CAUSES AND EVALUATION

OF MALE INFERTILITY

Dr. K.Senthilnathan
CAUSES OF MALE INFERTILITY

 Pre testicular

 Testicular

 Post testicular
PRE TESTICULAR CAUSES

 Endocrine  Drugs
• Gonadotrophin • Antihypertensives
deficiency • Antipsychotics
• Thyroid dysfunction
• Hyperprolactinaemia  Genetic
• Klinefelter’s Syndrome
 Psychosexual • Y chromosome deletions
• Erectile dysfunction
• Loss of libido
TESTICULAR CAUSES
 Immotile cilia
(Kartagener’s syndrome)
 Cryptorchidism
 Infection (mumps orchitis)
 Toxins : Drugs, radiation
 Varicocele
 Immunologic
 Sertoli cell only syndrome
 Primary testicular failure
 Oligoastheno-
teratozoospermia [OAT]
 POST TESTICULAR CAUSES
 Obstruction of efferent duct  Others
 Congenital  Ejaculatory failure
• Absence of Vas deference
• Young’s syndrome  Retrograde ejaculation
 Acquired infections
• Tuberculosis  Hypospadias
• Gonorrhoea
 Surgical  Bladder neck surgery
• Herniorrhaphy
• Vasectomy
WHEN TO EVALUATE?
 Recommended - deferring medical assessment until
12 months of unprotected intercourse

 Evaluation before 1 year if

 (1) male infertility risk factors such as a history of
bilateral cryptorchidism
 (2) female infertility risk factors - advanced female age
(older than 35 years), or
 (3) the couple questions the male partner’s fertility
potential

 Concurrent basic evaluation of the female partner is

also prudent
EVALUATION OF MALE INFERTILITY
 Method of approach
 A comprehensive medical history
 Review of systems
 Targeted physical examination
 Basic laboratory tests

 Essentials of investigation
 Rapid
 cost-effective
 noninvasive
 CLINICAL APPROACH TO MALE INFERTILITY
CLINICAL DETAILS
 Infertility History
• Age of partners, length of time the couple has been attempting to
conceive
• Contraceptive methods / duration
• Previous pregnancy (current partner / other partner)
• Previous treatments
• Treatments / evaluations of female partner.

 Sexual History
• Potency, libido, lubricant use
• Ejaculation, frequency/timing of intercourse

 Childhood and Development

• Cryptorchidism, hernia, testicular trauma
• Testicular torsion, infection (e.g. mumps)
• Sexual development, puberty onset
 Treated Undescended testis (regardless of timing
of orchiopexy)
 13.3% are azoospermic in unilateral disease
 34% are azoospermic in bilateral condition

 In untreated cases
 30% are azoospermic in unilateral disease
 80%are azoospermic in bilateral disease
 Pubertal mumps orchitis affects
 unilaterally in 67%
 bilaterally in 33%.

 In bilateral disease
 36% result in Testicular atrophy

 Infertility occurs in 13%

 Medical history
• Systemic diseases (Diabetes, Cirrhosis, Hypertension)

 Diabetes and neurological diseases affect

• Ejaculatory function &
 Erectile function

 Thyroid disease(hypo or hyper functioning) affect

 Steroid hormone metabolism &
 Sperm quality
 Previous Surgeries
• Orchidopexy, herniorrhaphy, orchidectomy
(testicular cancer, torsion)
• Retroperitoneal and pelvic surgery
• Other inguinal, scrotal and perineal surgery
• Bladder neck surgery
• Transurethral resection of the Prostate
 Neoplasms impair spermatogenesis due to
 Endocrine disturbances,
 Malnutrition
 Hypermetabolism with associated fever
 Immunologic factors

 Testicular tumors impair spermatogenesis by

 The destruction of surrounding tissue
 Local secretion of HCG and other paracrine factors
 Intrascrotal temperature elevation
 Alterations in the local blood flow
 Gonadotoxin Exposure
• Alcohol, cocaine, marijuana abuse
• Medication (Chemotherapy agents, Cimetidine,
Sulfasalazine, Nitrofurantoin, thiazide, α &β blockers,
Calcium blockers,Finasteride)
• Anabolic steroids, tobacco use
• High temperatures
• Radiation (Therapeutic, Nuclear power plant workers)

 Family History
• Cystic fibrosis
• Infertility in the family
 Family history of cystic fibrosis -> diagnosis of
congenital bilateral absence of the vas deferens
(CBAVD)
 Associated vasal, epididymal, and seminal vesicle
anomalies

