Male Infertility

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? ? ? ?

• ????? ????
• ????? ??
• ? ? ?

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Male Infertility

• ?? No pregnancy in couples
• who use no contraceptive
• measures within 1 year
• Incidence 13
• M F M F 1 1 1

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Testis

• ??? ?? ??? ?? ??
• 3.8 x 2.7 x 2.1 cm
• 10gm, 20ml ??
• ??? Testosterone synthesis
• Spermatogenesis
• ??? 85 ???

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Spermatogenesis

• Primitive stem cell
• Type A spermatogonia
• Type B spermatogonia
• Primary spermatocyte
• Secondary spermatocyte
• Spermatid
• Spermatozoa

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Spermatogonium?? sperm? ??? ??? ??

• Stage I-VI 1 cycle
• ? ??? ??? ?? 16 ?
• mature sperm? ???
• 4.6??? ??
• ??? 16 x 4.6 74?

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Leydig cell

• Function
• 1) regulation of gonadotropin secretion
• by H-P-G axis
• 2) initiation maintenance of spermatogenesis
• 3) differentiation of int. ext. genital system
• during fetal development
• 4) promotion of sexual maturation at puberty

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Sertoli cell

• ???? ?? ?? ??? ?? ??
• rest on basement membrane
• function
• blood - testis barrier immunologic Fx.
• production of ABP
• production of inhibin

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Testosterone

• From Leydig cell(90)
• Diurnal pattern
• TeBG 98, free testosterone 2
• Fx. of testosterone
• spermatogenesis
• regulation of gonadotropin
• differentiation of fetal male genital
  system
• promotion of sexual maturation

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Role of epididymis

• Sperm maturation
• storage
  
• transport
• absorption

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Journey of Sperm

• 250 seminiferous tubules
• rete testis
• ductuli efferentes
• epididymis
• vas
• ejaculatory duct
• emission
• ejaculation

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?? ? ??
?????? ???????????(Kallmann
syndrome) ??????????(fertile
eunech) ??????????? ??? ????????? ???
???? ?? ????????(??, ??? ??, ??,
???) ??????? ???? ??? ???(?????-????? ??,
???????? ??, ????????, ????????)
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?? ??
??? ??(Klinefelters syndrome, XX disorder
sex reversal syndrome, XYY syndrome) Noonans
syndrome(male Turners syndrome) Myotonic
dystrophy ??? ????(Vanishing testes
syndrome) Sertoli cell only syndrome(germ cell
aplasia) ?? ???(??, ???) ??? ? ? ????(???, ???,
??????) ????? ?? ? ?? ?? ???? ?????
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?????

• ?? ?? ??? 10-15
• ?? ??? 30-40
• ?? 90, ??? 40
• ?? ??? ??? ??
• 1) ?? ??? ??
• 2) ??????? ?? ???? ??
• ???? ?? ?????? ???
• ?? ??
• 3) ?? ??? ????

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?? ? ??

• ??? ???? ???,???,???
• ??? ??? ? ????
• ?? ??? ??? ??
• ????
• ??? ??
• ??? ??
• ??

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• semen spermatozoa seminal plasma
• seminal plasma
• seminal vesicle (60)
• prostate (20)
• bulbourethral gland
• urethral gland
• ejaculation
• 1st portion most of spermatozoaprostatic
• 2nd portion a few spermatozoaS.V. sec.

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Evaluation of male infertility(1)

• 1. Clinical evaluation
• 1) History taking
• 2) P/E
• general
• genital

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Evaluation of male infertility(2)

• 2. Lab. evaluation
• 1) S/A
• sperm collection
• sperm count
• sperm motility
• sperm morphology
• fructose

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???? ???

• ????
• ? ? 2.0ml ??
• ?? ?(/ml) 20 x 106 ??
• ? ?? ?(/????) 40 x 106 ??
• ??? 50?? ??? ??
• (categories
  ab)? ?????,
• ??????
  ???(category a)25??
• ? ? ????? 30 ??
• ? ? 75?? ??
• ????
• a-Glucosudase(??) ?????? 20mU ??
• ??(??) ?????? 2.4umol ??
• ???(??) ?????? 52 umol ??
• ??????(??) ?????? 200 U ??
• ??(??) ?????? 13umol ??

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Evaluation of male infertility(3)

• 2) Hormonal evaluation
• endocrinologic cause 3
• testosterone, FSH, LH, prolactin
• elevated FSH germinal epithelial
• damage

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Chromosome Study

• ???
• 1) ?? ??? 2-5ml, ??? ??,
• ???????,
• FSH? LH?? ?? ??
• 2) ??? ??, ?? ??? ???
• ????? ?? ????

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Testis biopsy Vasography

• ?? ??? ?????
• ???? ?? ?? ?????
• ?? ??
• Obstructive azospermia ? ??

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Treatment(1)

• 1. Medical Tx
• 1) Endocrine Tx hCG, hMG
• 2) Immunologic infertilitycorticosteroid
• 3) Empirical Tx clomiphene
• 4) Tx of retrograde ejaculation

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Treatment(2)

• 2. Surgical Tx
• 1) Varicocelectomy
• 2) Vasovasostomy
• 3) Epididymovasostomy
• 4) TUR of ejaculatory duct
• 5) MESA(microsurgical epi. sperm
• aspiration)
• 6) TESE(testicular sperm extraction)

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????

• AID, AIH
• ART(Assisted Reproductive Technique)
• Sperm bank

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?? ????

