ORIGINAL ARTICLES Ephehiatrics in General Practice l\. If. Fynn - - ■ list Male Infertility Dorrien Fenn ■ - 171 Intravenous Fluid Technique M. A. Kibe! ■ - - Fractures of Radial Head with Medial 180 Displacement E. J. Mangle - - - 185 Dermatitis Gangrenosa Infantum M. Gelfami - - 187 Fevers of Africa 6.— Leishmaniasis South of Sahara I*. K. ( Manson-Hahr 180 B.M.A. (Mashonaland) Evidence on Medical School 104 EDITORIALS Epidemiology of Tuberculosis in the Belgian Congo and the Ruanda Urundi 100 Medical School Planning Committee 200 City of Salisbury Medical Report, 1955-50 201 B.C.G. Campaign in Eastern Districts 201 Twenty-one Years as M.O.H. to Salisbury 201 Dr. C. K. Joshi, M.B.H. 202 Salisbury Clinical Club 203 Obituary, L. E. W. Bevan, M.R.C.V.S. 201 Book Reviews ------209 Final Appeal for Prof. Drennan Presentation F u n d ...... 200 The Journal Library ------210 Correspondence ...... 207 In the Federal Assembly - - - - 211 In Rhodesia Then ------208 Latest Pharmaceutical Preparations 213 PUBLISHED MONTHLY, ANNUAL SUBSCRIPTION 42 2s. Od. Registered at tile Genera! Post Olbce as a Newspaper, T he Central African Vol. 3. No. 5. May, 1957 J ournal of Medicine

and the medical profession alike. Dr. Marion *The Evaluation and Treatment Sims, the pioneer of the rational study of sterility, of Male Infertility encountered tremendous opposition and no little abuse from his colleagues in America, when in BY 1868 he advocated semen examination and the demonstration of spermatozoa as a criterion of DORRIEN VENN, f .r .c .s. fertility in men. He was the first to make a Urologist, Johannesburg post-coital examination of the cervical mucous, and when he described this test, which still bears As the perpetuation of the species is prim arily his name, he was severely criticised in the medical dependent upon its reproductive ability it is no Press of his day, one journal in particular stating wonder that the problem of sterile wedlock is that “ this dabbling in the vagina with speculum one which has concerned mankind from time and syringe was incompatible with decency and immemorial. Many references to the recogni­ self respect.” Enlightened views unfortunately tion and treatment of infertility may be found often take time for their acceptance, and it was even in the earliest writings of man, and from not until early in this century that medical those early times until the present there has prejudice was overcome and the teachings of been an unending quest for the answer to this Sims began to be recognised and put into regular problem, the path of which has led through many p ra c tic e . strange fields ranging from the divine to the Although medical prejudices have been over­ witches brew. This is evidenced by the vast number of heathen, mythological, and other come the battle as far as the lay public is fabulous deities and powers in which the faculty concerned has not as yet been won. The necessity of being able to restore fertility has been invested for systematic examination of the husband in by credulous mankind. In China to-day for a case of infertile union is an acknowledged example statues of the goddess of fertility, Kwan fact by the medical profession. This view Yen are to be seen with their kneeling stones unfortunately is by no means universally accepted by the suspect husbands and there are still many almost worn away by the knees of countless who resent any question as to their reproductive thousands of barren women who. by supplication to this deity, believed that the blessing of ability and who resent even more the suggestion of any examination likely to cast doubt upon fecundity would be bestowed upon them. Like­ wise the folklore of virtually every nation on their manhood. earth contains many and varied, and often weird There are no doubt many reasons for this rites and ceremonies to say nothing of extra­ male antagonism, but probably the most ordinary recipes and formulae, all of which important is the firm belief by many men that are believed capable of exorcizing the evil spirit the capacity to be a husband is synonymous with of sterility. the capacity to be a father; in other words, the Whether on this account or because of pre­ ability to have sexual intercourse is ample proof judice or because of ignorance, the fact remains of their fertility. Another strong reason for that the scientific investigation of the barren reluctance to undergo examination is the fear marriage has been curiously delayed until com­ that not only may the examination reveal infer­ paratively recent years. For centuries the entire tility with its attendant blow to masculine pride, onus of infertility has always been placed on the but also the fear that evidence of previous woman and it was not until less than a century disease, indiscretions, or sexual aberrations may ago that the husband’s aptitude for inducing thus be brought to light. pregnancy was ever questioned, and furthermore There are many other more or less subtle it is only in the last 25 years that this bitter prejudices which make some husbands hesitant blow to masculine pride has been more or less to submit to an examination, but all in