Dr. Sujoy Dasgupta is a consultant in reproductive medicine who has extensive qualifications and experience in the field. He lists his academic achievements and positions held at several hospitals in Kolkata. The document provides an overview of Dr. Dasgupta's expertise in evaluating and treating male infertility through a discussion of topics like semen analysis, varicocele, cryptorchidism, hormonal abnormalities, genetic defects, ejaculatory issues, and treatment strategies including IUI, IVF and ICSI.

1. Dr Sujoy Dasgupta
MBBS (Gold Medalist, Hons)
MS (OBGY- Gold Medalist)
DNB (New Delhi)
MRCOG (London)
Advanced ART Course for Clinicians (NUHS, Singapore)
Diploma, Sexual & Reproductive Medicine (South Wales, UK)
Consultant: Reproductive Medicine, Genome Fertility Centre, Kolkata
Visiting Consultant, RSV Hospital, Kolkata
Bhagirathi Neotia Women and Child Care centre
Woodlands Multispeciality Hospital, Kolkata
Managing Committee Member, Bengal Obstetric & Gynaecological Society
(BOGS)
Secretary, Subfertility and Reproductive Endocrinology Committee, BOGS
Executive Committee Member, Indian Fertility Society (IFS)- West Bengal Chapter
Executive Committee Member, Indian Society for Assisted Reproduction (ISAR)-
Bengal
Winner, Prof Geoffrey Chamberlain Award, RCOG World Congress, London, 2019
Male Infertility

2. Treatment burden for MALE
infertility falls on FEMALE

3. WHO Standard 2010
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2
3
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5
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4. Esteves S C. Clinical relevance of routine semen analysis and controversies surrounding the 2010
World Health Organization criteria for semen examination. Int Braz J Urol. 2014; 40: 443-53

5. Esteves S C. Clinical relevance of routine semen analysis and controversies surrounding the 2010
World Health Organization criteria for semen examination. Int Braz J Urol. 2014; 40: 443-53

6. Limitations of WHO 2010 Guideline
• Based on parameters in a large group of fertile men
along with defined confidence intervals from recent
fathers with known time-to-pregnancy (TTP).
• The WHO does not consider the values set as true
reference values but recommends or suggests
acceptable levels.
• Day to day variation

7. Is “Routine” Semen
Analysis
ENOUGH?

8. Sperm DNA Fragmentation
(SDF)
Infertile men with:
• Repeated IUI or IVF failure
• Recurrent spontaneous miscarriages (ESHRE, 2018)
• Previous low fertilization, cleavage or blastulation rate

9. Significance of SDF
• Live birth after IUI/ IVF/ ICSI- ?
• Oocytes can repair the damaged DNA
• Lack of standardization
• Lack of definitive treatment

11. From which Laboratory?

12. Issues in Semen Collection
• Privacy
• Relaxation
• Bed
• Partner
• Washing facility
• Ask- Why Difficulty
• Erection issue
• Vibroejaculator
• Coitus interruptus
• Nontoxic condom
• Home Collection
• Urine (In RE)
• Prostatic Massage
• Electroejaculation

13. Leukocytospermia

15. MAGI (Male Accessory Gland Infection)
• The clinical significance of an increased
concentration of leukocytes in the ejaculate is
controversial.
• Special Tests- Round cells vs Pus cells
• Method of collection
• Hand washing before collection
• Culture of semen
• Antibiotics- only when documented infections
• Look for phimosis
• Consider prostatic fluid culture
EUA, 2018; ASRM, 2020; Vignera et al., J Med Microbiology, 2014

16. EUA, 2018

17. “Pus Cells” and ART outcome

18. “Mild” Male Factor

19. What is “Mild”?
• TMSC= Total Motile sperm count = Sperm
concentration x total volume x total motility (TM)
• TMSC >5/ 10/ 20 million

20. Mild Male Factor
• Investigations- NOT
usually
recommended
• Repeat semen after 3
months (NICE, 2013; EUA,
2018; ASRM, 2020)
• Antioxidants
• CC
• Other adjuvant
Lifestyle changes
1. Heat exposure to scrotum
2. Obesity
3. Food habit
4. Smoking
5. Alcohol
6. Anabolic steroids
7. Chronic scrotal fungal
dermatitis (EUA, 2018; ASRM, 2020)

21. Severe Male Factor

22. Male Infertility- A health-opportunity
• Diabetes
• Cardiovascular diseases
• Lymphoma, extragonadal germ cell tumours, peritoneal cancers
• Repeated hospitalization
• Increased mortality
Choy and Eisenberg, 2020; Bungum et al., 2018; Eisenberg et al., 2013; Jungwirth et al., 2018; Hotaling and Walsh, 2009

23. Self-Testicular
Examination
•Atrophic Testes
•H/O undescended testicles
•Testicular microcalcification

24. Revisiting History
• Age
• Duration of subfertility
• Lifestyle
• Occupation- Driving, IT, chemical industry (heavy
metal, pesticides)
• Medical history- Diabetes, Mumps, Cancer
• Surgical history- Hernia, Orchidopexy, Pituitary
Surgery, Bladder neck surgery
• Drug history- Sulphasalazine, Finesteride,
cytotoxic drugs, steroids
• Sexual history- Low libido, ED

25. Darren et al. Male infertility – The other side of the equation . 2017

26. Varicocele- always CLINICAL Diagnosis
• Subclinical: not palpable or
visible, but can be shown by
special tests (Doppler
ultrasound).
• Grade 1: palpable during
Valsava manoeuvre, but not
otherwise.
• Grade 2: palpable at rest, but
not visible.
• Grade 3: visible at rest.

