SPERM COUNT

ABCNews' "World News Tonight" on Friday examined the emotional aspects of egg donation for female college students -- who are the "most desirable market" for fertility clinics because of their age and education -- and the opinions among former egg donors about whether the experience was positive or negative. According to Debora Spar -- a professor at [click link for full article]

An obstetrician well known for his care of and research into multiple-birth pregnancies has found that dietary changes can affect a woman's chances of having twins, and that her overall chance is determined by a combination of diet and heredity. [click link for full article]

In this week's Analytical Chemistry, scientists at Indiana University Bloomington report biochemical machinery that allows mouse sperm cells to follow the weakest of scents. Even when ovary extracts were diluted 100,000 times, some sperm cells still found their mark. A video demonstrating sperm chemotaxis (oriented motion in response to a chemical gradient) [click link for full article]

CBS' "Evening News" on Wednesday reported on the "emerging market" of fertility clinics paying female college students to donate their eggs. According to CBS, 75% of current egg donors are college-age women. Debora Spar -- professor at [click link for full article]

According to new research, women who consume animal products, especially dairy, are five times as likely to have twins than vegan women - women who consume no animal products at all. Dr. Gary Steinman, Long Island Jewish (LIJ) Medical Center in New Hyde Park, NY, said the consumption of dairy products, especially, raised a woman's chances of having twins. You can read about this study in the Journal of Reproductive Medicine, May 20 Issue. [click link for full article]

As medical technology continues to advance, fertility procedures such as in-vitro fertilization and donor insemination are becoming more commonplace. However, a study in the May issue of The Journal of Pediatrics warns that, even after thorough screenings of sperm donors, genetic disorders can be transmitted to the conceived children. [click link for full article]

Commenting on today's decision by the HFEA* to extend the criteria for pre-implantation embryo selection to prevent the passing on of a genetic predisposition to conditions such as breast cancer, the BMA's Head of Ethics and Science, Dr Vivienne Nathanson, said: "The BMA believes that it is right to use advances in medical technology to reduce suffering and impairment and we therefore welcome today's decision to extend the criteria for embryo selection. [click link for full article]

The AP/Seattle Post-Intelligencer on Tuesday examined how physicians "too seldom" advise young men and women diagnosed with cancer that treatments they might receive could affect their fertility. Some forms of chemotherapy, radiation and surgeries can render cancer patients infertile, according to the AP/Post-Intelligencer. [click link for full article]

The popular birth control pill, ORTHOTRI-CYCLEN(R) LO (norgestimate/ethinyl estradiol) Tablets, is notassociated with an increased risk of pregnancy in heavier women, accordingto findings(1) presented today at the 54th Annual Clinical Meeting of theAmerican College of Obstetricians and Gynecologists (ACOG). [click link for full article]

An international collaboration of researchers, headed by Dr. Shiping Wang (Huazhong Agricultural University, China) has discovered that a single gene in rice regulates both male fertility and pathogen resistance, providing an unexpected genetic link between reproductive success and the disease resistance... click link for more info.

NPR's "Morning Edition" on Wednesday examined how stem cell researchers are competing with fertility clinics for human egg donations. Although there has not yet been a significant demand for human eggs for research purposes, the "promise of embryonic stem cells may change that," according to NPR... click link for more info.

Greenpeace on Tuesday called on the European Union to pass legislation that would tighten regulations for the chemical industry, citing scientific research that some toxic chemicals found in consumer products cause fertility problems, low sperm counts and other reproductive disorders, the Associated Press reports... click link for more info.

With the UK government currently considering whether to fortify flour with folic acid, results of a study in this week's issue of The Lancet highlight how such fortification may increase the rate of twin births after in-vitro fertilisation (IVF) where more than one embryo is transferred... click link for more info.

Irvine Scientific, a leadingmedical device/biotechnology company located in Santa Ana, CA announcedthat the first vitrification product for blastocysts (day 5 human embryosfrom an in vitro fertilization procedure) is available in the U.S. afterrecently receiving clearance from the U.S. Food and Drug Administration... click link for more info.

MTT Agrifood Research Finland researchers have identified the birth mechanism of an infertility problem afflicting Finnish Yorkshire pigs. A retroposon, or "jumping gene", was found to be behind the hereditary defect giving rise to the immotile short-tail sperm defect (ISTS) in boars, by producing a mutation in the KPL2-gene in pigs... click link for more info.

Dr. Patricia Rashbrook, 63, from Lewes, East Sussex, England, will become Britain's oldest mother to give birth. Dr. Rashbrook was treated by Severino Antinori, a controversial fertility doctor, at an undisclosed European country. Dr. Antinori, who has a fertility clinic in Rome, considers 63 to be the age-limit for IVF treatment... click link for more info.

