Male infertility Work up and Management overview

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Male infertilityWork up and Management overview

• Dr. Anmar Nassir, FRCS(C)
• Canadian board in General Urology
• Fellowship in Andrology (U of Ottawa)
• Fellowship in EndoUrology and Laparoscopy
  (McMaster Univ)
• Assisstent Prof Umm Al-Qura
• Consultant Urology KFSH RC

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8-15 of couples Male 50
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Pituitary-Gonadal Axis
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LH FSH

• LH
• Activate testicular T production from Leydig
  cells
• Feed back inhibition by testosterone
• FSH
• Stimulate Sertoli cells spermatogonial
  membranes
• The major stimulator of seminiferous tubule
  growth during development
• Feed back inhibition by inhibin from Sertoli cells

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• Testosterone will initiate and maintain
  spermatogenesis
• Sperm fertility maturation, achieved at the level
  of the distal corpus or proximal cauda
  epididymis.

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Physiology

• Epididymis
• Maturation
• Transport
• Storage
• Vas
• Transfer of sperm
• Seminal vesicles
• (The main bulk of the ejaculate)
• Secretory products e.g.
• fructose, prostaglandin, clotting factors
• Ejaculation
• Coagulation of semen
• Prostate
• Liquifaction
• Zn antibacterial sperm stabilization

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• The scrotal temperature is is 2C to 4C below
  rectal temperature due to counter-current
  mechanism

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Anatomical Physiology

• Epididymis
• Maturation
• Transport
• Storage
• Vas
• Transfer of sperm
• Seminal vesicles
• (The main bulk of the ejaculate)
• Secretory products e.g.
• fructose,
• prostaglandin,
• clotting factors
• Ejaculation
• Coagulation of semen
• Prostate
• Liquifaction
• Zn antibacterial sperm stabilization

Seminal vesicles ? 1.5 to 2.0 mL. Prostate ? 0.5
mL, Cowper's glands ? 0.1 to 0.2 mL,
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Evaluation ofInfertile patient
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• Abnormalities in the woman are involved in
  approximately 75 of infertile couples.
• 30 Ovulatory disorders
• 25 fallopian tube abnormalities
• 4 endometriosis
• 4 cervical mucus abnormalities
• 4 hyperprolactinemia
• Conception rates drop more rapidly in the 35- to
  39-year-old age group.

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• Many of the genes that affect male reproduction,
  including the androgen receptor gene, are located
  on the X chromosome.
• Therefore, family history should focus on the
  phenotype of the maternal uncles

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Impairing Spermatogenesis

• Medications
• nitrofurantoin ,
• cimetidine ,
• sulfasalazine ,
• Anabolic steroid
• Substances
• cocaine
• marijuana
• Nicotine
• pesticides

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Physical Exam
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Laboratory Assessment

• Semen analysis X2
• Quantitation of leukocytes in semen
• Lab Baseline, gluc. , U/A
• Hormonal assay FSH, LH, Prol, TSH,
• Antisperm antibodies semen or blood
• Advanced sperm fertility tests

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Semen

• The WHO (1999) defines the following reference
  values

Volume 2.0 ml or more
pH 7.2 or more
Sperm concentration 20 106  or more sperm/ml
Total sperm number 40 106  or more spermatozoa per ejaculate
Motility 50 or more with grade A B motility or 25 or more with grade A motility
Morphology 30 15 or more by strict criteria
Viability 75 or more of sperm viable
White blood cells Less than 1 million/ml
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Hormonal Evaluation
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Diagnostic Studies

• TRUS
• US scrotum
• Testicular biopsy

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Asthenospermia

• Pretesticular Testicular
  Posttesticular
• Endocrine Varicocele
  Antispermantibodies
• Environment Infection
• Febrile illness Partial
  ductal obst.
• Intrinsic defect

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Varicocele
Semen 3cc, 10m/cc, 34 motile, 29 normal
morphology and 0.9(10x6) WBC. On scrotal exam
bag of worms

• 15 of the population
• 35 of male with 1ry infertility
• 75 of male with 2ry infertility
• 40 bilateral
• Varicocele repair
• 75 improvement of semen
• 35 initiate pregnancy

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Varicocele

• Semen samples from infertile men with varicoceles
  have demonstrated decreased motility in 90 of
  patients and sperm concentrations less than 20
  million sperm/mL in 65 of patients.

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• Improvement in seminal parameters is demonstrated
  in approximately 70 of patients after surgical
  varicocele repair.
• Improvements in motility are most common,
  occurring in 70 of patients, with improved sperm
  densities in 51 and improved morphology in 44
  of patients.
• Conception rates have averaged 33 to 50
  compared with 16 in the control group

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Treatment

• Surgical
• Inguinal
• Retroperitonial
• Microscopic sub inguinal
• Laparoscopic
• Percutaneous venous occlusion

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Pyospermia

• Round cells WBCs and immature germ cells.
• Semen Culture

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ED Obstruction
Semen 0.9cc, 0.2m/cc,20 motile and negative
post void sperm.

• TRUS Dilated Ej Duct.
• TURED

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Causes of Obstructive Azospermia

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Testicular Biopsy

• Diagnostic
• Obstruction
• vs
• Sertoli Cell-only
• vs
• maturation arrest
• Therapeutic
• Harvesting sperms for ICSI

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Indications for ICSI

• Immunological infertility
• Severe oligoasthenospermia
• Obstruction azospermia
• Nonobstruction azospermia
• Anejaculation ?
• pregnancy rate 30 - 60
• Live delivery / initial ICSI cycle 20-40

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Risk of Congenital Anomalies with ICSI

• 1.8 congenital anomalies
• Miscarriage and congenital anomalies are same for
  ICSI and IVF

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Genetic Evaluation

• CF gene
• Karyotyping abnormality
• Y-chromosome microdeletion

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