Infertility is defined as the inability of a couple to conceive after at least one year of regular unprotected intercourse. Male infertility refers to a male's inability to cause pregnancy in a fertile female.

1. Male Infertility:
An Overview
Dr Shahjada Selim
Associate Professor
Department of Endocrinology, BSMMU

2. Presentation Flow
• Definition and Epidemiology of Male
Infertility
• Etiology
• Evaluation
• Carry Home Message

3. Definition of Infertility
1.The Obstetrician & Gynaecologist 2020;22:267–74.
2. Leslie SW et al. 2020-11-26
Infertility is defined as the inability of a couple to conceive
after at least one year of regular unprotected intercourse.1
Male infertility refers to a male's inability to cause pregnancy
in a fertile female.2

4. Types of Infertility
1. Akyuz A et al. Int J Fertil Steril 2013;6:286-93.
There are 2 types of infertility:
➢ primary infertility – where someone who's never
conceived a child in the past has difficulty conceiving
➢ secondary infertility – where someone has had 1 or more
pregnancies in the past, but is having difficulty conceiving
again.1

5. Impacts
1. Akyuz A et al. Int J Fertil Steril 2013;6:286-93.
2. Brugh VM et al. Med Clin North Am 2004;88:367-85.
Among other complications, male infertility can lead to
psychological problems, ridicule or domestic violence.2
Since the male is partially or completely responsible for half
the cases of infertility (Fig. 1) among couples, this
underscores the importance of delivering a specialized
male fertility evaluation for those seeking fertility.3

6. Epidemiology
1. The Obstetrician & Gynaecologist 2020;22:267–74
2. World J Mens Health 2020 Jul 38(3): 308-322
• The prevalence of male infertility is difficult to estimate in
the general population, mainly because of variations in the
definitions used in different studies.1
• Data from the HFEA indicate that male infertility accounts
for 37% of IVF treatments, usually in combination with ICSI.2
*HFEA-Human Fertilization and Embryology Authority
IVF- In vitro fertilization
ICSI - intracytoplasmic sperm injection

7. FIG. 1. INCIDENCE OF INFERTILITY1,2
1. WORLD J MENS HEALTH. 2020 JUL;38(3):308-322 . 2. HTTPS://DOI.ORG/10.5534/WJMH.190068

9. Epidemiology
1. https://www.nhs.uk/conditions/infertility
• Around 1 in 7 couples may have difficulty conceiving.
• About 84% of couples will conceive naturally within a year if
they have regular unprotected sex (every 2 or 3 days).
• For couples who have been trying to conceive for more than 3
years without success, the likelihood of getting pregnant
naturally within the next year is 1 in 4, or less.1

10. Etiology of Male infertility
Variable
20-25%

11. 1. World J Mens Health 2020 Jul 38(3): 308-322
Causes of male infertility can be classified into-
LH: luteinizing hormone, FSH: follicle-stimulating hormone

12. Lifestyle factors and male infertility1,2
Although the causes of male infertility and impaired
gametogenesis cannot often be readily identified, extrinsic
factors have been linked to male infertility.
➢ Obesity and weight loss
➢ Diet
1. Ash P et al. Br J Ra- diol 1980;53:271-8.
2 .Thonneau P et al. Hum Reprod 1998;13:2122-5.
➢ Vitamins and antioxidants
➢ Cigarette smoking and vaping
➢ Alcohol
➢ Caffeine
➢ Stress
➢ Sleep
➢exposure to heavy metals (lead, cadmium), ionizing
radiation, and high temperatures (testicles)

13. Evaluation of Male Infertility

15. FIG. 2. EVALUATION OF MALE INFERTILITY1,2
1. WORLD J MENS HEALTH. 2020 JUL;38(3):308-322 .2. HTTPS://DOI.ORG/10.5534/WJMH.190068
IUI: intrauterine insemination, IVF: in vitro fertilization, ICSI: intracytoplasmic sperm injection, GU: genitourinary, OAT:
oligo-astheno-teratozoospermia, FSH: follicle-stimulating hormone, LH: luteinizing hormone, CFTR: cystic fibrosis
transmembrane conductance regulator, MRI: magnetic resonance imaging.

16. EVALUATION OF MALE INFERTILITY1,2
1. WORLD J MENS HEALTH. 2020 JUL;38(3):308-322 . 2. HTTPS://DOI.ORG/10.5534/WJMH.190068
IUI: intrauterine insemination, IVF: in vitro fertilization, ICSI: intracytoplasmic sperm injection, GU: genitourinary, OAT:
oligo-astheno-teratozoospermia, FSH: follicle-stimulating hormone, LH: luteinizing hormone, CFTR: cystic fibrosis
transmembrane conductance regulator, MRI: magnetic resonance imaging.

17. 1.WH0 2010
Semen analysis
Semen analysis is the single most important investigation during the
evaluation of infertile men. A single SA is usually sufficient to determine the
most appropriate management pathway. If the initial SA shows one or more
abnormal parameters, a repeat should be considered.1
Parameter WHO reference range
Total sperm count in ejaculate 39–928 million
Ejaculate volume 1.5–7.6 mL
Sperm concentration 15–259 million per mL
Total motility (progressive and
non-progressive)
40–81 percent
Progressive motility 32–75 percent
Sperm morphology 4–48 percent

19. EVALUATION OF MALE INFERTILITY1
1. WORLD J MENS HEALTH. 2020 JUL;38(3):308-322 . HTTPS://DOI.ORG/10.5534/WJMH.190068
FSH: follicle-stimulating hormone, LH: luteinizing hormone, CFTR: cystic fibrosis transmembrane conductance regulator,
MRI: magnetic resonance imaging.

20. EVALUATION OF MALE INFERTILITY1
1. WORLD J MENS HEALTH. 2020 JUL;38(3):308-322 . HTTPS://DOI.ORG/10.5534/WJMH.190068

21. 1. The Obstetrician & Gynaecologist 2020;22:267–74
Sperm DNA fragmentation (SDF)1
Even though SA is an essential part of the infertile male
workup, its diagnostic accuracy is limited because it lacks
adequate discriminatory power and does not predict ART
Outcomes.
Several studies using these tests have shown the percentage
of spermatozoa with DNA fragmentation to be higher in
infertile men than fertile men.

22. 1. The Obstetrician & Gynaecologist 2020;22:267–74
Sperm DNA fragmentation1
Several tests to evaluate sperm DNA fragmentation (SDF)
are now available, including:
✓ Sperm chromatin structure assay (SCSA),
✓ Sperm chromatin dispersion (SCD) test,
✓ Terminal deoxynucleotidyl transferase mediated
deoxyuridine triphosphate nick end-labelling (TUNEL) and
✓ The single cell gel electrophoresis (COMET) assay

23. 1.World J Mens Health 2020 Jul 38(3): 308-322
Sperm DNA fragmentation1
Recent guidelines have been published highlighting the
clinical indications of SDF testing:
✓ Unexplained infertility,
✓ Recurrent spontaneous abortion,
✓ Varicocele,
✓ Recurrent ART failure and
✓ Lifestyle risk factors have been linked with higher SDF levels

24. 1. World J Mens Health 2020 Jul 38(3): 308-322
Sperm DNA fragmentation1
Several treatment options are available for patients with high
levels of SDF:
✓ Risk reduction,
✓ Frequent ejaculations,
✓ Treatment with antioxidants,
✓ Varicocele ligation and
✓ The use of sperm selection techniques and/or testicular sperm for
intracytoplasmic sperm injection (ICSI).

25. 1.World J Mens Health 2020 Jul 38(3): 308-322
Seminal oxidative stress1
ROS: Reactive Oxygen Species

26. 1. World J Mens Health 2020 Jul 38(3): 308-322
Seminal oxidative stress1
The advantages of oxidative stress testing are perhaps more
pronounced in men with idiopathic infertility as the test
result can direct treatment decisions.
Examples of treatments that can be offered include:
✓ Application of risk reduction strategies,
✓ Treatment of genital tract infections or varicocele and
✓ The monitored use of oral antioxidants.

27. Genetic testing in male infertility1
Genetic testing is currently recommended in specific
circumstances, specifically the evaluation of the severely
oligospermic or azoospermic male, with the goal of-
✓ Firstly, it aims to identify genetic conditions that could be
passed on to the offspring.
✓ Secondly, genetic testing could help to identify individuals
who would likely benefit from surgical sperm retrieval
procedures.

28. Genetic testing in male infertility1
1.The Obstetrician & Gynaecologist 2020;22:267–74
Genetic tests routinely recommended in the evaluation of
severe male factor infertility include:
✓ Karyotype,
✓ Y chromosome microdeletion analysis and
✓ Cystic fibrosis transmembrane conductance regulator
(CFTR) mutation analysis for men with congenital bilateral
absence of the vas deferens (CBAVD).

29. Past, present, and future sperm function tests1
1. World J Mens Health 2020 Jul 38(3): 308-322
HEPA: hamster egg penetration assay, ORP: oxidation reduction potential, ROS: reactive oxygen
species, SDF: sperm DNA fragmentation, TUNEL: transferase-mediated dUTP nick end labeling,
SCSA: sperm chromatin structure assay, SCD: sperm chromatin dispersion test, TAC: total
antioxidant capacity, Comet: single cell gel electrophoresis.

30. Azoospermia- Workup1
Absence of sperm in the ejaculate, is a not uncommon presentation
occurring in up to 15% of men consulting for infertility.
Vital information picked up during the history, physical examination and
laboratory assessment may point out whether the azoospermia is of
obstructive or non-obstructive nature.
Classically speaking,
✓ Obstruction is generally suspected in patients with normal testicular
size, full epididymides and normal hormone evaluation.
Testicular biopsy can accurately discriminate these two conditions, however,
it is rarely performed for diagnostic purposes solely.
✓ While non-obstructive azoospermia (NOA) is assumed in patients
with small testicular size, flat epididymides, and deranged hormonal
assessment.

31. 1.World J Mens Health 2020 Jul 38(3): 308-322
Azoospermia1
CFTR: cystic fibrosis transmembrane conductance
regulator, ICSI: intracytoplasmic sperm injection, FSH:
follicle-stimulating hormone, LH: luteinizing hormone,
US: urethrography, TURED: transurethral resection of
ejaculatory ducts
SA

32. Ref: World J Mens Health 2020 Jul 38(3): 308-322
Varicocele1
Varicocele, defined as the dilatation of the pampiniform plexus of
veins together with reflux of blood, is a common etiology of male
factor infertility.
This clinical condition also seen in patients with normal fertility potential.
✓ Varicocele can affect testicular function through a number of
mechanisms, the most commonly accepted include hyperthermia
and testicular tissue hypoxia or ischemia.

33. 1. World J Mens Health 2020 Jul 38(3): 308-322
Varicocele1

34. Selection in assisted reproductive technology
(ART)
Will be talked PROF DR JESMINE BANU

35. Conclusion
Infertility is a global health problem affecting one in seven couples
✓ In half of these cases, male factor is, in part, responsible.
✓ It is important to be aware of modifiable lifestyle factors that
provide opportunities for therapeutic intervention, as well as
available sperm assessment and selection tests, including genetic
tests, because these could alter clinical management in the not-
so-distant future.
✓ With continued improvement in biotechnology, new generation
tests of sperm function are underway to help understand the
various pathophysiologies of testicular dysfunction.

36. Thank you