1. Male Infertility and Impotence

2. 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.”

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

4. Major Causes

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

6. 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

7. 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.

8. 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

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

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

11. Other Etiologies PID Cx conization/cautery Smoking IUD Endometriosis
Genetics

12. 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

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

14. 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

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

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

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

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

19. 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 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

20. Semen Analysis Abnormal semen results Azospermia Oligospermia
Athenospermia
Teratospermia

21. 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

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

23. Imaging Studies
Transrectal Ultrasound (TRUS)
Vasography
Testis Biopsy

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

25. 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.

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

27. 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.

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

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

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

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

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

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

34. Hormonal Immunological
FSH LH
Estrogen
Progesterone
TSH
Prolactin
Testosterone
Antisperm antibody

35. 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….

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

37. 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.

38. 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.

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

40. 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.

41. Blastocyst
Artificial insemination in laboratory disc