Improving ART OUTCOME:Looking beyond SFA in male factor infetility Dr Ekwempu C.C (MBBS;FWACS) Consultant OB/Gyn Fertility /endocrinology unit Jos University teaching Hospital

Introduction Infertility is a cause of emotional and economic stress Male factor detected in 40-50% of cases in our environment ART has significantly improved the outlook for many couples Failure rate is still unacceptably high Causes of failure unexplained

Investigation for male factor infertility History taking Examination Seminal fluid analysis Endocrine tests Genetic testing

Seminal fluid analysis(WHO reference limits) Volume- 1.5mls (95% CI 1.4-1.7) Sperm concentration- 15 million(12-16) Total sperm number- 39 million/ejaculate(33-46) Morphology -4% normal forms(3-4) using “strict” Tygerberg method Progressive motility-32%(31-34) Total motility(progressive+non progressive-40%(38-42)

Seminal fluid analysis(contd.) Not always a good predictor of fertility Bond JP et al. Lancet 1998 Guzick et al . NEJ 2001 Lack of sperm does not indicate lack of sperm production

Other specialized test Sperm autoantibody testing Semen biochemistry(semen fructose) Sperm- cervical mucus interaction tests Acrosome reaction Zona free hamster oocyte penetration test Human Zona pellucida binding test Sperm reactive oxygen species generation Sperm chromatin/DNA assays

Endocrine tests Serum Testosterone LH/FSH

Genetic testing Genetic abnormalities: Detects deletions and microdeletions Translocations Lead to dysfunctional sperms that impact on male fertility and pregnancy outcome

Current indications for genetic testing Sperm concentration <5million/ml Azoospermia with testicular atrophy in a couple considering ivf Oligo or azoospermia with absence of one vas deferens on physical examination Azoospermia with evidence of normal spermatogenesis Family history of genetic disorders

Oxidative stress The imbalance between ROS and natural antioxidants=oxidative stress ROS associated with poor semen quality and male infertility

Oxidative stress tests Seek to detect ROS, total antioxidant capacity(TAC), and lipid peroxidation. Chemiluminiscence and flow cytometry Enhanced chemiluminiscence assays

Drawbacks Specialised testing is expensive Adds to the already high cost of fertility treatment Not readily available in our environment Doesn’t significantly improve pregnancy rates

recommendations Proper history taking and thorough physical examination cannot be overemphasized Urological involvement Use of antioxidants(Showel et. al cochrane databse 2012.) donor sperm: prevents transmission of genetic defects

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