Male infertility

Diagnosis and Management

Achmad Zulfa Juniarto

 Male Infertility: Prevalence

15% of couples suffer from infertility

A male factor is responsible for the couple
infertility in 30-50% of cases

~5-10% of males are infertile or sub-fertile

 GnRH

INHIBIN

FSH
LH
T PITUITARY/TESTIS
FEEDBACK SYSTEM

CONCENTRATION
T = Testosterone
LH = Leuteinizing Hormone (regulates T secretion)
FSH = Follicle Stimulating Hormone (regulates seminiferous tubule function)TIME
GnRH = Gonadotropin Releasing Hormone (regulates LH & FSH secretion)
INHIBIN from Sertoli cells feedsback on the pituitary to regulate FSH secretion
 Male Reproduction:
Anatomy & Physiology

1. Sperm Production

2. Sperm Transport
SPERMATOGENESIS

1) SPERMATAGONIA
Stem cell (diploid) renewal and progression into meiosis.

2) SPERMATOCYTES
Cells enter meiosis (meiosis = a lessening) for reduction and
division ( two divisions in rapid succesion
{1 diploid cell becomes 4 haploid cells}).
Continued.

3) SPERMATIDS
After reduction & division, the diploid cells differentiate
towards becoming mature sperm, a process called spermiogenesis,
during which time they acquire a tail (flagellum) and acrosome that
develops from the Golgi body.

4) SPERM (Spermatazoa)
At completion of spermiogenesis, each spermatid dissengages
excess cytoplasm and is released into the lumen of the seminiferous
tubule (spermiation).
1) SPERMATAGONIA SPERMATOGENESIS

Ad
Stem cell renewal 16 days
4) SPERM
16d

Ap

SPERMIATION
Stem cell to SPERM (1 Day)
9d B 74 days

Spermiogenesis 25 days d
1d
Meiosis (24d)
d
MI MII Sa b c
8d
8d 2d 6d
2) SPERMATOCYTES
3) SPERMATIDS
SPERMATAGONIA Stem cell renewal
(Mitosis)
16 d

Ad
16 d

Ad 16 d

Ap Ad

SPERM
9d B

Meiosis
MI (24 d) SPERMATIDS d
1d

MII SPERMIATION
d
Sa b c
SPERMATOCYTES
8d
8d 2d 6d
 Etiologic Factors in Male Infertility
Pretesticular
Endocrine Posttesticular
Erectile dysfuction Epididymal Hostility
Ejaculatory
Accessory GFland Infection
Immunologic
Testicular Vasal
Congenital Genetic
Antispermatogenic Agents Cystic Fibrosis
Vascular
Immunologic
Idiopathic
Genetic
Klinefelters Syndrome
Y Chromosome Microdeletions
 Etiology of Male Infertility
Multi-factorial Prevalence
Varicocele 35%
Idiopathic 25%
Infection genito-urinary tract 10%
Genetic 10%
Endocrine 1 - 5%
Immunologic 1 - 5%
Obstruction 1 - 5%
Developmental 1 - 5%
Lifestyle: smoking, diet, heat ???%
 Male Infertility: Evaluation
History
(Questionnaire)
Physical examination
Standard semen
analysis
Hormonal evaluation
Genetic counseling and
evaluation
Imaging studies
 Semen Analysis:
World Health Organization Guidelines

Parameters Normal range

Volume 1.5 - 5 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 (parameters are highly

variable)
Management
 Varicocele

Dilated testicular veins

Mechanisms of Injury:
Increased Heat
Venous Stasis
 Varicocele

Varicocele treatment should be offered when all of the

following are present:

1. A varicocele is palpable.
2. The couple has documented infertility.
3. The female has normal fertility or potentially correctable
infertility.
4. The male partner has one or more abnormal semen
parameters .
 Infection
acute : smallpox, mumps, other viral
infections
chronic : TB, leprosy, prostatitis, sexually
transmitted diseases
 There is a possibility infection with
mycoplasma,ureaplasma, or trichomonas, both
partners should be treated with doxycycline (100
mg orally twice a day for 10 days) or
metronidazole (2 g orally four times a day for 10
days).
 Genetic

General Population 15%

Male Factor 40%

y-chromosome microdeletion 7%
Oligospermia+Azoospermia 30%
Oligospermia+Azoospermia 30%

Y-chromosome
Y-chromosome
microdeletion
microdeletion
30% 30%
 Endocrine

Hypogonadotropic hypogonadism is rare but

a correctable cause of male infertility.
Therapy can be either gonadotropins or
gonadotropin-releasing hormone.
 Immunologic
Men with high levels of antisperm antibodies in their
semen have reduced fertility.
Antisperm antibodies should be suspected in patients
with clumping of sperm, sperm with poor motility, or
unexplained infertility.
The three forms of treatment that are advocated in
such cases are the administration of high doses of
cortico-steroid to the man, intrauterine insemination,
and the use of assisted-reproduction techniques.
 Intra Uterine Insemination
However, drug treatments are ineffective in the
treatment of idiopathic male infertility.
IUI offers couples with male subfertility benefit
over timed intercourse
Intrauterine insemination with or without
ovarian stimulation is an effective
treatment where the man has abnormalities
of semen quality