Male Infertility Is Still A Puzzle

Male infertility is a neglected area of medicine, partly because of the hoary old belief that when a couple cannot produce a child, it is the woman’s “fault”, a myth that has been a long time dying.

In fact, male infertility accounts for about a quarter to a third of all childless couples, meaning that almost half a million men have fertility problems.

“Our knowledge of male reproductive physiology is 20 years behind our understanding of female fertility,” according to Professor Robert Aitken of the Medical Research Council’s reproductive biology unit in Edinburgh.

There is no clinical discipline to deal with it. If you are a woman, you go to see a gynecologist, but there is no one for a man to go to. Often men are sent to gynecologists, who are not trained in andrology (the study of male fertility) or they are sent to urologists, who know a lot about kidneys, but know little about human reproduction.

He and other experts would like to see a sub-specialty of andrology developed, to ensure that men with fertility problems are seen by someone with an understanding of the subject.

Men Are Wrongly Diagnosed As Infertile

Dr. Christopher Ford, the senior research fellow at Bristol University’s Department of Obstetrics and Gynecology, believes some men are being wrongly diagnosed as infertile when they could father a child, just because the discipline is new and underdeveloped.

Dr. Ford says, “The usual method of diagnosis is by a semen analysis: counting the number of sperm and checking their motility and morphology (movement and shape).”

But the British Andrology Society (BAS) did a pilot control exercise with 20 laboratories recently. It showed a big disparity between the laboratories. What one laboratory called abnormal; another might say was normal.

Some people are undoubtedly being misdiagnosed. This is a matter of legitimate concern. If a man is labeled infertile, which is largely untreatable at present, it has big implications. He and his partner might become reconciled to it, or they might adopt a baby or choose donor insemination. These are big steps to take and should be taken based on a reliable test.

“In the BAS,” says Dr. Ford, “we are organizing educational courses to train people to do semen analysis properly. We would like to see quality control systems introduced and a system of laboratory accreditation. This is happening with pathology laboratories, all of which will have to be accredited by 2000. We want andrology laboratories to be part of the process. We would like to see GPs thumping the table and demanding a good service, with a reliable standard for tests. Because of the lack of laboratory standardization, men often must repeat the test. Specialist centers will not always accept the results from the district general hospital. Patients often object to that.”

Why Are So Many Men Infertile?

Professor Aitken says, “The real tragedy about male infertility is that we do not know the causes.” There are a few well-defined conditions that cause problems, such as Kalman’s Syndrome, in which sufferers do not produce enough gonadotrophic hormone; mumps and other infections, which can affect sperm production; injury to the testes and chemotherapy for cancer.

Men may also produce antibodies to their own sperm, or they may have a blockage in the vas deferens, the tube that leads from the testes to the penis. But in most cases, the cause is unknown.

“It is misleading, in many ways, to talk about fertility and infertility, because it is a continuum,” Professor Aitken adds.

“If an infertile man marries a very fertile woman, they may well have children, but if he marries someone who is also infertile, it will be difficult. The exception is azoospermia, where the man does not produce any sperm at all, but that accounts for less than 5 percent of cases.”

Although steroids can be given in cases where men produce antibodies to their own sperm and surgery can unblock the vas deferens, in most cases, nothing can be done. Men are often advised to wear loose underwear and keep the testes cool because that is supposed to boost sperm production, but some doctors are skeptical about the value of such advice.

Sperm Counts Are Falling

Research shows that sperm counts in men are falling. No one knows the reason, but certain theories have been put forward.

Work carried out in Edinburgh and Copenhagen suggests that it is due to increased exposure to estrogens in the womb since these hormones are common nowadays in farming, pharmaceuticals, and the water supply, but sperm levels are still high enough in most cases to produce fertility.

Some scientists believe that male infertility may be helped by taking high-dose Vitamin E tablets. When free radicals in the blood react with lipid molecules, they can cause a chain reaction which is thought to damage the sperm membrane. Doctors think that high levels of Vitamin E might be able to interrupt that chain reaction. Clinical trials are about to begin in Dr. Ford’s department in Bristol, subject to the consent of the ethical committee.

But such trials are in their early stages. So, for the moment, most men who discover that they are infertile are offered no medical solutions. Consequently, if they want to have children, they and their partners are likely to opt for either adoption or donor insemination.

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