Infertility – a civilisation disease of the 21st century

What is infertility

Let us first ask ourselves – what is male fertility and how does it differ from infertility and sterility? The meaning of these terms is extremely important, because although they sound similar, they mean something completely different.

Fertility

Fertility in humans is the ability to conceive a human being. The activation of fertility occurs with the activation of the hormonal activities of the reproductive system. This is when the different physiological characteristics of boys and girls develop, making sexual intercourse possible [3]. Fertility in men depends on the correct production of sperm, the patency of the vasa deferentia and the ability to engage in sexual activity. A man who fulfils these conditions is potentially fertile until advanced old age, unless he develops diseases that may cause loss of fertility [4].

Sterility

In Poland, it is estimated that up to one in five couples of reproductive age faces fertility problems. According to the definition provided by the World Health Organisation (WHO), sterility is defined as the permanent inability to reproduce in one of the partners (this applies to both women and men). This condition is incurable and therefore the only way for the affected couple to have offspring is through insemination with donor sperm, adoption, or in vitro fertilisation (provided the woman is fertile) [5].

Infertility

Infertility is defined by the World Health Organisation as the inability to become pregnant for at least 12 months despite regular sexual activity (3-4 times a week) and without the use of any contraceptives. The WHO now recognises infertility as a civilisation disease of the 21st century. Nearly 20% of couples in Poland, i.e. about 1.5 million people, are already struggling with it [6].

Infertility vs. sterility

How to distinguish infertility from sterility? Sterility is an irreversible condition that cannot be cured by available methods, while infertility is a temporary condition that can be treated. The problem of sterility or infertility usually affects one of the partners, and the causes of this condition can be multifaceted. In women, it may be related to a history of surgery in the pelvis minor area, menopause, endometriosis, as well as sexually transmitted diseases and genetic mutations. Among men, this problem can affect those who had childhood mumps, a complication of which can be bilateral orchitis. Additional factors may also be cancer, past injuries and inflammation or a lack of sperm in the semen. Other factors contributing to infertility in men include overheating of the testicles, stimulants, stress, being overweight, varicose veins of the spermatic cord (varicocele), testicular tumours or systemic diseases. The most common symptoms include testicular pain, decreased libido, abnormal semen smell and colour or erectile dysfunction [7].

Infertility affects as many as 1 in 6 people worldwide

According to the Polish Society for Reproductive Medicine, approximately 1.5 million couples in Poland are treated for infertility. In 40% of cases, the cause of infertility occurs on the female side and in 40% on the male side. For the remaining 20%, the cause is not fully determined [8]. According to the WHO, approximately 17.5% of the adult population, i.e. roughly 1 in 6 people worldwide, struggle with infertility. In Poland, this problem affects between 1 and 1.5 million couples, which represents as much as 20% of the population of reproductive age [9].

Male infertility diagnosis

In the diagnosis of male infertility, the seminogram, or semen test, is crucial. This test evaluates the quality of semen, the number of spermatozoa (semen should contain between 40 and 500 million spermatozoa), the motility (approximately 40%) and the amount of sperm (1.5–6 ml of semen). However, bear in mind that below-normal values do not necessarily mean infertility. It is important that hormone levels (testosterone, gonadotropic hormones, TSH, FT4) are within normal limits. It is important to remember that a healthy lifestyle, a proper diet and correct semen quality play a key role in trying for offspring [10].

Varicose veins of the spermatic cord

Of the numerous potential causes of male infertility, varicose veins of the spermatic cord (varicocele) are the most common, occurring in 15% of men and in up to 40% of patients already diagnosed with infertility. Varicocele is a common condition occurring during puberty and the most common correctable cause of infertility. Most varicose veins occur on the left side due to valvular insufficiency and because of the right angle of the left testicular outlet to the left renal vein [11]. Venous reflux into the testicular vein and the pampiniform plexus causes venous congestion leading to hyperthermia and hypoxia of the testicular tissue causing infertility. During the diagnosis of varicocele, the presence of a renal tumour should always be ruled out, as it can impair venous blood flow through its progressive growth, thus causing retrograde dilatation of the veins of the pampiniform plexus, as well as the deleterious effects of oxidative stress on nascent spermatozoa.

Infertility treatment methods

Available surgical treatments include traditional surgery using the Palomo or Ivanissevich technique, laparoscopic surgery, radiological embolisation of the testicular vein, microsurgical surgery using magnifying loupes or a surgical microscope.

Microsurgical treatment using the surgical microscope

The European Association of Urology (EAU) and the American Urological Association (AUA) consider microsurgical treatment using a surgical microscope as the standard and first-choice method, as it is characterised by the best efficacy and the lowest risk of complications and recurrence. This treatment increases testosterone levels, reduces oxidative stress, improves ultra-morphology and semen quality, thus more than doubling the chance of achieving pregnancy by natural means. An improvement in results is obtained approximately three months after the surgery. The advantage of this method over others is the lower rate of recurrence and complications, as well as being less invasive. The surgery is carried out under local anaesthesia, allowing the patient to return to activity immediately after the procedure. The use of a microscope giving 20-fold magnification allows more effective identification of the testicular artery or vas deferens artery [12].

