Evaluation of male infertility

1. Aboubakr Elnashar
Benha University, Egypt
Evaluation of male
infertility
ABOUBAKR ELNASHAR

2. CAUSES
Pretesticular:
Hypothalamic pituitary disease (Secondary
hypogonadism): 1-2%
Testicular:
Primary hypogonadism: 10-15%
Post-testicular defects
disorders of sperm transport: 10 to 20 %
Idiopathic:
Seminiferous tubule dysfunction: 60-80%
including microdeletions of the Y chromosome
ABOUBAKR ELNASHAR

3. CAUSES OF MALE INFERTILITY
I. Hypothalamicpituitary disorders
(GnRH; LH and FSH deficiency)
Congenital disorders
Congenital GnRH deficiency: Kallmann syndrome
Hemochromatosis
Multiorgan genetic disorders: PraderWilli syndrome,
Laurence Moon Beidl syndrome, familial cerebellar ataxia
ABOUBAKR ELNASHAR

4. Acquired disorders
Pituitary and hypothalamic tumors:
macroadenoma,craniopharyngioma
Infiltrative disorders: sarcoidosis, histiocytosis,
tuberculosis, fungal infections
Trauma, postsurgery, postirradiation
Vascular: infarction, aneurysm
Hormonal: hyperprolactinemia, androgen excess, estrogen
excess, cortisol excess
Drugs: opioids and psychotropic drugs, GnRH agonists or
antagonists
 Systemic disorders: Chronic illnesses, Nutritional
deficiencies, Obesity
ABOUBAKR ELNASHAR

5. II. Primary gonadal disorders
Congenital disorders
Klinefelter's syndrome (XXY) and its variants
(XXY/XY; XXXY)
Cryptorchidism
Myotonic dystrophy
Functional prepubertal castrate syndrome:
congenital anorchia
Varicocele
Androgen insensitivity syndromes
5 alphareductase deficiency
Y chromosome deletions
ABOUBAKR ELNASHAR

6. Acquired disorders
Viral orchitis: mumps, echovirus, arbovirus
Granulomatous orchitis: leprosy, tuberculosis
Epididymoorchitis: gonorrhea, chlamydia
Drugs: alkylating agents, alcohol, marijuana, antiandrogens,
ketoconazole, spironolactone, histamine2 receptor antagonists
Ionizing radiation
Environmental toxins: dibromochloropropane, carbon disulfide,
cadmium, lead, mercury,environmental estrogens and phytoestrogens
Hyperthermia
Immunologic disorders: polyglandular autoimmune disease
Trauma
Torsion
Castration
Systemic illness: renal failure, hepatic cirrhosis, cancer,
sickle cell disease, amyloidosis, vasculitis, celiac diseaseABOUBAKR ELNASHAR

7. III. Disorders of sperm transport
Epididymal dysfunction: drugs, infection
Abnormalities of the vas deferens: congenital
absence, Young's syndrome, infection, vasectomy
Ejaculatory dysfunction: spinal cord disease,
autonomic dysfunction, premature ejaculation
IV. Unexplained male factor infertility
ABOUBAKR ELNASHAR

8. EVALUATION
●History
●Examination
●Investigation
1. Conventional Semen analyses
2. Specialized Semen analysis
3. Endocrine testing
4. Genetic tests
ABOUBAKR ELNASHAR

9. A. History
 Focuses on causes of infertility.
Personal:
Age, occupation, special habits
Present:
Type of infertility, duration
Sexual:
Frequency, erection, ejaculation, dysparunia, habits.
libido
ABOUBAKR ELNASHAR

10. Past:
Medical:
Chronic medical illness
Infections: mumps orchitis, sinopulmonary symptoms,
STI, and GUI (prostatitis)
Surgical:
inguinal and scrotal areas such as vasectomy,
orchiectomy, and herniorrhaphy
 Trauma
 Developmental:
testicular descent, pubertal development, loss of body
hair, or decrease in shaving frequency
ABOUBAKR ELNASHAR

11. Drugs and environmental exposures:
alcohol, radiation therapy, anabolic steroids,
cytotoxic chemotherapy, drugs that cause
hyperprolactinemia
exposure to toxic chemicals (e.g. pesticides,
hormonal disrupters)
School performance
determine if he has a history of learning disabilities
suggestive of Klinefelter's syndrome
ABOUBAKR ELNASHAR

12. PHYSICAL EXAMINATION
General:
Evidence of androgen deficiency
depend upon the age of onset.
during early gestation: ambiguous genitalia
late gestation: micropenis
Childhood: delayed pubertal development
Adulthood: decreased sexual function, infertility,
loss of secondary sex characteristics.
ABOUBAKR ELNASHAR

