1. DIAGNOSIS &DIAGNOSIS &
MANAGEMENT OFMANAGEMENT OF
MALE INFERTILITYMALE INFERTILITY
Dr. SHASHWAT K. JANIDr. SHASHWAT K. JANI
Assistant Professor
Sheth V.S. Gen. Hospital
AHMEDABAD.
Mob : 99099 44160Mob : 99099 44160
Email : drshashwatjani@gmail.comEmail : drshashwatjani@gmail.com

2. INTRODUCTIONINTRODUCTION
• The number of couples affected by infertilityThe number of couples affected by infertility
is currently estimated to be 15%is currently estimated to be 15%
• Of all couples attempting to have children.Of all couples attempting to have children.
The difficulties are attributable to a significantThe difficulties are attributable to a significant
male factor alone in 30% of couples.male factor alone in 30% of couples.
• Combination of male and female factors in anCombination of male and female factors in an
additional 20%.additional 20%.
Therefore, in 50% of all infertile couples,Therefore, in 50% of all infertile couples,
an abnormal male factor contributes toan abnormal male factor contributes to
reproductive failure.reproductive failure.

3. INTRODUCTIONINTRODUCTION
• The primary care practitioner often is the firstThe primary care practitioner often is the first
health care professional the patient seekshealth care professional the patient seeks
Absolute critical initial evaluation of theAbsolute critical initial evaluation of the
subfertile male.subfertile male.
• Thorough history and physical examinationThorough history and physical examination
• Laboratory tests, including at least a semenLaboratory tests, including at least a semen
analysisanalysis
• Hormonal evaluation.Hormonal evaluation.
Appropriate to refer the couple to anAppropriate to refer the couple to an
infertility specialist.infertility specialist.

4. Definition of "Infertility"Definition of "Infertility"
• Infertility is a disease **. The duration of the failure toInfertility is a disease **. The duration of the failure to
conceive should be twelve or more months before anconceive should be twelve or more months before an
investigation is undertaken unless medical historyinvestigation is undertaken unless medical history
and physical findings dictate earlier evaluation andand physical findings dictate earlier evaluation and
treatment.treatment.
• ** Any deviation from or interruption of the normal** Any deviation from or interruption of the normal
structure or function of any part, organ, or system, orstructure or function of any part, organ, or system, or
combination thereof, of the body that is manifested bycombination thereof, of the body that is manifested by
a characteristic set of symptoms or signs, and whosea characteristic set of symptoms or signs, and whose
etiology, pathology, and prognosis may be known oretiology, pathology, and prognosis may be known or
unknown:unknown: Dorland's Medical DictionaryDorland's Medical Dictionary 1988:481.1988:481.
Approved by the Practice Committee of the American Society forApproved by the Practice Committee of the American Society for
Reproductive Medicine (Formerly The American FertilityReproductive Medicine (Formerly The American Fertility
Society), March 27, 1993.Society), March 27, 1993.
Approved by the Board of Directors of the American Society forApproved by the Board of Directors of the American Society for
Reproductive Medicine (Formerly The American FertilityReproductive Medicine (Formerly The American Fertility
Society), July 17, 1993.Society), July 17, 1993.

7. PRE-TESTICULAR CAUSES OF INFERTILITYPRE-TESTICULAR CAUSES OF INFERTILITY
• Hypothalamic diseaseHypothalamic disease
– Isolated gonadotropin deficiency (Kallmann'sIsolated gonadotropin deficiency (Kallmann's
syndrome) syndrome)
– Isolated LH deficiency ("Fertile eunuch") Isolated LH deficiency ("Fertile eunuch")
– Isolated FSH deficiency CongenitalIsolated FSH deficiency Congenital
hypogonadrotropic syndromeshypogonadrotropic syndromes
• Pituitary diseasePituitary disease
– Pituitary insufficiency (tumors, infiltrativePituitary insufficiency (tumors, infiltrative
processes, operation, radiation)processes, operation, radiation)
– Hyperprolactinemia Hyperprolactinemia
– Hemochromatosis Hemochromatosis
– Exogenous hormones (estrogen-androgen excess,Exogenous hormones (estrogen-androgen excess,
glucocorticoid excess, hyper and hypothyroidism).glucocorticoid excess, hyper and hypothyroidism).

8. TESTICULAR CAUSES OF INFERTILITYTESTICULAR CAUSES OF INFERTILITY
• Chromosomal abnormalities (Klinefelter'sChromosomal abnormalities (Klinefelter's
syndrome, XX disorder (sex reversal syndrome),syndrome, XX disorder (sex reversal syndrome),
XYY syndrome)-XYY syndrome)-
• Noonan's syndrome (male Turner's syndrome)-Noonan's syndrome (male Turner's syndrome)-
• Myotonic dystrophy-Myotonic dystrophy-
• Bilateral anorchia (vanishing testes syndrome)Bilateral anorchia (vanishing testes syndrome)
• Sertoli-cell-only syndrome (germinal cell aplasia)Sertoli-cell-only syndrome (germinal cell aplasia)
• Gonadotoxins (drugs, radiation)Gonadotoxins (drugs, radiation)
• OrchitisOrchitis
• TraumaTrauma
• Systemic disease (renal failure, hepatic disease,Systemic disease (renal failure, hepatic disease,
sickle cell disease)sickle cell disease)
• Defective androgen synthesis or action-Defective androgen synthesis or action-
CryptorchidismCryptorchidism
• VaricoceleVaricocele

