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	):	SEMEN PROFILE OF MALE PARTNERS OF WOMEN ATTENDING INFERTILITY CLINIC IN  ZARIA NIGERIA












Authors: 
Abdulrazaq Garba-Alkali
Adebiyi Adesiyun
Abdullahi Randawa

Affiliation: 
Department of Obstetrics and Gynaecology
Ahmadu Bello University Teaching Hospital (ABUTH)
Zaria Nigeria

Correspondence: 
Dr. Abdulrazaq Garba-Alkali
Department of Obstetrics and Gynaecology
Ahmadu Bello University Teaching Hospital (ABUTH)
Zaria Nigeria
ABSTRACT 
Background: Semen analysis is an important entity in the evaluation of male factor infertility. Diminishing semen profile have been widely reported mostly attributed to environmental factor and lifestyle changes. Male infertility is a public health problem that is sometimes overlooked in Africa but prevalent and mostly preventable. 

Methods: The subjects comprised of a total of 154 consecutive male partners of women attending infertility clinic of ABUTH, Zaria,. The data were collected using questionnaires, semen analyses, semen cultures and body mass index (BMI).

Results: The semen analyses done showed normozoospermia rate of 46.8% while about 53.2% had abnormal semen profile. Also, among the abnormal semen profile, asthenozoospermia constituted the most common with rate of 22% followed by oligoasthenozoospermia (15.6%), azoospermia(10.4%) and oligozoospermia(5.2%). In the study only 3.9% of the subjects� semen who have significant round cells also cultured bacteria. There was no significant statistical difference between the round cells and bacteria culture. Bacteria growth were mainly staphylococcus aureus followed distantly by E .coli ,gardnerella vaginalis and klebsiella growth . There was statistical significant difference between the semen profile and demographic variables at p=<0.05. in the case of the tribe  and semen profile. There were also significant statistical differences between the semen profile and the risk factors in the history for infertility, medication use and coital frequency per week and semen culture.

Conclusions.  Infertility is a public health problem in our environment. There should be proper and heightened health education program on awareness  and prevention of male infertility.



Keywords: Semen analysis; Male infertility; Round cells; Semen culture. 

                      
INTRODUCTION 
It is estimated that about one in ten couples have difficulty in conceiving successfully. Infertility presents serious psychosocial problems to the affected couples and challenges to the attending  gynecologist. Women suffer more than men as the causes are often attributed to them, especially in Africa. The etiological pattern of infertility in couples varies among different populations. In general, about 35% are  caused by male factors, 35% by female factors; while 20% are due to combined male and female factors and in about 10% of the couples, the causes are unexplained1. Causes of male infertility generally result from endocrine disorders, anatomic disorders, abnormal spermatogenesis, abnormal motility, infection of genital tract and sexual dysfunction2. Infections of the male genital tract are common causes of male infertility in Africa. Gonococal, chlamydial and coliform infections may cause semen profile abnormalities. Inflammatory damage may result in Vas Deferens or Epididymal block with resultant severe oligozoospermia or azoospermia.1, 2 Infertility may be prevalent among men with elevated body mass index (BMI). Forty percent of men presenting to an infertility clinic in a study in California, USA, were overweight3. 
Semen analysis is one of the most important investigations used to evaluate the male partners of women presenting with infertility. The World Health Organization (WHO) reference values and criteria are widely used as guide for normal parameters, 4. These have been reviewed four times since 1980, in 1987, 1992, 1999 and 2010 by the W.H.O 4,5,6,7 .Males with good or reasonable fertility potential under in vivo condition are identified on the basis of semen quality. Also, male with poor fertility potential are identified and introduced to treatment including Assisted Reproduction Technology (ART). A fertile female may compensate for the fertility problem of the male and thus infertility usually only becomes manifest if both partners have reduced fertility. The prognostic factors for male infertility are: duration of infertility; age; primary or secondary infertility; result of semen analysis and fertility status of the female4,7,8,9. There has been significant advances in Assisted Reproductive Technology(ART), from artificial insemination, improved embryo culture media to intra-cytoplasmic sperm injection (ICSI) and pre-implantation genetic diagnosis(PGD),which have resulted in remarkable increase in invitro fertilization and embryo transfer (IVF-ET) pregnancy rates. Potent drugs are also now available for erectile dysfunction. These, in addition to the increasing public awareness and acceptance of assisted reproductive technology (ART), have spurred many couples in sub Saharan African societies with infertility to seek medical care2, 10. The setting of this study is preparing to set up an Assisted Reproductive Technology (ART) center. There is therefore, the need to study the semen profile of the male partners of the women presenting with infertility in our clinic. This may assist   health managers, policy makers, health educators, medical ethicist and clinicians in better management of male infertility and infertility in general.   This study evaluated the semen profile of the male partners of women attending infertility clinic.



