male infertility

1. DR. RABI NARAYAN SATAPATHY
ASST.PROFESSOR
DEPT. OF OBST.& GYNAECOLOGY
SCB MEDICAL COLLEGE, CUTTACK
MOB-09861281510
EMAIL-drrabisatpathy@gmail.com

2. Relative Prevalence Of The Etiologies Of Infertility
10% 10%
40-50%
25-40%
Both male & female
factor
Female factor
Male factor
Unexplained
infertility
Incidence Of Male Infertility Is Increasing ! !Incidence Of Male Infertility Is Increasing ! !

3. PRESENTATION OF MALE INFERTILITYPRESENTATION OF MALE INFERTILITY
ABDOMINAL SEMEN PROFILEABDOMINAL SEMEN PROFILE MALE SEXUAL DYSFUNCTIONMALE SEXUAL DYSFUNCTION
 AZOOSPERMIAAZOOSPERMIA  ERECTILE DYSFUNCTIONERECTILE DYSFUNCTION
 OLIGOSPERMIAOLIGOSPERMIA  EJACUALATORY DYSFUNCTIONEJACUALATORY DYSFUNCTION
 ASTHENOSPERMIAASTHENOSPERMIA  RETROGRADE EJACULATIONRETROGRADE EJACULATION
 TERATOZOOSPERMIATERATOZOOSPERMIA  PREMATURE EJACULATIONPREMATURE EJACULATION
 HIGH LEUCOCYTE COUNTHIGH LEUCOCYTE COUNT
 COMBINATIONCOMBINATION

4. PretesticularPretesticular TesticularTesticular PosttesticularPosttesticular
EndocrineEndocrine
Hypogonadotropic hypogonadismHypogonadotropic hypogonadism
Hypothyroidism,Hypothyroidism,
hyperprolatinaemiahyperprolatinaemia
DiabetesDiabetes
Coital disordersCoital disorders
Erectile dysfunctionErectile dysfunction
Ejaculatory failureEjaculatory failure
GeneticGenetic
Klinefelter’s SyndromeKlinefelter’s Syndrome
Y chromosome deletionY chromosome deletion
Immotile cilia syndromeImmotile cilia syndrome
CongenitalCongenital
CryptorchidismCryptorchidism
Infective (orchitis)Infective (orchitis)
Antispermatogenic agentsAntispermatogenic agents
Heat, Chemotherapy, Drugs,Heat, Chemotherapy, Drugs,
IrradiationIrradiation
VascularVascular
TorsionTorsion
VaricoceleVaricocele
ImmunologicalImmunological
IdiopathicIdiopathic
ObstructiveObstructive
EpididymalEpididymal
CongenitalCongenital
InfectiveInfective
VasalVasal
Genetic: Cystic fibrosisGenetic: Cystic fibrosis
Aquired: VasectomyAquired: Vasectomy
Epididymal hostilityEpididymal hostility
Epididymal asthenospermiaEpididymal asthenospermia
Accessory glandAccessory gland
infectioninfection
ImmunologicalImmunological
IdiopathicIdiopathic
Post vasectomyPost vasectomy
ETIOLOGICAL FACTORS IN MALE INFERTILITYETIOLOGICAL FACTORS IN MALE INFERTILITY

5. CAUSECAUSE PERCENTAGEPERCENTAGE
No demonstrable causeNo demonstrable cause
Idiopathic abnormal semenIdiopathic abnormal semen
VaricoceleVaricocele
Infectious factorsInfectious factors
Immunologic factorImmunologic factor
Other acquired factorsOther acquired factors
Congenital factorsCongenital factors
Sexual factorsSexual factors
Endocrine disturbancesEndocrine disturbances
48.5%48.5%
26.4%26.4%
12.3%12.3%
6.6%6.6%
3.1%3.1%
2.6%2.6%
2.1%2.1%
1.7%1.7%
0.6%0.6%
Frequency of Etiologies in Male Factor InfertilityFrequency of Etiologies in Male Factor Infertility
WHO Study 1994, Eshre Capri Workshop Group (7057 men)WHO Study 1994, Eshre Capri Workshop Group (7057 men)

