This document discusses male infertility, including its definition, causes, evaluation, and treatment options. It notes that male factors contribute to 40% of infertility cases. Causes can be pre-testicular, testicular, or post-testicular and include genetic conditions, infections, varicocele, hormonal imbalances, and blockages. Evaluation involves history, exam, semen analysis, genetic/radiographic tests. The goal is to identify reversible causes, plan ART for irreversible conditions, and detect issues affecting offspring health. Treatment depends on the underlying cause and may involve surgery, medication, or ART like IVF/ICSI.

1. MALE
INFERTILITY
Dr. Tanmoy Debnath
HMO
Department of Urology

2. DEFINITION
Failure to conceive after 1 year of
regular unprotected sexual
intercourse (at least 2 times in a
week)

3. INCIDENCE
15% of couples are infertile
▫ 40% male factor
▫ 40% female factor
▫ 20% both

4. TYPES
Primary infertility:
Who never conceive
Secondary infertility:
Couples who have been fertile in the
past, but have fewer than the desired number of
children

5. CAUSES
• Pre testicular cause
• Testicular cause
• Post testicular cause

6. PRE TESTICULAR CAUSE
• Hypothalamic disease
▫ Kallmann syndrome (gonadotropin deficiency)
▫ Isolated LH deficiency (Fertile Eunuch)
▫ Isolated FSH deficiency
▫ Congenital hypogonadotrophic syndrome

7. Cont..
• Pituitary disease
▫ Pituitary insufficiency
 Tumour
 Infarct
 Surgery
 Radiation
 Secondery infiltration
▫ Hyper prolactinemia : Prolactin-secreting pituitary
adenoma

8. Cont..
• Exogenous or endogenous hormone
 Increase Estrogen
 Increase Glucocorticoids
 Increase Androgen
 Hypo or hyperthyroidism
 Growth hormone deficiency

9. TESTICULAR CAUSES
• Klinfelter syndrome (47XXY)
• Noonan syndrome (Male Turner syndrome)
• Bilateral anorchia
• Y chromosomal microdeletion
• Gonadotoxin
 Radiation
 Drugs - Calcium channel blocker, Cimetidine,
Sulfasalazine, Spironolactone, Allopurinol, Alpha-
blocker, TCA, Anti-psychotic, Nitrofurantoin

10. Cont..
• Systemic disease:
 Renal failure
 Liver failure
 Sickle cell disease
• Testis injury:
 Mumps orchitis
 Trauma
 Torsion
• Cryptorchidism
• Varicocele
• Idiopathic

11. POST TESTICULAR CAUSES
• Reproductive tract blockages
▫ Congenital blockages
 Cystic fibrosis - Congenital bilateral absence of vas deferens(CAVD)
 Young Syndrome
 Idiopathic epididymal obstruction
 PKD
 Ejaculatory duct obstruction
▫ Acquired blockages
 Vasectomy
 Groin & hernia surgery
 Infection
▫ Functional blockages
 Sympathetic nerve injury
 Pharmacological

12. Cont..
• Disorder of sperm function & motility
 Immotile cilia syndrome
 Infection
 Immunological Infertility
• Disorder of coitus:
 Impotence
 Hypospadias
 Chordee
 Timing & frequency

13. EVALUATION/WORK UP/INDICATION
Couple should have a joint evaluation at one year, unless
the following factors are present
In male:
 Bilateral cryptorchidism
 Testicular torsion
 Previous Unexplained infertility
 Prior chemotherapy
In female:
 Advanced marital age (>35 yrs)
 Irregular or abnormal menstruation
 Previous unexplained infertility
 H/O PID

14. GOAL OF WORK UP
Identification of
▫ Reversible conditions
▫ Irreversible conditions managed by ART
▫ Irreversible conditions adversely affecting any
offspring e.g. genetic or chromosomal abnormality
▫ Medical conditions related to infertility

15. WORK-UP
• History
• Physical examination
• Investigations

16. HISTORY
• Medical history
• Surgical history
• Fertility history
• Sexual history
• Family history
• Medication history
• Social history
• Occupational history

17. MEDICAL HISTORY
• H/O Mumps, Liver disease, Renal failure
• Hyperthyroidism/Hypothyroidism
• Fever
• Systemic illness : DM, Cancer, Infection
• Genetic disease : Cystic fibrosis, Klinefelter
syndrome

18. SURGICAL HISTORY
• Cryptorchidism, Orchidopexy
• Trauma, Torsion of testis
• Hypospadias, Varicocele
• Pelvic, bladder, retroperitoneal surgery
• Herniorrhaphy, Vasectomy
• TURP, BNI,RPLND, Lumbar sympathectomy

19. FERTILITY HISTORY
• Duration of marriage
• Previous pregnancy
• Duration of infertility
• Previous treatment for infertility
• Female evaluation

