What is immunological infertility? Immunological infertility in men: causes. Immunological factor of infertility

The immune system protects the human body from pathogenic and harmful bacteria and viruses. But in some cases, because of her increased activity or malfunctions may occur serious problems with the conception of a child. This pathology known as immunological infertility, which affects both women and men. The main negative role is played by antibodies that have an antisperm effect and causing disturbance sperm fertility. Infertility associated with an immunological factor is diagnosed in 5% of couples who, for one reason or another, do not become pregnant.

What is immunological infertility

Immunological infertility is the inability of a single couple to conceive, in the absence of any reproductive or somatic abnormalities. Thus, a man and a woman who have good health and potentially fertile, are unable to become pregnant. The main reason for this condition is individual intolerance to individual components contained in the biological fluids of partners. The female body perceives the sperm of a particular man as a foreign compound. The only way The only way to get pregnant is to change sexual partners.

It should be remembered that immunity to individual components of sperm is developed not only in female body. Modern research proved that sperm can be neutralized not only in the female genital tract, but also in male testicles, by analogy with the autoimmune process.

The clinical picture of immunological infertility indicates the preservation of erectile abilities and spermatogenesis activity in men. Normal functions of the female body are also preserved. But, despite this, full sexual intercourse cannot cause pregnancy. This main reason pathology that cannot be recognized for a long time.

Causes of immunological infertility in women

Antisperm bodies are found in the female body more often than in men. IN in good condition they eliminate defective sperm. But, if their number significantly exceeds the norm, a serious obstacle to fertilization is created. Often the development of a woman's own antibodies occurs due to the ingestion of male sperm, which also contains antibodies. The immunogenic properties of such sperm increase.

In addition, antisperm antibodies are produced in the female body under the influence of a number of factors associated with urogenital infections. One of the reasons is considered to be a high concentration of leukocytes in male sperm, in the presence of nonspecific bacterial prostatitis. The effect of female antisperm bodies is manifested in the inability of sperm to penetrate the uterus through the cervical mucus of the cervix.

A serious cause of pathology can be the presence of viruses and opportunistic organisms in the uterus for a long time. They prevent the creation of a barrier that protects the embryo from antibodies attacking it.

The immunological conflict of organisms manifests itself when hemolytic disease in the fetus. It is caused by the presence of the Rh factor on the red blood cells of the fetus, inherited from the father, which is a specific antigen. It is absent in the maternal blood, so the production of antibodies begins against the fetal red blood cells and causes their destruction. As a rule, this situation is not dangerous for the first fetus, but the next embryo may be seriously damaged.

Reasons for men

Immunological infertility in men often develops as a result of injury to the testicles, during which the seminiferous tubules are damaged. Because of this, antigens enter the bloodstream, causing the immune system to fail. When serious damage occurs, the functional tissue that produces sperm is replaced by connective tissue.

If the damage is less severe, then natural recovery process integrity of the blood-testis barrier and further sperm production. However, after injury, the body begins to produce specific antisperm antibodies. Circulating in the blood, they prevent sperm maturation. Thus, all sperm are susceptible to immune attack, regardless of whether the testicle is injured or healthy. They become less mobile, and agglutination or gluing occurs. Penetration into the uterus through the cervical canal becomes impossible. In addition, the acrosomal reaction is disrupted, which precludes even artificial fertilization of the egg.

A serious cause of male autoimmune infertility is the presence of urogenital infections. Cross reaction causes the production of antibodies not only against the infectious agent, but also against normal sperm.

Diagnosis of immunological infertility

For the purpose of reliable diagnosis, special postcoital tests and samples are prescribed to determine motor activity sperm in the mucus of the cervical canal.

The classic test is the Shuvarsky-Guner test, during which the composition and structure of the mucus located in the cervical canal and posterior vaginal vault. It is carried out two hours after ejaculation. The essence of the test is to determine viable sperm contained in cervical and vaginal mucus. Results are assessed by quantity active sperm, caught in the field of view of the microscope. If their number exceeds 10, the test is considered positive. In a questionable test, this figure is less than 10. And finally, negative test points to complete absence viable sperm, which indicates immunological infertility.