10. History of the Infertile MaleHistory of the Infertile Male
• Male ReproductiveMale Reproductive
HistoryHistory
• Duration ofDuration of
unprotectedunprotected
intercourseintercourse
• Previous pregnanciesPrevious pregnancies
• Previous infertilityPrevious infertility
evaluationsevaluations
• FemaleFemale
ReproductiveReproductive
HistoryHistory
• AgeAge
• Gravida/paraGravida/para
• Physician's namePhysician's name
• Ovulation withOvulation with
technique to assesstechnique to assess
• Current status ofCurrent status of
female infertilityfemale infertility
evaluationevaluation

11. Personal HistoryPersonal History
DevelopmentalDevelopmental
• PubertyPuberty
(normal/delayed/pre(normal/delayed/pre
cocious)cocious)
• History ofHistory of
undescended testesundescended testes
• History ofHistory of
gynecomastiagynecomastia
SurgicalSurgical
• Pelvic surgery (Y-VPelvic surgery (Y-V
plasty to bladderplasty to bladder
neck, transurethralneck, transurethral
surgery)surgery)
• Inguinal surgeryInguinal surgery
(herniorrhaphy,(herniorrhaphy,
orchidopexy)orchidopexy)

12. HistoryHistory
• Sexual HistorySexual History
• Potency/libidoPotency/libido
• Coital techniqueCoital technique
• Timing and frequencyTiming and frequency
of intercourseof intercourse
• Use of lubricantsUse of lubricants
• Family HistoryFamily History
• Cystic fibrosisCystic fibrosis
• Androgen receptorAndrogen receptor
deficiencydeficiency
• HypogonadismHypogonadism

13. GonadotoxinsGonadotoxins
• Chemical exposureChemical exposure
(work, therapeutic)(work, therapeutic)
• Smoking (marijuana,Smoking (marijuana,
cigarettes)cigarettes) --
OccupationalOccupational
• Thermal exposureThermal exposure
(saunas, hot tubs,(saunas, hot tubs,
briefs)briefs)
• Radiation exposureRadiation exposure
(work, diagnostic,(work, diagnostic,
therapeutic)therapeutic)
MedicationMedication
• Maternal (DES)Maternal (DES)
• Personal usePersonal use
• SteroidsSteroids
• EndocrineEndocrine
HistoryHistory
• Headaches, visualHeadaches, visual
disturbances,disturbances,
anosmiaanosmia
• Excessive growth ofExcessive growth of
hands, feet, jawhands, feet, jaw
• Retardation of hairRetardation of hair
growth (facial, body)growth (facial, body)
• Breast changesBreast changes

14. The duration of the couple's infertilityThe duration of the couple's infertility
and whether or not other treatmentand whether or not other treatment
has been attemptedhas been attempted
In the past, the fertility evaluationsIn the past, the fertility evaluations
• 1 year of unprotected intercourse.1 year of unprotected intercourse.
Current philosophyCurrent philosophy
• Evaluation of one's fertility may properly begin atEvaluation of one's fertility may properly begin at
whatever time patients express concern, andwhatever time patients express concern, and
both the male and female portions of a fertilityboth the male and female portions of a fertility
workup can be undertaken simultaneously in anworkup can be undertaken simultaneously in an
efficient, cost-effective, and timely fashionefficient, cost-effective, and timely fashion..

15. History of bladder, pelvic, orHistory of bladder, pelvic, or
retroperitoneal surgeryretroperitoneal surgery
Suggesting the possibility of..Suggesting the possibility of..
• Ejaculatory dysfunction withEjaculatory dysfunction with
associatedassociated
• Incomplete or retrograde ejaculation.Incomplete or retrograde ejaculation.

16. Sexual habitsSexual habits
• TimingTiming: The optimal timing for intercourse is: The optimal timing for intercourse is
every 48 hours & time when ovulation is mostevery 48 hours & time when ovulation is most
likely (usually at the female's midcycle).likely (usually at the female's midcycle).
• Coital habitsCoital habits:Cautione- to use lubricants only:Cautione- to use lubricants only
if necessary,only in limited amounts.if necessary,only in limited amounts.
Spermatotoxic lubricants (such as K-Y Jelly,Spermatotoxic lubricants (such as K-Y Jelly,
Lubifax, Surgilube, Keri LotionLubifax, Surgilube, Keri Lotion) and) and eveneven
salivasaliva cancan impair sperm motility.impair sperm motility.
• Other lubricantsOther lubricants, such as raw egg white,, such as raw egg white,
vegetable oil, safflower oil, peanut oil, andvegetable oil, safflower oil, peanut oil, and
petroleum jelly,petroleum jelly, do not impairdo not impair in vivoin vivo spermsperm
motility.motility.

