This document discusses male infertility, including its assessment and treatment in India. It notes that male factor infertility accounts for about 50% of infertility cases in India. While gynaecologists play an important role in evaluating couples for infertility, many lack expertise in male infertility. The document outlines key areas of male infertility evaluation including semen analysis, sperm function tests, hormonal and genetic testing, and treatments such as antioxidants and IUI for mild male factor cases. It emphasizes the need for a multidisciplinary approach and timely referral to infertility specialists for optimal management of male infertility.

1. MALE INFERTILITY :
CRITICAL REVIEW OF
Assessment & treatment in India
& Way Forward
Dr. Sharda Jain
Dr. Jyoti Agarwal
ISO 14001:2004 (EMS)
…..Caring hearts, healing hands

2. D.G.F. ,s CME MALE INFERTILITY 2017 DELHI

3. DEDICATED TO
GYNAECOLOGIST OF INDIA
who don’t call themselves
Infertility / ART Expert

4. 1 in 2 INDIAN COUPLES SUFFERING
FROM INFERTILITY have
MALE FACTOR

5. GYNAECOLOGIST DO NOT KNOW
ANYTHING ABOUT
MALE INFERTILITY
To become infertility or
ART expert... knowledge
& skill in male infertility is necessary

6. There is
NO
Elevator
to success ,
you have to take the stairs
that means step by step growth

7. 1990..
INTRACYTOPLASMIC
SPERM INJECTION
(ICSI)
Major breakthrough in 100 years

8. SPERM RETRIEVAL TECHNIQUES.. are
added boon for MALE INFERTILITY

9. ANDROLOGY + SPERMATOLOGY
IS EXPANDING FAST
TESTES
PRODUCTION
OF SPERMS
EPIDIDYMIS
maturation
of sperms
VAS
DEFERENCE
Storage
Of sperms

10. GENETICS & IMMUNOLOGICAL
KNOWLEDGE HAS WIDENED

11. MALE INFERTILITY...IS NOW A
UNPRECEDENTED REVOLUTION IN THE TREATMENT
OF HUMAN INFERTILITY
SUPERSPECIALITY

12. **FERTILITY PRESERVATION**
Of Male & Female
has already become
Subspecialty of ART
due to UNPRECEDENTED REVOLUTION IN THE TREATMENT
OF young Male & female cancer cases

13. Next Decade will see another
NEW SUPER SUPER SPECIALITY..OF
**** REGENERATIVE MEDICINE....USING
STEM CELLS RESEARCH+ TISSUE ENGINEERING
Where man will not be
required for human
reproduction

14. Defining Infertility
Infertility is defined as an inability to get
pregnant after one year of trying.

15. Male factor is responsible
solely in about 50 %cases .
It is important that both male & female
partner is evaluated simultaneously .
The purpose of this PPT is to provide
Gynaecologist with principles & strategies
for the evaluation of couple with male
infertility problems , also manage them or
refer them timely to experts as needed.

16. India performs approx. 1 Lac cycles
of IVF per year
50% are
done for
MALE
infertility
Annual number of IVF cycles
 High (>10,000)
 Moderate (5,000-10,000)
 Low (<5,000)

17. Unfortunately, Only
50%
IVF centers
have
ICSI & FREEZING
facility
BY 2020..2.6 LAC IVF
PROCEDURES WILL BE DONE

18. Indication for Evaluation
• All couples who fail to achieve a successful
pregnancy after 12 months of regular
unprotected intercourse.
• Couple need earlier evaluation & treatment , if
indicated by medical history & physical findings
• After 6 months for couple in which the female
partner is 35 years old
• Men highly concerned about fertility should be
evaluated .

19. Why 50 millions sperms are required to
fertilize one egg-- is BIG QUESTION

20. 1. Follicular phase – egg development
2. Ovulation – releasing egg from the ovary
3. Egg descends through the fallopian tubes
4. Egg fertilization
5. Uterus lining get ready to accept implantation
6. Implantation of embryo
Conception is a simple and yet
amazingly complex process!

