The cause for infertility could be in the male or the female or both or neither-as in ‘Unexplained Infertility.’ Male infertility is usually caused by problems that affect either sperm production or sperm transport. 

1. Assessment and Treatment of
Male Factor Infertility.
www.femelife.com

2. Male Infertility.
• The cause for infertility could be in the male
or the female or both or neither-as in
‘Unexplained Infertility.’
• Male infertility is usually caused by problems
that affect either sperm production or sperm
transport.

3. Male Infertility Data
• Primary Infertility is more often due to a male
factor - 57 % (WHO multicentric study).
• Femelife fertility Data: 2016
• Oligo/astheno/teratozoospermia----45%.
• Azoospermia--------------------------22%.
• Normal---------------------------------23%.
• Sexual Dysfunction------------------10%.

4. Male Infertility.
•
• The diagnosis and treatment of infertility has a
profound impact on people’s lives. It affects
psychology of both partners and could be a
cause of marital disharmony.

5. Male Infertility
• Physiological aspects:
• The age of spermarche is not known in
most countries and in most populations.
Unlike in women, men never undergo
spermopause though there may be a
questionable occurrence of ‘Andropause’.
• Spertmatozoa production occurs at a rate
of 1000/spermatozoa/second in adult
healthy men.

6. Male Infertility
• Physiological aspects:
• Spermatozoa movement from the posterior
vaginal fornix to the uterine cavity and the
fallopian tube was considered to be a random
movement.
• Recent data by Ral D et al 1994 indicate that
spermatozoa movement is directed by
chemotaxis and not a random movement.

7. Male Infertility
• Physiological aspects:
• Much emphasis was placed on the role of
epididymis on spermatozoa maturation. Even
an ‘Epididymal Forward Motility Protein’ was
postulated.
• We have observed on several occasions motile
spermatozoa from all over the uro genital
tract.

8. Male Infertility
• Work by us (Femelife-2016) and many others
have found that the ‘Human epididymis does
not confer any known function to the
spermatozoa.
• Human epididymis has no storage function.
• Spermatozoa gain motility over time and not
on epididymal transit.

9. Male Infertility.
• History:
• Age: male fertility, also declines with age. The
decline starts by late 20s and is continuous.
• Occupation: association between certain jobs
and male infertility- jobs involving continuous
exposure to heat and chemicals like lead,
arsenic, mercury etc.

10. Male Infertility.
• History:
• History of surgery for maldescent,
hypospadias,hydrocele,hernia.
• History of drug intake-anti hypertensives,anti
epileptics,sulphasalazine,nitrofurantoin,
• cimetidine,ranitidine.

11. Male Infertility.
• History of smoking(tobacco use)/alcohol
consumption, use of hard drugs.
• History of STD/genital tract infections/mumps.
• History of lubricants.
• History of coital frequency/ proper coitus.

12. Coital frequency and conception.
Weekly frequency Conception within 6
months (%).
< 1 17
1 to 2 32
2 to 3 46
3 to 4 51
> 4 83

13. Male Infertility.
Clinical Examination:
• Hypoandrogenisation, eunuchoidal
features- Hypogonadism- Klinefelter’s
syndrome.
• Penis- site of urethral opening-
Hypospadias and epispadias. Improper
deposition of semen-infertility.
• Testis- small sized testes/crypt orchid
testes often lead to infertility.
• Presence or absence of vas and varicocele.

14. Semen analysis
• Single most important test.
• Normal Semen (WHO criteria):
• Volume----------2 ml or more.
• Concentration—20 million/ml or more.
• Motility----------50% or more with forward
progression.
• Morphology-----30% 0r more normal forms.

15. Abnormalities in the Semen
Picture.
• Semen picture is very variable even amongst
normal fertile individuals.
• No decision on the putative fertility of a man
can be made on a single semen picture.
• Abnormalities in the semen picture could be
due to several collection and analysis artifact.

16. Normal and abnormal semen.
• Spermatozoa
Motility.
• Spermatozoa
concentration.
• Agglutination.
• Viability.

17. Normal and Abnormal Semen.

18. Abnormalities in the Semen
picture.
• Aspermia: Aspermia is absence of an
ejaculate.
• Causes:
• 1)Anejaculation-Failure of ejaculation- could
be Global or situational.
• 2)Retrograde Ejaculation- semen goes back
into the bladder.

19. Abnormalities in the Semen
picture.
• Volume– Very high-Hyperspermia- above 8 ml-
may cause dilutional Oligozoospermia.
• Treatment: Spermatozoa processing and Intra
Uterine Insemination after Controlled Ovarian
Hyper stimulation.

