Men's Health
Male Infertility.png

Today 19th November is International Men's Day (IMD).

So, some tips for men's health- as well as an attempt to eliminate some myths and misconceptions.

Men’s health

1. Stay healthy

Check regularly whether foreskin of penis (the skin covering the red portion of the penis, called “glans penis”) can be retracted backwards or not. This is for male who are not circumcised. And clean the materials (“white materials”- called smegma) collected beneath the skin regularly. If it cannot be retracted normally or during urination or intercourse, it is likely to be abnormal. And it may be a condition called “Phimosis”. If you feel you have phimosis or tight foreskin, do not force to retract it, because in doing so you will land up in more difficult and emergency situation, called “Paraphimosis”. So, only solution is to get it checked by doctor. Phimosis is common in males with diabetes and those having repeated infections. It can lead to further infections, problems during urination (that may even damage kidneys) and even cancer of penis in the long run.

Man presented to Fertility Clinic with absent Ejaculation. On examination he was found to have severe phimosis and blood test revealed he was having uncontrolled diabetes. (Pic with permission)

Do not ignore any abnormal swelling or ulcer or pain or tumour or any white or reddish patch in penis or scrotum. But some conditions are very normal like that look like small reddish or pinkish granules at the broader end of the glans penis. Similarly it is very common to have very dark pigmentation of penis and scrotum, even in very fairly skinned persons, especially in our country.

Picture showing the ultrasound report of scrotum of a young man presented with aspermia (No semen discharge on repeated attempts) with no scrotum seen in seen during physical examination (no testes seen in correct position)

Testicles should be checked regularly, at least once a week. Please remember, both testes are not of exactly same size and they do not lie exactly at the same level (one little above and one little low). And scrotum reacts with change of temperature. So, in cold days, scrotum contracts and you have scrotum lifted up so that testes lie at higher position. Conversely at warm days, they hang down more. There are some concerns that testicular cancers are increasing throughout the world and interestingly, it's more common in young men. One particular concern is "Undescended testes", where one or both testes may not be present in the scrotal sac and this is not only associated with infertility, but also, with increased risk of testicular cancer. So, any such condition must be treated in childhood.

But never ignore any injury, swelling or pain in scrotum or testes. Some peculiar sensation (“pain in lower abdomen”) is common during accidental pressing of testes and this indicates testes are normal. Absence of such sensation is usually abnormal. But if testicular pain persists you should not ignore it. The pain may be due to stone in kidney or infection in urine or testes or even tumour. And sharp stabbing pain indicates that there may be torsion which is a medical emergency (twisting of testis, if not treated early, can damage testes). The causes of testicular swelling are usually hydrocele (collection of water outside testes). Infection or tumour. Remember, testicular tumour or cancer is very common malignancy in young male but it responds well to treatment. Any swelling in scrotum above testes should also be noted. Sometimes it may be varicocele (swelling of veins above testes), hernia or some cysts.

2. Urinary problems

Do not ignore if you have difficulty in urination like pain, requiring more pressure, increased frequency, difficult to start, not feeling any desire or very strong urge that is difficult to control. In younger age it is due to stone or infection or some narrowing of passage (urethral stricture). In older age, it is likely to be due to prostatic enlargement. Remember, prostate enlargement is common after 40 years but in very few cases, it may be cancer. Men with family history of prostatic cancer needs ‘cancer screening” like regular check up for detection of cancer in early stage.

Blood in urine is another problem that indicates some injury or stone, tumour or infection. Even cancer in urinary tract can cause passage of blood in urine.

3. Sexual Problems

Most of the sexually active men are often obsessed about size of the penis. But it actually maters little for satisfaction unless it is abnormally low (“Micropenis”). Do not feel that the pictures shown in internet or film are real. So all the methods of ‘’enlargement techniques” are actually bogus. If it is micropenis, it needs proper evaluation to diagnose the cause of the cause and then the cause needs to be treated to achieve actual normal size.

Masturbation is not harmful for sexual health except that it may interfere with concentration in other activities (like study and work) and sometimes can lead to premature ejaculation.

Low libido- libido means desire for sex. The causes of low libido include- hormonal problems (like deficiency of thyroid hormones, testosterone in men and estrogen in female, high prolactin), blood sugar, liver diseases, anaemia, heart diseases etc. Sometimes it may be due to psychological factors like depression or anxiety. Again in some cases, poor performance during sex or past experience of pain or injury during sex may often lead to avoidance of sex by an individual. So, what can be done- simple thing, do not feel shy, consult your doctor so that the proper cause is diagnosed and treated and thus you would be able to enjoy your family life. Remember, especially for men, viagra will never lead to increased libido.

Pain during intercourse- Although not common in men, sometimes men may feel pain during intercourse. The cause is often due to incorrect position or due to phimosis (very tight foreskin). Some men have the idea that tight foreskin will 'break" with repeated intercourse but this is a wrong idea. Phimosis, if ignored can lead to infections, urinary and sexual problems and even cancer. So, do not ignore it.