The Kurzrock-Miller test is similar to the previous study, with the difference that the test uses an artificial environment rather than natural conditions. In women and men, mucus is collected from the internal genital organs and sperm. They are combined with each other at constant temperature conditions at 37 degrees, allowing to exclude unfavorable inflammatory and infectious factors. The mucus, placed under a microscope, contains the sperm of the sexual partner and healthy donor sperm. Observation carried out over a period of six hours determines the degree of mobility of each of them. If immunological infertility is present, the motility of the tested sperm will be significantly lower compared to donor ones or will not exist at all. The test results are confirmed by conducting a crossover study.

Treatment

The problem of immunological infertility is quite difficult to overcome. However, there are ways to increase the likelihood of recovery:

• Condom therapy, which completely eliminates unprotected sexual intercourse. With long-term adherence this condition, the sensitization of the female body to sperm components decreases. After a while, you can try to get pregnant naturally.
• Use of hyposensitizing therapy. In this case, immunological infertility is treated with glucocorticoid hormones and antihistamines, administered to a woman for a week.
• Immunotherapy.
• Intrauterine insemination of washed sperm.
• In vitro fertilization.

– a hyperimmune state of the female or male body, accompanied by the secretion of specific antisperm antibodies. Immunological infertility is manifested by the failure of conception and pregnancy with regular sexual activity without contraception in the absence of other female and male factors of infertility. Diagnosis of immunological infertility includes the study of spermogram, plasma antisperm antibodies, postcoital test, MAR test and other studies. For immunological infertility, corticosteroids, immunization methods and assisted reproductive technologies are used.

Immunological infertility has a rather specific nature: ASATs are produced by the sperm of a particular man, and when a partner changes, the possibility of pregnancy arises. With full treatment using modern ART, immunological infertility can be overcome in most mild cases. Probability of pregnancy in natural cycle in the absence of treatment, men with MAR IgG > 50% are

Operation human body would be impossible without the immune system. Immunity protects a person from small and large dangers, sometimes not distinguishing a real enemy from an ordinary cell. The body is able to get rid of even its own tissues that have ceased to perform their functions. One of the most striking examples is cancer, which is cells that begin to multiply beyond measure. In this article we will consider the concept of immunological infertility.

Some cells of the body never connect with immune cells, therefore, upon sudden contact, the body’s defense attacks unknown, although its own, elements. Thus, neurons in the brain and sperm in the testicles are separated from the immune system. There is a separation between the brain tissue and the blood itself, as well as the ovarian tissue. This is due to the fact that some protein structures are missing at birth, when the immune system remembers the native cells. Sperm begins to be produced only at 11-13 years of age, so the immune system will attack it. To avoid this, spermiogenesis occurs in spermatogenic tubules, which filter oxygen and necessary substances, but prevent contact with blood.

Immunological infertility

Immunological infertility is a condition in which a couple is unable to conceive a child due to aggressive effects on sperm. Antibodies are immunoglobulins (proteins) that are produced by the human immune system and are designed to attack foreign objects.

Immunological factors prevent an average of 10% of infertile couples from conceiving a child. Antisperm antibodies, which trigger the process of destruction of germ cells, are found in both sexes (15% of diagnoses in men and 32% in women). Antibodies can be contained in the blood, as well as in other environments (sperm, follicular fluid, cervical mucus, etc.).

The male body is capable of producing antisperm antibodies in the blood or sperm to destroy germ cells. The female body produces antibodies to destroy or paralyze sperm. In women, antibodies are present in the blood and cervical mucus vagina. It happens that antisperm antibodies were detected in both partners at once.

The intensity of the impact is determined by the characteristics of the antibodies: class, quantity, density of germ cell coverage. Antibodies can disrupt the development of sperm, paralyze cells in the cervical mucus, and prevent implantation of a fertilized egg in the uterus.

Antisperm antibody classes:

• Ig, M - attached to the tail of the sperm, stopping its movement in the cervical mucus (the fertilization process remains unchanged);
• Ig, G - are attached to the head of the cell, which does not affect mobility, but prevents the penetration of sperm into the female sex cell(the number of leukocytes increases, acidity decreases, liquefaction time decreases);
• Ig, A - change the morphology of the cell, can be successfully treated (restoration of the blood-testis barrier between the vessels and seminiferous tubules).

The nature of immune infertility in men

Before puberty, sperm is not formed, so its antigens are not perceived by the immune system. The only reason why the immune system does not destroy sperm, consists of a biological barrier. Sperm is isolated from immune cells found in the blood. The blood-testis barrier acts as protection between blood vessels and seminiferous tubules.