20. SEXUAL HISTORY
• Libido, Erection
• State of ejaculation
• Timing & frequency
• Lubricants, used or not

21. FAMILY HISTORY MEDICATION HISTORY
• Hypospadias
• Cryptorchidism
• Midline defects
• Exposure to diethylstilbesterol
• F/H of infertility
• Nitrofurantoin
• Alpha blocker
• Calcium channel blocker
• Cimetidine
• Sulfasalazine
• Spironolactone
• Thiazide
• Radiation

22. SOCIAL HISTORY OCCUPATIONAL HISTORY
• Smoking/tobacco
• Cocaine
• Anabolic steroids
• Exposure to ionizing radiation
• Chronic heat exposure
• Aniline dye
• Pesticides
• Heavy metals

23. PHYSICAL EXAMINATION
GENERAL EXAMINATION
To detect signs of hypogonadism (Secondary sex
characteristics)
 Body hair distribution
 Fat distribution
 Voice
 Breast
 Thyroid

24. LOCAL EXAMINATION
TESTIS: Size: Length 4.6cm (3.6-5.5cm)
Breadth 2.6cm (2.1-3.2cm)
Volume 18.6cc +/- 4.0cc
Consistency : Firm (normal), Soft (abnormal)
EPIDIDYMIS: Normally placed on postero-lateral aspect
of testis
Tenderness ,Induration ,Cyst, Nodule
SPERMATIC CORD: Varicocele
Vas deferens – Present or absent (2%)

25. PENIS: Length (at least 5cm is normal),
Hypospadias , Chordee, Phimosis
DRE: Prostate - Developed or not, features of
infection (tenderness,boggyness), features of
malignancy
Seminal vesicle - Enlarged or not

26. INVESTIGATIONS
• Laboratory tests - a) Semen analysis
b) Genetic assessment
• Radiographic evaluation
• Testicular biopsy
• Vasography

27. SEMEN ANALYSIS
COLLECTION
▫ Sexual abstinence for 48-72 hours
(With each abstinence, 0.4 ml semen volume is raised up to 1
week And Sperm motility tends to fall when abstinence
period > 5 days)
▫ Collected by
• Self stimulation (masturbation)
• Intercourse with special nonspermicidal condom
• Coitus interruptus ( less ideal)
▫ Collected in a wide mouth ,clean plastic or glass bottle
▫ Specimen should be examined within 1 hour of
procurement
▫ During transit,the specimen should be kept at body
temperature
▫ 3 separate samples should be collected within period of 4-6
wks before final report

28. CONT.
Physical characteristics
• Fresh semen is a coagulum that liquefies within 15-30
minutes of ejaculation
• Normal characters :
Ejaculate volume : 1.5 – 5.5 ml
Sperm count : > 20 million /ml
Motility : >50 %
Forward progression : 2 ( scale 1-4)
Morphology : >30 % WHO normal forms
>4 % Kruger normal forms
pH : Alkaline
Increased viscosity and no clumping

29. Some Nomenclatures
• Aspermia : Absence of ejaculate or seminal fluid.
Cause - Retrograde ejaculation
Post coital urinalysis confirms the dianosis
• Normospermia : Sperm count > 20 million/ ml
• Oligospermia (Oligozoospermia) : Sperm count < 20
million / ml
Cause : Varicocele, Cryptorchidism
• Azoospermia : Absence of sperm
Cause - Ejaculatory duct obstruction
Bilateral absence of vas deference
Cyst related to epididymis
Primary testicular failure
FSH is high > 2 times than normal

30. Cont.
• Asthenospermia ( Asthenozoospermia ) : Motility < 50
% ( < 50 % motile)
• Teratozoospermia : Morphology < 30 % than normal form
• Oligoasthenoteratozoospermia : Density , Motility &
Morphology less than minimum standards of adequacy
• Pyospermia / Leucospermia :
 Increase in WBC in the seminal fluid
 > 1 million / ml is significant
 Cause : Infection
Sensitization of immune system to sperm antigen
Low grade toxin – alcohol, cigarattes

31. Genetic assessment
 Chromosomal analysis : Barr body
Karyotyping
 CF mutation testing

32. Radiographic evaluation
Scrotal ultrasound
Indication :
• Patient who have hydrocele
• Abnormality of peri testicular region
• Varicocele (Color Doppler )
Findings :
• Size of testis
• Peri testicular abnormality
• Varicocele – Pampiniform venous diameter >3mm is
consider abnormal

33. Cont..
TRUS ( Transrectal ultrasound)
Indication :
• Azoospermic patient
• Semen volume < 1.5 ml
• pH – Acidic
• When semen does not coagulate
Findings :
• Anatomical evaluation of prostate, seminal vesicles,
ejaculatory duct & distal vas - tumors or congenital anomaly
Dilated seminal vesicles > 1.5 cm in width or Dilated
ejaculatory duct > 2.3 mm in association with cyst ,
calcification or stone along the duct  highly suggest
obstruction

34. CT & MRI
• The advent of TRUS limits its indication
• Indications include evaluation of patient with solitary
right varicocele which may be associated with
retroperitoneal pathology and evaluation of the
nonpalpable testis

35. Testicular biopsy
• Differentiate between testicular outflow obstruction &
primary testicular failure in azoospermic patient
• Indications : In azoospermic patient, whose vas
deference is present ( detected by palpation & TRUS )
with normal hormone level ( FSH,LH,testosterone) &
normal volume of testis.
• Symmetric testis – unilateral biopsy
• Asymmetric testis – bilateral biopsy

36. Cont..
Testicular biopsy evaluates
▫ Distinction between a failure of sperm production &
obstruction within the reproductive tract
▫ The size & number of seminiferous tubules
▫ The thickness of tubular basement membrane
▫ The relative number & types of germ cell within the
seminiferous tubules
▫ The degree of fibrosis in the interstitium &
▫ The presence of condition of Leydig cells.

37. VASOGRAPHY
Indications : Azoospermic patient with -
▫ Normal testis size,
▫ Normal FSH level &
▫ Normal spermatogenesis on testis biopsy
Technique :
• Vasography involves injection of dye or contrast media
into vas deferens towards the bladder from scrotum
• If sterile saline is injected into the vas towards the
bladder & if free flow is noted , no need for injecting
contrast media into the vas.

38. Cont..
• In the film of radiograph , contrast material can
delineate the anatomy of proximal vas deferens, seminal
vesicle & ejaculatory duct and determine whether
obstruction is present.
• If an obstruction is identified on vasography , surgical
correction is recommended during the same sitting
• Sampling of vasal fluid during the same procedure can
be done & inspected under microscope to determine the
presence of sperm
If sperm present – suggests obstruction distal to that
site, i.e. no obstruction in the testis & epididymis
If sperm absent – suggests more proximal obstruction

39. Treatment
Treatment depends on the cause of infertility
Options :
a ) Surgical
b ) Medical
c ) Artificial reproductive technology (ART)

40. Azoospermia :
a ) Low volume azoospermia :
 Ejaculatory duct obstruction : Transurethral resection of
ejaculatory duct ( TURED)
 Congenital absence of vas deference (CAVD):
Microscopic epididymal sperm aspiration (MESA)
followed by ICSI
 Midline prostatic cyst : Transurethral resection
b ) Normal volume azoospermia
 Vasal or epididymal obstruction : Microsurgical
reconstruction, e.g. Vasovasostomy or
vasoepididymostomy

41. Spermatogenic failure :
i) Primary spermatogenic failure ( hypergonadotropic
hypogonadism ):
Testicular sperm extraction/aspiration ( TESE /
TESA)  ICSI
ii) Secondary spermatogenic failure (hypogonadotropic
hypogonadism) : Replacement of gonadotrophin, i.e.
FSH,LH
Induction of virilization : hCG

42. Oligoasthenoteratozoospermia
• Elimination of spermatotoxin : i.e. Cimetidine ,
Spironolactone , Nitrofurantoin
Semen analysis should be repeated 2-3 months after
elimination
• Medical therapy : ( to increase spermatogenesis )
▫ Clomiphene citrate (antiestrogen) : dose 12.5- 50 mg
/day continuously or with a 5 days rest period.
▫ Tamoxifen citrate : 10-15 mg/day for 3- 6 months
▫ Antioxidant : Glutathione 600 mg/day or, Vit E 400 –
1200 U/day
▫ Kallikrein
• Surgical therapy : For Varicocele - Ligation of the veins

43. Retrograde ejaculation :
 Sympathomimetic drugs : Imipramine : 25-50 mg/bd
or, Sudafed plus : 60 mg TDS - Need to start several
days before ejaculation
 If fails – Sperm harvesting technique with IUI to achieve
pregnancy

44. Anejaculation :
• Due to spinal cord injury , pelvic nerve injury
• Treatment :
Electroejaculation :
With rectal probe electroejaculation  sympathetic
nerves undergo stimulation  contraction of vas
deferens, seminal vesicle, prostate reflex ejaculation is
induced  followed by ART
Vibratory stimulation :
High frequency penile vibration - Patient may be taught
to perform the procedure & attempt to conceive at home
with cervical insemination

45. Hyperprolactinaemia
 Transphenoidal surgery
 Bromocriptine 5- 10 mg daily
Pyospermia :
• Antibiotic – Doxycycline, Co-trimoxazole
• Antioxidants- Antioxidant vitamins, Glutathione, omega-
3 fatty acid

46. Others :
Coital therapy :
• Coital timing, frequency (Coitus every other day around
the ovulation)
• Gonadotoxin avoidance
• Avoidance of coital lubricants