17. Childhood illnesses and disordersChildhood illnesses and disorders
• CryptorchidismCryptorchidism: both unilateral and bilateral,: both unilateral and bilateral,
frequently is associated with oligospermia.frequently is associated with oligospermia.
– 30% with unilateral cryptorchidism and30% with unilateral cryptorchidism and
– 50% of men with bilateral cryptorchidism50% of men with bilateral cryptorchidism
• have sperm densities below 20 million/mL,have sperm densities below 20 million/mL,
• 80% with unilateral Cryptorchidism are fertile80% with unilateral Cryptorchidism are fertile..
• fertility rate is only 50% for couples in whom the malefertility rate is only 50% for couples in whom the male
has a history of bilateral cryptorchidismhas a history of bilateral cryptorchidism..
• testes remaining undescended until after puberty dotestes remaining undescended until after puberty do
not function well and that fertility rates are notnot function well and that fertility rates are not
improved with postpubertal orchidopexy.improved with postpubertal orchidopexy.

18. Childhood illnesses and disordersChildhood illnesses and disorders
Testicular trauma or a history of unilateralTesticular trauma or a history of unilateral
testiculartesticular torsion also may adversely affecttorsion also may adversely affect
the testes. Approximately 30% to 40% of menthe testes. Approximately 30% to 40% of men
with a history of unilateral testicular torsionwith a history of unilateral testicular torsion
have an abnormal semen analysis.have an abnormal semen analysis.
???? A breakdown in the blood-testis barrierA breakdown in the blood-testis barrier maymay
be the causebe the cause
The testis susceptible to torsion may have hadThe testis susceptible to torsion may have had
a preexisting spermatogenic defect (a higha preexisting spermatogenic defect (a high
incidence of impaired spermatogenesis in theincidence of impaired spermatogenesis in the
biopsiedbiopsied contralateralcontralateral testis).testis).

19. Childhood illnesses and disordersChildhood illnesses and disorders
• Delayed or incomplete pubertyDelayed or incomplete puberty may reveal anmay reveal an
endocrinologic etiology (such as Klinefelter'sendocrinologic etiology (such as Klinefelter's
syndrome or idiopathic hypogonadism).syndrome or idiopathic hypogonadism).
• gynecomastiagynecomastia may also suggest anmay also suggest an
underlying endocrine problem.underlying endocrine problem.
• Bilateral mumps orchitisBilateral mumps orchitis experiencedexperienced
prepubertally seems to have no effect, butprepubertally seems to have no effect, but
mumps orchitis experienced postpubertally ismumps orchitis experienced postpubertally is
associated with severe testicular damage inassociated with severe testicular damage in
10% of patients.10% of patients.

20. • Diabetes mellitus or multiple sclerosisDiabetes mellitus or multiple sclerosis
can impair potency as well ascan impair potency as well as
ejaculation.ejaculation.
• Treatment for cancer affects fertilityTreatment for cancer affects fertility..
treated withtreated with radiation or chemotherapyradiation or chemotherapy forfor
testis ,any other cancer is at risk oftestis ,any other cancer is at risk of
impaired spermatogenesis.impaired spermatogenesis.
Patients with testicular cancer arePatients with testicular cancer are
particularly affected.particularly affected.
• Past history of a herniorrhaphyPast history of a herniorrhaphy
suggests the possibility of an iatrogenicsuggests the possibility of an iatrogenic
vasal injuryvasal injury..

21. Inflammatory processInflammatory process
• Any inflammatory processAny inflammatory process that involvesthat involves
the lower urinary tract may lead to adversethe lower urinary tract may lead to adverse
scarring of the ductal system,scarring of the ductal system,
• e.g., ejaculatory duct stenosise.g., ejaculatory duct stenosis oror
obstruction,obstruction, that may affect fertility.that may affect fertility.
• AnyAny generalized febrile episodegeneralized febrile episode maymay
transiently impair spermatogenesis.transiently impair spermatogenesis.

22. • Immotile cilia syndromeImmotile cilia syndrome (nonmotile(nonmotile
sperm secondary to an ultrastructuralsperm secondary to an ultrastructural
defect in the sperm tail) may be thedefect in the sperm tail) may be the
cause of infertility in the male withcause of infertility in the male with
recurrent respiratory infectionsrecurrent respiratory infections
(Kartagener's syndrome or Young's(Kartagener's syndrome or Young's
syndrome).syndrome).
• A gene forA gene for cystic fibrosiscystic fibrosis is carriedis carried
without their knowledge by a number ofwithout their knowledge by a number of
men who may also have congenitalmen who may also have congenital
absence of the vasa and seminalabsence of the vasa and seminal
vesicles and, consequently,vesicles and, consequently,
A low ejaculate volume and azoospermia.A low ejaculate volume and azoospermia.

23. Exposure to elements increasingExposure to elements increasing
the overall scrotal temperaturethe overall scrotal temperature
• CryptorchidismCryptorchidism
• Scrotal varicocelesScrotal varicoceles
impaired spermatogenesis associatedimpaired spermatogenesis associated
with these disorders.with these disorders.
To optimize their sperm production, menTo optimize their sperm production, men
are encouraged to avoid the use ofare encouraged to avoid the use of
saunas and hot tubs.saunas and hot tubs.

24. Medications, Toxins, and DrugsMedications, Toxins, and Drugs
Associated with Male InfertilityAssociated with Male Infertility
MedicationsMedications ToxinsToxins
• Androgenic steroidsAndrogenic steroids Agent OrangeAgent Orange
• AntihypertensivesAntihypertensives Anesthetic gassesAnesthetic gasses
• Cancer chemotherapyCancer chemotherapy BenzeneBenzene
• HH22 blockersblockers DibromochloropropaneDibromochloropropane
• KetoconazoleKetoconazole LeadLead
• SpironolactoneSpironolactone ManganeseManganese
• CychlosporineCychlosporine
• NitrofurantoinNitrofurantoin Other DrugsOther Drugs
• SulfasalazineSulfasalazine AlcoholAlcohol
• ColchicineColchicine HeroinHeroin
• AllopurinolAllopurinol MarijuanaMarijuana
• TetracyclineTetracycline MethadoneMethadone
• ErythromycinErythromycin TobaccoTobacco
• GentamicinGentamicin

25. Physical ExaminationPhysical Examination
• Body HabitusBody Habitus Decreased body hairDecreased body hair
GynecomastiaGynecomastia
Eunuchoid proportionsEunuchoid proportions
• PhallusPhallus Peyronie's diseasePeyronie's disease
Congenital curvatureCongenital curvature
HypospadiasHypospadias
• ScrotumScrotum Testicular volumeTesticular volume
Epididymal indurationEpididymal induration
Presence/absence of vas deferensPresence/absence of vas deferens
VaricoceleVaricocele
• Digital Rectal ExaminationDigital Rectal Examination
Prostate sizeProstate size
Prostatic/seminal vesicularmass /Prostatic/seminal vesicularmass /
induration/cystsinduration/cysts

26. Semen AnalysisSemen Analysis
• 48 to 72 hours of abstinence.48 to 72 hours of abstinence.
• Collection ideally, at the laboratoryCollection ideally, at the laboratory
• By masturbationBy masturbation
• Into a container furnished by theInto a container furnished by the
laboratory that has been tested tolaboratory that has been tested to
ensure that it will not alter the spermensure that it will not alter the sperm
sample's quality.sample's quality.
• Should be analyzed within 1 hour andShould be analyzed within 1 hour and
kept at body temperature before.kept at body temperature before.

27. Semen AnalysisSemen Analysis
• Characteristics analyzed are semenCharacteristics analyzed are semen
volume, sperm density, sperm motility,volume, sperm density, sperm motility,
forward progression, and spermforward progression, and sperm
morphology. In addition, the sample ismorphology. In addition, the sample is
analyzed for the presence of leukocytesanalyzed for the presence of leukocytes
that might indicate infection orthat might indicate infection or
inflammationinflammation
• An aliquot of the sample is air-dried onAn aliquot of the sample is air-dried on
a slide and stained for determination ofa slide and stained for determination of
sperm shape or morphology. Normalsperm shape or morphology. Normal
semen samples contain at least 50%semen samples contain at least 50%
morphologically normal sperm.morphologically normal sperm.

28. World Health Organization (WHO)World Health Organization (WHO)
CriteriaCriteria
For Normal Semen ValuesFor Normal Semen Values
VolumeVolume 1.5 – 5.01.5 – 5.0
mlml
pHpH 7.2-7.87.2-7.8
Sperm concentrationSperm concentration > 20 million/ml> 20 million/ml
ViscosityViscosity < 3 scale ( 0< 3 scale ( 0
– 4)– 4)
Total sperm countTotal sperm count > 40 million/ejac> 40 million/ejac
MotilityMotility > 50%> 50%
Forward progressionForward progression >2 scale ( 0 –>2 scale ( 0 –
4 )4 )
MorphologyMorphology > 30% normal forms> 30% normal forms

29. Normal biochemical ValuesNormal biochemical Values
• Acid PhosphataseAcid Phosphatase25,000-60,000 IU/ml25,000-60,000 IU/ml
• ZincZinc 90-250 mg/100 ml90-250 mg/100 ml
• FructoseFructose 150-600/100 ml150-600/100 ml

30. NomenclatureNomenclature
• AspermiaAspermia- Failure of formation or emission- Failure of formation or emission
of semenof semen
• Oligospermia/ Oligozoospermia-Oligospermia/ Oligozoospermia- TheThe
count <20 million /mlcount <20 million /ml
• Poly zoospermia-Poly zoospermia- Count >350 million /mlCount >350 million /ml
• Azoospermia-Azoospermia- No spermatozoa in theNo spermatozoa in the
semensemen
• Asthenospermia-Asthenospermia- reduction in vitality /reduction in vitality /
Motility of spermatozoaMotility of spermatozoa
• Necrospermia/Necrozooospermia-Necrospermia/Necrozooospermia-
spermatozoa are dead or motionlessspermatozoa are dead or motionless
• Teratospermia/ Teratozoospermia-Teratospermia/ Teratozoospermia-
Presence of high number of malformedPresence of high number of malformed
spermatozoaspermatozoa

31. Semen analysisSemen analysis
• Color;Color; Whitish grey to yellow tends to be moreWhitish grey to yellow tends to be more
yellowish with longer abstinence, genital tractyellowish with longer abstinence, genital tract
infection-finally reddish in sever form.infection-finally reddish in sever form.
• OdorOdor: Chestnut flowers/amniotic fluid like FromChestnut flowers/amniotic fluid like From
oxidation of spermine –prostatic gland secretionoxidation of spermine –prostatic gland secretion
• Coagulation and LiquefactionCoagulation and Liquefaction: within 5-40 mins: within 5-40 mins
• Coagulative enzyme – in seminal vesicalCoagulative enzyme – in seminal vesical
• Liquefying enzyme Seminine –prostate gland.Liquefying enzyme Seminine –prostate gland.
Complete lack of coagulation –Complete lack of coagulation –
Agenesis of seminal vesical or
occlusion of ejaculatory ducts.
Failure to liquefyFailure to liquefy - Poor prostate lytic activity.
• Following liquefaction SF achieves viscous state.-Following liquefaction SF achieves viscous state.-
Hyperviscocity impairs sperm motility.Hyperviscocity impairs sperm motility.