all these accepted, and that the scientific investigation prejudices and antagonisms are slowly dis­ of the barren marriage has included the routine appearing, and the suspect husband is now evaluation of the husband’s potentialities in this putting his fragile ego in his pocket with far respect as well as those of the wife. greater frequency, and accepting his possible Prejudices which delayed progress in this responsibility in this matter with better grace direction were initially shared by the lay public * than ever before. * Paper read before the Medical Association of These prejudices are mentioned not only Southern Rhodesia on 1st September, 1956. because of the part they have played in delaying Page One Hundred and Seventy-One May, 1957 The Central African MALE INFERTILITY Journal of Mf.mcink

scientific investigation of male infertility, but A simple classification of the etiological factors also because they do still exist and must be of male infertility may therefore be made, also fully recognised and tactfully dealt with by the under three main headings, each representing practitioner if new converts to the cause are a deviation from the normal requirements for to be made. fertility just mentioned.

Although this paper is lim ited to the question (a) Inability to have normal sexual inter­ of infertility in the male it must be stressed course, i.e., impotence. at the outset that the study of infertility is (b) The presence of certain anomalies or complete only when it includes both marital disorders of the genital tract. p a rtn e rs . fc) The production of defective germ plasm Incidence of Barren Marriage: incapable of fertilizing the ovum, i.e., Before a marriage can be considered possibly defective . infertile it is obvious that a certain period of Each of these causative factors must be con­ time must elapse during which no pregnancy sidered separately and in more detail. ensues in spite of the couple leading a normal uncontracepted married life. Strictly speaking ( a) Impotence: this should include the entire reproductive life The inability to consummate the sexual act is of the couple, as a first pregnancy may not due to a failure of any one of the three requisites occur until after many years of normal married of potency:— erection, intromission and ejacula­ life. For practical purposes, however, the tio n . arbitary time lim it of two years is generally accepted. Erection is dependent upon an intact and functioning parasympathetic system through the On the basis of this two-year lim it about 10 second, third and fourth sacral nerves and is per cent, of all marriages are infertile and of considerably influenced in its initiation and these the male is the responsible partner in 40 maintenance by the higher centres and the per cent, to 50 per cent, of cases. It is also psyche. Any abnormality affecting normal estimated that in approximately 20 per cent, function of these, therefore, may have disastrous of infertile marriages both partners are to a effects on the power of erection. greater or lesser degree at fault, a finding which underlines the importance of investigating both Failure of erection may be due to local or the male and the female and not exonerating general causes. The local causes include con­ the one merely because a cause for the infertile genital abnormalities, injury to or disease union is found in the other. processes of the . The general causes include general systemic disease and debility, Causative Factors in Male Infertility disease or injury to the central nervous system Before considering the various causes of male or local peripheral nerves, e.g., cauda equina infertility it is as well to review the main factors lesions, and psychogenic factors, this last being upon which reproductive ability depend, as these by far the most common cause. form a basis not only on which a satisfactory Failure of intromission may be due to com­ classification of the causative factors can be made, plete or partial failure of erection. Penile but also from which a system for their evaluation anomalities and deformities may also preclude and treatment can be evolved. intromission, even though partial erection is The factors concerned are: achieved. A less common, but no less important (1) The ability to have normal sexual inter­ cause of failure of intromission is ignorance of marital technique on the part of the male. Many course, i.e., potency. truly amazing cases have been reported and will (2) The possession of a normal genital tract. no doubt continue to occur in the future. Not (3) The production of germ plasm capable infrequently this lack of knowledge is found of fertilizing the ovum. in men of high intellectual attainments, and it These factors are obviously closely inter­ is therefore unwise to assume that any man is dependent, but any one or more of them is necessarily well acquainted with the technique liable to a particular group of anomalies and of sexual intercourse, and in all cases a careful disorders which, depending on their nature and history of the patient’s marital habits must be severity, may result in relative or absolute obtained, as the solution to an infertile union infertility. may well lie there. Page One Hundred and Seventy-Two ay T b e Central African M , 1957 MALE INFERTILITY J ournal of MeOicink

