MANAGEMENT OF MALE

INFERTILITY

DR. EMMANUEL FILIBUS

DEPT. OBS $ GYNAE, JUTH, JOS.
30/11/2010

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OUTLINE
 INTRODUCTION
 INCIDENCE
 GOALS OF MANAGEMENT
 CLINICAL PRESENTATION
 INVESTIGATIONS
 TREATMENT
 CONCLUSION
 REFERENCES
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INTRODUCTION

 Infertility in couples is a worldwide problem.

 The woman is often blamed erroneously, for the

misfortune of the infertile couple.

 It is associated with family stress.

 Male factor contribution to infertility is 25-40%

worldwide.

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 Definition infertility is the inability of a couple to
achieve a pregnancy after 12 months despite regular
unprotected intercourse.

 Normal fertile couples having frequent intercourse,

the fecundability is 20–25%.

 About 90% of couples with unprotected intercourse

will conceive within 1 year.
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INCIDENCE
 1 in 7 couples will have problems with fertility.

 USA, Singapore, Bangladesh: male factor contribute 23-30%

 In Africa, male factor contribution is 40-48%

 In Nigeria, male factor contribution base on SFA 54%

 Male factor only, contribute to 20% of infertility.

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 Jos:
Imade GE et al (2001)
normal SFA 29%
abnormal SFA 71%

Daru PH et al (2008)
normal SFA 35%
abnormal SFA 65%
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 UCH Ibadan
Adeniji RA et al (2003)
Normal SFA : 72%
Abnormal SFA: 28%

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ANATOMY

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GOALS OF MANAGEMENT
 Identify reversible factors

 Identify irreversible factors

 Identify underlying medical conditions

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 HISTORY

Couple’s approach
 General information

 Fertility history
 Sexual habits
 Childhood illnesses
 General medical history

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 Surgical history
 Drug history
 Urogenital history/STIs
 Family history
 Occupational history
 Habits

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PHYSICAL EXAMINATION
 General examination
- Features of eunochoidism
- Blood pressure
- Rule out chronic debilitating disease
- Secondary sexual characteristics

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 Central Nervous System
- Visual fields (pituitary adenoma)
- Sense of smell (Kallmann Syndrome)

 Abdomen/pelvis
- Surgical scars

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 Urogenital examination

 Penis
- Length (normal development)
- Position of urethral meatus (deposition of semen)
- Discharge
- Induration of the urethra
- Tenderness

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 Prostate (DRE)
- Size
- Firmness
- Tenderness
- Presence of cysts

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 Scrotal examination
- Presence of testis
- Hydrocele
- Varicocele
- Masses
- Nodules
- Tenderness

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 Varicocele:
Is a group of dilated veins in the Pampiniform
plexus of the spermatic cord.
- Affect 15 % healthy men
- Affect 25% of men with abnormal SFA
-Dragging sensation/pain on affected side
(usually left side).

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 Testis:
 - position ( ?cryptorchidism)

 - size (4cm × 2.5cm)

 - volume (normal ~15-25ml)*

 - firmness (normal = firm)

 *Note: Normally, >70% of testis volume is from germ

cells alone. Therefore, a soft and/or small testis is
indicative of abnormal spermatogenesis.

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The orchidometer

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INVESTIGATION
 SFA

 ENDOCRINE TEST
- FSH
-LH
-Testosterone
-Prolactin

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 Chromosomal and genetic studies
-Sperm chromatin structure assay (SCSA)
-comet
-Terminal dUTP nick-end labeling (TUNEL)

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 Testicular biopsy
No more favourable

 Imaging Of Male Genital Tract

-Retrograde venography
-Ultrasound and Doppler
-Radionucleotide angiography
-Thermography

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 OTHER TESTS
-postcoital test
-antibody study (immunobead test)
-sperm penetration assay (zona-free hamster
egg penetration test)

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 SEMINAL FLUID ANALYSIS

 Set of descriptive measurements of spermatozoa and

seminal fluid parameters that help to estimate semen
quality

 Normal values issued by WHO in 2010 should serve

as reference values

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 SFA
 Semen is an exception among biological fluids as it’s
parameters display very wide inter- and intra-
individual variations

 Seminal analysis should be repeated to take intra-

individual variations over time into account in order
to confirm the parameters

 Sensitivity 89.6%
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 SFA
Collection of seminal for analysis

- Abstinence for 2 - 7 days

- Masturbation

- Coitus interruptus

- Special condoms

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 SFA: WHO REFERENCE VALUES, 2010
Table A1.1 Lower reference limits (5th centiles and their 95% confidence intervals)
for semen characteristics

Parameter Lower reference limit

 Semen volume (ml) 1.5 (1.4–1.7)
 Total sperm number (106 per ejaculate) 39 (33–46)
 Sperm concentration (106 per ml) 15 (12–16)
 Total motility (PR + NP, %) 40 (38–42)
 Progressive motility (PR, %) 32 (31–34)
 Vitality (live spermatozoa, %) 58 (55–63)
 Sperm morphology (normal forms, %) 4 (3.0–4.0)

Other consensus threshold values

 pH ≥ 7.2
 Peroxidase-positive leukocytes (106 per ml) <1.0
 MAR test (motile spermatozoa with bound particles, %) <50
 Immunobead test (motile spermatozoa with bound beads, %)<50
 Seminal zinc (mol/ejaculate) ≥2.4
 Seminal fructose (mol/ejaculate) ≥13
 Seminal neutral glucosidase (mU/ejaculate)
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EJACULATE VOLUME, SPERM CONCENTRATION, SPERM
COUNT AND VIABILITY

