Download Male infertility

Male infertility
Male factor: it accounts for 40% of all cases of infertility. It is important to identify potentially
correctable conditions as irreversible ones that are amenable to ART which will spare couples
the distress of attempting ineffective therapies. Thorough genetic counselling is needed when
genetic abnormalities that may affect the offspring are suspected.
Causes
I. Coitus problems
Subcategories
Ineffective normal ejaculation
Contributes to less than 5% of male infertility and may due to:
- incorrect timing
- abnormal semen deposition ( hypospadias)
- erectile dysfunction (psychogenic or organic)
Management
Counselling is important in these cases (reassurance and sex education) which may improve the
effectiveness of coitus in addition to medical treatment. Some of these cases may need IUI and
few might end in IVF.
Retrograd ejaculation; in this condition, failure of the bladder neck closure during emission
allows the semen to escape into the bladder. This is diagnosed from a history of orgasm without
ejaculation and is confirmed by presence of sperm in post ejaculate urine. Reasons should be:
- neurogenic (diabetes mellitus, multiple sclerosis)
- Iatrogenic (prostate surgery, bladder neck surgery)
Management
Sympathomimetic drugs (Ephedrine, Imipramine) may induce antegrade ejaculation. IUI or
IVF/ICSI using sperms from post ejaculatory urine may be needed preceded by use of sodium
bicarbonate to reduce toxic effect of urine on sperm. Sometimes the use of electro-ejaculation
might be helpful.
Failure of ejaculation; is diagnosed by absent ejaculation with no sperm in post ejaculate urine.
This could be due to:
- Neurogenic (spinal chord injury, multiple sclerosis)
- Drugs (antihypertensive drugs)
- Pelvic surgeries (sympathectomy)
Management
-Rectal electroejaculation (REE) is effective in producing semen in most cases for ICSI
application
-Surgical sperm recovery from the testes is recommended if electro-ejaculation (EE) is
unsuccessful
II-Suboptimal semen quality
Is present in 75%of male infertility. The primary sperm defect is reduced sperm count
(oligospermia), low motility (asthenospermia) and poor morphology (teratospermia). If all these
defects are present it is called oligoasthenoteratospermia (OATS)
Subcategories of OATS
- Mild (10-20 million/ml)
- Moderate (5-10million/ml)
- Severe (less than 5million/ml)
- Causes
1.Idiopathic (in the majority of cases)
2.Evident causes
 Developmental factors
i.Undescended testis (cryptoorchidism) one or both testis may fail to descend from the
abdomen into the scrotum during fetal development. This is a serious condition as the testes
are exposed to high internal body temperature. This will lead to disturbance in sperm
production and infertility. Treatment is through surgical interference by fixation of testis to
the scrotum (Orchidopexy). This should be performed as early as possible in childhood
before the age of two years to allow subsequent normal development and rarely succeeds
after puberty.
ii.Varicocele is a collection of dilated veins in the scrotum that impair normal cooling of the
testicle. Therefore temperature increases in the scrotum, hindering function and leading to
reduced sperm count, motility and normal morphology. It usually appears at puberty and is
associated with partial testicular atrophy of the testes. They occur in 15% of fertile men and
in 30-40% of sub-fertile men. Varicocele is graded according to its severity and may be
unilateral or bilateral.
 Genitourinary infections include sexually transmitted diseases (STD) like Chlamydia and
Gonorrhea in addition to urethritis, prostatitis and mumps. Recurrent infection leads to
inflammation, scarring, and blockage of sperm passage therefore causing infertility. Male
infertility due to infection is usually reversible after treatment.
 Hypogonadotrophic hypogonadism; is a rare cause of male infertility that usually presents with
delayed puberty or undescended testes in adolescence. The treatment is gonadotrophin
injections (HCG with HMG) from 3-12 months. Natural pregnancy often occurs even with low
sperm concentrations as the spermatozoa secreted are functionally normal
 Genetic factors; as in translocations, klinfelter's syndrome (XXY) and Y chromosome
microdeletion.