32. Semen analysisSemen analysis
• VolumeVolume
Hypospermia: Volume <1.5 mlHypospermia: Volume <1.5 ml
Hyperspermia:>5.5mlHyperspermia:>5.5ml
Plasma : Vehicle/ DiluentPlasma : Vehicle/ Diluent
/Buffering medium/Source of energy./Buffering medium/Source of energy.
Semen volume mainly –Seminal vesicalSemen volume mainly –Seminal vesical
secretions.secretions.
↓↓↓↓S. Vol.- Androgen defi., proximal occlusionS. Vol.- Androgen defi., proximal occlusion
of ejaculatory duct or incomplete ejaculation.of ejaculatory duct or incomplete ejaculation.
• PHPH
>8 –Acute disease of seminal vesical or>8 –Acute disease of seminal vesical or
delayed measurementdelayed measurement
<7 occlusion of ejaculatory duct occlusion,<7 occlusion of ejaculatory duct occlusion,
contamination with urinecontamination with urine

33. Microscopic ExaminationMicroscopic Examination
MotilityMotility
Grade 4Grade 4 Rapid and Linearly progressiveRapid and Linearly progressive
Grade 3Grade 3 Slower sluggish linear or non linearSlower sluggish linear or non linear
Grade 2Grade 2 Non progressive motilityNon progressive motility
Grade1Grade1 immotileimmotile
Freshly ejaculated sperm cell velocity 75Freshly ejaculated sperm cell velocity 75µ/sµ/s
Standardization of temperatureStandardization of temperature
Motility loss of 10-20% with in 3 hr consideredMotility loss of 10-20% with in 3 hr considered
WNL.WNL.

34. Automated Semen AnalysisAutomated Semen Analysis
• Closed circuit- Video tape-digital data display-1973Closed circuit- Video tape-digital data display-1973
• Doppler /turbidimetric method -1974-77Doppler /turbidimetric method -1974-77
• Light scattering determination of motility 1978Light scattering determination of motility 1978
• Multiple –Exposure photographic techniqueMultiple –Exposure photographic technique
Present scenarioPresent scenario
• Cellsoft system: cell size and luminosityCellsoft system: cell size and luminosity
• The Hamilton Thorn system:infrared beamThe Hamilton Thorn system:infrared beam
Provide Data forProvide Data for
– ConcentrationConcentration
– MotilityMotility
– VelocityVelocity
– LinearityLinearity
– Lateral head displacement, circular motio ,MorphologyLateral head displacement, circular motio ,Morphology

37. Biochemical analysisBiochemical analysis
• Epididymal fluid-Epididymal fluid-
Glycerylphosphorycholine(GPC) &Glycerylphosphorycholine(GPC) &
carnitinecarnitine
• Inhibin by sertoly cellInhibin by sertoly cell ↓FSH control↓FSH control
• Prostate gland fluid ; [Enzymes(AcidProstate gland fluid ; [Enzymes(Acid
Phosphatase etc.), citric acid, Zinc,Phosphatase etc.), citric acid, Zinc,
spermine]spermine]
• Seminal Vesical ; Fructose,Seminal Vesical ; Fructose,
ProstaglandinesProstaglandines
• Sperm Creatine phosphokinaseSperm Creatine phosphokinase

38. Usual Findings of Hormonal StatusUsual Findings of Hormonal Status
Correlated to Clinical DiagnosisCorrelated to Clinical Diagnosis
Clinical Status FSH (mIU/mL) LH (mIU/mL) Testosterone (ng/100 mL)
Normal men Normal Normal Normal
Germinal aplasia Elevated Normal Normal or decreased
Testicular failure Elevated Elevated Normal or decreased
Hypogonadotropic
hypogonadism
Decreased Decreased Decreased
Hypergonadotropic
hypogonadism
Elevated Elevated Low-normal or decreased

39. AdditionalAdditional Laboratory TestsLaboratory Tests
• Between 10% and 20% "unexplained"Between 10% and 20% "unexplained"
infertility.infertility.
• In the female, this percentage is rapidlyIn the female, this percentage is rapidly
decreasing as more sophisticateddecreasing as more sophisticated
techniques have been developed totechniques have been developed to
accurately identify the efficacy ofaccurately identify the efficacy of
evaluation.evaluation.
• In the male, additional tests to identifyIn the male, additional tests to identify
other abnormalities of semenother abnormalities of semen
parameters. leukocyte and antispermparameters. leukocyte and antisperm
antibody identification, as well as testsantibody identification, as well as tests
of sperm function.of sperm function.

