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Fifth stage
Gyne
Part 1
د.أحمد جاسم
2017
Male Infertility
Objectives :-
• After attending lecture, the student will can:
• Know the causes of male infertility.
• Discuss history and examination.
• Know investigation and treatment.
• Discuss assisted reproductive technique.
the causes of male infertility are:
1. Spermatogenesis disorder
2. Sperm transport impaired.
3. Ejaculatory dysfunction.
4. endocrinological causes.
5. Immunological factors.
1) Spermatogenesis disorder :-
Spermatogenesis requires testicular growth and differentiation and it is under endocrine
control by FSH. LH acts mainly on Leydig cells and stimulates production of testosterone. It
takes about 74 days.
Causes affect spermatogenesis:
1- increased in scrotal temperature which may impair spermatogenesis.
The normal scrotal temperature is one degree (1° c ) lower than the rest of body
temperature, and increased in scrotal temperature may impair spermatogenesis, this
occur in:
• Hot baths, tight cloths .
• cryptorchidism ( undescended tests)
• varicocele.
2- Chromosomal abnormality: microdeletion of Y chromosome, Klinefelter's
syndrome. (azospermic and severly oligozoospermic men should have chromosomal
karyotypeing before their sperm used for ICSI.
3- Orchitis: Fertility is affected if bilateral orchitis occurs after puberty (mumps).
4- Testicular torsion,trauma, neoplasm and effect of subsequent chemotherapy,
haemosiderosis
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5- Occupational and environmental factors :
Toxic effects of radiation, drugs, chemicals, heavy metals, and pesticides as well as
Tobacco, cannabis, alcohol can affect the rapidly dividing germ cells which are the
precursors of spermatozoa.
6- Drugs (Iatrogenic):
alcohol, cigarettes, opiatsand marijuana can suppress spermatogenesis
anabolic steroids, antifungal drugs, sulfasalazine, corticosteroids causing reversible
effect.
chemotherapy can cause permanat damage to spermatogenesis.
2) Sperm transport impaired: (obstructive male infertility) :-
• obstruction can occur at any level of male reproductive tract from rete testis and
epididymis to vas deferencs.
• Azoospermia in the presence of normal testicular volume and normal FSH suggests
the possibility of genital tract obstruction.
• Immotile spermatozoa are released into the lumen of the seminiferous tubules and
travel to ampulla of vas deference where they acquire motility.
Impariement of sperm transport in :
1- Epididymal malformation.
2- Vas deference obstruction, inflammation, enlargement, absence.
3- Immobile cilia syndrome.
4- After vasectomy.
3) Ejaculatory dysfunction:
May be due to:
1- failure of ejaculation (Anejaculation) due to neurological disorder, medication or
psychological difficulties.
2- Premature ejaculation.
3- Retrograde ejaculation.(sperm enter the bladder rather than the penile urethra at
ejaculation which can follow from neurological disorders, diabetes, bladder neck or
prostate surgery.
4- Drug induced. antidepressants, sedatives and antihypertensives.
5- Idiopathic metabolic and systemic conditions as diabetes.
4) endocrinological causes:
1- hypogonadotrophic hypogonadism, thyroid and adrenal disease.
2- hyperprolactinaemia in men can lead to impotence but has little effect on sperm
production.
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5) immunological causes:
• antisperm antibodies present
management of male with infertility:
history:
Important historic points in the male:-
• Age.
• occupation (including abscense from home, or have excessive heat exposure, X-ray
exposure or occupation dealing with substance has effect in spermatogenesis as
agricultural chemicals, paint products).
• history of use tight clothes, hot baths, saunas.
• Duration of infertility.
• Fertility in other marriage.
• Frequency of intercourse, sexual dysfunction.
• Medical history (childhood illnesses, STD disease, genital trauma, orchitis).
• surgical history ( previous genitourinary surgery (operations for hernia or varicocele).
A history of previous inguinal hernia repair can indicate an accidental ligation of the
spermatic artery.
• Medications and Alcohol, cigarette, marijuana use.
• Previous tests and therapy for infertility.
• A complete review of systems may be helpful to identify any endocrinological or
immunological problem that may be associated with infertility.
Male examination:
Examination of the man is not usually necessary unless indicated by:
• his medical history (such as previous orchidopexy, inguinal hernia repair, or
testicular torsion)
• or if his initial semen analysis result is abnormal.
Male should be examined by urologist for:
• General build and appearance.
• Attention should be directed to congenital abnormalities of the genital tract.
examine for inguinal hernia or surgical scars, gynaecomastia or evidence of systemic illness
genital examination for Palpation of testicles for size , constancy, epididymis , vas
deference assessment. urethral stenosis, and presence of varicocele are also determined.
