Journal of Medicinal Plants Research Vol. 5(25), pp.

5936-5945, 9 November, 2011

Available online at http://www.academicjournals.org/JMPR
ISSN 1996-0875 ©2011 Academic Journals
DOI: 10.5897/JMPR11.244

Review

Introduction to male infertility

Faisal Zakai1, Shahab Uddin1, M. Akram1*, E. Mohiuddin2, Abdul Hannan3 and
Khan Usmanghani3
1
Department of Basic Medical Sciences, Faculty of Eastern Medicine, Hamdard University, Pakistan.
2
Department of Surgery and Allied Sciences, Faculty of Eastern Medicine, Hamdard University, Pakistan.
3
Department of Basic Clinical Sciences, Faculty of Eastern Medicine, Hamdard University, Pakistan.
Accepted 20 September, 2011

Infertility is one of the most tragic of all marital problems. The infertility may be due to an inadequate
number of spermatozoa in the semen, the failure of the spermatozoa to move with sufficient vigor
towards their goal or that they are deficient in other respects. In this review article, introduction,
evaluation of the male patient, routine laboratory testing, normal values for semen parameters,
ejaculation difficulties, diagnostic considerations, possible causes of falling sperm counts, normal
spermatogenesis, male fertility tests, therapeutic considerations, botanical medicines, male infertility
statistics has been discussed herewith.

Key words: Infertility, sperm count, artificial insemination (AI), assisted reproductive technology (ART), semen
collection devices (SCD), precoital sexual stimulation (PSS), erectile dysfunction (ED).

INTRODUCTION

Infertility represents the inability to reproduce. The
inability to reproduce can be from husband (male) and /or
wife (female). However, male infertility presents a
particularly vexing clinical problem, while semen is the
initial target for diagnostic and therapeutic interventions
and analysis. As a result, epidemiologic assessment
regarding male reproductive dysfunction presents
formidable task for the diagnosis and treatment of
infertility. Infertility is defined as the inability to achieve
pregnancy after one year of unprotected intercourse. An
estimated, 15% of couples meet this criterion and are
considered infertile (Zavos et al., 2003). Historically, the
work-up for the infertile couple focused primarily on
conditions of the female. Conditions of the male are
estimated to account for nearly 30% of infertility cases
and conditions of both the female and the male account
for another 20% (Zavos et al., 1998). Conditions of the
male that affect fertility are still under-diagnosed and
under-treated. In general, causes of infertility in men can
be explained by deficiencies in ejaculated volume, sperm
concentration or too few sperm (oligospermia), complete
absence of sperm in the ejaculate (azoospermia), sperm
*Corresponding author. E-mail: makram_0451@hotmail.com.
Tel: 92-021-6440083. Fax: 92-021-6440079.
motility (asthenospermia), or sperm morphology
(teratospermia). Nearly 70% of conditions causing
infertility in men can be diagnosed by history, physical
examination, testicular volume estimation, and hormonal
and semen analysis. A rational approach is necessary to
perform the appropriate work-up and to choose the best
treatment options for the couple (Lawrence et al., 2000;
Goodpasture et al., 1987).
Technological advancements in assisted reproduction
technologies make conceiving a child possible with as
little as one viable sperm and one egg. While the work-up
traditionally has been delayed until a couple has been
unable to conceive for 12 months, beginning the work-up
at the first visit is now recommended because of a recent
trend towards delaying family planning. This article
summarizes current knowledge of causes of infertility in
men and describes its work-up, and treatment modes.
Evaluation of the male patient
1. The evaluation of the male patient is three-fold:
a. Detailed history taking;
b. Physical examination; and
c. Routine laboratory testing, including semen analysis.
The evaluation of the male patient begins with a thorough