Bleeding during intercourse- If a male sees bleeding from penis after intercourse, it may be due to phimosis (as mentioned above) or some tumour or more commonly due to some injury in penis. It needs medical attention immediately, as delay will make the problem worse.

Erectile dysfunction (ED)- some men may feel problems in achieving adequate hardness in penis during intercourse. Remember, almost all men can sometimes face this problems, especially with increase in age. But if it occurs repeatedly, then it reduces your self-confidence. Some causes may be due to psychological factors like anxiety or depression, but majority of ed is due to some diseases that may be missed if you do not take proper action. Such diseases include diabetes, heart disease, diseases of nerves, blood, hormones (thyroid, testosterone, prolactin) or even some chronic diseases. Sometimes abnormalities in blood flow in penis may cause ed. But do not get scared, at the same time do not feel shy. Just have a visit to your doctor's chamber and check the exact cause. It almost always responds well to medicines.

Ejaculation problems- some men may feel difficult to ejaculate semen. Most of them actually have retrograde ejaculation (re)- that may be due to some diseases of the nerves surrounding the prostate gland. In this condition, the semen does not flow forward, rather it moves back towards urinary bladder, so that semen is mixed with urine.

But more common problem faced by many men is premature ejaculation (PE)- that often leads to very short duration of sex. It is easily treatable with the help of some drugs and sex exercises. Some special sex tips also help a lot. You just need to have better control over ejaculation of semen and reduce sensitivity of the penis- simple thing.

4. Infection

Infection in sex organs may have long term consequences like urinary problems, infertility, sexual problems etc and so must not be ignored. Common cause of infection include poor hygiene, phimosis, diabetes, accumulation of sweat, but the most important one is STI (Sexually transmitted infections). The common signs include pain during intercourse or urination, abnormal discharge, swelling and sometimes fever. Never ignore them. Your doctor can advise some tests including blood tests, semen analysis and some swab from penis to diagnose the infection and give the correct antibiotics.

5. Male Infertility

Literally, the word “Infertility” means inability to conceive. But in reality, there are very few couples, who have no chance of natural conception and are called “Absolutely Infertile”. In fact, in many couples who present to infertility clinics, pregnancy may be the matter of time, thus the chance factor. Infertility does not only affect the female. In the male partner, sperms are normally produced in the testes after puberty (after attainment of characters like growth of beard, moustache etc). From the testes, they are carried through the sperm conducting ducts (epididymis, vas, seminal vesicle and prostate gland). Then during sexual stimulation, after proper erection and ejaculation, they come out through penis. During sexual intercourse, these sperms, present in semen, are deposited inside the vagina.

Thus the common causes of male infertility may be- total absence of production of sperms, less than adequate number of sperms, problems in morphology and motility of sperms (most sperms not healthy or movable), blockage in transport of sperms and inability to deposit sperms in the vagina (sexual dysfunction- Erectile Dysfunction or less commonly, Ejaculatory Dysfunction). Examples include hormonal problems (Testosterone, thyroid, prolactin), diabetes, liver problems, causes present since birth, chromosomal abnormalities, surgery, infection, sexually transmitted diseases, smoking, exposure of scrotum to high temperature, some medicines or psychological causes

Semen analysis is an indispensable part of evaluation of an infertile couple. It is accepted that if semen analysis report is normal, male factor is usually said to be normal. However, a single abnormal semen analysis does not always mean that there is any abnormality in the man. This is, because, semen consists of 2 parts- the sperms and the fluid ("seminal plasma"). In a man, sperm production requires 3 months and it needs cool temperature than rest of the body. This is why, men have their testes hanging outside the body in the scrotum.Thus, today's semen analysis reflects a man's health 3 months before. If, for any reason (for example, high fever, tight underwear, hot tub bath etc), man's health was abnormal 3 months ago, the semen analysis may become abnormal. Again, the results can vary from one laboratory to another.

What happens if a man cannot collect semen? Collection of semen in unfamiliar environment is understandably a matter of discomfort and seems awkward. Proper counseling and maintenance of privacy can help. Stress-free approach is needed. If it fails, do not hesitate to inform your doctor, especially if you are not accustomed to masturbation or had difficulty earlier.. Some medicines can help. But in those, who are unable to masturbate, there are some instruments, like vibro-ejaculator, can help to solve this problem. This is a small device applied on the front part of the penis ("Glans Penis") to stimulate the organ to discharge the semen. The other options include rubbing the penis against a special Non-Toxic Condom (Not ordinary condom) or intercourse with that condom. Some men feel comfortable to practise coitus interruptus.

In few men, when no semen comes out, the problem may be retrograde ejaculation (Semen going into bladder instead of moving forward). In that case, sperms can be collected from the urine immediately after masturbation. If it fails, options include some medicines, electroejaculation (Putting current in prostate gland by a small probe inserted through the anus under general anaesthesia), prostatic message and sometimes collecting sperms from testes with a small fine needle.

