|Ahead of print publication
Is male factor infertility rising? Another side of the equation from an in vitro fertilization clinic in southwestern Nigeria
Gbolahan Oladele Obajimi1, Charles Oluwabukunmi Kolade2, Ademola Aladejare3
1 Department of Obstetrics and Gynaecology, Assisted Conception Unit, University College Hospital, Ibadan, Nigeria
2 Vine Branch Fertility Centre, Ibadan, Nigeria
3 Vine Branch Fertility Centre, Andrology Unit, Ibadan, Nigeria
|Date of Web Publication||02-Aug-2021|
Gbolahan Oladele Obajimi,
Department of Obstetrics and Gynaecology, Assisted Conception Unit, University College Hospital, Ibadan.
Source of Support: None, Conflict of Interest: None
Background: Male factors account for about half of the causes of infertility and a high premium is placed on childbirth and rearing in developing countries. With the introduction of assisted conception, the burden of care for managing male infertility has shifted to the female partner. Male infertility is generally evaluated via seminal fluid analysis which includes parameters such as concentration, motility, and morphology. The etiology of male infertility is multifactorial, and majority of cases are known to be idiopathic. Materials and Methods: A descriptive cross-sectional study of 77 male partners of infertile couples presenting to an in vitro fertilization clinic in Ibadan, Nigeria, between January 1 and June 30, 2019. Participants were selected consecutively at their first consultation visit. A self-administered questionnaire was completed by each participant comprising socio-demographic information, results of laboratory screening, and seminal fluid analysis. Data was analyzed using the Statistical Package for Social Sciences (SPSS, IBM, NY), version 22. Descriptive statistics were generated, and presented with the aid of a bar chart, pie chart, and frequency tables. Results: The average age of the participants was 43.64 ± 3.1 years and 97.4% (75) were in a stable relationship. Duration of infertility ranged between 3 and 17 years with an average of 7.6 ± 1.8 years. Human immunodeficiency virus, syphilis, hepatitis B, and hepatitis C were diagnosed in 3%, 4%, 5%, and 1%, respectively. Over half of the participants had semen volume and liquefaction time of 1-2 mL and 15-30 min, respectively. 34 men (44.1%) had normal semen parameters while the remaining 43 (55.9%) had various forms of abnormalities. Mid-piece defects were the most prevalent morphological defects and were found in 70 men (90.9%) while immature spermatozoa were found in 38 men (49.4%). Only one participant had azoospermia (1.3%). Conclusion: The impact of male factor infertility cannot be over-emphasized. Male contribution to infertility is thought to be rising and this study from male partners of infertile couples revealed semen abnormalities in over 50% of the participants. Addressing preventable causes of male infertility through health awareness and lifestyle modifications are important steps towards engendering optimal reproductive health.
Keywords: Infertility, in vitro fertilization clinic, male factor, semen analysis
|How to cite this URL:|
Obajimi GO, Kolade CO, Aladejare A. Is male factor infertility rising? Another side of the equation from an in vitro fertilization clinic in southwestern Nigeria. Afr J Infertil Assist Concept [Epub ahead of print] [cited 2021 Nov 28]. Available from: https://www.afrijiac.org/preprintarticle.asp?id=322646
| Introduction|| |
Infertility refers to the inability of a couple to achieve conception after 12 months of unprotected sexual intercourse. Male factors are known to account for 30%–50% of the causes of infertility. Male factor infertility is multifactorial with about 70% of cases classified as idiopathic. Infertility typically affects 15%–20% of couples with male factor contributing about 50% and acting as a sole contributor in about 30% of cases., The contributions of male infertility especially in Nigeria, have become a source of concern due to the psychosocial consequences which often threaten relationships thus resulting in conjugal mobility. A high premium is placed on childbearing in many developing countries and failure to conceive places an enormous emotional, financial, and psychological burden on the couple.
