2. Terminology
Infertility problems that caused by systemic disorders such as :
◦ Occupational causes
◦ Environmental causes
◦ Drug related
◦ Infection related
◦ Consequences of medical and surgical conditions
Excluding
◦ Endocrine related – Hypogonadism
◦ Genetic disorders
◦ Immunologic
Irvine DS., 1998
4. Sexual History
Frequency and Quality of sex
◦ Libido; may be interrelated to endocrine disorder, and / or systemic medical
problems e.g. DM
◦ ED, PE; may be interrelated to systemic medical problems, and / or medications
◦ Low ejaculate volume; may be interrelated to obstruction, infection, or medication
factors
Sabanegh ES., 2011
8. Occupational and Environmental
Factors as Cause for Male
Infertility
Excessive Heat
Hot environments depress spermatogenesis
hot bathing,
prolonged car driving, and
using laptop
An exposure of the testis to elevated temperature may temporarily have the
same effect.
Schill, et al. 2006
9. Occupational and Environmental
Factors as Cause for Male
Infertility
Heavy Metals : Pb, As, Cd, Hg
◦ bind to enzymes and proteins critical to cell function, negating their role in
biochemical and physiological processes
◦ Induces necrosis and apoptosis
Lipshultz et al. 2009
10. Occupational and Environmental
Factors as Cause for Male
Infertility
Gonadotoxicants : organochlorines
◦ Bind avidly to nucleophilic groups on enzymatic and structural
proteins, as well as RNA and DNA
◦ Peroxidative damage of membrane lipids leads to loss of
integrity of organelles and even the cell membrane
◦ Carcinogenesis
◦ Overproduce of ROS
◦ Disruption of the balance between germ cell gain via mitosis
and loss by apoptosis
Lipshultz et al. 2009
11. Occupational Factors as Cause
for Male Infertility
Endocrine-Disrupting Chemicals
◦ Environmental Estrogens in live stocks
◦ Pesticides : mimicking endogenous estrogens
◦ suppression of androgen production
◦ suppression of androgen receptor (AR) expression
◦ reduction of Sertoli cell numbers and sperm production
◦ suppression of insulin-like factor 3 (INSL3) in fetal Leydig cells
◦ Pesticides : vinclozolin, linuron, procymidone, DDT
◦ Anti androgenic activity
Lipshultz et al. 2009
12. Infections as Cause for Male
Infertility
Fever
Affecting sperm concentration, morphology and motility
parameters
suppress spermatogenesis for a period of up to 6 months.
sperm DNA damage
Schill, et al. 2006
13. Infections as Cause for Male
Infertility
Chlamydia and Mycoplasma,
◦ are associated with decreased sperm counts and higher sperm DNA
fragmentation
Improve with antibiotic therapy
Sabanegh ES., 2011
14. Infections as Cause for Male
Infertility
HIV-1
HIV-1 infected men can ejaculate sperm that contain HIV-1 DNA, and may be associated
with increased sperm DNA fragmentation
impair of spermatogenesis, and disease severity related
Another mechanisms include hypogonadism, cytokine release, leucocytospermia, direct
involvement of the testes or epididymis
Using sperm processing accompanied by Antiretrovirals, ART can be done.
Sabanegh ES., 2011
Schill, et al. 2006
Schill, et al. 2006; Gunasekaran and Pandiyan, 2017
15. Infections as Cause for Male
Infertility
HPV
Does not correlate with an impact on the sperm parameters
HSV
no association to sperm parameters or male infertility
HBV
Ability to cross the Blood Testis Barrier into the sperm genome; the
integration of virus into the sperm genome can cause mutagenic and
hereditary effects that are serious threats in vertical transmission.
alterations in sperm parameters in HBV-infected semen samples including
decrease in sperm concentration, motility, and morphology
Spermatozoa aneuploidy
Gunasekaran and Pandiyan, 2017
16. Infections as Cause for Male
Infertility
Mumps
◦ The classical orchitis is associated with infectious parotitis (mumps)
◦ Following an attack of mumps orchitis, the recovery of fertility is variable
◦ Mumps occurring before puberty and mumps not accompanied by orchitis
do not interfere with fertility
Schill, et al. 2006
17. Consequences of Medical and
Surgical Conditions as Cause for
Male Infertility
Liver failure
◦ Hypogonadism and feminization
◦ Related to the severity of cirrhosis.
◦ Serum estradiol, sex hormone-binding globulin and gonadotrophins are
elevated, while testosterone levels are low
◦ Loss of libido, erectile dysfunction, infertility, reduced secondary sex hair,
testicular atrophy, and gynaecomastia are frequent
Schill, et al. 2006
18. Consequences of Medical and
Surgical Conditions as Cause for
Male Infertility
Renal failure - Mechanism
◦ Reduced sexual activity and libido
◦ Diminished fertility
◦ Adverse effects on the overall sperm fertilizing capacity
◦ Primary gonadal damage by uremic toxins, hypospermatogenesis, maturation arrest or germ cell aplasia
◦ Suboptimal serum testosterone with elevated LH, FSH, and prolactin levels
Schill, et al. 2006
19. Consequences of Medical and
Surgical Conditions as Cause for
Male Infertility
Renal failure - Management
◦ Haemodialysis
◦ Renal transplant
◦ In patients with symptomatic secondary hyperparathyroidism:
◦ Total parathyroidectomy combined with partial autotransplantation of
parathyroid tissue subcutaneously
◦ zinc therapy
◦ Present-day :
◦ IVF - ICSI
Schill, et al. 2006
20. Consequences of Medical and
Surgical Conditions as Cause for
Male Infertility
Metabolic
◦ Obesity is associated with
◦ low androgen/ estrogen ratio due to increased peripheral
conversion of androgens to estrogens by the enzyme aromatase
in adipose tissue.
◦ Disturbed testicular thermoregulation
Schill, et al. 2006
21. Consequences of Medical and
Surgical Conditions as Cause for
Male Infertility
Carcinoma
◦ Disease Related
◦ Testicular cancer, Hodgkin’s disease, non-Hodgkin lymphomas and leukaemia have deleterious
effects on fertility
◦ Therapy Related
◦ Irradiation in the genital region will most probably cause irreversible arrest of spermatogenesis
with subsequent sterility
◦ Alkylating agents usually cause irreversible damage
◦ Cisplatin-based regimens for testis neoplasm induce temporary azoospermia to permanent
damage
◦ Cryopreservation
Schill, et al. 2006; Hellstrom, 1997
22. Consequences of Medical and
Surgical Conditions as Cause for
Male Infertility
Respiratory Tract Diseases
◦ Chronic respiratory tract disease includes chronic sinusitis, chronic
bronchitis, and bronchiectasis.
◦ These conditions are sometimes associated with disorders of the sperm
flagellum such as in the immotile cilia syndrome, or with secretory
disturbance in the epididymis with obstructive azoospermia.
Schill, et al. 2006
23. Medications as Cause for Male
Infertility
Direct effect on sperm or testicles
Indirect effect by altering HPG axis
Sabanegh ES., 2011
24.
25. Habits and Social Conditions
as Cause for Male Infertility
Alcoholism
◦ Excessive alcohol consumption causes systemic disease in multiple organs,
including the liver and probably indirectly the testis.
◦ Impair spermatogenesis
◦ Reduce sexual function through inhibition of testosterone biosynthesis.
◦ These effects are prominent if alcohol abuse occurs on an almost daily basis
and exceeds approximately 6 units per day.
Schill, et al. 2006
26. Habits and Social Conditions
as Cause for Male Infertility
Smoking
◦ Nicotine and its water soluble metabolite, cotinine are detectable in the seminal
fluid of smokers
◦ affects sperm production, motility, and morphology
◦ increased oxidative damage to the sperm DNA,
◦ impaired secretory functions of male accessory sex glands
◦ alterations in serum hormone levels.
◦ Heavy metals involvement (Cadmium)
◦ lower spontaneous pregnancy rates and lower success rates following intrauterine
insemination, in vitro fertilization and ICSI
◦ maternal smoking can adversely affect semen quality in male off spring
Schill, et al. 2006
Lipshultz et al., 2009; Cavallini and Beretta, 2015
27. Habits and Social Conditions
as Cause for Male Infertility
Recreational Drugs Abuse
◦ Marijuana
◦ reduce testosterone released from Leydig cells,
◦ modulate apoptosis of Sertoli cells,
◦ decrease spermatogenesis, decrease sperm motility, decrease sperm capacitation, and decrease
acrosome reaction
◦ Heroin
◦ abnormal sexual function and remained so even after cessation
◦ Cocaine
◦ increases in serum prolactin, and decreases in serum total and free testosterone
Cavallini and Beretta, 2015
Schill, et al. 2006
28. Reference
Cavallini, G., Beretta, G. (Eds.), 2015. Clinical Management of Male Infertility. Springer International Publishing, Cham
Gunasekaran, K., Pandiyan, N. (Eds.), 2017. Male Infertility. Springer India, New Delhi.
Hellstrom, W.J.G. (Ed.), 1997. Male Infertility and Sexual Dysfunction. Springer New York, New York, NY.
Irvine, D.S., 1998. Epidemiology and aetiology of male infertility. Hum. Reprod. 13, 33–44.
Lipshultz, L.I., Howards, S.S., Niederberger, C.S. (Eds.), 2009. Infertility in the male, 4th ed. ed. Cambridge University
Press, Cambridge, UK ; New York.
Sabanegh, E.S. (Ed.), 2011. Male Infertility. Humana Press, Totowa, NJ.
Schill, W.-B., Comhaire, F.H., Hargreave, T.B. (Eds.), 2006. Andrology for the clinician. Springer, New York, NY.
