MALE INFERTILITY

Dr. Ohazurike

OUTLINE
INTRODUCTION MALE REPRODUCTIVE PHYSIOLOGY. AETIOLOGICAL FACTORS EVALUATION TREATMENT.

INTRODUCTION
Definition - failure of a couple to achieve a pregnancy after one year of unprotected, adequately timed intercourse. Approx. 15% of couple attempting their first pregnancy meets with failure. 80 - 85% of couples will achieve conception within 12months

 30% of cases of infertility, pathology is solely in the man in 20%, both the man and woman are abnormal (Stephen Shaman 1999) infertility is on the increase; 50% reduction in sperm count, 20% reduction in semen volume in the past 50years (BMJ 1992 volume 305

 6% of the cases of habitual abortion as a result of abnormal sperm. 25-35% of infertile couple will conceive with intercourse alone within 2 years.

Physiologic anatomy of male sexual organ

PHYSIOLOGIC ANATOMY OF MALE REPRODUCTION

A.

hypothalamic - Pituitary - Gonadal axis. Hypothalamus regulates production and secretion of GnRH. GnRH is released in a pulsatile manner stimulating LH and FSH release from the anterior pituitary. LH and FSH binds to specific receptors on the Leydig and sertoli cells to produce testosterone and inhibin respectively. Prolactin inhibits GnRH, LH, testosterone production secretion and function.

B. Testes
leydig cells: produces and secretes testosterone in a diurnal pattern with peak levels in early morning 2% is free, 44% bond to SHBG, 54% bond to albumin and other proteins Its broken down in target cells to DHT responsible for spermatogenesis, differentiation of male internal and external genitalia inutero, promotion of sexual maturation at puberty.

C. Seminiferous tubules.
Accounts for 85 - 90% of testicular volume Has germ cells and sertoli cells Tight junction between sertoli cells forms the blood- testes barrier. Germ cells are arrange in order of 10, 20 spermatocytes and spermatids from BM to lumen.

Spermatogenesis
Spermatogonia -10 spermatocytes -20 spermatocytes - spermatids - spermatozoa. Generation is a sequence of developing germ cells spermatogenic cycle is 74 days transportation, maturation and storage of sperm occurs in epidydymis. Vas and ejaculatory ducts aids in transportation of sperm by peristalsis, emission and ejaculation prostrate contributes proteolytic enzymes, Zn, phospholipids, spermine, phosphatase to semen.

Fertilization
Cervical mucus changes, capacitation, acrosome reaction.

CAUSES OF MALE INFERTILITY

Pretesticular Testicular Post tesicular

MANAGEMENT OF INFERTILE MALE

HISTORY PHYSICAL EXAMINATION DIAGNOSTIC EVALUATION TREATMENT

HISTORY
Age of both partners Duration of marriage/infertility Duration of unprotected intercourse
Alternate day, sexual hx(difficulties,lubricants)

Previous use of contraception Knowledge of fertile period

 Past fertility of each, present or past union Results of previous invxs, previous or current treatment to infertility Radiation exposure- work, treatment, diagnostic Thermal exposure Any disease DM, HT,TB thyroid vascular dx, STD (prostate, vesicles) DES exposure microphallus,epididymal cyst, hypertrophy of prostatic utricle

 Any treatment for above Dx Drugs - cytotoxic, spironolactone DDT, alcohol, smoking Surgery Herniorrhaphy Orchidopexy vasectomy Repair of undescended tests

PHYSICAL EXAMINATION
Look for stigmata of Cushings dx body habitus Hypogonadism amt of hair & distribution gynaecomastia Hypothyroidism pattern of fat distribution Height, weight, BP, unusual length of extremities Neurologic examination for anosmia, visual acuity (pituitary disorders) Thyroid gland Operative scars

 Urogenital system Penis Palpate testes for location, consistency, tenderness Measure it with Praders orchidometer (<6ml Klinefelter syndrome, 15ml in normal patients

Palpate epididymis & vas deferens for cystic formation, tenderness or thickening - chronic inflammatory disease Swelling in scrotum presence of varicocele Inspect the groins for LN, scars Do Rectal examination for prostate

