This document provides information on male infertility including: - Common causes of male infertility include abnormal semen profile, sexual dysfunction, genetic factors, infections, etc. - Evaluation of male infertility involves history, physical exam, semen analysis, and additional tests like hormone assays, immunological tests, and genetic analysis. - Treatment depends on the underlying cause but may include lifestyle changes, medications, surgery, assisted reproductive technologies like IVF/ICSI.

1. DR. RABI NARAYAN SATAPATHY
ASST.PROFESSOR
DEPT. OF OBST.& GYNAECOLOGY
SCB MEDICAL COLLEGE, CUTTACK
MOB-09861281510
EMAIL-drrabisatpathy@gmail.com

2. Relative Prevalence Of The Etiologies Of Infertility
10% 10%
40-50%
25-40%
Both male & female
factor
Female factor
Male factor
Unexplained
infertility
Incidence of Male Infertility is increasing ! !Incidence of Male Infertility is increasing ! !

3. PRESENTATION OF MALE INFERTILITYPRESENTATION OF MALE INFERTILITY
ABNORMAL SEMEN PROFILEABNORMAL SEMEN PROFILE MALE SEXUAL DYSFUNCTIONMALE SEXUAL DYSFUNCTION
 AZOOSPERMIAAZOOSPERMIA  ERECTILE DYSFUNCTIONERECTILE DYSFUNCTION
 OLIGOSPERMIAOLIGOSPERMIA  EJACUALATORY DYSFUNCTIONEJACUALATORY DYSFUNCTION
 ASTHENOSPERMIAASTHENOSPERMIA  RETROGRADE EJACULATIONRETROGRADE EJACULATION
 TERATOZOOSPERMIATERATOZOOSPERMIA  PREMATURE EJACULATIONPREMATURE EJACULATION
 HIGH LEUCOCYTE COUNTHIGH LEUCOCYTE COUNT LOCAL ANATOMICAL DEFECTLOCAL ANATOMICAL DEFECT
 COMBINATIONCOMBINATION

4. PretesticularPretesticular TesticularTesticular PosttesticularPosttesticular
EndocrineEndocrine
Hypogonadotropic hypogonadismHypogonadotropic hypogonadism
Hypothyroidism,Hypothyroidism,
HyperprolatinaemiaHyperprolatinaemia
DiabetesDiabetes
Coital disordersCoital disorders
Erectile dysfunctionErectile dysfunction
Ejaculatory failureEjaculatory failure
GeneticGenetic
Klinefelter’s SyndromeKlinefelter’s Syndrome
Y chromosome deletionY chromosome deletion
Immotile cilia syndromeImmotile cilia syndrome
CongenitalCongenital
CryptorchidismCryptorchidism
Infective (orchitis)Infective (orchitis)
Antispermatogenic agentsAntispermatogenic agents
Heat, Chemotherapy, Drugs,Heat, Chemotherapy, Drugs,
IrradiationIrradiation
VascularVascular
TorsionTorsion
VaricoceleVaricocele
ImmunologicalImmunological
IdiopathicIdiopathic
ObstructiveObstructive
EpididymalEpididymal
CongenitalCongenital
InfectiveInfective
VasalVasal
Genetic: Cystic fibrosisGenetic: Cystic fibrosis
Aquired: VasectomyAquired: Vasectomy
Ejaculatory duct obstructionEjaculatory duct obstruction
Epididymal hostilityEpididymal hostility
Epididymal asthenospermiaEpididymal asthenospermia
Accessory glandAccessory gland
infectioninfection
ImmunologicalImmunological
IdiopathicIdiopathic
Post vasectomyPost vasectomy
ETIOLOGICAL FACTORS IN MALE INFERTILITYETIOLOGICAL FACTORS IN MALE INFERTILITY

5. CAUSECAUSE PERCENTAGEPERCENTAGE
No demonstrable causeNo demonstrable cause
Idiopathic abnormal semenIdiopathic abnormal semen
VaricoceleVaricocele
Infectious factorsInfectious factors
Immunologic factorImmunologic factor
Other acquired factorsOther acquired factors
Congenital factorsCongenital factors
Sexual factorsSexual factors
Endocrine disturbancesEndocrine disturbances
48.5%48.5%
26.4%26.4%
12.3%12.3%
6.6%6.6%
3.1%3.1%
2.6%2.6%
2.1%2.1%
1.7%1.7%
0.6%0.6%
Frequency of Etiologies in Male Factor InfertilityFrequency of Etiologies in Male Factor Infertility
WHO Study 1994, Eshre Capri Workshop Group (7057 men)WHO Study 1994, Eshre Capri Workshop Group (7057 men)

