MALE INFERTILITY AND

SEXUAL DYSFUNCTION
Presented at ASI Congress, Surabaya, August 20 -24, 2006

DEPARTMENT OF MEDICAL BIOLOGY AND ANDROLOGY

KM Arsyad
KMA MI & SD

LEARNING OBJECTIVES

1.
2.
3.
4.

Student be able to know and

understanding :
Infertile Couples,
The etiology of male Infertility
Sexual Function
Etiology of Male Sexual Dysfunction

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LEARNING CONTENTS:
1.
2.
3.
4.
5.
6.
7.

INTRODUCTION
INFERTILE COUPLES
THE ETIOLOGY OF MALE INFERTILITY
MANAGEMENT OF MALE INFERTILITY
SEXUAL FUNCTION
ETIOLOGY OF MALE SEXUAL DYSFUNCTION
MANAGEMENT OF MALE SEXUALDYSFUNCTION

KMA MI & SD

1.
1.ANDROLOGY
ANDROLOGY
2.
THE
2. THEROLE
ROLEOF
OFSEXUAL
SEXUAL
RELATIONSHIP
RELATIONSHIP
3.
BRANCHS
3. BRANCHSOF
OFMEDICINE
MEDICINE
RELATED
TO
INFERTILE
RELATED TO INFERTILECOUPLES
COUPLES

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1.1. ANDROLOGY

Term : andros & logos

DEFINISI :
Cabang ilmu Kedokteran mengenai
kesehatan SRP, mulai dari masa
perkembangan sampai masa dewasa
meliputi masalah infertilitas,
hipogonadism, disfungsi seksual pria,
Pria lansia dan kontrasepsi pria

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1.1. DEFINITION

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1.1. DEFINITION , CENTRAL TOPICS

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1.2. THE ROLE OF SEXUAL RELATIONSHIP :

PROCREATION

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PLEASUR
E

LOVE

1.3. THE BRANCHES OF MEDICINE RELATED TO

INFERTILE COUPLES
Infertile couples

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2.1.HUMAM REPRODUCTION

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2.3. REQUIREMENT FOR PREGNACY

MALE ASPECTS
1. The male must produce satisfactory numbers of
normal motile spermatozoa.
2. He must have patent conduits and potency to
ejaculate spermatozoa into the vagina,
3. The spermatozoa must reach to cervix, pass through
the cervical mucus, and ascend through the uterus
and oviduct at an appropriate time to encounter an
ovum,
4. The spermatozoa must be capable of penetrating and
fertilizing ovum,

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2.3. REQUIREMENT FOR PREGNACY

FEMALE ASPECTS
5. The female must release an ovum that has
access to a patent oviduct,
6. The fertilized ovum must move into the
uterus and find an endometrium prepared
for implantation.
7. The embryo must implant, develop normally,
and produce the glycoprotein gonadotropin
(HCG) to rescue the corpus luteum
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FACTORS AFFECTING REPRODUCTIVE PERFORMANCE :

1. Age of the Wife
2. Age of the Husband
3. Frequency of Intercourse, and
4. Duration of Coital Exposure.
Age
Mean Conception
Age
Conception
in less
Of wife
delay in months
of husband than 6
months(%)
16
12
<25
75
17
10
25 29
48
18
9
30 - 34
38
19
8
35 - 39
25
20
7
40 / >
23
21-23
6
Weekly freq.
Conceptions
in under
24
5
of intercourse 6 months
(%)
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25
6
<1
17 13
26
8
once
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2.2. Probability Of Infertile Couple

No

Treatment

Husband

Wife

Infertilty

1.

FERTILE

FERTILE

IDIOPATHIC

ART/ IMMUNOLOGIC

2.

FERTILE

SUBFERILE

WIFE FACTOR

WIFE

3.

FERTILE

STERILE

WIFE FACTOR

ADOPTION

4.

SUBFERTILE

FERTILE

HUSBAND FACTOR

HUSBAND

5.

SUBFERTILE

SUBFERTILE

BOTH

BOTH

STERILE

FERTILE

HUSBAND FACTOR

ART/CLONING

STERILE

SUBFERTILE

BOTH

ART/CLONING

8.

STERILE

STERILE

BOTH

ADOPTION

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2.1. INFERTILITY :

Infertility is defined as the failure of a

couple to achieve pregnancy after
unprotected intercourse,
Prevalence 8 % (50 80 Million population)
2 Million new Infertile couples each year
Male infertility has many causes from
hormonal imbalances, to physical
problems, to psychological and/or
behavioral problems,
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3. THE ETIOLOGY OF MALE INFERTILITY :

1.

2.

3.

4.

Hormonal
Imbalances,
Physical
Problems,
Psychological
Problems,
Behavioral
Problems,
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3.1.HORMONAL IMBALANCES :

Disorders on the
hypothalamus-pituitary
testis axis,
Hyperprolactinemia,
Hypogonadotropic
Hypopitutarism,
Panhypopituitafism,
Hypothyroidism,
Congenital Adrenal
Hyperplasia.
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3.2. PHYISICAL PROBLEMS :

Varicocele,
Damaged

Sperm Ducts :
congenital, or acquired,
Infection and Diseases,
Retrograde Ejaculation,
Torsion.

