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Male factor in the childlessness question


Infertility: The male question

For a man to be able to naturally impregnate a woman, he must be able to produce viable, structurally normal sperm that can swim well and in adequate numbers.

Two weeks ago, the Fertility and Andrology Society of Kenya was officially launched. However, despite the joyous moment, it was impossible to make mention of the importance of the existence of this society without reference to the pain, isolation and devastation that couples, and especially women with fertility challenges, undergo.

In a room full of the very best specialists the country has to offer with regards to fertility, every speaker reminded us over and over again that as gynaecologists, we were the leaders in championing the rights of the voiceless. The focus on the frustration of childlessness among Kenyan women and indeed women in Africa, cannot be overstated.

Seeing the exchange among our politicians on social media, making reference to the state of childlessness in one of them, hit right under the belt. I can only imagine how many women who are battling infertility were cringing in their corners.

However, while the advocacy front has primarily highlighted the impact on the woman, the men are almost forgotten. Partly, the contribution to this neglect arises from the societal mindset that men are hardly ever infertile.

Tim*, a mild-mannered senior lecturer at a local university, has been married for 12 years. His wife Celeste* is a nurse at a local hospital and is longing to be a mother. However, she has no way of broaching the subject with her husband. He is extremely religious and his only response is that they will have a baby when God wills it.

Due to his reticence, Celeste has decided to have her fertility tested without his knowledge. So far, the tests indicate all is well. She is at a loss on how to ask him to see a specialist without hurting his feelings.

INADEQUATE RESEARCH
Tim is not alone in this predicament. Statistics show overall, approximately 15 per cent of couples struggle with fertility. Of these, 30 to 35 per cent are due to the male factor, a similar rate is due to the female factor and the remaining 30 per cent is linked to both partners. There is paucity of statistics for Kenya due to inadequate research.

Social media comments in the recent past have made light of the male infertility factor with comments such as, “African culture demands that a man raises all the children in his home without question”, or “only a mother knows the true father of her child”. As much as they may invoke a lot of mirth, it deeply affects men who may truly be in such situations through no fault of their own.

For a man to be able to naturally impregnate a woman, he must be able to produce viable, structurally normal sperm that can swim well and in adequate numbers. In this case, adequate numbers means no less than 40 million sperm per millilitre of semen. An adequate ejaculation should be no less than two to three millilitres, hence we are looking at a whopping 100 million sperm to make one baby!

This is how delicate the science of conception is. Many sperm will die before they traverse the female reproductive tract from the cervix to the mid-Fallopian tube where the egg is waiting. Successful sperm must be able to swim a distance that is akin to a grown man swimming across the English Channel (over 200km).

It is also a fallacy that the first sperm to arrive is the one that fertilises the egg. A few hundred thousand sperm shall make it and surround the egg but the mystery of which sperm is permitted in has still not been scientifically deciphered.


BRAIN TUMOURS
The male reproductive centre is the testicle. Here, reproductive hormones (testosterone and di-hydrotestosterone) and sperm are made. Their manufacture is further controlled by additional hormones made in the hypothalamus and pituitary gland in the brain (gonadotropin-releasing hormone, follicle stimulating hormone and luteinising hormone).

Therefore, a man can have one of three distinct causes of infertility. Pre-testicular causes arise where there is an interference with the hormonal control. A genetic abnormality in Kallmans Syndrome results in brain-level hormones being absent, specifically gonadotropin-releasing hormone.

Brain tumours may destroy the pituitary gland or the hypothalamus, hence cause hormonal insufficiency. Overproduction of non-reproductive hormones such as prolactin and insulin interferes with the pattern of release of the brain hormones, resulting in low or absent sperm.

The testicular causes of infertility include any cause that destroys the intrinsic architecture of the testicular tissue. In cryptorchidism, the testes are absent hence the sperm-making factory does not exist. This is why the paediatricians pay particular attention to the baby boys at birth to ensure the testicles are present. Where they have not developed properly and are stuck in the abdomen, surgery is done to bring them to normal position very early on in life to prevent infertility.

Other abnormalities include varicoceles (varicose veins within the scrotum) and hydroceles (fluid accumulation in the scrotum) which cause increased temperatures in an organ that specifically hangs outside the body to stay cool. This negatively affects the function of the sperm factory. Other causes include traumatic injuries that damage the testicles or infections that destroy the sperm-making cells such as mumps. This is why all babies need the mumps vaccine early.

CAUSE BLOCKAGE

Post-testicular causes are those that block readily-manufactured sperm from exiting the testicles and finding their way into the female reproductive tract. In these cases, everything works just fine but there is blockage in the vas deferens that carries sperm from the testis to the urethra. This may be due to injury sustained during trauma and healed with scars causing blockage or from sexually transmitted infections. In rare cases, the sperm may travel normally up the vas deferens, but during ejaculation, they go up the urethra to the bladder rather than down and out, a condition called retrograde ejaculation.

Treatment may entail simple measures like surgery to relieve hydroceles or varicoceles. It may involve complex procedures to harvest sperm directly. It is important to note that though the urologists are important in providing the surgical treatment, the ultimate male fertility specialist is not the urologist, but an andrologist. This is the subspecialist involved in the fine art of managing male infertility. We may have had only one in the whole country for several years, but it is encouraging to know we have churned out a few more and several are in training. There is hope for Tim, after all!