The barrier can be damaged due to anatomical disorders such as inguinal hernia, testicular torsion, underdevelopment or absence of the vas deferens. Protection may also be affected by sexually transmitted infections. Injury and surgery to the pelvis and scrotum also increase the risk of barrier disruption. At risk are men with chronic inflammation genitourinary system.

All these factors can damage the blood-testis barrier and release sperm. When it enters the bloodstream, it will launch a protective process.

There are several types of antibodies that can affect reproductive system men. Sperm immobilizers can partially or completely stop the activity of the germ cell. Sperm agglutinators glue sperm together with excess (destroyed cells, mucus, epithelial particles). Both phenomena give rise to immunological infertility.

The possibility of a slight penetration of germ cells beyond the barrier and into the blood cannot be ruled out, but immunological tolerance does not allow protective mechanisms to take hold.

The blood-testis barrier can be damaged by infection or trauma (mechanical or during surgery). Violation of the integrity of the barrier entails the penetration of antibodies into the genital tract, which opens up access for the immune system to sperm.

The appearance of antibodies is associated with the following phenomena:

• varicocele (dilation of the veins of the seminal canal, which causes overheating of the testicles);
• oncological diseases;
• cryptorchidism (testicles not descended into the scrotum);
• infections;
• surgical intervention.

Immunological infertility in women

The immune system in women is in contact with the reproductive system, but this does not prevent it from accepting sperm aggressively. Nature has built a woman's genitals in such a way that sperm can survive in an aggressive environment and be protected from the immune system. Despite the fact that foreign sperm enter a woman’s body during sexual intercourse, the immune system does not destroy them (in healthy body). The fact is that the vaginal environment protects sperm from immune cells.

In the female body, antibodies arise against the background of:

• damage to the mucosa;
• excess of leukocytes and lymphocytes in seminal fluid;
• entry of sperm bound to antibodies;
• history of IVF attempts;
• penetration of germ cells into the gastrointestinal tract (during oral or anal sex);
• irregular sex life with high concentration abnormal male reproductive cells;
• abnormal structure of the reproductive tract, which allows sperm to enter the peritoneum;
• in the anamnesis.

The effect of antibodies on the reproductive system

For quite a long time, medicine did not know exactly how antibodies affect human reproductive function and cause immunological infertility. Today scientists have proven the fact of the following phenomena:

1. Antibodies inhibit active germ cells. By attaching to sperm, antibodies significantly inhibit them. Cells cannot move forward male body, and in women's. Antisperm antibodies stick together germ cells and paralyze them. The degree of disturbance depends on the amount of antibodies and their localization on the sperm. It is believed that when attached to the head, the sperm suffers the most.
2. It is more difficult for sperm to penetrate the cervical mucus. The ability of sperm to penetrate the vaginal environment determines the chances of conception. In the presence of antibodies, the germ cell begins, as they call it in science, to “tremble in place.” This phenomenon can be seen during the Shuvarsky test and. Antibodies can partially or completely block sperm from penetrating the mucus.
3. Disturbances during spermatogenesis.
4. Fertilization disorders. It has been proven that antibodies affect gametes. Immune cells block the penetration of sperm into the membrane of the egg. The nature of the phenomenon has not been fully studied, but the fact remains that antibodies interfere with the acrosomal reaction (overcoming the barrier of the female germ cell by the male germ cell).
5. Problems with the attachment of a fertilized egg in the uterus.
6. Inhibition of fetal growth and development. Antisperm antibodies affect the condition of the embryo. This is a serious problem when treated with methods artificial insemination.

Symptoms of immunological infertility

Immunological infertility is dangerous because it develops without symptoms in both sexes. With this form of infertility, men are able to have sex, their spermiogenesis is preserved. Women have no physiological factors infertility (uterine, tubo-peritoneal).

The only reason to consult a doctor is the absence of pregnancy for more than a year with regular sexual activity without contraception. At the same time, the woman has normal menstrual cycle, and the man does not lose his erection. Often, with immunological infertility, pregnancy occurs, but the fetus cannot gain a foothold in the uterus and is released with menstruation. The woman does not even notice that conception has occurred.

