Chapter 2:

Literature
review
(Section 1)
Chapter 2: Section 1 Literature review

2. Literature Review
2.1 Infertility – Definition
Infertility defines as a failure to conceive in a couple trying to reproduce for
a period of one-two years without conception. Approximately 15 percent of
couples are infertile and among these couples, male factor infertility accounts for
approximately 50% percent of causes. Male infertility is a multifactorial syndrome
encompassing a wide variety of disorders. In more than half of infertile men, the
cause of their infertility is unknown (idiopathic) and could be congenital or
acquired (Peterson, 2006).
Infertility regarded as a major problem which is related to the developing
countries’ developments due to modern lifestyle. It affects an estimated 15% of
couples globally, amounting to 48.5 million couples. Males are found to be solely
responsible for 20-30% of infertility cases and contribute to 50% of cases overall
(Kamiński et al., 2020).
Approximately 85% of infertile couples have an identifiable cause. The most
common causes of infertility are ovulatory dysfunction, male factor infertility, and
tubal disease. Infertility can also be a marker of an underlying chronic disease
associated with infertility (Ammar et al., 2012).

2.1.1 Types of Infertility

Infertility can be classified as follows:
1- Primary infertility: refers to a couple who has not been able to conceive after at
least one year of attempting to do so through unprotected intercourse (Obeisat et
al., 2012).
2- Secondary infertility: occurs following one or more pregnancies; approximately
15% of couples attempting their first conception fail (Gediman et al., 2008). Those
who frequently miscarry spontaneously or whose pregnancy results in a stillbirth
and are then unable to carry a pregnancy to a live birth would be considered
secondarily infertile (Gurunath et al., 2011).
3- Unexplained infertility: This term refers to the diagnosis of infertility that
cannot be explained. Couples in whom all of the standard examinations, such as

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ovulation tests, tubal patency tests, and sperm analysis, are normal (Ray et al.,
2012).
Unexplained infertility affects about 15% of couples seeking medical advice,
though some studies claim that as many as 37% of people are infertile for unknown
reasons (Polyzos et al., 2008).
2.1.2 Male reproductive system
2.1.2.1 The external male reproductive organs
. Penis.
. The glands.
. Scrotum.
. Testicales (testes).
. Epididymis, (Sharma S and Hanukoglu, 2019).

2.1.2.2 The Internal male reproductive organs

. Vas deferens.
. Ejaculatory ducts.
. Urethra.
. Seminal vesicles.
. Prostate gland.
. Bulbourethral glands, (Sharma S and Hanukoglu, 2019).

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2.1.2.3 The reproductive utility of the male can be divided into three
major parts
a. Spermatogenesis which is defined as the formation of sperm.
b. Performance of the male sexual act.
c. Regulation of male reproductive functions by the various endocrinal hormones
(Kelton, 2008).
2.1.4 Spermatogenesis
Spermatogenesis, or the formation of mature sperm, is an intricate
biological process that takes place in the seminiferous tubules of the testis that
requires the concerted actions of various hormones and testis-specific genes. The
hypothalamic-pituitary-gonadal (HPG) axis is responsible for regulating the
hormonal milieu to facilitate spermatogenesis. Gonadotropin-releasing hormone
(GnRH) is released by the hypothalamus, which stimulates the anterior pituitary to
release follicle-stimulating hormone (FSH) and luteinizing hormone (LH), FSH
acts on Sertoli cells to promote spermatogenesis and luteinizing hormone (LH)
stimulates Leydig cells to produce testosterone, (Merchant et al., 2011).
Spermatogenesis can be divided into three parts: the proliferative phase, the
meiotic phase, and spermiogenesis, as describe by Neto (2016).
First: in the proliferative phase, spermatogonial stem cells proliferate and
differentiate into A-dark spermatogonia and A-pale spermatogonia. A-pale
spermatogonia differentiate further into type B spermatogonia, a process that is
mediated by factors secreted by Sertoli cells as described in Figure (2-1), (Du
Plessis et al., 2011; Neto et al., 2016).
Type B spermatogonia then undergo a series of mitotic events to give rise to
primary spermatocytes, (After completion of meiosis I, primary spermatocytes
become secondary spermatocytes, and subsequently round spermatids following
completion of meiosis II.
Seconde: The meiotic phase is characterized by the maturation of spermatocytes
through meiosis.
The final phase: known as spermiogenesis, is the process whereby round
spermatids become spermatozoa, during spermiogenesis, round spermatids

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first become elongating spermatids which undergo acrosomal development,

nuclear condensation, tail elongation, and cytoplasm reduction, all of whichare
critical for normal sperm development.