6. EVALUATION OF MALEEVALUATION OF MALE
INFERTILITYINFERTILITY
 HistoryHistory
 Physical examinationPhysical examination
 Semen analysisSemen analysis
 Additional proceduresAdditional procedures
- Sperm function tests- Sperm function tests
- Immunological tests- Immunological tests
- Semen culture- Semen culture
- Hormone assays- Hormone assays
-Testicular biopsy-Testicular biopsy
- Chromosomal analysis- Chromosomal analysis
-Vasography-Vasography
- Scrotal ultrasound- Scrotal ultrasound
-Transrectal ultrasound (TRU)-Transrectal ultrasound (TRU)
- DNA integrity tests- DNA integrity tests

7. HISTORYHISTORY
 Age and duration of marriageAge and duration of marriage
 Occupation –hyperthermia, pesticides, bicycling, stressOccupation –hyperthermia, pesticides, bicycling, stress
 H/O childhood problems – Cryptorchidism – surgeryH/O childhood problems – Cryptorchidism – surgery
Delayed pubertyDelayed puberty
 Medical History – Mumps, syphilis, leprosy, tuberculosisMedical History – Mumps, syphilis, leprosy, tuberculosis
Chronic respiratory diseases –Chronic respiratory diseases –
Young’s syndrome – epididymal obstructionYoung’s syndrome – epididymal obstruction
Immotile cilia syndrome – Sperms are immotileImmotile cilia syndrome – Sperms are immotile
Cystic fibrosis – Congenital absence of VASCystic fibrosis – Congenital absence of VAS
Endocrine disorder, diabetes, hypothyroidism,Endocrine disorder, diabetes, hypothyroidism,
Renal failure, Liver disease, hypertension, multiple sclerosisRenal failure, Liver disease, hypertension, multiple sclerosis

8. HISTORY (Contd…)HISTORY (Contd…)
 Surgical & Traumatic History – Damage of VAS –Surgical & Traumatic History – Damage of VAS –
Hernia,Hernia,
Orchidopexy, Vasectomy, Trauma, Torsion, Spinal cordOrchidopexy, Vasectomy, Trauma, Torsion, Spinal cord
injuryinjury
 Sexual history – Timing, frequency ,conception windowSexual history – Timing, frequency ,conception window
H/O–Erectile & Ejaculatory problem -H/O–Erectile & Ejaculatory problem -
Nocturnal penile trumescence (NPT)Nocturnal penile trumescence (NPT)
 Family history –Family history –
 History of smoking, alcohol, radiation, heavy metals,History of smoking, alcohol, radiation, heavy metals,
estrogen exposureestrogen exposure
 Drugs – Antipsychotic, Antihypertensives, CimetidineDrugs – Antipsychotic, Antihypertensives, Cimetidine
Anticonvulsants, Sex steroids, EnvironmentalAnticonvulsants, Sex steroids, Environmental

9. PHYSICAL EXAMINATIONPHYSICAL EXAMINATION
 General – Obesity, Secondary sexual character , gynaecomastia, BodyGeneral – Obesity, Secondary sexual character , gynaecomastia, Body
habitus, Thyroid gland, Galactorrhoea, Visual field defect, Features ofhabitus, Thyroid gland, Galactorrhoea, Visual field defect, Features of
endocrinopathyendocrinopathy
 Per abdomen – Scar of hernia, lymph nodePer abdomen – Scar of hernia, lymph node
 Local examinationLocal examination
* Scrotum- hernia, hydrocele, varicocele* Scrotum- hernia, hydrocele, varicocele
* Testes – Present or absent* Testes – Present or absent
Size (18-20ml)Size (18-20ml)
SensationSensation
* Penis – Hypospadius, phimosis* Penis – Hypospadius, phimosis
* Epididymis & VAS – Presence, feel, presence of cyst* Epididymis & VAS – Presence, feel, presence of cyst
* Rectal examination* Rectal examination