history, including duration of the problem, sexual habits,
prior pregnancies and previous treatment, as well as the
general health of the patient. A childhood or
developmental history along with the patient’s medical
and surgical history should be discussed, including items
such as a history of diabetes, prostate surgery, or hernia
repairs. Exposure to possible toxic agents such as
radiation, heavy metals, and organic solvents should also
be included (Goodpasture, 1987).
Numerous publications (Zavos et al., 2005, 1992) have
shown that smoking negatively affects male fertility in
terms of sperm characteristics, sexual frequency and
sexual satisfaction. If both the male and female smoke,
there is also an additive effect. It has been shown via
electron microscopy that smoking causes damage to the
ultrastructure of the axoneme of human spermatozoa.
Patients that smoke should be advised to stop smoking
prior to any further infertility treatment.
More recently, it has been shown, for the first time, that
there is an aging effect on not only sexual behavioral
characteristics but also on the seminal and sperm
characteristics. The sperm parameter most commonly
affected by age is the percentage normal sperm
morphology. Although, there was a consistent decrease
in the percentage normal sperm morphology as assessed
by World Health Organization (WHO) guidelines with
increasing age, this decrease was more pronounced
when employing strict morphology criteria (Kuhnert et al.,
2004). In summary, a number of factors that can cause or
contribute to male infertility are:
1. Sexually transmitted diseases (STDs);
2. Fevers and infections;
3. Surgery of the reproductive tract;
4. Damage to the vas deferens (vasectomy);
5. Scrotal varicose veins (varicocele);
6. Use of depression or high blood pressure medications;
7. Exposure of the testes to high temperatures;
8. Use of tobacco, marijuana, or alcohol;
9. Medical conditions (diabetes);
10. Genetic or hormonal problems; and
11. Testicular injury.
During physical examination, particular attention should
be paid to the discerning features of hypogonadism. This
would typically be viewed as poorly developed secondary
sexual characteristics, eunuchoidal skeletal proportions,
and the lack of normal male hair distribution. Testicular
examination is essential and normal adult testes are 4.5
cm long and 2.5 cm wide on average, with a volume of
approximately 20 cc. Small and firm testes may signify
damaged seminiferous tubules before puberty, whereas
small and soft testes may suggest possible post-pubertal
damage.
Epididymal irregularities suggest a previous infection
and possible obstruction. Examination may reveal a small
prostate with androgen deficiency or slight tenderness
Zakai et al. 5937
(bogginess) in men with prostatic infection. Any penile
abnormalities like hypospadias, abnormal curvature, or
phimosis, should be looked for. The scrotal contents
should be carefully palpated with the patient in both the
supine and standing positions. Varicoceles can often
result in smaller left testes, and a discrepancy in size
between the two testes should arouse suspicion. Both
vas deferens should be palpated, as 2% of infertile men
have congenital absence of the vas and seminal vesicles
(Zavos, 2005, 1992).
Routine laboratory testing
Semen analysis
The initial test performed is a semen analysis, which
allows the clinician to examine the sperm count, motility
and morphology. The semen analysis results could
provide vital information revealing the cause of the
infertility. The parameters normally assessed during the
evaluation are:
1. Sperm count: Normal range of ≥ 20 million /ml to 300
million sperm per milliliter with low sperm count
(oligozoospermia) of fewer than 20 million per milliliter.
2. Sperm motility: Low sperm motility or movement
(asthenozoospermia) may reduce the chances of
conception, especially when paired with low sperm count
– normal sperm motility of 50%.
3. Sperm morphology: abnormally shaped sperm are
often unable to swim effectively or penetrate the various
oocyte investments during fertilization. A normal sperm
has an oval head, slender midsection and a tail that beats
in a wave-like motion.
Seminal specimens should be collected after three to four
days of sexual abstinence via either masturbation or at
intercourse. Seminal physical characteristics are also
very important as they may indicate certain deficiencies.
Additional laboratory tests
Depending on the results of the semen analysis, more
tests can be performed to diagnose specific causes of
infertility. If the semen analysis shows clumping or signs
of infection, a semen culture, prostate fluid culture and
urinalysis may be ordered. Antisperm antibody testing
