Male infertility

Male infertility (Enah" or "Enanat")

 As per Unani concept Male infertility termed as"ENAH" or "ENANAT" defined as inability to perform sexual act & reproduction while zofe bah termed as sexual debility, defined as weakness in the performance & reproductive organs. It's fact zofe bah lead to male infertility

Male infertility refers to a male's inability to cause pregnancy in a fertile female. In humans it accounts for 40–50% of infertility.^[1][2][3] It affects approximately 7% of all men.^[4] Male infertility is commonly due to deficiencies in the semen, and semen quality is used as a surrogate measure of male fecundity.^[5]

Causes

Factors relating to male infertility include:^[6]

Immune infertility

Antisperm antibodies (ASA) have been considered as infertility cause in around 10–30% of infertile couples.^[7] ASA production are directed against surface antigens on sperm, which can interfere with sperm motility and transport through the female reproductive tract, inhibiting capacitation and acrosome reaction. Risk factors for the formation of antisperm antibodies in men include the breakdown of the blood‑testis barrier, trauma and surgery, orchitis, varicocele, infections, prostatitis, testicular cancer, failure of immunosuppression and unprotected receptive anal or oral sex with men.^[7][8]

Testicular factors

Testicular factors refer to conditions where the testes produce sperm of low quantity and/or poor quality despite adequate hormonal support and include:

Varicocele

Varicocele, is a condition of swollen testicle veins.

It is present in 15% of normal men and in about 40% of infertile men.

It is present in up to 35% of cases of primary infertility and 69-81% of secondary infertility.^[9]

Other

Age (see also: Paternal age effect)

Genetic defects on the Y chromosome

Y chromosome microdeletions

Abnormal set of chromosomes

Klinefelter syndrome

Centriole^[10]

Neoplasm, e.g. seminoma

Idiopathic failure

Cryptorchidism

Trauma

Hydrocele

Mumps

Malaria

Testicular cancer

Defects in USP26 in some cases^[12]

Acrosomal defects affecting egg penetration

Idiopathic oligospermia - unexplained sperm deficiencies account for 30% of male infertility.^[13]

Pre-testicular causes

Pre-testicular factors refer to conditions that impede adequate support of the testes and include situations of poor hormonal support and poor general health including:

Hypogonadotropic hypogonadism due to various causes

Obesity increases the risk of hypogonadotropic hypogonadism.^[14] Animal models indicate that obesity causes leptin insensitivity in the hypothalamus, leading to decreased Kiss1 expression, which, in turn, alters the release of gonadotropin-releasing hormone (GnRH).^[14]

Undiagnosed and untreated coeliac disease (CD).  In men, CD can reduce semen quality and cause immature secondary sex characteristics, hypogonadism and hyperprolactinaemia, which causes impotence and loss of libido.^[16] The giving of gluten free diet and correction of deficient dietary elements can lead to a return of fertility.^[15][16] It is likely that an effective evaluation for infertility would best include assessment for underlying celiac disease, both in men and women.^[17]

Drugs, alcohol

Strenuous riding (bicycle riding,^[18] horseback riding)

Medications, including those that affect spermatogenesis such as chemotherapy, anabolic steroids, cimetidine, spironolactone; those that decrease FSH levels such as phenytoin; those that decrease sperm motility such as sulfasalazine and nitrofurantoin

Genetic abnormalities such as a Robertsonian translocation

Tobacco smoking

There is increasing evidence that the harmful products of tobacco smoking may damage the testicles^[19] and kill sperm,^[20][21] but their effect on male fertility is not clear.^[22]  Smoking tobacco increases intake of cadmium, because the tobacco plant absorbs the metal. Cadmium, being chemically similar to zinc, may replace zinc in the DNA polymerase, which plays a critical role in sperm production. Zinc replaced by cadmium in DNA polymerase can be particularly damaging to the testes.^[23]

DNA damage

Common inherited variants in genes that encode enzymes employed in DNA mismatch repair are associated with increased risk of sperm DNA damage and male infertility.^[24]  These findings suggest that DNA damage is an important factor in male infertility.

Epigenetic

An increasing amount of recent evidence has been recorded documenting abnormal sperm DNA methylation in association with abnormal semen parameters and male infertility.^[27][28]

Post-testicular causes

Post-testicular factors decrease male fertility due to conditions that affect the male genital system after testicular sperm production and include defects of the genital tract as well as problems in ejaculation:

Vas deferens obstruction

Lack of Vas deferens, often related to genetic markers for cystic fibrosis

Infection, e.g. prostatitis

Retrograde ejaculation

Ejaculatory duct obstruction

Hypospadias

Impotence

Dignosis

Medical history

The history should include prior testicular or penile insults (torsion, cryptorchidism, trauma), infections (mumps orchitis, epididymitis), environmental factors, excessive heat, radiation, medications, and drug use (anabolic steroids, alcohol, smoking).