22. • The couple is not seen together
• Husband contributes to 50% to Infertility..still
Husband’s semen analysis not performed till late.
• Investigations are performed in a piecemeal
fashion rather than as part of an overall strategy.
COMMON MISTAKES -WHICH
We Indian doctors DO !
COUPLES TOO ARE RELUCTANT FOR INVESTIGATIONS

23. • Experience shows …MEN LOOSE TRUST early when its
come to their treatment with Urologist.
• They want baby .. Not just increase in sperms
• Some how , the temptation to try many empirical,
possibly useless medical treatments is Considerable
• Large sums of money is often spent at the hands of
• * Quacks
* Spiritual healers
* Even self styled gynaecologists/ andrologist
Our Knee jerk reaction
is to send them to urologist

24. What is the Role of doctors who are
not Gynaecologist
• REFER to Trained infertility Experts
If women is not pregnant with in a
year of marriage, provided they are
staying together & not using
contraceptive.

25. • SEMEN Examination
• TUBE PATENCY TESTING ,
• DAY 21 , S. PROGESTERONE
WHO

26. SPECIAL INVESTIGATIONS…
WHICH GUIDE OUR TREATMENT

27. “Meet the Expert” – May 2012
CURRENT TRENDS & SCENARIO IN
MALE INFERTILITY

28. CRITICAL REVIEW OF SPECIAL AREAS
• Maturation cycle of sperm
• Causes of male infertility & azoospermia
• Limitations of semen analysis
• DNA fragmentation test
• Azoospermia Diagnosis
• Testicular Biopsy
• Hormonal Evaluation
• Immunological evaluation
• Geneting Testing
Treatment
• Antioxidants
• Limitation of IUI
• Azoospermia
• Vericocele

29. From Initiation of Sperm Production
to Ejaculation
Misell LM et al.: A stable isotope-mass spectrometric method for
measuring human spermatogenesis kinetics in vivo.
J Urol. 2006; 175: 242-6.
Old concept ~80-90 days
New concept ~60 days

30. Classification of Male infertility on the
Basis of initial Evaluation
Five following groups
1. Absent or low volume ejaculate ‘
2. Azoospermia
3. Oligosthenospermia (OAT)
4. Normal but infertile
5. Idiopathic infertility ..60- 70%

31. Male infertility
• SEXUAL DYSFUNCTIONS- non consummation
of marriage, erectile dysfunction, Anatomical
abnormalities like hypospadius, spinal cord
injury etc.
• OLIGOZOOSPERMIA- OAT- mild, moderate or
severe
• AZOOSPERMIA which can be further
subdivided between pretesticular, testicular
and post testicular or obstructive

32. Pretesticular:
Hypothalamic pituitary disease
(Secondary hypogonadism): 1-2%
Testicular:
Primary hypogonadism: 10-15%
Post-testicular defects
disorders of sperm transport: 10 to 20 %
Idiopathic:
Seminiferous tubule dysfunction: 60-80%
including microdeletions of the Y chromosome
CAUSES OF AZOOSPERMIA

33. SEMEN ANALYSIS
• Concentration
• Motility
• Morphology

35. Shape of Normal Sperm
WHO GIVES LOT EMPHASIS ON KRUGERS CRITERIA---BUT
NO LAB IN INDIA GIVES REPORT USING KRUGERS CRITERIA

36. TESTES
PRODUCTION
OF SPERMS
EPIDIDYMIS
maturation
of sperms
VAS
DEFERENCE
Storage
Of sperms
SPERM FUNTION TESTS are now available for every
movement of sperm---GOI is very keen that these
tests are offered right in beginning itself
Semen Analysis + sperm function test should be combined