Diagnosis of immunological infertility

Immunological infertility is studied comprehensively: in women (consult with a gynecologist), in men (with a urologist-andrologist).

Stages of diagnosing immunological infertility:

For a man:

1. Blood test.
2. Spermogram (pay attention to antibodies in sperm). With an immunological factor, infertility will show a reduction in the number of cells, a change in their structure and shape, weak activity and low durability.

For woman:

1. Analysis of cervical mucus.
2. Blood test for antisperm antibodies.
3. Compatibility test cervical mucus and reproductive cells of the partner (postcoital or Shuvarsky test). allows you to detect antibodies in cervical mucus after sexual intercourse. Cells associated with antisperm antibodies are characterized by specific movements and low motility.
4. MAR test (antibody-coated sperm counting). The results of the MAR test indicate the number of motile cells connected to antibodies (infertility occurs at 50% of Ig, G antibodies).
5. Kurzrock-Miller test (studying the ability of germ cells to penetrate mucus).
6. Bouveau-Palmer test (consolidation of the Kurzrock-Miller test result).
7. 1BT test. The test shows the location of antibodies on germ cells and calculates the percentage of sperm that are bound.
8. Flow cytofluorometry method. It can be used to calculate the concentration of antibodies on one germ cell.

At bad results spermogram and postcoital test, it is recommended to undergo enzyme immunoassay ( biochemical reaction, which allows you to detect antibodies in the blood and calculate their quantity). Sometimes polymerase testing is also performed chain reaction(detection of urogenital infections).

During the study, you should stop taking medications (especially hormonal drugs). It is worth establishing a daily routine and proper nutrition. Test results largely depend on the patient’s mood.

Treatment of immunological infertility in men

Immunological infertility in men is treated with the help of auxiliary reproductive medicine. You can study the sperm and select those suitable for intracytoplasmic injection into the egg, or select one, but best cage for the IVF procedure.

The treatment strategy for immunological infertility in men will depend on the causes of this condition. Some patients require surgery to restore blood flow or relieve an obstruction. Also effective hormone therapy. In any case, infertility treatment will be long and complex.

Getting rid of female immunological infertility

Treatment of immunological infertility in women involves the use of contraceptives and drugs to suppress antibodies in the partner. If there is no effect, the woman is also recommended to undergo assisted reproduction. First they carry out. If pregnancy does not occur, they turn to in vitro fertilization.

In women, antibodies arise against the background of inflammation or infection. Treatment will also depend on the underlying cause. The doctor must take into account the degree of impairment and the woman’s health condition.

Treatment for women consists of three steps:

1. Correction of the immune system, treatment of the underlying disorder and concomitant diseases. At this stage, the immune deficiency is eliminated (corticosteroids). It is necessary to cure all infections and inflammations, normalize the intestinal and vaginal environment (antihistamines and antibacterial agents). Will be useful general strengthening body and psychological help. List of immunomodulatory drugs that are acceptable in in this case, limited. Injecting the partner with lymphocytes from a spouse or a healthy donor is considered effective.
2. Preparation before pregnancy. This stage should begin at least a month before conception. The gynecologist determines treatment individually for each patient.
3. Therapy during pregnancy, fetal preservation. After fertilization, you need to monitor hemostasis and check the blood for autoantibodies. All deviations must be corrected on time.

If antibodies are present in the cervical mucus, contraceptives should be used to prevent sperm from entering the genital tract. The course of barrier treatment should be 6-8 months. When there is a combination of male and female immunological infertility, assisted reproductive medicine is also recommended.

Of all types of infertility, immunological infertility is relatively rare and accounts for about 10% of cases. Its reasons lie in the conflict between the genes of a married couple. Once sperm enters the uterus, it is perceived as an aggressive foreign body. It turns out that the female immune system works abnormally actively and produces anti-sperm antibodies that destroy the male germ cell that gets inside. Accordingly, the sperm simply has no chance of reaching the egg, and pregnancy does not occur.

The question of identifying immunological infertility as a fundamental reason for the inability to get pregnant remains open. The fact is that antisperm antibodies are also found in blood serum, cervical mucus and peritoneal fluid, even in healthy women. Their number can vary between 5-65%. That is, you need to look for another, more specific reason. At the same time, many specialists prescribe a test for the presence of antibodies and try to provide treatment that can correct their number.