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3.2.1. INFECTION and DISEASES :

1.
2.
3.
4.
5.
6.
7.

Sexual transmitted diseases.

Orchitis,
Accessory glands infection (MAGI),
Diseases with high fever,
TBC
Diabetes Mellitus
Others systemic diseases affected to
Liver or Kidney function,

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3.3.PSYCHOLOGICAL PROBLEMS :
The

term mental illness covers a

broad range of disorders cause
psychological, personality or
behavioral symptoms,
1) Neuroses, stress, depression
2) Psychoses,
3) Sexual deviation.
4) Drug uses for mental therapy
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3.4. BEHAVIORAL PROBLEMS :

Occupational

diseases,
Lifestyle (Alcoholism, Smoking,
Drug addiction, etc)
Tight underwear
Pollution (air, water and food)
Handphones, Laptops

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ETIOLOGIC
ETIOLOGIC FACTORS
FACTORS INFLUENCES
INFLUENCES SPERM
SPERM

FREE RADICAL

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Laboratory Assays for

Evaluation of Human Semen
No Lab Test

Parameters

1.

Seminal fluid volume, Sperm count, motility,

Morphology, Viability, Leukocytes in semen,

Routine
Evaluation

Sperm antibodies

2.

3.

Function

Membrane integrity, Sperm-cervical mucus

interaction, CASA, Capacitation, Acrosome
reaction, Zona pellucida binding, Zona
pellucida penetration, Oocyte-sperm fusion

Sperm
Function

HOST, Postcoital test, SPA, Acrosome reaction

tests, , HemiZona Assay, IVF

Specialized
Sperm

Assays
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NILAI NORMAL SPERMIOGRAM

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NOMENKLATUR SPERMIOGRAM
1. NORMOZOOSPERMIA = Ejakulat normal sesuai
sesuai nilai baku,
2. OLIGOZOOSPERMIA = Konsentrasi sperma
kurang
dari nilai baku,
3. ASTHENOZOOSPERMIA = Motilitas sperma
kurang
dari nilai baku,
4. TERATOZOOSPERMIA = Morfologi sperma kurang
dari nilai baku,
5. OLIGOASTHENOTERATO ZOOSPERMIA = Ketiga
variabel baku
abnormal,
MI & SD
6. AZOOSPERMIA = tidakKMAadanya
sperma di dalam
ejakulat,

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4. MANAGEMENT OF INFERTILE MAN

Pemeriksaan Andrologi.
Anamnesa

Treatment ?

Pemeriksaan fisik :

Diagnosa Kausatif ?

1. Umum
2. Khusus /
Reproduksi
Analisis Semen
Rutin

Kualitas Sperma
Uji sperma khusus
Pemeriksaan Penunjang
lainnya
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TERAPI SUAMI DAN PASANGAN

(PIA)
FAKTOR PRIA
BISA DIOBATI
T E R A PI :

GAG A L

I ST R I
NORMAL

1)EMPIRIK
2)KAUSATIF

I ST R I
ABNORMAL

TUGAS TULIS ; MACAM MACAM ART/TRB

FAKTOR
ISTRI
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SUKSES RATE ART/TRB

T R B / ART

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4. SEXUAL FUNCTION CYCLES:

1.
2.
3.
4.

Sexual Response cycle has 4 phases :

Excitement, Plateau, Orgasmic, Resolution .
Male Sexual Function has 4 components :
libido,
erection,
ejaculation,
orgasm.

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5. SEXUAL RESPONSE CYCLE

4 Phases :
1. Excitement
2. Plateau
3. Orgasmic
4. Resolution
Keempat rentetan siklus reaksi
seksual diatas merupakan satu siklus yang lengkap
Plateau
phase
Penetrasi
(Fore play )

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Orgasmic
phase
Resulution
Phase
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NEURAL PATHWAYS THAT INFLUECES SR

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Disorders of Sexual Responses

on Male
No

Disorder of Functions*
Syndrome
Pathology

1)

Disorder of interest or libido

2)

Disorder of excitement or
arousal

3)

Disorder of orgasm

4)
5)

Pain related disorder

Fear/anxiety related disorder

Inhibited sexual desire ,Low sexual interest

Erectile dysfunction
Anorgasmia, Premature ejaculation, Delayed ejaculation
Ejaculatory pain, Erectile dysfunction
(performance anxiety)
sexual phobia

Kok Lee Peng, Psychosexual Counseling.1999

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6. MALE SEXUAL DYSFUNCTION :

Male sexual dysfunction is a problem with 1 of

the 4 main components of male sexual
function (libido, erection, ejaculation, orgasm)
that interferes with interest in or ability to
engage in sexual relations.

