a summarized and easily palatable discussion on male infertility

1. MALE
INFERTILITY
Dr. Tanmoy Debnath
HMO
Department of Urology

2. DEFINITION
Failure to conceive after 1 year of
regular unprotected sexual
intercourse (at least 2 times in a
week)

3. INCIDENCE
15% of couples are infertile
▫ 40% male factor
▫ 40% female factor
▫ 20% both

4. TYPES
Primary infertility:
Who never conceive
Secondary infertility:
Couples who have been fertile in the
past, but have fewer than the desired number of
children

5. CAUSES
• Pre testicular cause
• Testicular cause
• Post testicular cause

6. PRE TESTICULAR CAUSE
• Hypothalamic disease
▫ Kallmann syndrome (gonadotropin deficiency)
▫ Isolated LH deficiency (Fertile Eunuch)
▫ Isolated FSH deficiency
▫ Congenital hypogonadotrophic syndrome

7. Cont..
• Pituitary disease
▫ Pituitary insufficiency
 Tumour
 Infarct
 Surgery
 Radiation
 Secondery infiltration
▫ Hyper prolactinemia : Prolactin-secreting pituitary
adenoma

8. Cont..
• Exogenous or endogenous hormone
 Increase Estrogen
 Increase Glucocorticoids
 Increase Androgen
 Hypo or hyperthyroidism
 Growth hormone deficiency

9. TESTICULAR CAUSES
• Klinfelter syndrome (47XXY)
• Noonan syndrome (Male Turner syndrome)
• Bilateral anorchia
• Y chromosomal microdeletion
• Gonadotoxin
 Radiation
 Drugs - Calcium channel blocker, Cimetidine,
Sulfasalazine, Spironolactone, Allopurinol, Alpha-
blocker, TCA, Anti-psychotic, Nitrofurantoin

10. Cont..
• Systemic disease:
 Renal failure
 Liver failure
 Sickle cell disease
• Testis injury:
 Mumps orchitis
 Trauma
 Torsion
• Cryptorchidism
• Varicocele
• Idiopathic

11. POST TESTICULAR CAUSES
• Reproductive tract blockages
▫ Congenital blockages
 Cystic fibrosis - Congenital bilateral absence of vas deferens(CAVD)
 Young Syndrome
 Idiopathic epididymal obstruction
 PKD
 Ejaculatory duct obstruction
▫ Acquired blockages
 Vasectomy
 Groin & hernia surgery
 Infection
▫ Functional blockages
 Sympathetic nerve injury
 Pharmacological

12. Cont..
• Disorder of sperm function & motility
 Immotile cilia syndrome
 Infection
 Immunological Infertility
• Disorder of coitus:
 Impotence
 Hypospadias
 Chordee
 Timing & frequency

13. EVALUATION/WORK UP/INDICATION
Couple should have a joint evaluation at one year, unless
the following factors are present
In male:
 Bilateral cryptorchidism
 Testicular torsion
 Previous Unexplained infertility
 Prior chemotherapy
In female:
 Advanced marital age (>35 yrs)
 Irregular or abnormal menstruation
 Previous unexplained infertility
 H/O PID

14. GOAL OF WORK UP
Identification of
▫ Reversible conditions
▫ Irreversible conditions managed by ART
▫ Irreversible conditions adversely affecting any
offspring e.g. genetic or chromosomal abnormality
▫ Medical conditions related to infertility

15. WORK-UP
• History
• Physical examination
• Investigations

16. HISTORY
• Medical history
• Surgical history
• Fertility history
• Sexual history
• Family history
• Medication history
• Social history
• Occupational history

17. MEDICAL HISTORY
• H/O Mumps, Liver disease, Renal failure
• Hyperthyroidism/Hypothyroidism
• Fever
• Systemic illness : DM, Cancer, Infection
• Genetic disease : Cystic fibrosis, Klinefelter
syndrome

18. SURGICAL HISTORY
• Cryptorchidism, Orchidopexy
• Trauma, Torsion of testis
• Hypospadias, Varicocele
• Pelvic, bladder, retroperitoneal surgery
• Herniorrhaphy, Vasectomy
• TURP, BNI,RPLND, Lumbar sympathectomy

19. FERTILITY HISTORY
• Duration of marriage
• Previous pregnancy
• Duration of infertility
• Previous treatment for infertility
• Female evaluation

20. SEXUAL HISTORY
• Libido, Erection
• State of ejaculation
• Timing & frequency
• Lubricants, used or not

21. FAMILY HISTORY MEDICATION HISTORY
• Hypospadias
• Cryptorchidism
• Midline defects
• Exposure to diethylstilbesterol
• F/H of infertility
• Nitrofurantoin
• Alpha blocker
• Calcium channel blocker
• Cimetidine
• Sulfasalazine
• Spironolactone
• Thiazide
• Radiation