 Secretions from the accessory glands – a major

component of seminal fluid

 Ejaculate volume not directly related to spermatogenesis

 Total number of spermatozoa/ejaculate reflects

spermatogenesis

 Wide range of sperm density even in fertile men

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SPERM MOTILITY

 Severe alterations of sperm motility may indicate

ultrastructural defects

 Motility is defined based on demonstration of

flagellar movement

 The multitude of steps required for ovum

fertilization renders sperm motility as only a
crude index of fertilizing capacity
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MORPHOLOGY

 Strict criteria (Kruger et al)

- Give better predictive value in IVF

Reported normal IVF rates for cases with >14%

normal spermatozoa

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 SFA
 Identification of other cell types present in semen

- Immature sperm cells

- Leukocytes (>1×106/mL – bacteriological

cultures)

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 SFA

 Semen quality in man is declining worldwide

 Nigeria: Poor semen quality accounts for 20-40% of

infertile unions

 Jos Study(2008): 65.3% of men had ≥1 semen

abnormality

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TREATMENT

 General measures
-stopping smoking
-Reducing alcohol consumption
-Avoid tight cloth underwear
-Avoid hot baths (43-45oC) for 30 minutes/day

 Treat specific cause identified, target treatment

-surgical
-non-surgical

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SURGICAL TREATMENT

Treatment options progress from least to most invasive or

the use of donor sperm.

 Mild to moderate disease

treatment: Intrauterine insemination (IUI)

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 Severe disease (< 2 million motile sperm)
- Intracytoplasmic sperm injection ( ICSI)

Indications for ICSI:

1) Poor SFA parameters
2) Fertilization failure with standard IVF
3) Spermatozoa defects leading to poor
fertilization
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Epididymal sperm retrieval

 Microscopic Epididymal Sperm Aspiration

(MESA)

 Percutaneous Epididymal Sperm Aspiration

(PESA)

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Testicular Sperm Retrieval

 Testicular sperm aspiration (TESA)

 Testicular sperm extraction (TESE)

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 Obstructive defect
Treatment:
- surgical reanastomosis
- Retrieval of sperm via MESA or TESA for
the use with ICSI

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 Vasectomy reversal

 Macroscopic technique

 Microsurgery

Cryopreservation of spermatozoa should be

suggested when counselling for vasectomy
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 Varicocele
1) Clinical varicocele: present in 15% of men
Treatment: ligation leads to improved pregnancy
(contradicting evidence)

2) Subclinical varicocele:
Treatment:? Indication for correction

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Varicocele repair

 Operative – Ligation of testicular vein

 Non operative – Percutaneous varicocele embolization

 Specially designed underwear with irrigation system

to cool the scrotum

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NON-SURGICAL TREATMENT

 Genital tract infections

-Significant cause of male subfertility

Rx -Anti-inflammatory agents

-Antibiotics

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 Hypogonadotrophic hypogonadism

Rx - hCG
- hMG
- Pulsatile GnRH analogues
- GH/gonadotrophins

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 Hyperprolactinaemia
- Bromocriptine

 Isolated Testosterone deficiency

i.m depot preparations of testosterone
- Testosterone enanthate
- Testosterone cypionate

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 Congenital Adrenal Hyperplasia
- Glucocorticoid replacement

 Immunologic infertility
- Oral Prednisolone (rarely successful)

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Disorders of ejaculation

Retrograde ejaculation

o alpha-adrenergic agents
- Ephedrine
- Pseudoephedrine
- Imipramine
- Phenylpropanolamine

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 Anejaculation

 Rectal probe electroejaculation (RPE)

 Penile vibratory stimulation

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 Empirical Therapy

 Anti-oestrogens: Clomiphene Citrate

 Anti-oxidants: Vitamin E
Pentoxyphylline
Platelet Activating Factor
Gluthatione
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 When male infertility is not amenable to therapy,
Rx: Donor sperm for insemination or for IVF

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CONCLUSION
 Male infertility is a worldwide problem.
Evaluation and treatment of the identified cause
of the infertility as well as MESA and TESA for
IVF gives hope.

 When male factor infertility is not amenable to

therapy; there is room for donor sperm for
insemination or for IVF.

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REFERENCES
 WHO Laboratory Manual for the Examination and Processing Human
Semen, 5th edition, 2010: 1-227.

 Daru PH, Ekwempu CC, Pam IC, Egboodo CO, Imade G and Sagay
AS. Revisit of Current Patterns of Semen Quality among Male
Partners of Infertile Couples seen at the Jos University Teaching
Hospital. Highland Medical Research Limited, 2008; 6/7 (2/3): 71-75.

 Imade GE, Sagay AS, Pam IC, Ujah IOA and Daru PH. Semen
Quality in Male Partners of Infertile Couples in Jos, Nigeria. Trop
Obst Gynaecol, 2001;7(1):24-26.

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 Kumar A, Ghadir S, Eskandari N and Decherney AH. Infertility.
In: Decherney AH, Nathan L, Goodwin TM and Laufer N (eds),
Current Obstetrics and Gynaecology, 10th edition, USA, McGraw
Hill, 2007; 917-925.

 Adeniji RA, Olayemi O, Okunlola MA and Aimakhu CO. Pattern

of Semen Analysis of Male partners of Infertile Couples at the
University Collage Hospital, Ibadan. WAJM, 2003; 22(3): 243-
245.

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 Okpere E (ed). Infertility . In: Clinical Gynaecology, Mindex
Publishing, Nigeria, 2007: 124-144.

 Ganong WF (ed). The Gonads: Development and Function of the

Reproductive System. In: Review of Medical Physiology, 22nd
edition, Mc Graw Hill, 2005: 411-453.

 Bhattacharya S. In: Edmonds DK (ed), Dewhurst’s Textbook of

Obstetrics and Gynaecology, 7th edition, UK, Blackwell
Publishing, 2007: 440-460.

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1Thank you
for
listening

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