This document provides an overview of male infertility, including: 1. It defines concepts of infertility, sterility, and sexual impotence according to WHO and other medical organizations. 2. Male infertility can be caused by diseases that affect sperm production or transport. Diseases of sperm production include problems with testicle function, hormone imbalances, infections, and genetic disorders. Diseases of sperm transport involve blockages or issues with the ducts that carry sperm. 3. Diagnosis involves clinical history, physical exam, semen analysis, hormone tests, and other investigations to identify reversible or irreversible causes and rule out genetic issues. Treatment depends on the underlying cause but may include lifestyle changes, supplements, hormone

1. Yaquelin Gonzalez Ricardo. MD, MSc,
Endocrinologist Consultant. GPHC.
Georgetown, Guyana
2019
INFERTILITY IN MALE. OVERVIEW

2. INTRODUCTION
-1889 = injected dog testis
extracts.
- The Lancet; “…The day after
the first subcutaneous
injection ... a radical change
occurred in my… ", and
illustrated how their physical
and mental abilities improved.
2

3. 1.CONCEPT OF INFERTILITY
WHO : "a disease of the
reproductive system
defined by failure to
achieve a clinical
pregnancy after 12 months
of regular unprotected sex"
[*].
[*]OMS. http://www.who.int/reproductivehealth/topics/infertility/definitions/en/ 3

4. 1.CONCEPT OF STERILITY
American Society for
Reproductive Medicine:
(ASRM) : “…it is a disease of
the reproductive system that
inhibits the body's ability to
fulfill the basic function of
reproduction…" [*].
*. Comité de Práctica de la Sociedad Americana de Medicina Reproductiva (ASRM por sus siglas en inglés) (2008).
Definitions of infertility and recurrent pregnancy loss. Fertility and Sterility, 90(5 Suppl), S60. [arriba] 4

5. 1.CONCEPT OF SEXUAL IMPOTENCE
-Male sexual impotence
(erectile dysfunction):
the persistent inability to
achieve or maintain an
erection that allows a
satisfactory sexual
relationship.
5

6. 2019 ?
2.EPIDEMIOLOGY
-After having unprotected sex
for a year: 15% of couples
cannot conceive.
-After 2 years: 10% of
couples.
-Between 20% and 37% of
couples under 30 + good
health cannot conceive in the
first 3 months. 6

7. On average: "out of every 10
couples of reproductive age,
1 or 2 have an infertility
condition“[*] .
- However, 8 out of 10 cases
of infertility can be avoided .
The key is to know, prevent
and act.
*http://www.cecolfes.com/es/prevenir-la-infertilidad/como-prevenir-la-infertilidad-y-preservar-la-fertilidad
??
2.EPIDEMIOLOGY OF INFERTILITY
7

8. 3. Normal Anatomy
8

9. 3.Normal Hormone Secretion
? 9

10. ANDROGEN-BINDING PROTEIN(ABP)
-ABP = glycoprotein produced by Sertoli cells in the seminiferous tubules
(ST) + bind to testosterone (T), dihydrotestosterone (DHT), and 17-beta-
estradiol.
-T and DHT become less lipophilic and concentrate in the luminal fluid
of the ST. ADECUATE levels of T and DHT= spermatogenesis .
- ABP production : regulated under the influence of FSH in Sertoli cells,
AUGMENTED by INSULIN, retinol and testosterone .
ABP has the same amino acid sequence as sex hormone binding
globulin (SHBG). 10

11. SEX HORMONE-BINDING GLOBULIN ( SHBG)
-SHBG transports ANDROGENS through the
bloodstream.
-The highest proportion of serum T is linked to
SHBG and Albumin(T in free form=3-5%).
11

12. CONDITIONS ASSOCIATED WITH ALTERATIONS IN SHBG CONCENTRATION
Decrease[SHBG ].
-DM /Moderate Obesity / Nephrotic syndrome
- Glucocorticoids, progestins and steroids
- Hypo- Hyperthyroidism, Acromegaly
Increase [SHBG ]
-Age / Hepatic cirrhosis and hepatitis /
Anticonvulsants
-Estrogens / HIV infection / Hyperthyroidism
12

13. 3.Normal Hormone Secretion
? 13

14. ANDROGENS
-SOURCE: testicles and
adrenal glands
-DEVELOPMENT THE
MALE reproductive system
-Prostate, penis & scrotum:
T is converted to
Dihydrotestosterone (DHT)
through 5 α reductase and
both stimulate the androgen
receptor .
14

15. 15
Synthesis of steroid hormones from cholesterol
=

16. 4.Etiologic classification
I.Diseases that affect sperm
production.
1.Those that affect the functioning of the
testicles.
2.Hormonal imbalances.
II.Diseases that affect the transport
of sperm)
3.Obstruction of the male reproductive
organs.
16