 Family history of intersex disorders ->

Abnormalities of the androgen receptors
 Medications can impair fertility by
 Direct toxic effects on gonadocytes
 Disturbance of the hypothalamic-pituitary-gonadal
axis
 Disruption of ejaculatory or erectile function,
 Inhibition of libido.
 Antibiotics exhibiting direct gonadotoxicity
 Nitrofurantoin
 Erythromycin
 Tetracycline
 Gentamycin
 Androgen production is inhibited by
 Spironolactone
 Ketoconazole
 Cimetidine
Sulfazalazine is associated with
reversible reductions in sperm concentration and
motility
α Blockers, are associated with retrograde
ejaculation,
Effect more prominent with Tamsulosin than
with other selective α blockers
 5-α reductase inhibitors
 Reductions in semen volume
 Impaired Erectile function
 Ejaculatory dysfunction
 Alcohol
 Associated with global suppression of the
hypothalamic-pituitary gonadal axis
 Suppression of spermatogenesis

“Moderate intake is not associated with significant

deterioration in fertility”
 Smoking
 Causes decline in
Sperm concentration,
 Viability,

 Forward motility,

 Morphology

 Sperm penetration ability

 Fertilization rates

“Defects in these parameters also lower assisted

reproduction success rates”
PHYSICAL EXAMINATION
GENERAL EXAMINATION

 To look for adequacy of virilization

 Androgen deficiency
 Decreased body hair
 Absence of temporal pattern balding
 Gynecomastia
GENERAL EXAMINATION FINDING
INTERPRETATION

 Abnormalities in these areas suggest possible

endocrinopathies to include
 Low serum testosterone
 Hyperprolactinemia
 Abnormal estrogen to testosterone ratio
 Adrenal dysfunction
 Genetic syndromes with subvirilization (Klinefelter
syndrome)
GENERAL EXAMINATION

 Palpation of the thyroid gland for any nodules

 Hepatomegaly -> hepatic dysfunction -> altered

sex steroid metabolism, hence impair fertility
GENITAL EXAMINATION
Examination of the phallus
 Penile curvature

 Chordee

 Hypospadias

May interfere with semen deposition in the vaginal

vault
GENITAL EXAMINATION
Examination of the scrotal contents
 The entire testicular surface should be palpated
to assess
 Consistency
 Rule out masses
 Testicular size - Assessed with either an
orchidometer, calipers, or sonographic
measurement
 Normal -4 × 3 cm or 20 mL in volume

 Because 85% of the testicular volume involves

sperm production, decreased testicular size leads
to impaired spermatogenesis
THE EPIDIDYMIS
 Enlargement or induration - Indicate
downstream obstruction or inflammatory
conditions such as epididymitis
 Granulomatous changes
 Tuberculosis,
 BCG treatments, and
 Sarcoidosis
PALPATION OF THE VAS DEFERENS

 Inability to palpate - Agenesis

 Nodularity - Prior infections like tuberculosis

 Vasal thickening is associated with prior scrotal

surgery or downstream obstructions

 Look for varicocele

 Presence of varicocele :
 Dilatation & tortuoisity of pampiniform plexus.

o Diagnosed with patient in standing position.

o Gradings :
 Grade O: sub clinical.

 Grade I: Detected only by valsalva.

 Grade II: by Palpation.

 Grade III: Diagnosed by Inspection.

RECTAL EXAMINATION
 Look for midline cysts such as müllerian duct
cysts, which can obstruct the ejaculatory ducts
 Prostatic induration or tenderness may be
seen in acute or chronic prostatitis
 The seminal vesicles are not palpable but
prominent in the setting of ejaculatory duct
obstruction
INVESTIGATIONS
1) Semen analysis
2) Sperm function tests
3) Endocrine evaluation
4) Genetic evaluation
5) Transrectal, Scrotal and Renal Ultrasonography
6) Magnetic resonance imaging
7) Vasography
8) FNAC of Testis.
9) Testicular biopsy.
 1. SEMEN ANALYSIS
 Cornerstone of the initial evaluation.
 Before a definitive conclusion, results from at least
two
(preferably three), separate seminal analyses must
be obtained.