20. Abnormalities in the Semen
picture.
• Very low—Less than 0.5 ml-Hypospermia-
inadequate volume to access the cervix.
• Treatment:-spermatozoa processing and
Intra uterine insemination after Controlled
Ovarian Hyper stimulation.
• Viscosity: highly viscous semen sample
may impair sperm motility.
• Treatment:- Spermatozoa processing and
Intra uterine insemination.

21. Abnormalities in the Semen
Picture.
• Liquefaction: Non-liquefied semen sample
may impair fertility.
• Treatment: Repeated syringing of the semen
sample without needle, spermatozoa
processing and Intra uterine insemination after
Controlled Ovarian Hyper stimulation.

22. Abnormalities in the Semen
Picture.
. Normozoospermia.
• Oligozoospermia.
• Asthenozoospermia.
• Necrozoospermia.
• Teratozoospermia.
.

23. Abnormalities in the Semen
Picture.
• Azoospermia.
• Aspermia.
• Oligo astheno teratozoospermia.
• Cryptozoospermia.
.

24. Normal and Abnormal Semen.
• Sperm agglutination.
• Normozoospermia.
• Oligozoospermia.
• Asthenozoospermia.
• Teratozoospermia.

25. Abnormalities in the Semen
Picture.
• Azoospermia:Absence of spermatozoa in the
ejaculate both in a neat semen sample and in
a centrifuged resuspended semen sample.
• Obstructive Azoospermia.
• Non- Obstructive Azoospermia- Borderline
Azoospermia.

26. Azoospermia.
• Obstructive Azoospermia:
•1) Ejaculatory duct obstruction.
•2) Vasal obstruction—vasectomy,
Vasal Aplasia.
•3) Epididymal obstruction.
•4) Intra testicular obstruction.

27. Obstructive Azoospermia
Condn S.FSH T. Size Se. vol Fruct
Ej d ob Normal Normal V low Absent
V abs Normal Normal V low Absent
V obstr Normal Normal Normal Present
Ep Obs Normal Normal Normal Present
Te.obst Normal Normal Normal Present

28. Azoospermia
• Non obstructive Azoospermia.
• 1) Seminiferous tubular failure(testicular
failure).
• 2) Hypogonadotrophic hypogonadism.
• 3) Borderline azoospermia.

29. Non Obstructive Azoospermia
Condition FSH Test Size S.Vol Feature
Hypo
gon.Hypo
gonadism
Low or
undetec
table
Small Normal Hypo/an
osmia
Semin tub
failure
Raised Small Normal ----
Border
line Azoo
Normal,
mild
elevatn
Normal,
small
Normal Hist: Mat
arrest/Hy
posperm

30. Oligozoospermia
• Definition: the presence of less than 20
million spermatozoa per ml of semen is
considered as Oligozoospermia.
• Causes:1) Partial obstruction.
• 2)Seminiferous tubular failure.
• 3)Varicocele.
• 4)Genital tract infections.

31. Oligozoospermia
• Mild -------------------5 to 19 million/ml.
• Moderate--------------1to 4 million/ml.
• Severe-----------------<1 million/ml.

32. Oligozoospermia
Condition. Testes size S.FSH Mgmt.
Seminiferou
s tubular
failure
Small Raised Active-
IUI/FSP/IV
F/ICSI.
Partial
Obstruction
/Idiopathic
Normal. Normal. Scrotal
Exploration
/IUI/etc.
Varicocele Normal to
small
Normal
mild
elevation.
Varicocelec
tomy/IUI/A
RT.

33. Asthenozoospermia.
• 1)Prolonged abstinence.
• 2) Pyospermia.
• 3)Polyzoospermia.
• 4) Teratozoospermia.

34. Asthenozoospermia.
• 5)Varicocoele.
• 6)Partial obstruction.
• 7)Paraplegia.
• 8)Seminal vesicular dysfunction.
• 9)Artefact.

35. Total Asthenozoospermia.
• Sperm tail defect—immotile cilia syndrome.
• Diagnosis by electron microscopy.
• Should be differentiated from dead
spermatozoa( Necrozoospermia)- by supravital
stain.

36. Retrograde Ejaculation
• Diagnosis by history & examination of post
coital urine sample for spermatozoa.
• Treatment –non invasive method of collecting
post coital urine into culture medium &
preparation for insemination of wife around
ovulation.

37. Varicocele Story
• Common cause of
Oligoasthenoteratozoospermia.-OATS.
• 1) Intrascrotal venous stasis raises scrotal
temperature & impairs spermatogenesis.
• 2) presence of adrenocortical &
adrenomedullary metabolites in the refluxing
blood may lead to impaired spermatogenesis.

38. Varicocele--diagnosis
• 1) Clinical examination in the erect posture-
moderate to severe degrees can be felt at the
neck of scrotum.
• 2) Milder forms—Valsalva manoeuvre.
• 3) Contact ultrasonography.
• 4) Doppler –reflux of blood flow.