22. SOCIAL HISTORY OCCUPATIONAL HISTORY
• Smoking/tobacco
• Cocaine
• Anabolic steroids
• Exposure to ionizing radiation
• Chronic heat exposure
• Aniline dye
• Pesticides
• Heavy metals

23. PHYSICAL EXAMINATION
GENERAL EXAMINATION
To detect signs of hypogonadism (Secondary sex
characteristics)
 Body hair distribution
 Fat distribution
 Voice
 Breast
 Thyroid

24. LOCAL EXAMINATION
TESTIS: Size: Length 4.6cm (3.6-5.5cm)
Breadth 2.6cm (2.1-3.2cm)
Volume 18.6cc +/- 4.0cc
Consistency : Firm (normal), Soft (abnormal)
EPIDIDYMIS: Normally placed on postero-lateral aspect
of testis
Tenderness ,Induration ,Cyst, Nodule
SPERMATIC CORD: Varicocele
Vas deferens – Present or absent (2%)

25. PENIS: Length (at least 5cm is normal),
Hypospadias , Chordee, Phimosis
DRE: Prostate - Developed or not, features of
infection (tenderness,boggyness), features of
malignancy
Seminal vesicle - Enlarged or not

26. INVESTIGATIONS
• Laboratory tests - a) Semen analysis
b) Genetic assessment
• Radiographic evaluation
• Testicular biopsy
• Vasography

27. SEMEN ANALYSIS
COLLECTION
▫ Sexual abstinence for 48-72 hours
(With each abstinence, 0.4 ml semen volume is raised up to 1
week And Sperm motility tends to fall when abstinence
period > 5 days)
▫ Collected by
• Self stimulation (masturbation)
• Intercourse with special nonspermicidal condom
• Coitus interruptus ( less ideal)
▫ Collected in a wide mouth ,clean plastic or glass bottle
▫ Specimen should be examined within 1 hour of
procurement
▫ During transit,the specimen should be kept at body
temperature
▫ 3 separate samples should be collected within period of 4-6
wks before final report

28. CONT.
Physical characteristics
• Fresh semen is a coagulum that liquefies within 15-30
minutes of ejaculation
• Normal characters :
Ejaculate volume : 1.5 – 5.5 ml
Sperm count : > 20 million /ml
Motility : >50 %
Forward progression : 2 ( scale 1-4)
Morphology : >30 % WHO normal forms
>4 % Kruger normal forms
pH : Alkaline
Increased viscosity and no clumping

29. Some Nomenclatures
• Aspermia : Absence of ejaculate or seminal fluid.
Cause - Retrograde ejaculation
Post coital urinalysis confirms the dianosis
• Normospermia : Sperm count > 20 million/ ml
• Oligospermia (Oligozoospermia) : Sperm count < 20
million / ml
Cause : Varicocele, Cryptorchidism
• Azoospermia : Absence of sperm
Cause - Ejaculatory duct obstruction
Bilateral absence of vas deference
Cyst related to epididymis
Primary testicular failure
FSH is high > 2 times than normal

30. Cont.
• Asthenospermia ( Asthenozoospermia ) : Motility < 50
% ( < 50 % motile)
• Teratozoospermia : Morphology < 30 % than normal form
• Oligoasthenoteratozoospermia : Density , Motility &
Morphology less than minimum standards of adequacy
• Pyospermia / Leucospermia :
 Increase in WBC in the seminal fluid
 > 1 million / ml is significant
 Cause : Infection
Sensitization of immune system to sperm antigen
Low grade toxin – alcohol, cigarattes

31. Genetic assessment
 Chromosomal analysis : Barr body
Karyotyping
 CF mutation testing

32. Radiographic evaluation
Scrotal ultrasound
Indication :
• Patient who have hydrocele
• Abnormality of peri testicular region
• Varicocele (Color Doppler )
Findings :
• Size of testis
• Peri testicular abnormality
• Varicocele – Pampiniform venous diameter >3mm is
consider abnormal

33. Cont..
TRUS ( Transrectal ultrasound)
Indication :
• Azoospermic patient
• Semen volume < 1.5 ml
• pH – Acidic
• When semen does not coagulate
Findings :
• Anatomical evaluation of prostate, seminal vesicles,
ejaculatory duct & distal vas - tumors or congenital anomaly
Dilated seminal vesicles > 1.5 cm in width or Dilated
ejaculatory duct > 2.3 mm in association with cyst ,
calcification or stone along the duct  highly suggest
obstruction