11. Varicocele

15. SEMEN ANALYSIS (WHO 1999)SEMEN ANALYSIS (WHO 1999)
VolumeVolume > 2ml> 2ml
pHpH 7.2-7.87.2-7.8
Sperm concentrationSperm concentration ≥≥20milion/ml20milion/ml
Total sperm countTotal sperm count ≥≥40milion40milion
MotilityMotility ≥≥50% with normal50% with normal
morphologymorphology
MorphologyMorphology ≥≥30% normal forms30% normal forms
WBCWBC < 1 X 10< 1 X 1066
/ ml/ ml
MAR testMAR test < 10% spermatozoa with< 10% spermatozoa with
adherent particleadherent particle

16. SEMEN ANALYSISSEMEN ANALYSIS
ENDTZ test can distinguish between leukocytes &ENDTZ test can distinguish between leukocytes &
immature germ cells (both round cells)immature germ cells (both round cells)
Sperm vitality test:Sperm vitality test:
* Eosin Nigration test* Eosin Nigration test
** Hypoosmotic swelling testHypoosmotic swelling test
* H33258 Flurochrome test* H33258 Flurochrome test
Fructose estimation-Absent in Ejaculatory duct obstructionFructose estimation-Absent in Ejaculatory duct obstruction
Split Ejaculate-Split Ejaculate-

17. Limitations of WHO criteria
 Significant overlapping of sperm characteristics
between fertile and infertile men
 Sperm motility and concentration are more
important than sperm morphology
 Change of cut off values and introduction of new
parameters are needed to differentiate between
fertile and infertile men
Kiran P et al;Fertil Steril, vol 85,No 3,March 2006:629-34

18. MATURE SPERMATOZOA

19. SPERM FUNCTION TESTSPERM FUNCTION TEST
 Sperm cervical mucus interactionsSperm cervical mucus interactions
a. In Vivo –a. In Vivo – Post Coital TestPost Coital Test (Sim’s Hunner test)(Sim’s Hunner test)
b. In Vitro –b. In Vitro –
I. Sperm cervical mucus contact test (SCMC test)I. Sperm cervical mucus contact test (SCMC test)
II. Tube test (Kremar test)II. Tube test (Kremar test)
 Hemizona test (Human zona binding assay)Hemizona test (Human zona binding assay)
 Hypoosmotic swelling testHypoosmotic swelling test
 Swim up testSwim up test
 Computerised assisted seminal analysis (CASA)Computerised assisted seminal analysis (CASA)
 Evidence of acrosomal reactionEvidence of acrosomal reaction

20. IMMUNOLOGICAL TESTSIMMUNOLOGICAL TESTS
Indications –
• Abnormal semen profile
• Abnormal cervical mucus sperm interaction
• Failed Vasectomy reversal
• Marked Agglutination (more than 10%)
Two Tests –
a. Immunobead testa. Immunobead test
b. MAR testb. MAR test
c. Others – TAT test, Kibrick’s test, Frankling Duke test, Isojama’s
test (Not done now a days)

21. MIXED AGGLUTINATION REACTION
(MAR) TEST
 Screening test for detection of antisperm antibodies
on the surface of sperm head or tail.
 Washed sperms from the patient are mixed with
antibody coated RBC, (Sheep RBC + rabbit antibody)
 These antibody will form mixed agglutinates with
motile sperms carrying immunoglobulins
 MAR test is positive when particulate binding is found
in over 10% spermatozoa.

22. HORMONE ASSAYSHORMONE ASSAYS
Indication-Indication- when Sperm count is less than 10when Sperm count is less than 10
million/mlmillion/ml
 FSHFSH
 LHLH
 TestosteroneTestosterone
 EstradiolEstradiol
 ProlactinProlactin
 TSHTSH

23. HORMONAL CONTROL OF SPERMATOGENESISHORMONAL CONTROL OF SPERMATOGENESIS
HypothalamusHypothalamus
GGnnRHRH
Anterior PituitaryAnterior Pituitary
FSHFSH LHLH
Sertoli cellSertoli cell Leydig cellLeydig cell
InhibinInhibin ABGABG TT
ABG+TABG+T
- Ve- Ve - Ve- Ve
- Ve- Ve
SpermatogenesisSpermatogenesis andand
spermsperm maturationmaturation