27. Surgery for Varicocele (EUA, 2018)
• Grade 3 varicocele
• Ipsilateral testicular atrophy
• Abnormal semen parameters
• No other fertility factors in the couple

28. In couples seeking fertility with ART, varicocele repair
• may offer improvement in semen parameters
• may decrease level of ART needed

29. Varicocelectomy- How, when?
• Sclerotherapy
• Embolization
• Scrotal operation
• Inguinal operation
• Laparoscopic approach
• High ligation
• Microsurgical
varicocelectomy- most
effective method with
minimum risks of
complications and lower
recurrence rates (EUA, 2018)
Positive Predictive Factors
1. Grade 3 varicocele
2. TMSC ≥5 million
3. High SDF
Samplaski and Jarvi, 2016

30. Congenital bilateral absence of
vas deferens (CBAVD)
• Semen- Volume <1.5 ml, pH <7.0, fructose negative
• Renal ultrasound
• CFTR testing (EUA, 2018; ASRM< 2020)
• Partner testing
• Indian prevalence- 1:10,000- 1:40,000 (Kapoor et al., 2006;
Prasad et al., 2010)

31. Cryptorchidism in adults (EUA, 2018)
• In adulthood, a palpable undescended
testis should NOT be removed because
it still produces testosterone.
• Correction of B/L cryptorchidism,
even in adulthood, can lead to sperm
production in previously azoospermic
men
• Perform testicular biopsy at the time of
orchidopexy in adult- to detect germ
cell neoplasia in situ

32. Importance of history and examination
Rt sided orchidopexy during appendicectomy at 18 yr
Subsequently Rt testis atrophied
Lt side operated after 6 months, could not be brought to scrotum,
biopsied, seen by MRI (not seen in USG)

33. Imaging
Scrotal ultrasound
1. Clinically abnormal findings-
mass/ atrophy
2. Tight scrotum (Cremasteric
reflex)
3. Obese patient
• NOT for Varicocele detection
• NOT the replacement for
clinical examination (EUA,
2018; ASRM, 2020)
Transrectal ultrasound (TRUS)
1. Low volume and pH of
semen
2. Ejaculatory disorders (EUA,
2018; ASRM, 2020)

34. Abnormal Imaging
Epididymal Cysts
• NOT associated with
infertility (Weatherly et al.,
2018)
Testicular Microlithiasis
• Premalignant condition (EUA,
2018)

35. Sperm concentration <10 million/ml
Sexual dysfunction
Clinically suspected endocrinopathy
FSH, LH, Testosterone, HbA1C
FSH/ LH low
Testosterone low
Serum Prolactin
Pituitary
Imaging
FSH high
LH high
Testosterone low
Global
Testicular
failure
LH normal
Testosterone normal
Spermatogenesis
defect
LH high
Testosterone normal
Subclinical
hypogonadism
Prolactin, TSH if
clinically suspected

36. Testosterone Supplementation?
• Should only be done in men with primary
hypogonadism, NOT interested in fertility (EUA, 2018;
EUA, 2016; AUA, 2018; CUA, 2015)
• They provide feedback inhibition on pituitary
gonadotrophins (FSH and LH) leading to
secondary hypogonadism (de Souza and Hallak, 2011; McBride and
Coward, 2016; WHO, 2010)

37. Alternative Strategy
• If T:E2 ratio <10
(T- ng/dl, E2- pg/ml),
consider Aromatase
Inhibitors (Letrozole,
Anastrozole)
EUA, 2018; AUA, 2018
Asian J Andr, 2019

38. Hypogonadotrophic Hypogonadism
• hCG 2000-5000 IU 3 times a week
• Serum testosterone should be checked every 1–2 months
• The sperm count should be monitored monthly
• Sperm parameters become normal within 6 months but
sometimes it can take 24 months of time
• If hCG alone cannot restore spermatogenesis, FSH is
added in the dose of 75-150 IU 3 times a week
EUA, 2018

39. Other hormonal therapies
Primary
hypogonadism
• SERM- CC,
tamoxifen AUA, 2018
Idiopathic Male
Subfertility
• CC, Tamoxifen, hCG,
Letrozole
• Empirical
• Level of evidences ?
EUA, 2018

40. I n f e r t i l i t y

42. Smits RM, Mackenzie-Proctor R, Yazdani A, Stankiewicz MT, Jordan V, Showell MG. Antioxidants for
male subfertility. Cochrane Database Syst Rev. 2019;3(3):CD007411. Published 2019 Mar 14.
• may improve live birth rates
• clinical pregnancy rates may also increase.
• Overall, there is no evidence of increased risk
of miscarriage, however antioxidants may give
more mild gastrointestinal upsets
• Subfertilte couples should be advised that
overall, the current evidence is inconclusive.