13. General appearance
Eunuchoidal proportions (upper/lower body ratio
<1 with an arm span 5 cm >standing height):
androgen deficiency antedating puberty.
increased body fat and decreased muscle mass:
current androgen deficiency.
Skin
Loss of pubic, axillary, and facial hair,
decreased oiliness of the skin, and
fine facial wrinkling: long-standing androgen
deficiency.
Breasts
Gynecomastia suggests a decreased androgen to
estrogen ratio.
ABOUBAKR ELNASHAR

14. External genitalia
● Tanner stage
Phallus and testes
●Scrotum
Absence of the vas
Epididymal thickening
Varicocele
Hernia
•Varicocele
should be confirmed with the man standing and
performing a Valsalva maneuver.
ABOUBAKR ELNASHAR

15. Examination for Varicocele:
distension of the pampiniform venous plexus in the
spermatic cord.
3 grades:
1. Palpable during Valsalva s maneuvers.
2.Palpable without Valsalva s maneuver.
3. Visible distension
Varicocele assessment are not correlated with
pregnancy
(ESHRE, 2009)
ABOUBAKR ELNASHAR

16. ABOUBAKR ELNASHAR

17. ABOUBAKR ELNASHAR

18. ●Testes:
Decreased volume of the seminiferous tubules can
be detected by measuring testicular size by Prader
orchidometer or calipers.
ABOUBAKR ELNASHAR

19. ABOUBAKR ELNASHAR

20. I. STANDARD SEMEN ANALYSIS
A. Macroscopic
1. Delayed liquefaction
2. Increased viscosity
3. Semen volume
4. pH
B. Microscopy
1. Agglutination
2. Concentration
3. Motility
4. Morphology
5. Round cells
6. Leukocytes
ABOUBAKR ELNASHAR

21. Semen analysis: WHO, 2010
:
:
Lower reference limitParameter
1.5 mlVolume
7.2pH
15 million/mlConcentration
39 million/ejaculateTotal sperm number
40% or
PR: 32%
Total motility: (PR+NP)
58% live spermatozoaVitality
4% (strict criteria).Normal forms
ABOUBAKR ELNASHAR

22. Other threshold values
Peroxidase-positive leukocytes (106 per ml): <1.0
Mixed Antiglobulin Reaction (MAR) test (motile
spermatozoa with bound particles, %): <50
Immunobead test (motile spermatozoa with bound
beads, %) <50
Seminal fructose (ųmol/ejaculate): ≥13
Seminal neutral glucosidase (mU/ejaculate): ≥20
Seminal zinc (ųmol/ejaculate): ≥2.4
ABOUBAKR ELNASHAR

23. Collection:
After 2-7 d of sexual abstinence
at the doctor's office
Masturbation
If this is not possible:
condoms without chemical additives
delivered to the laboratory within 1 h
At least 2 samples collected 1-2 w apart & not more
than 3 months apart.
{marked variation of sperm production within one individual}
Any systemic disease during sperm generation time
(72 days for spermatogenesis & 14 days for transport through the
epididymis & vas): ±negative impact.
ABOUBAKR ELNASHAR

24. A. Macroscopic
1. Delayed liquefaction
liquifaction after 1 h
Due to:
chronic prostatitis
seminal vesiculitis
ABOUBAKR ELNASHAR

25. 2. Increased viscosity= Hyperviscosity
length of the thread that forms on withdrawal of
a glass rod >2cm
Due to:
chronic prostatitis
seminal vesiculitis
Kartagner s syndrome
: interfere with the semen analysis, in particular,
evaluation of sperm motility.
Treatment in the laboratory
1. passing the sample via a large gauge needle
2. diluting with a physiological solution
3. enzyme digestion before testing for sperm parameters
ABOUBAKR ELNASHAR

26. 3. pH < 7
+Azoospermia
Due to:
Dysgenesis of vas deferens,
seminal vesicles
epididymis
ABOUBAKR ELNASHAR

27. 4. Semen volume
Mean: 3.7 mL
lower limit: 1.5 mL
low volume+ azoospermia or severe
oligozoospermia
Genital tract obstruction
Congenital absence of vas deferens: diagnosed
by physical examination and low semen pH
Ejaculatory duct obstruction: diagnosed by dilated
seminal vesicles on transrectal US
ABOUBAKR ELNASHAR