METHODOLOGY

This was a cross-sectional  conducted  in year 2010 .The study population was made up of the male partners of women attending infertility clinic, who  consented and presented their semen for analysis as part of investigation for infertility .
.
Inclusion criteria are: first  seminal fluid  analysis, no  prior treatment (medical or surgical) for infertility ,semen fluid analysis and culture done in the laboratory of the study setting; Ahmadu Bello University Teaching hospital, Zaria.

Exclusion criteria are:  subjects who did not consent or withdrew their consent,  semen samples which method of collection did not comply  with the instructions or contaminated sample, subjects on antibiotics or treatment for infertility.

SAMPLE SIZE DETERMINATION
Sample size determination using: 	
n=Z2 PQ
     	    	   d2
Where 	n= the desired sample size (when population is greater than 10,000)
Z =the standard normal deviation (set at 1.96 or 95% Confidence interval)
P = the proportion in the target population estimated to have particular characteristic,  
Q= 1.0-p
 d=degree of accuracy desired (set at 0.05)    
	
 Using prevalence rate of normal semen analysis of 73% in a similar study in Ibadan, Nigeria11.
p = 0.73, q = 0.27, Z=1.96 and d = 0.05
:. n= (1.96)2(0.73) (0.27)		= 	3.84 x 0.2
	       (0.05)2 				   0.0025		= 307.7
The estimated entire population of semen samples within the study period of one year is 260. Since the entire population is not up to 10,000 within the study period, then the following formula is used to calculate the final sample estimate (NF) 12
:.  NF = 	     n   .
		 1 + n
		        N 
NF	= the desired sample size when population is less than 10,000   
n 	= the desired sample size when population is more than                           10,000          
N	= the estimate of the population size. 
:.  nf = 	     n   .
	 1 +  n
		        N 
:.  nf = 	     307   		=	 307			=	307
	 1 +  307			1+1.2	2.2			140
		        260 
:. nf	140 

Therefore the sample size shall be 140.
Adding an attrition rate of 10%, the sample size becomes 154.

DATA COLLECTION
Structured questionnaire (with both closed and open ended questions) was used to collect data on demographic characteristics, past medical and surgical history, family history, social history, and drug history. The questionnaire was pretested among 14(10% of sample size) male patients attending other clinic and necessary amendment was made to correct the questionnaire.  Body mass index  was calculated by measuring the height of the men in meters and taking the weight with standardized weighing scale in kilograms using the formula BMI= weight/height2.World health organization(WHO) method of classification of BMI shall�be�used ; underweight<18.5, normal-range 18.5-24.9, overweight e"25.00,0bese e"30.00        

The WHO (1992) reference values and criteria was used as normal parameter guide for semen profile. Statistical relationships and differences shall be tested using chi-square test(x2). The statistical significance shall be put at p<0.05.

RESULTS

 A total of 154 semen samples was analyzed,  the age of the subjects were between 20 to 60 years. More than half   86(55.9%) of the subjects were within age group of 31-40years, followed by 34(22%) in age group 41-50years, then 28(18.2%) in 20-30years age group .The least age group in the study was 51-60years with 6(3.9%). Hausa tribe constituted the major tribe in the study  with 72(46.7%) . Majority of the subjects were civil servants 54(35.0%) followed by  lecturers/teachers 26(16.9%).More  than three quarter, 136( 88.3%)  resided in urban centers. Almost two third 94(61.0%) of the subjects had tertiary education. Majority, 68(44.2%) of the subjects had history of 1-3 years duration of infertility followed distantly by 7-9years duration in 30(19.5%) patients. The least duration of infertility was 4-6 years  22(14.3%) patients. The type of marriage in more than three quarter, 124(80.5%) of the subjects were monogamy while only 30(19.5%) were practicing polygamy.  Almost two third ,100(64.9%) of the subjects  has had coital frequency of equal or greater than 3 times per week, while the remaining had less than 3times/week. About one third,44(28.9%) had secondary infertility and the remainder had primary infertility.