37. New WHO Standards
Not accurate to discriminate fertile and
infertile men
A comprehensive
infertility workup,
including sperm function
testing, is crucial to
assess the male fertility
potential

38. INTERPRETING SEMEN ANALYSIS
Normal semen
parameters
• Despite looking
normal, sperms
may still be
damaged
• RO species
damage  DNA
fragmentation
Poor semen
parameters
• Oligospermia
• Asthenospermia
• Teratozoospermia
Azoospermia
• Obstructive
• Non obstructive
No Pregnancy

39. Effects of high sperm DNA
fragmentations are
• Infertility
• Recurrent pregnancy loss
• Poor outcomes in IUI and IVF
Men with poor semen parameters are
more likely to have high DNA
fragmentations

40. The term DNA fragmentation refers to Damaged sperm
DNA that can not be repaired
DNA Fragmentation - New
SPERM FUNCTION Test.. should Be
COMBINED with Semen Analysis
routinely

41. Non Fragmented SPERMATOZOA : Peripheral halo
Fragmented SPERMATOZOA : no peripheral halo
Two Tests – SCSA Test & Tunel Test
Abnormal test are 25% - 27% for SCSA test &
35% for TUNEL assay

42. DNA Fragmentation levels are closely correlated with
IUI, IVF and ICSI outcomes
and pregnancy rates
DFI is independent predictor
of pregnancy in couple
undergoing IUI/ IVF

43. ICSI Treatment is more likely to result in pregnancy than IUI
& IVF if DFI value is above 30%
Bungum et.al. Hum Reprod 2007

44. Sperm DNA Integrity Testing & ART
0%
5%
10%
15%
20%
Pregnancy by Sperm
DNA Integrity Results in
IUI
DFI ≤30% DFI >30%
Live birth (%)
OR 0.07 (0.01-0.48)
50,00%
40,00%
30,00%
20,00%
10,00%
0,00%
ICSI
Pregnancy by Sperm DNA
Integrity Results in IVF and
ICSI
IVF
DFI>30%
* <.05
*

45. Azoospermia Diagnosis

46. Diagnosis of Azoospermia
The diagnosis of azoospermia can be
established only when the pellet is
examined
The current WHO criteria for
evaluation sperm morphology are
similar to the “strict criteria”
described by kruger

47. Testicular Biopsy
• Shall we do testicular biopsy ?
• Where & who should do
testicular biopsy
• How should the information
be interpreted ?
• Which technique should be
used

48. Shall we do testicular biopsy ?
YES
It is both diagnostic
&
Therapeutic
(sperm retrieval techniques used before ICSI)
Testicular Sperm TESE is the technique of choice
Spermatogenesis may be focal that means in
about 50% of men with NOA sperms can be
found & use for ICSI

49. WHERE & WHO SHOULD DO
TESTICULAR BIOPSY
• It should be done in IVF
setting where sperm
freezing facilities are
available
• It is crime to do it
otherwise specially in
cases of non obstructive
azoospermia

50. How should the information be
interpreted ?
• Sertoli cell only , no germ cells
• Spermatogonia only
• Arrest at primary or secondary
spermatocyte level
• Spermatids round or elongated present
• Spermatozoa present but only in few
tubules
• Normal spermatogenesis

51. Hormonal evaluation
Endocrine abnormalities are
rarely present when the sperm
concentration is greater than 10
million / ml

52. Clinical Diagnosis based on Hormonal
Status
Clinical Status FSH LH Testosterone
Normal
men or obstruction Normal Normal Normal
Isolated spermatogenic
failure Normal Normal
Testicular failure
Normal or
Hypogonadotropic
hypogonadism

53. Recommendation
Recommendation Grade
Effective drug therapy is available o achieve
fertility in men with Hypogonadotrophic
Hypogonadism .
A
Testosterone replacement is
strictly contraindicated for the treatment of
male infertility (low levels of FSH & LH)
A

