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Seminar on male infertility
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INTRODUCTION
INFERTILITY - one year of unprotected intercourse
without conception
SUBFERTILITY- couples who conceive after 12
months of attempted impregnation.
FECUNDABILITY - probability of achieving
pregnancy within a single menstrual cycle
FECUNDITY - probability of achieving a live birth
within a single cycle.
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It is sole cause in 20% of infertile couple
Contributing factor in 20-40% couples
Female infertility in 40-55%
PREVALENCE
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SPERMATOGENESIS
• During embryogenesis, there are approximately
300 thousand spermatogonia in each gonad.
• Each undergoes mitotic division, and by
puberty 600 million in each testis.
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Sperm production takes place in seminiferous tubules
within testis.
Spermatogenesis takes about 75 days
Adult males produce 100-200 million sperm each day.
Under the effect of LH, Leydig cells produce
testosterone (which along with FSH, stimulates
spermatogenesis).
Maturation of sperms takes place in epididymis.
Transport of sperms – vas deferens 5
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Physiology of Semen after
Ejaculation
1. Liquefaction
2. Capacitation
3. Acrosome reaction
4. Cortical reaction
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Klinefelter syndrome:
47XXY and other forms & no. of CAG repeats
• Small firm testes
• FSH & LH and Testosterone
• Cryptorchidism
• Long arms & legs
• Psychosocial abnormalities
• Pulmonary diseases
• Mediastinal germ cell tumors, breast cancer
PRIMARY GONADAL DISORDERS
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Y chromosome deletions: 20% men with infertility
• Severe oligospermia & azoospermia
• Genetic counselling offered before ICSI, as these
deletions are transmitted to sons.
Single gene mutations & polymorphism:
No. of CAG repeats inversely proportional to sperm
concentration & fertility
PRIMARY GONADAL DISORDERS
14. Cryptorchidism: Failure of testicular descent.
An androgen dependent process.
FSH levels raised. LH normal
Risk of tumors
Varicoceles: Dilatation of pampiniform plexus of spermatic veins.
More common on left side.
No causal relationship with infertility
Radiation: 0.015 Gy (15 rads) supress spermatogenesis
> 6 Gy permanent azoospermia
PRIMARY GONADAL DISORDERS
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Epididymal dysfunction: Intrauterine exposure to
DES. Causes isolated asthenospermia
CBAVD: Congenital bilateral absence of the vas
deferens related to CFTR gene mutations. 1-2% of
infertile men
Kartagener syndrome: Recurrent sinus infection,
bronchiectasis, situs inversus, male infertility.
SPERM TRANSPORT DISORDERS
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Goals are to Identify-
• Specific cause & correct it
• Individuals who can be offered IUI & ART
• Individuals with genetic abnormality that may affect
offspring conceived by ART
• Adoption & donor sperm options for those who are
not candidate for ART
• Underlying Medical condition
MALE INFERTILITY EVALUATION
18. Time to start evaluation : When pregnancy fails to occur after 1 yr of
regular unprotected intercourse.
Earlier evaluation for men with any obvious infertility factor.
HISTORY:
• Duration of infertility & previous fertility
• Coital frequency & sexual dysfunction
• h/o previous evaluation & t/t
• Childhood illness
• Previous surgical & medical illness
• Past episodes of STI
• Exposure to gonadotoxins & heat
• Medications & allergies
• Occupation & addictions
MALE INFERTILITY EVALUATION
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PHYSICAL EXAMINATION:
• Examination of penis, location of urethral meatus
• Palpation of testes & size
• Presence & consistency of vas & epididymis
• Secondary sexual characteristics, habitus, hair &
breast development
• Digital rectal examination
MALE INFERTILITY EVALUATION
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Collection method: After a defined period of
abstinence of 2-3 days.
Semen may be collected in a clean container by
masturbation or via intercourse using silastic
condom that does not contain spermicidal agents.
Sample should be examined within an hour of
collection.
If abnormal, repeat it after 4 weeks.
SEMEN ANALYSIS
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Volume 1.5 ml (1.4 – 1.7)
Sperm concentration 15 million/ml (12 - 16)
Total sperm number 39 million/ejac (33-46)
Total motility 40% (38 - 42)
Progressive motility 32% (31 - 34)
Normal morphology 4% (3 - 4)
Vitality 58% (55 - 63)
To assess prognosis for achieving pregnancies with their
partner
Lower Reference Limits
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The lower limit is 1.5 ml
pH : 7.2 or higher (Alkaline)
CBAVD or Bliateral Ejaculatory duct block – acidic
pH
High volumes >5ml
Indicate inflammation of accessory glands
Ejaculate volume & pH
25. Azoospermia : Complete absence of sperm on microscopic
examination in ejaculate.