34. CT & MRI
• The advent of TRUS limits its indication
• Indications include evaluation of patient with solitary
right varicocele which may be associated with
retroperitoneal pathology and evaluation of the
nonpalpable testis

35. Testicular biopsy
• Differentiate between testicular outflow obstruction &
primary testicular failure in azoospermic patient
• Indications : In azoospermic patient, whose vas
deference is present ( detected by palpation & TRUS )
with normal hormone level ( FSH,LH,testosterone) &
normal volume of testis.
• Symmetric testis – unilateral biopsy
• Asymmetric testis – bilateral biopsy

36. Cont..
Testicular biopsy evaluates
▫ Distinction between a failure of sperm production &
obstruction within the reproductive tract
▫ The size & number of seminiferous tubules
▫ The thickness of tubular basement membrane
▫ The relative number & types of germ cell within the
seminiferous tubules
▫ The degree of fibrosis in the interstitium &
▫ The presence of condition of Leydig cells.

37. VASOGRAPHY
Indications : Azoospermic patient with -
▫ Normal testis size,
▫ Normal FSH level &
▫ Normal spermatogenesis on testis biopsy
Technique :
• Vasography involves injection of dye or contrast media
into vas deferens towards the bladder from scrotum
• If sterile saline is injected into the vas towards the
bladder & if free flow is noted , no need for injecting
contrast media into the vas.

38. Cont..
• In the film of radiograph , contrast material can
delineate the anatomy of proximal vas deferens, seminal
vesicle & ejaculatory duct and determine whether
obstruction is present.
• If an obstruction is identified on vasography , surgical
correction is recommended during the same sitting
• Sampling of vasal fluid during the same procedure can
be done & inspected under microscope to determine the
presence of sperm
If sperm present – suggests obstruction distal to that
site, i.e. no obstruction in the testis & epididymis
If sperm absent – suggests more proximal obstruction

39. Treatment
Treatment depends on the cause of infertility
Options :
a ) Surgical
b ) Medical
c ) Artificial reproductive technology (ART)

40. Azoospermia :
a ) Low volume azoospermia :
 Ejaculatory duct obstruction : Transurethral resection of
ejaculatory duct ( TURED)
 Congenital absence of vas deference (CAVD):
Microscopic epididymal sperm aspiration (MESA)
followed by ICSI
 Midline prostatic cyst : Transurethral resection
b ) Normal volume azoospermia
 Vasal or epididymal obstruction : Microsurgical
reconstruction, e.g. Vasovasostomy or
vasoepididymostomy

41. Spermatogenic failure :
i) Primary spermatogenic failure ( hypergonadotropic
hypogonadism ):
Testicular sperm extraction/aspiration ( TESE /
TESA)  ICSI
ii) Secondary spermatogenic failure (hypogonadotropic
hypogonadism) : Replacement of gonadotrophin, i.e.
FSH,LH
Induction of virilization : hCG

42. Oligoasthenoteratozoospermia
• Elimination of spermatotoxin : i.e. Cimetidine ,
Spironolactone , Nitrofurantoin
Semen analysis should be repeated 2-3 months after
elimination
• Medical therapy : ( to increase spermatogenesis )
▫ Clomiphene citrate (antiestrogen) : dose 12.5- 50 mg
/day continuously or with a 5 days rest period.
▫ Tamoxifen citrate : 10-15 mg/day for 3- 6 months
▫ Antioxidant : Glutathione 600 mg/day or, Vit E 400 –
1200 U/day
▫ Kallikrein
• Surgical therapy : For Varicocele - Ligation of the veins

43. Retrograde ejaculation :
 Sympathomimetic drugs : Imipramine : 25-50 mg/bd
or, Sudafed plus : 60 mg TDS - Need to start several
days before ejaculation
 If fails – Sperm harvesting technique with IUI to achieve
pregnancy

44. Anejaculation :
• Due to spinal cord injury , pelvic nerve injury
• Treatment :
Electroejaculation :
With rectal probe electroejaculation  sympathetic
nerves undergo stimulation  contraction of vas
deferens, seminal vesicle, prostate reflex ejaculation is
induced  followed by ART
Vibratory stimulation :
High frequency penile vibration - Patient may be taught
to perform the procedure & attempt to conceive at home
with cervical insemination

45. Hyperprolactinaemia
 Transphenoidal surgery
 Bromocriptine 5- 10 mg daily
Pyospermia :
• Antibiotic – Doxycycline, Co-trimoxazole
• Antioxidants- Antioxidant vitamins, Glutathione, omega-
3 fatty acid

46. Others :
Coital therapy :
• Coital timing, frequency (Coitus every other day around
the ovulation)
• Gonadotoxin avoidance
• Avoidance of coital lubricants