Cause of immunological infertility

This deviation occurs in both men and women. As mentioned above, in women they are synthesized as a reaction to sperm. Being in the mucous membrane of the cervical canal (less often in the tubes), they cause complete immobilization of sperm, that is, their agglutination. Antibodies are formed as a result of sperm-specific antigens entering the secretion of the female reproductive tract.

The appearance of AT is often associated with the reaction of the immune system to various infections: genital herpes, trichomoniasis, gonorrhea, chlamydia, urea and mycoplasmosis. Their appearance is also influenced by chronic inflammatory diseases genital organs (cervicitis, endometritis, salpingoophoritis), genital endometriosis. As a result of too high activity of the immune system, spermatozoa also come under attack, and whether they belong to a regular partner or a casual one makes no difference.

There are cases of autoimmune or allergic reaction to the antigens of the corresponding follicular fluid and the zona pellucida of the follicle. In body healthy man sperm do not enter the blood, but are isolated. Therefore, the body’s protective reaction to the antigen can begin only in the presence of anatomical disorders in the form of an inguinal hernia, varicocele, obstruction of the vas deferens, cryptorchidism, testicular torsion, agenesis of the vas deferens. Sexually transmitted infections, injuries and various operations on the pelvic organs or scrotum. Chronic inflammatory diseases (prostatitis, epididymitis, orchitis) also do not go away without leaving a trace. All this leads to the destruction of the natural barrier between the blood vessels and seminiferous tubules; the body perceives unfamiliar cells as hostile and defends itself.

ASAT (antisperm antibodies) are:

• sperm-immobilizing, leading to partial or complete sperm stupor;
• sperm agglutinating, due to which sperm stick together with each other, their speed of movement decreases (sometimes they simply sway from side to side in one place). Of course, the process of fertilization becomes impossible.

Diagnosis of immunological infertility

In order to confidently make a diagnosis of “immunological infertility”, specific laboratory research depending on the gender of the patient. Men must donate blood and semen to be tested for the presence of ASAT and tested for STIs (sexually transmitted infections). If ACAT is detected by any of laboratory methods(MAR test, 1BT test, ELISA/ELISA, etc.) you can see the presence of autoimmune reactions against sperm. If ACAT covers more than 50% of motile sperm, then a diagnosis of “male” is made. immune infertility" Women's blood and cervical fluid are taken for analysis, and a series of tests are carried out to determine the compatibility of both partners. These include:

• postcoital test (PCT) - preferably performed after monthly use condom, 6 hours after intercourse;
• Kurzrock-Muller test (the test allows you to evaluate the penetrating ability of sperm in cervical canal during the period of ovulation in a woman);
• determination of antibodies to phospholipids, to DNA and to factors thyroid gland;
• determination of the genotype of spouses using class II HLA antigens;
• Izojima test (detects the degree of sperm immobility);
• Shuvarsky's test;
• Bouveau-Palmer test.

Treatment of immunological infertility

Used to treat women various kinds corticosteroids, immunomodulators, etc. The whole process is aimed at suppressing antisperm antibodies. In case of low effectiveness of treatment, there is an alternative in the form of assisted reproductive technologies: intrauterine insemination, in vitro fertilization. With men everything is much more complicated, since in this moment not found yet effective method ridding sperm of ASAT. The only thing left to do is to use artificial insemination methods, the most effective of which is considered to be ICSI - intracytoplasmic injection of sperm into the egg.

Traditional medicine in the fight against immunological infertility

There are also traditional methods treatment of immunological infertility. We bring to your attention several healthy recipes.

1. Infusion of red geranium. Pour boiling water over a pinch of geranium and leave for 10 minutes. Both partners can drink a tablespoon half an hour after eating.
2. Pour 2 cups of boiling water over the cinquefoil herb, 2 tbsp. l. Let it sit for 1 hour. Take on an empty stomach.
3. Valerian root bath. Pour 30 grams of chopped grass into 1 liter cool water and leave for an hour. Boil the infusion for 20 minutes and leave to “rest” under the lid for 5 minutes. Then filter through cheesecloth and add to the bath. We take a bath before bed, the water should not be higher than body temperature. The course of treatment is 12-14 baths.
4. Chamomile and calendula douching. 1 tbsp. chamomile and 2 tbsp. Pour boiling water over the calendula and leave for 12 hours. Strain and syringe with the resulting infusion.
5. Mix 1:1 calendula tincture and 1% propolis alcohol extract or 20% tincture. 1 tbsp. l. dilute the resulting mixture in boiled warm water and douche for 10 days.