• 1-3% male population, 10-15% male infertility
• To confirm diagnosis semen is centrifuged & pellet examined
1. OBSTRUCTIVE: blockage in ductal system ( CBAVD, scrotal or
inguinal surgery)
2. NON OBSTRUCTIVE: primary testicular failure,
endocrinopathies that suppress spermatogenesis.
Oligospermia : sperm density < 15 million/ml. Severe when < 5
million/ml
Sperm Concentration & Total Sperm
Count
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% of total sperm exhibiting any motion
Total motile sperm count = total sperm count & % of
progressively motile sperm
Asthenospermia : Poor sperm motility. Suggests
anti sperm antibodies, genital tract infections, partial
obstruction of ejaculatory duct, varicoceles,
vasectomy reversal, prolonged abstinence
Motility, Total motile count, Vitality
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Viable non-motile sperm- Kartagener syndrome
Vitality test- to differentiate viable non motile sperm
from dead sperm for ICSI
Motility, Total motile count & Vitality
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To evaluate attachment to zona pellucida, penetration of
the oocyte, release of acrosomal enzymes.
Sperm autoantibodies (PCT)
Sperm penetration assay
Human Zona Binding Assay
Computer Assisted Sperm Analysis
Acrosome reaction
Biochemical test
Sperm Chromatin Structure & DNA
SPECIALIZED TEST
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Cycle fecundity 3-10% infertile partner sperm
9-30% donor sperm
Processed motile sperm count at least 1 million
Best results when no. of TOTAL MOTILE SPERMS > 10 million
Success rates
• Highest > 14% sperm have normal morphology
• Intermediate 4-14%
• Poor <4% (advised IVF & ICSI)
INTRAUTERINE INSEMINATION
42. INDICATIONS :
1. Azoospermia
2. Immunological factors not correctable
3. Genetic disease in husband
Donor Sperm
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1. Vasovasostomy & vasoepididymostomy- In
vasectomized men
2. Transurethral resection of the ejaculatory ducts- in
men with Ejaculatory duct obstruction (1-5% of
infertile men)
3. Varicocele repair- In men with varicoceles (20-45%
of infertile men)
4. Orchipexy – In cryptorchidism
5. Vibratory stimulation & Electroejaculation – In
neurological dysfunctions
SURGICAL TREATMENT
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Assisted Reproductive Techniques
IVF-ET – In vitro fertilization & embryo transfer
GIFT – Gamete intra fallopian transfer
ZIFT – Zygote intra fallopian transfer
POST – Peritoneal oocyte & sperm transfer
TET – Tubal embryo transfer zone
SUZI – Subzonal insemination
ICSI – Intracytoplasmic sperm injection
AH – Assisted Hatching
IVM – In vitro maturation of oocyte
PGD – Preimplantation genetic diagnosis
Hth & pit tumors like craniopharyngioma & macroadenoma. Infilterative dis like sarcoidosis, histiocytosis hemochromatosis. Drugs like gnrh analogs for prostate cancer, androgen, opiates estrogen
Obesity caause increase aromatase activity leading to conversion into estrogen
Infections like orchitis leprosy tb
Drugs like antiandrogens cimetidine
Gonadotoxins smoking pesticides
Chrnic illness like cancer renal insufficiency
Infections like gonorrhea chlamydia tb
Ejaculatory dysfunction like spinal cord diseases autonomic dysfunction
As left spermatic vein is longer & joins left renal vein at right angle. Hypoxia stasis delayed removal of toxins increaseed temp likely responsible
normal semen production. Mechanical blockage. Post infection, vasectomy, congenital
Abnml sperm analysis i.e sperm conc <10mill/ml, decrs libido
Sr estradiol in pt wid severe oligo
Testes small in testicular failure, epididymal fullness in obstruction, CBAVD , spermatic cord palpation for varicocele
Renal scan to detect renal agenesis in men wid vasal agenesis
Cong hypog hypogonadism t/t can induce sec sex charact but not initiate or support normal spermatogenesis
Cycle fecundity is probability of pregnancy per cycle
Success declines with increasing maternal age.>35, family ho early menopause, chemo/radiation With poor ovarian reserve reduced success with Ivf & poor chance with IUI
Risk of multiple ovulation, hyperstimulation higher, costs poor quality sperm with exogenous gonadotropin
Neurological dysfunctions due to diabetes spinal cord injuries demyelinating diseases
Art encompasses all procedures that involve manipulation of gametes & embryos outside the body