6. EVALUATION OF MALE INFERTILITYEVALUATION OF MALE INFERTILITY
 HistoryHistory
 Physical examinationPhysical examination
 Semen analysisSemen analysis
 Additional proceduresAdditional procedures
- Sperm function tests- Sperm function tests
- Immunological tests- Immunological tests
- Bacteriological tests- Bacteriological tests
- Hormone assays- Hormone assays
- Testicular biopsy- Testicular biopsy
- Chromosomal analysis- Chromosomal analysis
- Vasography- Vasography
- Transrectal ultrasound (TRU)*- Transrectal ultrasound (TRU)*

7. HISTORYHISTORY
 Age and duration of marriageAge and duration of marriage
 Occupation –hyperthermia,pesticidesOccupation –hyperthermia,pesticides
 H/O childhood problems – Cryptorchidism – surgeryH/O childhood problems – Cryptorchidism – surgery
Delayed pubertyDelayed puberty
 Medical History – Mumps, syphilis, leprosy, tuberculosisMedical History – Mumps, syphilis, leprosy, tuberculosis
Chronic respiratory diseases –Chronic respiratory diseases –
Young’s syndrome – epididymal obstructionYoung’s syndrome – epididymal obstruction
Immotile cilia syndrome – Sperms are immotileImmotile cilia syndrome – Sperms are immotile
Cystic fibrosis – Congenital absence of VASCystic fibrosis – Congenital absence of VAS
Endocrine disorder, diabetes, hypothyroidism,Endocrine disorder, diabetes, hypothyroidism,
Renal failure, Liver disease, hypertension, multiple sclerosisRenal failure, Liver disease, hypertension, multiple sclerosis

8. HISTORY (Contd…)HISTORY (Contd…)
 Surgical & Traumatic History – Damage of VAS –Surgical & Traumatic History – Damage of VAS –
Hernia,Hernia,
Orchidopexy, Vasectomy, Trauma, Torsion, Spinal cordOrchidopexy, Vasectomy, Trauma, Torsion, Spinal cord
injuryinjury
 Sexual history – Timing, frequency ,conception windowSexual history – Timing, frequency ,conception window
H/O–Erectile & Ejaculatory problem -H/O–Erectile & Ejaculatory problem -
Nocturnal penile trumescence (NPT)Nocturnal penile trumescence (NPT)
 Family history –Family history –
 History of smoking, alcohol, radiationHistory of smoking, alcohol, radiation
 Drugs – Antipsychotic, Antihypertensives,CimetidineDrugs – Antipsychotic, Antihypertensives,Cimetidine
Anticonvulsants, Sex steroids, EnvironmentalAnticonvulsants, Sex steroids, Environmental

9. PHYSICAL EXAMINATIONPHYSICAL EXAMINATION
 General – Obesity, Secondary sexual character , gynaecomastia, BodyGeneral – Obesity, Secondary sexual character , gynaecomastia, Body
habitus, Thyroid gland, Galactorrhoea, Visual filed effect, Features ofhabitus, Thyroid gland, Galactorrhoea, Visual filed effect, Features of
endocrinopathyendocrinopathy
 Per abdomen – Scar of hernia, lymph nodePer abdomen – Scar of hernia, lymph node
 Local examinationLocal examination
* Scrotum- hernia, hydrocele, varicocele* Scrotum- hernia, hydrocele, varicocele
* Testes – Present or absent* Testes – Present or absent
Size (18-20ml)Size (18-20ml)
SensationSensation
* Penis – Hypospadius, phimosis* Penis – Hypospadius, phimosis
* Epididymis & VAS – Presence, feel, presence of cyst* Epididymis & VAS – Presence, feel, presence of cyst
* Rectal examination* Rectal examination

