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Prof. DR. Dr. Nukman Moeloek, SpAnd dr. Silvia W Lestari, M.

Department of Medical Biology Faculty of Medicine, University of Indonesia

Infertility Hypogonadism Sexual dysfunction Male aging Male contraceptive

is the inability to conceive after at least one year of unprotected intercourse in men : -hormone disorders -illness -reproductive anatomy trauma and obstruction -sexual dysfunction can temporarily or permanently affect sperm and prevent conception.

Both Couples need to be counseled and evaluated. HISTORY TAKING is initiated and followed with: PHYSICAL EXAMINATION : Measuring the testicular volume Checking for varicocele or any abnormality Appointment for semen analysis

The search for the cause of infertility usually begins with the male less complicated. A thorough examination and a review of the man's medical and surgical history are necessary chronic disease, pelvic injury, childhood illness, abdominal or reproductive organ surgery, recreational drug use, and medications can affect fertility. Physical examination may detect testicular irregularities, evidence of hormonal disorders or evidence of testosterone deficiency.

General History includes any potential exposure to environmental toxins, either through occupation or hobbies. Medical History of any condition that would potentially affect erectile function, the testes, or the hormonal status of the patient It will also include a review of additional medical conditions for which the patient is being followed, including any condition that would require radiotherapy or chemotherapy. Surgical History during the male infertility visit focuses on any history of GU surgeries at any point during the life of the male undergoing evaluation. Sexual History include the overall pattern of sexual activity , history of sexually transmitted infections asked about the used of lubricants Medication History Prescription drugs can affect sperm count, motility, and morphology, and the dose and duration of use should be documented Social History Cigarette smoking, excessive alcohol consumption, and consistent marijuana use are all known to be gonadotoxins Family History should include a discussion of testicular or other GU malignancies and specifically any cancer history, prostate or bladder problems in other family members. Female Partner History should include details of any previous pregnancies, menstrual cycle length, whether she is undergoing evaluation for fertility issues, and any medical or surgical management that has been necessary

Assessing reproductive-fertility history is important; specialists typically inquire about the following: Early puberty (may result from hormonal disorder) Late puberty (may result from Kallmann's syndrome) Previous pregnancy Sexual intercourse timing (understanding ovulation) STDs (can cause scarring, obstruction) Use of lubricants (may kill sperm)

may detect testicular irregularities (e.g., varicocele, absence of vas deferens, tumor) evidence of hormonal disorders (e.g., underdeveloped reproductive enlarged breast tissue), or evidence of testosterone deficiency.


Male Reproductive System


Varicocele is a mass of enlarged and dilated veins that develops in the spermatic cord within the scrotal sac. If the valves that regulate bloodflow from these veins are congenitally (from birth) defective, causing swelling in the veins above and behind the testicles with resulting warming of the testes.

Pempiniform plexus distended and tortous Testes soft and depressed Exposure to heat and metabolites affect sperm profile

A varicocele can develop in one testicle or both, but in about 85% of cases it develops in the left testicle. The left spermatic vein drains into the left renal vein, which transits between the superior mesenteric artery and the aorta; cause increased distal backpressure and dilation, resulting in formation of a varicocele. The right spermatic vein drains directly into the inferior vena cava and develops a varicocele less frequently




Incidence of varicocele is 10-20% and the condition develops sometime around puberty. The sudden development of varicocele in an older man may indicate a retroperitoneal tumor blocking the spermatic vein, although this is quite rare.

Testosterone production declines naturally with age. Low testosterone, or testosterone deficiency (TD), may result from disease or damage to the hypothalamus, pituitary gland, or testicles that inhibits hormone secretion and testosterone production, and is also known as hypogonadism.

Depending on age, insufficient testosterone production can lead to abnormalities in muscle and bone development, underdeveloped genitalia, and diminished virility. Testosterone is the androgenic hormone primarily responsible for normal growth and development of male sex and reproductive organs, including the penis, testicles, scrotum, prostate, and seminal vesicles. It facilitates the development of secondary male sex characteristics. Additionally, normal testosterone levels maintain energy level, healthy mood, fertility, and sexual desire.

Testosterone production increases rapidly at the onset of puberty and decreases rapidly after age 50 (to 2050% of peak level by age 80). Recent estimates show that approximately 13 million men in the United States experience testosterone deficiency and less than 10% receive treatment for the condition.

Men with obesity, diabetes, or hypertension may be twice as likely to have low testosterone levels. Hypogonadism may be present at birth (congenital) or may develop later (acquired). Causes of the condition are classified according to their location along the hypothalamic-pituitary-gonadal axis: Primary, disruption in the testicles Secondary, disruption in the pituitary gland Tertiary, disruption in the hypothalamus

Klinefelter syndrome. Congenital hormonal disorders such as e.g., Kallmann syndrome also may cause testosterone deficiency. Other congenital causes include absence of the testes (anorchism; may also be acquired) and failure of testicles to descend into scrotum (cryptorchidism).