Ejaculation is a complex function involving ejaculatory ducts may occur as a result of both the sacral parasympathetic outflow (second chronic infection, but is of rare occurrence. to fourth nerves) and the sympathetic nervous ( c ) system . Defective Spermatogenesis The production of defective germ plasm The local causes of ejaculatory failure include incapable of fertilizing the ovum implies quali­ congenital abnormalities, e.g. the more advanced tative and quantitative deficiencies not only in cases of hypospadias where the semen is the spermatozoa but in the semen as a whole. deposited outside the vagina, and retrograde ejaculation into the bladder which occurs when The production of normal semen is dependent the function of internal vesical sphincter is upon a correctly functioning endocrine system, destroyed as for example in prostatic surgery. testes capable of reacting to this system by Post-inflammatory lesions, particularly urethral producing normal spermatozoa as well as stricture may also impede normal ejaculation. androgens and oestrogens, and finally upon an intact spermatic tract which not only ensures It has been shown that bilateral sympathectomy the normal maturation and onward passage of involving L 1 ganglia results in loss of ejacu­ the spermatozoa, but also provides the secretory latory power in a high proportion of cases. As contributions to the semen from the seminal with erection, ejaculation is under the control vesicles and the . of the higher centres, and the general causes of its failures may be found not only in psycho­ The physiology of testicular activity is not genic but also organic disturbances of the completely known, but the following simplified central nervous system. concept however is one which enjoys wide acceptance to-day. ( ) b Anomalies and Disorders of the Genital The anterior lobe of the pituitary which itself T ract is probably controlled by the hypothalamus Under this heading is included the congenital produces two gonadotrophic hormones which anomalies and obstructive lesions in so far have a fundamental affect on the testes. as they prevent the access of the spermatozoa (1) The follicle stimulating hormone (F.S.H.) to the . Such lesions must of course or Prolan A. This controls the differentiation be bilateral to cause infertility. and function of the seminiferous tubules by Congenital anomalies of the and acting on both the spermatogenic and Sertoli vas are not uncommon and represent varying cells. degrees of failure in the development of the (2) The interstitial cell-stimulating hormone Wolffian system. Thus absence of the epididymis (I.C.S.H.), also known as the luteinising hormone or vas or both in part or whole may occur and (L.H.) or Prolan B. This controls'insterstitial developmental strictures not only of the vas but (Leydig) cell differentiation and function. The also of the epididymal duct are more prevalent mature Leydig cells in turn produce androgens than is generally realized. Separation of the (testosterone) and also it is thought, oestrogens. epididymis from the testis and also of the vas The testicular androgens probably in combina­ from the epididymis may likewise be encountered tion with those produced by the reticular cells amongst the developmental disorders of this of the adrenal cortex are responsible for the region. The former is not confined to undes­ appearance and maintenance of the secondary cended testis as formerly thought and may be sexual characteristics. These androgens and found in normally descended organs. oestrogens also have a controlling influence''on Post-inflammatory stricture of the duct of the the pituitary by inhibiting the output of both epididymis is a fairly common sequel to both the gonadotrophic hormones. non-specific and gonococcal epididym itis, but may The structural units for spermatogenesis are also be traumatic in origin. the seminiferous tubules, each of which is from Similar strictures may occur in the vas and one to three feet in length, and, as each testis likewise traumatic division both accidental and possesses about 300 to 600 of these units, the deliberate occurs. total length of the tubules is in the region of Chronic infections of the vesicles and prostate half a mile! The spermatozoa develop from the were long considered factors in low fertility. germinal cells in the tubules which are in a Contemporary opinion, however, is that there is continuous process of maturation and division. little if any connection between prostatic infection Five stages have been recognised in this process and male' infertility. Obstruction to the ranging front'the through the Page One Hundred and Seventy-Three May, 1957 T he Central African MALE INFERTILITY J ournal ok Medicine