10. SEMEN ANALYSIS (WHO 1999)SEMEN ANALYSIS (WHO 1999)
VolumeVolume > 2ml> 2ml
pHpH 7.2-7.87.2-7.8
Sperm concentrationSperm concentration ≥≥20milion/ml20milion/ml
Total sperm countTotal sperm count ≥≥40milion/ml40milion/ml
MotilityMotility ≥≥50% with normal50% with normal
morphologymorphology
MorphologyMorphology ≥≥30% normal forms30% normal forms
WBCWBC < 1 X 10< 1 X 1066
/ ml/ ml
MAR testMAR test < 10% spermatozoa with< 10% spermatozoa with
adherent particleadherent particle

11. SEMEN ANALYSISSEMEN ANALYSIS
ENDTZ test can distinguish between leukocytes &ENDTZ test can distinguish between leukocytes &
immature germ cells (both round cells)immature germ cells (both round cells)
Sperm vitality test:Sperm vitality test:
* Eosin Nigration test* Eosin Nigration test
* Hypoosmotic swelling test* Hypoosmotic swelling test
* H33258 Flurochrome test* H33258 Flurochrome test
Split EjaculateSplit Ejaculate

12. SPERM FUNCTION TESTSPERM FUNCTION TEST
 Sperm cervical mucus interactionsSperm cervical mucus interactions
a. In Vivo –a. In Vivo – Post Coital TestPost Coital Test (Sim’s Hunner test)(Sim’s Hunner test)
b. In Vitro –b. In Vitro –
I. Sperm cervical mucus contact test (SCMC test)I. Sperm cervical mucus contact test (SCMC test)
II. Tube test (Kremar test)II. Tube test (Kremar test)
 Hemizona test (Human zona binding assay)Hemizona test (Human zona binding assay)
 Hypoosmotic swelling testHypoosmotic swelling test
 Swim up testSwim up test
 Computerised assisted seminal analysis (CASA)Computerised assisted seminal analysis (CASA)
 Evidence of acrosomal reactionEvidence of acrosomal reaction

13. IMMUNOLOGICAL TESTSIMMUNOLOGICAL TESTS
Indications –
• Abnormal semen profile
• Abnormal cervical mucus sperm interaction
• Failed Vasectomy reversal
• Marked Agglutination
Two Tests –
a. Immunobead testa. Immunobead test
b. MAR testb. MAR test
c. Others – TAT test, Kibrick’s test, Frankling Duke test, Isojama’s
test (Not done now a days)

14. MIXED AGGLUTINATION REACTION
(MAR) TEST
 Screening test for detection of antisperm antibodies
on the surface of sperm head or tail.
 Washed sperms from the patient are mixed with
antibody coated RBC, (Sheep RBC + rabbit antibody)
 These antibody will form mixed agglutinates with
motile sperms carrying imunoglobulins
 MAR test is positive when particulate binding is found
in over 10% spermatozoa.

15. HORMONE ASSAYSHORMONE ASSAYS
 FSHFSH
 LHLH
 TestosteroneTestosterone
 EstradiolEstradiol
 ProlactinProlactin
 TSHTSH

16. HORMONAL CONTROL OF SPERMATOGENESISHORMONAL CONTROL OF SPERMATOGENESIS
HypothalamusHypothalamus
GGnnRHRH
Anterior PituitaryAnterior Pituitary
FSHFSH LHLH
Sertoli cellSertoli cell Leydig cellLeydig cell
InhibinInhibin ABGABG TT
ABG+TABG+T
- Ve- Ve - Ve- Ve
- Ve- Ve
SpermotogenesisSpermotogenesis andand
spermsperm maturationmaturation