Yes there are alternatives to this product and I have been recommending the following alternatives until I found the VolumePills product.

Alternative 1: One of the best ways of increasing your sperm volume by 100% would be to change your diet and your life style. By doing the following you can probably double the amount of sperm you produce and that is based on my experiences:

• Stop Smoking
• Reduce intake of alcohol
• Exercise Regularly and loose Weight if needed
• Vitamin supplements for your diet

Notice that I said these things are free solutions but the results that you want are a lot harder to achive and vitamins and exercising usually incur a cost. By stopping smoking and drinking this will generally help your body as well as helping to increase sperm count.

Alternative 2: You can attempt to make your own Volume Pills, type formula with natural ingredients. This is one of the best ideas I thought so I set about doing this. The problem is Volume Pills do not reveal to you how their ingredients are blended or the exact ingredients. However making up your own formula can have some small success. There are herbs out there that can help increase your sperm count but by the time you have purchased all the herbs you know are in the Volume Pills formula you have spent a small fortune and you would be taking 10-15 different tablets a day. I should know I tried it and it caused severe upset stomach for me, however it is an alternative if albeit an expensive and less productive one so I feel it is my duty to list it.

Until recently the best advice that I could give was to dramatically change your diet. Diet and too much masturbation are the 2 main causes of poor sperm quality and lack of volume. By eating nuts and cutting down on masturbation and sex you can increase your sperm production over several months. This used to be my advice until recently when I came across a 100% natural product which claimed you could increase your sperm volume without cutting back on your sexual activities or changing your diet.

I investigated this product and actually tested it. It claimed that you would be producing more sperm within just a few days so it was easy to test. The results are remarkable, the product works, their blend of 100% natural ingredients works to increase the sperm volume, count and quality. The first thing that I personally noticed was that my sperm was a lot thicker and a deeper white in colour and I could feel that my ejaculations where more intense thanks to this. After the initial benefits of the product I continued its use and sure enough I was producing at least 3-4 times more sperm than before and it was thick white sperm which obviously showed it was of high quality. The orgasms felt more intense then they did when I was a teenager. This product was being used by male porn stars so that they could orgasm more often and produce more when they ejaculate.

The product that I recommend and use is called Volume Pills. Their product is 100% natural, this is one of the main reasons that I tried it. I have tried to shop around for a similar product to recommend but their site is the only site which sells this pill which is used by male porn stars across the world. They even have testimonials on their site from porn stars. The natural pill can be used for to increase fertility as well as for recreational purposes. The website located at VolumePills is geared towards promoting the recreational benefits of producing up to 500% more sperm, such as showering your lover from head to toe in sperm. The site also clearly points out that their product will without a doubt increase male fertility and the sperm quality.

Below are some of the benefits associated with taking VolumePills:

• Up to 500% increase in sperm volume - The ingredients stimulate sperm and testosterone production in the testes so that when you come to ejaculate there is up to 500% sperm.

• Increased male fertility & sperm quality - The unique blend from VolumePills will provide the nutrients needed to produce high quality thick sperm with good motility and life.

• Experience rock hard erections - The natural ingredients will provide you with harder erections which can mean more pleasurable sex for you and your partner.

• Longer more intensified orgasms - When you produce more sperm your orgasms are more intense and last longer resulting in more satisfying sex.

• Increased sexual desire & appetite - The natural ingredients act as an Aphrodisiac an increase your sexual desire meaning 1 session will not always be enough.

• Recreational benefits - You will be able to cover your lover in sperm or shoot it all over their face! Many men and women fantasize about situations like this.

The above benefits is a summary of what VolumePills product can do for you. This product comes highly recommended by myself and they even offer a full money back guarantee on their product. Obviously I do not expect you take my words at face value I am just telling you a product that I have tested and know will work for you. You should take a good look at their site and do some research. However I gather that you would have done this before finding my article on the subject. The pill produced by Volume Pills is not overly expensive but is not cheap. You pay for results and I still order and use this product myself because it is by far the best solution currently on the market. You can visit the  website here.

Many men wish to increase their sperm count and quality. There are 2 main reasons for this, the first reason is for recreational pleasure. If your sperm just dribbles out when you orgasm it can leave men feeling embarrassed and women feeling like they have done something wrong. Many men wish to orgasm like male porn stars ( like Peter North) as they know that women watch porn movies and this is what they expect. The other main reason is to increase fertility. If a male produces more sperm then it is more likely that his sperm will make it to the females egg. There is no point in producing more sperm though if the quality is poor. If the sperm is thick and a deep white colour then you have healthy sperm, if on the other hand it is runny and only a little white then your sperm is of low quality.

