Dr Sujoy Dasgupta moderated a panel discussion on "Male Infertility" in a CME organised by Zydus Nutriva held on 17 February 2024.

1. Male Infertility
Moderators
• Dr Sujoy Dasgupta
Panelists
• Dr Kaushiki Roy
• Dr Rohit Gutgutia
• Dr Saurav Prakash Maity

2. Semen Report 1
Collection Method Masturbation Total Motility 30%
Abstinence 4 days Progressive
Motility
16%
Collection Complete Non progressive
Motility
14%
Volume 1.5 ml Immotile 70%
Viscosity Normal Motile Sperm
Count
0.54 million
Liquefaction Time 45 minutes Normal
Morphology
1%
pH 7.6 Vitality 34%
Sperm
Concentration
1.2 million/ ml Round cells Nil

3. Semen Report 1
Collection Method Masturbation Total Motility 30%
Abstinence 4 days Progressive
Motility
16%
Collection Complete Non progressive
Motility
14%
Volume 1.5 ml Immotile 70%
Viscosity Normal Motile Sperm
Count
0.54 million
Liquefaction Time 45 minutes Normal
Morphology
1%
pH 7.6 Vitality 34%
Sperm
Concentration
1.2 million/ ml Round cells Nil

4. Male Infertility- Mild or Severe?
• TMSC= Total Motile sperm count = Sperm
concentration x total volume x total motility (TM)
• TMSC >5/ 10/ 20 million

5. What next?
• Straightaway donor sperm IUI
• Antioxidants for 3-6 months and repeat test
• Directly ICSI with self sperms
• Investigate in details

6. Prolonged use of antioxidants?

7. Severe Male Factor- if not left
untreated ???
• Overall, 16 (24.6%) of 65
patients with severe
oligozoospermia developed
azoospermia.
• Two (3.1%)patients with
moderate oligozoospermia
developed azoospermia
• None of the patients with
mild oligozoospermia
developed azoospermia.

9. Smits RM, Mackenzie-Proctor R, Yazdani A, Stankiewicz MT, Jordan V, Showell MG. Antioxidants for
male subfertility. Cochrane Database Syst Rev. 2019;3(3):CD007411. Published 2019 Mar 14.
• may improve live birth rates
• clinical pregnancy rates may also increase.
• Overall, there is no evidence of increased risk of
miscarriage, however antioxidants may give more
mild gastrointestinal upsets
• Subfertilte couples should be advised that overall, the
current evidence is inconclusive.

10. Hormonal Investigations
• FSH 5.21 IU/L (normal 1-10)
• LH 6.8 IU/L (normal 1-10)
• Testosterone 159 ng/dl (normal 200-800 )

11. Testosterone Supplementation?
• Should only be done in men with primary
hypogonadism, NOT interested in fertility (EUA,
2018; EUA, 2016; AUA, 2018; CUA, 2015)
• They provide feedback inhibition on pituitary
gonadotrophins (FSH and LH) leading to
secondary hypogonadism (de Souza and Hallak, 2011;
McBride and Coward, 2016; WHO, 2010)
• If T:E2 ratio <10 (T- ng/dl, E2- pg/ml),
consider Aromatase Inhibitors (Letrozole,
Anastrozole) (EUA, 2018; AUA, 2018)

12. Ultrasound showing varicocele

13. Varicocele- always CLINICAL Diagnosis
• Subclinical: not palpable or
visible, but can be shown by
special tests (Doppler
ultrasound).
• Grade 1: palpable during
Valsava manoeuvre, but not
otherwise.
• Grade 2: palpable at rest, but
not visible.
• Grade 3: visible at rest.