24. Hormones in different clinicalHormones in different clinical
conditionsconditions
FINDINGSFINDINGS DIAGNOSISDIAGNOSIS
1.1. Azoospermia or OligospermiaAzoospermia or Oligospermia
Small testesSmall testes
FSH - HighFSH - High
Primary testicular failurePrimary testicular failure
(Severe tubular damage)(Severe tubular damage)
2. Azoospermia2. Azoospermia
Normal testicular volumeNormal testicular volume
FSH – Normal levelFSH – Normal level
i. Bilateral genital tract obstructioni. Bilateral genital tract obstruction
ii.Sertoli cell only syndromeii.Sertoli cell only syndrome
3. FSH – Lower or undetectable3. FSH – Lower or undetectable
LH – LowLH – Low
Testosterone – LowTestosterone – Low
Other evidences of androgen def.Other evidences of androgen def.
HypogonadismHypogonadism
4. LH – High4. LH – High
Testosterone – HighTestosterone – High
Androgen receptor defectAndrogen receptor defect

25. TESTICULAR BIOPSYTESTICULAR BIOPSY
 Obstructive AzoospermiaObstructive Azoospermia
 Non Obstructive Azoospermia – To detect isolatedNon Obstructive Azoospermia – To detect isolated
areas containing sperm cells for TESE – ICSIareas containing sperm cells for TESE – ICSI
Grading – Johonson’s Scoring System ( 1 – 10)Grading – Johonson’s Scoring System ( 1 – 10)
2 – Sertoli cell only2 – Sertoli cell only
3 – Spermatogonia3 – Spermatogonia
4,5 – Spermatocytes4,5 – Spermatocytes
6,7 – Spermatids6,7 – Spermatids
8,9,10 – Spermatozoa8,9,10 – Spermatozoa

26. Histology Of Normal Testis

27. Histology of seminiferous
tubule

30. GENETIC ANALYSISGENETIC ANALYSIS
IndicationsIndications
 Azoospermia, Severe Oligozoospermia,Azoospermia, Severe Oligozoospermia,
VarietiesVarieties
 Klinefelter’s Syndrome (47XXY), Sex ReversalKlinefelter’s Syndrome (47XXY), Sex Reversal
Syndrome (46 – XX male)Syndrome (46 – XX male)
 Deletion of a part of Long arm of Y containingDeletion of a part of Long arm of Y containing
azoospermic factor (AZF) means Azoospermiaazoospermic factor (AZF) means Azoospermia
 Mutation of specific gene like mutation of CFTR geneMutation of specific gene like mutation of CFTR gene
in cystic fibrosisin cystic fibrosis

32. Y Chromosome in Azoospermic
men
 Solid bars indicate
presence of genetic
material
 Dashed regions indicate
missing of genetic
material in NOA men
 Y-chromosome deletion
in AZFb region indicates
absence of sperms in
sperm retrieval
procedure

33. Sex Chromosome Abnormalities LeadingSex Chromosome Abnormalities Leading
to Male Infertilityto Male Infertility
Syndrome Karyotpe abnormalities Phenotype
Klinefelter’s syndrome 46, XY/47, XXY mosaic,
47, XXY – 49, XXXY
Male with increased
height, small firm testes
possibly female hair
distribution
Mixed gonadal dysgensis 45, X/ 46, XY mosaic,
possibly normal 46, XY
Male, female, or
ambiguous genitalia, testis
are streak
XX male syndrome 46, XX SRY translocation
to the short arm of X
Male with Sertoli-cell-
only on testis biopsy
XYY male 47, XYY Male, possibly increased
height

34. TREATMENT MODALITIES OF MALETREATMENT MODALITIES OF MALE
INFERTILITYINFERTILITY
• General MeasuresGeneral Measures
• Medical ManagementMedical Management
• Surgical Management:-Surgical Management:- Vasovasostomy, Epididymovasostomy,Vasovasostomy, Epididymovasostomy,
Repair of varicocele, Orchidopexy, Surgery forRepair of varicocele, Orchidopexy, Surgery for
HypospadiusHypospadius
• Artificial Insemination:-Artificial Insemination:- Intrauterine insemination (IUI)Intrauterine insemination (IUI)
• Assisted Reproductive Technology:-Assisted Reproductive Technology:- IVF & ET,IVF & ET,
Intracytoplasmic sperm injection (ICSI),Intracytoplasmic sperm injection (ICSI), PESA, MESA &PESA, MESA &
TESE –TESE – ICSI, GIFT, ZIFTICSI, GIFT, ZIFT
• Management of Male Sexual DysfunctionManagement of Male Sexual Dysfunction