In this article I am going to discuss the methods that are available to increase your sperm quality, production, volume and fertility by up to 500%. It is very easy to achieve 500% more quality sperm every time you ejaculate but first lets see what other benefits can be gained from producing more sperm.

Increased orgasm intensity - Having a larger amount of sperm pass through the penis during a male orgasm can prolong coitus (orgasm experience). The intensity of a male orgasm as been proven to be directly related to the amount of semen travelling through the penis. Therefore when you start to produce more semen your orgasms will be more intense. Because more semen is being ejaculated your orgasm will also last longer (30 seconds +).

Improved fertility - In order to fertilize an egg a large amount of sperm is required, many hundreds of millions. While the average man can produce this many sperm multiples times per day, there are some external factors that can adversely affect the sperm count. Things such as smoking, drug use, poor diet, lack of exercise, and even wearing tight clothing in the groin area can all decrease the sperm count. Increasing the volume of your sperm increases your fertility by increasing the number of sperm that are produced during each ejaculation. If you are trying to have children, the number of sperm you ejaculate is quite important, as is their condition. You need high quality sperm and more of it.

Female sex enjoyment - When you ejaculate, your penis pumps semen, which many men and women find pleasurable. When you increase the amount of you ejaculate the pleasurable pumping feeling lasts longer, and also increases your partners pleasure. More sperm during oral sex can be pleasurable and satisfactory for both you and your partner.

Infertile couples with severe male factor infertility (poor sperm count, motility, or morphology) can be treated with intracytoplasmic sperm injection (ICSI). Now, even men with no sperm in the ejaculate (azoospermia), whether from obstructions or sperm production problems (non-obstructive azoospermia), may have a chance to father a biological child. 

Obstructive azoospermia

Men with obstructive azoospermia include those with congenital absence of the vas deferens, failed vasectomy reversals, and other irreparable obstructions. In these situations, the woman goes through a typical in vitro fertilization (IVF) cycle and on the day of egg retrieval, sperm are also retrieved. Sperm may also be retrieved ahead of time and frozen. Sperm can retrieved by:

1. Micro Epididymal Sperm Aspiration (MESA), a delicate surgical technique using the microscope to aspirate sperm from near the obstruction.
   
2. Percutaneous Epididymal Sperm Aspiration (PESA), in which a small needle and a local anesthetic are used to aspirate sperm from near the obstruction.
   
3. Testicular Sperm Biopsy (TESE), in which a small biopsy of testicular tissue is taken under anesthesia. TESE is most often used when no sperm are obtained with MESA or PESA.

* These procedures are done on an outpatient basis.

Sperm obtained through MESA, PESA, or TESE must be processed by an experienced IVF lab for ICSI. The sperm are injected into the mature eggs retrieved from the woman, and embryos are placed in the uterus three or five days later. These sperm fertilize well with ICSI and pregnancy and delivery rates are no different than with regular IVF. Pregnancy and delivery rates are dependent on the age of the biological mother. Epididymal sperm can be frozen for future use.

Non-obstructive azoospermia

IVF with ICSI has also been shown to be successful in men with non-obstructive azoospermia; that is, men whose testicles do not appear to produce sperm. Most patients with non-obstructive azoospermia have miniscule production of sperm by the testicles, but no sperm in their ejaculate. In approximately 50 percent of these men, an extensive testicular biopsy can yield enough sperm to perform ICSI. Even patients whose routine diagnostic testicular biopsy did not reveal sperm may yield enough sperm with a thorough search of testicular tissue. 

Fertilization, cleavage, and pregnancy rates with ICSI from men with non-obstructive azoospermia may be lower than in patients with obstructive azoospermia. Non-obstructive azoospermia probably has a genetic cause for many of these men. Azoospermia may be passed on to male offspring from IVF with ICSI.

Sperm from a man's body unites with a woman's egg to create a totally unique and genetically irreplaceable human life. It's an amazing process.

Yet most men know very little about what contributes to reproductive health -- or conversely, what undermines it. We seldom think about our fertility or the health of our sperm...except perhaps during sexual activity. Yet science tells us we should consider our fertility and be protective of it.

Indeed, there are things we can do to safeguard our reproductive health...and the well- being of our future children. It all starts with being more knowledgeable about our health in general, and about behavioral choices and environmental hazards that can adversely affect our reproductive well-being.

INFERTILITY ISN'T JUST THE "WOMAN'S PROBLEM" ANYMORE.
It used to be, and not so long ago, that if a couple was unable to conceive, the woman was the "infertile one."

Now it is generally recognized within medical circles that the problem lies with the man in 35% of cases (some say a couple's inability to conceive is due to male conditions 40% - 50% of the time).

