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MALE INFERTILITY

Hospital Raja Perempuan Zainab II


Kota Bharu
Department of O&G
by Dr. Wan Zahanim

Case
Puan RH, 31 year old housewife
Presented to GOPD in 1995 with history of
primary infertility after 5 years of marriage
Shes a healthy lady
Shes married to a 38 year old lorry driver
who smokes 20 cigarettes per day for
almost 20 years

Cont. history
He had history of Gonorrhoea in 1987 with
multiple attacks and had been treated by GP
He had no other medical or surgical illness
This is his second marriage in which his first
marriage lasted for 5 years without any
children
Currently his first wife remarried another man
and shes pregnant

Cont.examinations
Wife normal
Husband: Genitalia: Both testis appears
atrophic and soft
R testis : 2.5x1.5 cm
L testis : 3.0x2.0 cm
Volume less than 10 mls

Cont.investigations
Seminal fluid analysis : AZOOSPERMIA
Repeated 3 times : AZOOSPERMIA
Post SI urine for sperm negative
LH/FSH level : HIGH

Cont. diagnosis
TESTICULAR FAILURE
He was referred to urologist and testicular
biopsy performed in 1997
NO SPERM SEEN
MANAGEMENT : this couple was advised
for ADOPTION

INTRODUCTION
INFERTILITY : failure to conceive within
12 months of unprotected intercourse.
50% of normal couples conceive within 5
months and 85% within 12 months
Second pregnancy occur sooner which is
50% within 2 months

Current
estimates suggest about 6% of men
between the ages of 15 and
50 are infertile.
A man will eject nearly 200 million
sperm. However, because of the natural
barriers in the female reproductive tract
only about 40 sperm will ever reach the
vicinity of an egg

EPIDEMIOLOGY
Most fecund couples conceive soonest
because the chances of conception decline
with the duration of infertility
5% of couples desiring children have none by
the end of their reproductive life
Male infertility may be the largest single
cause of human infertility and it responsible
for one third of all primary infertility

EPIDEMIOLOGY - cont
Male factor also responsible for 20% of
secondary infertility and 20% of primary
infertility that involve both partners
AZOOSPERMIA is found in
approximately 10% of infertile couples

Table 1.

Causes of Male Infertility


Deficient sperm production
Ductal obstruction
Congenital defects

Postinfectious obstruction
Cystic fibrosis
Vasectomy

Ejaculatory dysfunction
Premature ejaculation
Retrograde ejaculation

Disorders of accessory glands


Infection
Inflammation
Antisperm antibodies
Coital disorders
Defects in technique
Premature withdrawal
Erectile dysfunction

Table 2. Possible

Causes of Falling Sperm Counts

Increased scrotal temperature


Tight-fitting clothing and briefs
Varicoceles are more common

Environmental
Increased pollution
Heavy metals (lead, mercury, arsenic, etc.)
Organic solvents
Pesticides (DDT, PCBs, DBCP, etc.)

Dietary
Increased saturated fats
Reduced intake of fruits, vegetables, and whole grains
Reduced intake of dietary fiber
Increased exposure to synthetic estrogens

Table 4. Causes

of Temporary Low Sperm Count

Increased scrotal temperature


Infections, the common cold, the flu, etc.

Increased stress
Lack of sleep
Overuse of alcohol, tobacco, or marijuana
Many prescription drugs
Exposure to radiation
Exposure to solvents, pesticides, and other toxins

AZOOSPERMIA- CAUSES
ABSENT SPERMATOGENESIS
OBSTRUCTIVE AZOOSPERMIA
RETROGRADE EJACULATION

Absent Spermatogenesis

1. Abnormalities at the hypothalamus or pituitary


a)Congenital- Kallmans Syndrome
b)Acquired- trauma, tumour
2. Abnormalities at the testis
a)Congenital- chr. abn,cryptorchidism,
Sertoli cell only syndrome
b)Acquired- infection, trauma,
DXT,chemo

Obstructive azoospermia
Congenital - absence of vas deferens
Acquired - bilateral epididymo-ochitis or
trauma

Retrograde ejaculation
Congenital- anomalies at the bladder neck
or urethral valves
Neurological abnormalities
Previous surgery
Idiopathic

