Male infertility evaluation

1. EVALUATION OF MALE INFERTILITY
Dr Pritam Mandal

2. DEFINITION AND CLASSIFICATION
• Infertility is the inability of a sexually active, non-contraceptive couple to
achieve spontaneous pregnancy in one year
• Primary infertility
 Never had a child and cannot achieve pregnancy after at least twelve
consecutive months having sex without using birth control methods
• Secondary infertility
 Able to achieve pregnancy at least once before

3. EPIDEMIOLOGY
• About 15% of couples do not achieve pregnancy within one year and seek
medical treatment for infertility
• In 50% of involuntarily childless couples, a male-infertility-associated
factor is found, usually together with abnormal semen parameters

4. MALE REPRODUCTIVE PHYSIOLOGY
The male reproductive system along with its regulatory entity comprises of:
 Brain centers, which regulate
pituitary release of gonadotropins
and sexual behavior
 A pair of testes, which produce
sperm and hormones
 A ductal system (vas deferens and
epididymis), which stores and
transports sperm
 Accessory sex glands (seminal
vesicles, prostate, and bulbourethral
glands) to support sperm viability
 The penis

7. ETIOLOGIES OF MALE INFERTILITY

10. MALE INFERTILITY CAUSES AND ASSOCIATED FACTORS
AND PERCENTAGE OF DISTRIBUTION

12. CASE
• A 29-year-old man is referred for evaluation of male infertility. He and his
29-year-old wife have been trying to conceive for 2 years. His wife has had
a complete evaluation that revealed regular ovulatory cycles and normal
reproductive anatomy

13. DIAGNOSTIC WORK-UP
• Medical and reproductive history
• Physical examination
• Semen analysis
• Hormonal evaluation
• Other investigations(e.g., genetic analysis and imaging)

14. HISTORY
• The most important determinant of a couple’s reproductive potential is
maternal age
• T- Toxins
• I- infectious disease
• C- childhood history
• S- sexual history

15. SPERMATOTOXICITY
Endocrine Modulators
• Antiandrogens :bicalutamide,
flutamide, and nilutamide
• Antihypertensive : spironolactone
• Antiretroviral: indinavir, stavudine
• Corticosteroids
• Exogenous estrogen
Antihypertensives
• Beta blockers
• Calcium channel blockers
Recreational Drugs
• Cannabis
• Chronic alcohol intake
• Cigarette smoking
Antipsychotics
• Risperidone
• Olanzapine
• Selective serotonin reuptake
inhibitors (SSRIS)
Opioids

16. Antibiotics
• Nitrofurans
• Minocycline
• Penicillins
• Quinolones
• Tetracyclin
Cytotoxic Chemotherapeutics
• Cyclophosphamide
• Doxorubicin, vincristine, and
prednisone
• cisplatin, etoposide, and bleomycin
• local instillation of BCG into the
bladder for superficial transitional
cell
Anti-Inflammatory Agents
• Sulfasalazine
• Colchicine
Phosphodiesterase V Inhibitors
• Sildenafil
• Tadalafil
Environmental Toxicants
• bisphenol A
• Maternal beef consumption
• insecticide and pesticide: dieldrin
• Lead, molybdenum, boron
• Air pollution

17. Thermal Toxicity
• Cryptorchidism provides a model by which the effects of heat can be
studied on sperm production
• Increasing testis temperature to that of the abdominal cavity significantly
impairs spermatogenesis
Radiation
• Testes directly exposed to ionizing radiation suffer germ cell loss and
Leydig cell dysfunction
• cell phone use : linear decrease in sperm count, motility, viability, and
normal morphology

18. INFECTIONS AND INFLAMMATION
• Infections of the testis, epididymis, prostate, and urethra may lead to male
infertility through anatomic and functional means
prostate
•Escherichia coli
•Pseudomonas aeruginosa
•Klebsiella
•Proteus
•Enterococcus species
Epididymis
•Neisseria gonorrhoeae
•Chlamydia trachomatis
•E. Coli
Urethra
•N. Gonorrhoeae
•C. Trachomatis
•Mycoplasma species
•Trichomonas vaginalis
Testis
•Rubulavirus ,mumps
•Coxsackievirus B
•N. Gonorrhoeae
•C. Trachomatis
•E. coli, P. aeruginosa, and Klebsiella
•Staphylococcus, and Streptococcus
• Mycobacterium tuberculosis may affect any reproductive organ and cause scarring of the
vas deferens and epididymis