This is an incredible statistic, when you consider that the average, healthy male releases somewhere between 120 million and 600 million sperm each time he ejaculates, and manufactures an estimated 400,000,000,000 sperm in his lifetime. It would appear that men have it made in the reproductive department, but this is not always the case, and sometimes things go haywire.

The most common reason for infertility in the male is the inability to produce adequate numbers of healthy sperm. Infertility in men may also be caused by problems delivering sperm into the vagina, as occurs in impotence or in disorders affecting ejaculation, including inhibited ejaculation and retrograde ejaculation (when ejaculate is forced backward into the bladder). It may also be caused by failure of the testes to descend into the scrotum, by diseases or severe physical injuries which damage the sperm-producing structures, or by antibodies to the sperm found in either the male or the female.

OBSTACLES TO FERTILIZATION
A number of problems can prevent fertilization from taking place, and many of these can indeed originate with the male. The major cause of male infertility is an inability to produce enough healthy sperm.

All of the unwanted pregnancies occurring each year in the U.S. might lead you to believe otherwise, but for fertilization to occur, all systems have to be A-OK, on-line, and fully functional.

For example, your sperm must be present in sufficient volume, it must be active, it must not be clumping together, it must be relatively normal in shape and size, and it must not be adversely affected by sperm antibodies either in the man or in the woman. Further, it must be able to penetrate the barrier of the woman's cervical mucus and overcome staggering odds to ever even reach the fallopian tubes and go on to meet the egg.

When the couple can't conceive despite repeated attempts, your doctor may recommend a semen analysis to assess male factors which might be preventing fertilization. Your sperm will be put under the microscope, literally and figuratively.

DELIVERING THE SPECIMEN
You will be asked to provide a semen sample by masturbating into a clean, large-mouth, glass jar or plastic specimen cup, or by ejaculating into a special condom without spermicide during intercourse with your partner. The important thing is to keep the sample warm (men are often asked to carry the container under their armpits), and get the sample to the laboratory for analysis quickly. Most fertility experts want your semen within an hour, preferably sooner.

WHAT IS SEMEN MADE OF?
As mentioned previously, the average, healthy man will have anywhere from 120 million to 600 million sperm in a single ejaculation. Besides sperm, semen contains water; simple sugars (to provide fuel for sperm); alkalies (to protect sperm against the acidity of the male urethra and the vagina); prostaglandins (substances that cause contractions of the uterus and fallopian tubes, and are thought to aid in the sperm's passage to the womb); vitamin C; zinc; cholesterol; and a few other things.

While semen can transmit a variety of diseases, including the AIDS virus, healthy semen doesn't contain anything that's harmful or bad for the health.

WHAT DOES A SEMEN ANALYSIS ANALYZE?
The complete semen analysis includes:

• Volume of the semen
• Sperm count (the amount of sperm in a certain volume of semen, also known as the sperm concentration or sperm density)
• Sperm size and shape (morphology)
• Sperm motility (percentage of actively moving sperm)

New, computer-assisted sperm analysis may help assess sperm motility more accurately. Using a computer in combination with the microscope, a technician can assess how rapidly sperm move and how straight they swim.

Other factors that infertility specialists look at include the quality of the seminal fluid in which sperm swim, and the sperm's ability to survive in and move through cervical mucus, as well as its ability to penetrate and fertilize an egg.

WHAT'S THE "NORM" IN SEMEN?

Volume: 3 milliliters (2 to 6 mL range considered normal)

Concentration: 20 million sperm or more per milliliter

Motility: 50% of sperm still active after two hours

Normal forms/appearance: 60% of the sperm

Viscosity

ejaculate normally liquefies within an hour

pH: 7 to 8 HOW TO ENHANCE YOUR REPRODUCTIVE HEALTH

• Stop smoking. Smoking is linked to low sperm counts and sluggish motility, and recent findings suggest a 64 percent increase in miscarriage when both partners smoke or when just the man smokes.
• Give up marijuana. Long-term use of marijuana in men results in a low sperm count and sperm that exhibit abnormal patterns of development.
• Stay off the sauce. Chronic alcohol abuse damages the intricate plumbing of the male reproductive system, reducing a man's ability to produce normally formed sperm cells.
• Ease up on intense exercise. Men who exercise excessively may be reducing their sperm count due to the heat that builds up around the testicles during strenuous exercise.
• Up your C. Low vitamin C levels may cause sperm to clump together, rendering as many as 16 percent of all men infertile.
• Check into your antibiotics. Some groups of antibiotics have been shown to affect sperm quality temporarily by decreasing count and motility. These groups are nitrofurans (nitrofurazone or nitrofurantoin) and macrolides (erythromycin).
• Stay clear of environmental poisons and hazards. These include pesticides/insecticides, organic solvents, lead, ionizing radiation, heavy metals, and toxic chemicals.
• Check your nutrition. If you're malnourished or not getting enough of the right foods and nutrients, your sperm count could suffer.
• Keep your scrotum cool. Watch out for excessive heat in the scrotal area. Wear loose-fitting underwear (not tight jockey shorts), and avoid tight-fitting jogging pants. Avoid hot tubs, hot baths, saunas, or hot work environments.
• Abstain, but not too long. Brief periods of sexual restraint (three to six days) seem to increase both the volume and potency of semen. Prolonged abstinence, on the other hand, will result in a higher volume of older sperm, which exhibit decreased motility.