17. I. Diseases that affect sperm production
1.Those that affect the functioning of the testicles. (IT)
Cryptorchidism = not treated = 70%
infertility. Decreases with adequate
and early treatment before 2-3 years
(laparoscopic orchidopexy)
17
Radiation
(Chemotherapy
and radiotherapy)
Infections
(Inflammation)
-Mumps, gonorrhea
or chlamydia

18. I. Diseases that affect sperm production (IT)
Varicocele (dilation of scrotal veins) = interrupts blood
flow in the testicle and causes an increase in
TEMPERATURE (present in 40% of men with fertility
problems)
Injuries in the testicles
18

19. I. Diseases that affect sperm production
Injuries in the testicles
Increase in TEMPERATURE
Sagging
Some jobs expose male genitalia at high
temperatures (working with boilers or
furnaces, being a baker, truck driver,
dancer). 19

20. Increase in TEMPERATURE(Injuries in the testicles)
-The heat caused by this type of
bath can affect the quality of sperm Some sports
-Repeated use of the
laptop on the lap
and cell phone
(at the waist)
20

21. I. Diseases that affect sperm production.
2.Hormonal imbalances.
-DIABETES MELLITUS
-Hyperprolactinemia.
- Thyroid disease
21

22. MALE
HYPOGONADISM
22
A decrease in testicular function, + low production of T (Androgen
deficiency).
Primary Secondary ORGAN
RESISTANCE
Related to age
I. Diseases that affect sperm production.
2.Hormonal imbalances.

23. 23
S . Klinefelter
(47XXY)
Testicles do not respond
to hormone stimulation.
-Congenital disorder :
Klinefelter's syndrome.
-Acquired : radiation
treatment,
Chemotherapy, mumps,
tumors or trauma to the
testes. Anorquia

24. 24
T.: - 0.0.25 ( 2.7-10.7 g/ml)
PRL: 573.0 ( 1,6-17 g/ml)
LH :-0.100 ( 0.7-7.4)
Secondary

25. 25
MALE HYPOGONADISM
Hypogonadism may increase the risk for cardiovascular
disease, Type 2 DM, metabolic syndrome, premature death
in older men, and Alzheimer's disease .
ORGAN
RESISTANCE
RELATED TO
AGE
-Feminization due to
androgenic resistance or
alpha 5 reductase
deficiency
-Estrogen deficit due to
aromatase deficiency

26. I. Diseases that affect sperm production
Serum levels
increase(T)
Decrease serum levels(T)
Cimetidine
Finasteride
Rafampicin
Tamoxifen
Valproic acid
Phenytoin
Anabolic steroids Carbamazepine
Cyclophosphamide Digoxin
Estrogens Ketoconazole Opioids
Spironolactone
Tetracycline Verapamil
Cyproterone
MEDICATIONS
26

27. 27

28. II. Diseases that affect the transport of sperm
-The inability to transport sperm (testes to penis)= 10%
- A natural obstruction of the ducts that carry sperm from the testicles to
the penis or a vasectomy= 20% of male infertility .
-Cystic fibrosis (not ducts that carry sperm out of the testicles (infertile,
not sterile).
-Erectile dysfunction.
-Retrograde ejaculation (the sperm is directed towards the bladder)
28

29. VARIATIONS IN THE PLASMA TESTOSTERONE LEVELS /
FLASH
-Age (decrease in plasma levels from T 1
to 2% per year).
-Random circadian (pick 8 - 11 am).
- Episodic secretion: 30% with mild
hypogonadism, will present normal serum
T levels in repeat examination.
29

30. FLASH / MALE IFERTILITY IS DUE TO:
1. Low sperm production,
2. Abnormal sperm function
3. Blockages that prevent the delivery
of sperm.
Illnesses, injuries, chronic health problems,
lifestyle choices and other factors can play
a role in causing male infertility.
30

31. 5.Clinical Presentation
/Signs & Symptoms:
31

32. 32
THE INFLUENCE OF TESTOSTERONE

33. 6.DIAGNOSIS/
Investigations.
CLINIC
Clinical history and
detailed physical examination. 33

34. Goals of evaluation of infertility men
34
1.Identification of reversible disorder.
2.Identification of irreversible condition.
3.Identification of chromosomal & genetic
abnormalities that may affect the
offspring.
4.Identification of idiopathic cases .

35. Diagnostic
35
-General physical examination and medical history.(+ General labs)
-Semen analysis.
-Scrotal ultrasound. -Hormone testing
-Post-ejaculation urinalysis
-Genetic tests.
-Testicular biopsy. -Specialized sperm function tests
-Transrectal ultrasound. A small, lubricated wand is inserted into your
rectum. It allows your doctor to check your prostate and look for
blockages of the tubes that carry semen (ejaculatory ducts and seminal
vesicles).