may also be considered to evaluate potential immune
system disorders. Fructose testing may reveal structural
problems or blockage of the seminal vesicles. New
studies suggest that sperm with certain levels of DNA
fragmentation (sperm chromatin structural assay) serve
as a strong predictor of reduced male fertility.
When considering that the central component of
laboratory testing is the semen analysis, it must be
5938 J. Med. Plants Res.
Table 1. Normal values for semen parameters.
Parameter
Volume (ml)
Sperm concentration (million/ml)
Motility (%)
Forward progression (25%)
Normal morphology by WHO criteria (%)
Normal morphology by strict criteria (%)
Total sperm count (million)
Total motile sperm (million)
Total functional sperm (million)
Source: World Health Organization (WHO, 2006).
insisted upon that this test is performed correctly. At
collection the man is generally asked to obtain a
specimen through masturbation. Special containers are
also available for home collection, but prompt return of
the specimen to the laboratory (within one hour) is man-
datory. Table 1 lists normal standard values for adequate
semen parameters as outlined by the WHO.
It is important to note that these values are not the
absolute values needed to achieve a pregnancy, but
rather the statistical limits below which male infertility is
more likely to be a problem. Due to significant variations
in one or several semen parameters from one specimen
to another, which are not uncommon, it is recommended
that at least two semen specimens should be analyzed.
Adherence to strict collection techniques and abstinence
periods is therefore crucial to minimize variation and
maximize accuracy.
Ejaculation difficulties
Semen collection
Semen specimens collected for evaluation should
resemble the ejaculate delivered during intercourse, as
closely as possible, if the male infertility factor is to be
properly identified and treated. The most accepted
method of semen collection in humans for the purpose of
semen analysis, artificial insemination (AI), or assisted
reproductive technology (ART), is via masturbation.
Since some males have difficulty in producing a
seminal specimen via masturbation, recent developments
have allowed semen collection to be performed via the
use of semen collection devices (SCD). Those devices
generally consist of non-spermicidal condoms made of
polyurethane or silicone rubber. Due to their acceptability
by patients, lack of negative effects on sperm viability,
and assistance in the improvement of collected speci-
mens to closely resemble the ejaculates obtained at
intercourse, these devices may be used to better
evaluate the male (Zavos, 2005).
Normal values
2–4
>20
>50
25%
>30
>30%
>20 million
>20
>6
Precoital sexual stimulation
It has also been demonstrated that ejaculates produced
under increasing intensity of precoital sexual stimulation
(PSS), can bring about significant increases in ejaculate
characteristics. PSS should therefore be considered
during production of seminal specimens, particularly in
patients with spermatogenic dysfunctions such as
hypospermia, oligospermia, asthenospermia, or others.
Erectile dysfunction
Erectile dysfunction (ED) is the inability to attain and
maintain penile erection sufficient to permit satisfactory
intercourse and afflicts approximately 10% of the adult
population of US men (Matsuda et al., 2004). This is
increasingly evident in men who are asked to produce
seminal specimens on demand for infertility evaluation
and treatments. The inability to achieve penile erection is
only part of the overall multifaceted process of male
sexual function, which comprises various physical capa-
bilities with important psychological and behavioral
overtones. In addition, it should be recognized that sexual
desire, orgasmic capacity and ejaculatory capacity might
be intact in the presence of erectile dysfunction or may
be deficient to some extent and contribute to the overall
sexual dysfunction.
Recently, sildenafil citrate (Viagra®) has been
considered as an effective treatment for erectile
dysfunction (ED). Initial studies have shown that when
Viagra is administered to men with ED, it can bring about
erection and subsequent ejaculation. Various studies
show a beneficial effect of Viagra with side effects that
were not severe enough to discontinue treatment. It has
been shown for the first time that not only does sildenafil
citrate help males with erectile dysfunction, but also that
the seminal characteristics of ejaculates produced at
intercourse, along with semen preparation for use in
subsequent intrauterine inseminations or ART, show
normal values according to WHO criteria (Lawrence

