In most conventionally patriarchal societies, the UAE being no exception, the female partner is often blamed for infertility. However, the truth of the matter is that of the approximately 150,000 cases of infertility in the UAE, approximately 30 per cent are cases related solely to male infertility, going by reports released by various fertility clinics in the region.
Couples in the UAE in which the male factor is one of multiple factors involved is estimated to be three to four of every 10 cases of infertility as per a 2015 NBCI report. This is a significantly higher rate of incidence of male infertility than the global average of one in every two cases. The American Urological Association, Inc.’s (AUA) Male Infertility Best Practice Policy Committee (MIBPPC) in 1998, led by Dr Ira Sharlip, estimated that of the 15 per cent of couples globally who could not conceive a child after one year of regular, unprotected intercourse – 50 per cent was due to a solely female factor, while 20 to 30 per cent were purely male factors. The balance 20-30 per cent was a combination of both male and female factors.
A report by Aster IVF concludes that with 25 per cent of adults in the UAE being diabetic and a similar percentage being pre-diabetic, combined with the rise in smoking habits, has led to the rampant rise of infertility in recent years. A 2015 International Diabetes Federation assessment found that diabetes had risen by 35 per cent over just the previous year, primarily due to increase in obesity in the region. The WHO estimates that about 34.5 per cent of Emiratis are obese and 70.6 per cent are overweight.
Dr Kirnesh Pandey, India’s leading diabetes, thyroid and obesity specialist based in Bombay Hospital in Indore, shares one of his experiences from the two to three cases of male infertility he comes across daily.
“A 50-year-old patient, a smoker, who had been diabetic for over 10 years was referred for his inability to maintain a proper erection despite normal libido. On investigation, it was found that his glucose has not been under control. As a result, his penile arteries were atherosclerosed (artery wall thickened as a result of invasion and accumulation of white blood cells and proliferation of intimal-smooth-muscle cell creating an fibrofatty plaque) preventing engorgement. Based on this diagnosis, he was recommended surgery for revascularisation.”
Dr Pandey further explains: “Diabetics, despite not having clinically detectable atherosclerotic disease, are impacted more severely from atherosclerotic events than non-diabetics. Thus diabetes is to be viewed as an advanced atherosclerotic disease equivalent. Low testosterone, a key cause of erectile dysfunction, is also linked to diabetes.”
Male infertility is usually defined by abnormal results on semen analysis. However, investigation is carried out for various other factors including the following: a) Varicoceles, presented by dilated scrotal veins, present in 16 per cent of all men but being more prevalent in infertile men at 40 per cent. They impair sperm development by preventing the proper drainage of blood. This is the most common correctable cause of male infertility; b) Retrograde ejaculation caused by the failure of nerves and muscles in the bladder neck or the opening into the urethra to close during orgasm. Retrograde ejaculation occurs when semen pushes backwards into the bladder instead of out into the penis; c) Immunologic infertility triggered by a man’s immunologic response to his own sperm, due to injury, surgery or infection.
Antibodies while attacking the sperm prevent its normal movement and function, making it more difficult for sperm to swim to the uterus and penetrate eggs; d) Obstruction that blocks sperm from its normal passage, due to a number of factors, including repeated infections prior to surgery, inflammation or other development problems; e) Hormones are responsible for stimulating the testicles to make sperm. Pituitary gland hormones play a pivotal role in fertility. Low levels may cause poor sperm development; f) Genetic abnormalities in chromosomal numbers and structure as well as deletions on the important Y chromosome present in normal males can also impact fertility; g) Certain medications for conditions such as conditions like arthritis, depression, digestive problems, infections, hypertension and even cancer may affect sperm production, function and ejaculation.
“In the Middle East we also see region specific problems that impact fertility greatly. These are: consanguinity (not only if the couple are related as cousins, but if the wife’s parents or husband’s parents are relatives), reduced number of eggs at a very young age (that recently has to be related with low levels of vitamin D and chronic lack of sun exposure) and high prevalence of male and female obesity,” informs Dr. Human Fatemi, Medical Director, IVI Middle East Fertility Clinics.
He further advises, “Lifestyle in the UAE is a huge contributor to the rising rate of male infertility in the region. Smoking has been associated with lower fertility rates in both men and women. You should give it up when you are planning to start a family. The other aspect is obesity. Your extra weight involves hormonal changes that can affect semen production. Losing as little as just 5 to 10 per cent of body weight can boost fertility in men.”
The minimum full evaluation for male infertility includes a complete medical and reproductive history, a physical examination by a urologist or other specialists in male reproduction, and further detailed semen analyses. Other tests used to elucidate the etiology of a patient’s infertility include additional semen analyses, endocrine evaluation, postejaculatory urinalysis, ultrasonography and specialised tests on semen and sperm.
Dr Fatemi shares his experience with a particularly complicated case with difficult history and combined factors. “An Emirati couple in their early 40s, Ayesha and her husband Hamid, were fighting secondary infertility for nine years with a history of three failed IVF cycles. They had no problem conceiving their first child, but trying for a second baby was getting complicated.”
IVI’s evaluations revealed that Ayesha had very low ovarian reserve while Hamid was diagnosed with azoospermia – a condition which results in no sperm in the ejaculation process. Post first consultation, Hamid was administered a hormonal therapy for three months that significantly improved his sperm quality. It was also recommended that he freeze his semen multiple times so that they could be used later in the In-Vitro Fertilization (IVF)/ Intracytoplasmic Sperm Injection (ICSI) treatment.
ICSI is one of the most utilised and successful methodologies in IVF, involving the injection of a single sperm directly into a mature egg in the IVF laboratory.
Additionally, Pre-implantation Genetic Screening (PGS) was done on the resulting embryos to rule out any chromosomal abnormality due to Ayesha's advanced maternal age. This test is done to screen for abnormalities in the embryos prior to the transfer to ensure a healthy child.
Ayesha is now over eight months pregnant and about to deliver her second child.
Michael (full name witheld on request), 32, recommends couples not to delay seeking treatment on Aster IVF's site that records patient experiences while sharing his personal struggle with infertility. It was when his wife showed no signs of conceiving even after several months of their decision to start a family that he consulted an endocrinologist. "I was devastated when I learnt that I had an obstruction in the epididymis, a duct located at the back of the testicles that stores and carries sperm. This blockage meant that there was zero sperm count in the semen."
It was hard to get over the initial shock, he admits. "I was completely shattered thinking we’d never have a family of our own."
On consulting Dr Gautam Allahbadia, IVF Consultant and Head at Aster IVF Clinic, he was advised to go in for a testicular sperm aspiration (TESA) procedure to retrieve sperms surgically. “The sperms thus drawn out were fertilised with my wife’s egg in vitro [outside the body in a laboratory], and fortunately for us, the very first attempt was a success. My wife is two months pregnant now and we hope to have a healthy baby early next year.”
Clearly the high rate and rise in male infertility in the UAE is a result of multiple factors, some of those avoidable such as effective management of blood glucose levels, unhealthy eating habits, smoking and obesity.
There is significant benefit for those with less controllable or treatable factors to seek medical advice at the earliest. But more importantly, it’s key that men in the UAE note that medical science finds that there are equal or even greater chances that the couples’ infertility is owing to himself and not necessarily the woman. This shift in attitude is required for men to be open to the idea of being investigated, as much as women, when faced with difficulties in conception.