 The interval between the analyses is generally 1-2

weeks.
COLLECTION

o Semen specimen is collected after about 3 days of

sexual abstinence.

o Longer period of abstinence reduces the motility of

sperms.

o Shorter duration of sperms (< 3 days) leads to lower

sperm count
 DON’T….

o Condom collection is not recommended

[ spermicidal agents interfere with the motility of
spermatozoa]

o Coitus interruptus is not a reliable means of semen

collection
[ First portion of the ejaculate may be lost /
cellular & bacteriological contamination of the sample/
low pH of the vaginal fluid could affect sperm motility ].
 COLLECTION
o Masturbation - Clean, Dry, Sterile and Wide mouthed
plastic container.
o Avoid spillage outside the container - Hypospermia.
o Entire ejaculate should be collected.
o Sample must be brought to the laboratory within1 hr of
collection.
o Transport to the laboratory
[Tempt. 20 °C - 37 °C].
o Microbiological laboratory
- Within 3 hours.
(I) INITIAL MACROSCOPIC EXAMINATION

 Liquefaction :
 Usually liquefies within 15 minutes at room
temperature,
Although rarely it may take up to 60 minutes or
more.

 If complete liquefaction does not occur within

60 minutes, this should be recorded.
 (A) SEMEN VISCOSITY
 It can be estimated by aspirating it into a wide-bore plastic
disposable pipette (1.5 mm diameter) allowing the semen to
drop by gravity.
 A normal sample leaves the pipette in small discrete drops.

 If viscosity is abnormal, the drop will form a thread more than

2 cm long.

 Impression - High viscosity can interfere with

 Determination of sperm motility
 Sperm concentration
 Detection of antibody-coated spermatozoa
 Measurement of biochemical markers
 (B) APPEARANCE OF THE EJACULATE
 A normal liquefied semen sample has a
homogeneous, grey-opalescent appearance.

 It may appear less opaque if the

sperm concentration is very low

 Red : When red blood cells are present

(haemospermia)

 Yellow : In case of jaundice or T/t with certain

vitamins or drugs.
(C) SEMEN VOLUME
 Contributed by seminal vesicles, prostate gland,
bulbourethral glands and epididymis.

 Normal volume : 1.5 mL

Low semen volume :

- Collection problems (loss of a fraction of the ejaculate)
- Partial retrograde ejaculation
- Androgen deficiency

High semen volume :


Active inflammation of the accessory organs.
 (D) SEMEN PH
o The pH values of accessory gland secretions mainly alkaline
seminal vesicular secretion & acidic prostatic secretion.

o Normal pH: 6.0 to 10.0 [Reference values - 7.2].

o pH is less than 7.0 - Ejaculatory duct obstruction, Congenital

bilateral absence of the vas deferens.

o pH is more than 7.0 -

pH increases with time as natural buffering
decreases, provides little clinically
useful information.
(II) INITIAL MICROSCOPIC INVESTIGATION
 A phase-contrast microscope is recommended
for all examinations of unstained preparation.
 This provides Overview of the sample:

• Mucus strand formation;

• Sperm aggregation or agglutination;

• Other cells e.g. Epithelial cells, leukocytes, immature

germ
cells) and isolated sperm heads or tails of fresh semen.
• Assessment of sperm motility.
(B) AGGLUTINATION OF SPERMATOZOA
o Agglutination specifically refers to motile
spermatozoa sticking to each other, head-to-head,
tail-to-tail or in a mixed way

Grade <10 spermatozoa per agglutinate, many free

1: spermatozoa
Isolated
Grade 2: 10–50 spermatozoa per agglutinate, free spermatozoa
Moderat
e
Grade 3: Agglutinates of >50 spermatozoa, some spermatozoa still
Large free

Grade 4: All spermatozoa agglutinated and agglutinates

Gross interconnected
 (III) SPERM MOTILITY

 Sperm motility within semen should be assessed as

soon as possible after liquefaction of the sample,
preferably at 30 minutes to limit the deleterious effects
of dehydration, pH or changes in temperature on
motility.
CATEGORIES OF SPERM MOVEMENT
Progressive motility (PR) :
Spermatozoa moving actively, either linearly or in a large
circle, regardless of speed.

 Non-progressive motility (NP) :

All other patterns of motility with an absence of progression
e.g. swimming in small circles, the flagellar force hardly
displacing the head or when only a flagellar beat can be
observed.

 Immotility (IM) : No movement.

 NORMAL RANGE

 The lower reference limit for total motility (PR + NP)

is
40%

 The lower reference limit for progressive motility (PR)

is
32%
(IV) SPERM VITALITY
 Assessed by identifying those with an intact
cell membrane from dye exclusion or by hypotonic
swelling.