Table 2. Possible causes of falling sperm counts.
S/N Causes of falling sperm counts
1 Increased scrotal temperature
2 Tight-fitting clothing and briefs varicoceles are more common
3 Environmental
4 Increased pollution heavy metals (lead, mercury, arsenic, etc.)
5 Organic solvents
6 Pesticides (DDT, PCBs, DBCP, etc.)
7 Dietary
8 Increased saturated fats reduced intake of fruits, vegetables, and whole grains
9 Reduced intake of dietary fiber increased exposure to synthetic estrogens
et al., 2000; Goodpasture et al., 1987).
Treatment for male factor infertility
Treatments for male infertility range from surgical
intervention or intrauterine insemination (IUI) to various
forms of ART, such as in vitro fertilization (IVF) or
intracytoplasmic sperm injection (ICSI). Depending on the
source of the problem, sperm can be taken from the
man’s ejaculate for use in assisted fertilization
procedures. With the advent of IVF and other modes of
ART, the overall treatment of male infertility has changed
dramatically. One treatment option for men who do have
sperm in the ejaculate is intrauterine insemination (IUI).
Intrauterine insemination is an infertility treatment in
which sperm are placed directly into the female’s uterine
cavity near the time of ovulation. IUIs are commonly
performed when there is a low sperm count or low
motility. The sperm that will be injected during the
procedure are prepared using a process called sperm
washing (Lawrence et al., 2000; Goodpasture et al.,
1987).
Since IUI is primarily used when there is very little or no
male factor involved, a variety of ARTs are available for
the male patient depending on the severity of the male
factor. Patients who have suboptimal sperm counts
(oligospermia) or motility (asthenospermia) in combi-
nation with a female factor should be advised to undergo
3
IVF. Only 100 ×103 (correct to 10 ) motile sperm are
needed per egg and the resulting embryos can be
transferred directly into the uterine cavity of the female for
subsequent implantation.
If only a few motile sperm are present with no forward
progression, then the patient should be advised to have
IVF in combination with ICSI. As opposed to conventional
IVF, only one sperm is needed per egg, and is injected
directly into the ooplasm. Confirmation of fertilization and
transfer of embryos are similar to IVF. If the patient
presents with azoospermia, a testicular biopsy is needed
to determine whether there are any sperm in the testes,
in order to diagnose the azoospermia as either
Zakai et al. 5939
obstructive (does produce sperm) or non-obstructive
(does not produce sperm). In cases of obstructive
azoospermia, advanced sperm retrieval techniques,
including testicular sperm aspiration (TESA), per-
cutaneous sperm aspiration (PESA), testicular micro-
dissection and testicular biopsy, combined with IVF and
ICSI, now allow men with either a low sperm count or no
sperm in their ejaculate to have the chance to produce a
child.
Diagnostic considerations
Semen analysis is the most widely used test to estimate
fertility potential in the male. The semen is analyzed for
concentration of sperm and sperm quality. The total
sperm count as well as sperm quality of the general male
population has been deteriorating over the last few
decades. In 1940, the average sperm count was 113
million per ml, in 1990 that value had dropped to 66
million (Zavos et al., 1990).
Adding to this problem, the amount of semen fell
almost 20% from 3.4 to 2.75 ml. Altogether, these
changes mean that men are now supplying about 40% of
the number of sperm per ejaculate compared to 1940
levels. The downward trend in sperm counts has led to
speculation that environmental, dietary, or lifestyle
changes in recent decades may be interfering with a
man's ability to manufacture sperm (Paulson et al., 2001).
In diagnosing male infertility on the basis of sperm
concentration, it is important to point out that as sperm
counts have declined in the general population, there has
also been a parallel reduction in the accepted line which
differentiates infertile from fertile men, that is, from 40 to
either 20, 10 or 5 million/ml. One of the key reasons
these values have dropped so drastically is that,
researchers are learning that quality is more important
than the quantity. A high sperm count means absolutely
nothing if the percentage of healthy sperm is not also
high (Tables 2 and 3).
Whenever the majority of sperm are abnormally
shaped, or are entirely or relatively non-motile, a man can
5940 J. Med. Plants Res.
Table 3. "Normal" spermatogenesis.
Criteria
Volume
Density
Motility
Normal forms
be infertile despite having a normal sperm concentration.