Sexual habits, frequency and timing of intercourse, use of lubricants, and each partner's previous fertility experiences are important.

Loss of libido and headaches or visual disturbances may indicate a pituitary tumor.

A family history may reveal genetic problems.

Physical examination

Usually, the patient disrobes completely and puts on a gown. The physician, physician assistant, or nurse practitioner will perform a thorough examination of the penis, scrotum, testicles, I vas deferens, spermatic cords, ejaculatory ducts, urethra, urinary bladder, anus and rectum. An orchidometer can measure testicular volume, which in turn is tightly associated with both sperm and hormonal parameters.^[4] A physical exam of the scrotum can reveal a varicocele, but the impact of detecting and surgically correct a varicocele on sperm parameters or overall male fertility is debated.^[4]

Sperm sample

The volume of the semen sample, approximate number of total sperm cells, sperm motility/forward progression, and % of sperm with normal morphology are measured. This is the most common type of fertility testing.^[29][30] Semen deficiencies are often labeled as follows:

Oligospermia or Oligozoospermia - decreased number of spermatozoa in semen

Aspermia - complete lack of semen

Hypospermia - reduced seminal volume

Azoospermia - absence of sperm cells in semen

Teratospermia - increase in sperm with abnormal morphology

Asthenozoospermia - reduced sperm motility

Necrozoospermia - all sperm in the ejaculate are dead

Leucospermia - a high level of white blood cells in semen

Normozoospermia or Normospermia - It is a result of semen analysis that shows normal values of all ejaculate parameters by WHO but still there are chances of being infertile. This is also called as Unexplained Infertility ^[31]

Blood sample

Common hormonal test include determination of FSH and testosterone levels. A blood sample can reveal genetic causes of infertility, e.g. Klinefelter syndrome, a Y chromosome microdeletion, or cystic fibrosis.

Ultrasonography

Scrotal ultrasonography is useful when there is a suspicion of some particular diseases. It may detect signs of testicular dysgenesis, which is often related to an impaired spermatogenesis and to a higher risk of testicular cancer.^[4] Scrotum ultrasonography may also detect testicular lesions suggestive of malignancy.

Prevention

Some strategies suggested or proposed for avoiding male infertility include the following:

Avoiding smoking^[32] as it damages sperm DNA

Avoiding heavy marijuana and alcohol use.^[33]

Avoiding excessive heat to the testes.^[33]

Maintaining optimal frequency of coital activity: sperm counts can be depressed by daily coital activity^[33] and sperm motility may be depressed by coital activity that takes place too infrequently (abstinence 10–14 days or more).^[33]

 Wearing a protective cup and jockstrap to protect the testicles, in any sport such as baseball, football, cricket, lacrosse, hockey, softball, paintball, rodeo, motorcross, wrestling, soccer, karate or other martial arts or any sport where a ball, foot, arm, knee or bat can come into contact with the groin.

Diet: Healthy diets (i.e. the Mediterranean diet) rich in such nutrients as omega-3 fatty acids, some antioxidants and vitamins, and low in saturated fatty acids (SFAs) and trans-fatty acids (TFAs) are inversely associated with low semen quality parameters. In terms of food groups, fish, shellfish and seafood, poultry, cereals, vegetables and fruits, and low-fat dairy products have been positively related to sperm quality. However, diets rich in processed meat, soy foods, potatoes, full-fat dairy products, coffee, alcohol and sugar-sweetened beverages and sweets have been inversely associated with the quality of semen in some studies.  

Treatment

Treatments vary according to the underlying disease and the degree of the impairment of the male fertility. Further, in an infertility situation, the fertility of the female needs to be considered.

Pre-testicular conditions can often be addressed by medical means or interventions.

Testicular-based male infertility tends to be resistant to medication. Usual approaches include using the sperm for intrauterine insemination (IUI), in vitro fertilization (IVF), or IVF with intracytoplasmatic sperm injection (ICSI). With IVF-ICSI even with a few sperm pregnancies can be achieved.

Obstructive causes of post-testicular infertility can be overcome with either surgery or IVF-ICSI. Ejaculatory factors may be treatable by medication, or by IUI therapy or IVF.