Tauber method

One of the more interesting methods of treating varicocele is the Tauber method. In the 1970s, the German urologist Dr Roland Tauber described the technique of initial sclerotherapy for the treatment of varicocele. Tauber found that the recurrence rate was only 10% [13]. The procedure is usually performed under local anaesthesia with the patient lying on his back. First the skin is anaesthetised at the base of the scrotal sac at the level of the body of the penis. A skin incision of approximately 2-3 cm is then performed. The spermatic cord is isolated and secured through the incision and anaesthetised under visual guidance. An incision is made in the wall of the spermatic cord, after which a single venous vessel is isolated, into which a cannula is inserted to administer saline, contrast and ultimately a 3% solution of Aethoxysclerol, which is designed to cause thrombosis and closure of the spermatic cord’s venous vessels. The punctured vein is ligated and transected. The wound is closed with layered sutures using an absorbable intradermal suture [14,15].

Equipment used for infertility treatment procedures

As procedures of this type are being performed more and more each year, infertility clinics or hospitals should have the necessary equipment to perform this type of surgery. The use of a microscope and X-ray C-arm requires both the introduction of numerous safeguards in the operating theatres and the use of an appropriate operating table. During the surgery, the patient lies in a supine position, is awake and can talk to the team. However, if you look at the operating field, you are immediately struck by the specific posture of the surgeons, who have to sit in the forced position for an hour or two. The essence of the surgeon’s good access to the operated site is the mobility of the operating table and the translucency of the tabletop. The table base must not restrict the position of the surgeon, who must sit at the table with their legs tucked under the tabletop. Adopting the correct position enables efficient manoeuvring of the microscope and provides a better view of the operated area.

The Famed OPTIMA operating table allows positioning of the patient for urological procedures.

Co-operation with the X-ray C-arm

A table with a fully X-ray-transparent carbon fibre top would be ideal here. The controls will also be an important element of such a table; they should provide the surgeon with adequate precision, speed of movement and good parameters for travel, tilt, height adjustment range and maximum load. The table base should be flat and provide sufficient leg room for the surgeon. There should also be no protruding parts to ensure safe interaction with the C-arm and other devices. Another important aspect will be the possibility of installing additional accessories or even tabletop segments to extend and widen the tabletop and increase the imaging window.

Summary

As can be seen, the problem of infertility is affecting more and more people around the world, and its future progression seems inevitable. Many couples are looking for a solution to this problem, although there is no perfect method that guarantees 100% success. However, by changing habits and lifestyles, and using specialised treatment, it is possible to significantly increase the chance of having offspring. The sperm maturation process takes about three months, so it is worth being patient and waiting for positive changes [16]. Regularity and consistency are key to success.

Sources:

[1] https://pl.wikipedia.org/wiki/Ojciec (dostęp 01.05.2024)

[2] 2. https://www.mp.pl/pacjent/ginekologia/choroby/260266,nieplodnosc (dostęp 01.05.2024)

[3] Z. Zdrojewicz, A. Wiśniewska, Rola cynku w seksualności mężczyzn https://www.dbc.wroc.pl/Content/2035/x21_Zdro2.pdf (dostęp 01.05.2024)

[4] Łepecka-Klusek, A. Pilewska-Kozak, G. Jakiel, Niepłodność w świetle definicji choroby podanej przez WHO, Medycyna Ogólna i Nauki o Zdrowiu, 2012

[5] Tamże.

[6] Tamże.

[7] https://dziendobry.tvn.pl/in-vitro-nauka-czy-cud/nieplodnosc-to-problem-na-skale-swiatowa-statystyki-sa-zatrwazajace-st6304932 (dostęp 01.05.2024)

[8] https://salvemedica.pl/blog/okiem-specjalisty/nieplodnosc-polakow-jak-wygladamy-na-tle-innych-krajow (dostęp 01.05.2024)

[9] https://www.focus.pl/artykul/nieplodnosc-nowy-raport-who (dostęp 01.05.2024)

[10] https://www.nfz.gov.pl/aktualnosci/aktualnosci-centrali/wazne-badanie-dla-mezczyzn-finansowane-przez-nfz,8543.html (dostęp 01.05.2024)

[11] https://www.krefftclinic.pl/zylaki-powrozka-nasiennego/?gclid=Cj0KCQjwmMayBhDuARIsAM9HM8cEBLDqfSpNTXnXcPeqWFzM-moZOIntm1royyEX3XloZgi2fv_8t1waApBiEALw_wcB (dostęp 01.05.2024)

[12] https://www.krefftclinic.pl/zylaki-powrozka-nasiennego/?gclid=Cj0KCQjwmMayBhDuARIsAM9HM8cEBLDqfSpNTXnXcPeqWFzM-moZOIntm1royyEX3XloZgi2fv_8t1waApBiEALw_wcB (dostęp 01.05.2024)

[13] Tauber R, Johnsen N. Antegrade scrotal sclerotherapy for the treatment of varicocele: technique and late results. Urol 1994; 151: 386–90

[14] Tauber R, Johnsen N.Die antegrade skrotale Verödung zur Behandlung der Testisvarikozele. Urologe [a] 1993; 32 : 320–6

[15] Pfeiffer D, Johnsen N, Tauber R. Die antegrade skrotale Sklerosierung der Varicocele testis im Kindes- und Jugendalter. Aktuelle Urol 1994; 25 : 268–71

[16] Jeznach-Steinhagen, A. Czerwonogrodzka-Senczyna, Postępowanie dietetyczne jako element leczenia zaburzeń płodności u mężczyzn z obniżoną jakością nasienia, Zakład Żywienia Człowieka, Warszawski Uniwersytet medyczny, 2013