Klinefelter Syndrom

Semen Analysis
An evaluation spermiogenesis. of spermatogenesis and

Modern approach is to interpret with regard to: diagnosis of specific lesions; and indicators of dysfunctional and/or functional potential. Requires understanding of the relevance of sperm patho-physiology. In any case, the results must be accurate and reliable.

Appearance/colour Odour Liquefaction Volume Viscosity pH Concentration Motility Morphology Total sperm count Other cell

Azoospermia is the absence of sperm in the semen. Men with normal reproductive tracts and hormone systems can have azoospermia due to a lack of sperm-producing tissue in the testes or an obstruction. Obstructions can be viewed with x-ray. The World Health Organization has established criteria for normal sperm concentration, morphology, and motility. Total motile sperm count, which should be about 40 million, is calculated by multiplying volume by concentration by motility. Sperm concentration <20million/mL is named oligozoospermia.

The semen fluid test looks at factors that may impede sperm performance. Abnormally thick semen may cause sperm to swim more slowly through cervical mucus, obstructing fertilization. Abnormal sperm shape (70% or more of sperm in semen is abnormally shaped.

The sperm penetration assay (SPA), or sperm-oocyte interaction test, examines the ability of sperm to penetrate the egg by combining it with a hamster egg. The immunobead test looks at semen for the presence of antibodies that damage sperm The fructose test The sperm chromatin integrity assay The Y chromosome microdeletion assay

A sexual dysfunction, refers to a problem during any phase of the sexual response cycle that prevents the individual or couple from experiencing satisfaction from the sexual activity. Research suggests that sexual dysfunction is common (43% of women and 31% of men report some degree of difficulty), it is a topic that many people are hesitant to discuss. Fortunately, most cases of sexual dysfunction are treatable, so it is important to share the concerns with the partner and doctor.

Sexual dysfunction can be a result of a physical or psychological problem. Physical causes: Diabetes, heart and vascular (blood vessel) disease, neurological disorders, hormonal imbalances, chronic diseases such as kidney or liver failure, and alcoholism and drug abuse. In addition, the side effects of certain medications, including some antidepressant drugs, can affect sexual desire and function. Psychological causes: These include work-related stress and anxiety, concern about sexual performance, marital or relationship problems, depression, feelings of guilt and the effects of a past sexual trauma.

The most common sexual problems in men are ejaculation disorders, erectile dysfunction and inhibited sexual desire.

There are different types of ejaculation disorders, including: Premature ejaculation: This refers to ejaculation that occurs before or soon after penetration. Inhibited or retarded ejaculation: This is when ejaculation is slow to occur. Retrograde ejaculation: This occurs when, at orgasm, the ejaculate is forced back into the bladder rather than through the urethra and out the end of the penis.

In some cases, premature and inhibited ejaculation are caused by psychological factors, including a strict religious background that causes the person to view sex as sinful, a lack of attraction for a partner and past traumatic events. Premature ejaculation, the most common form of sexual dysfunction in men, often is due to nervousness over how well he will perform during sex. Certain drugs, including some anti-depressants, may affect ejaculation, as can nerve damage to the spinal cord or back.

Retrograde ejaculation is common in males with diabetes who suffer from diabetic neuropathy (nerve damage). This is due to problems with the nerves in the bladder and the bladder neck that allow the ejaculate to flow backward. In other men, retrograde ejaculation occurs after operations on the bladder neck or prostate, or after certain abdominal operations. In addition, certain medications, particularly those used to treat mood disorders, may cause problems with ejaculation.

Also known as impotence, erectile dysfunction is defined as the inability to attain and/or maintain an erection suitable for intercourse. Causes of erectile dysfunction include diseases affecting blood flow, such as : -atherosclerosis (hardening of the arteries) -nerve disorders -psychological factors, such as stress, depression, and performance anxiety (nervousness over his ability to sexually perform) -injury to the penis Chronic illness, certain medications, and a condition called Peyronie's disease (scar tissue in the penis) also can cause erectile dysfunction.

Previously: psychogenic factors > organic factors Now : organic factors > psychogenic factors

Inhibited desire, or loss of libido, refers to a decrease in desire for, or interest in sexual activity. Reduced libido can result from physical or psychological factors. It has been associated with low levels of the hormone testosterone. It also may be caused by : -psychological problems, such as anxiety and depression -medical illnesses, such as diabetes and high blood pressure -certain medications, including some anti-depressants -and relationship difficulties.

The doctor likely will begin with a thorough history of symptoms and a physical exam. He or she may order other tests to rule out any medical problems that may be contributing to the dysfunction. The doctor may refer you to other doctors, including an andrologist or urologist (a doctor specializing in the urinary tract ), an endocrinologist (a doctor specializing in glandular disorders), a neurologist (a doctor specializing in disorders of the nervous system), sex therapists, and other counselors.

The End