Male Infertility in Bangladesh: What Serve Better-Pharmacological Help or Awareness Programme?
Gazi Mahabubul Alam,
Abul Quasem Al-Amin
Treatment of male infertility is one of the challenging tasks
in developing nation given the nature of tradition and superstation of professed
the issue of human infertility is mainly considered infertility
in women which is a mistaken
and orthodox attitude. Due to a number of constraints especially collecting
data, research in this area is often ignored. However, since it is a vital area
to investigate in order to mapping the scenario and to provide policy guidance
especially for awareness and for further course of actions of both governmental
and institutional as well as family levels, we took an initiative to work at
this area using the small amount of data available at Infertility Treatment
and Research Centre (ITRC), in Bangladesh. Since July 2004 about 9000 couples
have been recorded and evaluated at the ITRC. Three semen analyses have been
made with an interval of one week. Special care was taken for collection, preservation
and analysis in respect of macroscopic, microscopic and biochemical analysis.
Repeated microscopic examination has been made in some cases to avoid errors.
The fructose test was done for azoospermic in every sample at ITRC laboratory.
Our study indicates that in 60% cases, male are responsible for Infertility
either fully or partially. Of them 40% were azoospermia 34% were oligospermic
and the rest 5% were asthenospermia and teratospermia 1% case was due to non
descendent and mal development of testes rest per cent was design as unexplained
infertility. This paper suggests that awareness on male infertility helps more
than having medical treatment with pharmacological aid and supplement.
Infertility is a graver concern affecting couples including loss of status
within the family and community. About 20% men could suffer worldwide from fertility
problems and the rising level of male infertility has become a serious trepidation
for public health (Orbiclinic, 2011). Fertility has been
the main study of civilization since immemorial time but the progression is
rather sluggish. Infertility can be defined as the incapacity to fulfill pregnancy
after 12 months of unprotected sex (Orbiclinic, 2011;
Gaur et al., 2007). Global data confirms that
male are to be responsible either fully or partially for 35-40% cases of infertility,
while female partners are responsible for 35-40% and the remaining 20-30% is
the combination of couples and a small percentage of unknown causes (Orbiclinic,
2011). Generally, infertility risk factors particularly for the case of
male may append by gland infection, mumps orchitis, varicocele and cryptorchidism
(Okonofua et al., 1997; Berger,
1990). According to Orbiclinic (2011), common causes
of male infertility include low sperm counts; abnormal morphology (shape and
size of sperm), slow sperm motility (movement) and related problems with semen.
Several studies have demonstrated that hazardous effect by environmental factors
such as toxic substances radiation and pesticides can affect the male reproductive
function (Upton, 2002). The abuse of tobacco, alcohol
and caffeine also has been seen as a way of linkage with male infertility (Oladepo
and Brieger, 2000; Zhang et al., 2000; Kunzle
et al., 2003). However, the intensities of risk factors for male
infertility in different countries and regions vary and the identification of
major risk factors in any particular country would have importantly significant
to public health.
In developing countries, patterns of infertility are quite different from those
in developed countries and the incidence of preventable infertility is much
higher in developing countries (Bashed, 2011). Many cases
of male infertility require sophisticated and expensive treatment. Therefore,
the addressing the issue of male infertility appears to be one of the priority
tasks of infertility programmes in the developing countries; Bangladesh is not
an exception. Traditionally, the major focuses of fertility problems in the
past have been the female partners. Infertility as a socio medical problem can
be considered in Bangladesh because male infertility adversely and negatively
causes family unrest, multiple marriages, divorce and even sometime suicide.
There are about three million couples in Bangladesh are infertile and it is
increasing rapidly changing in socio economic norm. Unfortunately like other
developing nations, wives in Bangladesh are mostly blamed albeit husbands are
responsible for 60% happenings.
There are ample literature can be found on the issues on human diseases and
diagnosis, women infertility, medial problem, pharmaceutical issues, drug inefficiencies,
diagnosis difficulties, social and socioeconomic issues and negative incidents,
research in men infertility is yet to receive much attention (Arora
and Samples, 2011; Rafi et al., 2011; Risvanli,
2011; Attitalla, 2011; Osman,
2011; Raja et al., 2010; Rahman,
2010; Mathur et al., 2010; Moeini
et al., 2009; Lokesh, 2009; Saki
et al., 2009; Pasqualotto et al., 2008;
Iheukwumere et al., 2008; Ghasemzad
et al., 2007; Lorzadeh et al., 2007;
Jensen et al., 2006; Mayyas
et al., 2005; Golam Sadik et al., 2001;
Agarwal et al., 1995; Alexander
and Anderson, 1989; Lastikka et al., 1976).