19. CHILDHOOD DISEASES
• Pediatric Surgery
 Hydroceles and hernias repaire may cause vasal obstruction
• Testis Torsion
 half of men with torsion will develop adverse spermatogenic effects
• Cryptorchidism
 Surgical correction of undescended testes after puberty is not
benificial
• Genetics
 whether any blood relatives experienced difficulty conceiving offspring
 The presence in the patient’s family of genetic syndromes known to be
related to reproductive dysfunction such as cystic fibrosis

20. SEXUAL HISTORY
• Duration of infertility & previous fertility
• Coital frequency and timing, age of partner, contraceptive methods
previously used
• Did puberty and virilization proceed normally
• Have there been changes in libido, potency, or hair loss suggestive of
hypogonadism?
• Are there anatomic abnormalities (e.g., hypospadias, microphallus)?

21. • Lubricants commonly used during sexual activity such as K-Y Jelly, Keri
Lotion, Astroglide, and saliva are associated with impaired sperm motility
• Erectile function(PE,ED) should be inquired,because obviously if
intercourse is impeded or impossible, sperm will not be deposited
successfully in the vaginal vault near the cervical os
• Stress itself may impair semen quality, creating a vicious circle for men
experiencing infertility and its related psychological distress

22. CASE
• Past history
 Hypertensive on beta blockers and multivitamins
• Personal history
 He works as a software developer. He has smoked a pack of cigarettes
daily for at least 10 years, and he occasionally drinks a cocktail. He does
not smoke marijuana or use other drugs of abuse. He has never fathered a
child
• Family history
 He has no family history of hypogonadism, cleft palate, or infertility; he
has 3 brothers who have fathered children

23. PHYSICAL EXAMINATION
• General Physical Examination
 Female facial characteristics
 Alterations in secondary sexual characteristics such as facial, truncal,
axillary, and pubic hair
 High-pitched voice
 Gynecomastia
 Obesity
• Systemic examination

24. • The Tanner stage should be noted because an adult that is not stage V may
have an underlying endocrinological or genetic abnormality as the cause
of their underdevelopment and infertility

25. MALE REPRODUCTIVE PHYSICAL EXAMINATION
• Examining the Scrotum
 One or both sides may be hypoplastic, indicating an absence of the scrotal
contents since birth
 Hydrocele or tumor
 Varicocele
 Proximity to the thighs in a large or obese male may indicate an
insufficient difference between intrascrotal and body temperature

26. • Examining the Testis and Epididymis
 Palpates the testis and epididymis through the scrotum, for any
abnormalities
 The epididymis if easily palpated, is likely engorged, which suggests
obstruction
 The size of the testis may be assessed by calipers often referred to as the
Seager orchidometer
 The long axis of the testis is gently grasped between the jaws of the
calipers, and a measurement of 4.6 cm or less is associated with
spermatogenic impairment

27.  A second method to ascertain testis size is to compare the examiner’s
palpation findings with a string of ellipsoids of increasing size with marked
volumes
 A volume of 20 mL or less is considered low
 Testis volume may be more directly measured by ultrasonography of the
scrotum

29. • Examining the Spermatic Cord
 Palpation of the spermatic cord : whether the vas deferens is palpable,
and whether a varicocele is present
 Meacham’s maxim technique
 Unilateral absence of the vas deferens suggests the possibility of a
complete lack of wolffian ductal development on that side, including renal
agenesis
 If both vasa are absent, the man has a high likelihood of a cystic fibrosis
gene mutation

31. • Examining the Phallus
 Semen must be deposited proximal to the cervical os for optimal chance
of reproduction
 Any abnormality of the phallus that may prevent placement of the semen
at cervical os should be noted by the examining physician
 Phimosis, meatal displacement in hypospadias or epispadias, and
significant penile curvature

32. • Examining the Prostate and Seminal Vesicles
On PR examination
 The size of the prostate, as it may be aplastic or hypoplastic in cases of
congenital malformation or significant hypoandrogenism
 The seminal vesicles cannot typically be palpated
 If they are palpable, it is an abnormal finding suggesting engorgement and
possible ejaculatory ductal obstruction

33. CASE
• Physical examination
 His physical examination is normal (including a normal male voice and
normal torso-limb proportions), except for a body mass index of 35 kg/m2,
bilateral nontender gynecomastia, a normal genitourinary examination
with normally descended testes that are 12 cc bilaterally (measured by
Prader orchidometer), and easily palpable vasa deferentia

34. SEMEN ANALYSIS
• A man can be absolutely considered sterile only when no sperm are
present in semen
• Substantial range of values for any parameter do not discriminate
between male fertility and infertility
• Provide useful information on the status of germ cell epithelium,
epidiymides, and accessory glands
• After 1 day of abstinence , at least 2 samples, 4 weeks apart
• In a clean container by masturbation or via intercourse using silastic
condom or electrostimulation
• Examined within an hour of collection.

36. BULK SEMEN PARAMETERS AND THE WORLD HEALTH
ORGANIZATION CRITERIA

37. CART ANALYSIS FOR SEMEN PARAMETERS
Semen parameters Lower range Upper range
Volume 1ml -
Sperm density 13.5 million/ml 48.0 million/ml
Sperm motility 32% 63%
Sperm morphology 9% 12%
Sperm vitality 58% 79%

38. MACROSCOPIC EVALUATION OF SEMEN
• Appearance
• Semen volume
• pH
• Viscosity

39. APPEARANCE
• Normal semen sample is opaque(white or light gray) in appearance and
homogenous
• A yellow or green hue may indicate infection, jaundice, or vitamins or
medication
• Brown is often observed in spinal cord–injured men
• Red suggests blood

40. VOLUME
• WHO lower reference limit is 1.5ml
• Seminal hypovolemia
 Ejaculatory ductal obstruction or hypoplasia of the prostate and seminal
vesicles as may occur in severe androgen deficiency or CBAVD
 Retrograde ejaculation
 Neurologic conditions, such as in spinal cord injury, diabetes mellitus, or
multiple sclerosis
 Pharmacologic factors:α-adrenergic blocking agents such as tamsulosin

41. • Aspermia, dry ejaculate, and anejaculation refer to the condition in which
no fluid is discharged from the urethra during male orgasm
• If aspermia or seminal hypovolemia is observed
 Postejaculatory urinalysis is performed to identify retrograde
ejaculation (number of sperm in the urine nears or exceeds that in the
antegrade specimen)
 Transrectal ultrasonography (TRUS) to evaluate whether ejaculatory
ductal obstruction may be present
• Seminal hypervolemia with an ejaculate volume exceeding 5 mL is a rare
condition. It is proposed to interfere with male reproduction by diluting
sperm

42. VISCOSITY
• Semen viscosity measures the seminal fluid’s resistance to flow
• High viscosity is determined by the elastic property of the semen sample
when it is free dropped from a pipette
• A thread length greater than 2 cm is considered abnormally viscous
• High viscosity after complete liquefaction can affect motility,
concentration, and antibody-coated spermatozoa

43. SEMEN PH
• The semen sample is primarily made up of the alkaline fluid from the
seminal vesicles and the acidic fluid from the prostate
• The pH of the two fluids combined should be in the range of 7.2–8.2
• A pH of <7.0 in a semen sample may indicate an obstruction in the
ejaculatory duct. This results in an absence of alkaline secretions from the
seminal vesicle fluid
• A higher pH could indicate the presence of an underlying infection

44. MICROSCOPIC EVALUATION OF SEMEN
• Round cells
• Leukocytospermia
• Concentration
• Motility
• Progressive motility
• Morphology
• Vitality

45. Round Cells
• Round cells in the semen sample
consist of immature germ cells
and leukocytes
• Excessive may indicate an
environment of oxidative stress
(OS) during spermatogenesis
Leukocytospermia
• Presence of >1 × 106 wbc/mL of
the sample is indicative of
leukocytospermia
• Harmful to sperm, ROSs may be
the destructive mechanism

46. SPERM DENSITY
• WHO lower reference limit is 15 millions/ml
• The term oligospermia refers to low sperm density, and cryptozoospermia
denotes sperm so few as to be difficult to reliably measure
• A man with a single semen sample demonstrating 10 million/mL who has
had no difficulty impregnating his wife may not be oligospermic
• whereas one with small testes, an elevated FSH, and densities on several
semen analyses ranging from 20 to 25 million/mL may be reasonably
considered oligospermic

47. SPERM MOTILITY
 WHO lower reference limit is 40%
 Sperm motility is assessed optimally within 30 minutes of liquefaction and
refers to a percentage of sperm observed with defined motion
 Low motility is termed asthenospermia
 Three categories—progressive, nonprogressive, and immotility

48. PROGRESSIVE MOTILITY
• WHO lower reference limit is 32%
• Progressive motility is defined as sperm “moving actively, either linearly or
in a large circle, regardless of speed
• Non-progressive motility as “all other patterns of motility with an absence
of progression

49. SPERM MORPHOLOGY
 The reference range according to the WHO strict criteria is ≥4% normal
forms
 Most laboratories quantify morphology using WHO guidelines or the
Kruger’s strict criteria classification
 An overabundance of abnormal forms is termed teratozoospermia
 If the acrosome fail to form, the sperm will have small, round heads, a
disorder referred to as globozoospermia

50. SPERM VITALITY
• Vitality refers to the portion of sperm that are metabolically active living cells
• If near or total asthenospermia is observed , to discriminate whether the lack
of motility is a result of cell death or of dysfunction of molecular processes
involved in sperm motion
• A method of assessing sperm vitality is hypo-osmotic swelling (HOS) test
• When incubated in hypoosmotic medium, the tails of live sperm with
unimpaired membranes swell within 5 minutes, allowing for identification of
viable gametes
• Necrospermia is the condition describing a large number of nonliving sperm

51. COMPUTER-ASSISTED SEMEN ANALYSIS
• With the complexity associated with providing an accurate and reliable
semen analysis, several manufacturers provide systems that automate the
process of assessing sperm parameters such as motility, density, and
morphology
• Alternative method to the manual semen analysis

52. SPERM-FUNCTION TESTING
Fructose
• Fructose is the energy source for sperm motility and is present in all
semen specimens except for males with congenital bilateral absence of
vas deferens or bilateral ejaculatory duct obstruction
• A qualitative fructose is usually performed on azoospermic specimens
with a semen volume of less than 1.5 mL

53. SECONDARY SEMEN ASSAYS
• Conditions observed to be associated with antisperm antibody formation
include vasectomy, testis trauma, orchitis, cryptorchidism, testis cancer,
and varicocele
• Use of an assay for antisperm antibodies should be considered
 If agglutination of sperm is observed
 if sperm motility is decreased
• Two direct assays are available, the mixed antiglobulin reaction (MAR) test
and the immunobead assay

54. TERTIARY AND INVESTIGATIONAL SPERM ASSAYS
Sperm DNA Integrity Assays
• In general, there are two types of test methods that assess DNA structural
integrity
• In one, DNA fragmentation is measured directly
• In the other, DNA is denatured before analysis

57. TUNEL assay. Bright field is shown in A. Sperm heads by fluorescence are demonstrated in B.
TUNEL-positive sperm are identified in C.

60. Reactive Oxygen Species
• Naturally occurring chemical reactions generate highly reactive molecules
with unpaired electrons termed free radicals
• Free radicals produced from oxidative reactions are referred to as reactive
oxygen species
• If present in excess, seminal ROSs may cause reproductive dysfunction
Acrosome Reaction
• fluorescent labeling of acrosomal contents
• Subsequent use of flow cytometry allowed real-time analysis of acrosomal
function

61. Sperm Mucous Interaction
• The postcoital test, also known as the Sims-Huhner test, assesses sperm
interaction with mucus in two parts:
 first, it appraises mucus characteristics favorable to sperm penetration
 second, it gauges the number and motility of observed sperm
• The Penetrak assay
• The Tru-Trax assay

62. Sperm Ovum Interaction
• In the sperm penetration assay (SPA), hamster zona pellucida are
removed, and human sperm are incubated with the denuded hamster ova,
simulating IVF
Sperm Ultrastructural Assessment
• Sperm motility is dependent on the ultrastructural arrangement of
microtubules in the tail with a peripheral array of nine pairs and a central
two microtubules connected by dynein arms
• Semen samples with less than 10% motility and vitality demonstrated by
testing may be investigated with electron microscopy to assess tail
ultrastructural defects

63. CASE
• Semen analysis
 Seminal fluid analysis by computer-assisted semen analysis revealed no
sperm, but manual inspection under high-power microscopy revealed
several immature sperm. Seminal fluid volume is 2.5 cc, with a normal pH
(≥7.2) and fructose. Repeat seminal fluid analysis yielded similar results

64. ENDOCRINE EVALUATION
INDICATIONS TESTS
Abnormal semen parameters,
particularly sperm concentration
is<10mill/ml
FSH
Total testosterone
Free testosterone
Inhibin B
sexual dysfunction,ED LH
Specific endocrinopathy PRL, TSH, estradiol