Figure (2-1): view of complex spermatogenesis and following processes:maturation, capacitation, and
fertilization based on (Du Plessis et al., 2011).

Structurally, mature. spermatozoa have an acrosome located on the anterior surface

of the head, as well as a midpiece and tail (O’Donnell, 2014).

2.1.5 Spermatozoa
Following spermiogenesis, mature spermatozoa are released from the apical
surface of Sertoli cells within the testis, into the lumen of a seminiferous tubule.
Sperm is then transported through the male reproductive tract whereby additional
biochemical and morphological changes occure in the epididymis until ejaculation
(van Der Horst et al., 1999). the epididymis which transports spermatozoa frome

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the testis to vas deferens. is a single duct, composed of three anatomical regions:
the head (caput), the body (corpus) and the tail (cauda). The movement of
spermatozoa through relies on smooth muscle contractions in the epididymis wall
(Antonangeli et al., 2009) and composed of:
A- Head: The human sperm head, which is about 4.5 m long and 3 m wide,
consists primarily of a nucleus that contains highly compressed chromatin material.
The nuclear DNA of spermatozoa is highly organized into loop domains that are
attached at bases to a nuclear matrix (Reid et al., 2011).
B- Middle segment: The highly organized segment containing the helically
arranged mitochondria contains the enzymes required for oxidative metabolism
and the production of adenosine triphosphate (ATP), as mentioned previously
(Menkveld et al., 2009). This section is bounded by a set of outer dense fibers rich
in disulfide bonds, which are thought to provide the sperm tail with the rigidity
required for progressive motility (Nallella et al., 2006).
C- Flagellum: The mature sperm tail is made up of three major components:
1) A central skeleton composed of 11 microtubules collectively known as an
axoneme, which contains the enzymes and structural proteins required for the
conversion of adenosine triphosphate (ATP) chemical energy into mechanical
movement, resulting in sperm motility (Cooper et al., 2010).
2)Axoneme is protected by a thin cell membrane.
3)The body of the tails a collection of mitochondria that surrounds the axoneme in
the proximal part of the tail (Morales et al., 2006), As show in Figure (2-2).

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Figure (2-2): Structure of sperm (Warwick, 2006).

2.1.6 Male infertility:

Male infertility is a condition in which the male reproductive tract and
sperm has diminished the capacity and lead to the eventual fertilization of the egg
to produce an embryo. Sometimes male infertility can refer commonly due to
deficiencies in the semen, and semen quality (Brugh and Lipshultz, 2004).
Infertility affects an estimated 15% of couples globally, amounting to 48.5 million
couples. Males are found to be solely responsible for 20-30% of infertility cases
and contribute to 50% of cases overall. However, this number does not accurately
represent all regions of the world. Indeed, on aglobal level, there is a lack of
accurate statistics on rates of male infertility (Ashok et al., 2015). Male
infertility is a multifactorial syndrome encompassing a wide variety of disorders.
In more than half of infertile men, the cause of their infertility is unknown
(idiopathic) and could be congenital or acquired. Infertility in men can be
diagnosed initially by a semen analysis. Seminograms of infertile men may reveal
many abnormal conditions, which include azoospermia, oligozoospermia, and
teratozoospermia, to male's inability to cause pregnancy in a fertile female
(Callister, 2010).

2.1.7 Standard semen analysis

Males were considered infertile with sperm parameters below the WHO
normal value (Plachot et al., 2002). The most significant of these are low sperm
concentration (oligospermia), poor sperm motility (asthenospermia), and abnormal
sperm morphology (teratospermia). Some other factors are less well associated
with infertility include semen volume and other seminal markers of epididymal,
prostatic, and seminal vesicle function (Harris et al., 2011). The most significant
cause of infertility is less sperm concentration, 90% of male infertility problems
are related to count, there is a positive association between the abnormal semen
parameters, and sperm count (Sabra and Al-Harbi 2014). The problem with sperm
count, motility, and morphology stems from disarray in control mechanism,
including pre-testicular, testicular, and post-testicular factors (Wamoto 2007).