Male Sexual Dysfunction:

Dysfunction of Libido,
Erectile Dysfunction,
Ejaculatory Dysfunction,
Orgasmic Dysfunction

1.
2.
3.
4.

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6.1. DYSFUNCTION of LIBIDO :

Hormonal

imbalance :
eq :Hypogonadism, Hyperprolactinemia,
Physical Problems :
eq : Diabetes, Anemia, etc
Psychological Problems :
eq Stress, Sexual deviation, etc

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6.2. ERECTILE DYSFUNCTION

A man who is unable to develop or sustain an

erection sufficient for penetrative sexual
intercourse is usually or traditionally labeled
impotent- a word that not only has pejorative
implication, but also takes little account of the
complex process of male sexual function.

Erectile Dysfunction (ED) is the inability to

achieve or maintain a hard, erect penis sufficient
for sexual intercourse.

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6.2.1. PREVALENCE AND RISK OF

ERECTILE DYSFUNCTION
Prevalence

:
5% among 40 years olds
10% among 60 years olds
15% among 70 years olds
Risk Factors :
Diabetes Mellitus, Hypertension,
Hyperlipidaemia, Depression, Smoking,
Hypothyroidism, Chronic Renal Failure,
Hypogonadism and Hyperprolactinemia.
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6.2.2. CAUSES OF ED :
1.
2.
3.
4.
5.
6.
7.

Psychogenic,
Psychiatric
Neurogenic,
Endocrine,
Arteriogenic,
Venous,
Drugs
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6.2.2.1.CAUSES OF
PSYCHOGENIC ED

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6.2.2. CAUSES OF ARTERIOGENIC ED :

1.
2.
3.
4.
5.

1.

Hypertension,
Smoking,
Diabetes Mellitus,
Hyperlipidemia,
Peripheral vascular disease,
CAUSES OF VENOUS ED :
Functional impairment of the venoocclusive mechanism
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6.2.2.3. CAUSES OF ENDOCRINE ED :

1.
2.
3.

Hormonal deficiency
low testosterone
Raised SHBG,
High Prolactin

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6.2.2.4. CAUSES OF NEUROGENIC ED :

1.
2.
3.
4.
5.
6.
7.

Trauma,
Myelodysplasia,
Intervertebral disc lesion,
Multiple Sclerosis,
Diabetes mellitus,
Alcohol,
Pelvic Surgery.
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6.2.2. 5. CAUSES OF DRUG ED :

1.
2.
3.
4.
5.
6.
7.
8.

Major tranquilizer,
Anticholinergics,
LH-RH analogues
Anti Androgen
Antihypertension,
Antidepressant
Anxioloytic,
Psychotropic drugs.
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6.3. EJACULATORY DYSFUNCTION :

Unejaculation
Retrograde

ejaculation
Damaged ducts :
Congenital Duct and Accessory glands Agenesis
Acquired duct obstruction
Premature

ejaculation :
Short Frenulum
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6.4. ORGASMIC DYSFUNTION :

Physical

Problems:
Anatomical anomaly
(Hypo/epispadia),
Psychological Problems
Behavioral Problems (Lifestyle)

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7.The Management of MSD :

History ( to confirm that the patient is

suffering from SD, to assess the severity of
the condition, to identify a possible underlying
aetiology)
Physical examination (secondary sexual
characteristics, blood pressure, abdominal
aneurysm, external genitalia and prostate,
lower limb pulses).
Clinical investigation ( urine, serum glucose,
serum testosterone,SHBG, probating,
creatinine, thyroid hormones, fasting lipid
profile, PSA)
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. DIAGRAM GOAL ORIENTED TREATMENT

OPTION

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CONCLUSION :
Infertility

is inability of man to
conceive his wife,
The causes of infertility could
interfere male sexual function and
also the role of sexual relationship,
A full history and thorough clinical
examination of the patient can help to
elucidate the cause of MSD,

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REFERENCES :
1.

2.

3.

4.

5.

Biology, 5th Ed. Campbell,NA,Reece,JB, Mitchel,LG,

Addison Wesley Longman, Inc., New York 1999.
page. 913 - 935
Richardson,D Overview:What do we tell our patient?,
dalam: The Assessment and Treatment of Erectile
Impotence, editors :Stricker,P.,Richardson,D. Excerpta
Medica,Australia, 1992
Nieschlag,
E.,
Behre,H.M.,
Andrology,
Male
Reproductive
Health
and
Dysfunction,
Springer.Berlin,2000.
Kok Lee Peng
Psychosexual Counseling, 7th
Workshop & Seminar on Male & Female Sexual
Dysfunction, Singapore, 20-21 March 1999.
Carani,C.,Granata,ARM.,Faustini,M.,and Marrama,P.
Prolactine and Testosterone : their role in male sexual
function, Int. J. of Andrology, 19: 48 54,1996.
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Prof David de Kretser

King and Queen

Seatle, Washingon, USA

Brisbane, Australia

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