“Despite advances in the diagnosis and treatment of infertility, the conception rate remains stable, said Assistant Professors of Pharmacy Practice Stacey Friedman and Ryan Dull in Male Infertility: An Overview of the Causes and Treatments (published in the June 2021 issue of US Pharmacist). “A recent increase in demand for infertility services has been attributed to a greater awareness of treatment options, increased infertility, and a trend toward delayed marriage and childbirth leading to more fertility issues.”

CAUSES

There are several causes of male infertility including infection, tumours, antibodies that attack sperm, and Celiac disease. Below are the six most common causes.

Testicular deficiency: Sometimes referred to as nonobstructive azoospermia, testicular deficiency is a spermatogenic failure caused by conditions other than obstruction or HPG dysfunction, Friedman et al. explained. “This category of dysfunction can be further subdivided into congenital, acquired, or idiopathic testicular failure. Congenital failure can manifest as anorchia, testicular dysgenesis, cryptorchidism, or genetic abnormalities. Acquired testicular failure can be the result of trauma, testicular torsion, orchitis, exogenous factors (e.g. medications, systemic diseases, varicocele), or surgeries that damage the vascular structure of the testes. About 15% of the general male population and approximately 40% of men presenting with male infertility have varicoceles.”

Varicocele: A varicocele is a swelling of the veins that drain the testicle resulting in reduced quality of the sperm. According to Mayo Clinic it's the most common reversible cause of male infertility. “Although the exact reason that varicoceles cause infertility is not clearly understood, it may be related to abnormal blood flow.” Treating the varicocele can improve sperm count and function, and may potentially improve outcomes when using assisted reproductive techniques such as in-vitro fertilisation.

Hormonal abnormalities: “Idiopathic hypogonadotropic hypogonadism is caused by a deficiency of follicle-stimulating hormone (FSH) and luteinising hormone (LH),” explained professor of andrology Dr Amr Raheem and urologist Dr David Ralph (Male infertility: causes and investigations published in Trends in Urology & Men’s Health). “The main congenital type is Kilmann’s syndrome, which occurs in one in every 10 000 males at birth, and is caused by a deficiency in a gonadotrophin-releasing hormone.” Brain tumours, head injuries, and radiotherapy may also cause hormone abnormalities that lead to infertility. “Other hormonal abnormalities such as thyroid gland disorders, elevated levels of prolactin, and low testosterone levels will also impair sperm production.”

Genetics: “Structural and numerical chromosomal abnormalities are found in approximately 5% of infertile patients and the prevalence may increase in men with complete absence of sperm,” doctors Raheem and Ralph stated. “Genetic abnormalities include Y chromosome microdeletions, aneuploidy, and chromosomal translocations. Klinefelter syndrome (47 XXY), the most common example of a numerical abnormality, occurs in 1:600 live male births and in up to 10% of patients with non-obstructive azoospermia. There are numerous other genes not yet identified that regulate sperm production, hormone production, and hormone receptors. Any defect in such genes will weaken the chances of fertility.”

Certain medications: Testosterone replacement therapy, long-term anabolic steroid use, cancer medications (chemotherapy), some ulcer drugs, some arthritis drugs, and certain other medications can impair sperm production and decrease male fertility, advised Mayo Clinic.

Lifestyle factors: Generally speaking, lifestyle factors affect male reproductive system in various ways. While several studies have found that occupation, behavioural habit, dietary habit, and other factors can play a role in the decreased fertility, according to Dr Qiuqin Tang et al. (Environmental Factors and Male Infertility published in Spermatozoa - Facts and Perspectives) a patient’s unhealthy lifestyle (smoking, alcohol consumption, diet, recreational drugs) may be one of the greatest contributing factors that cause infertility.

TREATMENT

Proper diagnosis of infertile male patients is important as treatment and management is directly related to cause. There are a wide range of treatment options for managing male infertility which include:

Antioxidant therapy: Dietary supplements represent a possible approach to improve sperm parameters and male fertility Dr Andrea Garolla et al. said in their paper Dietary Supplements for Male Infertility: A Critical Evaluation of Their Composition published online. There is extensive evidence highlighting the role of oxidative stress in male infertility due to elevated levels of sperm DNA fragmentation and abnormal semen parameters. According to Dr Asha Sharma, antioxidant therapy reduces the excess reactive oxygen species (ROS) (Male Infertility; Evidences, Risk Factors, Causes, Diagnosis and Management in Human, published in the Annals of Clinical and Laboratory Research Volume 5). In the evidence-based review Antioxidant supplements and semen parameters (published in the International Journal of Reproductive Biomedicine Volume 14), researchers Sedigheh Ahmadi et. al. found that the administration of supplementations like L-carnitine, selenium, vitamin C, and vitamin E may lead to improving sperm concentration, motility and morphology, and sometimes DNA integrity. However, Dr Garolla et al. stressed the importance of the formulation of supplements in general, highlighting the need for the correct ingredients and concentration.

Lifestyle modifications: Losing weight for obese men and eating a balanced diet that consists of fruits and vegetables can be helpful. Quitting smoking, limiting caffeine, and limiting or eliminating alcohol are also recommended. Lastly, the use of performance-enhancing supplements is strongly discouraged. “Anabolic steroids used to enhance strength and fitness can actually drastically lower a man’s sperm count, sometimes even to zero in many cases. Similarly, testosterone supplements can also cause sperm counts to plummet,” warned fertility specialists at Fertility Answers.

John Hopkins Medicine recommends the following fertility treatments:

• Artificial insemination: This method puts many healthy sperm at the entrance of the cervix or right into the partner's uterus. The sperm can then make their way to the fallopian tubes.
• IVF, GIFT, and other techniques: In vitro fertilisation (IVF) and gamete intra-fallopian transfer (GIFT) work like artificial insemination. The sperm is collected and thereafter the eggs are mixed with a lot of high-quality sperm. Also, the eggs and sperm may be mixed in the lab or the partner’s fallopian tube.
• Intracytoplasmic sperm injection (ICSI): A healthcare practitioner injects a single sperm into an egg after which fertilisation takes place under a microscope. The fertilised egg will then be placed in the partner’s uterus.

“The pharmacist plays a vital role in identifying medications that contribute to male infertility, counselling the couple on medications used to treat infertility, and promoting healthy lifestyles that minimise infertility factors,” stressed Assistant Professors of Pharmacy Practice, Stacey Friedman and Ryan Dull (Male Infertility: An Overview of the Causes and Treatments, published in the June 2012 issue of US Pharmacist).