However, male infertility studies are rather scare in the related literature,
particularly in Bangladesh (Nikbakht and Hemadi, 2012;
Anwary et al., 2011; Akhter
et al., 2011; Abdalla, 2011; Bashed,
2011; Karthishwaran et al., 2010; Saalu,
2010; Osibote et al., 2010; Tayrab
et al., 2010; Abbasalizadeh et al., 2008;
Tabarraie et al., 2008; Zeighami
et al., 2007).
A number of factors that can cause or contribute (medical, socio-economic and
environmental) to male infertility are such as by (a) infections, (b) surgery
of the reproductive tract, (c) damage to the vas deferens (vasectomy), (d) scrotal
varicose veins (varicocele), (e) depression, (f) exposure of the testes to high
temperatures, (g) use of tobacco, marijuana, or alcohol, (h) medical conditions
(diabetes), (i) genetic or hormonal problems, (j) testicular injury, (k) change
of environment, (l) indiscriminate use of contraceptive (m) dietary, intake
of fruits, vegetables and grains and (n) socio economic condition and pressure
(Fig. 1). In our study an analytical approach is used to figure
out and to justify the prevailing disagreements in Bangladesh by providing specific
evidences. Therefore, this study intended to comprehend the major gaps in the
subject matter by providing specific evidences by a socio medical problem. Doing
the above, this study understands the necessary provision and expanded roles
of partners as wives are mostly blamed in Bangladesh.
MATERIALS AND METHODS
This study considered a sample of 9000 couples since 2004. The comprehensive
methodology of the evaluation and recorded process has been used (Bashed,
2011). Briefly, three semen analyses have been made with an interval of
one week. Analyses have been made as per WHO (2000) schedule
(Fig. 1). Special care was taken for collection, preservation
and analysis in respect of macroscopic, microscopic and biochemical analysis.
In some cases repeated microscopic examination has been made in a particular
sample. In azoospermic cases, fructose test was done in every sample at the
ITRC laboratory by the same pathologist. The following steps have been done
to find out the scenario of male infertility in Bangladesh.
Semen collection and test: The semen quality and movement are important
than the number. To be an effective fertile, at least 50% of the sperm should
be motile for 2 h after ejaculation. Normal human semen contains a great variation
in number and verity of abnormalities in sperms shapes and even motility than
most of the mammalian species. Generally, up to 40% of sperm may show abnormal
morphology without any basis for infertility. It has been emphasized that abnormal
morphology is more important in diagnostic sense than its questionable affect
on infertility. Normal ejaculation has a volume between 1 to 6 cc. Lower volume
associated with absence of sperm in the post coital test suggest the need of
artificial insemination. However, we have used several methods such as IVF (Invito
Fertilizatin), ICSI (Intra-cytoplasm Sperm Injection), IVM (In Vitro Maturation)
but IUI (Inter uterine Insemination) gives better outcome than others applied
The entire specimen has been collected because there are variations in both
sperm count and movement between the first and second ejaculation.
||IUI (Inter uterine insemination) ITRC, Dhaka, Bangladesh
All collections are made in a reasonable hygienic condition, ventilated clear
room with hygienic environment. Several cautions have been also taken care in
the semen collection. For example, an attempt to collect by withdrawal, during
intercourse runs the risk of missing rich portion and collection in a condom
can decreases the motility due to spermicidal agents. Frequent coitus may degrade
motility and count of sperm. As advised, time period of abstinence of intercourses
as 48 h abstinence for collection was taken care to have better result.
Finally, men with Klinefelter syndrome have taken care of as usually have small
testis and azoospermia. Varicocele, Hydrocele, hernia is most important factors
for impotency and in turn influencing semen quality and fertility. We have been
also cautious during our sample collection as speculation concerning the effect
by a possible elevation in testicular temperature and local pressure. Whereas
the physical examination of the male dose not uncovers the abnormality, testicular
biopsy PESA, MESA, TESA (Testicular Sperm Aspiration), TESE (Testicular Sperm
Extraction) utilized to find out the abnormality and infertility azoospermia
associated with normal spermatogenesis and ductile obstruction (Fig.