Vitamin E helps counter oxidative stress,^[35] which is associated with sperm DNA damage and reduced sperm motility.^[36] A hormone-antioxidant combination may improve sperm count and motility.^[37] However there is only some low quality evidence from few small studies that oral antioxidants given to males in couples undergoing in vitro fertilisation for male factor or unexplained subfertility result in higher live birth rate.^[38] It is unclear if there are any adverse effects.^[38]

Hormonal therapy

Administration of luteinizing hormone (LH) (or human chorionic gonadotropin) and follicle-stimulating hormone (FSH) is very effective in the treatment of male infertility due to hypogonadotropic hypogonadism.^[39] Although controversial,^[40] off-label clomiphene citrate, an antiestrogen, may also be effective by elevating gonadotropin levels.^[39]

Estrogen, at some concentration, has been found to be essential for male  

Low-dose estrogen and testosterone combination therapy may improve sperm count and motility in some men,^[48] including in men with severe oligospermia.^[49]

 Future potential treatments

Researchers at Münster University developed in vitro culture conditions using a three-dimensional agar culture system which induces mouse testicular germ cells to reach the final stages of spermatogenesis, including spermatozoa generation.^[50] If reproduced in humans, this could potentially enable infertile men to father children with their own sperm.^[51][52]

Researchers from Montana State University developed precursors of sperm from skin cells of infertile men.^[53][54][55]

Sharpe et al comment on the success of intracytoplasmic sperm injection (ICSI) in women saying, "[t]hus, the woman carries the treatment burden for male infertility, a fairly unique scenario in medical practice. Ironically, ICSI’s success has effectively diverted attention from identifying what causes male infertility and focused research onto the female, to optimize the provision of eggs and a receptive endometrium, on which ICSI’s success depends."^[56][57]

UNANI Treatment

A.Treat the cause specially. 

B. Generally zofe bah is treated under 3 stages

1. Taskeen o Tabreed

 2. Taqweeat

3 . Tahreek 

1. Taskeen o Tabreed. In this stage musakkinat o mubarridat advia are used locallly like natool post khadkhash, phitkiri mahlool, tila musakkin as well as orally such as talmakhana, toodari, moosli, beejband, singhara khusk, kushta qalyi and dawaus shifa  etc

2. Taqweeat . In this stage muqavviyate bah advia are used orally such as laboob kabeer majun salab             majun ard kurma etc.

3. Tahreek. In this stage muharrikat bah advia are used orally like majune falasfa, habbe ahmar etc. and as well as locally like tila shabab awar, tila Azam etc.

Islahe hazm o jigar are adopted in all stages. 

Course of the treatment depends upon chronicity of the disease.

List of musakkinat o mubarridat

Kushta qalyi

Kushta nuqra

Kushta jast

Kushta musallas

Qurs jiryan

Laboob barid

Majun ard khurma

Majun jiryan khas

Majun mughalliz jawahar 

Misali 

Matosin

Balooti

Jernide

Tila musakkin

Fitkiri mahlool

Roguan khaskhash

 List of muqavviyate

Laboob kabeer

Laboob Azam

Majun salab

Majun jalai

Majun momyayi

Majun ard khurma

Majun shabab awar

Majun jaleenoos lului

Habbe ambar momyayi

Habbe khas

Habbe jaleenoos

Habbe jadwar

Dawa tokore

 List of musakkinat

Khusta sammul far

Qurs khrateen

Qurse alhahmar

Qurs kushta shangraf

Habbe ahmar 

Majun flasfa

Habbe azaraqi

Tila Azam 

Tila shabab awar 

Tila Nishat angez

Tila ajeeb

Roghan beer bahooti

Roghan kharateen

Varicocele



The scrotum is a skin covered sac that holds your testicles.it also contains the arteries and veins that deliver blood to the reproductive glands. A vein abnormality in the scrotum may result in a varicocele.these veins are called the pampiniform plexus.


varicocele (VAR-ih-koe-seel) is an enlargement of the veins within the loose bag of skin that holds your testicles (scrotum). A varicocele is similar to a varicose vein you might see in your leg. Varicoceles are a common cause of low sperm production and decreased sperm quality, which can cause infertility. However, not all varicoceles affect sperm production. Varicoceles can also cause testicles to fail to develop normally or shrink. Most varicoceles develop over time. Fortunately, most varicoceles are easy to diagnose and many don't need treatment

Varicoceles are common. They can be found in 15 percent of the adult male population and around 20 percent of adolescent males. They’re more common in males aged 15 to 25.

symptoms


A VARICOCELE often produce no sign or symptoms rarely it might cause pain
swelling in the scrotum, mostly on left side, above testis.
Mild to moderate pain on standing for longer time.
Heaviness in the testes.
Impaired fertility

NOTE

withtime varicocele might enlarge andbecome more noticeable.A varicocele has been described as looking like a ‘bag of worms’



Causes

HOwever, many experts believe a varicocele forms when the valves inside the veins in the cord prevent your blood from flowing properly. The resulting backup causes the veins to widen (dilate). This might cause damage to the testicle and result in worsened fertility.