WHAT CAN HURT YOUR FERTILITY AND YOUR CHANCES OF FATHERING A HEALTHY CHILD?
Your fertility is often a reflection of your general health. If you are healthy and abide by principles of good healthy living, chances are your sperm will also be healthy, provided you haven't sustained permanent damage to your sperm-making equipment in the past (through trauma or infection, for instance), or weren't born with a disorder or structural problem that could prevent you from producing viable sperm. The following list of "threats" to male fertility, while certainly not all-inclusive, will help you to avoid injurious substances, situations, and behaviors:

 

• Smoking (smoking significantly decreases both sperm count and the liveliness of sperm cells)
• Prolonged use of marijuana
• Use of other "recreational" drugs (e.g., cocaine)
• Chronic alcohol abuse
• Use of anabolic steroids (which can cause testicular shrinkage and infertility)
• Overly intense exercise (excessive exercise may lower your sperm count by producing higher levels of adrenal steroid hormones, which lower the amount of testosterone in the body. This testosterone deficiency, in turn, decreases sperm production)
• Inadequate vitamin C and zinc in the diet
• Some groups of antibiotics (e.g., nitrofurans and macrolides)
• The antidiarrheal drug sulfasalazine
• The anti-fungal medication ketoconazole
• Azulfidine, a drug used to treat ulcerative colitis
• Varicocele (a varicose vein in the testicle that produces too much heat, which harms and kills sperm)
• Infections of reproductive system structures, such as prostatitis, epididymitis, and orchitis
• Infectious diseases that affect the testes, such as mumps in adulthood
• Trauma or injury to the testes
• Exposure to DES (diethylstilbestrol) during your mother's pregnancy, which can cause testicular and epididymal abnormalities and decreased sperm production
• Fevers
• Tight underwear or jogging pants
• Hot tubs, saunas..anything that raises the temperature of your scrotum, including overheated vehicles and hot work environments
• A testosterone deficiency
• Exposure to environmental hazards such as pesticides, lead, paint, radiation (x-ray), radioactive substances, mercury, benzene, boron, and heavy metals
• Chemotherapeutic (cancer-treating) agents
• A blockage or structural abnormality in the vas deferens
• Damage to the spermatic ducts, usually due to a sexually transmitted disease such as gonorrhea or chlamydia. Also, passing a sexually transmitted infection onto your partner may render her infertile
• Malnutrition and anemia
• Tuberculosis
• Excessive stress

CAN DAMAGED SPERM RESULT IN BIRTH DEFECTS?
Researchers now suspect that reproduction and fetal development may be affected if the biological father has been exposed to lifestyle or occupation hazards, such as smoking cigarettes, drinking alcohol, taking non-prescribed drugs, and being exposed to toxic chemicals.

GOOD ADVICE FOR COUPLES TRYING TO CONCEIVE:
Stop smoking, drinking, doing drugs, and taking any unnecessary medications at least three months before you start working on getting pregnant.

Scientists used to believe that if sperm were damaged, they could not fertilize an egg; therefore, only the "fittest" sperm would carry on the species --some call this the "macho sperm" theory. Research now shows sperm are vulnerable and that even when damaged, they may still fertilize an egg. Some toxins may alter the sperm's chromosomes, which carry genetic information. If this happens, the results may range from infertility and miscarriage to stillbirth, birth defects, learning disabilities, and even childhood leukemia and kidney cancer.

It is therefore wise for men who want to have children to change unhealthy lifestyle habits and, when possible, protect themselves from hazards and toxins in the environment and workplace. Sperm develop over a three-month period; that means your mature sperm today may have been affected by how you lived 3 months ago. The message: if you plan to have a child, quit smoking, drinking, using recreational drugs, etc., and wait three months before trying to conceive a child with your partner.