14. Surgery for Varicocele (EUA, 2018)
• Grade 3 varicocele
• Ipsilateral testicular atrophy
• Abnormal semen parameters
• No other fertility factors in the couple

15. In couples seeking fertility with ART, varicocele repair
• may offer improvement in semen parameters
• may decrease level of ART needed

16. Male factor- IUI/ IVF/ICSI?
• Assess
1. Tubal factor
2. Ovarian reserve
3. Duration of Infertility
4. Age of the female partner

17. TMSC PR/CYCLE
 10–20 million 18.29%
 5–10 million 5.63%
 <5million 2.7%
Guven et al, 2008;Abdelkader & Yeh, 2009
Hamilton et al., 2015
Criteria TMSC Treatment
Pre wash TMSC > 5 million IUI
Pre wash TMSC 1 - 5 million IVF
Pre wash TMSC <1 million ICSI
IUI, IVF or ICSI?

18. TMSC <5 million
• “Trial IUI”
• See IMSC (inseminating motile sperm count)
IMSC Next action
> 1 million further 3-4 cycles of IUI
<1 million
Morphology ≥4% further IUI can be
attempted
Morphology <4% ICSI

19. Any other thing?
• obtaining a second semen sample when the
motile sperm yield of the first semen sample is
1 million to 5 million significantly increases
the total motile sperm count in the final
inseminate.

20. Double Ejaculate often produces
better quality of sperms

21. • Sperm concentration <5
million/ml
• Azoospermia
• Testicular atrophy
• Elevated FSH
(EUA, 2018; ASRM/ AUA, 2020)
• Karyotyping
• Y chromosome
Microdeletion (YMD)
Genetic testing in severe male
subfertility?

22. Genetic changes- what to do?
45, XY rob (14, 21), (q10, q10)
Robertsonian Translocation
46,XYqh-
Normal variant (polymorphism)

23. Semen Report 2
Collection Method Masturbation
Abstinence 5 days
Collection Complete
Volume 3.0 ml
Colour Whitish
Viscosity Normal
Liquefaction Time 45 minutes
pH 7.8
Sperm Concentration Nil (even after centrifugation)
Round cells Nil

24. Semen Report 2
Collection Method Masturbation
Abstinence 5 days
Collection Complete
Volume 3.0 ml
Colour Whitish
Viscosity Normal
Liquefaction Time 45 minutes
pH 7.8
Sperm Concentration Nil (even after cetrifugation)
Round cells Nil

25. What next?
• Straightaway donor sperm IUI
• Testicular FNAC?

26. FNAC- role?
ASRM/ AUA, 2020
• Consider TESA in indeterminate cases- NOT
NECESSARY
FSH >7.6 <7.6
Testicular long axis <4.6 cm >4.6 cm
89% chance of NOA 96% chance of OA

27. Case 1- FNAC
• Azoospermia- one occasion
• FNAC- B/L maturation arrest
• FSH 0.22, LH 0.34, Testo 139
• Pituitary MRI- normal
• Started hCG f/b FSH
• After 6 months- 2 mil/ml

28. How to manage- Hypo-Hypo?
• hCG 2000-5000 IU 3 times a week
• Serum testosterone should be checked every 1–2 months
• The sperm count should be monitored monthly
• Sperm parameters become normal within 6 months but
sometimes it can take 24 months of time
• If hCG alone cannot restore spermatogenesis, FSH is
added in the dose of 75-150 IU 3 times a week
• Often can father the baby at much lower sperm
concentration
EUA, 2018; ASRM/AUA, 2020

29. Hormone treatment vs ART
• Priority for natural conception
• Other indications of ART- female partners
• Age of female partners
• Time to pregnancy
• Cost

30. Case 2- FNAC

31. Orchidectomy/ Orchidopexy in adult?
• In adulthood, a palpable undescended testis should NOT be
removed because it still produces testosterone.
• Correction of B/L cryptorchidism, even in adulthood, can
lead to sperm production in previously azoospermic men
• Perform testicular biopsy at the time of orchidopexy in adult- to
detect germ cell neoplasia in situ
EUA, 2018

32. Case 3- FNAC
“No sperms”
46,XX; SRY positive

33. Case 4- FNAC
• LH 30.10, FSH 43.70, E2 38.48, Testo 432

34. Can we refuse surgical sperm
retrieval?
• Testicular volume 8 cc each side
• Serum FSH 20.52
FSH, testicular size or other markers-
can NOT be used for prediction/ refusal
(EUA, 2018; ASRM/AUA, 2020)

35. If previous FNAC showed unfavourable
report?
Diagnosis Chance of sperm retrieval by
Micro TESE
Sertoli-cell-only syndrome
(Germ cell hypoplasia)
32%
Maturation arrest 66.7%
(Late MA> Early MA)
Hypospermatogenesis 100%
Tuberous sclerosis 33.3%
Mixed atrophy 95.2%
(Schwarzer, 2013)

36. Y chromosome microdeletion

37. Predictors of sperm retrieval?
• No reliable positive prognostic factors guarantee
sperm recovery for patients with NOA
• The only negative prognostic factor is the
presence of AZFa and AZFb microdeletions.

38. Semen Report 3
Collection Method Masturbation
Abstinence 2 days
Collection Complete
Volume 0.5 ml
Colour Whitish
Viscosity Normal
Liquefaction Time 45 minutes
pH 6.8
Sperm Concentration Nil (even after centrifugation)
Round cells Nil

39. Semen Report 3
Collection Method Masturbation
Abstinence 2 days
Collection Complete
Volume 0.5 ml
Colour Whitish
Viscosity Normal
Liquefaction Time 45 minutes
pH 6.8
Sperm Concentration Nil (even after centrifugation)
Round cells Nil

40. What to assess?
• Abstinence period
• Completeness of collection
• Usual amount of ejaculate
• Exclude retrograde ejaculation- Post
masturbation urine
• Suspect obstructive pathology- TRUS

41. Congenital bilateral absence of vas
deferens (CBAVD)
• Semen- Volume <1.5 ml, pH <7.0, fructose negative
• TRUS
• Renal ultrasound
• Cystic fibrosis mutation (CFTR) testing (EUA, 2018;
ASRM/AUA, 2020)
• Partner testing if the man is carrier
• Indian prevalence- 1:10,000- 1:40,000 (Kapoor et al., 2006;
Prasad et al., 2010)

42. Cases of CBAVD- TRUS and CFTR mutation
Partner testing needed
Partner testing NOT needed

44. What to do?
• Antibiotics?
• Culture?
• Anything else?

45. MAGI (Male Accessory Gland Infection)
• The clinical significance of an increased
concentration of leukocytes in the ejaculate is
controversial.
• Special Tests- Round cells vs Pus cells
• Method of collection
• Hand washing before collection
• Culture of semen
• Antibiotics- only when documented infections
• Look for phimosis
• Consider prostatic fluid culture
EUA, 2018; ASRM, 2020; Vignera et al., J Med Microbiology, 2014

46. “Pus Cells” and ART outcome

47. Collection Method Masturbation Abstinence 4 days
Collection Complete Volume 2 ml
Colour Whitish Viscosity Normal
Liquefaction Time 45 minutes pH 7.6
Sperm Concentration 36 million/ ml
Total Motility 46% Progressive Motility 33%
Non progressive Motility 13% Immotile 54%
Motile Sperm Count 16.56 million/ ml TMSC 33.12 million
Normal Morphology 5% Abnormal Morphology 95%
Vitality 32% Round cells Nil
• Treated for “male factor” with antioxidants
• Unexplained subfertility
• Conceived naturally, delivered
A silly question?

48. Reliance of Semen “Reference Range”

49. Limitations of WHO Semen Analysis
Guideline
• 5 percentile and time-to-pregnancy (TTP) concept
• Not true reference values but recommends
acceptable levels.
• Day to day variation
• Functional ability of the sperms?

50. Treatment burden for MALE
infertility falls on FEMALE