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1
MALE INFERTILITY
2
CONTENTS Introduction
Spermatogenesis
Causes
Evaluation
Management
What’s new in male infertility
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INTRODUCTION INFERTILITY - one year of unprotected
intercourse without conception
SUBFERTILITY- couples who exhibit decreased reproductive efficiency
FECUNDABILITY - probability of achieving pregnancy within a single menstrual cycle
FECUNDITY - probability of achieving live birth within a cycle.
Speroff 15th ed.
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SPERMATOGENSIS
• During embryogensis, there are approximately 300 thousand spermatogonia in each gonad.
• Each undergoes mitotic division, and by puberty 600 million in each testis.
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Sperm production takes place in seminiferous tubules within testis.
Spermatogenesis takes about 70 daysAdult males produce 100-200 million sperm
each day.Leydig cells produce testosterone (which
along with FSH, stimulates spermatogenesis).Maturation of sperms takes place in
epididymis.Transport of sperms – vas deferens
Speroff 15th ed.
1.Plasma membrane2.Outer acrosomal membrane3.Acrosome4.Inner acrosomal membrane5.Nucleus6.Proximal centriole7.Rest of the distal centriole8.Thick outer longitudinal fibers
9.Mitochondrion10.Axoneme11.Anulus12.Ring fibersA.HeadB.NeckC.Mid pieceD.Principal pieceE.Tail
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SPERM STRUCTURE
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Physiology of Semen after Ejaculation1. Liquefaction2. Capacitation3. Acrosome reaction4. Cortical reaction
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Relative prevalence of the etiologies of infertility
Percentage
Male Factor 20-30
Both male & Female 10-40
Female Factor 40-55
Unexplained Infertility 10-20
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SEMEN ANALYSIS
• Abstinence for 2-3 days (Not less than 2 days & not more than 7 days)
• Abnormal sperm count - analysis at least after 4 weeks.
• Analysis: Volume, number, motility, morphology
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Short intervals of abstinence- decreases the sperm density and semen volume.
Longer abstinence intervals - increase in the proportion of dead, immotile and morphologically abnormal sperms.
Semen specimen should be collected in a clean container.
Semen can also be collected in a silastic condom, which does not contain any antispermicidal agents.
Semen sample should be examined within an hour after collection
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Parameters Normal Reference Values
Lower Reference Limits
Volume 1.5-5.0 mL 1.5 (1.4-1.7) mLP H >7.2
Viscosity <3Sperm Concentration
>20 million/mL 15 (12-16) million/mL
Total sperm number
>40 million/ejaculate 39 (33-46) million/ejaculate
Percent motility >50% 40 (38-42)%
Forward progression
>2 (scale 0-4) 32 (31-34)%
Normal morphology
>15,30,50% normal 4(3-4)%
Round cells <5 million/mLSperm agglutination
<2 (Scale 0-3)
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Semen analysis
Ejaculate volume and pH:• Low or absent – CBAVD, ejaculatory duct
obstruction, hypogonadism, retrograde ejaculation.
• High volume (>5ml)- Inflammation of accessory gland
Seminal vesicle secretions are alkaline and contains fructose.
EDO- semen is acidic (prostrate secretions), and has no sperm or fructose.
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Sperm concentration and total sperm count:
1. Azoospermia, Oligospermia
2. OBSTRUCTIVE: blockage in ductal system ( CBAVD, scrotal or inguinal surgery)
3. NON OBSTRUCTIVE: primary testicular failure, endocrinopathies that suppress spermatogenesis.
4. Endocrine and genetic evaluation indicated in men with severe oligospermia.
5. Total sperm count is the product of multiplying semen volume and sperm concentration.
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Abnormalities of sperm
Oligozoospermia - reduced sperm count
Asthenozoospermia – reduced sperm motility
Teratozoospermia- increased abnormal sperms
Oligoasthenoteratozoospermia – sperm variables are subnormal
Azoospermia- no sperm in semenAspermia – no ejaculateLeucocytospermia – increased WBCNecrozoospermia – all sperms are
nonvaiable and motile.