Conversely, a low sperm count does not always mean a
man is infertile. Numerous pregnancies have occurred
with men having very low sperm counts. For example, in
studies at fertility clinics 52% (Ford et al., 2000) of
couples whose sperm counts were below 10 million/mL
achieved pregnancy and 40% of those with sperm counts
as low as 5 million/ml are able to achieve pregnancy.
Because of these confirmed successes in men with low
sperm counts, it is recommended that conventional
semen analysis be interpreted with caution regarding the
likelihood of conception and that more sophisticated
functional tests should be used, especially when
screening couples for in vitro fertilization (Table 4).
Until recently, pregnancy was the only proof of the
ability of sperm to achieve fertilization. Now there are
several functional tests which in use. The post-coital test
measures the ability of the sperm to penetrate the
cervical mucus after intercourse. In vitro variants of this
test are also available. One of the most encouraging tests
is based on the discovery that human sperm under
appropriate conditions can penetrate hamster eggs. It
was established that fertile males exhibit a range of
penetration of 10 to 100% and that penetration less than
10% is indicative of infertility. The hamster egg
penetration test is considered to predict fertility in 66% of
the cases compared to about 30% for conventional
semen analysis.
Another important test in the percentage diagnosis of
infertility is the detection of antisperm antibodies. These
antibodies, when produced by the man, usually attack the
tail of the sperm thereby impeding the sperm's ability to
move and penetrate the cervical mucus. In contrast, the
antisperm antibodies produced by women are typically
directed against the head. The presence of antisperm
antibodies in semen analysis is usually a sign of past or
current infection in the male reproductive tract.
Therapeutic considerations
Standard medical treatment of oligospermia can be quite
effective when the cause is known, for example,
increased scrotal temperature, chronic infection of male
sex glands, prescription medicines, and endocrine
disturbances (including hypogo-nadism and
hypothyroidism). However, as stated in the foregoing, in
about 90% of the cases of oligospermia, the cause is
Value
1.5-5.0 ml
>20 million sperm/ml
>30% motile
> 60%
unknown (idiopathic oligospermia). In regards to
azoospermia, if the cause is ductal obstruction, new
surgical techniques are showing some good results
(Carlsen, 1992).
In the treatment of idiopathic oligospermia or
azoospermia, the rational approach is to focus on
enhancing those factors which promote sperm formation.
In addition to scrotal temperature, sperm formation is
closely linked to nutritional status. Therefore, it is critical
that men with low sperm counts have optimal nutritional
intake. In addition to consuming a healthful diet, there are
several nutritional factors that deserve special mention:
vitamin C and other antioxidants, fats and oils, zinc,
folate, vitamin B12, arginine, and carnitine. In addition, it
appears important for men with low sperm count to avoid
dietary sources of estrogens. Some herbs, especially
Panax ginseng and Eleutherococcus senticosus, are
known to increase sperm counts.
BOTANICAL MEDICINES
Ginseng
Current scientific investigation suggests that both Panax
ginseng (Chinese or Korean ginseng) and Eleuthero-
coccus sentiosus (Siberian ginseng) are likely effective in
the treatment of male infertility. Both botanicals have a
long history of use as male "tonics. Panax ginseng has
been shown to promote the growth of the testes, increase
sperm formation and testosterone levels, and increase
sexual activity and mating behavior in studies with
animals. Siberian ginseng has also shown some benefit
to the male reproductive function in animal studies as it
has been shown to increase reproductive capacity and
sperm counts in bulls. These results seem to support the
use of either ginseng as a fertility and virility aid.
In general, Panax ginseng is regarded as being more
potent in effects (particularly stimulant effects) than
Eleutherococcus senticosus. Although Siberian ginseng
contains no ginsenosides and is not a true ginseng, it
does possess many of the same effects that Panax
ginseng exerts, but it is generally regarded as being
milder. Pygeum Africanum: Pygeum may be effective in
improving fertility in cases where diminished prostatic
secretion plays a significant role. Pygeum has been
shown to increase prostatic secretions and improve the
composition of the seminal fluid (Purvis et al., 1992;
 Zakai et al. 5941