PRE-TESTICULAR CAUSES OF INFERTILITY

 

	Hypothalamic disease
	Isolated gonadotropin deficiency (Kallmann's syndrome)
	Isolated LH deficiency ("Fertile eunuch"
	Isolated FSH deficiency
	Congenital hypogonadrotropic syndromes

 

 

	Pituitary disease
	Pituitary insufficiency (tumors, infiltrative processes, operation, radiation)
	Hyperprolactinemia
	Hemochromatosis
	Exogenous hormones (estrogen-androgen excess, glucocorticoid excess, hyper and hypothyroidism).

 

HYPOTHALAMIC DISEASE

Kallmann's syndrome which is an isolated gonadotropin (LH and FSH) deficiency occurs in both a sporadic and familial form and although uncommon i.e. 1 in 10,000 men, it is second to Klinefelter's syndrome as a cause of hypogonadism. The syndrome is often associated with anosmia, congenital deafness, hair lip, cleft palate, craniofacial asymmetry, renal abnormalities, color blindness. The hypothalamic hormone GnRH appears to be absent. If exogenous GnRH is administered, both LH and FSH are released from the pituitary. Except for the gonadotropin deficiency, anterior pituitary function is intact. The syndrome appears to be inherited either as an autosomal recessive trait or an autosomal dominant trait with incomplete penetrance. The differential diagnosis should include delayed puberty. Kallmann's syndrome distinguishing features though are testes less than 2 cm in diameter and positive family history with the presence of anosmia. "Fertile eunuch" are individuals with isolated LH deficiency. They have eunuchoid proportions with variable degrees of virilization and gynecomastia. They characteristically have large testes and semen containing a few sperm. Plasma FSH levels are normal but both the serum LH and testosterone concentrations are low normal. The cause appears to be a partial gonadotropin deficiency in which there is adequate LH to stimulate testosterone production with resultant spermatogenesis but insufficient testosterone to promote virilization. In isolated FSH deficiency which is rare, patient's are normally virilized and have normal testicular size and baseline levels of LH and testosterone. Sperm counts range from O to a few sperm. Serum FSH levels are low and do not respond to GnRH stimulation. Congenital hypogonadotropic syndromes are associated with secondary hypogonadism and a multitude of other somatic findings. Prader-Willi syndrome is characterized by hypogonadism, hypomentia, hypotonia at birth and obesity. Laurence-Moon-Bardet-Biedel syndrome is an autosomal recessive trait characterized by mental retardation, retinitis pigmentosa, polydactyly and hypogonadism. These syndromes are felt to be due to a defect in hypothalamic deficiency of GnRH.

 

PITUITARY DISEASE

 

Pituitary insufficiency may result from tumors, infarctions, iatrogenic causes like surgery and radiation or one of several infiltrative processes. If pituitary insufficiency occurs prior to puberty, growth retardation associated with adrenal and thyroid deficiency is the major clinical presentation. Hypogonadism that occurs in a sexually mature male usually has its origin in a pituitary tumor. Decreasing libido, impotence and infertility may occur years before symptoms of an expanding tumor i.e. such as headaches, visual abnormalities, or thyroid/adrenal hormone deficiency. Once an individual has passed through normal puberty, it takes a long time for secondary sexual characteristics to disappear unless adrenal insufficiency is present. The testes will eventually become small and soft. The diagnosis is made by low serum testosterone levels with low or low normal plasma gonadotropins concentrations. Depending on the degree of panhypopituitarism, plasma corticosteroids will be reduced with plasma TSH and growth hormone levels.

Hyperprolactinemia can cause both reproductive and sexual dysfunction. Prolactin-secreting tumors of the pituitary gland whether from a microadenoma (less than 10 mm) or a macroadenoma, can result in loss of libido, impotence, galactorrhea, gynecomastia and alter spermatogenesis. Patients with a macroadenoma usually first present with visual field abnormalities and headaches. They should undergo CT or MRI scanning of the pituitary and laboratory testing of anterior pituitary, thyroid and renal function. These patients have low serum testosterone levels but basal serum levels of LH and FSH are either low or low normal and reflect an inadequate pituitary response to depressed testosterone.

Approximately 80% of men with hemochromatosis have testicular dysfunction. Their hypogonadism may be secondary to iron deposition in the liver or may be primarily testicular as a result of iron deposition in the testes. Iron deposits have also been found in the pituitary, implicating this gland as the major site of abnormality.

