Men without Sperms

Introduction: Men without sperm (azoospermic) make up about 15% of all infertile men in reproductive age of fatherhood. Male infertility is a health and social problem in many communities. Subjects and Methods: This retrospective study was carried from 2010 to 2015. Initially, 907 men were included in the study among whom 109 (12.02%), 346 (38.15%) and 452 (49.83%) were azoospermic, oligospermic and normospermic, respectively. This study only investigated the association between age, BMI, semen volume, liquefaction time and pus cells among normospermic and azoospermic men. Standard semen analysis was performed and subjects were categorized by age into <30, 30 39.9, 40 49.9, 50 59.9 and ≥60 years and by body mass index into normal (18.5 24.9), overweight (25.0 29.9) and obese (≥30). Results: The 562 subjects of the study had means (±sd) age of 42.6 (±7.10) years and BMI of 27.0 (4.1) kg/m respectively. In all, 109 (19.4%) were azoospermic. Overweight and obese men were, respectively, more than 11⁄2 and about 21⁄2 times more likely to be azoospermic compared to normal weight men. Azoospermic men were significantly heavier than men with normal sperm count (t = −0.34; P-value = 0.003). Among those with normal weight, liquefaction time was significantly shorter (t = 5.49, P-value = 0.000001) in azoospermic (28.70 min.) than in men with normal sperm count (31.82 min.). Obese azoospermic men were about 4 times as likely to have high pus cells in semen than normal weight azoospermic men (OR = 3.82; 95% CI: 0.39, 37.01). Multivariate regression analysis shows a strong but negative coefficient correlation between sperm concentration and BMI (coef. = −0.48, Std Err. = 0.25, P-value = 0.05, 95% CI: −0.96, 0.10). Conclusion: Our findings suggest that high BMI is associated with azoospermia. Azoospermia also did not seem to negatively impact liquefaction time.