INVESTIGATIONS
SEMEN ANALYSIS

POST COITAL TEST

Hormone profile Vasography Testicular & prostate USS (transrectal) OTHERS

SEMEN ANALYSIS
MACROANALYSIS Appearance coagulum, liquefies 30mins Odor Smells like amniotic fluid (pungent b/c of oxn of spermine ) Colour Translucent or white grey Viscosity - .may be associated with poor liquefaction which may affect motility Volume 2.5 5ml PH 7.2 7.8 ( a balance between acidic prostatic secretion and alkaline seminal vesicle secretion)

MICROANALYSIS
Agglutinations Cellular elements Morphology >50% normal forms (>15% Kruger criteria) Motility/ % forward progression (0-4 grades) Count (density) 20 x 106/ml Total count - > 50 x 106/ml

 Seminal fluid fructose 120- 450mg/dl Produced by the seminal vesicle Reduced in cases of androgen insufficiency, partial obstruction, incomplete ejaculation, seminal vesiculitis. Absence in CAVD, complete obstruction, absence seminal vesicle TRUS necessary to confirm obstruction.

Sperm function test

Sperm penetration assay Human zona binding site Sperm viability testing- normal sperm will swell in hypotonic solution. Post coital test CASA- Curvilinear velocity,Cross beat velocity,Lateral head displacement

POST COITAL TEST

Done in preovulatory/midcycycle 6 10hrs after intercourse Abstinence for 3 days Also called Sims - Huhner test Normal 7 cells PHF, no agglutination, progressive movement Inconclusive I 7PHF without agglutination progressive movement

 Suspected immunological factor Regardless of total number of cells PHF & agglutination Abnormal Non- moving cells or absent Influenced by
Vaginal PH Composition of cervical mucus Coital technique Vaginal infection Wrong timing

Hormone profile
Aim to identify endocrinopathy 3% of men with infertility has primary endocrine problem
Testosterone LH FSH TSH/T3/T4 Prolactin oestogen

Radiography
Testicular USS + Doppler Transrectal USS Vasography Necessary for diagnosis of scotal mass, varicocele In cases of suspected obstructions Absence of vas deferens

Vasography
is indicated in the azospermic patient with documented sperm cell testicular iopsy tissue. Useful in diagnosing obstruction Injection of contrast into the vas in the direction of the ejaculatory duct. Point of obstuction is then noted in the

Testicular biopsy
Can be open or closed Fixed in bouin solution Finding may reveal normal spermatogenesis, hypospermatogenesis, arrest of spermatogenesis, absence of germ cell, absence of leydig cell, mixed lesion

Treatment
Make a diagnosis and treat : Treatable cause Idiopathic Non- treatable

Treatable Medical Sugical

Medical
Lifesyle modification Infection culture results Gonadotrophin def Gn replacement therapy. HCG/FSH Immunological High Dose Glucocorticoids has been tried Withdrawal of drugs Antioestrogen antioxidant

Medical
Treatment for anejaculaton- alpha agonist, parasympathomimetic, neostigmine. Treatment of retrograde ejaculation alpha agonist, anticholinergic, antihistamine. Failure, resort to sperm retrieval from urine. Infertility associated with erectile dysfunction, sildenafil etc can be used.

Surgical
Obstruction microsurgery preferred e.g vasovasostomy, epididymovasostomy - Aspiration of sperm for cryopreservation is advised due to possible antisperm antibody formation Varicocele varicocelectomy, ligation or sclerozing agent Carcinoma insitu & testicular tumours Orchidectomy chemoradiation therefore sperm cryopreservation is advised

Management of Idiopathic causes

Hormonal Non Hormonal Hormonal Treatment GnRH/HmG Recombinant FSH Exogenous testosterone Antiestrogens Clomiphene, tamoxifen

Non-Hormonal
Kallikrein Antioxidants Vit E Bromocriptine

Management of Non- treatable causes - ART

Start from cheaper interventions IUI/ intracervical insermination Azoozpermic husband/normal wives Normal sperm, poor delivery Unexplained infertility Serious non treatable causes IVF/ET, GIFT, ZIFT, ICSI. Mode of sperm retrieval can be PESA, MESA, TESA, TESE

Mode of sperm retrieval

PESA MESA TESA TESE Success rate 90% MESA ,TESE open microsurgical procedure PESA, TESA needle aspiration

OTHERS
Adoption Fostering Donor sperm

CONCLUSION
Male factor infertility is now a medico-social problem. It requires a diligent search to determine the precise cause. Although many cases are idiopathic, new technologies like ICSI has given hope to these males to have their own genetic offspring.