40. Cervical Mucus/Sperm InteractionCervical Mucus/Sperm Interaction
AssaysAssays
• The postcoital test (PCT), first performed by Sims,The postcoital test (PCT), first performed by Sims,
This test evaluates sperm concentration and motility inThis test evaluates sperm concentration and motility in
an aspirate of cervical mucus at midcycle shortly afteran aspirate of cervical mucus at midcycle shortly after
the couple has intercourse. a normal PCT- >20the couple has intercourse. a normal PCT- >20
spermatozoa/hpf. An abnormal PCT secondary tospermatozoa/hpf. An abnormal PCT secondary to
inappropriate timing of coitus,ASA, anovulation, aninappropriate timing of coitus,ASA, anovulation, an
abnormal hormonal milieu, female or male genital tractabnormal hormonal milieu, female or male genital tract
infections, poor semen quality, and male sexualinfections, poor semen quality, and male sexual
dysfunction.dysfunction.
• presence of motile spermatozoa indicates thatpresence of motile spermatozoa indicates that
spermatozoa can survive in the cervical mucus, failurespermatozoa can survive in the cervical mucus, failure
to find motile spermatozoa is more difficult to interpret.to find motile spermatozoa is more difficult to interpret.

41. Computer-Assisted Semen AnalysisComputer-Assisted Semen Analysis
(CASA)(CASA)
• introduced in the 1980s to provide an automated,introduced in the 1980s to provide an automated,
objective, and standardized evaluation of spermobjective, and standardized evaluation of sperm
concentration and movement.concentration and movement.
• The variables measured are sperm density, percentThe variables measured are sperm density, percent
motility, straight-line velocity, curvilinear velocity,motility, straight-line velocity, curvilinear velocity,
linearity, average path velocity, amplitude of laterallinearity, average path velocity, amplitude of lateral
head displacement, flagellar beat frequency, andhead displacement, flagellar beat frequency, and
hyperactivation This technology is based onhyperactivation This technology is based on
digitalized sperm images that are visualized by adigitalized sperm images that are visualized by a
video camera and analyzed by a computer.video camera and analyzed by a computer.

42. • Viability stain assays.Viability stain assays.
• Sperm Capacitation Assays,Sperm Capacitation Assays,
• Mannose-Ligand Receptor Assays,Mannose-Ligand Receptor Assays,
• Acrosome Reaction AssaysAcrosome Reaction Assays
• Sperm Penetration Assay (SPA)Sperm Penetration Assay (SPA)
• Reactive Oxygen Species (ROS) AssayReactive Oxygen Species (ROS) Assay
OTHER TESTS ARE :OTHER TESTS ARE :

43. Diagnostic studiesDiagnostic studies
• Transrectal ultrasound (TRUS) :
1.1. Standard criteriaStandard criteria - low volume and acidic- low volume and acidic
azoospermic semen specimens. These findingsazoospermic semen specimens. These findings
suggest absence of seminal vesicle fluid in thesuggest absence of seminal vesicle fluid in the
semen consistent with complete ejaculatory ductsemen consistent with complete ejaculatory duct
obstruction. Also, dilated seminal vesicles areobstruction. Also, dilated seminal vesicles are
suggestive of ejaculatory duct obstruction due to asuggestive of ejaculatory duct obstruction due to a
midline cyst, which may respond to a transurethralmidline cyst, which may respond to a transurethral
resection of the ejaculatory ducts (TURED).resection of the ejaculatory ducts (TURED).
2.2. Ultrasound guidance may be used during needleUltrasound guidance may be used during needle
aspiration of the seminal vesicles, which may helpaspiration of the seminal vesicles, which may help
determine if there is ejaculatory duct obstruction.determine if there is ejaculatory duct obstruction.

44. VasographyVasography
• Performed at the time of testicular biopsy ifPerformed at the time of testicular biopsy if
normal spermatogenesis is demonstrated.normal spermatogenesis is demonstrated.
• A transverse micro-incision in the vas near theA transverse micro-incision in the vas near the
junction of the straight and convoluted portionsjunction of the straight and convoluted portions
will allow immediate examination of thewill allow immediate examination of the
effluxing fluid for the presence of sperm as welleffluxing fluid for the presence of sperm as well
as localization of the level of obstruction.as localization of the level of obstruction.
• Saline, Indigo caramine or hypaque orSaline, Indigo caramine or hypaque or
renograffin should be injected in antegraderenograffin should be injected in antegrade
direction to check the level of obstruction .direction to check the level of obstruction .
• A microsurgical technique should be used toA microsurgical technique should be used to
repair the vasotomy site, i.e., closure with 10-0repair the vasotomy site, i.e., closure with 10-0
and 9-0 monofilament microsutures.and 9-0 monofilament microsutures.

45. Testicular BiopsyTesticular Biopsy
• Performed in patients with azoospermia,severe unexplainedPerformed in patients with azoospermia,severe unexplained
oligospermia,assymetrical testicular lesion,for mapping of theoligospermia,assymetrical testicular lesion,for mapping of the
testes for later sperm aspiration for ICSI,for screening of germtestes for later sperm aspiration for ICSI,for screening of germ
cell neoplasia or CIScell neoplasia or CIS
• . Local anesthesia using a cord block and local infiltration often. Local anesthesia using a cord block and local infiltration often
with mild sedation utilized or general anesthesia. A "window"with mild sedation utilized or general anesthesia. A "window"
techniqueis used.With a no-touch technique, the specimen istechniqueis used.With a no-touch technique, the specimen is
excised with sharp Iris scissors and promptly placed in Bouin's,excised with sharp Iris scissors and promptly placed in Bouin's,
Zenker's, or buffered glutaraldehyde solution.Prior to placingZenker's, or buffered glutaraldehyde solution.Prior to placing
the specimen into the solution, a touch preparation slide can bethe specimen into the solution, a touch preparation slide can be
made for immediate review, i.e., testicular cytology.made for immediate review, i.e., testicular cytology.
• Hemostasis is obtained with careful use of electrocautery, andHemostasis is obtained with careful use of electrocautery, and
the tunica albuginea is closed with fine, absorbable suture asthe tunica albuginea is closed with fine, absorbable suture as
are the layers of the scrotum.are the layers of the scrotum.