primary and secondary to the it is not wise to summarily pronounce a cryptor­ and finally the which chid as being incapable of parentage. if only is set free in the lumen of the tubule. These one testis is undescended there is not much testicular spermatozoa are in some way immature danger of impairment of fertility provided that and not capable of fertilization. There is con­ the descended organ is normal. siderable experimental evidence to show that As far back as 1892 Griffiths found the testes the fertilizing ability of the sperm progressively of a dog underwent degenerative changes if increases the further it migrates from the replaced in the abdominal cavity, but he failed to testis, so presumably maturation occurs in the recognise that it was the increased temperature epididymal duct and during its onward passage of their new environment that caused these in the seminal tract. The means by which the changes, and it was not until 1922 that Crew sperms pass along the seminal tract is not first suggested that the temperature factor was definitely known, but it is generally accepted the operative one in the testicular atrophy of the the sperms are not sufficiently motile to leave cryptorchid. Since then a great deal of experi­ the epididymis under their own power, and mental work has confirmed these observations, therefore peristaltic action is the most likely and the fact now emerges that to ensure active propulsive force. spermatogenesia the testes must be kept at least Spermatogenesis is a delicately balanced 2° C. below the general body temperature, function which is easily upset by many different and, if this rule is not observed, spermatogenesis conditions, and when disturbed the spermatogenic is at first temporarily depressed, and after a deficiencies are reflected in the spermatozoa time completely and irreversibly destroyed. themselves, and may result in a decrease in Hanley (1955) using a thermocouple needle has numbers (oligozoospermia) ; or even their recorded a temperature difference of 4.5° C. complete absence (azoospermia). Alterations of between a retained on the inguinal canal form and motility may also occur in varying and its normally descended fellow. degrees depending on the nature and severity of These investigations not only demonstrate the the upset. The significance of these deficiencies deleterious effect of excessive temperature on will be discussed later, and in the meantime spermatogenesis, but also emphasize the im por­ the causes of spermatogenic failure will be tant part which the plays in the considered. regulation of testicular temperature. The The known conditions which may affect action of the cremaster and muscles spermatogenesis are: varies the position of the testes in relation to 1. Congenital anomalies of the testis. the body according to the temperature demands, 2. Acquired injury to the testes. and by this means any over-heating of the testes is prevented. 3. Endocrine disturbances. There is a further large group of cases in It is clear therefore that in cryptorchids which spermatogenic deficiency is present permanent damage to spermatogenesis will without demonstrable cause. occur if the condition is not relieved. Nelson (1950) has presented histological evidence that ( 1 ) Congenital Anomalies of the Testis degeneration of germinal epithelium of the Under this heading is included not only the undescended testis does not occur until about so-called congenital testicular aplasias but also the age of seven to eight years, and from this undescended and ectopic testes, although it is time on it is progressive until after puberty difficult to be sure that these are not in fact when total aplasia of the germinal epithelium prim arily endocrine in origin. results. It has long been known that cryptorchidism ( 2 ) Acquired Injury to the Testes results in atrophy of the testes and damage to spermatogenesis. In the early years of the Traumatic injuries to the testes may be due nineteenth century, Sir Astley Cooper taught to mechanical, thermal, X-ray, or radioactive that patients with bilateral retained testes were agencies. usually sterile, and the story goes that having told Direct mechanical injuries to the testes this to a class, one of his pupils, a cryptorchid, short of castration do not usually result in left the room and committed suicide. At the destruction of spermatogenesis; castration, how­ ensuing post mortem examination motile sperma­ ever, obviously precludes any possibility of tozoa were demonstrated. The moral being that fertility, but it might be mentioned that, contrary Page One Hundred and Seventy-Four May, 1957 T he Central African MALE INFERTILITY Journal of Meoici.nl

