiency or total sperm immobility. Relative indications are lower than normal sperm parameters, high antibody titers or 1 failure of conventional IVF fertilization or unexplained infertility.
Pharmacological treatment of idiopathic male infertility
Up to 40-75% of male infertility has no known cause and is called idiopathic male infertility. They usually present only with abnormal sperm quality such as oligospermia, weak sperm and/or teratozoospermia. Such patients usually receive a range of empirical medications or assisted reproduction treatments.
Testosterone has an important role in spermatogenesis and maturation, but high doses of exogenous testosterone can feedback inhibit sex hormone secretion, leading to reduced androgen production and diminished or stopped spermatogenic function. When exogenous androgens are discontinued, sperm counts rebound and increase. Based on this principle, low-dose androgen therapy and testosterone rebound therapy are currently available for the treatment of idiopathic male infertility. However, androgens are generally not recommended clinically for the treatment of idiopathic male infertility due to the lack of theoretical basis and the risk of persistent azoospermia, gynecomastia feminization, and cholestasis that may occur with androgens.
Gonadotropins, HCG and HMG are also currently used clinically for the treatment of infertility in patients with normal gonadotropins. Although this treatment remains controversial, further study of its mechanisms is still valuable in the treatment of patients with idiopathic male infertility.
Anti-estrogenic drugs, by occupying estrogen receptors in the cytoplasm of the hypothalamus, eliminate the negative feedback inhibition of estradiol in the blood circulation, increase the pulsatile release of GnRH from the hypothalamus, resulting in an increase in LH and FSH secretion, thus increasing testosterone and decreasing estradiol levels, and are used to improve semen quality. The most commonly used drugs are clomiphene, tamoxifen.
Traditional Chinese medicine. The use of evidence-based treatment to give symptomatic treatment has some effect.