Past sexually transmitted diseases(STD) constituted the major risk factor with 42(27.3%),followed by alcohol intake and urethral penile discharge in 22(14.3%),then cigarette smoking in 20(13%).Among the medications used,medication for the treatment of peptic ulcer disease ranked highest with 18(11.7%),followed distantly by medication for HIV/AIDS with 8(5.2%). Majority 134(87%) of the subjects were not on chronic medication. (Table I)



Majority of the subjects 72(46.8%)had normal semen  analysis (normozoospermia).The abnormality seen in the subjects were  asthenozoospermia ,34(22.0%),oligoasthenozoospermia  24(15.6%),azoospermia 16(10.4%)and the least abnormality was  oligozoospermia, 8(5.2%).Teratozoospermia,Aspermia and oligoasthenozppspermia were not seen.( Figure I) Majority of the semen cultured did not grow any organism in 132(85.7%). Among the cultured organism, staphylococcus aureus were the commonest with 14(63.6%) Table II. Table I shows that there are significant statistical difference between the normal semen analysis and abnormal semen analysis in relation to the risk factors, chronic medication, and coital frequency. While, there was no significant statistical difference in relation to duration of infertility, types of infertility and types of marriage. Normal body weight were in majority with 84(54.5%), followed distantly by overweight in 46(29.9%) ,then underweight and obese with 14(9.1%) and 10(6.5%) respectively.The study shows no significant statistical difference between normal semen analysis and abnormal semen analysis in terms of body mass index.(Table III)

About 24(15.6%) of the semen cultured grew organism while the rest,130 (84.4%) did not grew any organism. There was  no significant statistical difference between the normal and abnormal semen analysis in relation to the semen culture (Table IV). In the semen analysis, there were non-significant semen round cells(<5.0 x 106 ml) in 104(67.5%) of the semen analyzed, while about 50(32.5%) had significant semen round cells of greater than 5.0 x 106. There was no significant statistical difference among the subjects with significant round cell count and bacteria growth (Table V).

DISCUSSION

Semen analysis is the most widely used preliminary investigation  to assess a man fertility, it is relatively easy to perform, affordable and widely available. However, it is pertinent to note that the interpretation of semen analysis abnormalities serves at best as a guide. This is because fertility potential has not been found to be directly proportional to the gross appearance. In fact there have been surprising fertility recorded in some men with poor count and wide variations even in normal fertile men 13. The semen analysis done shows a normozoospermia rate of 46.8% while about 53.2% had abnormal semen profile . This is similar to reported rates of 29% to 42.4% for normozoospermia from other studies14,15,16,17. Although in contrast to high rates of normozoospermia that ranged from 62.7% to 78.4% from other series11,18,19. The abnormality of  semen profile in this study is above average (53.2%). Among the abnormal semen profile, asthenozoospermia constitute the most common with 22% followed by oligoasthenozoospermia (15.6%), azoospermia(10.4%) and oligozoospermia(5.2%). These rates and array of abnormalities are similar to the study findings from Ibadan Nigeria 11, but in contrast to the findings of a study done in Jos Nigeria, 17. Treatment and preventive strategy need to be mounted by the public health educators to reduce the problem. Assisted reproduction technique will be necessary in the hospital or region to assist some of the cases. 