to popular belief, it does not necessarily destroy of hypogonadism, and, according to the nature p o te n cy. of the deficiency and the gland involved, so Thermal trauma has already been mentioned may various definite patterns of hypogandism in connection with undescended testes. It has be produced. been shown, however, that impairment of This supposition is to some extent correct as spermatogenesis may occur as a result of raised definite clinical syndromes associated with testicular temperature brought about by such hypogonadism do exist. There are, however, every-day means as scrotal supports and snug- many cases where this it not so, and particularly fitting underpants which, by bolding the testes perplexing are those in which spermatogenic in close contact with the body, create the deficiencies occur, presumably of endocrine unfavourable thermal environment. origin, but without any demonstrable stigmata There are two other local conditions which of endocrine dysfunction. Between this group may be associated with lowered fertility, due and the group which can be labelled as clinical most likely to their interference w ith the exacting syndromes are many intermediate degrees which temperature requirements of the testes, namely, are not easy to classify, and less easy to under­ varicocele and hydrocele. It has been shown stan d. by Davidson (1954) Russell (1955) and Tulloch On the basis of gland dysfunction two main (1955) that varicocele in particular is not hypogonadal syndromes are described. infrequently associated with subfertility and that (1) Pituitary Hypogonadism. this is the result of the increased total scrotal (2) Primary Testicular Hypogonadism. temperature which varicocele occasions. This is further borne out by Hanley’s observation ( 1 ) Pituitary Hypogonadism may be of two types depending upon whether the hypofunction that the temperature difference between a large varicocele and the rectal temperature in an is total or limited to the gonadotrophin output otherwise normal male may be as little as by the anterior lobe. 0 .2 ° C. Where there is total pituitary hypofunction, Sustained hyperpyrexia for any length of pan-hypopituitary hypogonadism results. If time may also cause a temporary depression of this is prepubertal in onset, dwarfism, sexual spermatogenesis, but can hardly be cited as a infantilism, myxoedema, and adrenal insuffi­ cause of infertility. ciency result. M inor degrees of this condition are probably represented by those cases which The germinal epithelium of the testes is are described under the heading of Frohlich’s very sensitive to X-rays, and irradiation from syndrome. If on the other hand the onset is radioactive substances, and either temporary or in adult life the syndrome commonly known as permanent spermatogenic arrest may result from Simmond’s disease occurs. exposure to them. The Sertoli and Leydig cells are, however, far more resistant and do not When the gonadotrophin output by the anterior lobe of the pituitary is below normal, suffer material damage in doses crippling to hypogonadotrophic hypogonadism is the out­ the germinal elements. come, the clinical picture depending again upon ( 3 ) Endocrine Disturbances the time of onset. Prepubertal onset results Although there have been considerable in a hypogonadal syndrome similar to that of advances in the knowledge and understanding the prepubertal eunuchoid which is usually of the individual glands and of their integrated characterised by the very tall, long-legged function in the endocrine system as a whole, slender individual with markedly retarded there still remain many unsolved problems, and secondary sexual characteristics. the testis as an important member of the system Onset in adult life produces a very similar is not exempt from these. It is hardly surpris­ picture of that of the post-pubertal eunuchoid, ing therefore that the part played by endocrine where there is little retrogression of the secondary disturbances in the production of infertility is sexual characteristics, except that sterility ensues also incompletely understood. and potency is often absent; gynaecomastia and obesity are also common accompaniments. The endocrine axis prim arily concerned with reproductive function comprises the pituitary and ( 2 ) Primary Testicular Hypogonadism, as th e the testes. It is therefore not unreasonable to term suggests, occurs when the testes themselves suppose that any depression of function affecting are prim arily at fault. There is depression of this axis may well produce one or another form interstitial cell activity and a deficiency in Page One Hundred and Seventy-Five Tm : Central Af ku.aN May, 1957 MALE INFERTILITY J ournal ok M koicink androgen output. Eunuchoidism results, the The Evaluation of Male Infertility type of which again depends on the stage of Having briefly considered the physiology of development of the individual at which it occurs. reproductive function and the main etiological Three types of eunuchoidism are described: factors in its failure, it is necessary to consider prepubertal, pubertal and post-pubertal. The the various methods at our disposal for evaluating general features of the pre- and post-pubertal this condition. varieties have already been mentioned. The Needless to say, a complete history and pubertal form shows some evidence of secondary thorough physical examination are just as sexual characteristics, but their development is essential in dealing with a case of infertility incomplete and is a halfway stage between the as with any other whose roots may lie in almost other two eunuchoid types. every system in the body. Owing to the rather There is a further type of testicular hypogona­ special nature of this condition, however, there dism recently described, where the failure is are certain aspects of the history and examination reputed to be prim arily