17. Hormones in different clinicalHormones in different clinical
conditionsconditions
FINDINGSFINDINGS DIAGNOSISDIAGNOSIS
1.1. Azoospermia or OligospermiaAzoospermia or Oligospermia
Small testesSmall testes
FSH - HighFSH - High
Primary testicular failurePrimary testicular failure
(Severe tubular damage)(Severe tubular damage)
2. Azoospermia2. Azoospermia
Normal testicular volumeNormal testicular volume
FSH – Normal levelFSH – Normal level
i. Bilateral genital tract obstructioni. Bilateral genital tract obstruction
ii.Sertoli cell only syndromeii.Sertoli cell only syndrome
3. FSH – Lower or undetectable3. FSH – Lower or undetectable
LH – LowLH – Low
Testosterone – LowTestosterone – Low
Other evidences of androgen def.Other evidences of androgen def.
HypogonadismHypogonadism
4. LH – High4. LH – High
Testosterone – HighTestosterone – High
Androgen receptor defectAndrogen receptor defect

18. TESTICULAR BIOPSYTESTICULAR BIOPSY
 Obstructive AzoospermiaObstructive Azoospermia
 Non Obstructive Azoospermia – To detect isolatedNon Obstructive Azoospermia – To detect isolated
areas containing sperm cells for TESE – ICSIareas containing sperm cells for TESE – ICSI
Grading – Johonson’s Scoring System ( 1 – 10)Grading – Johonson’s Scoring System ( 1 – 10)
2 – Sertoli cell only2 – Sertoli cell only
3 – Spermatogonia3 – Spermatogonia
4,5 – Spermatocytes4,5 – Spermatocytes
6,7 – Spermatids6,7 – Spermatids
8,9,10 – Spermatozoa8,9,10 – Spermatozoa

19. CHROMOSOMAL ANALYSISCHROMOSOMAL ANALYSIS
 Azoospermia, Severe Oligozoospermia, Klinefelter’sAzoospermia, Severe Oligozoospermia, Klinefelter’s
Syndrome (47XXY), Sex Reversal Syndrome (46 – XXSyndrome (47XXY), Sex Reversal Syndrome (46 – XX
male)male)
 Azoospermic factor (AZF) at Long arm of Y –Azoospermic factor (AZF) at Long arm of Y –
Chromosome -absence of AZF ( Deletion of that part)Chromosome -absence of AZF ( Deletion of that part)
means Azoospermiameans Azoospermia

20. Sex Chromosome Abnormalities LeadingSex Chromosome Abnormalities Leading
to Male Infertilityto Male Infertility
Syndrome Karryotpe abnormalities Phenotype
Klinefelter’s syndrome 46, XY/47, XXY mosaic,
47, XXY – 49, XXXY
Male with increased
height, small firm testes
possibly female hair
distribution
Mixed gonadal dysgensis 45, X/ 46, XY mosaic,
possibly normal 46, XY
Male, female, or
ambiguous genitalia, testis
are streak
XX male syndrome 46, XX SRY translocation
to the short arm of X
Male with Sertoli’s-cell-
only on testis biopsy
XYY male 47, XYY Male, possibly increased
height

21. TREATMENT MODALITIES OF MALETREATMENT MODALITIES OF MALE
INFERTILITYINFERTILITY
• General MeasuresGeneral Measures
• Medical ManagementMedical Management
• Surgical Management:-Surgical Management:- Vasovasostomy, Epididymovasostomy,Vasovasostomy, Epididymovasostomy,
Repair of varicocele, Orchidopexy, Surgery forRepair of varicocele, Orchidopexy, Surgery for
HypospadiusHypospadius
• Artificial Insemination:-Artificial Insemination:- Intrauterine insemination (IUI)Intrauterine insemination (IUI)
• Assisted Reproductive Technology:-Assisted Reproductive Technology:- IVF & ET,IVF & ET,
Intracytoplasmic sperm injection (ICSI),Intracytoplasmic sperm injection (ICSI), PESA, MESA &PESA, MESA &
TESE –TESE – ICSI,GIFT,ZIFTICSI,GIFT,ZIFT
• Management of Male Sexual DysfunctionManagement of Male Sexual Dysfunction