The finding that about 10.4% of the subjects have azoospermia is worrisome because this is quite a significantly high rate. The possible causes are; sexually transmitted diseases (STD), trauma, congenital problems , viral infection like mumps amongst others and this warrant further investigation and treatment by the urologist. A related study showed the commonest association between azoospermia and past illness of small pox, where out of 31subjects with history of smallpox, 15 showed complete azoospermia, and one showed sperm density of less than 10 million per ml20. Most subjects in this category will   require treatment by assisted reproduction technique (ART), and they would likely need donor sperm. This is a challenge to the practice of ART especially in settings where there is no regulation or law guiding the art, as cultural inclination and religious belief may be against some forms of ART treatment practises. The commonest abnormality of astenozoospermia has problem with motility which is vital for fertilization process, while oligoasthenozoospermia has a combination of low sperm count and motility .These group of patients may  benefit from ART or intrauterine insemination (IUI) if not severe. Training and re-training of trainers and qualified trainees towards making IUI more accessible at most secondary and tertiary health institutions would help a long way.

In this study about 3.9% of the subjects� semen who have significant semen round cell count also cultured bacteria. This proportion is small compare to the total and there was no significant statistical difference between the semen round cells count and bacteria culture. This is a similar finding to the  studies from Jos Nigeria17  and Ibadan Nigeria21. The implication is that having significant semen round cells in semen microscopic analysis does not translate to  growth of an organism in the semen. This should be born in mind when interpreting results by the physicians that the level of semen round cells does not translate to  bacteria growth when the semen is cultured 

Bacteria growth in this study was 14.3%, mainly staphylococcus aureus (63.6%) followed distantly by Escherichi coli ,Gardnerella vaginalis and klebsiella growth .This is in consonance with similar  studies from the southern part of Nigeria15,21. However, it is in contrast to the study result from Tunisia ; on semen culture and polymerase chain reaction assay, prevalence of bacteriospermia in semen was 56.9% and the common bacteria species detected were Chlamydia trachomatis followed distantly by Ureaplasma urealyticum and Mycoplasma hominis 3. Extrapolation from this study result may imply that these organisms might be as a result of contamination   during collection and or transportation, especially with the growth of unusual organisms like Gardnerella vaginalis and high yield of Staphylococcus. It is also pertinent to note that the organisms  implicated in the causation of low sperm count and sperm  function  (mainly sexually transmitted organisms) need special means of transportation and culture techniques which were not applied in this study. 

 In this study, there were also significant statistical differences between the normal and abnormal semen profile in relation to the risk factors  for infertility, medication use and coital frequency per week. While there was no statistical significant difference in semen profile and the duration of infertility, types of marriage, and body mass index (BMI). Infertility may be prevalent among men with elevated body mass index(BMI). Forty percent of men presenting to an infertility clinic in a study in California, USA, were overweight3.However,the relationship between male obesity and other fertility parameters has not been well established. Decreased testosterone, sex hormone binding globulin, and testosterone /estrogen ratios and inhibin B have all been documented among infertile obese compared with infertile non obese men and fertile obese men22.
                 