tubular. This is known which must be emphasized as being of relatively as hyaline tubular sclerosis, or the Klinefelter, greater importance than others. In addition Riefenstein, Albright-syndrome. It is a fam ilial there are certain further clinical and laboratory disease occurring about the age of puberty. tests which are of great value, and, in some Either gynaecomastia or eunuchoid features or instances, indispensable to the evaluation of both occur, and in all cases impotence and male infertility. aspermatogenesis are present. The testes are For reasons already mentioned it is of the small and biopsy reveals marked sclerosis of utmost importance to obtain a full account of the tubules. the patient’s m arital life, and when dealing with Apart from disturbances involving the a husband who still retains the mid-Victorian pituitary-testicular axis other endocrine gland attitude in all matters pertaining to sex, this dysfunction may also affect fertility and in may tax the doctor’s tact and diplomacy to the particular hypothyroidism and hyperadrenalism u tm o st. must be mentioned. During the examination particular note should be made of any features which may suggest an As already stated, to add to the complexity underlying endocrine disturbance. The external of the picture there are many gradations of the genitalia likewise deserve particular scrutiny: described syndromes, and also many atypical the penis, for any evidence of hypogenitalism, cases which are baffling even to the trained congenital abnormality or other lesion, and the endocrinologist, and therefore usually incompre­ testes, for position, size, and in particular, hensible to the average urologist. consistency. Testes smaller than usual and of Under the heading of endocrine disturbances soft consistency are often associated with low mention must also be made of the male climateric, or absent spermatogenesis. Hanley (1955) is for which there is sufficient clinical and labora­ in complete agreement with this view, and goes tory evidence to regard as a definite entity. It as far as to state that if a testis feels normal, occurs in some men past middle age and is a normal biopsy w ill invariably result, whereas characterised by psychological and vasomotor if it feels atrophic a biopsy is hardly necessary disturbances, but infertility is affected only in to confirm the fact. so far as these men are usually impotent, a Associated varicocele or hydrocele are also of feature of this condition which must be distin­ importance. guished from impotence due to psychoneurotic Any separation of the epididymis from the causes. testis, cystic degeneration or other palpable Finally there remains that large group of abnormality must be sought for, and both cases to which, unfortunately, the majority of spermatic cords carefully examined for vasal patients seen in practice belong, namely those defects. normal healthy men suffering from varying degrees of imperfect spermatogenesis, for which Special Investigations: no cause can he found. It is possible that these Over the years a number of special tests have cases are due to some subclinical endocrine been evolved for the study of male infertility, disturbance, which in some may or other a few of which are essential for its accurate adversely affects the maturation of the germinal evaluation, and must always be employed; others epithelium. however, although of value in special cases, are Page One Hundred and Seventy-Six T he Central African M ay, 1957 MALE INFERTILITY Journal of M edicine mainly of academic and research interest and Above the critical 20 m illion per cc. level the are not employed routinely. chances of conception do not rise proportionately The tests of special value are:— with increase of sperm count. It appears also that it is the density per cc. that matters and not ( 1 ) The Post-Coital Examination of the Wife the total sperm count. In spite of much that has been written to |e ) Morphology — this is studied either in the contrary, this is one of the most useful the fresh or stained specimen. The average prelim inary investigations of the infertile couple. number of abnormal forms is about 10 per It is performed at the estimated time of ovulation cent., the normal range being from 6 to 25 per and consists simply of the microscopic examina­ cent. More than 25 per cent, of abnormal tion of the cervical mucous some 12 to 18 hours forms is considered corroborative evidence of after intercourse. The presence of fifty or sub-fertility. more highly motile sperms on two separate In evaluating the results obtained from a examinations is strongly suggestive that the semen analysis, no single value, unless grossly male is not at fault. If on the other hand abnormal, appears to be more important than there are few or no motile sperms, the male any other; all aspects are important. Finally, partner should be more fully investigated. This the results of two separate semen specimens must test is simple and valuable as it not only affords be to hand before any prognostications are made. evidence of potency and fertility, but does so without examination of the male, and its use ( 3 ) Testicular