MALE INFERTILITYHospital Raja Perempuan Zainab II Kota Bharu Department of O&G by Dr. Wan Zahanim Case Puan RH, 31 year old housewife Presented to GOPD in 1995 with history of primary infertility after 5 years of marriage She’s a healthy lady She’s married to a 38 year old lorry driver who smokes 20 cigarettes per day for almost 20 years Cont. history He had history of Gonorrhoea in 1987 with multiple attacks and had been treated by GP He had no other medical or surgical illness This is his second marriage in which his first marriage lasted for 5 years without any children Currently his first wife remarried another man and she’s pregnant 5 cm L testis : 3.examinations Wife normal Husband: Genitalia: Both testis appears atrophic and soft R testis : 2.5x1.0 cm Volume less than 10 mls .0x2.Cont. investigations Seminal fluid analysis : AZOOSPERMIA Repeated 3 times : AZOOSPERMIA Post SI urine for sperm negative LH/FSH level : HIGH .Cont. Cont. diagnosis TESTICULAR FAILURE He was referred to urologist and testicular biopsy performed in 1997 NO SPERM SEEN MANAGEMENT : this couple was advised for ADOPTION . 50% of normal couples conceive within 5 months and 85% within 12 months Second pregnancy occur sooner which is 50% within 2 months .INTRODUCTION INFERTILITY : failure to conceive within 12 months of unprotected intercourse. However.Current estimates suggest about 6% of men between the ages of 15 and 50 are infertile. A man will eject nearly 200 million sperm. because of the natural barriers in the female reproductive tract only about 40 sperm will ever reach the vicinity of an egg . EPIDEMIOLOGY Most fecund couples conceive soonest because the chances of conception decline with the duration of infertility 5% of couples desiring children have none by the end of their reproductive life Male infertility may be the largest single cause of human infertility and it responsible for one third of all primary infertility . EPIDEMIOLOGY .cont Male factor also responsible for 20% of secondary infertility and 20% of primary infertility that involve both partners AZOOSPERMIA is found in approximately 10% of infertile couples . Table 1. Causes of Male Infertility Deficient sperm production Ductal obstruction Congenital defects Postinfectious obstruction Cystic fibrosis Vasectomy Ejaculatory dysfunction Premature ejaculation Retrograde ejaculation . Disorders of accessory glands Infection Inflammation Antisperm antibodies Coital disorders Defects in technique Premature withdrawal Erectile dysfunction . ) Dietary Increased saturated fats Reduced intake of fruits. vegetables. DBCP. mercury. arsenic. etc. PCBs.Table 2. etc.) Organic solvents Pesticides (DDT. and whole grains Reduced intake of dietary fiber Increased exposure to synthetic estrogens . Possible Causes of Falling Sperm Counts Increased scrotal temperature Tight-fitting clothing and briefs Varicoceles are more common Environmental Increased pollution Heavy metals (lead. Table 4. Increased stress Lack of sleep Overuse of alcohol. pesticides. etc. Causes of Temporary Low Sperm Count Increased scrotal temperature Infections. or marijuana Many prescription drugs Exposure to radiation Exposure to solvents. the common cold. and other toxins . tobacco. the flu. CAUSES ABSENT SPERMATOGENESIS OBSTRUCTIVE AZOOSPERMIA RETROGRADE EJACULATION .AZOOSPERMIA. Kallman’s Syndrome b)Acquired. trauma. DXT.chemo .chr. abn. Sertoli cell only syndrome b)Acquired. tumour 2.cryptorchidism. Abnormalities at the testis a)Congenital.infection. Abnormalities at the hypothalamus or pituitary a)Congenital.trauma.Absent Spermatogenesis 1. Obstructive azoospermia Congenital .absence of vas deferens Acquired .bilateral epididymo-ochitis or trauma . Retrograde ejaculation Congenital.anomalies at the bladder neck or urethral valves Neurological abnormalities Previous surgery Idiopathic . INVESTIGATION MALE FEMALE OVULATION HORMONAL BOM BBT TUBAL HSG LAP . MALE SFA X 3 AZOOSPERMIA POST SI URINE +ve -ve LH/FSH RETROGRADE EJACULATION REDUCED HYPOTHALAMIC PITUITARY NORMAL OBSTRUCTION INCREASED TESTICULAR FAILURE . INVESTIGATION SEMINAL FLUID ANALYSIS (SFA) .is the gold standard Specimen preferably produced after 3 days of abstinence Specimen collected by masturbation into wide mouthed sterile container