Especially for- Anya Logue

Male immunological infertility is a terrible and incomprehensible diagnosis for every couple. What is this? The end of hope for a full-fledged family or the beginning of the search for a way out of the maze?

Read in this article

Immunological (autoimmune) male infertility: symptoms and causes

The human body is designed in such a way that all systems and organs work smoothly. And to protect this organized work the immune system arises and reacts to any alarm signal, indicating a failure of the body’s normal functioning.

Is this always a 100% guarantee of success? Often immunity saves one system, bringing irreparable harm another. The consequence of such a failure is autoimmune infertility. A cause-and-effect chain occurs: the body’s defense by the immune system is a violation reproductive function men are a threat to remain childless forever.

From a physiological point of view, immunological infertility can be explained as follows: with injuries, surgical interventions, inflammatory process In the scrotum, the barrier created by certain antibodies is broken, and the immune system produces anti-sperm. They, in turn, put a block on the movement of sperm.

As a result of failures, male reproductive cells are mostly inactive and cannot come into contact with the egg. A man who has retained erectile ability cannot fertilize a woman’s egg during full sexual intercourse, which is a symptom of an immunological male infertility.

Diagnosis of male infertility is the first step to solving the problem

Universal " male doctor“For a very long time, a urologist was considered a urologist who diagnosed and treated both diseases of the genitourinary system and infertility problems.Sometimes men faced with impotence and decreased erectile function consulted a sex therapist.A modern man should know that an andrologist is a doctor who treats reproductive function in representatives of the stronger sex - will help him in diagnosing and treating autoimmune infertility.

The first step in diagnosis is the study of sperm parameters. It is necessary to properly prepare for the test, which is carried out using the MAR test.

• exclude sexual contact for at least two days, but no more than 6-7 days;
• a week before the analysis, remove fatty and spicy foods from your diet;
• If possible, avoid drinking coffee and completely stop drinking alcohol;
• do not visit the bathhouse, sauna, replace hot bath cool shower because overheating negatively affects sperm production;
• stop taking it seven days before medicines and try to avoid contracting colds and acute respiratory viral infections.

If the test shows from 0 to 25% of sperm covered with immune bodies, then it can be considered negative.

If the result revealed more high rate, then we can talk about a violation of a man’s ability to fertilize.

If a deviation from the norm is detected in the spermogram, the second step should be a step-by-step diagnosis using ultrasound of the scrotum and transrectal ultrasound, microbiological analysis sperm and hormonal studies.

Treatment of immunological infertility: stages and prognosis

If the diagnosis is confirmed, then it should be remembered that the treatment of infertile men with autoimmune reactions against sperm is a complex process. It can definitely be said that main goal there should be an improvement in spermatogenesis in men.

First, it is necessary to eliminate all development factors autoimmune process in the reproductive system, cure (if present) urogenital infections. You should also pay attention to the presence of injuries and damage that can be eliminated by surgery.

Secondly, hormonal and non-hormonal treatment. Prednisolone has proven itself well, taking it improves spermatogenesis and increases therapeutic effect treatment of immunological infertility in men.

We also recommend that you read the article. From it you will learn about all the reasons for a man’s inability to procreate, what types of male infertility exist, what signs can be used to detect the presence of a problem, how it is diagnosed and treated, as well as measures to prevent diseases of the male reproductive system.

There is also the so-called “washing” of spermatozoa from antibodies that interfere with fertilization and their union with the egg. It is carried out in specialized clinics.

In some cases, a combination of methods is necessary, as well as treatment aimed at strengthening the immune system. Therefore, you cannot do without visiting doctors. Unfortunately, in this case it is almost pointless to rely on traditional methods.

With absence positive result after treatment for a year, IVF or ICSI can be used, which involve the artificial connection of partners’ cells in a laboratory setting. The procedure is far from cheap, but in most cases it allows you to conceive in the shortest possible time.

Immunological infertility in men is a rare and complex diagnosis. But don't give up! There is always a way out, it’s just that the impossible takes a little more time.

Useful video

Watch this video about what immunological infertility is in men and what to do about it: