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Evaluation and Management of Male Infertility
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Dr Ajantha Boopathi MS(OG),DGO,MRCOG,DMAS, Diploma in Advanced Reproductive Medicine and Embryology Fertility Consultant Nova IVF Fertility , Anna Nagar , Chennai Evaluation and Management of Male Infertility
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MORE INFERTILITY -WHOSE FAULT IS IT ? 1/3 RD FEMALE CAUSES 1/3 RD MALE CAUSES REST 1/3RD – COMBINATION or UNEXPLAINED
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Epidemiology Males are found to be solely responsible for 20-30% of infertility cases and overall contribute to 50% of cases. In Current era Male factor infertility is in raising trend. Male factor infertility is seen as an alteration in sperm concentration and/or motility and/or morphology in semen analysis.
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Causes
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Hormonal Imbalance - Hypogonadism This causes are related to problem in secretion of Hormones like GnRH, FSH & LH in male. Testicles are not able to produce sufficient sperms due to this hormonal imbalance. Common causes are:- Kallmann Syndrome Hyperprolactinemia Pituitary tumors Exogenous administration of androgens
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Testicular Causes These factors are related to insufficient production of sperms from testicles Common causes are:- Varicocele Undescended testis (cryptorchidism) Mumps orchitis Testicular trauma/torsion Inguinal hernia surgery Chemotherapy Chromosomal abnormalities - Klinefelter syndrome (XXY) & Y microdeletion
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Obstruction to Sperm Transport These factors are related to obstruction in sperm transport via connecting channels Common causes are:- CBAVD (Congenital bilateral absence of vas deferences) Infections – STD (chlamydia, gonorrhoea and syphilis) Vasectomy Ejaculatory duct obstruction
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Problems with Sexual Intercourse Erectile dysfunction Premature ejaculation Painful intercourse Hypospadias Retrograde ejaculation Psychological problems
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Medications Related Certain medications can influence the processes of spermatogenesis and sperm maturation. anti bacterial and anti viral agents anti hypertensives anti inflammatory agents anticonvulsants antidepressants antineoplastic agents
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Health, lifestyle and related causes Obesity – by causing hormonal imbalance Sedentary lifestyle and lack of exercise Cigarette smoking Tobacco chewing Alcohol & Drug use Depression Emotional stress
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Environmental Causes Overexposure to environmental elements can reduce sperm production or sperm function Industrial chemicals - exposure to pesticides, organic solvents Heavy metal exposure - exposure lead & mercury Radiation exposure Overheating the testicles:- tight clothing , working on a laptop sitting for long periods, frequent use of hot baths
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General health history Age BMI Occupation Smoking Alcohol Stress Exposure to environmental toxins
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Medical History Hypertension Diabetes Surgery in pelvic region Chemotherapy, radiotherapy Hyperprolactinemia Cystic fibrosis Thyroid disorder
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History of infections PID UTI STI Mumps Tuberculosis Leprosy
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Family History Birth defect Genetic mutation or mental retardation History of infertility problems
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Drug History Phenothiazines Metoclopramide anti bacterial and anti viral agents anti hypertensives anti inflammatory agents anticonvulsants antidepressants antineoplastic agents
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Sexual History Erectile dysfunction Frequency of coitus Ejaculation failure
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Physical examination – Male Secondary sexual characteristics Scrotum Testis Penis Epididymis and vasa Gynecomastia
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Male Investigations General CBP HIV HbSAg HCV Blood glucose Vitamin D Hormonal 1.FSH 2. LH 3.T3,T4,TSH 4.Serum testosterone 5. Serum prolactin Genetics Karyotyping Y chromosome microdeletions Cystic fibrosis conductance regulator gene mutation Others 1.Ultrasound 2.Antisperm antibody tests 3.DNA fragmentation tests 4. Semen culture
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Semen Analysis Physicians should provide patients with standardized instructions for semen collection, including a defined pre-test abstinence interval of 3–5 days. some men with severe oligozoospermia can have equal or better sperm concentration with a short (hours) period of abstinence, supporting the potential use of multiple semen analyses during assisted reproductive technology treatment cycles.
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Semen collection Semen can be collected by means of masturbation into a specimen cup or by intercourse with the use of special semen collection condoms that do not contain substances toxic to sperm. Ideally, the specimen should be collected at the laboratory. If collected at home, the specimen should be kept at room or body temperature during transport and examined in the laboratory within 1 hour of collection. To ensure accurate results, the laboratory should have a quality control program for semen analysis .