The etiology of male infertility is multifactorial and includes a wide variety of disorders involving the endocrine, immune, and neural systems. Male infertility has been associated with poor health, increased mortality and malignancies. Causes of male infertility include testicular trauma, infections, genetic and anatomical disorders, autoimmune diseases, and neurological disorders. A recent meta-analysis has suggested a broader contribution of male infertility with values ranging between 20% and 70%., Seminograms may reveal various abnormalities such as azoospermia, oligozoospermia, teratozoospermia, asthenozoospermia, pyospermia, necrospermia, and a combination of disorders such as oligoasthenoteratozoospermia (OATS). These findings have implications for conception and often determine the type of assisted reproductive technique offered. The evaluation of the male partner should be done simultaneously with the female partner to prognosticate appropriately the chances of conception of the couple and to institute treatment early enough. Studies, however, have documented delays or lack of male partner evaluation in up to 18% of infertile couples., This is even more profound in developing countries where infertility is almost exclusively considered a female problem/challenge.
The uptake of assisted conception is gradually increasing in developing countries due to increased awareness, availability, and acceptability. However, the cost is often borne out of pocket as insurance coverage is virtually nonexistent. This limits the uptake to the middle and upper classes of the society, almost always excluding the lower class. The treatment for male infertility includes a variety of methods which may be pharmacological or nonpharmacological. The deployment of intra-cytoplasmic sperm injection (ICSI) has helped men with very poor-quality semen to reproduce with the possibility of semen extraction from the testis for injection. Exploring the seminal fluid characteristics of infertile men presenting for fertility treatment provides information on male contribution to infertility and further documents the pattern of abnormalities observed. This study seeks to provide a panoramic view of male contribution to infertility at an in vitro fertilization clinic in southwestern Nigeria.
| Materials and Methods|| |
A descriptive cross-sectional study of seventy-seven male partners of infertile couples presenting to an in vitro fertilization (IVF) clinic in Ibadan, Southwestern Nigeria, between January 1 and June 30, 2019. Participants were selected consecutively at their first consultation visit. An interviewee-administered questionnaire was completed by each participant, comprising socio-demographic information along with results of infectious screening, genotype, blood type, and seminal fluid analysis. Excluded from the study were nonconsenting male partners.
Data obtained from the participants were analyzed using the Statistical Package for Social Sciences (IBM SPSS, New York, USA) version 22. Descriptive statistics were generated, and the results were summarized with the aid of a bar chart, pie chart, and frequency tables.
| Results|| |
Seventy-seven male partners of infertile couples participated in the study. The average age of the participants was 43.64 ± 3.1 years. 75 (97.4%) men were in a stable relationship. Christianity was practiced by 62 participants (80.5%) and the Yoruba ethnic group represented 81.3% of the participants (61 men). The duration of infertility ranged between 3 and 17 years with an average of 7.6 ± 1.8 years. The average body mass index was 25.64 ± 4.16 kg/m2 with obese men accounting for about a quarter of the participants (24.7%) [Table 1]. Blood Group O was the commonest blood type occurring in 40 men (51.9%) while hemoglobin genotype A was seen in over two-thirds of the participants (49 men) [Table 1].
[Figure 1] depicts a pie chart on the distribution of infectious diseases. Human immunodeficiency virus (HIV), Syphilis, Hepatitis B and Hepatitis C were diagnosed in 3%, 4%, 5%, and 1%, respectively. Sixty-Seven men (87%) had no infectious disease. Majority of the men (57.1%) produced semen with volume between 1 and 2 ml, a minority (7.8%), however, produced semen in excess of 5 ml [Table 2]. Sixty men (77.9%) had a liquefaction time of 15–30 min with only 6 men (7.8%) taking over 60 min for liquefaction to take place [Table 2].
Thirty-four participants (44.1%) had normal semen parameters while the remaining 43 (55.9%) had various forms of abnormalities. Only one participant had azoospermia (1.3%). Motility was reported to be fast (normal) in 56 men (72.7%), while 14 (18.2%) demonstrated no motility [Table 2].
Morphological defects were noted in a large proportion of participants with mid-piece defects occurring most commonly and found in 70 men (90.9%). Other defects noted were head defects found in 60 men (77.9%) and tail defects found in 41 men (53.3%). Immature spermatozoa were found in 38 men (49.4%) [Figure 2].
| Discussion|| |
Male factor infertility is enigmatic as its etiology is multifactorial and often idiopathic. Conception is a Pas de deux (dance by two) suggesting that both male and female partners in a union have a role to play. Conventionally, both partners have been responsible for about 50% of the causes of infertility and emphasis has been placed on the need to evaluate the couple simultaneously. The role of the malefactor and its contributions to infertility has been interrogated over the years and it has been mooted that there may be a rise in the contribution of male factors. This study revealed abnormal semen parameters in 55.9% of the participants suggesting a slight rise in male factor contribution at our IVF clinic. While this might not be generalizable due to the limited study population, it, however, gives an insight to the current realities and provides an opportunity for further interrogation of male contribution to infertility in the general population.