Specimen should be protected from temperature fluctuation . cont Specimen should reached the lab within 1-2 hours of ejaculation Specimen must be thoroughly mixed before examinations under the microscope .INVESTIGATION. and bulbourethral glands. opaque. yellowishwhite.Definition: “ It is a penile ejaculate consisting of a thick. viscid fluid containing spermatozoa. a mixture produced by secretions of the testes. seminal vesicles. . prostate. flavins (enables the fluid to fluoresce. and acid phosphatase. Make only a minor contribution. Makes up about 20% -25% of the total volume. •FRACTION FOUR: Testes and epididymis. •FRACTION TWO: Seminal vesicles portion. . and potassium. Contributes approximately 7% of the total volume. zinc. •FRACTION THREE: Bulbourethral and urethral glands. Spermatozoa are found in this fraction. enzymes (for coagulation and liquefaction). citric acid.FRACTION ONE: Prostate portion. This portion is the nutrient medium for spermatozoa. containing citric acid. Contributes 60% or more of the total volume and contains fructose. 20-200 million/ml MOTILITY.more than 50% normal .2-6 ml DENSITY.more than 50% progressively motile MORPHOLOGY.SFA .NORMAL by WHO VOLUME . . . post SI urine The presence of sperm will make the urine TURBID On centrifugation and examination under microscope. there will be numerous sperms Treatment.INVESTIGATION.Crich and Jequier 1978 suggest to ejaculate with full bladder Alkalinizing the urine prior to ejaculation by ingestion of NaHCO3 then collect and centrifuge the urine for AIH . Klinefelter’s syndrome .INVESTIGATION.hormone FSH/LH REDUCED in hypogonadotrophic hypogonadism eg. Kallman’s syndrome NORMAL in patients with obstruction anywhere from the seminiferous tubules to the opening of the ejaculatory ducts into the prostatic urethra INCREASED in testicular failure eg. vasoepididymostomy Testicular biopsy.MANAGEMENT.obstruction Refer to urologist Vasovasostomy.presence of sperm Fertility following surgery usually poor ART can be offered . MANAGEMENThypogonadotrophic Gonadotrophic hypogonadism injections to promote spermatogenesis ( Wu 1985) ART also can be offered . testicular failure In severe cases in which the sperm is absent totally from the testicular biopsy.MANAGEMENT. ART can be offered . ADOPTION OR ART WITH DONOR SPERM In milder forms in which minimal amount of sperm is present in the testicular biopsy. MANAGEMENT FOR LOW SPERM COUNT GENERAL MEASURES DIET SUPPLEMENT BOTANICAL MEDICINE . and antiinflammatory drugs such as sulfasalazine .General Measures: Maintain scrotal temperatures between 94-96o F. Avoid exposure to free radicals. Identify and eliminate environmental pollutants Stop or reduce all drugs. especially anti-hypertensives. antineoplastics such as cyclophosphamide. exceptionally tight shorts. especially if a man is wearing synthetic fabrics. or tight bikini underwear: rowing machines. After exercising. simulated cross-country ski machines. In addition. and jogging. a man should allow his testicles to hang free to allow them to recover from heat buildup. and avoiding hot tubs. the following exercises can raise scrotal temperature. treadmills.This temperature reduction is best done by not wearing tightfitting underwear or tight jeans. . the testicle cooler looks like a jock strap from which long. thin tubes have been extended.Infertile men should wear boxer-type underwear and periodically apply a cold shower or ice to the scrotum. They can also choose to use a device called a testicular hypothermia device or "testicle cooler" to reduce scrotal temperatures. Still in its somewhat primitive stage. The . tubes are attached to a small fluid reservoir filled with cold water that attaches to a belt around the waist. Most users claim that it is fairly comfortable and easy to conceal . the reservoir must be filled every six hours or so. When the water reaches the surface of the scrotum it evaporates and keeps the scrotum cool. It is recommended that the testicle cooler must be worn daily during waking hours. The fluid reservoir is also a pump that causes the water to circulate. Because of the evaporation. Recommend the daily consumption of: 8-10 servings of vegetables. Increase consumption of: legumes. carotenes. 