 The presence of a large proportion of vital but immotile

cells may be indicative of structural defects in the
flagellum.

 A high percentage of immotile and non-viable cells

(necrozoospermia) may indicate epididymal pathology.

o Normally 75 % of sperms are viable.

o The lower reference limit for vitality

(membrane-intact spermatozoa) is 58%.
(V) SPERM CONCENTRATION

This is a measure of the capability of the testes

to produce spermatozoa and the patency of the male
tract.

 Normal sperm conc is > 20 x 106 /mL

 (VI) SPERM MORPHOLOGY
 3 main components :
 Head
 Neck
 Tail

 Normally 30% of
spermatozoa should show
normal morphology
(WHO 2010)
OTHER CELLS

o The presence of non-sperm cells in semen may be

indicative of

 Testicular damage (immature germ cells),

 Pathology of the efferent ducts (ciliary tufts)

 Inflammation of the accessory glands (leukocytes).

(VII) TESTING FOR ANTIBODY COATING OF
SPERMATOZOA

o If spermatozoa demonstrate agglutination, the presence

of anti sperm antibodies may be the cause.

o Anti-sperm antibodies (ASAs) in semen belong almost

exclusively to two immunoglobulin classes: IgA and
IgG.
o IgM antibodies because of their larger size are rarely
found in semen.
o IgA antibodies may have greater clinical importance
than IgG antibodies
IN-VIVO (POSTCOITAL) TEST
(SIMS-HUHNER) TEST

 Aim :- To determine the number of active spermatozoa

in the cervical mucus and to evaluate sperm survival
and sperm behaviour some hours after coitus

 Postcoital tests should be performed as close as possible

to, but before the time of ovulation, as determined by
clinical criteria
 Interpretation :

 Normal – Sperms normal in amount and

moving in forward direction, mucus
stretches at least 2 inches and dries in
a fern like manner

 Abnormal – Absence of sperms or large no of sperms are

clumped, cervical mucus cannot stretch 2 inches or
does not dry in a fern like manner
REFERENCE VALUES FOR SEMEN PARAMETERS, AS
PUBLISHED IN CONSECUTIVE WHO MANUAL

Semen parameters WHO 2010

1 Volume 1.5 mL
2 Sperm concentration 15 x 106 /mL

3 Total sperm concentration 39 x 106/mL

4 Total motility 40%
5 Progressive motility 32%
6 Vitality 58%
7 Leucocyte count < 1.0 x 106 /mL
2. SPERM FUNCTION TESTS
 Sperm DNA fragmentation seems to be one of the most important
causes of reduced fertility potential.

 An assessment of sperm DNA integrity is suggested in

the following situations :

 Infertile men present with a normal semen analysis as

determined by conventional methods

 Recurrent spontaneous abortion

 To determine the most suitable assisted reproductive

technology
3. ENDOCRINE EVALUATION

 Endocrine evaluation is suggested when the following

scenarios are present :
 A sperm concentration, 10 million/mL;
 Erectile dysfunction;
 Hypospermia (volume ,1 mL)
 Signs and symptoms of endocrinopathies or
hypogonadism

 The minimal evaluation includes the assessment

of serum FSH and testosterone levels, which reflect
germ cell epithelium and Leydig cell status
respectively.
 (A) TESTOSTERONE, FSH AND LH
o If the testosterone level is low, a second collection is
recommended along with free testosterone, LH and prolactin
measurements.
o Isolated FSH elevation is usually indicative of severe germ
cell epithelium damage.
o Highly elevated FSH and LH levels, when associated with
low-normal or below normal testosterone levels, suggest
diffuse testicular failure and may have either a congenital
(e.g., Klinefelter syndrome) or acquired cause.
o Concomitant low levels of FSH and LH may implicate
hypogonadotropic hypogonadism.
This condition may be congenital or secondary to
a prolactin-producing pituitary tumour.
o In azoospermic men with a normal ejaculate
volume-
- serum FSH level greater than two times the
upper limit of the normal range is reliably
diagnostic of dysfunctional spermatogenesis
(b) Gonadatrophin

 Gonadotropin values within the normal range

suggest an extraductal obstruction in
azoospermic subjects.
 (C) SERUM ESTRADIOL
 Serum estradiol levels should be determined in patients
presenting with gynecomastia.

 Infertile patients with a testosterone to estradiol ratio

less than 10 can harbor significant but reversible
seminal alterations.