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Hence, semen analysis remains the single most useful and fundamental
investigation with a sensitivity of 89.6%, that it is able to detect 9 out of 10 men
with a genuine problem of male infertility (Butt and Akram 2013). Although this
assay reveals useful information for the initial evaluation of the infertile male, it is
not a test of fertility (Jequier 2010). Itprovides no insights into the functional
potential of the spermatozoon to undergo subsequent maturation processes required
to achieve fertilization (Nand and Singh 2015). A simple test assesses the
formation and maturity of sperm as well as how the sperm interacts in the seminal
fluid. It also provides insight not only on sperm production (count), but also on the
sperm quality (motility, morphology) as well (Fisch 2008).
The WHO has revised lower reference limits for semen analyses: The following
parameters represent the accepted fifth percentile (lower reference limits and 95%
confidence intervals (Cis) in parentheses), derived from a study of over 1900 men
whose partners had a time-to-pregnancy of ≤ 12 months (Cooper et al., 2010).
• Volume: 1.5 mL (95% CI: 1.4-1.7)
• Sperm concentration: 15 million spermatozoa/mL (95% CI: 12-16)
• Total sperm number: 39 million spermatozoa per ejaculate (95% CI: 33-46)
• Morphology: 4% normal forms (95% CI: 3-4), using “strict” Tygerberg method.
• Vitality: 58% live (95% CI: 55-63)
• Progressive motility: 32% (95% CI: 31-34)
• Total (progressive+nonprogressive motility): 40% (95% CI: 38-42).
2.1.6 Abnormalities of sperm count and morphology
Sperm abnormalities are a critical factor in male infertility. These
abnormalities include:
1) Abnormalities related to sperm count
• Azoospermia: Absence of sperm in seminal plasma
• oligozoospermia Low sperm count: <15 million sperms/mL (Cooper et al., 2010).
2) Abnormalities related to sperm motility

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The efficient passage of spermatozoa through the cervical mucus depends on

rapid progressive motility that is, spermatozoa with a forward progression of at
least 25 A normal semen analysis must contain at least 50% grade A and B,
progressively motile spermatozoa. Persistent poor motility is a predictor of failure
in fertilization (Björndahl, 2010).
3) Abnormal sperm structure and shape (teratozoospermia)
For morphology of sperms, smears can be scored using the WHO classification
(2010). or by Kruger’s strict criteria classification (Menkveld et al., 1990).
Morphology should be used along with other parameters, and not as an isolated
parameter when determining clinical implications (Van Waart et al., 2001; Keegan
et al., 2007). as in Table (2-1) that shows the classification of sperm concentration.

No. Definition

When all the spermatozoa parameters are

1 Norozoospermia normal together with normal seminal
plasma and WBCs, and no agglutination.
2 Oligozoospermia The sperm concentration is ˃15million\ml.
3 Asthenozoospermia Progressive motile spermatozoa < 32%.

4 Tertazoospermia Normal morphology < 4%.

5 Oligoasthenoteratozoospermia Signifies disturbance of all the three
variables.

Table (2-1): Classification of sperm concentration (Keegan et al., 2007).

2.1.8 Etiology of male Infertility

There are different causes of male infertility, including spermatogenesis disorders,
chronic diseases, Tubular obstruction, illness or injuries, cancer, mumps, sexually
transmitted diseases, germ line distress following therapeutic complications such

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as chemotherapy and radiotherapy and occupational exposure to chemical or

physical deleterious matters (Nasser et al., 2014). The known causes of male
infertility are quite numerous but can be grouped into a number of major
categories, it has been associated with several genetic and non-genetic conditions
(Peterson, 2006).

2.1.8.1 The Role of Genetic or molecular causes of male infertility:

The Spermatogenesis is considered as an orchestrated procedure which is
regulated by many genes present on both the (autosomal and sex chromosomes),
as chromosomal disorders, monogenic disorders, and genetically based endocrine
disorders. Men with unexplained oligozoospermia and azoospermia have genetic
abnormalities, including numerical and structural chromosomal abnormalities
(Chandley, 2009).
The Genetic disorders foremost to the male infertility are responsible for 15 to 30
% of cases, with a prevalence of Y chromosome abnormalities by altering
spermatogenesis and/or sperm function. These disorders include karyotype
abnormalities (both autosomal and/or sex chromosomal) and deletions or mutations
of specific genes within various chromosomal loci. it is likely that most cases of
idiopathic infertility could be accounted for by underlying genetic causes.
Molecular defects and genetic alterations responsible for male infertility disrupt
physiological processes including hormonal homeostasis, spermatogenesis and
sperm quality (Colaco and Modi, 2019).
The Cytogenetic analysis and molecular biology genetic testing may identify
subfertility males misdiagnosed as having unexplained and idiopathic infertility.
Covert genetic abnormalities causing male infertility include Stacy (Colaco and
Deepak ,2018).
(1) Chromosomal complement changes in number (e.g., aneuploidy) or structure
such as translocations or inversions.
(2) Many different gene mutations and polymorphisms may lead to male infertility
(Xiong et al., 2015).
(3) DNA integrity defects.
(4) Mitochondrial DNA Mutations which causes asthenozoospermia.
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as well as many Male infertility in humans is frequently associated with

chromosome abnormalities; the klinefelter syndrome (XXY), Genetic central
hypogonadism is more frequently encountered in males than in females; in
particular, Kallmann syndrome has a prevalence of 1/5000 with a clearmale
predominance and specific translocations are well – established causes of male
infertility (Vassilakopoulos et al., 2014).
Point mutations in the androgen receptor and the cystic fibrosis
transmembrane conductance regulator (CFTR) gene, both of which are commonly
associated with congenital vas deferens abnormalities, are two important gene
defects conclusively associated with spermatogenic failure (Abur et al., 2019).