Introduction
Male infertility, from African perspective, is not just male infertility from the viewpoint of the developed countries.Infertility, especially of the male, is a more serious cause of anxiety and concern which affect married couples resulting in quiet stigmatization and loss of status within the family circuit and in the community at larger.Infertility of either male or female or of both is becoming a serious health problem affecting about 10% of all families worldwide [1] and possibly more in developing countries [2], probably as high as 25%.Infertility is the inability of a sexually active, non-contracepting couple to achieve spontaneous pregnancy in one year [3] and azoospermia, broadly speaking, is the absence of sperm in the ejaculate [4].The World Health Organization recommends that in such cases of absence of spermatozoa in wet preparation(on microscopic examination), the seminal fluid from which the sample came should be centrifuged at 3000× or more for 15 minutes and then examined again [3].If a minimum quantity of spermatozoa is observed in either of the centrifuged samples, this is referred to as cryptozoospermia while the complete absence of spermatozoa is defined as azoospermia.Both sexes are affected by infertility, a health burden of some epidemiological proportion.In approximately 50% of couples with involuntarily childlessness, male-infertility-associated factor is observed together with abnormal semen parameters [5].Fertile partners may recompense for fecundity problem of the man and thus infertility usually manifests if both partners are sub-fertile [3].
Recently, an exponential increase in the responsibility of male factor in couple's infertility has been observed and this could be attributed to comprehensive evaluation of the entire reproductive system of the male, the function of each part of that system and improved diagnostic tools [6].There are a variety of conditions that may inhibit spermatogenesis and diminish the production and quality of sperm thus causing azoospermia.Azoospermia may also occur because of a reproductive tract obstruction.A study has classified azoospermia into three primary categories: 1) pre-testicular, 2) testicular, and 3) post-testicular, speculating that, though 1) and 3) etiology of azoospermia are generally manageable, 2) is generally not [7].Other studies suggested causes of male infertility, including azoospermia, as urogenital infections such as genito-urinary tract tuberculosis [8], or filarial orchitis [9].It is claimed that male infertility, including azoospermia, also results from: 1) congenital or acquired urogenital abnormalities, 2) malignancies, 3) increased scrotal temperature (e.g. as a consequence of varicocele), 4) endocrine disturbances, 5) genetic abnormalities, and 6) immunological factors [3].It is established that overweight and obesity have a negative impact on female fertility profile [10] but few studies have been able to track the fertility profile of males.It is heartening to know that Oates [11] studied the genetic basis of male reproductive failure and concluded that evolving therapies have allowed the use of sperm from men with spermatogenic compromise, obstructive azoospermia, and sperm functional deficiency, enabling these men to procreate when unable to do so naturally.In sub-Saharan Africa, women are most often blamed for infertility in matrimonial relationships where the occurrence of infertility is involuntary and where hardly is the fault laid on both or on the male [12].In most African societies, the attitude, beliefs and cultural practices tend to exonerate men from inability to bear children.One of the most important aspects of life in most, if not all, African settings is the ability to father a child, or to be called a "mother", to continue the human lineage.Not being able to father a child from one woman often leads to serial relationships with other women.It is also a general but erroneous notion that the ability to have and sustain an erection and to engage in a heterosexual coitus with a woman means that men are fertile.Some men believe that just having penile erection or producing ejaculate of semen during sexual intercourse is enough to father a child which, in some cases, is contrary to the expected.That a man may not produce enough sperm is well documented [5] but not having sperm at all is a serious trepidation not only for the man but also for the family, the community and the physician.Sermondade, et al. [13] reported overweight and obesity as risk factors for azoospermia while Mac- donald, et al. [14] believed no significant correlation exists between BMI and the semen parameters with the exception of normal sperm morphology and that overweight and obese men showed no significantly increased relative risk of abnormal semen parameters.
Infertility, in general, is a huge public health problem which has not been adequately addressed in Nigeria.Because infertility is a public health burden which affects the mental and social well-being of individuals and the family, it has been included in the national program for reproductive and child health in India [15] though not in many African countries.Studies have shown that about 1% of all men in the general population suffer from azoospermia, and azoospermic men constitute approximately 10% to 15% of all infertile men [7].Studies have incriminated obesity (high body mass index) in adult male infertility [16] [17] [18] while others claim no significant correlation between body mass index and semen quality [19] [20] [21].Azoospermia and oligospermia, relative to age and body mass index of the male, have not been studied to any appreciable extent in a Black African population.Data on the association between azoospermia and both age and body mass index is rare on the continent.However, data from most of these studies emanated from industrialized countries and extremely few have come from a Black African population.Clinicians in sub-Saharan Africa often meet overweight and obese patients and there is need for more scientific information to clarify the burden of overweight and obesity on male fertility, especially.Therefore, the primary aims of this study was, first to document the pre-  Semen samples were collected by masturbation, in a comfortable room provided with electricity, water, bathroom and air-conditioner, within a maximum of 3 -5 minutes' walk to the laboratory and according to WHO specification [22].The man was counseled to abstain from sex for a minimum/maximum duration of 2 -5 days.The collected sterile semen sample was transported almost immediately to the laboratory for analysis within 30 minutes of production.Other relevant information given to each patient included: 1) accuracy in the semen collection, 2) semen should be collected in a wide-mouth measuring cylinder that was provided, and 3) the importance of reporting any loss of semen sample during collection.For this semen collection process, each patient was provided with a medical record form where data such as name, age (or date of birth), days of abstinence, date and time of collection, if there was any loss in semen volume during collection (incomplete collection) and the time of commencement of seminal fluid analysis in the laboratory were appropriately filled in by the patient and the laboratory staff who collected the semen sample.

