Dear Dr G,

I email you with a heavy heart, as I have discovered that our childlessness is my fault. My wife and I have been married for five years and despite an active sex life, we have not conceived a child.

We visited a fertility specialist and found that the issue lies with me. Until I underwent a semen analysis, I was unaware of male-factor infertility.

To my surprise, my ejaculation contains no sperm. I don’t understand why I seem normal in the bedroom; in fact, I consider our sex life quite healthy. I don’t understand why it is fruitless.

The doctor explained the problem might be due to blockages in the sperm ducts or damage to the sperm-producing cells. I eventually agreed to try IVF and underwent an operation to retrieve sperm for a test-tube baby.

I must confess I have no idea about ART, PESA, MESA, and TESE. After all the attempts, I was told I have Spermatogenesis Arrest.

In simple terms, I can never father a child in my life. I would like to put Dr G on the spot for clarifications on my seedless outcome.

How common is male-factor infertility? How do you differentiate between obstructive and non-obstructive problems?

What exactly is Spermatogenesis Arrest? Why is this happening to me? Is there really no light at the end of the tunnel?

Regards,

Arrested Development Andy

Dear Andy,

Infertility is defined as the inability of couples to conceive after one year or more of active sex without contraception. The World Health Organization (WHO) estimates 60 to 80 million couples are affected, often considered just the tip of the iceberg. Contrary to the common belief that infertility is predominantly a female problem, male infertility accounts for up to 40% of all cases. Since the late 20th century, the declining quality of semen has become apparent. A 1992 study revealed the number of sperm has declined by 1% per annum since 1938. This is echoed by studies worldwide showing declines not just in sperm counts, but also in motility, morphology, and seminal volumes in the male population.

Azoospermia, or the absence of sperm in ejaculate, can affect up to 3% of all males. The causes of azoospermia can be divided into acquired or congenital and further differentiated into obstructive and non-obstructive. The most common acquired obstructive azoospermia is vasectomy. Besides surgery, sexually transmitted infections or trauma to the genitalia can cause scarring, leading to azoospermia. Non-obstructive azoospermia can also be acquired or congenital. Infections like mumps can destroy sperm-producing cells in the testicles, and men born with genetically derived Spermatogenesis Arrest can also end up with male-factor infertility. The hope for fathering a child for a man with non-obstructive azoospermia is very slim.

Men with obstructive azoospermia can overcome infertility with ART (Artificial Reproductive Technology). PESA (Percutaneous Epididymal Sperm Aspiration), MESA (Microscopic Epididymal Sperm Aspiration), and TESE (Testicular Exploration Sperm Extraction) are the main surgical techniques to retrieve trapped sperm. Following sperm retrieval, creating embryos with IVF (in-vitro fertilisation) and subsequent baby delivery is usually a matter of time. In the absence of sperm during retrieval operations, biopsies are taken to identify the causes. In some cases, Spermatogenesis Arrest is identified.

Spermatogenesis Arrest refers to the disruption or cessation of the process by which sperm cells (spermatozoa) are formed within the seminiferous tubules of the testes. This arrest can occur at various stages of sperm development, leading to a reduced or complete absence of mature sperm in the semen. Spermatogenesis Arrest refers to the interruption of this process at a specific developmental stage: early maturation arrest, stopping at the spermatogonial or primary spermatocyte stage; or late maturation arrest, stopping at the spermatid stage, before final transformation into mature sperm.

Spermatogenesis Arrest can be due to intrinsic testicular defects or external factors that disrupt the testicular microenvironment. Genetic causes such as Y-chromosome microdeletions (AZFa, AZFb, AZFc regions) and mutations in genes involved in germ cell development (e.g., SYCP3, TEX11) are well recognised.

Other causes include hormonal imbalances, undescended testicles, trauma, chemotherapy, or mumps orchitis. Treatments such as hormonal therapy using Gonadotropins (hCG, FSH) for hypogonadotropic hypogonadism and anti-oestrogens (clomiphene citrate) are used in selected cases.

Lifestyle changes, such as ceasing smoking, alcohol, heat exposure, and toxin avoidance, can also improve spermatogenesis in mild cases. However, when sperm retrieval procedures yield no mature sperm for in-vitro insemination, the hope for ART treatment is slim.

Male infertility is a real struggle for many, as society assumes all sexually mature men to be fertile while the guilt of infertility is often shouldered by women. Childbearing is clearly not just a matter of sex, but a multifactorial issue of the overall well-being of couples.

Men with Arrested Development of Sperm Maturation often put Dr G on the spot for an opinion, and he is sorry to say: “Spermatogenesis Arrest clearly poses challenges of adversity, failure, and heartache even science.”