ANDROLOGY Dr hab. Rafał Kurzawa CLINIC of REPRODUCTION and GYNECOLOGY POMERANIAN ACADEMY of MEDICINE

Epidemiologia niepłodności

Symptomatology of male infertility TYPE I – erection problems (0,3-7%) TYPE I – erection problems (0,3-7%) TYPE II – azoospermia (0,9%-16%) TYPE II – azoospermia (0,9%-16%) TYPE III – immunological infertility (3,4%-25%) TYPE III – immunological infertility (3,4%-25%) TYPE IV – abnormal seminal quality (23%-48%) TYPE IV – abnormal seminal quality (23%-48%) TYPE V – idiopathic sperm dysfunction (0-25%) TYPE V – idiopathic sperm dysfunction (0-25%)

Diagnosis General examination General examination Semen analysis Semen analysis Other diagnostic tests: Other diagnostic tests: –USG –Hormonal diagnostic –Diagnostic tests for Assisted Reproductive Technology

TYPE I – erection problems (0,3-7%) Normal ejaculation Normal ejaculation –Hypospermia (semen volume < 2,0 ml) – chronic prostatitis –Impotence Retrograde ejaculation Retrograde ejaculation –Neurogenic– DM, SM –Anatomical –Jatrogenic – drugs, operations disejaculation disejaculation –Functional – anorgazmia –Neurogenic – spinal injury –Jatrogenic – drugs, chemiotherapy, radiotherapy, operations

TYPE II – azoospermia (0,9%-16%) Pre-testicular causes Pre-testicular causes –Hypothalamic or pituitary disorder – LH, FSH deficiency, Kallman syndrome, trauma, tumors, inflammation, meningitis Testicular causes Testicular causes –Primary testicular failure –Congenital – 47XXY, del Y, AZF –Acquired- mumps, testicular torsion, castration –Jatrogenic – radiotherapy, chemiotherapy Post-testicular causes Post-testicular causes –Congenital – CBAVD, CF –Acquired – inflammations (gonorrhea) –Jatrogenic – vasectomy, hernia operation

Diagnostic tests for Assisted Reproductive Technology- ICSI FSH FSH –If < 12IU – sperm biopsy is effective in 80-90% Blocked ejaculatory duct (Micro-Epidydymal Sperm Aspiration –MESE) Blocked ejaculatory duct (Micro-Epidydymal Sperm Aspiration –MESE) Other (Testicular Sperm Extirpation- TESE, Testicular Sperm Aspiration- TESA) Other (Testicular Sperm Extirpation- TESE, Testicular Sperm Aspiration- TESA)

TYPE III – immunological infertility (3,4%-25%) antisperm antibodies – the immune system may produce antibodies that attack and weaken or disable sperm antisperm antibodies – the immune system may produce antibodies that attack and weaken or disable sperm –Auto-immunological diseases –Concequences of testicular trauma

Congenital Congenital –Undescended testicles Sexually transmitted disease (gonorrhoea) or testicular infection (mumps) Sexually transmitted disease (gonorrhoea) or testicular infection (mumps) Vascular Vascular –Testicular torsion –Varicocoeles Diseases: Diseases: –Thyroid faiure; Addison disease, hepar diseases; DM, auto- immunological diseases; Environmental factors Environmental factors –Drugs (sulfasalazine, T, chemiotherapy) –Temperature –Other factors (X-rays, lead, cigarette smoke, alcohol; marijuana, frequently wearing tight-fitting pants and underwear) Immunological Immunological –Testitis Genetic Genetic –del Y, aberrations (count and structure of chromosomes) Idiopathic [46%] Idiopathic [46%] TYPE IV – abnormal sperm quality (23%-48%)

Obraz morfologiczny

Treatment Risk factor elimination Risk factor elimination Give up smoking Give up smoking Testicular temperatue decrease Testicular temperatue decrease Regular sexual intercourses (2-3 per week) Regular sexual intercourses (2-3 per week) Antioxydants Antioxydants –Vitamin E, C, Zinc Tetracicline Tetracicline –Chlamydia Trachomatis infection

Treatment (pharmacotherapy) Risk factor elimination Risk factor elimination Hormonal treatment Hormonal treatment –Testosterone –hCG –FSH –C.C, tamoxyphen

Varicose veins in the spermatic cord Physical examination Physical examination –I Valsalva test examination ( or during cough) –II large veins during palpation –IIIvisible varicouse veins Other diagnostic test Other diagnostic test –Semen analysis (SA) –USG Treatment Treatment –Operation –ART.: IUI, IVF, ICSI

Diagnostic and therapeutic algorithm (female) Diagnostic and therapeutic algorithm (female) Sperm analysis O, A, T, OA, OT, TA, OAT grave O, A, T, OA, OT, TA, OAT azoospermiaTesticular cells? TESE, MESA Treatment: operation, CC, hMG (FSH) ICSI IUI

Sperm analysis- recommendation by WHO –General female infertility diagnostic test- SA –sterility –sample should be delivered to laboratory in 60 min. after ejaculation –abstinence min. 48 hours max. 7 days –the next semen analysis between 7 days and 3 months

Seminal quality, cytology and sperm quantitation –liquefaction –viscosity –volume –color –pH –smell –Sperm count –Sperm motion analysis –WBC count (pyospermia) –Spermatozoa count –Antisperm antibodies –Sperm morphology –Microbiology

Semen analysis –Microscope –Makler counting chamber –Immunobead test (IgG, IgA or IgM) –CASA (computer-assisted sperm analysis)

Sperm motion analysis 0- immotile 1- weak movement with no forward progression 2- weak to moderate forward progression 3- good forward progression; active tail movement 4- rapid forward progression; vigorous tail movement

Seminal quality- ranges –Liquefaction < 60 minutes –Volume > 2 ml –Color- gray to white opalescent fluid –pH 7,2 – 8,0

IMMUNOBEAD TEST Microscopic polyacrylamide spheres, ranging in size from 2 to 10 um, coated with anti-human immunoglobins against human IgG, IgA or IgM Microscopic polyacrylamide spheres, ranging in size from 2 to 10 um, coated with anti-human immunoglobins against human IgG, IgA or IgM

Normal sperm range Motility >50% 4 or 3 ; or >25% 4 Motility >50% 4 or 3 ; or >25% 4 Sperm count >20·10 6 /ml Sperm count >20·10 6 /ml WBC count <10 6 /ml WBC count <10 6 /ml Spermatozoa <5·10 6 /ml Spermatozoa <5·10 6 /ml Autoagglutinating <10% Autoagglutinating <10% Immunebead test<10% Immunebead test<10% Sperm morphology >30% normal forms (WHO); 5-14% strict criteria (Kruger) Sperm morphology >30% normal forms (WHO); 5-14% strict criteria (Kruger)

Definitions of „abnormal” counts Normozoospermia Normozoospermia Oligozoospermia < 20·10 6 /ml Oligozoospermia < 20·10 6 /ml Astenozoospermia<50% 4 or 3 ; or <25% 4 Astenozoospermia<50% 4 or 3 ; or <25% 4 Teratozoospermia<30% Teratozoospermia<30% Azoospermia no sperm Azoospermia no sperm