2.1.7.2 non-genetic causes of male infertility

There are many causes for male infertility consider as non-genetic include
hypogonadotrophic hypogonadism, testicular maldescence, structural abnormalities
of the male genital tract (obstruction of spermatic ducts, sperm agglutination),
genital infections, impotency, previous scrotal or inguinal surgery, varicoceles,
chronic illness, medication, chemical exposure, environmental factors, and
immunological causes.
a) Hormonal factors: Hypogonadotrophic hypogonadism leads to insufficient
gonadal stimulation by Luteinizing Hormone (LH) and Follicle-Stimulating
Hormone (FSH), either due to insufficient/absent secretion of hypothalamic
Gonadotropin-Releasing Hormone (GnRH) or a compromised pituitary. The main
cause of GnRH insufficiency is the failure of migration of the GnRH secretory
neurons to the forebrain (Hart et al., 2016).
b) Hyperprolactinemia: Diabetes mellitus, thyroid disorders, adrenal disease,
hypothalamic-pituitary factors such as hyperprolactinemia (Van Den et al., 2011).
it causes low serum testosterone levels, infertility and sexual dysfunction (De Rosa
et al., 2003). The prevalence in a population of infertile men is, unknown.
c) Impotence: also known as erectile dysfunction, affects 10%–15% of all males
and can be emotionally and psychologically debilitating for men and their partners.
Drugs, blood flow abnormalities, nerve impulse abnormalities, and hormonal
abnormalities are the most common causes of erectile dysfunction in 80 percent of
cases.

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d) Infection: In young men, prior scrotal or inguinal surgery, gonorrhea, and

chlamydia, Herpes simplex virus (HSV) cause acute inflammation of the scrotal
contents (usually unilateral). Swellings in the scrotum that are painless are
common. The majority of these are small, round epididymal cysts or spermatoceles
that do not necessitate further investigation or treatment (Richens, 2004).
e) Varicoceles: which feel like a bag of worms in the scrotum, are linked to
infertility, A "subclinical varicocele" is a lesion that is too small to be detected by
physical examination (Richens, 2004). Varicoceles are dilations of the
pampiniform plexus veins that drain blood from the testicles. They are found in
15% of healthy men and 25% of males with abnormal semen analysis (Salonia et
al., 2020). Varicoceles alter testicular function in a variety of ways, but the most
widely accepted theory involves a relative stasis of venous blood in the
pampiniform plexus, which raises testicular temperature and leads in higher
reactive oxygen species (Durairajanayagam et al., 2015).
e) Chemical exposure: various chemicals have been implicated as reproductive
toxicants. Air pollutants are found in exposed men's blood, urine, and sperm and
may have an effect on sperm quality Sperm function tests have revealed that high
lead levels in sperm samples reduce the sperm's ability to bind to the egg as well as
penetrate and fertilize the egg (Selevan, 2000).
exposure to insecticides can have negative effects on sperm function (Queiroz and
Waissmann, 2006). Insecticides, pesticides and phthalates not only induce
oxidative stress but also disrupt the hypothalamo– pituitary–gonadal axis This
disruption inhibits the release of gonadotrophin-releasing hormone, which in turn
inhibits the release of luteinizing hormone and follicle-stimulating hormone. This
results in inhibition of gametogenesis and steroidogenesis (Queiroz and
Waissmann, 2006).
F) Radiation: Testes and spermatogonia are more sensitive to radiation than other
types of cells present in the body (Xu et al., 2008). Intensification of fragmentation
and total methylation of genomic DNA have been observed in men exposed to
radioactive substances (Kumar et al., 2013; Wdowiak et al., 2019).
Similar damage to the DNA structure has been observed in spermatozoa of males
exposed to nuclear waste (Goncharov et al., 1998). Radiation can be classified into
two categories: ionizing and non-ionizing radiation.