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Investigations of the male partner:
Earlier intervention (investigation before passing one year after marriage) is indicated in the
presence of specific high-risk factors in either partner. In the male, this could be a history of
azoospermia, testicular surgery, vasectomy or coital failure.
Semen analysis :-
• Semen analysis remains the most commonly performed investigation in the male.
Samples should be collected after a period after 2-3 days of sexual abstinence (no
sexual intercourse) but no more than 5 days of sexual abstinence.
• Previous paternity does not guarantee that his reproductive system has not been
affected since the birth of his offspring.
• The laboratory should receive the samples as quickly as possible and at least within
one hour of production. Sometimes there are facilities to produce specimens at the
laboratory.
semen analysis Reference values according to WHO criteria
Parameter Normal value
Volume 2.0 ml or more
PH 7.2 or more
liquefication complete in 30 minutes
Sperm concentration 20 × 106/ml or more
total sperm number 40 × 106/ml or more
Motility ≥ 50% (grade a+ b) or 25% with
progressive motility
Morphology > 30% normal form
Vitality 75% or more live
White blood cells Fewer than million (1 × 106)
• it is important to remember that these values are not the minimum requirement to
achieve pregnancy , therefore they are referred to as "reference" and not "normal"
values.
• biochemical analysis of seminal fluid can provide information about prostate, seminal
vesicles and epididymis.
• Abnormal semen analysis results can be attributed to various unknown reasons (eg,
short period of sexual abstinence, problems with sample production, laboratory
analysis) in addition to pathology; therefore, repeating the semen analysis at least 4
weeks later is important before a diagnosis is made. Although this will only sample the
same population of sperm, it will uncover any problems with sample production,
laboratory analysis or reproducibility.
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• To sample a different population of sperm, at least 12 weeks needs to elapse between
samples. Explaining to the patient the normal fluctuation that can occur between
semen samples is also important.
Interpretation of semen analysis :-
• Azoospermia: indicates absence of sperm
• Oligozoospermia: indicates a concentration of < 20 million sperm/mL(20 × 106).
• Asthenozoospermia: indicates sperm motility of less than 50%.
• Teratospermia: (< 30% normal forms) indicates an increased number of abnormal
sperm morphology at the head, neck, or tail level.
• Hypospermia: indicates a decrease of semen volume to less than 2 mL per
ejaculation.
• Sperm function tests:
sperm function tests are still academic
Further investigations of male infertility:
If values are normal according to WHO criteria, one test should be sufficient. Further
andrological investigation is only indicated if the results are abnormal in at least two tests or
if the history and clinical examination are suggestive.
1) Hormone assay to male :-
a. serum FSH:
• In men with azoospermia serum FSH levels help to differentiate between
obstructive and non-obstructive causes.
• Normal levels are indicative of obstructive azoospermia where surgical sperm
retrieval may be considered.
• elevated levels are suggestive of failure of spermatogenesis.
• In rare cases undetectable levels of FSH can be suggestive of hypogonadotrophic
hypogonadism where treatment with exogenous FSH may be effective.
b. Testosterone and LH measurements
are helpful in the assessment of men where androgen deficiency is suspected or where
there is a need to exclude sex steroid abuse or steroid secreting tumours of the testes or
adrenals.
c. prolactin level
As men with hyperprolactinaemia have sexual dysfunction, it is necessary to exclude
elevated prolactin levels in men with loss of libido and impotence. Persistently elevated
prolactin levels warrant further investigations such as imaging of the pituitary gland.
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2) chromosomal and genetic studies:
• Men with azoospermia or severe oligozoospermia should undergo: chromosomal
analysis.
• A cystic fibrosis screen should be performed
3) microbiology of semen:
• Semen culture is indicated in men with microscopic evidence of infection.
• Male partners of women with chlamydia infection should be screened.
4) imaging of the male genital tract:
• retrograde venography is the gold standard for varicocele.
• ultrasound and Doppler, radionucleotide angiography and thermography. Scrotal
ultrasound scans are helpful if testicular tumours are suspected.
• In obstructive lesions of the male genital tract, vasography can be used to detect the
site of obstruction.
5) testicular biopsy:
• it is procedure to define the histological diagnosis and the possibility of finding
sperm. When spermatozoa are detected, these can be cryopreserved for use in
future intra cytoplasmic sperm injection (ICSI) cycles.
• the risks of testicular biobsy are: reduction of testicular mass, devascularization,
fibrosis and autoimmune response.
6) antisperm antibodies:
• Tests for antisperm antibodies are not routine
SH.J
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