39. Varicocele—treatment
• Varicocoelectomy—Palemo’s approach, inguinal
approach.
• Laparoscopic varicocoelectomy.
• Embolisation/ injection of sclerosants into
veins.

40. Varicocelectomy-Data till 1999.
• Total no of Patients operated------ > 1000.
• Improvement in Spermiogram---- > 70%.
• Pregnancy Rate----------------------> 60%.
• Prognosis after varicocelectomy depends upon
testicular size, serum FSH values and the
biopsy report obtained concurrently with
varicocelectomy.

41. Surgical Management Of Male
Sub fertility.
• 1) To improve spermiogram—Varicocoelectomy.
• 2) To relieve ductal obstruction—VEA, VTA,
VVA.
• 3) To retrieve spermatozoa from the urogenital
tract.

42. Drug Therapy In Male Sub
fertility.
• Specific.
• Non specific/ empirical.
• Principles of drug therapy.
• Aimed at stimulating spermatogenesis; should
be given for at least three months before any
significant improvement can be expected.

43. Specific Drug Therapy
• 1) Hypogonadotrophic hypogonadism.
• 2) Hyperprolactinaemia.
• 3) Genital tract infections.
• 4) Retrograde ejaculation.

44. Sperm Retrieval Techniques
• Definition: Sperm retrieval techniques are
techniques which involve the
identification,isolation and suspension of
spermatozoa (in a suitable culture medium)
obtained from the urogenital tract other than
from the ejaculate.

45. Sperm Retrieval Techniques
• 1) MAESA—Macrosurgical Epididymal sperm
aspiration.
• 2) MESA- Microsurgical epididymal sperm
aspiration.
• 3)PESA—Percutaneous Epididymal sperm
aspiration.

46. Sperm Retrieval Techniques
• 4) TESE/ SPERT—Testicular sperm
extraction/Sperm retrieval from the testes.
• 5) FNAS-Fine needle aspiration of
Spermatozoa.
• 6)VASA-Vasal sperm aspiration.
• 7) SPERB—Sperm retrieval from the bladder.
• 8)Postmortem sperm retrieval.

47. Male Infertility and Assisted
Reproductive Technologies.
• Controlled Ovarian Hyper stimulation and Intra
uterine insemination- worth attempting if the
processed semen sample has greater than 1
million progressively motile spermatozoa..
• In- vitro fertilisation and Embryo transfer- IVF
and ET.
• Intra Cytoplasmic sperm Injection-ICSI.

48. Male Infertility and Assisted
Reproductive Technologies
• Assisted reproductive Technologies are
undertaken in all patients undergoing Sperm
Retrieval techniques.
• ICSI would be the treatment of choice – but we
have had pregnancy with IVF and IUI also and
even with frozen, thawed spermatozoa
obtained from sperm retrieval techniques.

49. Controversial Tests.
• Anti sperm antibody tests.
• Post coital tests.
• Sperm function tests.
• Cervical mucus sperm interaction tests.

50. Semen Bank
• First semen bank in the world-1953-Bunge et
al.
• First semen bank in India—1988 Pandiyan et al.
• Indications:
• 1) Heterologous samples.
• 2) Homologous samples—Frequent Travellers.
Prior to vasectomy.

51. Semen Bank
• Prior to ART.
• Sexual dysfunction.
• Prior to chemotherapy.
• MESA, TESE, PESA and other sperm retrieval
techniques.

52. Genetics of Male Infertility
• Why a male is a male?
The human sex is determined at three
crucial steps:
1)at Fertilisation- chromosomal sex.
2)Gonadal sex is determined by the
presence or absence of the Y chromosome.
3)Gonadal secretions-endocrine and
paracrine determine the development of
the internal and external genitalia.

53. Genetics of Male Infertility
• Gonadal development:for normal development
of the gonads both the sex chromosome are
essential.
• The short arm of the Y chromosome carries
genes essential for testicular development.
• The long arm of the Y chromosome carries
genes essential for spermataogenesis.

54. Genetics of Male Infertility
• Gonadal development: in the absence of
one sex chromosome-45xo-turner’s
syndrome or the presence of an extra
chromosome-47xxy-Klinefelter’s syndrome-
normal gonadal development will not take
place.
• Deletions involving the long arm of the Y
chromosome may lead to impaired
spermatogenesis and Oligozoospermia and
Azoospermia.

55. Genetics of Male Infertility
• The autosomes may also carry genes for
spermatogenesis.
• Impaired spermatogenesis may also be seen in
men with autosomal translocations.
• It has recently been discovered that the X
chromosome also carries genes essential for
spermatogenesis.

56. Future Trends
• Cloning.
• In-Vitro sperm maturation.
• In-vivo sperm maturation.
• In-vitro/in vivo spermatogenesis from stem
cells.
• Gene therapy.
• ?? Testes transplant.

57. Thank you