 It has been also suggested that hyperestrogenism

secondary to a higher conversion rate of testosterone
into estradiol in Klinefelter syndrome patients.
4. GENETIC EVALUATION
INDICATIONS
Men with infertility of unknown Y chromosome microdeletion
etiology and sperm concentrations, and G-band karyotyping
10 million/mL who are candidates
for ART

Non-obstructive azoospermia in a male Y chromosome microdeletion

considering testicular sperm retrieval for ART and G-band karyotyping

Azoospermic or oligozoospermic men CFTR gene mutation analysis

with the absence of at least one vas
deferens at physical examination

Azoospermic men with signs of normal CFTR gene mutation analysis

spermatogenesis (e.g., obstructive
azoospermia of unknown origin)

History of recurrent miscarriage or G-band karyotyping

personal/familiar history of genetic
syndromes
IMAGING STUDIES
 TRUS
 Vasography

 Scrotal ultrasonography

 Abdominal ultrasonography

 Venography
TRUS
 Provides excellent definition of the
 Prostate
 Seminal vesicles
 Ampulla of the vas deferens
 Ejaculatory ducts
TRUS
 Employs the 5- to 7-MHz endocavitary probe
 Scanning is possible in both the longitudinal and
transverse planes
 The bladder ideally should be partially filled
which improves the delineation of
 Bladder
 Perivesical fat
 Seminal vesicles
TRUS
INTERVENTIONS
 Guided aspiration of seminal vesicle

 Transrectal injection of radioopaque contrast into

the seminal vesicles

Preparation:
 Cleansing enema
 Broad-spectrum Antibiotic coverage with a
fluoroquinolone
TRUS - EJACULATORY DUCT CYST
TRUS – DILATED SEMINAL VESICLES
SCROTAL ULTRASONOGRAPHY
 High-quality, non-invasive, non-ionising imaging
of scrotal contents
 Excellent anatomic details of the epididymis and
testis
Indications :
 When there is significant size discrepency of
testis
 When there is a palpable abnormality of testis

 When a varicocele is suspected but difficult to

identify clinically
SCROTAL ULTRASONOGRAPHY
 Primarily indicated in difficulty to diagnose
varicoceles
 Also provides information regarding
 Testicular size
 Epididymal inflammation
 Epididymal cysts
 Germ cell tumors
 Potentially obstructive paratesticular tumor
A NONPALPABLE TESTICULAR MASS
(SEMINOMA)
COLOR DOPPLER ULTRASOUND
 Helps better to diagnose varicoceles
 Demonstration of reversal of venous blood flow with
the Valsalva

 Epididymitis difficult to diagnose could be

identified
 Enlarged epididymis
 Increased vascularity
VASOGRAPHY
 Gold Standard Test for assessing the patency of
vas
 Provides anatomic details of the
 Vas deferens
 Seminal vesicles
 Ejaculatory ducts

 Determination of the site of obstruction in the

azoospermic patient

 Ideally performed at the time of anticipated

reconstruction
VASOGRAPHY
INDICATIONS:(Absolute)
1. Azoospermia, plus
2. Complete spermatogenesis with many mature
spermatids on testis biopsy, plus
3. At least one palpable vas
INDICATIONS:(Relative)
1. Severe oligospermia with normal testis biopsy.
2. High level of sperm-bound antibodies that may
be due to obstruction
3. Low semen volume and poor sperm motility
(partial ejaculatory duct obstruction).
VASOGRAPHY - TECHNIQUE

 Puncture technique
 Vasotomy technique

PUNCTURE VASOTOMY

ADVANTAGE Preferred technique Easier access in to the lumen

Allows examination of the

Avoids full thickness
intravasal fluid for presence
opening of vas of sperm to confirm
epididymal
patency
DISADVANTAGE Technically difficult Requires microsurgical closure
VASOGRAPHY - TECHNIQUE

 25-30 gauge lymphangiogram needle

 Contrast is injected in antegrade fashion

 Proper vasogram will opacify vas deferens with filling

of ipsilateral seminal vesicle and the bladder
 Failure to opacify the bladder
 Insufficient injection of contrast or
 Evidence of obstruction
NORMAL VASOGRAM
VASAL OBSTRUCTION
BLIND-ENDING VAS
EJACULATORY DUCT OBSTRUCTION
VENOGRAPHY
 The most sensitive imaging modality but limited
specificity
 100% of clinical varicocele patients will
demonstrate reflux on venography
LIMITATIONS
 Invasive nature

 Anaphylaxis to contrast

 False-positive results
 High-pressure contrast instillation
 Placement of the catheter tip through a valve of the
proximal portion of the internal spermatic vein.
6. MAGNETIC RESONANCE IMAGING

 Done to assess :

 Presence of a varicocele,
 Seminal vesicle agenesis
 Undescended testis

 MRI has traditionally been used to exclude cranial

pathologies manifested by hormonal disturbances.
 9. TESTIS FNAC

• It has gained importance as a diagnostic tool for male

infertility.

