Management of Male Infertility in Rural Areas

Is it possible for both the partners to have children with previous marriage and yet have infertility?

About one third of the causes of infertility are due to male factors and another third due to combined factors. Hence it is possible that despite having children with previous marriages, couples can still present with infertility.

What are the risk factors in men?

The following are the risk factors for men:

• Heavy alcohol use
• Drugs addiction
• Smoking
• History of mumps and pox, chemotherapy, radiation, etc.
• Use of tight undergarments and men who work in hot areas.
• Some medicines like anti-hypertensives [high BP medicine] and medicine for stomach ulcers and antibiotics have also been implicated.

What about common factors?

The common factors include anti sperm antibodies, inability to deposit the sperms at the correct place due to anatomical defects and so on. Many of the factors are unexplained and sub fertility in both of them can combine to cause infertility.

What are the things that men should inform the doctor while going for evaluation of infertility?

The doctors are looking for the following:¹

• Duration of infertility
• Previous fertility in the patient and the partner
• Timing of puberty (early, normal, or delayed)
• Childhood urologic disorders or surgical procedures
• Current or recent acute or chronic medical illnesses
• Sexual history
• Testicular cancer and its treatment
• Social history (e.g., smoking and alcohol use)
• Medications
• Family history
• Respiratory disease
• Environmental or occupational exposure
• Spinal cord injury

What do the doctors look for during evaluation?

The doctors are looking for the following:¹

• Testicles (for presence, size, consistency, and bilateral symmetry)
• Epididymis (for presence bilaterally, as well as any induration, cystic changes, enlargement, or tenderness)
• Vas deferens (for presence bilaterally, as well as any defects, segmental dysplasia, induration, nodularity, or swelling)
• Spermatic cord (for varicocele)
• Penis (for anatomic abnormalities, strictures, or plaques)
• Rectum (for abnormalities of the prostate or seminal vesicles)
• Body habitus
• Swelling of the breasts and milk discharge from the nipple

What are the tests that are available for evaluation in rural areas?

The semen analysis is the most important test that is necessary.

• SEMANANALYSIS: This is the most important investigation for evaluation of infertility in men. The following are assessed:¹
  • Semen volume (normal, 1.5-5 mL)
  • Semen quality
  • Sperm density (normal, >20 million sperm/mL)
  • Sperm motility (normal, >60% of sperm having normal movement)
  • Sperm morphology (>60% of sperm should be normal, and fewer than 2-3% should be immature)
  • Signs of infection – An increased number of white blood cells (WBCs) in the semen may be observed in patients with infectious or inflammatory processes
  • Other variables (e.g., levels of zinc, citric acid, acid phosphatase, or alpha-glucosidase)

Testicular biopsy is indicated in azoospermic men with a normal-sized testis and normal findings on hormonal studies to evaluate for ductal obstruction, to further evaluate idiopathic infertility, and to retrieve sperm.

• OTHER TESTS: These might not be available in rural areas. However, if available could be carried out.
  • Antisperm antibody test
  • Hormonal analysis
  • Imaging studies employed in this setting may include the following:
    • Transrectal ultrasonography
    • Scrotal ultrasonography
    • Vasography
  • An abnormal postcoital test result is observed in 10% of infertile couples. Indications for performing a postcoital test include semen hyperviscosity, increased or decreased semen volume with good sperm density, or unexplained infertility.
  • If the test result is normal, consider sperm function tests, such as the following:
    • Capacitation assay
    • Acrosome reaction assay
    • Sperm penetration assay
    • Hypoosmotic swelling test
    • Inhibin B level
    • Vitality stains

However these might not add much more significant information to the regular semen analysis.

Is there any medical treatment that is helpful?

There is medical treatment that could help even in rural areas.¹

1. There are medicines like Clomiphene and Tamoxifen that help increase the hormones from the brain. They should be taken under supervision only.
2. When there is high level of a certain hormone that causes secretion of milk from the nipple and enlargement of the breasts, decreased libido etc. a medicine called bromocriptine could be taken.
3. Patients with antisperm antibodies [especially the couple who have had children earlier] could benefit from steroids.
4. Medicines are available for those who have retrograde ejaculation or feel that they have ejaculation but do not have semen. Testing the urine for sperms after sexual intercourse would prove that there was retrograde ejaculation.
5. A diet high in antioxidants such as vitamin C and vitamin E has been proposed to improve the quality of sperm by decreasing the number of free radicals that may cause membrane damage. Additionally, the use of zinc, fish oil, and selenium has been shown to be of benefit in some studies.
6. The optimal timing to perform intercourse for conception is every 2 days at mid cycle.