Table 4. Causes of temporary low sperm count.

S/N Causes of temporary low sperm count

1 Increased scrotal temperature
2 Infections, the common cold, the flu, etc.
3 Increased stress
4 Lack of sleep
5 Overuse of alcohol, tobacco, or marijuana
6 Many prescription drugs
7 Exposure to radiation
8 Exposure to solvents, pesticides, and other toxins

Table 5. Codes used in the diagnosis and management of male infertility.

ICD-9 Diagnosis codes

456.4 Scrotal varices
606 Male infertility
606.0 Azoospermia
606.1 Oligospermia
606.8 Infertility due to extratesticular causes
606.9 Male infertility, unspecified
Males that are 18 years or older are seen with one or more of the diagnosis codes.

Lucchetta et al., 1984). Specifically, pygeum administrat-
ion to men with decreased prostatic secretion has led to
increased levels of total seminal fluid plus increases in
alkaline phosphatase and protein. Pygeum appears to be
most effective in cases where the level of alkaline
phosphatase activity is reduced (that is, less than 400
IU/cm3) and there is no evidence of inflammation or
infection (that is, absence of white blood cells or IgA).
The lack of IgA in the semen is a good indicator of clinical
success. In one study, the patients with no IgA in the
semen demonstrated an alkaline phosphatase increase
from 265 to 485 IU/cm3. In contrast, those subjects with
IgA showed only a modest increase from 213 to 281
3
IU/cm .
Pygeum extract has also shown an ability to improve
the capacity to achieve an erection in patients with BPH
or prosta-titis as determined by nocturnal penile
tumescence in a double-blind clinical trial. BPH and pro-
statitis are often associated with erectile dysfunction and
other sexual disturbances. Presumably, by improving the
underlying condition, pygeum can improve sexual
function (Menchini-Fabris et al., 1988). Table 5 presents
the diagnosis and treatment codes for the analyses
detailed here. Diagnosis codes referring to laboratory
abnormalities (such as oligospermia) are mixed with
codes deriving from identifiable physical conditions (such
as varicocele) that may result in laboratory abnormalities.
Such overlapping diagnosis codes plague any analysis of
available data.
Table 6 lists the conditions identified in men presented
for evaluation of infertility in studies of distribution of
diagnoses from 1978 and 1997. It appears that in the 20
years between these two reports, more diagnoses
became available, and more risk factors for infertility were
identified. Interestingly, the proportion of men labeled
with idiopathic infertility remained similar, at approxi-
mately 25% in 1978 and 23% in 1997 (Clavert et al.,
1986; Carani et al., 1991).
OLIGOSPERMIA
Cases of male infertility are at increase in the world.
Quality of semen is declining over the years. In about 1%
of cases significant medical pathology which needs early
intervention is found. (Johnson et al., 1984) Early
evaluation of the male includes semen analysis and this
should be done before a treatment plan is to be instituted.
Semen quality is found to decrease due to increasing
amounts of environmental toxins; often oestrogenic in
effect. Management starts with avoidance of life style
issues that may be detrimental to sperm quality. Infertility
causes mental stress as well as financial stresses when
he adopts treatment plans like intrauterine insemination
(IUI), In vitro fertilization, intracytoplasmic sperm injection
(ICSI), percutaneous epididymal sperm aspiration
(PESA), testicular sperm aspiration (TESA) or other
assisted reproductive technologies. Many modern medi-
cine medications used for unrelated conditions have
negative effects on sperm quality. Surgical procedures on
the aetiological factors of defective spermatogenesis like
varicocoele itself are a factor may lead to oligospermia or
5942 J. Med. Plants Res.

Table 6. Distribution of male infertility diagnoses, 1978 and 1997.

Diagnosis 1978 percent (n = 420) 1997 percent (n = 1,430)

Varicocele 37.4 42.2
Idiopathic 25.4 22.7
Obstruction 6.1 14.3
Female factor ... 7.9
Cryptorchidism 6.1 3.4
Immunologic ... 2.6
Volume 4.7 ...
Agglutination 3.1 ...
Viscosity 1.9 ...
Ejaculatory dysfunction 1.2 1.3
Testicular failure 9.4 1.3
Drug/radiation ... 1.1
Endocrinologic 0.9 1.1
Infection ... 0.9
Sexual dysfunction 2.8 0.3
High density 0.5 ...
Necrospermia 0.5 ...
Systemic disease ... 0.3
Sertoli-cell only ... 0.2
Ultrastructural defect ... 0.2
Genetic ... 0.1
Testis cancer ... 0.1

azoospermia. mild, moderate and severe.

In Homoeopathy, it is not discussed with enough
importance by any of the authors. Rubric male infertility in
most of the repertories contains only a few medicines.
Defective sperm is the most common reason of male
infertility and the main spermal anomalies are:
a. Aspermia – Failure of formation or emission of semen.
b. Azoospermia – Absence of sperms in the ejaculate.
c. Oligospermia – Reduced sperm count (< 20 million/ml).
d. Asthenospermia – Motility deficiency.
e. Teratospermia – More malformed sperm cells.
f. Necrospermia – Dead or motionless sperm cells.
g. Polyspermia – Sperm count more than normal.
h. Globozoospermia – Round headed sperms.
i. Haematospermia – Blood cells in semen.
Oligospermia
Definition
Refers to sperm densities of less than 20 million sperm
per ml of semen or a total count of less than 50 million
sperm.
Mild: 10 to 20 million sperm cells /ml.
Moderate: 5 to10 million sperm cells/ml.
Severe below: 5 million sperm cells/ml.
Dilution oligospermia
In conditions where the semen volume is 5 ml or more,
count/ml may fall below normal. This is called dilution
oligospermia.
Prevalence of the condition
About 10% of the couples suffer from the trouble of
infertility. Among them 40% are caused by male factors,
30% by female factors and the rest 30% by combined
factors both male and female.
Azoospermia forms 10% of male infertility in long
standing cases. Disorders of sperm transport cause
infertility in 6% infertile men. In 5% of cases the cause is
found to be the autoimmunity. Congenital bilateral
absence of vas deferens is found in 1% of patients
attending male infertility clinic.

