Lecture name:-Male infertility.
Time :- 2 hours.
Aims of the lecture:At the end of the lecture, the students are able to:1-Identify the main causes of male infertility.
2-Diagnose and investigate cases of male infertility.
3-Treat cases of male infertility.
Male infertility:Infertility: - It is the inability of the couples to conceive after 1 year of unprotected
intercourse.
Causes:1-Male causes:- 30%.
2-Female causes:- 50%.
3-Mixed causes:- 20%.
Evaluation of male infertility:1) History:Thorough medical, surgical and sexual history is needed.
2) Physical examination:Precise physical examination is needed concentrating on:
1. General examination.
2. Examination of the external genitalia and breasts.
3. Neurological examination.
3) Lab. Investigation:-
1. Seminal fluid analysis (S.F.A):
Each infertile male should have at least 2 or 3 S.F.A over a period of several
weeks.
The specimens should be examined within 1-2 hr. of collection.
Normal values of S.F.A according to W.H.O. are:
.Ejaculate volume: 1.5 – 5 ml.
.Sperm count: > 20 million /ml.(↓sperm count called Oligospermia while
absent of sperm called Azospermia)
.Motility : > 50% forward movement grade (a+b).( ↓ motility of sperm called
Asthenospermia).
.Morphology: >30% normal.
.Semen PH: alkaline (7.2 or more).
2. Hormonal evaluation:
.Indicated in sever oligospermia (<10 million sperm/ml) and those with
impaired sexual function (impotence, low libido).
.F.S.H.,L.H and testosterone should be measured first in infertile male
patients with suspected hormonal abnormalities.
3. Additional tests:
According to individual case and include one or more of the fallowing's:
.Antisperm antibodies.
.Ultra structural evaluation.
.Semen culture.
.Sperm penetration assay.
4) Radiological evaluation: may include:
1. Vasography:
Indicated in azospermic patient with active spermatogenesis on testicular
biopsy to determine the site of obstruction.
2. Trans rectal ultrasonography (TRUS):
To evaluate the prostate, seminal vesicles and ejaculatory ducts.
3. Scrotal ultrasonography:
The main application is for dx. Of varicocele.
Etiology and treatment of infertile male:In general, the causes of male infertility can be classified into:
1) Pre testicular causes: include
A- Hypothalamic diseases:as
1. Hypogonadotropic hypogonadism:
Either: congenital (Kallmann syndrome) or acquired forms.
Kallmann syndrome:it is a genetic disorder ccc.by failure of gonadotropins
releasing hormone secretion by the hypothalamus lead to secondary
testicular failure.
It is inherited as X-linked disorder and those patient ccc. By anosmia ,
cryptorchidism, gynecomastia and micropenis.
The length of the arms and legs more than the trunk.
*Treatment:
.Androgen replacement therapy with testosterone preparations for verilization
Then gonadotropins treatment for initiation of spermatogenesis with HCG.
Addition of F.S.H is required to complete spermatogenesis in cong. form.
2. Isolated L.H. deficiency (Fertile Eunuch syndrome)
Ccc. By large testes and small volume ejaculate.
Plasma L.H. and testosterone are low while F.S.H. is normal.
*Treatment: HCG replacement.
3. Isolated F.S.H. deficiency:
Rare with normal verilization and normal size testes.
*Treatment: recombinant human F.S.H.
B- Pituitary diseases:
*The pituitary function may be affected by(tumour, infection, surgery,radiation
and others)lead to infertility,E.D., headache and visual field defects.
The testes are small and soft with plasma testosterone and gonadotropins
are low.
*Prolactin excess (hyperprolactinaemia) may occur due to pituitary tumours or
others as stress or medication may be the cause of infertility.
Treatment:
Medical:bromocreptin or cabergoline.
Surgical:.pituitary adenomectomy.
C- Adrenal gland diseases:(Androgen excess)
Androgen excess due to endogenous (as in CAH) or exogenous causes is a
male contraception because it cause negative feedback on the pituitary
gonadotropins.