Subjects and Methods
Other anthropometric, social and medical/surgical records were also collected from the patients.These included weight (in kg) and height (in cm) for the determination of body mass index (BMI), marital status, occupation, smoking and alcohol use, groin operation, sexually transmitted diseases, as well as family and social history.
Within 30 minutes of production and collection at the laboratory and after liquefaction, semen samples were analyzed strictly according to WHO guidelines [22] to detect semen volume, total sperm concentration, motility, and morphology (reported elsewhere).The volume of the ejaculate was measured by directly reading it on a wide-mouth measuring cylinder provided for each patient.A volume of 3 -5 µL of semen sample was transferred to the center of the chamber; mean progressive motility was determined using light microscope (×40) and was performed in 10 squares of the chamber, counting at least 200 spermatozoa and expressed as 10 6 spermatozoa/ml.The total sperm count is the end concentration, expressed as 10 6 spermatozoa/ml.After assessing sperm progressive motility in 100 random spermatozoa, these were described as 1) rapidly forward, fast progressive motility, 2) moderately forward, slow progressive motility, 3) jerky non-progressive motility, and 4) immotile/no movement.Other parameters assessed in the semen samples were color, viscosity, liquefaction time, pus cells per high power field and morphology.Age (years) was stratified into <30, 30 -39.9, 40 -49.9,50 -59.9and ≥60 and BMI was categorized according to WHO classification [23] as underweight (BMI < 18.5), normal weight (BMI 18.5 -24.9), overweight (BMI 25.0 -29.9) and obese (BMI ≥ 30).Patients who were not on any medication that would interfere with spermatogenesis, those not consuming herbal medication and who gave consent for their semen to be analyzed were included into the study.Non-indigenes, those with history of fulminant infections or patients with neoplasm were excluded from the study.At further analysis stage, this study specifically focused on men with normal sperm count and those with azoospermia.Patients' confidentiality was assured by excluding any information such as age, address which could identify any patient with the study.Data were also coded and stored in a computer with password known only to the Principal Investigator.
Data were analyzed using STATA 13; associations between Age, BMI and Age-for-BMI with normal sperm concentration and with azoospermia were assessed using chi-square, Odds Ratio and 95% Confidence Interval.Spearman correlation and analysis of variance (ANOVA), and a multiple linear regression analysis was performed to determine correlation coefficients and significance of means of two variables.In addition, the relative risks for men having azoospermia, giving reference range of the WHO [3], were calculated.A P-value of ≤0.05 was taken as significant.Data were presented as Tables and bar charts.
The mean semen volume (ml.) and liquefaction time (mins.)among the azoospermic men and those with normal sperm concentration is illustrated in Table 2. Overall, there was no significant difference in the mean semen volume or liquefaction time.However, when considered from the perspective of different age groups, there were substantial alterations (t = 3.13, P-value = 0.001, t = 3.88, Figure 1.Percent distribution of proportion of men with normal sperm concentrations and with azoospermia by age (years).Compared with patients aged < 30 years, there was no significant difference in the proportion of patients aged 30 -39.9 years (χ 2 = 0.07, P-value = 0.80), those aged 40 -49.9 years (χ 2 = 0.23, P-value = 0.64), those age 50 -59.9years (χ 2 = 0.03, P-value = 0.87) and those aged ≥ 60 (χ 2 = 0.31, P-value = 0.58) with sperm concentration of 15 × 10 6 /ml and those with azoospermia.
Also, overall, there was no significant difference in the mean liquefaction time of azoospermic and normal men but when categorized by age group, the mean liquefaction time of azoospermic men aged 30-39.9 years (28.33 ± 5.42) was significantly lower (t = 1.98,P-value = 0.03) than that of normal men in the same age group.
Furthermore, the mean semen volume of normal weight azoospermic men (1.89 ± 1.42 mls) was significantly lower (t = 2.90, P-value = 0.002) than that of their counterparts with normal sperm concentration (2.34 ± 1.58 ml.) and the mean liquefaction time of normal weight azoospermic men (28.70 ± 3.44 mins.) was significantly lower (t = 5.49, P-value = 0.000001) than that of their counterparts with normal sperm concentration (31.82 ± 9.85 mins.).
Though there was no significant variation in the mean pus cell count of men with normal sperm count and those with azoospermia, overall, obese men with Open Journal of Urology no sperm were 2.11 times and 3.75 times as likely to have pyospermia of 1 -3/hpf and of 4 -10/hpf respectively compared to men with normal sperm concentration.Overweight men with no sperm were 1.71 times and 3.33 times more likely to have pyospermia of 1 -3/hpf and of 4 -10/hpf respectively, compared to men with normal sperm concentration (Table 3).
The proportion of men in each age group that presented with azoospermia relative to their body mass index is as illustrated in Table 4 and in Figure 3 and   Obese vs. normal χ 2 = 0.26*, P-value = 0.61, OR = undefined, 95% CI: undefined; OR = undefined, 95% CI: undefined azoospermia compared to normal weight men in the same age group.Likewise, the risk of azoospermia in those aged 50 -59 years was higher among the overweight patients (RR = 1.80, 95% CI: 0.56, 5.79) and among obese patients (RR = 2.30, 95% CI: 0.56, 9.49) when compared with normal weight men in the same age category.There was no statistically significant difference in the proportion of men aged 60 years and above with and without azoospermia regardless of their BMI.