43. • Overall, 16 (24.6%) of 65 patients with severe
oligozoospermia developed azoospermia.
• Two (3.1%)patients with moderate
oligozoospermia developed azoospermia
• None of the patients with mild
oligozoospermia developed azoospermia.

44. IUI, IVF or ICSI?

45. TMSC and IUI – cut offs
TMSC PR/CYCLE
 10–20 million 18.29%
 5–10 million 5.63%
 <5million 2.7%
Guven et al, 2008;Abdelkader & Yeh, 2009
Hamilton etral., 2015
Criteria TMSC Treatment
Pre wash TMSC > 5 million IUI
Pre wash TMSC 1 - 5 million IVF
Pre wash TMSC <1 million ICSI

46. TMSC <5 mil/ml and IUI
• Counsel before IUI
1. Double Ejaculate Kucuc et al., 2004; Oritz et al., 2016
2. “Trial IUI”- Post wash- IMSC Ombelet et al., 2014
3. IMSC >1 mil/ml → Further IUI
4. IMSC <1 mil/ml → ICSI
5. No role of double insemination or any
special washing technique ESHRE., 2018

47. Tubal Patency before IUI?
• If no risk factors for
tubal block- 3 cycles
of IUI, then tubal
patency test
• If risk factors- tubal
patency first
• With severe male
factor chance of
tubal factor-
infertility decreases

48. Strategies in Severe OAT
• Donor sperm is NOT the solution
• Investigate the cause
• Consider freezing of the sperms
• Short “trial” of medical therapy
• Trial IUI- Double ejaculate, IMSC
• ICSI is the standard treatment

49. Ejaculate vs Testicular sperms

50. Azoospermia

51. Surgical Sperm Retrieval in
Azoospermia (OA>NOA)

52. FNAC- role?
• “Trial TESA”
• If obtained,
cryopreserve the
sperms
ASRM, 2020
• FSH >7.6 AND testicular
long axis <4.6 cm- 89%
chance of NOA
• FSH <7.6 AND testicular
long axis >4.6 cm- 96%
chance of OA
• Consider TESA in
indeterminate cases- NOT
NECESSARY

53. Indiscriminate FNAC
• 35 yr, office worker
• Secondary subfertility of 10 yrs
• Previous- one male baby, 12 yrs, natural conception; followed by 2 TOP
• Only female was evaluated initially- multiple cycles of OI with CC,
letrozole, hMG
• Azoospermia diagnosed
• FNAC- B/L normal spermatogenesis
• Low libido and ED→ FSH, LH, Testo all low → Nonfunctioning Pituitary
macroadenoma → Endoscopic surgery H/P Lymphocytic hypophysitis
• Sexual function and sec sex characters improved after Sx
• On cortisol, L-thyroxine supplementation
• Started hCG f/b hMG by endocrinologist
• Sperm conc 1-2/ hpf
• Advised to continue hMG

54. If previous FNAC was done (Schwarzer, 2013)
Diagnosis Chance of sperm retrieval
(Micro-TESE >> TESE)
Sertoli-cell-only syndrome
(Germ cell hypoplasia)
32%
Maturation arrest 66.7%
Hypospermatogenesis 100%
Tuberous sclerosis 33.3%
Mixed atrophy 95.2%

55. Predictors of sperm retrieval?
• FSH
• Testicular Size
• No reliable positive prognostic
factors guarantee sperm recovery
for patients with non-obstructive
azoospermia.
• The only negative prognostic
factor is the presence of AZFa
and AZFb microdeletions.

56. Genetic testing
• Sperm
concentration <5
million/ml
• Azoospermia
• Testicular atrophy
• Elevated FSH
• Karyotyping
• Y chromosome
Microdeletion
(YMD)

57. In presence of genetic defect
• Sperm Aneuploidy testing by FISH
• PGT-SR (previously- PGD) (EUA, 2018;
ASRM, 2020)

58. Klinefelter’s syndrome

59. 45, XY rob (14, 21), (q10, q10)

60. YMD Report

61. AZF microdeletion

62. Ejaculatory
Disturbances

63. Ejaculation Problems
• DM
• Spinal cord Injury
• Neurological diseases
• Obstruction
• Surgery to bladder neck
• Medication- SSRI, PDE-5 blockers, alpha-
blockers

65. Strategies in Ejaculatory
disorders
• Pharmacotherapy
• Vibroejaculator
• Post-masturbation urine (PMU)- After
alkalinization- IUI/ IVF/ ICSI
• Elactroejaculation
• TESA

66.  Meticulous semen analysis in a standard laboratory
 Repeat if abnormal
 Physical examination and rational investigations
 Avoid non-evidence based drugs for long time
 Donor sperm is NOT the only solution
 IUI or ICSI- depends on the overall assessment
Take Home Messages