Post testicular factors of male infertility
The infertility issue is no longer a “blame game” towards the female partner. There is enough evidence now to show that there are many causes for this condition. Surprisingly, the male factor is responsible for near 45% of infertility cases. We would like to clarify some of the reasons for this high incidence. With male infertility, there are 3 main causes. We have covered the first 2 in previous articles – Pre-testicular factors and Testicular factors.
We will now consider the third cause – Post-testicular factors. This covers the reasons why healthy sperm are obstructed from travelling to the penis for ejaculation.
Causes:
Obstruction: Blockages in the ducts are the main cause. One of the most important organs of the male reproductive system is the epididymis. It is a long coiled tube inside the scrotum that connects directly to the testis. The main function is to transport sperm to the ejaculatory ducts. When there is an obstruction, like a cyst or blockage, the movement of the sperm to the ejaculatory ducts is affected. At times, there is obstruction in the ducts themselves.
Genetic diseases: Sometimes an inherited condition such as Cystic fibrosis, which usually targets the lungs and pancreas, can cause fertility problems as well by affecting the vas deferens. Genetic disorders such as the Klinefelter Syndrome, Y chromosome microdeletions, Noonan Syndrome and chromosomal translocations can tell on the reproductive system by disrupting spermatogenesis (the production of mature sperm), causing azoospermia (inability to produce sperm cells) and oligospermia (low sperm count).
Infections resulting in blockages: These usually affect sperm quality by reducing concentration and motility. Also, infection may cause auto-antibodies against mature sperm. Male urinary tract infections can cause obstruction to the ejaculatory ducts. Chronic prostatitis (inflammation of the prostate) although it does not seem to cause obstruction of the male reproductive organs, does cause scarring of the ejaculatory and prostatic ducts. This results in low volume of semen.
Bilateral absence of the vas deferens: The vas deferens has a major role in transporting mature sperm to the urethra for ejaculation. It is a long tube from the epididymis to the pelvic cavity behind the bladder. Bilateral absence of the vas deferens occurs when these tubes do not develop properly before birth. Hence, they cannot transport sperm even though the testes develop and function normally. There are genetic links between the cystic fibrosis gene mutation and CBAVD (congenital bilateral absence of the vas deferens).
Vasectomy: This is a minor surgery for male sterilization. It prevents sperm from reaching the semen that is ejaculated. The semen will exist but without any sperm.
Ejaculation problems: Both psychological and physical stimulation are required to result in ejaculation. To function properly, it is essential that neurological integrity is maintained between the pelvic floor (group of muscles at the base of the pelvis) and the spinal cord. Ejaculatory dysfunction can occur in different ways such as premature ejaculation, retrograde ejaculation, anejaculation and delayed ejaculation. The last 3 forms are due to neurological defects. Some conditions which cause such symptoms are surgeries to the pelvic and retroperitoneal areas, congenital spinal abnormalities, spinal cord injury, multiple sclerosis and diabetes. Retrograde ejaculation causes the semen to enter the bladder instead of the penis, resulting in a dry orgasm where very little or no semen is ejaculated. Anejaculation is the lack of both antegrade (forward moving) and retrograde ejaculate. SCI (spinal cord injury) is the main cause for this. Delayed or impaired ejaculation is where a man takes an extended period of stimulation to release the semen from the penis. Some men with this problem are unable to ejaculate at all.
Treatments:
Surgeries can be performed to remove blockages from the impaired ducts. In the case of Vasectomy, a Vasectomy Reversal surgery can be performed. A vasoepididymostomy surgery to remove the blockage (if caused due to infection or unexplainable reasons) and connect the epididymis to the vas deferens is sometimes recommended. Vasovasostomy is a surgery to remove the blockage and connect both sides of the vas deferens. Although blockage in the ejaculatory ducts is not very common, a surgical procedure, TURED (Transurethral Resection of the Ejaculatory Ducts) can be performed. Other than surgeries, some sperm retrieval methods such as Cryopreservation (sperm freezing) can be suggested.
Conclusion: For the specialists to diagnose and treat the condition, physical and medical examinations need to be carried out. A semen analysis will reveal details of the sperm production as well as external characteristics of the sperm such as their concentration, shape and whether they are moving well (motility). Sometimes, a transrectal ultrasound will be recommended to show any blockages in the ejaculatory ducts. Based on the results of these tests, diagnosis and further treatment can be recommended and decided upon.
