Male Infertility and Impotence

Definition Infertility is “inability to conceive after one year of conjugal life without use of contraceptive methods.” The term "primary infertility" is applied to “the couple who has never achieved a pregnancy.” "secondary infertility" implies that “at least one previous conception has taken place.”

origin of problem: 35% female 35% male 20% both partners 10% unexplained

Major Causes

Etiology of Male Infertility Multi-factorial Prevalence Varicocele 35% Idiopathic 25% Infection/injury – genito-urinary tract 10% Genetic/systemic disease 10% Endocrine 1 - 5% Immunologic 1 - 5% Obstruction 1 - 5% Developmental 1 - 5% Lifestyle: smoking, diet, heat ???%

Aetiological Classification 1.Disorders of spermatogenesis: A)Hormanal Hypothalamic disorder Pituitary secretion of FHS and LH Hyperprolactinaemia causing Impotence or diminished libido. B) Primary testicular disorders: Idiopathic, Varicocele Chromosomal defect, i.e. klinefilter’s syndrome Crytorchism

Drugs,radiations Orchitis (traumatic,mumps, TB,gonorrhoea) Chronic illness Immunological disorders . 2) Duct obstruction: Congenital absence, inflammatory block, surgical trauma, 3)Accessory glands disorders:Prostitis, vasiculitis, congenital absence of vas in cystic fibrosis.

4.Disorders of sperms and vesicular fluid: Sperms antibodies and low fructose in seminal plasma. Sperms acrosome defect Zona pellucida binding defect Zona penetrations defect Oocyte fusion defect 5. Sexual dysfunctions: Low frequency coitus- wrong time Impotence, hypospadias Premature Ejaculation, retrograte ejaculation

6.Psychological factors and environmental factors like smoking,alcohol consumption,tobacco chewing,diabetes, Drugs: antihypertensive,antipsycotis,sex steroids, chemotherapy, beta-blockers, spirolactone,oestrogen

Female Infertility Etiologies Unexplained Cervical/mucus Endometrial/uterine Pelvic/peritoneal Tubal Developmental/genetic 10% 2-3% 5-10% 30-50% 40%

Other Etiologies PID Cx conization/cautery Smoking IUD Endometriosis Genetics

Aetiology 1.dyspareunia and vaginal causes 2.Congenital defect in the genital tract. 3.infection in the lower genital tract. 4.Cervical factors 5.Uterine causes 6.Tubal factors 7.Ovaries 8.Peritoneal causes 9.Chronic ill health – especially thyroid dysfuntion

The Most Important Factor in the Evaluation of the Infertile Couple Is: HISTORY

History-General Both couples should be present Age Previous pregnancies by each partner Length of time without pregnancy Sexual history Frequency and timing of intercourse Use of lubricants Impotence, anorgasmia, dyspareunia Contraceptive history

Male Infertility: Evaluation History (Questionnaire) Physical examination Standard semen analysis Hormonal evaluation Genetic counseling and evaluation Imaging studies

History-Male History of pelvic infection Radiation, toxic exposures (include drugs) Mumps Testicular surgery/injury Excessive heat exposure (spermicidal)

Physical Exam-Male Size of testicles Testicular descent Varicocoele Outflow abnormalities (hypospadias, etc)

Male Factors-Semen Analysis Collected after 3 days of abstinence Evaluated within one hour of ejaculation If abnormal parameters, repeat twice, 2 weeks apart

Semen Analysis: World Health Organization Guidelines Fresh sample (to lab within 30 mins.) –most sperm in initial ejaculate Male should be abstinent for 48 to 72 hours Parameters Normal range Volume 1.5 - 5 mL Sperm conc. >20 million/mL Sperm motility >50% Sperm morphology >30% normal forms Leukocyte density <1 million/mL Need at least 2 S/As

Semen Analysis Abnormal semen results Azospermia Oligospermia Athenospermia Teratospermia

Sperm Terms Normozoospermia Normal ejaculate Asthenozoospermia Teratozoospermia Azoospermia Aspermia Normal ejaculate Sperm concentration <20 × 106 /ml <50% spermatozoa with forward progression <30% spermatozoa with normal morphology No spermatozoa in the ejaculate No ejaculate

Hormonal and others GnRH FSH LH TSH Prolactin level Rule out genetic diseases. Chromosomal study Immunological study

Imaging Studies Transrectal Ultrasound (TRUS) Vasography Testis Biopsy

Transrectal Ultrasound (TRUS) Ejaculator ductal stones Seminal vesicle dilatation.

Vasography Indication Assessment of vasal obstruction or ejaculatory duct obstruction. An inguinal vasal obstruction should be suspected in an azoospermic patient with normal spermatogenesis and a history of prior inguinal or scrotal surgery.

Testis Biopsy Indication Distinguishing between obstruction and testicular failure. Identification of mature sperm for ICSI

Treatment- Male Factor Hypogonadotrophism:-GnRH Ligation Retrograde ejaculation Testosterone for spermatogenesis Clomiphene 50 mg daily for 3 months for oligospermia. Empierical medical therapy by administration of vit.c , B 12, folic acid. Varicocele:- surgical treatment Obstruction:-short-cut operation IVF/IUI :- last option.

Female Infertility: Evaluation History (Questionnaire) Physical examination Ovarian factor Tubal factors Hormonal analysis Immunological test Postcoital test

History-Female Previous female pelvic surgery PID/Infection Medical diseases:-TB, diabetes,STD IUD use/MR done Ectopic pregnancy history Proven fertility Endometriosis

History-Female Irregular menses, amenorrhea, detailed menstrual history Vasomotor symptoms Stress Weight changes Exercise Cervical and uterine surgery

Physical Exam-Female Pelvic masses Uterosacral nodularity Abdominopelvic tenderness Uterine enlargement Thyroid exam Uterine mobility Cervical abnormalities

Ovarian factors Fern test Endometrial biopsy in secretory phase Serial USG Serum progesterone Laparoscopy D & C.

Tubal factor Tubal patency test by:- Tubal insufflation test Hystero-salphingo-graphy Laproscopy dye insufflation test Hydrotubation

Hormonal Immunological FSH LH Estrogen Progesterone TSH Prolactin Testosterone Antisperm antibody

Treatment for female factor Anovular :- clomiphene citrate bromocriptine D&C:- histopathology, bacteriology Reconstructive surgery:- developmental defect Surgery:- tubal block If all method fails, then go for….

Assisted Reproductive Technologies Intrauterine Insemination(IUI) In Vitro Fertilization(IVF) IVF and Intra Cytoplasmic Injection of Sperms(ICSI)

Intrauterine insemination (artificial insemination) definition: Artificial introduction of semen into the vagina, cervix or uterus by means other than coitus to produce pregnancy is called artificial insemination. sperm can come from husband or donor or pool donor.

IUI, cont’d. 6000 babies / year born in US. as result of artificial insemination INDICATION OF ARTIFICIAL INSEMINATION:- Impotent husband. Sterile husband. Husband suffering from hereditary disease. Rh-incompatibility between husband and wife.

In vitro fertilization test - tube babies” 1st performed in 1978 (Louise Joy Brown) often performed on infertile women with tubal blockage

Test tube babies/ in-vitro fertilization Techniques:- The ovum is removed from ovary through abdominal wall and is fertilized with the sperm in a small laboratory dish in artificial medium.. At the stage of blastocyst, the embryo is return to uterus through cervix. Blastocyst is implanted in endometrium.

Blastocyst Artificial insemination in laboratory disc