With regard to the role of exogenous hormones, adrenocortical tumors, Sertoli cell tumors, interstitial cell tumors of the testes may all at times be estrogen-producing. Hepatic cirrhosis is associated with increased endogenous estrogens. Estrogens act primarily by suppressing pituitary gonadotropin secretion, resulting in secondary testicular failure. Androgens can also suppress pituitary gonadotropin secretion thereby leading to secondary testicular failure. The current use of anabolic steroids by certain athletes may result in temporary sterility. Endogenous androgen excess may be due to an androgen-producing adrenocortical tumor or testicular tumor but more likely to congenital adrenal hyperplasia. As a consequence of this disease, the production of androgenic steroids by the adrenal cortex is increased, resulting in premature development of secondary sexual characteristics and abnormal phallic enlargement. The testes failed to mature because of gonadotropin inhibition and are characteristically small. In the absence of precocious puberty, the diagnosis is extremely difficult since excessive virilization is difficult to detect in an otherwise normally sexually mature man. Careful laboratory evaluation is essential. Infertility caused by documented congenital adrenal hyperplasia is treatable with corticosteroids. Physicians have used corticosteroids in individuals with idiopathic infertility, but unless these abnormalities can be documented, steroid therapy has no place.

Sometimes glucocorticoid excess (prednisone usage) is exogenous in the therapy of ulcerative colitis, asthma, or rheumatoid arthritis. The result is decreased spermatogenesis. The elevated plasma cortisone levels depress LH secretion and can cause secondary testicular dysfunction. Correction of the glucocorticoid excess results in improvement in spermatogenesis. Hyper and hypothyroidism can alter spermatogenesis. Hyperthyroidism effects both pituitary and testicular function with alterations in the secretion of releasing hormones and increased conversion of androgens to estrogens.

TESTICULAR CAUSES OF INFERTILITY

- Chromosomal abnormalities (Klinefelter's syndrome, XX disorder (sex reversal syndrome), XYY syndrome)

- Noonan's syndrome (male Turner's syndrome)

- Myotonic dystrophy

- Bilateral anorchia (vanishing testes syndrome)

- Sertoli-cell-only syndrome (germinal cell aplasia)

- Gonadotoxins (drugs, radiation)

- Orchitis

- Trauma

- Systemic disease (renal failure, hepatic disease, sickle cell disease)

- Defective androgen synthesis or action

- Cryptorchidism

- Varicocele

Hormonal Control of Spermatogenesis
An intimate structural and functional relationship exists between the two separate compartments of the testis, i.e. the seminiferous tubule and the interstitium between the tubules. LH effects spermatogenesis indirectly in that it stimulates androgenous testosterone production. FSH targets Sertoli cells. Therefore, testosterone and PSH are the hormones that are directed at the seminiferous tubule epithelium. Androgen-binding protein which is a Sertoli cell product carries testosterone intracellularly and may serve as a testosterone reservoir within the seminiferous tubules in addition to transporting testosterone from the testis into the epididymal tubule. The physical proximity of the Leydig cells to the seminiferous tubules and the elaboration by the Sertoli cells of androgen-binding protein, cause a high level of testosterone to be maintained in the microenvironment of the developing spermatozoa. The hormonal requirements for initiation of spermatogenesis appear to be independent of the maintenance of spermatogenesis. For spermatogenesis to be maintained like for instance after a pituitary obliteration, only testosterone is required. However, if spermatogenesis is to be re-initiated after the germinal epithelium has been allowed to regress completely, then both FSH and testosterone are required.

Transport-Maturation-Storage of Sperm
Although the testis is responsible for sperm production, the epididymis is intimately involved with the maturation, storage and transport of spermatozoa. Testicular spermatozoa are non-motile and were felt to be incapable of fertilizing ova. Spermatozoa gain progressive motility and fertilizing ability after passing through the epididymis. The coiled seminiferous tubules terminate within the rete testis, which in turn coalesces to form the ductuli efferentes. These ductuli efferentes conduct testicular fluid and spermatozoa into the head of the epididymis. The epididymis consists of a fragile single convoluted tubule that is 5-6 meters in length. The epididymis is divided into the head, body, and tail. Although epididymal transport time varies with age and sexual activity, the estimated transit time of spermatozoa through the epididymis in healthy males is approximately four days. It is during the period of maturation in the head and body of the epididymis that the sperm develop the increased capacity for progressive motility and also acquire the ability to penetrate oocytes during fertilization. The epididymis also serves as a reservoir or storage area for sperm. It is estimated that the extragonadal sperm reservoir is 440 million spermatozoa and that more than 50% of these are located in the tail of the epididymis. The sperm that are stored in the tail of the epididymis enter the vas deferens which is a muscular duct 30-35 cm in length. The contents of the vas are propelled by peristaltic motion into the ejaculatory duct. Sperm are then transported to the outside of the male reproductive tract by emission and ejaculation.