The findings that risk factors for infertility, drug use for diseases, higher coital frequency are more associated with abnormal semen profile is not unexpected since they are established risk factors of infertility . In a study  of infertile African male at an andrology clinic in South Africa, 49% were secondarily infertile and 36% had previously received treatment for a urethral discharge. Varicoceles were present in 183 cases (11%) and 11% had serological evidence of previous exposure to syphilis 23. On the contrary, most patients in this series had primary infertility . In conclusion, the rate of abnormal semen profile was high in the study, also most men that had their semen analysed had primary infertility and there was significant association between abnormal semen profile and known risk factors of male infertility which are mainly preventable. These findings calls for focused and heightened preventive strategies towards decreasing the occurrence of these risk factors.
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(2) 	Ashim Kumar, Shahin Gadir, Niloofar Eskandari and Alan H. Decherney.Reproductive Endocrinology and Infertility. In: Current diagnosis and treatment in obstetetrics and gynecology.Mc Graw-Hill.2007; 917-936.
(3)	Oliva A, Spira A, Multigner L. Contribution of environmental factors to the risk of male infertility. Human Reprod.2001; 16:1768-1776.
(4)	World health organization, WHO laboratory manual for the examination of human semen and semen-cervical mucus interaction. Cambridge university press, Cambridge, 5th edition, 2010.
(5)	World health organization, WHO laboratory manual for the examination of human semen and semen-cervical mucus interaction. Cambridge university press, Cambridge, 2nd edition, 1987.
(6) 	World health organization (WHO) laboratory manual for the examination of human semen and semen-cervical mucus interaction. Cambridge university press, Cambridge, 3rd edition, 1992. 
(7) 	World health organization, WHO laboratory manual for the examination of human semen and semen-cervical mucus interaction. Cambridge university press, Cambridge, 4th edition, 1999.
(8) 	Idrisa A and Ojiyi E. Pattern of infertility in north eastern-Nigeria Trop J. Obstet Gynecol 2000; 17:27-29.
(9) 	Idrisa A, Ojiyi E. Tomfafi O, Kamara T.B. Male contribution to infertility in Maiduguri, Nigeria. Trop J.Obstet Gynaecol. 2001; 18:87-90.
(10)	Cook ID.Infertility.In: Keith Edmonds(Ed), Dewhurst�s Textbook of Obstetrics and Gynaecology for postgraduates. 6th edition. Oxford, London; Blackwell Scientific Ltd.1999:432-440.
(13)	Campana, A, deAgostini, A, Bischof, P., et al). Evaluation of infertility. Human reprod. Update, 1995; 1, 6:586-606
(12)	Araoye MA. Subjects selection. In: Research methodology with statistics for health and social sciences.1st edition. Nathadex publishers. Ilorin, Nigeria 2004:115-129.
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(14)	Salqado Jacobo MI et al. Frequency of altered male factor in an infertility clinic. Ginecol Obstet Mex 2003 May: 233-7
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Table I: Cross - tabulation of clinical variables and semen analysis(n=154).
Clinical VariablesNormal Semen analysis(%)Abnormal Semen analysis(%) Statistical 
significanceDuration of infertile(years)                      1-334(22.1)36(23.3)x2=4.619                     4-68(5.2)12(7.8)d=3                     6-920(13.0)14(9.1)p=0.2                     10 and above 10(6.5)20(13.0)Types of infertility
              Primary
              secondary        46(29.8)66(42.9)x2=3.18224(15.6)18(11.7)d=1Risk factors for infertility
Inginoscrotal problems  
2(1.3)

32(20.8)p=0.07446Past penile discharge 10(6.5)12(7.8)Past STD treatment 16(10.4)18(11.9)x2=31.02Smoking history 8(5.2)10(6.5)d=5Alcohol intake 22(14.3)8(5.2)p=0.000009282Erectile dysfunction 6(3.9)10(6.5)Medication    Medication use  12(7.8)22(14.3)x2=8.825Nil medication56(36.4)30(19.5)d=1Type of infertility 
            secondary
            primary p=0.00297124(15.6)20(13.0)48(31.2)62(40.2) x2=1.502,d=1Types of marriage
           Monogamy
           Polygamyp=0.2208.54(35.1)70(45.4)18(11.7)12(7.8)x2=2.626,d=1Coital Frequency/week
          Less than three
          Three &abovep=0.1051.18(11.7)36(23.4)x2=6.016,d=154(35.0)46(29.9)p=0.01418.Table II: Types of bacterial culture growth from semen culture
Bacterial  Growth Frequency  Percentage (%)Staph aureus1463.6Gardnerella Vaginalis29.1E.colli418.2Klebsella29.1
Table III: Body mass index (n=154)
Clinical VariablesNormal Semen analysis(%)Abnormal Semen Analysis(%) Statistical 
significanceBody mass index
          Underweight(<18.5)
           Normal weight(18.5-24.9)
           Overweight(e"25.0)
           Obese(e"30.0)
8(5.2)
36(23.4)
24(15.6)
2(1.3)
6(3.9)
48(31.1)
22(14.3)
8(5.2)x2 =4.451,d=3P=0.2167
Table IV: Semen Culture (n=154)
Clinical VariablesNormal Semen analysis (%)Abnormal Semen Analysis (%) Statistical 
significanceSemen culture x2 =6.052,d=1          Organism growth(24)  18(11.7)6(3.9)p=0.01389          Nil  organism  growth(130)62(40.2)68(44.2)
Table V: Proportion of those having significant semen round cells with or without bacterial growth (n=154).
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