The testicles are the primary male reproductive organs and spermatogenesis is an important factor in male infertility. Deviations or abnormalities in sperm production may lead to infertility. The diagnosis of male infertility relies heavily on seminal fluid analysis and components of this analysis include concentration/density, morphology, and motility. The evaluation of the male partner is usually commenced when the couple fails to achieve conception after 1 year of regular unprotected sexual intercourse. However, for female partners above 35 years, evaluation for male infertility is commenced after 6 months. Male infertility has also been proposed as a window to the health of men as a growing body of evidence suggest some association between male infertility and certain medical conditions such as autoimmune, cardiovascular, and oncologic diseases.
Obese men accounted for about a quarter of the participants (24.7%). Obesity has been linked to reduced testosterone and sperm count in men. This is thought to occur at the hypothalamic-pituitary-gonadal axis where dysregulation leads to reduced luteinizing hormone and diminished spermatogenesis. Lifestyle modifications including weight loss and consumption of a healthy diet are essential strategies in curbing obesity and improving semen function. Dietary counseling during infertility consultations should be incorporated at all levels of care in developing countries as a primary preventive strategy for reducing obesity.
The HIV prevalence amongst Nigerian adults has been estimated to be 3.2% and our study was in conformity with 3% of participants testing seropositive for HIV. It has been reported that semen parameters reflecting fertility are impaired in men with HIV and semen parameters have been shown to correlate positively with CD4 count. HIV-infected men are more likely to have orchitis, hypogonadism and consequently deranged seminal fluid parameters. Highly active antiretroviral therapy has also been associated with damage to spermatozoa and contributes to the reduced fertility potential observed in men with HIV. This manifests in the form of reduced count, motility, and increased abnormal forms.
The most common morphological defect observed in this study was a mid-piece defect which was found in 70 men (90.9%). Other defects noted were head defects found in 60 men (77.9%) and tail defects found in 41 men (53.3%). The morphology of spermatozoa is the outcome of a series of intricate processes occurring during spermiogenesis. It has been suggested that the proportion of certain sperm abnormalities and the mean number of abnormalities per abnormal spermatozoon (Multiple Anomalies Index) have prognostic value for both in vivo and IVF. Semen quality is said to demonstrate variations due to environmental toxins often acting as endocrine disrupters. Sperm morphological evaluation has been suggested to be a useful indicator of the environmental factors which can modulate spermatogenesis. These factors include ambient temperature, lifestyle/habits, and exposure to toxins. Furthermore, damage to sperm DNA integrity has been implicated in male infertility and a study among Nigerian couples with unexplained infertility revealed a high sperm DNA fragmentation index in the male partners.
Assisted reproduction is increasingly deployed in the management of male infertility and sperm selection is an important step that influences treatment success and the health of the progeny. The goal of managing male infertility relies on the ability to select a population of highly motile morphologically normal sperm cells for either insemination or injection. ICSI is the method of choice for men with semen abnormalities and it relies on techniques that help isolate sperm cells either by functional or morphological characteristics. Intracytoplasmic morphologically selected sperm injection involves sperm selection using the motile sperm organelle morphology evaluation to identify morphologically normal sperm cells for injection.
| Conclusion|| |
The contributions of male infertility in developing countries may be higher than expected, unfortunately, women often bear the burden of evaluation and treatment due to the perceived socio-cultural beliefs. A cursory view of the semen parameters of male partners of infertile couples at our fertility clinic suggests a marginal rise in male factor infertility as only 44.1% of the men had normal semen parameters. This may not be readily generalizable as it is a clinic-based survey with limited sample size. However, it opens a vista for future interrogation of male infertility especially in a developing and highly cultural country like Nigeria.
Assisted reproduction seeks to identify and utilize motile sperm which are functionally and morphologically sound for either injection or insemination and relies on a variety of selection procedures to achieve this objective. Promoting advocacy for lifestyle modification, safer sexual practices, and limiting exposure to environmental toxins especially in the reproductive years remains a key driver for health awareness, behavioral change, and optimum reproductive health.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]