• Vasectomy
• Vasovasostomy

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MALE SEXUAL DYSFUNCTION

• Rapid advance recently due to
• 1) progress in basic science
• 2) improve in diagnostic technique
• 3) effective treatment option

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TERMINOLOGY(1)

• Libido urge or biologic drive
• to initiate sexual activity
• Flaccid nonerect
• Erection tumescence rigidity
• Tumescence
• Rigidity
• Intromission introduction of penis

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TERMINOLOGY(2)

• Thrusting in out movement
• Emission deposition of semen
• Organism sensory experience of
• a sudden relief of sexual
  tension
• Ejaculation forcible expulsion of semen
• Detumescence loss of penile rigidity
• tumescence
• Latency

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ANATOMY

• Arterial system
• Int. pudendal A.( 4 branches )
• 1) cavernosal A.- helicine A.
• 2) dorsal A.- glans penis
• 3) bulbar A. urethral A.- C. spongiosum

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ANATOMY

• Venous system
• 1) superficial superficial dorsal V.
• 2) intermediate deep dorsal V.
• 3) deep emissary V.- circumflex V.
• cavernous V.

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NERVOUS SYSTEM

• ANS
• S2-S4 pelvic plexus - cavernous N.
• T12-L2
• Somatic motor N.
• S2-S4 - pudendal N.

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3 TYPES of ERECTION

• Reflexogenic induced by genital
• stimulation
• Psychogenic visual or auditory
• stimuli
• Nocturnal during REM sleep

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6 Phases of Erection

• Flaccid phase
• Initial filling phase
• Tumescent phase
• Full erection phase
• Rigid erection phase
• Detumescent phase

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Hemodynamics of Erection

• Relaxation of the smooth m.
• of the arteriolar tree trabeculae
• sinusoidal space arterial tree increase
• blood flow increase
• trapping of blood
• expansion of sinusoidal wall
• compression of subtunical V. emissary V.

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PATHOGENESIS(1)

• Psychogenic
• ?? 90 ?? 50?
• Neurogenic
• 1) CNS Ds., spinal cord injury
• 2) Peripheral neuropathy DM,alcoholism
• 3) trauma, surgery

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PATHOGENESIS(2)

• Hormonal
• 1) decreased libido
• 2) DM, hypogonadism, estrogen Tx.,
• hyperprolactinemia
• Arterial
• 1) arteriosclerosis, aging, DM
• 2) pelvic trauma

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PATHOGENESIS(3)

• Venous sinusoidal
• 1) defect of tunica albuginea or
• excessive No. or increased size of vein
• 2) fibrous replacement of cavernous smooth
• M.(priapism, DM, severe arterial Ds.)

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PATHOGENESIS(4)

• Drug induced
• 1) antihypertensive agents
• 2) psychotropic agents
• 3) marihuana, alcohol,cigarette
• 4) estrogen, cimetidin, ranitidine

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PATHOGENESIS(5)

• Systemic disease
• 1) DM neurogenic vasculogenic
• insulin dose, duration, adequacy of
• control unrelated
• 2) Renal disease(dialysis)

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DIAGNOSIS(1)

• History P/E
• Lab. LFT, FBS/2PPS, testosterone/LH/FSH,
  prolactin
• NPT test AVSS
• Intracavernous injection of vasoactive drug
• Psychologic studies
• Vascular studies
• Neurogenic studies

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?????? ??

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• ??????
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• ????? ???
• ?? ? ????

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?????

• ???
• 1) Yohimbin alpha-2 ???????
• 2) Trazodone ????
• 3) Sildenafil citrate
• 4) Apomorphine
• 5) Phentolamine(Vasomax)
• ????
• MUSE PGE1? ??? ??

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Sildenafil Citrate(Viagra)

• GC PDE5
• ? ?
• GTP-------gtcGMP-------gtGTP
• smooth M. relaxation
• ?? ?? ?? ???? 1?? ? ???
• ??? 4??
• ?? 1?? ?? ??
• ??? ????? ???
• Nitrate?? ???? ??
• ??? ???? ?? ?

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??????

• ??? ????.
• 30? ?? ???? ??? ??.
• 5-6?? ????? ???? ????
• ???? 200mmHg?? ??? ??
• 225mmHg?? ?? ???
• ?????? ???? ?? ??? ???? ??.

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?????????(1)

• ?? 70 ?? ???? ??
• ??? ?? ?? ?? ??
• ????
• 1)?? papaverin, PGE1
• 2)??
• papaverin phentolamine
• papaverin phentolaminePGE1
• PGE1 phentolamine

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?????????(2)

• ???
• 1) ?????, ?????? ???,
• ????, ???? ?
• 2) ??, ???, ?? ??
• ??? ??
• ???
• ????? ?? ??.

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????? ???

• ?? ??? ??? ??
• ? ?? ??? ?? ?? ??? ??
• ? ? ?? ?
• ??? ?? ?? ??? ??.
• ??? ?? ? ???? ??.
• ? ? ???? 90
• ???, ???, ?? ???

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?? ? ????

• Penile revascularization
• Ligation of vein

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???(1)

• ??
• ? ?? ? ??? 50?? ????
• ?? ?? ? ?? ??? ???
• ??? ??? ? ?? ??
• ??
• ???
• ???

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???(2)

• ??
• ???, ???
• ??
• 1) ????
• 2) ???? ????? ???
• 3) ???? ?? ???

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