36. 36

37. Standard tests Normal value
Volumen 2.0 ml or more
pH 7.2-7.8
Sperm concentration 20 x106 sperm / ml or more ( 15)
Total sperm 40 x106 sperm or more
Mobility 50% or + with progressive linear mobility or 25%
with rapid linear mobility (within 60 minutes of
collection)
Morphology 30% or more with normal morphology
Vitality 75% or more live
White blood cells Less than 1x106 / ml
Immunobead test less than 19% sperm with adherent particles
MAR test less than 19% sperm with adherent particles
37
Normal Spermiogram
MAR - Mixed Agglutination Reaction.

38. 38

39. 7.Treatment & Management
?
39

40. ?
?
?
I have no symptoms so how
can my condition be
serious?
?
I am afraid
of the unknown
I am anxious that my therapy
will cause side effects
What happens if I forget to take
my medication on a regular
basis?
What if my therapy fails?
?
?
?
?
CONSIDERING / PATIENTS PERSPECTIVE
40

41. Parameter Treatment Goal
Weight loss (for
overweight and
obese patients)
Reduce by 5% to 10%
Physical activity
150 min/week of moderate-intensity
exercise (eg, brisk walking) plus flexibility
and strength training
Diet/ MEAL
PLANNING
-Eat regular meals and snacks; avoid
fasting to lose weight.
-Consume plant-based diet (high in fiber,
low calories/ glycemic index, and high in
phytochemicals/antioxidants)
Therapeutic Lifestyle Changes
41

42. 42
7.Treatment & Management

43. 43
Included: androgens, gonadotropins,
antiestrogens, GnRH, and antiprostaglandins and
pentoxifylline.
-Success has been limited, and placebo-controlled
studies have been few.
7.Treatment & Management/ EMPIRIC THERAPY

44. 44
Supplements with studies showing potential benefits on improving
sperm count or quality include
-Black seed (nigella sativa)
-Coenzyme Q10
-Folic acid
-Horse chestnut (aescin)
-L-carnitine
-Panax ginseng
-Zinc

45. 7.Treatment & Management
The classification of hypogonadism has therapeutic
implications.
-If hypogonadism is secondary, hormonal stimulation
with hCG, FSH or GnRH can restore fertility in most
patients.
BUT if the deficit of T occurs before puberty, secondary
sexual characteristics do not develop and skeletal
alterations with eunuchoid proportions occur.
45

46. 7.Diagnostic / therapeutic agreement (T)
Values :
​​-+ 12 nmol / l (350 ng / dl) = DO NOT require
replacement therapy.
- = less than 8 nmol / l (230 ng / dl) = Yes.​​
- = 8 nmol / l (230 ng / dl) and 12 nmol / l (350 ng / dl) =​​
repeat the measurement of T + request SHBG+ albumin
to calculate free and / or bioavailable T.
-Free T immunoassays donot have adequate accuracy .
46

47. T*: Testosterone 47
TESTOSTERONE
-Enanthate or cypionate(T* IM) -1% Gel T*
-Patches Transdermal of T*. -Oral, bioadhesive, Capsules T*
-Pellets T* -T Oral Undecanoato
-Long-Acting Injectable Dedecanoate
-In "matrix" adhesive patches T*

48. 8. Prevention
BUT :prevention is the most
important part of the
treatment of each disease
whenever possible
48

49. -The heat caused by this type of
bath can affect the quality of
sperm
-Some sports
-Repeated use of the
laptop on the lap
and cell phone
(at the waist)
49
7. Prevention

50. Injuries in the testiclesIncrease in
TEMPERATURE
Sagging
50

51. 51

52. Patient
/ Endocrinologist
General
Practitioner
Registered
nurse
OTHERS Specialist
(OFTA,..)
Dietitian
Exercise
specialist
Mental health
care professional
Podiatrist
Comprehensive Management Team.
The multidisciplinary team: additional members
Urologist
(Surgeon)
52

53. 53

54. REFERENCES
54
-Kumar K, Deka D, Singh A, Mitra DK, Vanitha BR, Dada R. (2012) Predictive value of DNA
integrity analysis in idiopathic recurrent pregnancy loss following spontaneous conception. J
Assist Reprod Genet. 29 (9):861-7.
-World Health Organization Department of Reproductive Health and Research. WHO laboratory
manual for the examination and processing of human semen, fifth edition. WHO 2010. Available at:
http://www.who.int/reproductivehealth/publications/infertility/9789241547789/en/. Accessed October
2017.
-Leushuis E., van der Steeg J.W., Steures P., Repping S., Bossuyt P.M., Mol B.W. Semen
analysis and prediction of natural conception. Hum Reprod. 2014;29:1360–1367. [PubMed]
-Centres for Disease Control and Prevention. National Center for Health Statistics – Infertility
Statistics, 2016. Available at: https://www.cdc.gov/nchs/fastats/infertility.htm. Accessed October
2017.
-Daniel E Stein .Infertility Program Roosevelt Hospital -5 Common Causes of Male Infertility
available at: https://www.youtube.com/watch?v=6Ru9QFydnJs

55. 55