The first of the examinations to be requested from a couple who comes with the complaint of not having children is the sperm analysis of the man.
At the end of a sexual abstinence of 2-5 days, in cases where the sperm count, movement and deformity are detected as a result of the sperm analysis requested, a detailed evaluation and appropriate course of action are required by diagnosing the male problem.
In very rare cases, male infertility may be the first sign of an underlying and life-threatening serious disease such as testicular tumors. For this reason, when a significant level of male infertility is encountered, a urologist examination is required.
As a result of the researches, the most important causes of male infertility are undescended testicles, which is called “cryptorchism” in the medical language in childhood, infections in the reproductive organs and “varicocele” encountered in advanced ages.
Other less common causes of male infertility are; testicular tumors, testicular injury, high fever diseases, obstruction in the reproductive canals, backward discharge, nervous system causes, genetic disorders, hormonal and sexual dysfunctions.
In cases of infertility caused by genetic problems, genetic anomalies that will affect the health of the child to be obtained as a result of in vitro fertilization may also be detected.
THE IMPORTANCE OF GENETIC EXAMINATION IN MALE INfertility:
In recent years, advances in the field of genetics have enabled us to obtain very important information about the causes of male infertility. Deletions in the genes on the Y chromosome from the sex chromosomes lead to a situation such as decreased sperm production or no sperm production in the testis, although the body structure and functions are normal.
Likewise, in genetic diseases such as number anomalies in the sex chromosomes, for example 47 XXY Klinefelter syndrome, which is the most common, testicular development may be insufficient and sperm production may be decreased.
In addition, if the ducts carrying sperm from the testicles are not congenital, although there is normal sperm production in the testis, sperm cannot be seen in the semen because there is no way out. This is genetically linked to a disease called Congenital Bilateral Vas Deferens Agenesis (CBAVD).
Some of the men with infertility problems can be treated by replacing the hormones found to be deficient or by increasing sperm production with some drug treatments.
Patients whose sperm cells are not found in the sperm analysis (azoospermic) are evaluated with detailed examinations and it is investigated whether there is really sperm production in the testicles or the presence of obstruction in the channels through which the sperm passes.
In addition, varicocele (expansion in testicular veins, varicose veins), which is found in 15% of men in the society and found in 40% of men who apply with the diagnosis of infertility, is one of the factors that impair sperm production. Varicocele may impair sperm production and especially motility properties by affecting the intratesticular micro-circulation after the temperature increase in the testicles and the reflux of the used blood in the veins to the testis.
The diagnosis of varicocele, which can be seen in different degrees, can be made by examination and various radiological examinations.
It has been shown that there is no benefit in performing varicocele surgery, which is not detected by a specialist person’s examination, only shown by Doppler ultrasonography, that is, there is little existing.
Varicocele, which can sometimes be a cause of pain, is important if it is detected in men who want to have children. Varicocele, which starts in adolescence, can also prevent the development of testicles, which should be treated without delay. Varicocele can show its effect on sperm production over the years.
Varicocele can be treated using microsurgical methods; It is the most common cause of male infertility. In varicocele cases diagnosed correctly and treated with the successful application of microsurgical methods, an improvement in spermiogram values is achieved by 60-70%.
Generally, it is recommended that patients who do not become pregnant despite the improvement in spermiogram results within 6 months following the varicocele operation should switch to intrauterine insemination (IUI) or in vitro fertilization – microinjection.
It is possible to achieve pregnancy with sperm washing and inoculation in mild sperm disorders that are not excessive. The opinion of a urologist is taken and the problems that can be corrected are resolved. In severe sperm disorders, there is no benefit with vaccination and in vitro fertilization-microinjection treatment should be applied.
If there is no sperm in the sperm sample given, and if there is no obstruction as the reason for this, that is, if there is a lack of sperm production, then in vitro fertilization treatment should be performed with sperm to be obtained from the testicles (from the ovaries of the man) (PESA/TESA/TESE/MESA/microTESE surgeries).
Naturally, the most frequently asked question in male infertility is what causes it.
However, unfortunately, in most of the cases in which sperm count, movement and deformities are detected, it is not possible to reveal a clear cause neither in the history nor in the examination.
This is called male infertility of unknown cause. The procedures to be done are still the same, that is, if there is a certain amount of sperm, vaccination, if not, it is in vitro fertilization, more precisely, microinjection treatment.
PESA / TESA / TESE / MESA / microTESE surgeries
All surgical sperm retrieval methods can be performed under local anesthesia. In some cases, general anesthesia may also be preferred. All of them are interventions that do not require hospitalization. Processes often take between ten minutes and 2 hours. After the procedures, daily life can be continued.
All procedures are carried out in centers with an in vitro fertilization center or an andrology laboratory, and the samples taken are examined in the laboratory at the same time to see whether there are sperms. When sperm is found, the process is terminated. Sperm can be frozen for a long time under suitable conditions.
Generally, the most frequently applied procedures are TESA, TESE and micro TESE.
In the TESA procedure, a sample is taken from the testicular tissue by entering the testicles with a needle inserted through the skin without opening the pouch in which the testicles are located. If sperm cannot be obtained with this method, TESE’ method is used.
In the TESE method, the sac containing the testicles and the sheath surrounding each testis are opened with a small incision. Small pieces of testicular tissue are taken. The cut sections are stitched and the process is terminated.
Micro TESE procedure is the name given to the TESE procedure performed under the microscope. As in the Tese procedure, the sheaths around the testis are opened. The testicular tissue is examined with a microscope and samples are taken from the large parts. The cut sections are stitched and the process is terminated. This method is thought to cause less damage to the testicular tissue.
With surgical sperm retrieval methods, sperm can be found in 100% of obstructive azoospermia cases due to obstruction, and in 65% of nonobstructive azoospermia cases with production problems in the testis.
The viability rates of the sperm found by surgery of patients with azoospermia may decrease after the freezing-thawing procedure, but the pregnancy rates obtained with the use of these sperms are the same as using the sperm obtained by surgery on the same day, and cryopreservation can be safely applied.
Kiss. Dr. Abdullah Arman Ozdemir