 Trauma to the testes can result in permanent damage and increase the risk of the subsequent
production of anti-sperm antibodies as in cases of torsion and spinal cord injury
 Testicular cancer
 Life style as obesity which is associated with reduced serum androgen and elevated serum
estrogens, tobacco since nicotine reduces antioxidants in the semen. Also alcohol and anabolic
steroids suppress spermatogenesis
 Occupational factors; some men work in very hot environments as bakeries, factories,
industrial sites where there is exposure to high temperatures, toxins and chemicals. These
external factors may reduce sperm production and quality by either directly affecting the
testicular function or indirectly through impairment of the male hormonal system. Also
frequent use of hot tubs, saunas and tight underwear should be avoided.
 Medications (Salazopyrine, testosterone injections, radiation and chemotherapy).
 Medical conditions as diabetes mellitus (DM), thyrotoxicosis, renal failure and liver failure.
Management
Conservative approach; stop smoking, avoid alcohol and adverse medications.
-Antioxidants like vitamin E, C and zinc.
-Antibiotics for infections.
-Hormonal treatment; medications (Clomiphene, Gonadotrophic injections) are not promising in
improving semen quality. The condition which responds to gonadotrophins is hypogonadotropic
hypogonadism.
-Surgery; varicocele ligation was traditionally recommended as treatment for varicocele and
some showed improved semen quality and fertility. However meta analysis of controlled studies
didn’t show the evidence of this.
-Assisted reproduction approach; IUI or IVF is recommended in mild-moderate cases of OATS,
while ICSI is the best in severe cases.
III-Anti sperm antibodies
Sperm antibodies contribute to less than 5% of male infertility. They adhere to the sperm
membrane and reduce its motility by causing agglutination. Causes include genitourinary
infections, obstructive azospermia and post genital surgery
Management
- Corticosteroid therapy
-ART; IUI results are poor, ICSI is usually required.
IV-Azoospermia
 Is the etiology of 20% of male infertility
Causes
o Pretesticular factors; gonadotropin deficiency as in hypogonadotrophic hypogonadism
o Testicular factor; non obstructive azoospermia (primary testicular failure) which could be:
1.Acquired (trauma, infection, radiotherapy, chemotherapy)
2.Congenital: undescended testis, chromosomal abnormalities as klinfelter's syndrome and Y
chromosome microdeletion. Klinfelter's is the most important genetic cause of non
obstructive azospermia, it is due to sex chromosome aneuploidy 47, XXY and exists in 1 in
500 males. The patient may be tall with gynecomastia and scanty hair with small testes.
Hormones show elevated LH, FSH with low testosterone. In rare cases few sperms may be
present due to mosaicism. Sperm could be retrieved from 40-50% of non-mosaic cases.
Preimplantation genetic diagnosis (PGD) is recommended when ICSI is done to detect
abnormal embryos.
o Post testicular factors (obstructive azoospermia)
1.Acquired (herniorraphy and infections)
2.Congenital as in congenital absent vas deferense (CAVD) and ductal obstruction. CAVD is
present in 10-20% of men with obstructive azospermia. The diagnosis is confirmed by genital
exam (absent vas with normal size testis). This is a significant feature in cystic fibrosis so it
is important to screen both partners for CF mutations. PESA under local anaesthesia usually
gives good sperm outcome and PGD is recommended for embryos before ET.
Diagnosis
-Azoospermia is confirmed by two semen analyisis with absent sperm 2-3 weeks apart.
-Hormonal analysis and testicular size is important in differentiating the type of azoospermia. In
obstructive cases, FSH and LH levels and testicular size are normal while the hormones are
elevated in the non obstructive with small size testes.
Treatment
-Surgical sperm retrieval for application of ICSI technique with considering the importance of
genetic counselling