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WHO laboratory manual for the examination and processing of human semen, 2010
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Interpretation
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Ultrasound The testis for testicular volume The epididymis for cysts and size, and the spermatic cord for varicocoele. Clinicians should recommend TRUS in men with SA suggestive of ejaculatory duct obstruction (i.e., acidic, azoospermic, semen volume <1.5mL, with normal serum T, palpable vas deferens).
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Genetic Screening Men with nonobstructive azoospermia or severe oligozoospermia (<5 million/mL) are at increased risk for having a genetic abnormality compared to fertile men. Men with severely damaged spermatogenesis (spermatozoa < 5 million/mL) should be advised to undergo karyotype and Yq microdeletion testing for both diagnostic and prognostic purposes. Yq microdeletion also has important implications for genetic counselling.
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Percentage of men with Y-chromosome microdeletions increases to 16% in men with azoospermia or severe oligozoospermia . Such microdeletions are too small to be detected by standard karyotyping, but they can be identified with the use of polymerase chain reaction techniques. Microdeletions on the Y-chromosome are termed AZFa, AZFb and AZFc . If complete AZFa or AZFb microdeletions are detected, micro-TESE/c TESE should not be performed because it is extremely unlikely that any sperm will be found.
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Lifestyle Changes Healthy eating Good sleep Avoiding stress Moderate exercise Quitting smoking Cutting down on alcohol. Avoiding tight fitting clothes and holding a laptop in their lap.
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Medical Management
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Antioxidants , Cochrane review Antioxidants may lead to increased live birth rates (OR 1.79, 95% CI 1.20 to 2.67, P = 0.005, 7 RCTs, 750 men, I2 = 40%, low‐quality evidence) Antioxidants may lead to increased clinical pregnancy rates (OR 2.97, 95% CI 1.91 to 4.63, P < 0.0001, 11 RCTs, 786 men, I2 = 0%, low‐quality evidence) compared to placebo or no treatment. Antioxidants for male subfertility , cochrane review 2019 Roos M SmitsRebecca Mackenzie‐ProctorAnusch YazdaniMarcin T StankiewiczVanessa JordanMarian G Showell https://doi.org/10.1002/14651858.CD007411.pub4
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Surgical Management
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ART- Assisted Reproduction IUI AID IVF/ICSI .
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Psychological Effects of Infertility on Men The inability to impregnate their wife can be emasculating, regardless of if the fertility factor is male, female or both, which can lead to a compromised sense of identity. The fertility process itself, and repeated negative outcomes, can lead to depression and anxiety in men as well as women. Counselling and offering mental health support to male and female partners is very important.
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summary Evaluation and management of men in a couple with infertility involves a step-wise process of evaluation and consultation regarding treatment options. An increasing understanding of general health conditions associated with male infertility is valuable for counselling, as well as diagnosis of the underlying cause of the infertility. Evaluation should proceed in parallel for both male and female members of a couple to optimize treatment success.
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34 CENTRES IN 24 CITIES www.novaivffertility.com THANK YOU
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Goals of evaluation Ideally, the identification and treatment of correctable conditions will improve the male partner's fertility and allow conception to be achieved naturally. Detection of certain genetic causes of male infertility provides the opportunity to inform affected couples about the risk of transmitting genetic abnormalities that may affect the health of offspring, may affect the chance for successful treatment, and can help to guide treatment options. Evaluation of the infertile man also is aimed at identifying any underlying medical conditions that may present as infertility.
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Reproductive History 1) coital frequency and timing; 2) duration of infertility and previous fertility; 3) childhood illnesses and developmental history; 4) systemic medical illnesses (such as diabetes mellitus and upper respiratory diseases); 5) previous surgery; 6) medications 7) sexual history (including sexually transmitted infections); 8) exposures to gonadotoxins (including environmental and chemical toxins and heat).
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Previous fertility does not exclude the possibility of a newly acquired, secondary, male infertility factor. Evaluation is the same for men with primary infertility (never having fathered a pregnancy) and secondary infertility (having previously fathered a pregnancy).
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Medical History Identify risk factors and behaviors or lifestyles that could have significant impact on male infertility. 1) a complete review of systems 2) family reproductive history; and 3) a detailed social history, including any past or current use of anabolic steroids, recreational drugs, tobacco, and alcohol.
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Physical Examination 1) examination of the penis, noting the location of the urethral meatus 2) palpation and measurement of the testes 3) the presence and consistency of both vasa and epididymides 4) the presence or absence of a varicocele 5) secondary sex characteristics, including body habitus, hair distribution, and breast development 6) digital rectal examination where indicated.
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Endocrine Evaluation An endocrine evaluation is indicated for men having 1) abnormal semen parameters, particularly when the sperm concentration is <10 million/mL 2) impaired sexual function 3) other clinical findings that suggest a specific endocrinopathy.