INVESTIGATION
MALE

FEMALE

OVULATION

HORMONAL
BOM
BBT

TUBAL

HSG
LAP

MALE
SFA X 3
AZOOSPERMIA

POST SI URINE

+ve

-ve
LH/FSH

RETROGRADE
EJACULATION
REDUCED
HYPOTHALAMIC
PITUITARY

NORMAL

OBSTRUCTION

INCREASED
TESTICULAR
FAILURE

INVESTIGATION
SEMINAL FLUID ANALYSIS (SFA) - is the
gold standard
Specimen preferably produced after 3 days of
abstinence
Specimen collected by masturbation into wide
mouthed sterile container
Specimen should be protected from
temperature fluctuation

INVESTIGATION- cont
Specimen should reached the lab within 1-2
hours of ejaculation
Specimen must be thoroughly mixed before
examinations under the microscope

Definition: It is a penile ejaculate


consisting of a thick, opaque, yellowishwhite, viscid fluid containing
spermatozoa; a mixture produced by
secretions of the testes, seminal vesicles,
prostate, and bulbourethral glands.

FRACTION ONE: Prostate portion.


Makes up about 20% -25% of the total volume,
containing citric acid, enzymes (for coagulation and
liquefaction), zinc, and acid phosphatase.
FRACTION TWO: Seminal vesicles portion.
Contributes 60% or more of the total volume and
contains fructose, flavins (enables the fluid to fluoresce,
citric acid, and potassium. This portion is the nutrient
medium for spermatozoa.
FRACTION THREE: Bulbourethral and urethral
glands.
Make only a minor contribution.
FRACTION FOUR: Testes and epididymis.
Contributes approximately 7% of the total volume.
Spermatozoa are found in this fraction.

SFA - NORMAL by WHO


VOLUME - 2-6 ml
DENSITY- 20-200 million/ml
MOTILITY- more than 50% progressively
motile
MORPHOLOGY- more than 50% normal

INVESTIGATION- post SI
urine
The presence of sperm will make the urine TURBID
On centrifugation and examination under
microscope, there will be numerous sperms
Treatment- Crich and Jequier 1978 suggest to
ejaculate with full bladder
Alkalinizing the urine prior to ejaculation by
ingestion of NaHCO3 then collect and centrifuge
the urine for AIH

INVESTIGATION- hormone
FSH/LH
REDUCED in hypogonadotrophic hypogonadism
eg. Kallmans syndrome
NORMAL in patients with obstruction anywhere
from the seminiferous tubules to the opening of
the ejaculatory ducts into the prostatic urethra
INCREASED in testicular failure eg. Klinefelters
syndrome

MANAGEMENT- obstruction
Refer to urologist
Vasovasostomy, vasoepididymostomy
Testicular biopsy- presence of sperm
Fertility following surgery usually poor
ART can be offered

MANAGEMENThypogonadotrophic
Gonadotrophic
hypogonadism
injections to promote
spermatogenesis ( Wu 1985)
ART also can be offered

MANAGEMENT- testicular
failure
In severe cases in which the sperm is absent
totally from the testicular biopsy,
ADOPTION OR ART WITH DONOR
SPERM
In milder forms in which minimal amount
of sperm is present in the testicular biopsy,
ART can be offered

MANAGEMENT FOR LOW


SPERM COUNT
GENERAL MEASURES
DIET
SUPPLEMENT
BOTANICAL MEDICINE

General Measures:
Maintain scrotal temperatures between
94-96o F.
Avoid exposure to free radicals.
Identify and eliminate environmental
pollutants
Stop or reduce all drugs, especially
anti-hypertensives,
antineoplastics such as
cyclophosphamide, and antiinflammatory
drugs such as sulfasalazine

This temperature reduction is best done by not wearing


tightfitting
underwear or tight jeans, and avoiding hot tubs.
In addition, the following exercises can raise scrotal
temperature,
especially if a man is wearing synthetic fabrics,
exceptionally
tight shorts, or tight bikini underwear: rowing machines,
simulated cross-country ski machines, treadmills, and
jogging. After exercising, a man should allow his testicles
to
hang free to allow them to recover from heat buildup.