28. ABOUBAKR ELNASHAR

29. ABOUBAKR ELNASHAR

30. Low semen volume+ normal sperm concentration
1. Semen collection problems: loss of a portion of
the ejaculate
Repeat semen sample collection after emptying
the bladder
2. Partial retrograde ejaculation
{neuropathic disorders, including urogenital tract
surgery, sympathetic denervation, and diabetes}
low semen volume+ low sperm concentration
Androgen deficiency: Endocrine assessment
ABOUBAKR ELNASHAR

31. B. Microscopic
1. Agglutination
Stick of motile spermatozoa to each other.
≥10%: suggestive but not conclusive of
immunological infertility.
Confirmed by:
tests for sperm surface antibodies.
ABOUBAKR ELNASHAR

32. 2. Sperm concentration
Lower limit: 15 million/mL (95% CI 12-16)
However, some men with sperm counts considered to be
low can be fertile, while others above the lower limit of
normal can be subfertile and, for the purposes of fertilization
in vitro, 10 million/mL or even less can be satisfactory
ABOUBAKR ELNASHAR

33. If only a few spermatozoa/HPF
Sensitivity of detecting spermatozoa can be
increased by labeling the spermatozoa with a
fluorescent nuclei stain
ABOUBAKR ELNASHAR

34. If only a few spermatozoa/HPF
Sensitivity of detecting spermatozoa can be
increased by labeling the spermatozoa with a
fluorescent nuclei stain and then counting the
spermatozoa using a deep chamber. The sensitivity is
reduced to 2000 spermatozoa per mL ejaculate
If no spermatozoa are seen:
Centrifuge
whole pellet should be smeared on a slide and
examined for the presence of spermatozoa before
the diagnosis of azoospermia
ABOUBAKR ELNASHAR

35. 1. Adequate motile sperm in the pellet: ICSI with
ejaculated spermatozoa.
2. Few spermatozoa in the ejaculate:
spermatogenesis in a few seminiferous tubules:
microdissection Testicular Sperm Extraction
(TESE) and the testicular spermatozoa used for
ICSI
ABOUBAKR ELNASHAR

36. 3. Sperm motility
Progressive
non-progressive
immotile
At least 40%of spermatozoa should be motile
At least 32% should have progressive motility.
 If sperm motility is poor: sperm vitality should be
assessed by
supravital stains or
 hypoosmotic swelling test: determine whether
the majority of immotile spermatozoa are dead
The distinction between living, non-moving
sperm, and dead sperm influences the type of
ART
ABOUBAKR ELNASHAR

37. 4. Sperm morphology
 Previously based mainly on
shape
Now also include:
Length
Width
width ratio
area occupied by the acrosome
neck and tail defects (“strict” criteria)
Strict criteria:
good predictive value in terms of fertilization in
IVF.
ABOUBAKR ELNASHAR

38. 5. Round cells
not > 5 million/ml.
 Due to:
1. Leukocytes
2. Immature germ cells: usually indicate disorders
of spermatogenesis.
3. Degenerating epithelial cells.
ABOUBAKR ELNASHAR

39. 6. Leukocytes
Mainly polymorphonuclear leukocytes
frequently present in the seminal fluid.
Assessment by:
peroxidase stain
The peroxidase positive cells are counted using
the hemocytometer
Not ≥: one million/mL.
Increased WBC± :
genital infection/inflammation ±:
poor semen quality {release of reactive oxygen
species from the leukocytes}.
ABOUBAKR ELNASHAR

40. Prediction of fertility
The likelihood of infertility
increased with decreases in any of the 3
parameters: M, NM, C
Normal morphology had the greatest
discriminatory power.
ABOUBAKR ELNASHAR

41. II. SPECIALIZED SEMEN ANALYSIS
Not routinely performed
used to determine the cause of male infertility
1. Sperm autoantibodies
2. Semen biochemistry (semen fructose)
3. Semen culture
4. Sperm cervical mucus interaction tests
5. Sperm function tests
Computer aided sperm analysis
Acrosome reaction
Zona free hamster oocyte penetration test
Human zona pellucida binding test
Sperm reactive oxygen species generation
Sperm chromatin/DNA assays
ABOUBAKR ELNASHAR

42. 1. Sperm autoantibodies
4 to 8%of subfertile men.
The presence of agglutination in the initial semen analysis
suggests sperm autoimmunity; this should be confirmed by
the
Mixed antiglobulin reaction (MAR)
Immunobead test, both of which detect sperm
surface antibodies.
ABOUBAKR ELNASHAR

43. 2. Semen biochemistry
Rarely useful in clinical practice.
Fructose
marker of seminal vesicle function.
Low or non-detectable:
congenital absence of the vas deferens and
seminal vesicles or
ejaculatory duct obstruction
ABOUBAKR ELNASHAR