Discussion
Infertility, especially of male, in sub-Saharan Africa presents discrete and multifaceted worries far beyond those that the developed nations are used to.Although, Figure 3. Percent distribution of patients with normal sperm concentration (conc.)and with azoospermia in each age group relative to BMI of normal weight (wt.), overweight (overwt.) and obese.Overweight patients aged 30 -39.9 years were 1.70 more likely to be azoospermic compared to normal weight patients in the same age (χ 2 = 1.84,P-value = 0.17, OR = 1.79, 95% CI: 0.77, 4.19).
Obese patients aged 30 -39.9 years were 2.13 times more likely to be azoospermic compared to normal patients in the same age (χ 2 = 1.96,P-value = 0.16, OR = 2.13, 95% CI: 0.73, 6.19).Similar pattern in seen in other age groups except age < 30 and age ≥ 60 years.
it may seem that sub-Saharan Africa faced with over-population, which should be tackled instead of infertility which is expensive in its management, however, the burden of male infertility affects not only the man concerned but extends to his spouse and touches upon the male ego, the deepest being of the couple, their family members, their community and other institutions.The consequences of male infertility include severe economic depression, social isolation, mental disturbance, discrimination, stigmatization, suicide and murder.This problem is so intense that it is not often talked about openly though many men need medical support in this regard so as to help themselves and help their wives.
There are a number of major findings in this study which, as far as we know, may be the first of its kind in sub-Saharan Africa.Firstly, the 12.0% prevalence of azoospermia in the overall study group accords with the 10% -15% quoted by Gudeloglu and colleague [7] but much less than the 40% reported by Bashed et al. [24] in Bangladesh.Earlier and recent studies have also shown decline in some semen quality with age [25] [26] such as lower ejaculate volume and sperm motility [27] [28] and increased paternal age with sperm quality [29].There appears to be a phenomenon of gradual reduction in sperm quality of Africans as reported in a recent study [30].
Some earlier studies have reported a gradual decline in sperm quality in  Another key finding in this study, similar to what some other studies reported, was the significant difference, not only in age specifically, but in the combination of Age and BMI of men with no sperm compared to those with normal sperm concentration.Obese men between the ages of 30 -59.9 years were 2.13 -2.86 times more likely to have no sperms while overweight men in the same range were between 1.42 -2.05 as likely to have no sperms compared to their younger counterparts.The 1.84 relative risk of azoospermia observed among obese men aged 30 -39.9 years observed in this study was slightly higher than the 1.81 reported by Sermondale, et al. [35] and the relative risk of 2.04 observed among obese men aged 40 -49.9 years in our study was even higher.This suggests that obesity and azoospermia are both probably Age/BMI-dependent.It is likely that obesity fast-tracks reduction in sperm count as age advances to about 60 years, at least in indigenous Black Africans, after which no statistical difference was observed between age, body mass index and azoospermia.Obesity impacts male infertility in more than one way such as elevated risk of erectile dysfunction [35] [37]; hypogonadotropic hyperestrogenic hypogonadism due to aromatization of steroids in estrogens in peripheral tissues [38]; direct alterations of spermatogenesis and Sertoli cell function [39]; hip, abdominal and scrotal fat tissue accumulation leading to the increase of scrotal temperature [40] and accumulation of toxic substances and liposoluble endocrine disruptors in fatty tissue [41].
One of the most interesting findings in this study was the gradual increase in parameter among which are the changes in the hypothalamic-pituitary-gonadal axis, the aromatization of steroids to estrogens in peripheral tissue leading to hypogonadotropic hyperestrogenic hypogonadism [38], significant decrease in total and free testosterone levels and increase in estradiol (E 2 ) that combine to have deleterious effects on spermatogenesis [42].Other studies have illustrated a decrease of sex hormone-binding globulin among obese men, notably mediated by hyperinsulinemia, emphasizing the negative feedback effect of elevated total E 2 levels [43].Obesity is also associated with an increase in endorphins leading to both lower LH pulse amplitude and GnRH production [44].
Finally, the mean pyospermia of 1.56 ± 1.61 found among men with no sperm in this study was much lower than the 3.25 ± 0.26 found among azoospermic men in Pakistan and the 1.41 (0.69) found in men with normal sperm count was also lower than the 2.98 ± 0.04 found in proven fathers [45].Pus in semen is not often considered in fertilization work-up but it could be one of the most important causes of male infertility, though its role remains contentious [45].Pyospermia possibly has a deleterious effect not only on semen parameters but also in Artificial Reproduction Technique such as In-vitro fertilization (IVF), especially when pus in sperm is not considered.The report of Schirren [46] suggests that pus in sperm increases reactive oxygen species (ROS) which may trigger sperm damage or DNA fragmentation, causing substantial increase in male infertility.

