Sometimes dissolution of marriage (divorce) or remarriage is frequently arranged by male partners or by the relatives of the male partners for "Bongsher Bati".
Evaluation of male factor infertility and sterility
A couple is considered infertile if there has been no pregnancy after one year of unprotected sexual intercourse. This articles based on our study of 80 (67 oligospermic, 13 azoospermic) patients.
In fact, the principal reason for marriage is the desire for children, so fertility of the individual marriage is of importance. In our country, especially in rural people, having male children is a moral support to the parents. Thats why infertility is the most horrible calamity to them, which can befall a couple. In our rural society, infertile couple is not regarded with pity, but with scorn and contempt, though not in an cases. When the usual treatment by medicine, man cant cure the infertility the subjects appeal to the usual domestic remedies such as Fakir, Hekim, Kobiraj to have panipora, zhar fuk or the fetish priest.
Sometimes dissolution of marriage (divorce) or remarriage is frequently arranged by male partners or by the relatives of the male partners for Bongsher Bati.
Not only our peoples but also other countries like Ghana believe these types of ancient views. In Ghana, whether the causes of infertility lies on male or female partner, it is immaterial, failure of treatment for infertility leads the subject to appear to the fetish priest In their ancient view a wooden doll known as Akuaba plays an important role in the fetish priests treatment of infertility. The wooden fertility statue, Akuaba which the infertile married woman ovaries on her back by way of an amulet and taking care of the doll as she would take care of a child the woman may prove to the god that she can be a good mother, thus raising the chances of pregnancy.
Art historical investigation has shown that the Akuaba is not only similar in morphology with the Ankh - the symbol of life of ancient Egypt but also similar in significance and use. The resemblance between the biological female sign and the Akuaba can be explained by the fact of their common ongin. So what may be the ancient view, it is very important to evaluate an infertile couple with ,the available treatment facilities.
Couples presenting reproductive difficulty after 12 months of marriage, no contraceptive methods should be regarded as possible infertile and should be evaluated for treatment. One-third causes of infertility lies on the male partner, where as one-third lies on female partner. Rest one-third causes lies on both partners. It is extremely important to evaluate both couple together until a significant cause is uncovered. Sometimes a male partner comes after uncover and treatment of male factor infertility by a women physician without any result.
Here we tried to find out male factor infertility and sterility and accordingly tried to treat them.
We evaluated 80, otherwise normal, sexually mature men aged 30-63 years old seen between January 1995 to January 1998. All were fully virilized and sexually active. All patients were diagnosed having male infertility. Female physicians examined the female partner. Of them 78 were married and 2 were unmarried. Marriage life were 5 to 25 years. Of them 67 were oligospennic and 13 were azoospennic.
Follow up duration ranged from 6 months to 1 year (table 1). Criteria for preliminary diagnosis were divided into common criteria and special criteria. In common criteria there were counseling with infertile couples, clinical examination, semen analysis with culture and fructose test, prostatic smear examination and culture, routine blood examination. In special criteria there were tuberculin test, hormone analysis, antisperm antibody detection, immunological test for tuberculosis, filariasis and invasive procedures such as vasogram and testicular biopsy (table-2).
Patients were classified as having azoospermia if they had no sperm in the ejaculate after sperm pillet and patients were classified as having oligospermia if they had low sperm count (less then 20 million! ml) in the ejaculate. Semen analysis was performed within one hour after collection by masturbation or copulation. The semen parameter were shown in table-3.
Of 67 oligospermic and 13 azoospermic patients predisposing factors are shown in table-4. Of 67 oligospermic patients 4 (6%) had orchitis, 18 (27%) had chr. Prostatitis, 28 (42%) had varicocele, 6(%) had scrotal pathology and in 10(15%) causes were unknown.
Number of chr. Prostatitis patients were more than that of others. Among 13 azoospermic patients 4 (30.8%) had conj. absence of vas, 3(23%) had ejaculatory duct obstruction, 3 (23.1%) had epididymal block (dilated epididymis), 1(7.7%) had obstruction of the vas and 2 (15.4 %) had small testis or absent testis. The number of conj. absence of vas were more than that of other azoospermic patients.
The treatment protocol in case of oligospermia and azoospermia were shown in table-5. In case of oligospermia pharmacological treatment was with antibiotic, antifilarial drug steroid, hormone, antiandrogenic substances and surgical treatment were varicocelectomy, hydrocelectomy epididymal cystectomy, spermatocelectomy. In case of azoospennia endoscopic manipulation, vasovasostomy, vasoepididymostomy, peroperative irrigation of the vas during vasogram and no treatment - advice for child adaptation.