Infertile men should wear boxer-type underwear


and periodically
apply a cold shower or ice to the scrotum. They
can
also choose to use a device called a testicular
hypothermia device
or "testicle cooler" to reduce scrotal
temperatures. Still in
its somewhat primitive stage, the testicle cooler
looks like a
jock strap from which long, thin tubes have been
extended. The

tubes are attached to a small fluid reservoir filled with


cold water that attaches to a belt around the waist. The
fluid reservoir is also a pump that causes the water to
circulate. When the water reaches the surface of the
scrotum it evaporates and keeps
the scrotum cool. Because of the evaporation, the
reservoir must be filled every six hours or so. It is
recommended that the
testicle cooler must be worn daily during waking
hours. Most users claim that it is fairly comfortable
and easy to conceal

Diet: Avoid dietary sources of: free radicals;


saturated fats;
hydrogenated oils; trans-fatty acids; and cottonseed
oil. Increase
consumption of: legumes, especially soy (high in
phytoestrogens and phytosterols); good dietary
sources of
antioxidant vitamins, carotenes, and flavonoids
(darkcolored
vegetables and fruits); and essential fatty acids and
zinc (nuts and seeds). Recommend the daily
consumption
of: 8-10 servings of vegetables; 2-4 servings of fresh
fruits;
and 1/2 cup of raw nuts or seeds.

dietary
vitamin C plays a critical role in protecting
against sperm damage
and that low dietary vitamin C levels were
likely to lead to
infertility.

vitamin E, selenium, and


beta-carotene are also important
and should be supplemented.

Optimal zinc levels must be


attained if optimum male sexual
vitality is desired

Nutritional Supplements:
Multiple vitamin and mineral
Vitamin C - 1,000-3,000 per day in
divided doses
Vitamin E - 600-800 IU per day
Beta-carotene - 100,000-200,000 IU
per day
Folic acid - 400 g per day
Vitamin B12 - 1,000 g per day
Zinc - 30-60 mg per day

Botanical Medicines:
Panax ginseng (three times per day dosages)
High quality crude ginseng root - 1.5-2 g/d 3x/d
Standardized extract (5% ginsenosides) 500mg 3x/d
The dosage of ginseng is related to the ginsenoside
content. The typical dose (taken one to three times
daily)
should contain a saponin content of at least 25 mg of
ginsenoside
Rg1 with a ratio Rg1 to Rb1 of 2:1. For example,
for a high quality ginseng root powder containing
5% gin

ARTIFICIAL
REPRODUCTIVE
InTECHNIQUE
the couple with infertile man especially

with azoospermia, the treatment that we


provide in the late 20th century differs very
little from that offered by Galen in 160 AD
However the place of ART has gradually
progressed since the early 1980s

ART - cont
Success in the arena of ART has been
spectacular for those having donor
insemination and less so with IVF and
GIFT
Most advances have occurred this century
especially micromanipulation technique

ART- micromanipulation
technique

Basically there are 3 micromanipulative techniques


of assisting fertilization in azoospermic patients
1. PARTIAL ZONA DISSECTION (PZD)
Cohen et al 1988
2. SUBZONAL INSEMINATION (SUZI)
Ng et al 1988
3. INTRACYTOPLASMIC SPERM
INJECTION Palermo et al 1992

ART- PZD
The principles is making a hole in the Zona
pellucida by methods - zona drilling,
cracking or cutting by - acidified medium or
a sharp glass neddle
Intention is to permit weakly motile
spermatozoa to gain access to the oolemma

ART- SUZI
A process in which one or more
spermatozoa are inserted into the
perivitalline space
This procedure sometimes will end up with
polyspermy

ART- ICSI
This is the latest micromanipulative
technique and the method of choice for
patient with severe male infertility
It is a process of injecting a spermatozoon or
sperm head directly into the ooplasm
ICSI has transformed the treatment of severe
male infertility during the past 2 years

ICSI - cont
The method has become increasingly
successful and now offers the hope of
having children to many man with virtually
no spermatozoa
In centres expert in ICSI, the fertilization
rate can be as high as with good sperm and
the pregnancy rates can be as high as with
standard IVF for other indications

ICSI - cont
Current development now include the use of
immature epididymal sperm and immature sperm
obtained by testicular biopsy
The source of sperm doesnt effect the pregnancy rate
ejaculated epididymal testicular
cycle
2572
128
120
transfers
93%
91%
90%
preg/cycle 34%
39%
36%

CONCLUSION
Male infertility has been neglected until the
past few decades
Now that female infertility has been defined
and in many instances treated successfully, it
is timely to focus on the male
While most causes of male infertility are
incurable, there have been major advances in
basic knowledge and research which will

CONCLUSION- cont
foster development of better diagnostic and
therapeutic measures
Failure of conventional IVF has lead to
attempts to broach the barrier of zona
pellucida by micromanipulative methods
Success has been infrequent but fertilization
(20%) and pregnancy rate (5%) are
improving

CONCLUSION- cont
With these techniques, polyspermy is
common (10%)
ICSI has been reported to produce higher
fertilization rates (50%) even with severe
sperm abnormalities, zero motility and total
teratospermia

THANK YOU