Infertility and Impotence are quite different entities. Failure to distinguish between the two is a needless cause of embarrassment to many men who stay away from AMI clinics because of the stigma that goes with the latter term.

Medically a couple is considered to be infertile if there has been no pregnancy after one to one-and-half years of unprotected sexual intercourse. Both the man and the woman should be healthy and normal for the fertility process to proceed smoothly.
There is a large number of couples –who are infertile. Of these, in up to 50 percent of cases it is the male factor or the husband who is responsible for the infertility.

The male infertility factor was never dealt in detail.

INFERTILITY vs IMPOTENCE

It is important to note that infertility and impotence are quite different entities. Failure to discern the difference between the two is a needless cause of embarrassment to most men who stay away from AMI clinics because of the stigma that goes with the latter term.
Impotence means an inability to attain or sustain erections for satisfactory sexual intercourse.

The term has no bearing whatsoever on the fertility status of the man. It is thus possible for a totally impotent man to be potentially fertile and it will be possible to produce a pregnancy in the wife of such a man by insemination of the husband's semen.

Infertility, on the other hand, means an inability to produce children. This usually results from the husband's semen being infertile or sub-fertile. Most infertile men are perfectly normal in terms of potency and have very satisfactory sexual relations with their partners.

A number of clinical conditions and disease entities can render a man infertile:

• Varicocele
• Infections like acute: smallpox, mumps, other viral infections
• b. chronic: TB, leprosy, prostatitis
• Sexually transmitted diseases

Injury

• a. direct : testicular or pelvic trauma, heat, irradiation
• b. indirect : radiotherapy, chemotherapy, environmental toxins, drugs, marijuana, tobacco, alcohol
• Undescended testes (cryptorchidism)
• Previous surgery : inguinal, scrotal, retroperitoneal, bladder neck, vasectomy
• Obstructions : congenital (aplasia), vasectomy, post-infective
• Systemic illnesses esp. hepatic, renal
• Immunologic : infection, obstruction
• Ejaculatory disturbances
• Genetic, endocrine & familial disorders: Klinefelter's syndrome, Young's syndrome, cystic fibrosis, adrenal hyperplasia

Sometimes, in spite of the most meticulous search, no obvious cause can be found for the infertility. This group, known as the idiopathic infertility group, constitutes a large percentage.

MALE INFERTIFILITY –A BRIEF EVALUATION
Common tests to confirm male infertility & Semen Analysis - The first test in the evaluation of the infertile male is the semen analysis. This basic test gives valuable information.

Abnormalities why can show up on semen analysis are -
• Either the count is low (oligospermia)
• Sperms are altogether absent in the ejaculate (azoospermia).
• Sperm motility is seriously affected (asthenospermia) or
• Sperms are totally immobile or dead (necrospermia).
• There are many other anomalies that one may find on semen analysis.

When one finds anomalies in the semen analysis, the next step is to try and find a cause for it. There a is a range of additional investigations that can be done to further investigate –

Semen culture,
• Anti-sperm antibody estimation
• Scrotal ultrasound,
• Hormonal assays,
• Karyotyping,
• Vasography etc.

TREATMENT
Treatment of male infertility is difficult and sometimes frustrating. Immediate results are hard to produce and persistence with therapy is required.

The following modalities of treatment are generally employed.

1.Medical Treatment -This consists of the administration of certain drugs to improve seminal quality.

• Clomiphene citrate,
• mesterolone,
• tamoxifen,
• gonadotropin injections, antibiotics, steroids etc. are commonly used.

2. Surgeries Obstructions in the sperm conduction pathway, varicoceles, undescended testes etc. can be treated by operation.

Modern microsurgical techniques are of great help. Even patients who have undergone a vasectomy in the past can have their vasectomy reversed and the tubes recanalised successfully using microsurgery.

3. Assisted Reproduction (IVF)

In many cases, neither medicines nor operations are of help. In such cases, an attempt is made in the reproductive laboratory to improve semen quality and facilitate the penetration of the sperm into the ovum. This includes sperm washing/capacitation, intra-uterine insemination (IUI), gamete intra-fallopian transfer (GIFT), in vitro fertilisation (IVF), and micro-manipulation (ICSI).

Microsurgery and assisted reproduction require considerable training, skill and infrastructure.

Despite the availability of so many treatment modalities, some patients remain incurable and no treatment, cheap or expensive, can improve their fertility prospects. One then has no alternative but to recommend an AID (donor insemination) or adoption.

Awareness of the magnitude and importance of the male factor in infertility is relatively recent. Tremendous advances have been made in medical research over the past few years. If not today, one can envisage in the conceivable future, a situation where all males (and females) with infertility can be completely cured.