2-4 servings of fresh fruits. saturated fats. good dietary sources of antioxidant vitamins. and flavonoids (darkcolored vegetables and fruits). and essential fatty acids and zinc (nuts and seeds). and cottonseed oil. especially soy (high in phytoestrogens and phytosterols). .Diet: Avoid dietary sources of: free radicals. trans-fatty acids. hydrogenated oils. and 1/2 cup of raw nuts or seeds. dietary vitamin C plays a critical role in protecting against sperm damage and that low dietary vitamin C levels were likely to lead to infertility. . . selenium. and beta-carotene are also important and should be supplemented.vitamin E. Optimal zinc levels must be attained if optimum male sexual vitality is desired . 400 µg per day Vitamin B12 .000 per day in divided doses Vitamin E .1.000 IU per day Folic acid .Nutritional Supplements: Multiple vitamin and mineral Vitamin C .1.000 µg per day Zinc .600-800 IU per day Beta-carotene .100.30-60 mg per day .000-3.000-200. 5-2 g/d 3x/d Standardized extract (5% ginsenosides) 500mg 3x/d The dosage of ginseng is related to the ginsenoside content. For example. for a high quality ginseng root powder containing 5% gin . The typical dose (taken one to three times daily) should contain a saponin content of at least 25 mg of ginsenoside Rg1 with a ratio Rg1 to Rb1 of 2:1.Botanical Medicines: Panax ginseng (three times per day dosages) High quality crude ginseng root .1. ARTIFICIAL REPRODUCTIVE InTECHNIQUE the couple with infertile man especially with azoospermia. the treatment that we provide in the late 20th century differs very little from that offered by Galen in 160 AD However the place of ART has gradually progressed since the early 1980’s . cont Success in the arena of ART has been spectacular for those having donor insemination and less so with IVF and GIFT Most advances have occurred this century especially micromanipulation technique .ART . SUBZONAL INSEMINATION (SUZI) Ng et al 1988 3. INTRACYTOPLASMIC SPERM INJECTION Palermo et al 1992 .ART. PARTIAL ZONA DISSECTION (PZD) Cohen et al 1988 2.micromanipulation technique Basically there are 3 micromanipulative techniques of assisting fertilization in azoospermic patients 1. acidified medium or a sharp glass neddle Intention is to permit weakly motile spermatozoa to gain access to the oolemma . cracking or cutting by .ART.zona drilling.PZD The principles is making a hole in the Zona pellucida by methods . ART- SUZI A process in which one or more spermatozoa are inserted into the perivitalline space This procedure sometimes will end up with polyspermy ICSI This is the latest micromanipulative technique and the method of choice for patient with severe male infertility It is a process of injecting a spermatozoon or sperm head directly into the ooplasm ICSI has transformed the treatment of severe male infertility during the past 2 years .ART. . . the fertilization rate can be as high as with good sperm and the pregnancy rates can be as high as with standard IVF for other indications .cont The method has become increasingly successful and now offers the hope of having children to many man with virtually no spermatozoa In centres expert in ICSI.ICSI . . . . cont Current development now include the use of immature epididymal sperm and immature sperm obtained by testicular biopsy The source of sperm doesn’t effect the pregnancy rate ejaculated epididymal testicular cycle 2572 128 120 transfers 93% 91% 90% preg/cycle 34% 39% 36% .ICSI . CONCLUSION Male infertility has been neglected until the past few decades Now that female infertility has been defined and in many instances treated successfully. there have been major advances in basic knowledge and research which will . it is timely to focus on the male While most causes of male infertility are incurable. CONCLUSION.cont foster development of better diagnostic and therapeutic measures Failure of conventional IVF has lead to attempts to broach the barrier of zona pellucida by micromanipulative methods Success has been infrequent but fertilization (20%) and pregnancy rate (5%) are improving . CONCLUSION.cont With these techniques. polyspermy is common (10%) ICSI has been reported to produce higher fertilization rates (50%) even with severe sperm abnormalities. zero motility and total teratospermia . . THANK YOU .