infertility,azospermia

1. Male infertility
Dr. Omar Khalil
CABMS FIBMS EAU member

2. CAUSES
ABOUBAKRELNASHAR

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

3. EVALUATION
ABOUBAKRELNASHAR
●
History
●
Examination
●
Investigation

4. I. STANDARD SEMEN ANALYSIS
.A
Macroscopic
.1
Delayed liquefaction
.2
Increased viscosity
.3
Semen volume
.4
pH
.B
Microscopy
.1
Agglutination
.2
Concentration
.3
Motility
.4
Morphology
.5
Round cells
.6
Leukocytes
ABOUBAKRELNASHAR

5. Semen analysis: WHO,2010
ABOUBAKRELNASHAR
:
:
Parameter Lower reference limit
Volume 1.5 ml
pH 7.2
Concentration 15 million/ml
Total sperm number 39 million/ejaculate
Total motility: (PR+NP) 40% or
PR: 32%
Vitality 58% live spermatozoa
Normal forms 4% (strict criteria).

6. II. SPECIALIZED SEMEN ANALYSIS
ABOUBAKRELNASHAR

Not routinely performed

used to determine the cause of male infertility
.1
Sperm autoantibodies
.2
Semen biochemistry (semen fructose)
.3
Semen culture
.4
Sperm cervical mucus interaction tests
.5
Sperm function tests

Computer aided sperm analysis (CASA)

Sperm chromatin/DNA assays

Acrosome reaction

Zona free hamster oocyte penetration test

Human zona pellucida binding test

Sperm reactive oxygen species generation

7. 1. Sperm autoantibodies
ABOUBAKRELNASHAR

4 to 8%of subfertile men.

Agglutination:
Stick of motile spermatozoa to each other.

≥10%:

suggestive but not conclusive of immunological
infertility.

should be confirmed by
Mixed antiglobulin reaction (MAR)
Immunobead test
both of which detect sperm surface antibodies.

8. 2. Semen biochemistry
ABOUBAKRELNASHAR

Rarely useful in clinical practice.

Fructose
marker of seminal vesicle function.
Low or non-detectable:

congenital absence of the vas deferens
and seminal vesicles or

ejaculatory duct obstruction

9. .5
Sperm function tests

Routine:
Impractical and costly

Selective
when the standard semen analysis is normal
or near normal
ABOUBAKRELNASHAR

10. III. ENDOCRINE TESTS
.1
Serum testosterone
(T)
.2
Serum LH and FSH
.3
Prolactin
ABOUBAKRELNASHAR

11. .1
Serum testosterone
(T)

Morning T

In men with borderline values:

Repeat

FT
ABOUBAKRELNASHAR

12. .2
Serum LH and FSH

Indication:
T is low

Interpretation:

high FSH and LH:
primary hypogonadism

low or normal:
secondary hypogonadism.

low LH + low sperm counts +well-
androgenized: exogenous anabolic or
androgenic steroid abuse.
ABOUBAKRELNASHAR

13. 3. Prolactin
ABOUBAKRELNASHAR

Indication:

low T

normal to low LH
4. Inhibin
low serum inhibin concentrations may be an even
more sensitive test of primary testicular dysfunction
than high serum FSH concentrations, provided the
assay is specific for inhibin B

14. ABOUBAKRELNASHAR

15. iii. GENETIC TESTS
ABOUBAKRELNASHAR
.1
Karyotyping
.2
Y chromosome microdeletions
.3
Cystic fibrosis conductance regulator (CFTR)
gene mutation

16. 
ICSI:

Men with severe oligozoospermia and
azoospermia

Genetic risk:
.1
Cystic fibrosis conductance regulator (CFTR)
gene mutation
.2
Somatic and sex chromosome
abnormalities
.3
Microdeletions of the Y chromosome
ABOUBAKRELNASHAR

17. OBSTRUCTIVE AZOOSPERMIA

Azospermia +
Normal testicular volumes +
Normal FSH, and LH and T
.1
Bilateral congenital absence of the vas:

physical examination

low fructose level in the semen.
.2
Ejaculatory duct obstruction
Transrectal US:
dilated seminal vesicles.