During emission, secretions from the seminal vesicles and prostate are deposited into the posterior urethra. Prior to ejaculation peristalsis of the vas deferens and bladder neck occur under sympathetic nervous control. During ejaculation, the bladder neck tightens and the external sphincter relaxes with the semen being propelled through the urethra via rhythmic contractions of the perineal and bulbourethral muscles. It is true that the first portion of the ejaculate contains a small volume of fluid from the vas deferens which is rich in sperm. The major volume of the seminal fluid comes from the seminal vesicles and secondarily the prostate. The seminal vesicles provide the nourishing substrate fructose as well as prostaglandins and coagulating substrates. A recognized function of the seminal plasma is its buffering effect on the acidic vaginal environment. The coagulum formed by the ejaculated semen liquefies within 20 to 30 minutes as a result of prostatic proteolytic enzymes. The prostate also adds zinc, phospholipids, spermine, and phosphatase to the seminal fluid. The first portion of the ejaculate characteristically contains most of the spermatozoa and most of the prostatic secretions, while the second portion is composed primarily of seminal vesicle secretions and fewer spermatozoa.

 

FERTILIZATION

 

Fertilization normally takes place within the uterine tubes after ovulation has occurred. During the menstrual mid cycle, the cervical mucus changes to become more abundant, thinner and more watery. These changes serve to facilitate entry of the sperm into the uterus and to protect the sperm from the highly acidic vaginal secretions. Physiologic changes in the spermatozoa known as capacitation occur within the female reproductive tract in order for fertilization to occur. As the sperm cell interacts with the egg, there is initiation of new flagellar movement called hyperactive motility and morphologic changes in the sperm that result in the release of lytic enzymes and exposure of parts of the sperm's structure known as the acrosome reaction. As a result of these changes, the fertilizing sperm cell is able to reach the oocyte, traverse it's various layers, and become incorporated into the ooplasm of the egg.

CLINICAL FINDINGS

History
The cornerstone of the evaluation of infertile man is a careful history and physical examination. Specific childhood illnesses should be sought including cryptographies, post pubertal mumps orchitis and testicular trauma or torsion. Precocious puberty may indicate the presence of an adrenal-genital syndrome, whereas delayed puberty may indicate Klinefelter's syndrome or idiopathic hypogonadism. Prenatal exposure to diethylstilbesterol should be ascertained because this may cause an increased incidence of epididymal cysts or a slightly increased frequency of cryptorchidism. A detailed history of exposure to occupational and environmental toxins, excessive heat, or radiation should be elicited. Cancer chemotherapy has a dose-dependent and potentially devastating effect on the testicular germinal epithelium. The drug history should be reviewed for anabolic steroids, cimetidine, and spironolactone which can effect the reproductive cycle. Medications like sulfasalazine and nitrofurantoin may effect sperm motility. Illicit drugs and excessive alcohol consumption are associated with a decrease in sperm count and hormonal abnormalities. Previous medical and surgical diseases and their treatment may occasional compromise reproductive function. Men with unilateral undescended testes will have overall semen quality of considerably less than normal. Previous surgical procedures such as bladder neck operations or retroperitoneal lymph node dissection for testicular cancer may cause retrograde ejaculation or absent emission. Diabetic neuropathy may result in either retrograde ejaculation or impotence.

Both the vas deferens and the testicular blood supply can easily be injured during hernia repair. In patients with cystic fibrosis, the vas deferens or epididymis and seminal vesicles are usually absent. Any generalized fever or illness can impair spermatogenesis. The ejaculate may be affected for three months after the event, as spermatogenesis takes about 74 days from initiation to the appearance of mature sperm. There is also a variable transport time in the ducts. Sometimes events that have occurred in the previous 3-6 months are extremely important. Sexual habits including frequency of intercourse, frequency of ejaculation, use of coital lubricants and the patient's understanding of the ovulatory cycle should be discussed. Previous infertility evaluation and treatment and the reproductive history from previous marriages should be ascertained. A history of recurrent respiratory infections and infertility may be associated with the immotile cilia syndrome, in which the sperm count is normal but the spermatozoa are completely non-motile due to ultrastructural defects. Kartagener's syndrome, which is a variant of immotile cilia syndrome, consists of chronic bronchiectasis, sinusitis, situs inversus and immotile spermatozoa. In Young's syndrome, also associated with pulmonary disease, the cilia ultrastructure is normal but the epididymis is obstructed due to inspissated material, and these patients present with azoospermia. Loss of libido associated with headaches, visual abnormalities and galactorrhea may suggest a pituitary tumor. Other medical problems that have been associated with infertility include thyroid disease, seizure disorders, and Liver disease. Interestingly it is not the seizure disorder itself that causes infertility but it is the typical treatment of it with Dilantin (phenytoin). Dilantin decreases FSH. Chronic systemic diseases such as renal disease and sickle cell disease are associated with abnormal reproductive hormonal parameters.