4- Male infertility_ Ethiology, diagnosis and treatment

Male Infertility

• Male infertility is a significant issue, affecting a range of men.
• Infertility is defined as one year of unprotected intercourse without conception.
• Subfertility means decreased reproductive efficiency in couples.
• Fecundability is the probability of pregnancy in a single menstrual cycle.
• Fecundity is the probability of achieving a live birth within a cycle.

Contents

• Introduction
• Spermatogenesis
• Causes
• Evaluation
• Management
• Recent advancements in male infertility

Introduction

• Infertility encompasses a spectrum of conditions, from complete inability to conceive to reduced reproductive efficiency.
• Identifying causes is crucial for appropriate management.

Spermatogenesis

• Spermatogenesis is the process of sperm development, taking approximately 70 days.
• During embryogenesis, there are roughly 300,000 spermatogonia in each gonad.
• By puberty, the number increases to 600 million in each testis.
• Sperm production happens in the seminiferous tubules of the testes, a process stimulated by testosterone alongside FSH.
• Sperm maturation occurs in the epididymis.
• Sperm is transported through the vas deferens.

Sperm Structure

• The sperm's structure plays a critical role in its function.
• Core components include the head, neck, midpiece, and tail, each with specific functions.

Physiology of Semen after Ejaculation

• Semen undergoes liquefaction after ejaculation.
• Sperm undergoes capacitation.
• Sperm undergoes the acrosome reaction.
• Sperm undergoes the cortical reaction.

Relative Prevalence of Infertility Etiologies

• Data (percentages) showing frequency distribution of different infertility causes:
  • Male factor: 20-30%
  • Both male & female: 10-40%
  • Female factor: 40-55%
  • Unexplained infertility: 10-20%

Semen Analysis Parameters

• Normal semen volume range: 1.5-5.0 mL

• Normal semen pH range: >7.2

• Normal viscosity range: <3

• Normal sperm concentration range: >20 million/mL

• Other crucial parameters include sperm motility, morphology, WBC count, and appropriate antibody testing.

• Refer to specific values/guidelines provided from 1992 and 2010.

History of Infertility

• Duration of infertility.
• Sexual dysfunction.
• History of infertility treatment.
• Childhood illnesses.
• Previous surgeries and medical conditions.
• Exposure to STDs, toxins, and occupational hazards.
• Current medications, allergies.
• Alcohol, drug use.

Physical Examination

• Penis examination.
• Testicular palpation and sizing.
• Vasa and epididymis assessment.
• Varicocele identification.
• Secondary sexual characteristics.
• Digital rectal examination.

Other Investigations

• Absence of fructose in semen.
• Semen culture/microscopy (if applicable).
• Urologic evaluation.
• Endocrine evaluation (FSH, LH, testosterone levels).
• Ultrasound (transrectal/transcrotal/renal).
• Testis biopsy.
• Vasography.

Indications for Specific Tests

• Abnormal semen analysis.
• Low FSH, LH, testosterone.
• Abnormal spermatogenesis.
• Testicular failure (elevated FSH and LH, low/normal testosterone).

Genetic Evaluation

• Cystic fibrosis transmembrane conductance regulator (CFTR) gene mutations.
• Chromosomal abnormalities, like Klinefelter syndrome.
• Y chromosome deletions.

Surgical Management

• Cryptorchidism (orchidopexy).
• Varicocele repair (high ligation).
• Gonadal failure (surgical retrieval, ICSI).

Drugs that Impair Male Fertility

• List of drugs impairing spermatogenesis, pituitary suppression, anti-androgenic effects, ejaculation failure, erectile dysfunction.

Types of Infertility Treatment

• Hypogonadotropic hypogonadism treatment
• Hypergonadotropic hypogonadism treatment
• Pretesticular treatment
• Post-testicular treatment

Surgical Treatment for Male Infertility

• Vasovasostomy
• Vasoepididymostomy
• Transurethral resection of ejaculatory ducts
• Varicocele repair
• Orchiopexy
• Vibrating and electric ejaculation techniques

Surgical Management of Infertility

• Cryptorchidism management (orchidopexy)
• Varicocele management (high ligation)
• Gonadal failure management (surgical retrieval, ICSI)