Classification Aetiology

Depending on the count, oligospermia is divided into May be broadly divided into physiological and
 Zakai et al. 5943

Pathological. 11. Nutritional supplements

a. Saw palmetto.
12. Neurological diseases
Physiological a. Paraplegia.
b. Dystrophica myotonica.
1. Frequent intercourse 13. Hepatic failure.
2. Old age. 14. Renal failure.
15. Auto immune disorders.
a. Polyglandular autoimmune failure.
Pathological 16. Systemic diseases
a. Sickle cell disease.
Reduction in sperm density may be due to b. Amyloidosis.
c. Hodgkin’s Disease
1. Defective spermatogenesis. 17. Immotile cilia syndrome.
2. Partial obstruction of the efferent ducts. 18. Androgen resistance.
19. Retrograde ejaculation.
Defective spermatogenesis are: 20. Idiopathic.

1. Congenital
a. Undescended testes or maldescended testes. Obstruction of the efferent ducts
b. Cystic fibrosis.
2. Primary testicular diseases. Obstruction may be at any level starting from rete testes,
3. Thermal factor epididymis, in the vas deferens or in the ejaculatory duct.
a. Varicocoele, big hydrocoele or filariasis.
b. Using tight garments; working in hot atmosphere. 1. Congenital
c. High fevers. a. Unilateral absence of vas deferens (C.AV.D).
4. Infections b. Unilateral absence of corpus or cauda epididymis.
a. Mumps, orchitis after puberty. 2. Infection
b. Systemic illness, bacterial or viral a. Tubercular.
c. Infections of the seminal vesicle or prostate. b. Gonococcal.
d. T. mycoplasma or Chlamydia trachomatis infection. c. Chlymydia.
e. Orchitis occurring in lepromatous leprosy. d. Leprosy.
5. General factors. 3. Surgical trauma
a. Chronic debilitating diseases. a. Herniorrhaphy.
b. Malnutrition. b. Hydrocoele operation.
c. Heavy smoking. c. Varicocoele operation.
d. Alcoholism. 4. In utero Diethylstilbesterol exposure.
e. Narcotics. 5. Young’s syndrome.
f. Granulomatous diseases especially lewprosy. 6. Torsion of the testis.
6. Endocrine factors 7. Idiopathic.
a. Diabetes.
b. Pituatory adenoma, hypopituitarism Varicocoele are an enlargement of the veins that run
c. Thyroid dysfunction. along the spermatic cord in the scrotum, ie the
d. Adrenal tumors, adrenal hyperplasia. pampiniform or cremasteric plexi. It may be present in
e. Hyperprolactinoma. 15% of males but all may not necessarily suffer from
7. Genetic infertility or oligospermia. But it may be the cause in 30 to
a. Klinefetler’s syndrome. 40% of males. This develops when defective valves in
b. Reinfelter’s syndrome. the veins allow the normally one-way flow of blood to
8. Iatrogenic back up in the abdomen. Blood then flows from abdomen
a. Radiation to scrotum where a hostile environment for sperm
b. Drugs. development is created. Prolonged elevated temperature
9. Mechanical has a detrimental effect on sperm production. Due to
a. Trauma to testes, accidental or surgical. raised temperature of scrotum; it is also referred to as
10. Occupational “hot testicles”. Abnormal venous blood flow increases
a. Exposure to toxic substances or hazards on the job metabolic waste products and decreases availability of
such as lead, cadmium, manganese, mercury; ethylene oxygen and nutrients required for sperm development.
oxide; vinyl chloride, radioactivity and x-rays. Long term effects of compromised circulation interfere
5944 J. Med. Plants Res.

Table 7. Drugs thought to induce male infertility.