What are the possible surgical treatments?

The following are available:¹

• Varicocelectomy
• Vasovasostomy or vasoepididymostomy
• Transurethral resection of the ejaculatory ducts
• Sperm retrieval techniques
• Electroejaculation
• Artificial insemination
• Assisted reproduction techniques
• In vitro fertilization
• Gamete intrafallopian transfer (GIFT) and zygote intrafallopian transfer (ZIFT)
• Intracytoplasmic sperm injection

Are all these available in rural areas too?

Only the following are available in rural areas.

Varicocelectomy

This is the most commonly performed surgery for male infertility. The retroperitoneal approach may be performed as an open procedure or laparoscopically. Although minimally invasive and easy to perform there might be injury to the testicular blood supply very rarely.

The inguinal and subinguinal microscopic approach allows for ligation of individual veins with decreased risk of inadvertent arterial damage. Some therefore feel this is the safest and most effective technique.

Successful varicocelectomy results in improvement in semen parameters in 60-70% of patients. The repair also typically halts further testicular damage and improves function.

Persistent dilatation after repair is not unusual and does not necessarily represent surgical failure. Rather, the veins may remain clinically apparent owing to chronic stretching or thrombosis, even if venous reflux is no longer present. Semen analysis may show improvement as early as the 3-month follow-up visit.

Vasovasostomy or vasoepididymostomy

These microsurgical techniques are performed in patients with known epididymal or vasal obstruction, both congenital and acquired (e.g., due to surgery, trauma, infection). Improved surgical techniques and the use of the operating microscope have improved the outcomes in patients requiring vasectomy reversal or those with primary vas obstruction. We have described a low cost technique of doing this.¹

Transurethral resection of the ejaculatory ducts

Patients with a known or suspected obstruction of the ejaculatory ducts may be eligible for transurethral resection of the ejaculatory ducts (TURED), which durably improves semen quality in patients with ejaculatory duct obstruction.

Artificial insemination

Artificial insemination (AI) involves the placement of sperm directly into the cervix (i.e., intracervical insemination [ICI]) or the uterus (i.e., intrauterine insemination [IUI]). AI is most useful for couples in whom the postcoital test indicated no sperm, those who have very low sperm density or motility, or those who have unexplained infertility.

IUI allows the sperm to be placed past the inhospitable cervical mucus and increases the chance of natural fertilization. This result in a 4% pregnancy rate if used alone and a pregnancy rate of 8-17% if combined with superovulation. Both processes require semen processing.²

What are the facilities available at the SEESHA surgical camps?

The SEESHA surgical camps, especially at the Bethesda Hospital in Aizawl in Mizoram, offer all the possible treatments mentioned so far. The surgical treatment is available at the other places like the Karunya community hospital, ICC hospital at Coimbatore, the Sielmat hospital at Churachandpur and Family health clinic at Dimpur and at the other places.

Laparoscopic surgery is carried out through the most modern and safe procedure of single incision gasless laparoscopic surgery. With only a small incision at the level of the umbilicus, there is hardly any scar tissue visible. It can be carried out in rural areas with spinal anesthesia. Transurethral resection of the ejaculatory ducts is also available.

What are the results of treatment?

We have found that overall about 20 to 25% of the treated couples conceive every year at Bethesda Hospital. The specialist there is a lady doctor and much of the experience is with female patients. Although we have not followed up men with medical treatment more than 70% have significant improvement in the sperm count and characteristics and a fourth of them have conceived.

Dr. J. Gnanaraj MS, MCh [Urology], FICS, FARSI, FIAGES is a urologist and laparoscopic surgeon trained at CMC Vellore. He has been appointed as a Professor in the Electronics and Instrumentation Engineering Department of Karunya University and is the Director of Medical Services of the charitable organization SEESHA. He has a special interest in rural surgery and has trained many surgeons in remote rural areas while working in the mission hospitals in rural India. He has helped 21 rural hospitals start minimally invasive surgeries. He has more than 150 publications in national and international journals, most of which are related to modifications necessary for rural surgical practice. He received the Barker Memorial award from the Tropical Doctor for the work regarding surgical camps in rural areas. He is also the recipient of the Innovations award of Emmanuel Hospital Association for health insurance programs in remote areas and the Antia Finseth innovation award for Single incision Gas less laparoscopic surgeries. During the past year, he has been training surgeons in innovative gas less single incision laparoscopic surgeries.