Biopsy therefore in cases where the husband refuses to In spite of Hanley’s contention that testicular submit to such examination is obvious. biopsy is usually unnecessary, the general con­ sensus of opinion is that it has a very real ( 2 ) Detailed Semen Analysis value in the evaluation of testicular defects and This is the most important single test in the provides an excellent yardstick for the institution study of male infertility and should be done in of corrective measures or in the witholding of a ll cases. treatment in cases where the biopsy reveals a Certain qualitative and quantitative features hopeless prognosis for fertility. Biopsy is indi­ of the semen are considered important in evalu­ cated in patients w ith azoospermia and persistent ating fertility. These are as follows: oligozoospermia, as by this means only can it ( a) Volume — the average volume is given be definitely ascertained whether spermatogenesis as 3.5 cc., the normal range from 2 to 8 cc., is present or not. This is of great value in and the suggested minimum 1.0 cc. Most of the determining whether or not paucity or absence fluid probably comes from the prostate. The of sperm in the semen is due to obstructive significance of small volumes is difficult to lesions of the spermatic tract or testicular defect. assess, but when in very small amount may be The accurate interpretation of testicular biopsies due to occlusion of the ejaculatory ducts. is difficult and requires a special knowledge and ib) Viscosity — normally, semen when first understanding of testicular pathology. ejaculated is thick and viscid, but within half Amongst the tests which are not routinely an hour liquifies. Increased viscosity is thought employed but which are of use in special cases to im pair sperm m otility otherwise its effect on only, the following may be mentioned. fertility is not known. U rinary gonadotrophin assay. Here the urinary (c ) Motility — 45 per cent, to 60 per cent, content of follicle stim ulating hormone is obtained of the spermatozoa should be actively motile by biological tests, and by this means hypo- after two to six hours. The suggested minimum pituitary and prim ary testicular hypogonadism is 40 per cent. may be differentiated. 17-Ketosteroid excretion id) Count — the average normal count in in the urine and seminal vesiculography are also millions per cc. of semen is about 140, the reserved for special cases. commonly accepted range of normality is 30 Treatment : to 700 million per cc., and 20 million per cc. The various methods of treating subfertility the suggested minimum. The extensive investi­ and sterility in the male have been: gations of McLeod andrGold (1951) have shown that subfertility commences at the 20 million ( 1 ) General Measures per cc. level, although conception cannot be It is well known that the stress and strain precluded below that level as fertilization has of modern life may impair fertility not only by occurred with counts of under 1 m illion per cc. the psychological upheavals which it engenders, Page One Hundred and Seventy-Seven May, 1957 T he Central African MALE INFERTILITY J ournal of M edicine

but also by the general lowering of health and During the rebound phase it would seem to vitality which it may produce. In cases of me rational to give a course of pituitary gona­ impotence of psychoneurotic origin simple dotrophins in the hopes that both intestitial and psychotherapeutic measures may be successful, germinal cell activity may thereby be further if not the aid of a competent psychotherapist boosted. An empirical dosage of 100 mg. by may be necessary. The building up of general injection twice weekly for 15 weeks may be health and resistance is also of value. given, and at the conclusion of the treatment There is ample experimental evidence that a further semen analysis should be made to gross deficiencies of vitamins E, A and B may- assess the results of treatment. result in material damage to the reproductive The other condition which responds to testo­ tract of both male and female. In everyday sterone therapy is the male climateric. The practice, however, such deficiencies are rarely symptoms are relieved and potency restored and encountered, and therefore vitam in therapy must the results are usually so good that it serves play little part in the management of fertility. as a therapeutic test to distinguish the impotence of the male climateric from that of psychogenic ( 2 ) Endocrine Therapy origin which is unaffected by testosterone. It is reasonable to suppose that appropriate endocrine therapy should be effective in cases ( 3 ) Surgical Measures where deficiency can be demonstrated, be it of The surgery of male infertility is a subject the pituitary, testis, or thyroid. unto itself, but time and the imposition I have Thus in the treatment of panpituitary hypo­ made on your attention forbids more than a gonadism it is rational to give pituitary gona­ bare summary of the surgical treatment of this dotrophins, thyroid and adrenal cortical extract; c o n d itio n . likewise the treatment of hypogonadotrophic hypogonadism should be with pituitary gonado­ There