The patient ccc. By short stature, precocious puberty, premature enlargement
of the penis with small size testes.
*Treatment: Glucocorticoid decrease ACTH level and decrease peripheral
adrenal androgen and decrease negative feedback on pituitary gland.
2) Testicular causes( disorder of spermatogenesis):
A- Chromosomal disorders: as
1. Klinefelter syndrome :xxy
It ccc. By presence of extra x chromosome with small firm testes,
gynecomastia and increase gonadotropins level.
Azospermia is present with sclerosis of the seminiferous tubules on testicular
biopsy.
*Treatment:
No treatment improve spermatogenesis.
Recently , testicular sperm extraction can be done for those have mature or
immature sperms with A.R.T.
2. Noonans syndrome:
The phenotype is similar to turner syndrome and the karyotype is 46 xy.
Cryptorchidism and testicular atrophy are common and associated with
increase gonadotropins.
*No treatment for infertility in those patients.
3.Y- chromosome microdeletion:
Phenotype is normal male and the
karyotype is xy.
*No treatment improve spermatogenesis and those patients are candidate for
A.R.T.
B- Bilateral an orchia (Vanishing testes syndrome):
It is thought that the testes may be lost in utero secondary to infection,
vascular injury or testicular torsion.
*Treatment: infertility is untreated and exogenous testosterone is needed for
verilization.
C- Cryptorchidism:
Oligospermia is found in 50% of bilateral cases and 25% of unilateral cases.
*Treatment: Surgical correction improve fertility.
D-Varicocele:
*Improvement in the seminal fluid parameters occur in 70% of patients after $
E-Sertoli cell only syndrome:
Those patients present with small-normal size testes and azospermia.
*No treatment for infertility.
F- Others: as: cigarette, drugs, orchitis.
G- Idiopathic:
About 25% of patients with abnormal S.F.A. have no identified cause.
*Treatment:
.empirical treatment: should administered for a minimum 3-6 monthes.
It may include (Clomiphen citrate, androgens, antioxidants and others).
.A.R.T.
3) Post testicular causes(disorder of sperm transport):
A- Ductal obstruction:
The obstruction may be cong. as (CBAVD) or acquired(infection or iatrogenic)
*Treatment: surgical correction or A.R.T.
B- Ejaculatory problems:
It should be suspected in any pt. with low ejaculatory volume or absent
ejaculate.it can classified into:
.Anatomical: due to TURP or bladder neck $.
.Functional: due to neurologic abn. As D.M., M.S., spinal cord inj..
*Treatment: pharmacological treatment with ephedrine or imipramine useful
for functional causes. while those with anatomic cause need $.correction.
4- Sperm function disorders:
A- Immunological infertility:
*Treatment: 2 approaches
.Suppress antibodies formation by corticosteroid treatment.
.semen processing to remove antibodies or select those spermatozoa not
bounded by antibodies.
B- Ultra structural sperm abnormalities: dx. By E.M.
*Treatment: no cure for these abn. But these sperms can be used for A.R.T.
Assisted Reproductive Technique (A.R.T.):
These are techniques involve manipulation of sperm or ova or both in attempt
to improve the chance of conception. It include:
1) Intra uterine insemination (IUI):
By using small catheter to inject the processed sperm through the cervix into
the uterine cavity.
*Indications:
1. cervical mucous abn.
2. sever dysparonia.
3. retrograde ejaculation.
4. some cases of E.D.
5. Unexplained infertility.
2) In Vitro Fertilization (IVF):
In vitro insemination is performed by mixing the processed sperms with the
recovered oocytes and the developing embryo incubated for 2-5 days in a
culture medium then implanted into the uterus.
3) Sperm retrieval:
It considered in azospermic pt. or those with only nonviable sperms.
Percutaneous and open tech. are used for aspiration of sperms from the
epididymis or testes.