3). We made a decision in conclusion of infertility, if the biopsy reveals
complete hyalinization and fibrosis of the seminal tubules.
||PESA (Percutaneous epididymal sperm aspiration) ITRC, Dhaka,
|| A Normal Sperm, ITRC, Dhaka, Bangladesh
Leutinising hormone: Testosterone therapy once was popular but lately,
it has been limitedly considered. Unlike hormone therapy we have utilized Leutinising
Hormone (LH) and Human Chronic Gonadotropin (HCG). As the sperm motility is
more important for fertility than increase the sperm count, therefore, we exploited
Leutinising Hormone (LH). Some embryologist suggest the use of Human Chronic
Gonadotropin (HCG) to identify male infertility but it is reported to increase
the sperm count but to have only a limited effect on sperm motility. However,
the recently Human Menopausal Gonadotropin (HMG) preparations which have Follicular
Stimulation Hormone (FSH) and Leutinising Hormone (LH) have become available.
The advantages of using HMG and LH is the easily establishment of spermatogenesis
(Fig. 4). A number of European investigations have reported
improvement in the semen quality of oligospermic cases that have normal pituitary
function, therefore, is advised by sampling study (Bashed,
Frequency of exposure: Infertile couples concern the optimum frequency of expose
to achieve pregnancy. The frequency of sexual relation may have bearing with
fertility. However, men with border line semen numbers of daily exposure may
depress the counts to a level where chances for pregnancy are diminished.
|| Summary Statistics of male patients in ITRC, Dhaka, Bangladesh
|*BDT (Bangladesh Taka), Bangladeshi Currency, Exchange Rate
US$1: BDT 72.4 as in the late 2010, **Cost involvement as followed by including
Persistence and infrequent coitus or premature ejaculation may require sexual
General portrait: About 9000 couples were investigated in the Infertility
Treatment and Research Centre (ITRC) since 2004 and of them 5400 male were found
fully or partially responsible for the cases of infertility. Therefore, about
60% of our sampling males are somehow suffering for infertility. According to
our findings of the male patients, 40% were azoospermic, 34% were oligospermic,
5% were asthenospermia and teratospermia 1% cases. Moreover, in another test
56% found block of Vas and 34% found pregnancy out, 20% by socioeconomic issues,
10% for other issues (Table 1). The main causes of azoospermia
are due to measles, mumps, tuberculosis, trauma, small pox, STD and our sampling
indicates that the case history are very common in Bangladesh. The average age
of male patients was reported as 36 years with a mean age of marital life was
RATIO OF INCOME AND EXPENDITURE
The average monthly income of an infertile man is BDT 12000.00 equivalent to
USD 150. The treatment at Infertility Treatment and Research Centre (ITRC) includes
IUI (Inter Uterine Insemination), IVF (Invito Fertilizatin), ICSI (Intra-cytoplasm
Sperm Injection) and IVM (In vitro Maturation) with the cost ranges from
BDT 62,000 to 500,000. Since three out of five infertilities fully or partially
attributed due to male factors, it is incumbent on the family physician to be
knowledgeable in this field. According to our study, we find that after the
initial semen analysis it is the responsibility of doctor to determine whether
specialist consultation is required or not. There are still great deals of confusion
concerning which factor contributes for not forming normal sperm. We have come
out on the findings that 50% of pregnancies decrease when the sperm count drops
below 30 million per/cc which is heavily surrounded within the males in Bangladesh.
EFFICIENCY OF FIVE METHODS ADOPTED
We have observed specifically five methods in our study to test the infertility
(i.e. IUI, IVM, ICSI and ICVM). According to our sampling and study, we find
that IUI give better and satisfactory result than others. This method is also
deemed as the most cost effective one. Our findings indicate that not more than
0.5cc of sperm can be safely installed into the uterus to get the pregnancy.
Therefore, ITRC prefers to insert very high quality wash sperm after meticulous
monitoring of ovulation. We also utilize highly reported washed motile sperms
to the uterus by means of Teflon polyethylene catheter to test the pregnancy
and infertility. The patient remains on the table in a modified Trendelenburg
positing for at least 40 min.
We have observed several risk factors that are directly or indirectly linked
with the causes of male infertility in Bangladesh. They are, (a) age, (b) occupational
exposure, (c) drinking alcohol and caffeinated beverages, (d) smoking and infertility,
(e) psychological stress and (f) certain environmental and lifestyle factors.
A recent study estimates that the prevalence of infertility among couples which
was 40% male, 50% female and 10% involve both sexes (Anwary
et al., 2011). Another study was also conducted by Akhter
et al. (2011) and according to their findings infertility among couples
was present primary infertility in 61.9% and secondary infertility in 38%, a
positive male factor alone was found in 13% of couples and their findings also
indicated that oligospermia was the very common cause in Bangladesh.