66. CASE
• Endocrine evaluation
Total testosterone 6 nmol/L (normal, 10–32)
Free testosterone 87 pmol/L (normal, 220–640)
SHBG 16 pmol/L (normal, 13–90)
Estradiol < 20 pg/mL (normal, <50)
LH 2 mIU/mL (normal, 2–14)
FSH 6 mIU/mL (normal, 1–12)
Prolactine Normal Normal

67. GENOMIC ASSESSMENT
Karyotype

68. Y Chromosome Microdeletion Testing
• A region in the long arm of the Y chromosome is critical to the formation
of sperm in man, which became known as AZF (azoospermia factor)
• Microdeletions of three regions on the Y chromosome to be commonly
associated with azoospermia or oligospermia, which were termed AZFa,
AZFb, and AZFc
• AZFa and AZFb microdeletions cause significant pathology of the testis
resulting in diminishing low likelihood of sperm retrieval by surgery

69. Genomic Sequence Assessment
• These reports can be used to identify whether parents are carriers for a
large number of genetic diseases and the probability of affected offspring
Cystic Fibrosis Transmembrane Conductance Regulator Mutation
Assessment
• The most common severe mutation is ΔF508
• A severe mutation such as ΔF508 on each allele will result in a child with
cystic fibrosis
• Screening is compulsory for both the prospective father and mother for
those suspected of harboring genetic alterations in CFTR

71. IMAGING IN THE EVALUATION OF MALE INFERTILITY
• Obtaining imaging studies should be directed by medical history, physical
examination, and the results of the endocrine and genetic workup
Scrotal Ultrasonography
• Any abnormality on scrotal physical examination warrant scrotal
ultrasonography for further investigation
• Direction of flow may be assessed by color Doppler ultrasound, reversal of
flow is a positive prognostic sign that surgical treatment of varicocele may
result in improved seminal parameters

75. Vasography
• Contrast vasography in the direction of the abdomen allows determination
of patency of the vas deferens from the scrotum to the ejaculatory ducts
• It is invasive and may result in scar tissue formation in the vasal lumen and
obstruction
• Fluid, contrast or otherwise, should never be injected into the vasal lumen
in the direction of the epididymis because it will rupture the delicate
epididymal tubules

76. Venography
• Clinically significant varicoceles are palpable and require no further
imaging
• The treatment of varicoceles that are identifiable only by imaging and are
not palpable does not improve seminal outcomes
• If a clinically significant varicocele is to be treated by embolization, then
venography is used to plan the radiographic interventional approach

77. Transrectal Imaging
• The diagnosis of ejaculatory ductal obstruction is considered when
azoospermia in conjunction with low seminal volume
• Most prevalent method is TRUS
• Ejaculatory duct obstruction : anteroposterior seminal vesicle diameter of
greater than 1.5 cm with or without a midline prostatic cyst

81. Abdominal Imaging
• Renal ultrasound is sufficient
Cranial Imaging
• Cranial MRI allows assessment of whether hyperprolactinemia is
associated with an anatomic pituitary lesion
• MRI may distinguish between microadenomas and macroadenomas and
may assist in judging whether medical or surgical therapy is indicated

83. CASE
Imaging study
• Sella imaging revealed no hypothalamic or pituitary abnormalities

84. Diagnosis
• This patient has a presentation consistent with adult onset idiopathic
hypogonadotropic hypogonadism
• This diagnosis is uncommon and is characterized by normal puberty
followed by adult onset of very low serum T levels with low or
inappropriately normal gonadotropin levels
• Virtually all of these men have azoospermia and infertility

85. TESTIS BIOPSY
• The role of testicular biopsy is limited to select cases of azoospermia or
severe oligoospermia
• Provide important diagnostic information on underlying pathology and can
be therapeutically beneficial if viable sperm are found and can be
cryopreserved for future ICSI
• Useful when there is need to definitively distinguish between OA and NOA
in patients without obvious laboratory abnormalities
• May reveal normal spermatogenesis, hypospermatogenesis, germ cell
maturation arrest, germ cell aplasia (Sertoli-cell-only syndrome), tuberous
sclerosis, or a combination of these conditions

86. EFFECTS OF CKD AND RENAL TRANSPLANT ON MALE
INFERTILITY

88. THANK YOU