Urology

Infertility

Def.: The inability of a sexually active, non contracepting couples to achieve pregnancy in one year Def : failure to conceive after 1 year of unprotected sexual intercourse About 25% of couples do not achieve preg. within 1 year It affect about 15% of couples Roughly : 40 % male factor 40 % female factor 20 % both male & female

Male reproductive physiology

It depends on the hypothalamic (LHRH) – pituitary ( LH , FSH ) – gonadal axisLH – laydig cell – TSTFSH – Sertoli cellsSpermatogenesis is completed by meiotic divisionIn the seminiferous tubulesIt takes 74 daySperm maturation occurs in the epididymisFertilisation occurs in the ampullary portion of the fallopian tube during the middle of the cycle

Causes of male infertility

Pretesticular - Hypothalamic diseases Gonadotropin deficiency ( Kallmann syndrome )

- Pituitary diseases Pituitary insuficiency Hyperprolactinemia

Testicular

Chromosomal causes Klinefelter syndrome (47,XXY)

- Other syndromes Noonan syndrome ( male Turner syndrome 45 ,X ) Sertoli-cell-only syndrome Gonadotoxins Radiation Drugs ( calcium channel blockers , cimetidine , tricyclic antidepressants , nitrofurantoin , allopurinol )

- Systemic diseases

renal failure liver cirrhos Testicular injury orchitis , torsion , trauma Cryptorchidism Varicocele idiopathic


Post testicular
Reproductive tract obstruction … Congenital blockages ( cystic fibrosis, idiopathic epididymal obstruction, … Acquired obstruction ( vasectomy , groin surgery , infection ) … Functional obstruction ( sympathetic N. injury, pharmacologic)Disorders of sperm function or motility immotile cilia syndrome ,maturation defect,immunologic infertility, infectio

evaluation of male infertility depends on

History Physical exam. Semen analysis Hormonal assessment

Physical examination

Hormonal analysis
Evaluation of the pituitary – gonadal axis Includes : testosterone , FSH , LH , prolactAdjunctive testssemen leukocyte analysis, antisperm antibody test , sperm penetration assayChromosomal studySemen culture

Radiologic study

Scrotal U/S size of testes.,varicocele TRUS For obstruction of ejaculatory duct CT & MRI Vasography Testicular biopsy In azoo spermia to difrentiate between obstructive and non obstructive azoospermia

Treatment of male infertility

Surgical treatment Varicocele Vasovasostomy Ejaculatory duct obstruction – TURED Electroejaculation – spinal cord injury Sperm aspiration ( vasal aspiration , epididymal sperm aspiration , testis sperm retrieval ) Orchidopexy Pituitary ablationNon surgical treatment Pyospermia – antibiotics + antioxidant vitamins ( A,C,E ) Coital therapy - timing & frequency ( every other day around ovulation ) Immunologic infertility – corticosteroids suppression, sperm washing, IUI ,IVF ,ICSI

Medical therapy

Hyperprolactinemia - bromocriptine Hypo / hyperthyroid Empiric medical therapy 25% of infertility is idiopathicClomiphene: citrate anti estrogen – increase secretion of GnRH, LH,FSH Tamoxifen : anti estroginAntioxidant therapy : Vit E , glutathi

Assisted reproductive technologies

Intrauterine insemination ( IUI) : immunologic infertility, low sperm quality, hypospadias IVF & ICSI Gamete intrafallopian transfer ( GIFT )