1. Male infertility Work up and Management overview
Dr. Anmar Nassir, FRCS(C)
Canadian board in General Urology
Fellowship in Andrology (U of Ottawa)
Fellowship in EndoUrology and Laparoscopy (McMaster Univ)
Assisstent Prof Umm Al-Qura
Consultant Urology KFSH & RC

2. 8-15% of couples Male = 50%

3. Pituitary-Gonadal Axis

4. LH & FSH LH Activate testicular T production from Leydig cells
Feed back inhibition by testosterone
FSH
Stimulate Sertoli cells & spermatogonial membranes
The major stimulator of seminiferous tubule growth during development
Feed back inhibition by inhibin from Sertoli cells

5. Testosterone will initiate and maintain spermatogenesis
Sperm fertility maturation, achieved at the level of the distal corpus or proximal cauda epididymis.

6. Physiology Epididymis: Vas: Seminal vesicles Prostate:
Maturation
Transport
Storage
Vas:
Transfer of sperm
Seminal vesicles
(The main bulk of the ejaculate):
Secretory products: e.g.
fructose, prostaglandin, clotting factors
Ejaculation
Coagulation of semen
Prostate:
Liquifaction
Zn: antibacterial & sperm stabilization

7. The scrotal temperature is is 2°C to 4°C below rectal temperature due to counter-current mechanism

8. Anatomical Physiology
Epididymis:
Maturation
Transport
Storage
Vas:
Transfer of sperm
Seminal vesicles
(The main bulk of the ejaculate):
Secretory products: e.g.
fructose,
prostaglandin,
clotting factors
Ejaculation
Coagulation of semen
Prostate:
Liquifaction
Zn: antibacterial & sperm stabilization
Seminal vesicles  1.5 to 2.0 mL.
Prostate  0.5 mL,
Cowper's glands  0.1 to 0.2 mL,

10. Evaluation of Infertile patient

11. Abnormalities in the woman are involved in approximately 75% of infertile couples.
30% Ovulatory disorders
25% fallopian tube abnormalities
4% endometriosis
4% cervical mucus abnormalities
4% hyperprolactinemia
Conception rates drop more rapidly in the 35- to 39-year-old age group.

12. Many of the genes that affect male reproduction, including the androgen receptor gene, are located on the X chromosome.
Therefore, family history should focus on the phenotype of the maternal uncles

13. Impairing Spermatogenesis
Medications:
nitrofurantoin ,
cimetidine ,
sulfasalazine ,
Anabolic steroid
Substances:
cocaine
marijuana
Nicotine
pesticides

14. Infertility History

15. Physical Exam

16. Laboratory Assessment
Semen analysis X2
Quantitation of leukocytes in semen
Lab: Baseline, gluc. , U/A
Hormonal assay FSH, LH, Prol, TSH,
Antisperm antibodies: semen or blood
Advanced sperm fertility tests

17. Semen The WHO (1999) defines the following reference values: Volume:
2.0 ml or more
pH:
7.2 or more
Sperm concentration:
20 × 106  or more sperm/ml
Total sperm number:
40 × 106  or more spermatozoa per ejaculate
Motility:
50% or more with grade A + B motility
or 25% or more with grade A motility
Morphology:
30 %
15 % or more by strict criteria
Viability:
75% or more of sperm viable
White blood cells:
Less than 1 million/ml

19. Hormonal Evaluation

22. Diagnostic Studies
TRUS
US scrotum
Testicular biopsy

23. Asthenospermia Pretesticular Testicular Posttesticular
Endocrine Varicocele Antispermantibodies
Environment Infection
Febrile illness Partial ductal obst.
Intrinsic defect

24. Varicocele 15% of the population 35% of male with 1ry infertility
Semen 3cc, 10m/cc, 34% motile, 29% normal morphology and 0.9(10x6) WBC.
On scrotal exam : bag of worms
Varicocele
15% of the population
35% of male with 1ry infertility
75% of male with 2ry infertility
40% bilateral
Varicocele repair:
75% improvement of semen
35% initiate pregnancy

25. Varicocele
Semen samples from infertile men with varicoceles have demonstrated decreased motility in 90% of patients and sperm concentrations less than 20 million sperm/mL in 65% of patients.

26. Improvement in seminal parameters is demonstrated in approximately 70% of patients after surgical varicocele repair.
Improvements in motility are most common, occurring in 70% of patients, with improved sperm densities in 51% and improved morphology in 44% of patients.
Conception rates have averaged 33% to 50% compared with 16% in the control group

27. Treatment Surgical: Inguinal Retroperitonial Microscopic sub inguinal
Laparoscopic
Percutaneous venous occlusion

28. Pyospermia
Round cells: WBCs and immature germ cells.
Semen Culture

29. ED Obstruction TRUS Dilated Ej Duct. TURED
Semen: 0.9cc, 0.2m/cc,20% motile and negative post void sperm.
ED Obstruction
TRUS Dilated Ej Duct.
TURED

30. Causes of Obstructive Azospermia
*CBAVD = congenital bilateral absence of the vas deference .
Causes of Obstructive Azospermia *

31. Testicular Biopsy Diagnostic: Therapeutic: Harvesting sperms for ICSI
Obstruction vs
Sertoli Cell-only
maturation arrest
Therapeutic:
Harvesting sperms for ICSI

32. Indications for ICSI Immunological infertility
Severe oligoasthenospermia
Obstruction azospermia
Nonobstruction azospermia
Anejaculation ?
pregnancy rate %
Live delivery / initial ICSI cycle 20-40%

37. Risk of Congenital Anomalies with ICSI
Miscarriage and congenital anomalies are same for ICSI and IVF

38. Genetic Evaluation CF gene Karyotyping abnormality
Y-chromosome microdeletion