54. AGGLUTINATION of SPERMS makes
you suspect immunological problems
Antisperpm antibody
(ASA) are rare cause
of male subfertility
that do not required
routine testing & are
typically managed
with the used of ICSI)

55. GENETIC CAUSES
80%
10%
5%
5%
Genetic Causes of
Male Infertility
Klinefelter Syndrome (47,XXY)
Y-chromosome microdeletion
Congenital Vas Absence

56. GENETIC TESTS
• * Karyotyping
• * Y chromosome microdeletions
• * Cystic fibrosis conductance
regulator (CFTR) gene mutation

57. Recommendation For Genetic Testing &
Counselling
From a diagnostic view point , standard karyotype
analysis should be offered to all men with damaged
spermatogenesis (spermatozoa <10 million /mL) who
are seeking fertility treatment by IVF.
B
Testing for microdeletation is not necessary in men
with OA (with normal FSH) when ICSI used because
spermatogenesis should be normal
A
Men with severely damaged spermatogenesis
(spermatozoa <5 million /Ml) should be advised to
undergo Yq microdeletation testing for both diagnostic
& prognostic purpose. Yq microdeletation also has
important implication for genetic counselling
A

58. Recommendation For Genetic Testing &
Counselling
If complete AZFA or AZFB microdeletation are
detected , micro – TESE should not be performed
because it is extremely unlikely that any sperm will
be found
A
If a man with Yq microdeletation & his partner wish to proceed
with ICSI , they should be advised that microdeletation will be
passed to sons , but not to doughters.
A
When man has structural abnormalities of the VAS DEFERENS
(unilateral or bilateral absence), he & his partner should be
tested for CF GENE MUTATIONS
A

59. AZFa
deletion
No retrievable
sperm
AZFc
deletion
Sperm retrieved in
70% of cases
AZFb
deletion
No retrievable
sperm
Predictive Value of Ychromosome
Microdeletion Screening for
Sperm Retrieval in NOA

60. TREATMENT ASPECT OF
MALE INFERTILITY
FEW ISSUES

61. Antioxidants in Male Infertility
To whom?
Everyone
What Medicine
Vitamic C 500mg
Vitamin E 400 UI
LYCO Q 300 Is the dose
How long? – till she is pregnant

62. WHY
Antioxidants:
WHY ?
To whom and how
Seminal
Reactive Oxygen
Species (ROS)
2,5
2
1,5
1
0,5
0
Fertile Infertile

63. Antioxidant Treatment
Cochrane Review 2011
Outcome N
studies
N
participants
Effect size
(OR; 95% CI)
Live birth 3 214 4.85 [1.92, 12.24]
Pregnancy rate 15 964 4.18 [2.65, 6.59]
DNA fragmentation 1 64 -13.80 [-17.50, -10.10]
Miscarriage, sperm
count, sperm motility
6-16 242-700 No effect
Adverse effects 6 426 No effect
Improve the outcomes of live birth and pregnancy rate for
subfertile couples undergoing ART cycles
Showell MG, Brown J, Yazdani A, Stankiewicz MT, Hart RJ. Antioxidants for male subfertility. Cochrane Database of
Systematic Reviews 2011, Issue 1. Art. No.: CD007411. DOI: 10.1002/14651858.CD007411.pub2.

64. SPERM NUTRIENTS AND ANTI-OXIDANTS
• Coenzyme Q-10
• Lycopene and Astaxanthin
• Vitamin C
• Zinc
• Vitamin B-12
• L-Arginine
• Vitamin-E
• Selenium
• L-Carnitine

65. Take-home Messages
Antioxidants helpful to decrease oxidative stress.
Treatment effect is noted > 60 days later.

66. MICRONUTRIENTS , ANTIOXIDANTS
& PROTEIN RICH DIET
to be literally
started on DAY 1
BRIEFING AT FIRST VISIT

67. EXERCISE,MEDITATION

68. TOBACCO SMOKING
In MEN smoking affects
all parameters of sperm
quality

69. I.U.I.
ONLY & ONLY IN LOW RESOURSE SETTING
FOR MALE INFERTILITY

70. Intra uterine insemination
If the sperm count is between
10 million to 20 million/ ml, IUI
offers a good pregnancy rate
provided there is no female factor
However western world does not
agree