Varicoceles often form during puberty. Varicoceles usually occur on the left side, most likely because of the position of the left testicular vein.


Pressure above the plexus which disturbs the upward flow of venous blood, example are hernia, arterial pressure.

Incompetence of the valves of the plexus.
Spermatic cord problems which disturbs the flow of venous blood.
Varicocele disturbs the sperm production is controversial.
Some varicocele patients have good sperm production and some have abnormal production.
Varicocele patients also suffers from small testes and shrunken testes (in some cases).



Pooling of the blood in the veins of scrotum disturb the temperature of the testes and that leads to improper production of sperm.

COMPLICATION

Shrinkage of the affected testicle (atrophy). The bulk of the testicle comprises sperm-producing tubules. When damaged, as from varicocele, the testicle shrinks and softens. It's not clear what causes the testicle to shrink, but the malfunctioning valves allow blood to pool in the veins, which can result in increased pressure in the veins and exposure to toxins in the blood that may cause testicular damage.

Infertility. This condition can have an effect on fertility. Varicocele is present in 35 to 44 percent of men with primary infertility and in 45 to 81 percent of men with secondary infertility.

Primary infertility is generally used to refer to a couple that hasn’t conceived a child after at least one year of trying. Secondary infertility describes couples that have conceived at least once but aren’t able to again.

Prevention

Avoiding tight clothes like jeans.

Improper sitting postures.

Improper working conditions.

Exposure to excessive heat etc.

PRINCIPLES OF TREATMENT IN UNANI MEDICINES

PRINCIPLES OF TREATMENT IN UNANI MEDICINES

In unani system of medicine following basics principals are used in the management of diseases depending upon the pathology involved in the diseases process



1-Removal of the causative facter ( izala-i-sabab)

The causative factors in the pathology of the disease process are determine and removed for the proper management of the disease

2-Normalization of the morbid treatment ( tadil-i- mizaj)

The disease in which the temperament of a person is altered without affecting the quality and quantity of humors , only correction of simple morbid temperament is required.

This is achieved simply by modifying the lifestyle of the patient in the life of description of the essential and non- essential factors.

3-Evacuation of morbid material(Tanqiya)

The temperament is changed due to increase in the quantity of certain humours and that morbid material in the body gets accumulated the morbid material of the body is evacuated by various therapies through different routes of the treatment of the disease e.g.cupping (hijama) venesection (fasd),Leeching (Taliq) Concoctive(Munzij)Purgative (Mushil) Therapy, Expectoration (Tanfis) Diuresis (Idral-iBawl)and Diaphoresis(tariq)

4-Heterotherapy(Ilaj bi’-Didd)

This is the main principle of treatment in unani system of medicine in which the drug having temperament opposite to the disease is administered for the correction of morbid temperament and cure of illness.

5-Holistic aproch

In the management of the systemic diseases the entire lifestyle and the constitution of the patient is taken into account for making diagnosis and prescribing correct treatment. It includes habit, habitat, physical emotional temperamental and humoral status of the patient and condition of system /organof the body involved. Taking all these factors into account the treatment of the disease is prescribed.

Surgical and Para-surgical procedures (Ilaj bi l-Yad)

In unani system of medicine diseases of the structure and breach of continuity are treated by using suitable operative and Para operative techniques.

6-Psychiatric treatment (Ilaj Nafsani)

Unani system of medicine treats psychiatric diseases and psychic element of psycho-somatic diseases by using drugs modifying mind related processes like sleep and psychotherapy. It is able to use drugs by its discovery of the substance of mind i.e. psychic pneuma (Ruh Nafsani) while its appreciation of the medical importance of processes physical conditions etc. Which it organizes as Six essential factors Asbab sitta Daruriyya) helps it closely relate sleep etc to the improvement of psychiatric and psycho-somatic diseases. It also makes use of psychotherapy by manipulation of mind by verbal means.

7-Spiritual treatment (Ilaj-Ruhan)

Unani system of medicine recognises the role of spiritual health and treatment by discovering that the spirit is joined to the pneuma and through it to the body and leaves spiritual treatment of religious and spiritual counseling by spiritual authorities Although it does not oblige the physician to be a spiritual counseling which has a powerful role in healthcare by facilitating a healthy lifestyle and distressing.

8-Three primary sources of drugs (Marwalid Thalatha)
In unani system of medicine drug substances are obtained from herbal animal and mineral sources for the medication purposes in their natural form. Sometimes these drugs are used in simple form and sometimes in the form of a compound of various drugs. They may be subjected to physico chemical processes but without breaking up their natural character. Thus unani system of medicine uses only natural substances in treatment.