Infertility or childlessness has been a social, psychological, and family problem from times immemorial. In the epic Ramayana, King Dasaradha performed Putrakamisti Yagam to get four children:n Rama, Lakshmana, Bharata, and Satrugna. Similarly, many kings and Chakravathies followed the advice of their Kula guru to beget children. Even know in some parts of India people do Kratu poojas for getting children. It is said that Kratu had 60 thousand children, and their names are included in the eighth book of the Rigveda. Therefore, it is evident that childlessness has existed from the times of the Vedas.
In the recent era, according to a publication by PMC Pub Med Central Facts Views Vis Obgyn 2010;2(2):131–138, Infertility is a worldwide problem affecting 8-12 percent of couples (50-80 million) during their reproductive lives (WHO, 1991). In Sub-Saharan Africa, the prevalence of infertility ranged from less than 10 percent in Togo and Rwanda to about 25 percent in Cameroon and the Central African Republic of women aged 20-44 years (Larsen, 2000). However, the single major cause of infertility in all probability is gonorrhoea a sexually transmitted infection, through tubal infection and occlusion in women (Frank, 1983). A high level of infertility is associated with a high level of sexual mobility, premarital sex, divorce, extramarital sex, and prostitution. From Demographic and Health Surveys 1994-2000, it was found that 3.3 percent in Mozambique and 1.3 percent in Kenya of currently married women had no fertile pregnancies in the age group 25-49 and among those women who had sex but no pregnancy are 4.6 percent in the former and 2.5 percent in the latter country (Rutstein and Shah, 2004).
According to 1981 estimates, infertility in India was around 4-6 percent, and according to NFHS-1, National Family Health Survey, childlessness is around 2.4 percent of currently married women over 40 years in India (cited in Jeejeebhoy, 1998). Childlessness in India is estimated to be around 2.5 percent. It is around 5.5 percent for 30-49 age group and 5.2 percent for the 45-49 age group. In absolute terms, it is around 4.9 million, and if secondary infertility is also added to it then the total number of infertile couples is around 17.9 million (Shivaraya and Halemani, 2007). Infertility has been relatively neglected as both a health problem and a subject for social science research in South Asia, as in the developing world more generally. The general thrust of both programmes and research has been on the correlates of high fertility and its regulation rather than understanding the context of infertility (Jejeebhoy, 1998).
Infertility
In many testicular lesions, the defect involves only spermatogenic function and results in infertility. Endocrine manifestations are absent. Either the semen lacks sperm or the number or quality of sperm is diminished. Testicular biopsy has a major role in differentiating the various disturbances in spermatogenic activity and in determining prognosis. Azoospermia is usually associated with severe tubular fibrosis, germinal aplasia, or spermatogenic arrest, and oligospermia with germinal cell desquamation, hypospermatogenesis, incomplete spermatogenic arrest, and less severe forms of tubular fibrosis. In general, only azoospermia or severe oligospermia is associated with increased plasma FSH (Follicle-Stimulating Hormone) concentrations. In most cases the cause is unknown. Azoospermia may also result from obstruction in the afferent ducts secondary to gonorrhoea, tuberculosis, or a nonspecific infection. Absence or atresia of the vas deferens and a rudimentary epididymis are common bilateral lesions in boys with cystic fibrosis, but may occur spontaneously. Azoospermia in the presence of a normal FSH suggests obstructive disease and warrants biopsy and urologic consultation.
Oligospermia:
This condition is composed of many variants. There may be partial arrest of spermatogenesis at the primary or secondary spermatocyte stage or at the spermatid stage. Abnormalities of the meiotic chromosomes and reduction in chiasma formation have been noted in men with oligospermia. Sperm morphology may be abnormal. Of interest are the nonmotile sperm seen in Kartagener’s syndrome (sinusitis, bronchiectasis, and situs inversus). The cause of immotility is the absence of the dynein arms of the microtubular elements of the sperm tail, Dynein arms are protein complexes found in cilia and flagella, the hair-like appendages that enable movement in cells. They’re responsible for generating the force that causes these structures to bend and move, which is crucial for tasks like swimming in sperm or moving fluids in the lungs, and this defect is related to the immobility of the cilia in the bronchi. In some men with severe oligospermia, the fibroblasts have only half the normal number of androgen receptors. Thus, the effect of decreased androgen action at the tubule is the putative cause of the associated infertility.
Varicocele:
This condition is associated with decreased sperm count and infertility in 25 to 65 percent of men, and there are varying abnormalities of sperm morphology. In general, measures of endocrine function have been normal. Results of varicocelectomy have been uneven, the incidence of restored fertility varying from 25 to 75 percent. The role of the varicocele in producing infertility remains obscure.
Other causes:
Sterility is a common sequel of bilateral cryptorchidism and may occur in association with unilateral cryptorchidism. Cryptorchidism, also known as undescended testes, refers to a condition where one or both testicles fail to descend into the scrotum. Instead, they remain in the abdomen or the inguinal canal (groin). This is the most common birth defect of the male genital tract. Sterility may follow orchitis caused by mumps, gonorrhoea, brucellosis, leprosy, or occasionally other systemic tubule dysgenesis. Even relatively minor illnesses may cause profound depression in sperm count. Starvation and chronic spermatic function. Estrogen and androgen administration also inhibit spermatogenesis by suppression of gonadotropins with concomitant decrease in intratesticular testosterone concentration. The increasing survival and cure rates of men with lymphomas treated with multiple chemotherapeutic agents have shown that seminiferous tubules are sensitive to alkylating agents in particular, and permanent sterility may follow therapy. Recovery of function, which occurs rarely, may be monitored by measurement of plasma FSH. If fertility is an objective after therapy, sperm banking is an option.
The infertility treatment and other aspects will be discussed in the coming issue. (to be concluded).