46. Testicular BiopsyTesticular Biopsy
• Testicular Needle Biopsy:Testicular Needle Biopsy: office procedure, withoffice procedure, with
little pain and low morbidity, and yields adequatelittle pain and low morbidity, and yields adequate
information. Techniques have been described usinginformation. Techniques have been described using
the Vim-Silvermann26 or Tru-Cut biopsy needle27 tothe Vim-Silvermann26 or Tru-Cut biopsy needle27 to
obtain a core of tissue or using fine-needle aspirationobtain a core of tissue or using fine-needle aspiration
with material smeared on the microscope slide..with material smeared on the microscope slide..
• Testicular Fine-Needle Aspiration (FNA)Testicular Fine-Needle Aspiration (FNA)
Cytology:Cytology: described as a minimally traumaticdescribed as a minimally traumatic
procedure having high correction with histologicprocedure having high correction with histologic
studies. Testicular FNAstudies. Testicular FNA hashas notnot gained widespreadgained widespread
acceptanceacceptance in the evaluation of the infertile male forin the evaluation of the infertile male for
numerous reasons. Although cellular detail isnumerous reasons. Although cellular detail is
excellent, information regarding peritubular fibrosis,excellent, information regarding peritubular fibrosis,
the interstitial tissue, and cellular arrangement isthe interstitial tissue, and cellular arrangement is
lacking.lacking.
• Testicular Cytology:Testicular Cytology: "touch imprint and cytospin"touch imprint and cytospin
techniques.These methods provide a rapid means oftechniques.These methods provide a rapid means of
examining the cellular contents of the seminiferousexamining the cellular contents of the seminiferous
tubules.tubules.

47. VARICOCELEVARICOCELE
Dilatation of the pampiniform venous plexus.Dilatation of the pampiniform venous plexus.
• 15%of general population15%of general population
• Left > right, bilateral (30-50%)Left > right, bilateral (30-50%)
• Pathophysiology : Renal and adrenal reflux,Pathophysiology : Renal and adrenal reflux,
hypoxia,hormonal dysfunction,hyperthermia.hypoxia,hormonal dysfunction,hyperthermia.
• Impaired fertility,scrotal pain,etc.Impaired fertility,scrotal pain,etc.
• Surgical Rx : Scrotal, inguinal(modifiedSurgical Rx : Scrotal, inguinal(modified
ivanissevich),retroperitoneal(modified palomo)&ivanissevich),retroperitoneal(modified palomo)&
laproscopic approch.laproscopic approch.
• Nonsurgical Rx : Percutaneous venous occlusionNonsurgical Rx : Percutaneous venous occlusion
with use of detachable balloons,coils,andwith use of detachable balloons,coils,and
sclerotherapysclerotherapy
• 51-78% improvement in semen quality and 24-51-78% improvement in semen quality and 24-
53% pregnancy rate after varicocele Rx.53% pregnancy rate after varicocele Rx.

48. Pituitary tumorsPituitary tumors
• Mainly prolactin-secreting tumorsMainly prolactin-secreting tumors
• S/S:-impaired libido,visual fieldS/S:-impaired libido,visual field
changes,elevated prolactin,lowchanges,elevated prolactin,low
testosterone,normal LH.testosterone,normal LH.
• Radiographic diagnosisRadiographic diagnosis
• BromocryptineBromocryptine
• Surgical Rx: Transsphenoidal surgicalSurgical Rx: Transsphenoidal surgical
ablation or removalablation or removal

49. Procedures to Improve SpermProcedures to Improve Sperm
ProductionProduction
• VasovasostomyVasovasostomy::
##IndicationIndication: for congenital absence of the: for congenital absence of the
ductal system,stricture followingductal system,stricture following
infection,vasectomy,functional obstruction.infection,vasectomy,functional obstruction.
##TechniqueTechnique:under GA,vertical scrotal:under GA,vertical scrotal
incision,two layer anastomosis with 9-0 &incision,two layer anastomosis with 9-0 &
10-0 nylon10-0 nylon

50. **Epididymovasotomy:Epididymovasotomy:
• ForFor proximal obstructionproximal obstruction
• If sperm are absent more proximal epididymalIf sperm are absent more proximal epididymal
exploration is performedexploration is performed
• Anastomosis with nylon 10-0 in two layersAnastomosis with nylon 10-0 in two layers
• A new technique triangulation end-to-sideA new technique triangulation end-to-side
vasoepididymostomy with good results.vasoepididymostomy with good results.
**Incision of ejaculatory ductsIncision of ejaculatory ducts ::
• Patients with azoospermia or severePatients with azoospermia or severe
oligospermia,low semen volumes,palpablyoligospermia,low semen volumes,palpably
present vas deferenspresent vas deferens
• Transurethral incision over ejaculatory ductTransurethral incision over ejaculatory duct

