Of late, young couples planning families are not uncommon in the OPD of Dr Narmada Prasad Gupta, professor emeritus, urology and renal care at Medanta Gurugram. “A couple, clearly distraught by their inability to have a baby after five years of marriage, came to see me. The girl, under family pressure, broke down as she took a battery of fertility tests that came clean. The boy’s semen analysis revealed he had a low sperm count because of a congenital defect, that of unformed testes. He needed a minor surgery. Another young bride wanted her prospective groom to be tested. Both girls and boys now want to be mentally ready for their fertility chances,” he says.
Although infertility is assumed to be a woman’s problem, it is as much about the man. “In fact, if men address it early, it could be less expensive and effective than managing the condition later, which might require more costly and invasive female-focussed treatments. If we look at the total cases of infertility in the country, 40 per cent are because of male factors, another 40 per cent because of female factors, another 10 per cent are attributable to both and the remaining 10 per cent are unexplained or idiopathic,” says Dr Gupta, who had done considerable research on the subject as HOD, Urology at AIIMS, Delhi.
Sperm counts are falling globally. A meta-analysis in 2022 reported a 51.6 per cent decline in mean sperm concentration among unselected men globally between 1973 and 2018. “Even the World Health Organisation (WHO) has revised its criteria, considering 15 million sperm per militre (ml) as the lower end of the normal range. When I set up India’s first sperm bank in 1990, our sperm donor requirement was higher than the then normal count of 40 million per ml, the threshold for having what we call a baby in the bedroom. That’s no longer a possibility,” says Dr Anjali Malpani, fertility expert and professor emeritus at KEM Hospital, Mumbai.
What’s causing male infertility?
Infertility is usually defined as the inability of a person or couple to achieve pregnancy after one year of regular and unprotected physical intimacy. “It is not just about the sperm count. One has to consider sperm motility, which is the ability of sperm to move effectively to fertilize an egg, and their shape or morphology,” says Dr Gupta.
Male infertility triggers are almost similar to those in women. “Sperm quality, like the quality of eggs in women, significantly declines with age, known as the male biological clock. While men can remain fertile much later in life than women, aging impacts sperm quality that can impact the health of the offspring,” says Dr Gupta. So late parenthood cannot be ruled out as a stressor along with lifestyle factors like smoking and binge-drinking, poor diet, stress, anxiety and long work hours, all of which damage sperm DNA.
“But of late there is growing evidence of an association between air pollution, exposure to chemicals, micro and nanoplastics, hormone-disrupting chemicals and poor quality or damaged sperm. Higher concentrations of chemicals in the semen are known to affect sperm maturation. Chemicals like BPA, phthalates, and certain pesticides can mimic or block hormones, disrupting the body’s hormonal balance needed for sperm production and leading to lower testosterone levels. Pollutants like PM 2.5, heavy metals, and cigarette smoke generate free radicals that damage sperm DNA and testes. Nano plastics degrade sperm protein,” says Dr Gupta.
Common causes of male infertility in patient-participants in an AIIMS study include azoospermia, when there are no sperms in the sample, and OATS (oligo/astheno/teratospermia) syndrome when the total number of sperms, the number of motile sperms or the number of normal sperms is lower than normal. Sexual dysfunction is a less frequent cause.
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Dr Anup Gulati, Director of Urology, Andrology, and Renal Transplant at Fortis Escorts Hospital, Faridabad, has been tracking possible causes ever since the number of male patients seeking fertility therapies at his OPD have gone up from one person to five persons a week. “Youngsters keen to develop muscles take to anabolic steroids at the gym, which lower or eliminate sperm count significantly (a condition called azoospermia). The body is ‘tricked’ into thinking it is producing enough testosterone, which disrupts the natural hormone signals needed for sperm production,” he says. He also lists obesity, high blood pressure, regular sauna and prolonged sitting with laptops as affecting sperm. “Scrotal temperature is crucial for sperm production. The testes must be 2–3°C cooler than the core body temperature for development, maturation and functionality of sperm. When temperatures rise too high, they can damage sperm and lead to infertility,” he explains.
Lifestyle factors are, in fact, believed to be behind the rising cases of secondary infertility in men, which means they are unable to father a second child.
When should evaluation start?
All couples who have failed to conceive after one year of trying should go in for an evaluation. Men with a known reason, be it chemotherapy, radiation, or testicular tumours, should get assessed earlier than their partners.
Semen values can vary wildly, so it is important to get at least three semen reports on three different days. There should be a 2-3 day abstinence period before the test and preferably, the sample should be evaluated within an hour of collection. The normal values of a semen report include: > 2mL volume, > 20 million sperm/mL, > 50% total motility and > 30% normal forms.
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As for sperm freezing, Dr Gupta does not advise it unless the man has to take medical treatments that could affect fertility, such as chemotherapy or testicular surgery.
What are myths?
Many men suffering from erectile dysfunction feel they are infertile. “Fact is fertility has nothing to do with virility. Some men feel guilty of having a severe pelvic injury or fall in childhood. None of these is a factor. Male fertility depends on producing healthy sperm and delivering it to fertilize an egg,” says Dr Malpani.
She further emphasises that no tablets, whether allopathic, homeopathic or ayurvedic, can improve sperm counts. “I tell young men seeking medication to go for an assisted reproductive method as precious time cannot be lost for conception. The woman would have grown older in that period,” explains Dr Malpani. She vehemently opposes any kind of testosterone therapy. “It decreases sperm count by suppressing the body’s natural sperm production process. The external hormone lulls the brain into thinking there’s enough sperm,” adds Dr Malpani.
What about treatments?
Sometimes sperm production is affected by blockage in the reproductive tract, which can be corrected surgically. Varicoceles, an abnormal cluster of veins near the head of the testis, are the commonest correctable cause of male infertility.
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“Recent advances in science have made it possible to father a child through just one sperm. An embryologist retrieves live sperm from the testes. It can be used immediately or frozen for later use. We then inject a single live sperm directly into the egg. Once the egg is fertilized, the resulting embryo is cultured in the lab before being transferred to the woman’s uterus. IUI (intrauterine insemination) uses a healthy sperm sample and inserts it directly into the uterus around the time of ovulation. This is cheaper too,” says Dr Malpani. But most importantly, she says, partners are talking among themselves on parenthood. On equal terms.