Studies have shown that blood testosterone level decline with age and the risk
of becoming infertile doubled in men who are over 35 years old compared with
men who are under 25 years old and five times longer to conceive at the age
of 45 (Pasqualotto et al., 2008). Production
of testosterone hormone begins to decrease around the age of 40, sperm quality
changes with aging, also there is a decrease in the semen volume, motility and
normal morphology (Bayer et al., 2007). Some studies
point out that some solvents that are used in industry may have an adverse effect
on male reproductive function like carbon disulphide that had shown to affect
semen quality but in low exposures had shown no effect (Multigner
et al., 2007). The exposure to glycol ethers in work place associated
with decrease in the semen quality (Multigner et al.,
2007; Jensen et al., 2006). Furthermore,
welding may reduce the quality and quantity of semen, likewise, occupations
in which the workers exposed to heat they have reduced sperm count (Jensen
et al., 2006). Also workers in agriculture or in a pesticide factory
may experience a negative effect on reproduction (Jensen
et al., 2006). Furthermore, mercury and copper can interfere in spermatogenesis
(Queiroz and Waissmann, 2006).
Studies also find that consumption of alcohol and caffeinated beverages has
significant affect on infertility especially moderate to heavy alcohol intake
(Okonofua et al., 2005). Drinking caffeinated
beverages may interfere with fertility in men; a man who consumes more than
three cups of tea daily is associated with decreased fertility (Curtis
et al., 1997). Researches found that smoking has the potential to
damage a mans fertility in three areas: the quality of his sperm, his
ability to have sexual intercourse and his libido. Studies have found that smoking
men are more likely to produce sperm that has not been properly formed and is
generally of a poorer quality than the sperm of non-smokers. They have also
found signs of DNA or chromosome damage in smokers sperm. Furthermore,
nicotine releases secondary products in the body that have been found to reduce
the mobility of sperm, meaning that a smokers sperm may be at a disadvantage
when it comes to swimming to meet his partners ovum and that she has a
smaller chance of getting pregnant (Chia et al.,
2000). Research has shown that smoking reduces a mans desire for sex.
Carbon monoxide, one of the chemicals found in cigarettes has the potential
to reduce a mans testosterone level-that influences negative impact of
sex drive (Gaur et al., 2007; Chia
et al., 2000) Some studies also found that occupational stress was
negatively correlated with the proportion of normal sperm (Jensen
et al., 2006). The semen parameters of the men who are under stress
are significantly decreased (Collodel et al., 2008).
Level of stress as occupational stress is negatively correlated with the proportion
of normal sperm (Jensen et al., 2006).
POLICY DIRECTION FOR AWARENESS PROGRAMME
This study discovered that infertility in men is guided by nature mainly, however,
there are elements from our economy, society, lifestyle, work atmosphere, drinking
and food habit and some livelihood issues that supplement and subsidize the
infertility in men. No policy or awareness programme may help in reducing the
issue of infertility in men caused by nature. However, policy guidance and awareness
programme may help in addressing this unpleasant and cruel issue of family life
where infertility in men is caused through other variables discovered. A further
direction set up in this regards would also save the women for being the exclusive
victims for the issue of infertility as both genders can be responsible for
It is thus, alongside with the medical treatment, government can help by imposing
some effective governance and regulatory controls to these social and economic
issues. Particularly, government can interfere in some options such as; on use
of tobacco or alcohol, change of environment, indiscriminate use of contraceptive,
occupational exposure, dietary intake, medical condition socio economic condition
and certain lifestyle factors. Government may need to produce a policy document
in consultation with different stakeholders, beneficiaries and partners for
development to have a written guideline to address unwanted abuses and the fact
experienced in this regards (Alam et al., 2012,
Most of the developing countries have been suffering to place an effective
and appropriate policy in the national development agendas and health and family
planning mainly due to financial limitations (Al-Amin and
Alam, 2011; Zarra-Nezhad and Hosainpour, 2011).
Providing a decent policy may not be easy and straight forward but a starting
would probably take a long way to reach the goal one day. However, now there
is no alternative of being providing education and adequate knowledge and information
to infertile men as part of social mobility that may improve the situations
since simple changes in lifestyle can improve fertility which may not be received
by expanding a lot of money.
This study is the outcome of primary data sources with no conflict of interest.
We have our cordial acknowledgment to Infertility Treatment Research Center
(ITRC), Mohammadpur, Dhaka1207, Bangladesh to carry out the study.
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