51. *Microscopic epididymal sperm*Microscopic epididymal sperm
aspiration(MESAaspiration(MESA):):
• Popularized in 1988Popularized in 1988
• A man in whom sperm transport from the testicle toA man in whom sperm transport from the testicle to
the the ejaculate in not possible b/o agenesis orthe the ejaculate in not possible b/o agenesis or
obstructive problems.obstructive problems.
• Through an operating microscope,sperms upto 10-Through an operating microscope,sperms upto 10-
20million are directly aspirated from a single isolated20million are directly aspirated from a single isolated
epididymal tubuleepididymal tubule
• Success of pregnancy-25%-40%Success of pregnancy-25%-40%
**Percutaneous epididymal spermPercutaneous epididymal sperm
aspiration(PESAaspiration(PESA):):
• Blind procedure increase the risk of damageBlind procedure increase the risk of damage
• Appropriate when pt.has obstruction and desires onlyAppropriate when pt.has obstruction and desires only
one childone child
• Low success rate in copmare to MESALow success rate in copmare to MESA

52. TREATMENT :
•A )A ) SPECIFIC
THERAPY.
•B ) EMPIRIC THERAPY.

53. SPECIFIC THERAPY :SPECIFIC THERAPY :
• (A) Hypogonadotrophic hypogonadism :
CC + Gonadotrophins.
CC = 25 – 75 mg on alt. day.
For 3 -9 months.
First to initiate spermatogenesis:
hCG = 2000-3000 iu twice a wkfor 6
-8 wks till testosterone comes to normal.
Then , HMG / uFSH / 75iu added thrice a wk
and hCG once a wk.

54. • ( B ) Hyperprolactinemia:
For Pituitary Macroadenoma:
Surgically removed.
For Microadenoma :
Cabergolin 0.5mg – 2 mg. twice a wk.
Maintain level : 10 – 15 microgm /ml.

55. ( C ) Genital tract infection:
Chlamydia – Doxycycline.
( D ) Disorders of ejaculation
( E ) Immunological : no role of steroids.
( F ) Isolated testosterone deficiency:
hCG 2000 iu twice a wk.
( G ) Congenital adrenal hyperplasia :
dexamethasone 0.5mg HS.

56. EMPIRIC THERAPY :EMPIRIC THERAPY :
• 1) CC :
25 – 50 mg for 25 days for 3- 6 months.
2) hCG :
2500 – 5000 iu twice a wk.
3 ) FSH + hCG:
for idiopathic normogonadotrophic
oligozoospermia
4 ) Tamoxifen + Testosterone :
20 mg/ day
( for idiopathic oligozoospermia)

57. 5 ) Zinc : Very useful in low testosterone level
with Zinc deficiency.
120 -220 mg twice a day for 3 months.
6 ) Ketotifen : histamine release inhibitor .
1 mg BD for 3 – 6 months.
7 ) Antiserotonin agents :
Cyproheptadine HCL 4 mg TID for 3 mnths
8) Captopril :
ACE inhibitor . Kinase II inhibitor .
50 mg / day for 3 months.

58. • 9 ) Anti – inflammatory drugs :
Doxycycline : 100 mg bd for 14 days.
Tetracycline & Metronidazole also effective.
Helps in Oligoathenoteratozoospermia.
10 ) Indomethacin :
25 mg tds .
increases sperm count & motility.
11 ) Aanastrazole : Aromatase inhibitor
1 mg / day.
12 ) FSH + Nalotrexane :
Improve spermatogenesis.

59. ROLE OF ANTIOXIDANTS:ROLE OF ANTIOXIDANTS:
Systematic treatment of an infertile
man with antioxidants has received
great interest in recent years and it
seems to have some clinical
benefit , though the story remains
somewhat confused ….!!!

60. • 1 ) Vitamin E : ( Tocopherol )
improves motility.
300 – 600 mg/day for 6 -12 weeks.
2 ) Vitamin C : ( Ascorbic acid )
improves sperm quality & function.
1000 mg / day.
3 ) Vitamin B 12 :
Useful for synthesis of DNA & RNA .
For oligospermia & Asthenospermia.
1000 – 1500 microgm / day for 6 months.

61. • 4 ) Folic Acid :
Additive to other drugs to improve function.
5 mg / day.
5 ) Pentoxyphylline :
improves microcirculation.
improves count & motility.
1.2 mg / day for 3 – 6 months.
6 ) Arginine :
improves motility.
4 mg / day.

62. • 7 ) Selenium :
Antioxidants as well as Anti inflammatory.
Concentrated in Male reproductive tract.
Highest concentration in prostate.
225 microgm / day.
8) Glutathione :
Positive effect on sperm motility.
600 mg IM daily .
Not very popular.

63. • 9 ) L – Carnitine & L –Acetyl Carnitine :
Imp role in sperm cell metabolism.
Highest conc. in epididymal fluid.
Useful in OAT and low grade varicocle.
10 ) Co – enzyme Q10 :
Component of mitochondrial respiratory
chain.
Available as 50 – 100 mg soft gel capsules that
has 100 % absorption.

64. • 11) Lycopene :
Most potent lipophillic anti oxidants and
Carotinoid anti oxidants.
It protects sperm from damage by ROS .

65. THANK YOU
THANK YOU