Conclusion
To conclude, this study finds that the relatively high prevalence and risk of azoospermia among indigenous Black Africans is associated more with overweight and obesity and probably less with age.Liquefaction time was shorter among men without sperm compared with those with normal sperm concentration.These data strongly suggest that excessive increase in body weight possibly plays a key role in sperm non-production.Obese azoospermic men were about 4 times as likely to have high pus cells in semen than normal weight azoospermic men.The pathophysiology of azoospermia in men aged < 30 may be different from that in older men.
Periodic national longitudinal studies and randomized controlled trials on male infertility are urgently required.

Strengths and Limitations
This study has some strengths and weaknesses that need to be discussed.One of the strengths is that collection of semen samples was strictly adhered to by everyone.This may be because each couple was well-counseled by experts on at least two occasions before sample collection.Most of the patients gained the confidence of the consultants and felt free to abide by the regulations of the Fertility Center.Also, the height and weight of each patient was measured and the body mass index was calculated, not volunteered by the patients.The Fertility Center uses up-to-date laboratory equipment for semen analysis and in almost all cases each analysis was on two consecutive samples.Another strength of the paper is that there were ample number of patients with overweight and obesity.The same study criteria were used for all the patients.
Limitations of the study were that the semen was collected in three different locations and the samples were analyzed in three different laboratories of the same organization with the possibility of inter-laboratory variation.However, almost all the samples were examined twice with quite insignificant difference in

Figure
Figure 4.In age group < 30, overweight men were approximately twice as likely

Table 1 .
Anthropometric and sperm concentration characteristics of study participants.

Table 2 .
Mean semen volume (mls.) and liquefaction time (mins.) of azoospermic and normal men by age and by BMI of participants.

Table 3 .
Proportion of patients with low and high levels of pus cells per high power field among those with normal and no sperm cells relative to their age and BMI.

Table 4 .
Proportion of men in each age group that presented with azoospermia relative to their BMI.

Table 5 .
Multivariate regression analysis with sperm concentration as dependent variable and age, BMI, volume and pus cells as independent variables.