Male infertility

Male infertility is the absence of pregnancy with regular unprotected sexual intercourse for 1 year; a disease caused by diseases of the male reproductive system, which leads to a disruption of the generative and copulative functions and is classified as an infertile condition.

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Epidemiology

About 25% of couples do not achieve pregnancy within 1 year, among them - 15% of married couples are treated for infertility, but still less than 5% of couples remain childless. About 40% of cases are due to male infertility, 40% - to female, another 20% - to mixed.

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Causes male infertility

• hypogonadism;
• inflammatory diseases of the reproductive system;
• chronic systemic diseases;
• toxic effects (medicines, radiation, toxins, etc.);
• obstruction of the ducts of the epididymis or vas deferens;
• antegrade ejaculation;
• gonadal agenesis, sickle cell syndrome
• varicocele
• genetic disorders.

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Pathogenesis

The pathogenesis is caused by a decrease in the quantity, mobility, and changes in the morphology of spermatozoa, which leads to a disruption in the process of their penetration into the egg.

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Forms

A distinction is made between primary and secondary male infertility. In primary infertility, a man has never become pregnant, while in secondary infertility, a man has already become pregnant at least once. Men with secondary infertility usually have better prospects for restoring fertility. The classification developed by WHO (1992) is currently recognized.

Depending on the nature of the change in the level of gonadotropins in the blood, a distinction is made between:

• hypogonadotropic;
• hypergonadotropic;
• normogynadotropic.

In addition, the following are distinguished:

• excretory (in case of disruption of the passage of ejaculate through the genital tract):
• obstructive;
• caused by retrograde ejaculation
• immunological (with an increase in the level of antisperm antibodies),
• idiopathic (with a decrease in ejaculate parameters of unclear genesis).

Diagnostic categories according to the World Health Organization

Code	Disease	Code	Disease
01	Psychosexual disorders	09	Genital infection
02	The causes of infertility have not been identified.	10	Immunological factor
03	Isolated pathological changes in seminal plasma	11	Endocrine causes
04	Iatrogenic causes	12	Idiopathic oligozoospermia
05	Systemic diseases	13	Idiopathic asthenozoospermia
06	Congenital anomalies of the reproductive system	14	Idiopathic teratozoospermia
07	Acquired testicular disorders	15	Obstructive azoospermia
08	Varicocele	16	Idiopathic azoospermia

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Diagnostics male infertility

The disease is diagnosed based on the assessment of spermatogenesis by examining the ejaculate obtained after 3-5 days of sexual abstinence. A single study is not enough to make a diagnosis. The ejaculate analysis evaluates the number of spermatozoa, their motility, and an assessment of the morphology of spermatozoa is also mandatory.

In all cases, a hormonal examination should be carried out to determine the levels of LH, FSH, prolactin, testosterone, and estradiol in the blood.

Patients who have elevated FSH levels are not candidates for drug treatment.

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Treatment male infertility

Male infertility should be treated strictly using pathogenetic methods.

Male infertility due to hypogonadotropic hypogonadism

Gonadotropins are prescribed:

Chorionic gonadotropin intramuscularly 1000-3000 IU once every 5 days, 2 years

+

(after 3 months from the start of therapy)

Menotropins intramuscularly 75-150 ME 3 times a week.

The dose of hCG is selected strictly individually, under the control of the level of testosterone in the blood, which against the background of the therapy should always be within the normal range (13-33 nmol/l). To stimulate spermatogenesis, menotropins (menopausal gonadotropin) are added no earlier than 3 months after the administration of hCG. Combined therapy with gonadotropins is carried out for at least two years.

Evaluation of the effectiveness in relation to spermatogenesis is carried out no later than 6 months from the start of combined therapy with gonadotropins.

Male infertility due to other causes

In cases where hypogonadism is caused by prolactinoma, dopamine agonists are prescribed.

In case of infectious lesions of the genital organs, antibiotic therapy is indicated, which is prescribed taking into account the sensitivity of the microflora.

In the case of an immunological form of pathology, it is possible to carry out immunosuppressive therapy with GCS.

In case of varicocele and obstructive form of the disease, surgical intervention is necessary.

Evaluation of treatment effectiveness

The treatment effectiveness is assessed no earlier than 3 months after the start of treatment based on a spermogram analysis. The maximum duration of treatment should not exceed three years; if infertility persists for three years, artificial insemination must be used.

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Complications and side effects of treatment

In rare cases, breast enlargement, fluid and electrolyte retention, and acne vulgaris may occur, which disappear after treatment.

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Errors and unjustified appointments

Most often, when treating this condition, errors are caused by the wrong choice of medication.

In treatment, especially idiopathic, many methods of drug treatment that do not have rational pathophysiological prerequisites continue to be used (often for quite a long time, simultaneously or sequentially) - the so-called "empirical therapy".

When assessing the appropriateness of therapeutic approaches, it is necessary to adhere to the principles of evidence-based medicine, which requires controlled studies.

Unreasonable appointments include:

• gonadotropin therapy for normogonadotropic form of pathology;
• androgen therapy in the absence of androgen deficiency. Testosterone and its derivatives suppress pituitary secretion of gonadotropins, thereby leading to suppression of spermatogenesis. Azoospermia has been observed in a large percentage of patients receiving androgens;
• the use of selective estrogen receptor modulators (clomiphene, tamoxifen), which are drugs with a potential carcinogenic effect in the idiopathic form of the pathology;
• the use of aromatase inhibitors (testolactone), kallikrein, pentaxifylline, which are ineffective in this pathology;
• the use of dopamine receptor agonists (bromocriptine) in the idiopathic form of the pathology (effective only in infertility caused by hyperprolactinemia);
• the use of somatotropin, which leads to an increase in the volume of ejaculate, causes hypertrophy of the prostate gland, but does not affect the number and motility of sperm;
• the use of herbal preparations, the effectiveness of which for this pathology has not been proven.

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Forecast

The effectiveness of treatment is low and is less than 50%.

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