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Causes of Male InfertilityHypothalamic pitutary disorders
(1-2%)
Primary gonadal disorders (30-40%)
Disorders of sperm transport (10-20%)
Idiopathic (40-50%)
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Hypothalamic pitutary disorders Idiopathic isolated gonadotropin
deficiencyKallmann syndromeSingle gene mutations Hypothalamic and pitutary tumours Infiltrative disease Hyperprolactinemia Drugs Chronic systemic illness and
malnutrition Infections Obesity
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Primary gonadal disorders Klinefelter syndrome Y chromosome deletions Cryptorchidism Varicoceles Infections Drugs Radiation Environmental gonadotoxins Chronic illness
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Disorders of sperm transport Epididymal obstruction or dysfunction Infections causing obstruction to vas
deferns Vasectomy Kartagener syndrome Ejaculatory dysfunction Young syndrome
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CAUSES PRE TESTICULAR TESTICULAR POST
TESTICULAR ENDOCRINE: •
Hypogonadotropic hypogonadism
• Hypothyroidism •
Hyperprolactinaemia
• Diabetes
COITAL DISORDERS:• Erectile
dysfunction • Ejaculatory
failure
GENETIC:• Klinefelter
syndrome• Y chromosome
deletion• Immotile cilia
syndrome
CONGENITAL: • Cyptorchidism• Infective•
Antispermatogenic agents
heat, irradiation, drugs, chemotherapy
VASCULAR : Torsion VaricoceleIMMUNOLOGICAL
IDIOPATHIC
OBSTRUCTIVE: Epdidymal congenital infective Vasal Genetic: cystic fibrosis. Accquired: Vasectomy Ejaculatory duct obstructionAccessory gland infection Immunological Idiopathic post vasectomy
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Evaluation of male infertility To Identify and correct specific cause To identify the individuals whose fertility
cannot be corrected but could be over come by IUI and ART.
To identify- Genetic abnormality To identify any medical condition that
requires specific attentionTo identify the individuals whose
infertility can neither be corrected or overcome with ART, in whom adoption or donor sperm are considered.
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HISTORY Duration of infertility and previous infertility Coital frequency and sexual dysfunctionAny previous evaluation or treatment of
infertilityChildhood illness and developmental historyPrevious surgery and its outcome, systemic
medical illness History of exposure to STDExposure to environmental toxins Current medications and allergies Occupational exposure to tobacco, alcohol
and other drugs
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Physical examinations Examination of penis, Palpation of testes and measurement
of their size Presence and consistency of both vasa
and epididymides Presence of any varicoceleSecondary sexual characteristics, hair
distribution, and breast development Digital rectal examination
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Other investigations Absence of fructose: Congenital absence of seminal vesicle, Partial duct obstruction. Semen culture (If pus cells in microscopy)Urologic evaluationEndocrine evaluation - FSH, LH,
Testosterone. Transurethral or transcrotal USGRenal ultrasonography Testis biopsy- azoospermia Vasography
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Endocrine evaluation:
Indications: Abnormal semen analysis Serum FSH,LH and testosterone
Hypogonadotropic gonadism- FSH,LH,testosterone low
Abnormal spermatogenesis- FSH normal/increased, LH& testosterone normal
Testicular failure- high FSH and LH, low /normal testosterone
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Genetic evaluation1) Mutations within cystic fibrosis transmembrane conductance regualtor (CTFR gene)
2) Chromosomal anomalies resulting testicular dysfunction – klinefelter syndrome
3) Y chromosome deletions associated with abnormalities of spermatogeneis.
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Transrectal ultrasonography: less invasive
indicated in diagnosis severe oligospermia or azoospermia.
Renal ultrasonography: unilateral or bilateral vasal agenesis.
Trans scrotal ultrasonography: To confirm physical findings. Detect non palpable varicocele.
28
Testis biopsy : diagnostic purpose in azoospermic men.
when the testicular biopsy shows normal spermatogenesis obstruction to the vas deferens is suspected.
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Drugs that impair male infertility
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TreatmentHypogonadotropic hypogonadism: Pulsatile GnRh, hCG, hMG, Testosterone,
Clomiphen citrate, Tamoxifen
Hypergonadotropic hypogonadism: 1. IVF/ICSE, Donor sperm, Adaptation2. Androgen, FSH, Clomiphen3. Hyperprolactinemia-Dopamine agonists4. Strict control of DM, Hypothyroid
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Pretesticular Erectile dysfunction- PDE5 Inhibitor (Sildenafil)For ejaculatory problems(Retrograde
ejaculation): Imipramine , Pseudoephedrine/Ephedrine , PhenylpropalamineRetrograde ejaculation, Neurogenic
impotence, Severe Hypospadias Intrauterine insemination (IUI)
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Post testicular Prior vasectomy (most common
cause)- microsurgical vasovasostomy (better if less than 5 years)
Epididymal or vasal obstructionMESAPESATESETESA/FNAICSI
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Surgical treatment for male infertility Vasovasotomy Vasoepididymostomy Transurethral resection of ejaculatory
ducts Varicocele repair OrchiopexyVibratory stimualtion and electro
ejacualtion
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surgical managementCryptorchidism- Orchidopexy at 2-3 year of ageVaricocele-High ligation of internal spermatic veinGonadal failure- Surgical retrieval of spermatozoa, followed by ICSI
THANK YOU
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