Patients with obstructive azoospermia:
urologist specialized in infertility for further
evaluation and tt.
ABOUBAKRELNASHAR

18. ABOUBAKRELNASHAR

19. Abnormal semen
ICSI

Palpable varicocele: Varicoceletomy

low FSH &T: Hormonal TT.

Infection: TT ?
Mild
Moderate, Severe
or
Azoospermia
Low Resources
3 trial IUI
H. Resources
ABOUBAKRELNASHAR

20. ABOUBAKRELNASHAR

21. II. SPECIFIC TREATMENT
ABOUBAKRELNASHAR

Only for hypogonadotropic hypogonadism.
.1
Hyperprolactinemia

Medication:

medication should be discontinued,

lactotroph adenoma:

dopamine agonist:

cabergoline or bromocriptine.

22. 2. Other causes
ABOUBAKRELNASHAR

Hypothalamic or pituitary diseases:

gonadotropins

only men who have hypogonadotropic
hypogonadism due to hypothalamic disease
can be treated with GnRH.

23. 
lnfectios

Leukospermi
a, No
symptoms
Culture is negative:
10-day course of

Erythromycin or

Trimethoprim-sulfamethoxazole or

Quinolone.
ABOUBAKRELNASHAR

24. 
Varicocele:
(AUA&ASRM, 2004 & AFU, 2006)

Imaging examinations:
not indicated to characterize the varicocele.

TT when all of the following conditions are
present:
.1
Varicocele: Palpable
.2
Semen: Abnormal (at least one abnormality)
.3
Couple's infertility: Documented
.4
Female infertility problem: Curable
ABOUBAKRELNASHAR

25. .5
Obstructive azoospermia

Diagnosis:
Azoospermia or severe oligospermia +

normal size testis

normal FSH

normal testicular histology.
ABOUBAKRELNASHAR

26. 
Obstruction of the epididymis

microsurgical end-to-end anastomosis of the
epididymal duct to epididymal duct or to vas.
ABOUBAKRELNASHAR

27. 
Ejaculatory duct obstruction

Transurethral resection of the ejaculatory ducts

ICSI
can be combined to use sperm from men who
have obstructive azoospermia to fertilize ova of
their partners and achieve pregnancy.
ABOUBAKRELNASHAR

28. 
Obstruction due to vasectomy
surgical reanastomosis appears to be preferable
to
ICSI.

Congenital bilateral absence of the vas deferens
ICSI
ABOUBAKRELNASHAR

29. IV. EMPIRICAL THERAPY
ABOUBAKRELNASHAR

Examples:
CC
Aromatase inhibitors and
Other hormones, vitamins, and kallikrein

30. ABOUBAKRELNASHAR

31. V. ASSISTED REPRODUCTIVE TECHNIQUES
ABOUBAKRELNASHAR

Indications of IUI:
Mild male factor infertility

up to 6 cycles of IUI
(NICE, 2004; ESHRE Capri Workshop, 2009)

No IUI, Advise them to try to conceive for a total of 2y (including up to
1y before their fertility investigations) before IVF will be considered.
Exceptions: Social, Cultural, Religious
(NICE, 2013)

32. Male subfertility:
ABOUBAKRELNASHAR

Oligospermia, Asthenozoospermia,
Teratozospermia
(OAT syndrome).

Severe male infertility:
not candidate for IUI
Count<5million/ml
Normal morphology <2.5% or
Motility <10

ICSI is more cost effective than IUI when the
mean total motile sperm count is <10 million
(Van Voorhis et al,2001)

33. 
Indications of ICSI
(NICE, 2004; 2014)
.1
Severe deficits in semen quality
2.Obstructive azoospermia
3.Non-obstructive azoospermia
5. Mild
deficits in semen quality (high resource)
4. Previous IVF cycle with failed or very poor fertilizationa)
ABOUBAKRELNASHAR

34. THANK YOU