71. Indications of IUI:
• Mild male factor infertility
up to 3 cycles of IUI
•(NICE, 2004; ESHRE Capri Workshop, 2009)
**************************************************************************************************************
No IUI, Advise them to try to conceive for a total of 2years
(including up to 1y before their fertility investigations)
before IVF - ICSI will be considered.
Exceptions: Social, Cultural, Religious
• (NICE, 2013)
Only
Low
recourse
setting
Treatment
is
ICSI in Male
infertility

72. in
infertility
centre
IN-HOUSE
IUI
Should be
done

73. From Sperm deposition to – sperm
Ovum interaction :
4 steps take place in cervix ,uterus & FT
1. Capacitation
2. Acrosome Reaction
3. Hyperactivation
4. Sperm- Oocyte binding I.U.I. Takes away step I & II

74. Male subfertility:
* OAT syndrome
*Oligospermia,Asthenozoospermia,Teratozospermia
*Severe male infertility
*Not candidate for IUI if Count<10million/ml
*Normal morphology <2.5% or
* Motility <10
Only
ICSI
ICSI is more cost effective than IUI when the
mean total motile sperm count is <10 million
(Van Voorhis et al,2001)
If no natural pregnancy - ICSI

75. SEMEN BANK & DONOR insemination
• Therapeutic donor insemination in
azoospermic patients
• Homologous (husband’s) sperms can also be
preserved under the following circumstances-
1. In men who have difficulty in collecting semen on demand
(for treatment or procedures)
2. Men away from treatment place
3. Prior to the starting of treatment in men undergoing
cytotoxic chemotherapy or radiotherapy
4. Prior to vasectomy or after successful vasectomy reversal

76. Mild Moderate, Severe
or
Azoospermia
Low Resource
Setting
3 trial IUI
H. Resources
ICSI
Out line of Male infertility
treatment

77. Male Fertility Declines More
Gradually
*30% decline in most men would not be
sufficient to render them infertile.
•Very important factor - If the sperm can
fertilize eggs, we usually don't see poor
embryo quality due to reduced sperm
quality.
Males retain their fertility
well into old age

78. very very controversial
Fertility Restoration &
Spontaneous Pregnancy
Only Indication
Treatment of Clinical
Varicoceles prior to ICSI
may be beneficial for
patient subgroups of
severe oligozoospermia
and NOA.

79. Other Recommendation
• Adult male with palpable
varicocele , abnormal semen
parametar , desire for future
fertility or pain related to
varicocele
• Adolescent / young adults :
reduced ipsilateral testicular size
, abnormal semen parameters

80. 46%*
22%
66%
31% 31%
Varicocele and ICSI Outcomes
Treated Varicocele Untreated Varicocele
78%*
Fertilized Eggs
(%2PN)
Live Birth (%)
*P<0.05
Miscarriage (%)
Esteves SC, Oliveira FV, Bertolla RP. ... J Urol 2010;184:1442-1446
Odds ratio 1.87 0.43
95% CI 1.08 - 3.25 0.22 – 0.84
P-value 0.03 0.01

81. Azoospermia
it is not a synonymous of sterility

82. • Normal sperm production
• Mechanical blockage
• Vasectomy, Post-
infectious, Congenital
Obstructive
• Sperm production deficient
or absent
• Cryptorchidism, Radiation,
Chemotherapy, Trauma,
Genetic, Orchitis,
Varicocele, Gonadotoxins,
Unexplained
Non-
obstructive