44. 3. Semen culture
Indicated: semen samples contain inflammatory
cells
Results: usually not diagnostic.
Precautions during sample collection to prevent
skin contamination.
The yield of semen culture may be improved by
performing a prostatic massage before sample
collection.
ABOUBAKR ELNASHAR

45. 4. Sperm-cervical mucus interaction
identifies whether the problem is in the sperm or in
the cervical mucus
●The postcoital test :
female partner is in the preovulatory phase of the
cycle.
The number and motility of sperm in the cervical
mucus is assessed 9 to 24 h after SI
●The in vitro tests
the slide or the capillary tests
performed on sperm and cervical mucus from the
infertile couple together with donor semen and
cervical mucus. These so-called "crossed tests"
ABOUBAKR ELNASHAR

46. 5. Sperm function tests
Routine:
Impractical and costly
Selective
when the standard semen analysis is normal or near
normal
ABOUBAKR ELNASHAR

47. Computer-aided sperm analysis: CASA
Assess:
1. sperm concentration
2. morphology.
3. Motility: Quantitative measurement = sperm
kinematics
sperm velocity (curvilinear, straight line, average path)
Amplitude of lateral displacement
other derived functions.
ABOUBAKR ELNASHAR

48. Useful in:
identifying men with unexplained infertility, predicting
in vivo and in vitro fertilizing capacity, and in
toxicology studies.
Accuracy depend upon:
technology
analytic conditions, and
technical training of the operators.
ABOUBAKR ELNASHAR

49. Sperm reactive oxygen species
Generation of reactive oxygen species may be a
cause of sperm dysfunction and a predictor of
fertilization in vitro. Reactive oxygen species lead to
lipid peroxidation of the sperm membrane and are
also deleterious to sperm motility.
This is still regarded as a research test and is not
often used for diagnosis of a specific sperm defect.
ABOUBAKR ELNASHAR

50. ASSESSMENT OF SDF
TestPrincipleMethod
TUNEL
ISNT
Incorporation of probes
at the site of damage
Direct
SCSA
SCD
Comet
Susceptibility of DBs to
denature in acid
solution
Indirect
Aniline blue
Toluidine blue
Incorporation of probes
to nuclear proteins
Chromatin
incorporation
(Feijo and Esteves, 2014)
ABOUBAKR ELNASHAR

51. ABOUBAKR ELNASHAR

52. Normal= 10
Fragmented= 4
DFI= 4X100/10+4
=28.5%
normal
normal
normal
normal
normal
normal
normal
normal
normal
fragmented
fragmented
fragmented
fragmented
normal
≥30: male infertility
15-30: RM.
≤15: Excellent to Good fertility potential
ABOUBAKR ELNASHAR

53. ABOUBAKR ELNASHAR
There is insufficient evidence to recommend the
routine use of SDF testing in evaluation and
treatment of infertile couple {level C}
?????????
For diagnostic test
1. Results must be reproducible
2. Applicable to a given patient
3. Change management of patient

54. IV. ENDOCRINE TESTS
1. Serum testosterone (T)
Morning T
In men with borderline values:
Repeat
FT
ABOUBAKR ELNASHAR

55. 2. Serum LH and FSH
Indication:
T is low
Interpretation:
high FSH and LH: primary hypogonadism
low or normal: secondary hypogonadism.
 low LH + low sperm counts +well-androgenized:
exogenous anabolic or androgenic steroid abuse.
ABOUBAKR ELNASHAR

56. 3. Prolactin
Indication:
 low T
normal to low LH
4. Inhibin
low serum inhibin concentrations may be an even
more sensitive test of primary testicular dysfunction
than high serum FSH concentrations, provided the
assay is specific for inhibin B
ABOUBAKR ELNASHAR

57. ABOUBAKR ELNASHAR

58. IV. GENETIC TESTS
ICSI:
Men with severe oligozoospermia and
azoospermia to father children
Genetic risks:
1. Cystic fibrosis conductance regulator (CFTR)
gene,
2. Somatic and sex chromosome abnormalities
3. Microdeletions of the Y chromosome
ABOUBAKR ELNASHAR

59. ABOUBAKR ELNASHAR

60. OBSTRUCTIVE AZOOSPERMIA
Azospermia+Normal testicular volumes + Normal
FSH, and LH and T
1. Bilateral congenital absence of the vas:
 physical examination
 low fructose level in the semen.
2. Ejaculatory duct obstruction
Transrectal US:
dilated seminal vesicles.
Patients with obstructive azoospermia: urologist
specialized in infertility for further evaluation and tt.
ABOUBAKR ELNASHAR

61. ABOUBAKR ELNASHAR