35. Medical ManagementMedical Management
• Hormonal –Hormonal – HCG, HMG, GHCG, HMG, GnnRH, Testosterone, CC,RH, Testosterone, CC,
Thyroxine, BromocryptineThyroxine, Bromocryptine
• Antibiotics, Corticosteroids, Aromatase inhibitorAntibiotics, Corticosteroids, Aromatase inhibitor
• Sperm Vitalising Agents –Sperm Vitalising Agents – Pentoxifylline, KallikreinPentoxifylline, Kallikrein
• Emperical TherapyEmperical Therapy
• AntioxidantsAntioxidants – In increased ROS– In increased ROS

36. Oxidative stress status in an ejaculate.Oxidative stress status in an ejaculate.
Pro-and anti-oxidative molecules have antagonisticPro-and anti-oxidative molecules have antagonistic
functions in semenfunctions in semen

37. Vasectomy Reversal

38. Vasovasostomy

41. Repair of Vericocele

42. Verecocelectomy-Testis is
delivered to ligate
internal spermatic veins

43. INTRAUTERINE INSEMINATION
(I U I)
 Washed sperms are injected inside
the
uterine cavity in stimulated cycle with
proper monitoring of ovulation
Both fresh or frozen sperm can be used

44. Male:
 SEMINOPATHIES – OLIGOSPERMIA,
ASTHENOTERATOSPERMIA, LOW VOLUME SEMEN,
HIGH VISCOUS SEMEN
 ERECTILE FAILURE, EJACULATORY FAILURE,
PREMATURE EJACULATION, RETROGRADE
EJACULATION
Female:
 CERVICAL FACTOR ,OVULATORY
DYSFUNCTION,ENDOMETRIOSIS,VAGINISMUS
 UNEXPLAINED INFERTILITY
 IMMUNOLOGICAL INFFERTILITY
INDICATIONS OF I U I

45. STEPS OF INTRA-UTERINE
INSEMINATION
Ensure tubal patency Semen analysis & culture
Ovarian stimulation Sperm Collection
Monitoring of ovarian
Response & fixation of Sperm processing
Ovulation time
Insemination
& Luteal support

46. SWIM – UP TECHNIQUESWIM – UP TECHNIQUE
Semen processing media(Ham’s F-10)Semen processing media(Ham’s F-10)
&&
SEMEN SAMPLESEMEN SAMPLE
INCUBATE AT 370
C
30 MINUTE
Liquefied semen sample
Equal Quantity of MEDIA
Aspirate upper & middle
part
In another centrifuge tube
Centrifuge at 2000 RPM
FOR 1 MINUTE
Discard supermatant & Leave pellet
Centrifugation
at 2000 RPM
15 minute
Mix
well
Discard supernatant
& leave pellet
MEDIA
Pellet
Keep the tube
inclined at 300
In incubator at 370
c
For 45 minute
Layer 2 ml Media
Over Pellet
Add 0.5 ml. Semen processing media
& mix well
Sample ready for
IUI

47. SINGLE LAYER DENSITY GRADIENT CENTRIFUGATION TECHNIQUE
* DENSITY GRADIENT MEDIA
* SPERM WASHING * SEMEN SAMPLE
MEDIA (Han’s F10)
INCUBATE AT 370
C
30 MINUTE
Centrifugation
At 2000 RPM
LIQUEFIED SEMEN
D.G. Media
15 minute
Disard Supermatant Centrifugation at 2000 RPM Pellet with 2ml Add 2ml. Spermwashing
& Leave pellet 5 minute Spermwashing medium
Medium mix well with pellet Discard
supermatant
& leave pellet
Add 0.5 ml. Of
sperm washing
medium
Mix well with pellet
Pellet with
0.5 ml. Sperm washing medium
Keep at 370
c
10-15 minute
Sample ready for IUI

48. SWIM UP TECHNIQUE Vs LAYER
TECHNIOUE
 Simple
 Less expensive
 Not suitable for
abnormal semen
sample
 Time consuming
 Not so simple
 More expensive
 For seminopathy it is
better
 Less time is needed

49. RESULTS OF IUI
CLINICAL PREGNANCY – 10-25% IN AIH
20-40% IN AID
20-25% END IN MISCARRIAGE

50. Gamete Micromanipulation
 P Z D-Partial Zona dissection
 S U Z I-Subzonal dissection of sperm
 I C SI-Intracytoplasmic sperm
injection