Among the 67 oligospermic patients treated, 97 per cent were correcting and 8.96 per cent became father.
Three per cent did not responded with the above treatment protocol. There were significant difference. Changes in semen parameters of Oligospermic and asthenozoospennic patients of various grades were noted after treatment of infertility. The percentage of a
Traditionally, the major focuses of fertility
problems in the past has been the female partners. More recent data suggest that 50% of the infertility problems is present in male partners. Results of the treatment for oligospermic male were better than those of azoozpermic male.
chieved normospermia increased proportionately to tile initial semen state.
Pregnancy rate also increased proportionately to the initial seminal state. The pregnancies occurred after having achieved normospermia, while in 25.6% the seminal states were still below the accepted normal values.
Among the 13 azoospermic patients treated we did not get good result because follow-up duration was only 6 months. At least one year follow-up is necessary.
F or the evaluation and therapy of male factor infertility one should proceed in a parallel investigative manner until a significant problem is uncovered. The evaluation of the man should proceed in a logical, cost-effective sequence to elucidate possible causes of infertility. Coordination with the womans physician allows an efficient and appropriate workup and prevents the use of unnecessary tests or procedures.
The cornerstone of the evaluation of the infertile man is a careful history and physical examination. Episodes of genita1 tract infections or Chr. Prostatitis or conj. absence of vas should be investigated because they may led to reproductive tract obstruction or abnormal semen parameter.
Both the vas deferens and the testicular blood supply can be injured easily during a hernia repair or scrotal surgery, so previous surgical intervention should be noted. Trauma or torsion before puberty may result in testicular atrophy and if occur after the time of puberty, may be related to the presence of sperm antibodies.
About 10% of patients who develop bilateral mumps orchitis post puberty may end up with severe testicular damage, so careful examination of the testes is a part of the evaluation. The seminiferous tubules account for approximately 95% of testicular volume. Normal adult testes are on average of 4.6 cm long (range 3.6-5.5 cm) and 2.6 cm wide (range 2.1-3.2 cm), with a mean volume of 18.6 + 4.8 (SD) ml.
A ruler Caliper or Prader orchidometer may be used to measure testicular size. We developed our own orchidometer by which we measure the testicular vol. If the testes damage before puberty the testes become small and firm; with post-puberty damage, they are usually small and soft.
Epididyma1 examination is an important part for evaluation of male infertility, because irregularities and hardness in the epididymis or vas may suggest a previous infection and possible obstruction. Both vases should be palpated as 2% of infertile men have congenital absence of the vas and seminal vesicles.
In our study among azoospermic men 30.8% had congenital absence of vas. The examination of scrotum for varicocele is very important. The incidence of varicocele in the adult male population is between 10 and 15% in individuals evaluated for infertility. In our study we found it 42% in the infertile male, which is higher than that of others, probably, because Bangladesh is an endemic area for filarial infection, our patients of varicocele were infertile for varicocele caused by filariasis as we tested for filarial infection. Siraj Jinnat et al. reported, 25% of the patients studied had varicocele and 7% had abnormality in epididymis.
They found 24% varicocele in another study, however, in our study we found 42% varicocele and 27% chr. Prostatitis. The percentage of varicocele patients were higher than those of their studies, may be due to different study design or the number of patients in their study were more than that of our study population. At present we are studying with more number of infertile patients.
The cause of infertility due to varicocele is controversial. Because incidence of left varicoceles occuring in 16% of normal men. It is believed that clinical varicoceles are formed by left spermatic vein insufficiency or downward regurgitation that can be ascribed to a retrograde flow of blood from the left renal vein into the spermatic vein and thats why dilation of the veins of the pampiniform plexus.
Traditionally, the major focuses of fertility problems in the past has been the female partners. More recent data suggest that 50% of the infertility problems is present in male partners.
Results of the treatment for oligospermic male were better than those of azoozpermic male. We think long term follow up is needed for both Oligospermic and Azoospermic patients. On the basis of the above study we think more facilities and further research are needed to reach the goal. (Reprint)
Prof. Dr Hafizuddin Ahmed
Principal
Monowara Sikder Medical College
Professor, KHWAJA Younus Ali Medical College, Enaetpur, Sirajgonj, E-mail: [email protected]
Dr Ashrafuddin Mollik
Consultant Surgeon,
KHWAJA Younus Ali
Medical College