S/N Drug type

1 Anti-androgens spironolactone, cimetidine, flutamide
2 Androgen suppressors ketoconazole and leuprolide
3 Oestrogens and hormones oestrogen agonists, growth hormone, and anabolic steroids
4 Drugs of abuse anabolic steroids, alcohol, marijuana, cocaine and nicotine.
5 Psychoactive agents tricyclic antidepressants, amphetamine, tranquillisers and phenytoin.
6 CVS agents propanolol, digoxin and Ca2+ channel antagonists.
7 GIT and antibiotics, sulphasalazine and nitrofurantoin

with androgen (hormone) production. They may be small,
develop slowly with no symptoms. Some are large and
are visible in scrotum. Other symptoms include painless
testicular lump, scrotal swelling or bulge within scrotum.
Although they can develop on either side on either side of
testicle; 85% develop on similar side. They are non-
tender twisted mass that feel similar to a bag of worms. It
disappears on lying down. To be properly identified
during physical examination the patient must stand and
must be asked to bear down (or cough). It develops
between ages 15 to 25 years old. More than 80% of men
with secondary infertility have varicocoele. It progress-
sively declines fertility (Greenberg et al., 1978).
Semen analysis
Recommendation for standards in semen analysis was
done by parameter recommendation/ normal value as
follows:
(1) Abstinence 5 (3 to 7 days).
(2) Collection masturbation (coitus interruptus).
(3) Volume (2 to 6 ml).
(4) Viscosity full liquefaction within 60 months.
(5) Sperm density (40 to 250 million/ml).
(6) Sperm motility
(7) Progressive
(8) Quantitative
(9) Good- Very good.
(10) First hour - greater than or equal to 60%. 2 to 3 h
greater than or equal to 50%.
(11) Vitality (Less than or equal to 35% of dead cells).
(12) Sperm morphology (greater than or equal to 60%
normal).
(13) Acid phosphatase (25,000 to 60,000 IU/ml).
(14) Zinc (90 to 250 µg /ml).
(15) Fructose (150 to 600 mg/ml).
(16) Medicines for male infertility and oligospermia (on
the basis of Homoeopathic literature).
Drugs have been implicated in the development of male
infertility; however, many of them are commonly used
drugs (Table 7).
Conventional methods for the diagnosis and
treatments for male infertility
The following is a summary of the key methods currently
used to diagnose male infertility.
1. 30% of the cases of male infertility the causative
factors are idiopathic.
2. Standardized laboratory models for the diagnosis of
male infertility are unavailable.
3. Conventional therapeutic strategies are based on
speculative concepts and clinical observations
4. Consider female reproductive function in relation to
male infertility treatments, (timing of ovulation).
5. Develop good clinical experimental trials are necessary
that include endocrino-logical evaluation of reproductive
hormones.
6. Continuous record of technician performance are
mandatory for internal quality control.
7. Semen analysis only useful for determining
azoospermia and oligospermia (Sigman et al., 1997).
MALE INFERTILITY STATISTICS
Population Censuses in Pakistan have included standard
questions on fertility, but relatively little use has been made
of resulting data. The principal reason for this neglect has
been a concern over data quality. Some of the estimates
derived from previous censuses have been so clearly
defective that there has been a general reluctance to invest
effort in detailed analysis of the data. According to UN
projections, it will become the third most populous by the
year 2050. It is one of only ten countries as of the 1998 with
a population in excess of 100 million in combination with a
TFR in excess of five births per woman (United Nations,
1999). Pakistan stands apart from its populous neighbors in
South Asia, all of which (with the exception of Nepal)
experienced substantial declines in fertility prior to 1990 and
therefore shows markedly lower fertility in 2001.
Intercensal growth rates between 1951 and 1981 indi-
cated a rise in the population growth rate in the 60's and
70's largely attributed to the sharp declines in mortality seen
in the 50's and 60’s, which were not followed by any decline

in fertility in those decades. Intercensal growth rates actually
peaked in the 1961 to 1972 period and continued at fairly
high levels in 1972 to 1981 after which they began to
decline. The 1981 to 1998 period records a decline to 2.6
indicating that growth rates in the last few years of the 17
years intercensal period are likely to have been lower. While
the validity of the 1998 Census has generally been
endorsed, a post enumeration survey was not carried out. A
revised figure issued by the Census Organization places
Pakistan’s population in 1998 at 131.6 million and in 2001
this is likely to be closer to 140 million. Demographic
surveys from the 60’s until the 90’s also concur that growth
rates peaked in the 70 and 80’s and have come down quite
sharply for the first time since then. The PDS 1998 shows a
rate of natural increase of 2.4, which is one of the lowest
figures recorded since the 60’s. The following table
attempts to extrapolate the aforementioned incidence
rate for male infertility to the populations of various
countries and regions. As discussed in the foregoing,
these incidence extrapolations for male infertility are only
estimates and may have very limited relevance to the
actual incidence of male infertility in any region.
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