are, as already mentioned, a number trophins alone, and in prim ary testicular hypo­ of conditions which by causing impotence result gonadism testosterone should have the desired in infertility, and some of these are amenable effect. Finally hypothyroidism causing sperma- to surgical treatment. The correction of con­ togenic depression is treated with thyroid extract. genital anomalies of the penis, and the treatment In all these conditions there may be improvement of urethral stricture are instances of these. in the general clinical picture as a result of Some of the obstruction lesions of the seminal this hormone therapy, but, in so far as the ducts may be successfully treated by surgical associated spermatogenic deficiencies are con­ intervention. Examples of these are the recon­ cerned, the results of therapy, with the notable stitution of the vas after either accidental or exception of hypothyroidism, have been most deliberate division. Section of the vas does disappointing. not destroy spermatogenesis in the testis, and There are, however, two conditions where some Hanley fl955) quotes four personal successful response to endocrine therapy may be obtained. cases of surgical reconstitution of the vas after The one is the normal healthy subfertile oligo- deliberate section several years before — all had zoospermic male with a germinal epithelium sperms in the ejaculate two months after opera­ which on biopsy does not show gross defect. tio n . In these cases testosterone therapy is indicated, Congenital and inflammatory occlusion of the the usual dosage being 100 mg. of long-acting vas, if limited in extent, may be excised and depot-testosterone by intramuscular injection the vas reconstituted weekly, for six to eight weeks. This is followed by a definite depression in the sperm count Sim ilar lesions occur in the epididymal duct, which, for some unknown reason, is followed and the post-inflammatory ones in particular some six months later by a marked increase in often occur in the region of the body or tail. spermatogenic activity, known as the rebound These cases lend themselves to epididymo- phenomenon, producing sperm counts often far vasostomy whereby the patent vas is anastomosed in excess of the earlier levels. Although this to the head of the epididymis, thus by-passing the method is not effective in every instance, the obstructed area. A prerequisite to the success fact that a proportion of cases do show a of this procedure is the demonstration of live sustained satisfactory response makes it worthy sperms in the head of the epididymis, but even of trial, more particularly as there is nothing in spite of this the results of this procedure are to be lost, and possibly a lot to be gained. n o t good. Page One Hundred and Seventy-Eight May, 1957 T he Central African MALE INFERTILITY J ournal of Medicine

Those conditions which result in an altered ejaculate can with certainty be made to come thermal environment for the testes are in most into contact with the cervical os. Patients on the cases amenable to surgical correction. borderline of fertility with counts of about 20 Tulloch (1955) has produced some remarkable million per cc. are good candidates for this. results following the surgical treatment of vari­ cocele in patients with associated subfertility. Prognosis Of the 30 cases reported, 10 returned to normal In general the prognosis with regard to male fertility with subsequent successful pregnancy, infertility is poor. This is largely due to the and of these, two patients were initially azoo- fact that only in a small percentage of cases spermic. In a further 10 cases there was can the cause be determined, and, until this considerable improvement in the sperm count difficulty can be overcome it seems that the mostly to above the “infertile” level, but at the outlook must remain bleak. time of w riting no pregnancy had occurred. The remaining 10 cases were considered failures. REFERENCES From these results it is justifiable that, where 1. H otchkiss, R. S. (1944). Fertility in Men. (J. B. subfertility and varicocele coexist, the varicocele Lippencott Co., Philadelphia). should be treated. 2. MacLeod, J. and Gold. R. Z. (1951). J. Urol., The correction of bilateral undescended testes 66, 436. before puberty may prevent otherwise certain 3. Falk, H. C. and Kaufman, S.A. (1950). Fertil sterility. Bilateral orchiopexy, however, even and Steril, 1, 489-503. rew Anat., when performed at the optimum age of six to 4. C , F. A. (1922). /. 56, 99. elson Fertil and Steril, seven years is not often followed by normal 5. N , W. O. (1950). 1, 477-488. ettle Afr. med. J., . spermatogenesis, the result being purely cosmetic. 6. O , A. G. (1954). .S'. 1 7. Davidson, H. A. (1954). Practitioner, 173, 703. ( 4 ) Artificial Insemination 8. Russell, J. K. (1954). Brit. med. J., 1, 1231. The use of semen of the subl’ertile for artifi­ 9. Tullock, W. C. (1955). Brit. med. }., 356-358. cial insemination may be attended with success. 10. Hanley, H. G. (1955). Ann. Roy. Coll. Surg. Engl., Its value lies in that the greater part of the 17, 1955.

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