• It has greatest value in evaluation of spermatogenesis

in
azoospermic males, particularly in Non Obstructive
Azoospermia.
 INTERPRETATIONS
 Normal spermatogenesis
- Ratio of spermatogenic to sertoli cell should be atleast 1.5:1

 Hypospermatogenesis
- Ratio is less than 1.5:1

 Sertoli cell only/ germ cell aplasia

- Mainly sertoli cells no germ cells

 Atrophic pattern
- Mainly proteinaceous material, very scanty sertoli cells and
leydig cells

 Maturation arrest
- All types of germ cells except mature spermatozoa are seen
TESTICULAR BIOPSY
Diagnostic:
 Azoospermia with suspected obstruction as the
cause
 Normal testicular size and consistency
 Normal serum FSH levels

 Suspected testicular failure (occasionally)

 Small-volume testes, High serum FSH level
TESTICULAR BIOPSY
TESTICULAR BIOPSY
 Percutaneous testicular biopsy may be performed
using a cutting needle of core biopsy system using one
pass through the testis.

 Specimens should be placed in a fixative solution such

as Bouin’s, Zenker’s or glutaraldehyde.

 Formalin should not be used as it may disrupt the

tissue architecture.
THE SPECTRUM
MICROBIOLOGICAL ASSESSMENT
 Indications for microbiological assessment include
abnormal urine samples, urinary tract infections, ‘male
accessory gland infections’ (MAGI), and sexually
transmitted diseases (STDs).

 In combination with a small ejaculate volume: this may

point to a (partial) obstruction of the ejaculatory ducts
caused by a (chronic) infection of the prostate or
seminal vesicles.

 Gonorrhoea and Chlamydia trachomatis can also

cause obstruction of the genital tract.
SUMMARY

 Cause for male infertility may be pretesticular,

testicular , or post testicular
 Pre and post testicular causes are frequently
correctable whereas testicular cause is usually
irreversible except varicocele
 Evaluation after 1 year of regular unprotected
intercourse
 Concurrent basic evaluation of the female
partner is also prudent
 Seminal analysis is the cornerstone of initial
evaluation
 Minimal endocraine evaluation is FSH and
Testosterone , if testosterone is decreased then
LH and prolactin are tested
 Testicular biopsy – If the patient is azoospermic
with normal FSH level and normal testicular size
and consistency
Thank u
MEDICAL MANAGEMENT

 Empirical Therapy
- Antiestrogen.
- Aromatase inhibitor.
 ALTERNATIVE THERAPY
 Tocopherol (vitamin E), ascorbic acid (vitamin C),
acetylcysteine, or glutathione.

 Treatment with tocopherol improved sperm function (sperm–

zona pellucida binding capacity) and IVF rates.

 Increased sperm count, decreased ROS, and an augmented

acrosome reaction were reported in men who had oligospermia
after treatment with acetylcysteine and retinol (vitamin A)
together with tocopherol and essential fatty acids.

 Folic acid and zinc supplements have been also shown to

increase sperm concentration in subfertile men, whereas
seminal and hormonal parameters were unaffected.
SURGICAL MANAGEMENT
 Varicocelectomy

 Vasovasostomy

 Vaso-epididymostomy

 Micro-surgical Vaso-epididymostomy
 Micro-Anastomosis

 Standard Micr0-dot Technique (Godstein)

 Transurethral incision of ejaculatory ducts or

midline prostatic cyst
GLOBAL ACCESS TO INFERTILITY CARE IN DEVELOPING
COUNTRIES: A CASE OF HUMAN RIGHTS, EQUITY AND SOCIAL
JUSTICE

A need for ↑ reproductive health care education

 need for ↑ prevention programmes

• raising awareness: support of media and

patients networks needed
• implementation of more and accessible
infertility centres
→ Urgent need for simplified, safe and effective
methods (diagnostic procedures and art)
• prevention of complications is crucial.
• Facilities to handle complications have to be
available, including facilities for surgery
Thank you!!!!!!!