If a single report is abnormal, as mentioned above, it may not be conclusive. So, we usually advise repeating the test after few days, preferably from a second laboratory. At the same time, its important to diagnose the cause of this abnormality. To find out the cause, you may need physical examination of your genital organs. Your doctor may ask you some questions and with your permission, may check your body areas (hair growth, breast development), penis, scrotum, testicular size etc. Doctor can advise you some tests like ultrasound of your testes, or sometimes of your prostate gland. I severe cases, doctor can advise you some hormonal tests (blood tests- LH, FSH, Testosterone etc) and in some occasions, karyotyping (chromosomal analysis)

So, whenever we find abnormality, we have to detect the cause. Treatment without detecting thee cause is more likely to fail. So, first thing is- whether sperms are produced or not.

One important thing is to remember, sperm production has nothing to do with manliness. You may feel absolutely normal with normal sex life but sperm production may be defective. So, first thing is not to feel depressed when the report comes abnormal.

What treatment can be done? Every attempt is made to find out the cause and treat the cause so that you can father your baby using your own sperm by natural means. Treatment includes some life-style advice, some medicines (antioxidants etc). But if the problem is severe, medicines may not act. The only conditions, where medicines act very well, is when the sperms are not produced because of hormonal problems in the pituitary gland.

Picture showing the Karyotype results (Chromosomal Analysis) of a young man presented with Azoospermia (Absent sperms in semen which was also of very scanty quantity). The result showed Klinefelter Syndrome (47, XXY), that means instead of normal male pattern (46, XY), there was an extra X chromosome leading to features of small testes, abnormal breast development (Gynaecomastia) and very scanty body hair and beard and mustache development.

What lifestyle changes are advised? Remember, life style changes can improve your sperm count to some extent. You should avoid smoking, alcohol, taking drugs like anabolic steroids etc. You should try avoiding heat exposure to your scrotum. This can be done by avoiding tight underwear, avoiding prolonged sitting, avoiding prolonged driving, avoiding hot bath tub etc. Try keeping laptop and mobile phone away from your lap or thighs.

If the sperm count improves, then natural conception is possible. In other cases, we may not be able to improve the sperm count, but pregnancy is possible. If the problem is mild, intrauterine insemination (IUI) can be done, with the success rate 20-25% per cycle. “Intrauterine Insemination (IUI)” is the treatment where “prepared” semen is put inside the cavity of the uterus, near the Fallopian tubes. Thus, IUI bypasses some hurdles that can cause problems during natural intercourse. The vagina, cervix and the whole length of the uterus are bypassed, putting the sperms near the eggs.

If there is no sperms in the semen, we have to find out the exact problem. If the problem is due to adequate sperm production but blockage in the sperm conducting duct, some surgery can be done. However, such surgery is not widely available and may fail. So, most of the men usually opt for special type of IVF (In Vitro Fertilization) using the technique called ICSI (Intracytoplasmic sperm injection). Here sperms are collected from semen (is some sperms are there), or urine (in retrograde ejaculation) or by putting needle inside your scrotum (usually under anaesthesia). In case of block, the cahn=ance that we can collect your sperm from your body is 80-100%. That means, out of 100 such men, in more than 80 cases, sperms can be obtained from his testes. The procedures include TESA (Testicular Sperm Aspiration), TESE (Testicular Sperm Extraction), MESE (Microsyurgical Epididymal Sperm Extraction) and PESA (Percutaneous Epididymal Sperm Aspiration).

If it appears that the sperms are not produced well, still sometimes some sperms can be seen inside the testis. However, the chance of getting your sperms is 50%. So, if you agree, we can try collecting the sperms from your testes using TESA or TESE. Before that, we need to be sure that there is adequate chance of getting sperms from your body and so, you may need further investigations.

ICSI is a type of IVF. In standard IVF, your wife will be given some injections to mature her eggs, which will be collected under anaesthesia through the vagina using ultrasound. These eggs are then mixed with the sperms in the laboratory and the embryos, thus produced, are either directly put inside your wife's uterus or some may be frozen and kept for future use, if the 1st cycle fails. In ICSI, the best single sperm is chosen and is inserted directly inside the egg to produce the embryo.

If a man does not have any sperms or too few sperms to do IUI, IVF or ICSI is not affordable, donor IUI is an alternative. But it is not done without consent from both husband and wife. The donor is not known to the couple or the doctor and no identity of the donor is revealed. No relative or friend can serve as donor. Donor semen is frozen semen, collected 6 months ago and the donor is tested for diseases like STD, HIV, Hepatitis B or C. Usual attempt is taken to chose donor having blood group and skin colour similar to those of the husband. But remember, it’s only given after discussion and written consent by the couple.

6. Contraception

Condom is a very good method of contraceptive that also provides protection against infection. It prevents transmission of infection and STD (even HIV) from one partner to another. But correct use is very much important to know as often it breaks or slips due to incorrect use.

Medical methods of male contraceptives (like pills) are not very much popular, unlike females, due to very few studies and serious side effects (like permanent sterility).

Vasectomy is a very effective method of permanent family planning. It does not decrease sexual pleasure and needs very little operative time. It is very easy to do, even without need of hospitalization. But after vasectomy, the couple should use alternative contraceptive for at least 3 months, because immediately after vasectomy, the contraceptive benefits are not obtained.

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