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- Ionizing radiation: is a high-energy radiation, capable of causing thermal and

nonthermal (genetic) damage. Male infertility and testicular cancer, where
radiation therapy is common, are related to DNA damage (Kesari et al., 2018). In
cancer patients who have received radiotherapy, a significant but transient increase
in sperm DNA fragmentation (SDF) occurs in the first 2 years after treatment, but
normalised within 3–5 years (Cho & Agarwal, 2018).
Furthermore, patients with testicular cancer treated with radiation have a higher
sperm DNA fragmentation SDF, compared to testicular cancer patients who have
not received radiotherapy (Smit et al., 2010).
- Non-ionizing radiation: is a low-energy radiation, and the direct biological
consequences are attributed to low-energy transfer and thermal action
(Angelopoulou et al., 2009; Lavranos et al., 2012). Studies concerning non-
ionizing energy are less common due to the difficulty in quantifying the exposure.
However, radiation generated by cell phones, Wi-Fi, microwaves and laptops has
been associated with male infertility (McGill and Agarwal, 2014). Radiofrequency
electromagnetic wave (RF-EMW) radiation emitted from mobile phones affects
cells and organelles
and disturbs the electron flow in the membranes present inside the cells (Johnson et
al., 2007).
g) Systemic diseases: Poor diabetic control (HbA1c ≥ 7%) was significantly
associated with impaired sperm motility (reduced progressive motility) and sperm
abnormal morphology (double head, round and elongated spermatids and
cytoplasmic mid- and tail pieces). Metabolic syndrome is a complex disorder
consisting of multiple interrelated factors including insulin resistance, central
adiposity, dyslipidemia, endothelial dysfunction, atherosclerotic disease, Chronic
kidney failure is also been known to detrimentally influence fertility (Hart et al.,
2016; Iglesias, 2012).and low-grade inflammation. Ultimately, this may lead to a
low sperm count, impaired motility, and abnormality of sperm morphology. It is
known that hypertension can cause erectile dysfunction, either directly or as a side
effect of medication (Omu, 2013).
h) Oxidative stress in the male germ line Seminal oxidative stress:
Oxidative stress describes the condition in which levels of oxygen and
oxygen-derived free radicals overwhelm the natural antioxidant defences of the

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cell (Aitken, 2006). Oxidative stress has a negative effect on sperm function by
disrupting the integrity of the DNA as a result of concurrent damage to proteins
and lipids present in the sperm- cell plasma membrane, therefore affecting cell
membrane fluidity and permeability (Aitken, 2013).
Spermatozoa create a modest quantity of reactive oxygen species (ROS), which is
required for proper cell functions such capacitation, hyperactivation, and sperm-
oocyte union. Regardless of whether patients have normal or abnormal semen
parameters, elevated ROS levels have been identified as an independent indication
of male factor infertility (Agarwal 2006).
Antioxidants in seminal plasma are the most essential type of protection that
sperm have against ROS assault, despite the fact that the body employs a number
of mechanisms to limit ROS-induced damage (Cocuzza and Agarwal, 2007).
In addition, high ROS production is inversely related to In vitro fertilization
IVF outcome (Agarwal and Majzoub, 2017). Many factors can increase oxidative
stress leading to spermatozoa dysfunction and infertility. These factors include the
male reproductive system’s pathologic conditions, systemic disorders and
environmental factors (Tremellen, 2008; Darbandi et al., 2018).

i) other causes like Environmental, and lifestyle-related factor:

Cigarette smoking, caffene, marijuana and excessive alcohol consumptions,
frequency of coitus, dietary restriction and over-exercise, a sedentary lifestyle, and
paternal age (40+ years of age) all contribute to the risk of infertility. Furthermore,
environmental factors such as exposure to air pollution or persistent organic
pollutants, high temperature exposure, plasticizers, metals (particularly transition
metals such as cadmium, lead, iron, and copper), chemotherapeutic agents, and
environmental toxicants (acrylamide, endosulfan, bisphenol A, and phthalates),
Electromagnetic radiation all raise oxidative stress levels in spermatozoa
(Tremellen, 2008; Kumar, 2014). a diet high in saturated fats and proteins leads to
obesity, which causes hormonal imbalance and sperm function defects, is another
environmental and lifestyle factor that contributes to male infertility (Vander et al.,
2018). Obesity can also affect sperm production and quality by raising scrotal
temperature and increasing oxidative stress, resulting in decreased sperm motility

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and increased sperm Deoxyribonucleic acid (DNA) damage such as radiation or

chemotherapy (Naina and Amit, 2015).

Figure (2-3): The flow diagram shows the effect of protamine deficiency and DNA
damage on sperm's parameters and functions. (Iranpour et al., 2000).

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