83. AZOOSPERMIA
Determine the reason
Obstructive
Non-obstructive
• Clinical examination ( vas, epididymis, testis size)
• Volume, pH, fructose—all affected in OBST.AZOO
• FSH level—raised in NOA

84. Testicular failure need not mean no sperm
no sperm many spermfew sperm
Size of Testis in Azoospermia
P.T.F. Patchy spermatogenesis
Obstruction

86. Obstructive Azoospermia
• Microsurgical
reconstruction
• TURED
If young
patient
• Epididymis
• Testis
• Simple and
effective
Married for
long time
**Sperm
retrieval +
ICSI
Micro surgical
sperm
retrieval
techniques
MESA

87. Obstructive azoospermia
Recommendations
Treatment - surgery if young
Recommendation Grade
In azoospermia caused by EPIDIDYMAL
OBSTRUCTION standard procedures include
Vasovasostomy & Tubulovastomy
B
SPERM RETRIEVAL TECHNIQUES , such as MESA ,
TESA & PESA , can be used additionally . These
methods should be used only when cryostorage
of the material obtained is available.
B

88. Ductal Obstruction Causing
azoospermia
If old or pressure
to have a
child is more than
sperm retrieval
&
ICSI

89. H/O VASECTOMY...
SURGERY Results are rewarding

90. Esteves SC, et al. Success of percutaneous sperm retrieval and
intracytoplasmic sperm injection (ICSI) in obstructive azoospermic (OA) men
according to the cause of obstruction. Fertil Steril. 2010;94 (Suppl):S233.
Percutaneous SPERM
Retrieval –is almost 100%

91. Most azoospermic men with non obstructive
type are not sterile.
Sperm retrieval and reproductive potential
is dependent on the CAUSE of azoospermia.

93. Non-obstructive Azoospermia
TESA vs. TESE [better]
Controlled studies
for NOA men
Needle
Aspiration
Open Biopsy
Friedler et al
Human Reprod 12: 1488,
1997
4/37 (11%) 16/37 (43%)
Ezeh et al.
Human Reprod 13:3075 5/35 (14%)
22/35 (63%)

94. Non- Obstructive Azoospermia
Sperm
production
absent
Button
size
testis
Untreatable
condition
TESA
Can
retrieve
sperm in
50%
cases
TESA is
not
enough

95. BARIATRIC SURGERY
&
Infertility

96. Sleeve Gastrectomy &
Gastric Bypass surgery
are done routinely
Bariatric Surgery
Significant and sustained
weight loss of 40-50 kg is expected

97. Is Bariatric surgery safe?
It is a fact that… There are 40 Bariatric
surgeons in INDIA…it is not cup of any surgeon
In Good Hands
it is …as Safe as
Laparoscopic
Cholecystectomy

98. Weight loss is one of the corner stone to
achieve a healthy pregnancy and child birth

99. Our Experience with
Bariatric Surgery
Total cases - 23
5 had pregnancy with IUI & 6
had IVF ICSI pregnancy
11 Pregnancy
Hypertension, DM, Cholesterol has magical relief

100. ART has provided NOVEL PROTOCOLS for
FERTILITY PRESERVATION during
&
preceding ONCOTHERAPY in
young boys who are CANCER victims,

101. Fertility Preservation Male
Pre adolecents.do not produce sperm
so…testes has to saved & reimplanted
* Once semen production..then semen
samples to be saved

102. We work with accredited facilities that follow the
ICMR & ASRM standards andguidelines.

103. ADDRESS
11 Gagan Vihar, Near
Karkari Morh Flyover,
Delhi - 51
CONTACT US
9650588339
9599044257
011-22414049
WEBSITE :
www.lifecareivf.in
www.lifecarecentre.in
www.lifecareabs.in
ISO 14001:2004 (EMS)
…..Caring hearts, healing hands
ISO 9001:2008
Helpline : 9599044257
Web.www.lifecareivf.in
Helpline : 9910081484
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