51. Intracytoplasmic spermIntracytoplasmic sperm
injection (ICSI)injection (ICSI)
It involves the direct insertion of a single sperm cell intoIt involves the direct insertion of a single sperm cell into
the cytoplasm of a single oocyte by micropuncturethe cytoplasm of a single oocyte by micropuncture
 Indications –Indications –
Severe OATSevere OAT
ObstructiveObstructive azoospermiaazoospermia by MESA, PESA,TESAby MESA, PESA,TESA
````Nonobstructive azoospermiaNonobstructive azoospermia (NOA)(NOA) by TESEby TESE
Unexplained infertilityUnexplained infertility

52. Source of Sperms for ICSI
 EJACULATED SPERMS
 MESA: Microsurgical Epididymal sperm aspiration
 PESA: Percutaneous Epididymal sperm aspiration
 TESE: Testicular sperm extraction
 TESA: Testicular sperm aspiration

54. Distribution of sperms in
tubules of epididymis in obst.
azoospermia  Proximal part contains
maximum good sperms
 Distal part (identified by
yellow colour) contains
less and damaged
sperms

55. P E S A

56. M E S A

57. Testicular Fine Needle
Aspiration (TESA--TFNA)

58. PercBiopsy

59. MULTIPLE LARGETEST. BIOPSY
T E S E
Microsurgical
Conventional

62. ICSI Laboratory

63. ICSI IS GOING ON (IRM,
Kolkata)

68. RESULTS OF ICSIRESULTS OF ICSI
Fertilization rate -Fertilization rate - 60-70%60-70%
Pregnancy rate –Pregnancy rate – 20-40%20-40% /Embryo transfer/Embryo transfer
Male partner having abnormal karyotype inMale partner having abnormal karyotype in
Y-Chromosome micro deletion should undergoY-Chromosome micro deletion should undergo
genetic counselling before ICSIgenetic counselling before ICSI

69. TREATMENT OF OLIGOASTHENOTERATOZOOSPERMIATREATMENT OF OLIGOASTHENOTERATOZOOSPERMIA
(OAT)(OAT)
Infective
* Antibodies
Immunological
* Corticosteroid
* Condom
Endocrinal
* GnRH
* hCG
* hMG
* Testosterone
* CC
* Bromocryptine
* Thyroxin
Idiopathic
* CC
* Empirical
*Antioxidants
If FailsIf Fails
* IUI
*ART

70. TREATMENT OF AZOOSPERMIA
Azoospermia
Obstructive
* Surgery
* Epididymal sperm
Aspiration (MESA, PESA)
IVF-ET
GIFT
ZIFT
ICSI
* TESE – ICSI
* TDI
Non obstructive
* TESE – ICSI
* TDI
Endocrinal (Rare)
* GNRH
* HCG
* HMG
* CC

71. Treatment of
Erectile and Ejaculatory
DysfunctionErectile Dysfunction
* Withdrawal of drugs
* Treatment of underlying cause
* Psychosexual therapy
* Local injection ,Vacuum pump
* Transurethral pellet ,Penile implant
* Sildenafil(Viagra),Tadalafil,Vardenafil
Ejaculatory Dysfunction
* Psychosexual therapy
* Vibrator
* Electro-Ejaculation
Retrograde Ejaculation
* Coitus in full bladder
* Alphaadrenergic or cholinergic
drugs
* Insemination with post-voided urine
after processing
Premature Ejaculation
* Use of condom
* Pelvic Floor exercise
* Squeeze techniques
* IUI with ejaculated sperm

72. CONCLUSION
 Male factor is involved up to half of infertile couples
 Thorough evaluation is needed to detect the
abnormality.
 There are only few cases in practice where specific
drug therapy is indicated
 Though IUI is an effective procedure it has little role
in severe OAT.
 ICSI has revolutionized the management of male
infertility. But it is a very expensive procedure

73. CONCLUSION (Contd…)
 Sexual dysfunction should always be enquired and be dealt
with sympathy
 Vibrator and Viagra are two effective tools available in
ejaculatory and erectile failure
 More research is needed to know paracrine regulation of
spermatogenesis and to develop newer treatment to
improve sperm parameters in VIVO
 Irrespective of problems adoption of general measure is
important in achieving pregnancy