22. Medical ManagementMedical Management
• Hormonal –Hormonal – HCG, HMG, GHCG, HMG, GnnRH, Testosterone, CC,RH, Testosterone, CC,
Thyroxine, BromocryptineThyroxine, Bromocryptine
• Antibiotics, Corticosteroids,Aromatase inhibitorAntibiotics, Corticosteroids,Aromatase inhibitor
• Sperm Vitalising Agents –Sperm Vitalising Agents – Pentoxifylline, KallikreinPentoxifylline, Kallikrein
• Emperical TherapyEmperical Therapy
• Antioxidants – In increased ROSAntioxidants – In increased ROS

23. Washed sperms are injected inside the
uterine cavity preferably in stimulated
cycle with proper monitoring of ovulation

24.  SEMINOPATHIES – OLIGOSPERMIA,
ASTHENOTERATOSPERMIA, LOW VOLUME
SEMEN, HIGH VISCOUS SEMEN
 CERVICAL FACTOR – PCT NEGATIVE
 IMMUNOLOGICAL INFFERTILITY
 UNEXPLAINED INFERTILITY
 ERECTILE FAILURE, EJACULATORY FAILURE,
PREMATURE EJACULATION, RETROGRADE
EJACULATION
INDICATIONS OF I U I

25. STEPS OF INTRA-UTERINE
INSEMINATION
Ensure tubal patency Semen analysis & culture
Ovarian stimulation Sperm Collection
Monitoring of ovarian
Response & fixation of Sperm processing
Ovulation time
Insemination
& Luteal support

26. SWIM – UP TECHNIQUESWIM – UP TECHNIQUE
Semen processing media(Ham’s F-10)Semen processing media(Ham’s F-10)
&&
SEMEN SAMPLESEMEN SAMPLE
INCUBATE AT 370
C
30 MINUTE
Liquefied semen sample
Equal Quantity of MEDIA
Aspirate upper & middle
part
In another centrifuge tube
Centrifuge at 2000 RPM
FOR 1 MINUTE
Discard supermatant & Leave pellet
Centrifugation
at 2000 RPM
15 minute
Mix
well
Discard supernatant
& leave pellet
MEDIA
Pellet
Keep the tube
inclined at 300
In incubator at 370
c
For 45 minute
Layer 2 ml Media
Over Pellet
Add 0.5 ml. Semen processing media
& mix well
Sample ready for
IUI

27. SINGLE LAYER DENSITY GRADIENT CENTRIFUGATION TECHNIQUE
* DENSITY GRADIENT MEDIA
* SPERM WASHING * SEMEN SAMPLE
MEDIA (Han’s 110)
INCUBATE AT 370
C
30 MINUTE
Centrifugation
At 2000 RPM
LIQUEFIED SEMEN
D.G. Media
15 minute
Disard Supermatant Centrifugation at 2000 RPM Pellet with 2ml Add 2ml. Spermwashing
& Leave pellet 5 minute Spermwashing medium
Medium mix well with pellet Discard
supermatant
& leave pellet
Add 0.5 ml. Of
sperm washing
medium
Mix well with pellet
Pellet with
0.5 ml. Sperm washing medium
Keep at 370
c
10-15 minute
Sample ready for IUI

28. RESULTS OF IUI
CLINICAL PREGNANCY – 10-25% IN AIH
20-40% IN AID
20-25% END IN MISCARRIAGE

29. INTRACYTOPLASMIC SPERM INJECTIONINTRACYTOPLASMIC SPERM INJECTION
(ICSI)(ICSI)
 It involves the direct insertion of a single sperm cellIt involves the direct insertion of a single sperm cell
into the cytoplasm of a single oocyte byinto the cytoplasm of a single oocyte by
micropuncturemicropuncture
 Indications – Severe OAT, Obstructive azoospermiaIndications – Severe OAT, Obstructive azoospermia
by MESA, PESA, Nonobstructive azoospermia byby MESA, PESA, Nonobstructive azoospermia by
TESE, Unexplained infertilityTESE, Unexplained infertility
MESA:MESA: Microsurgical Epididymal sperm aspirationMicrosurgical Epididymal sperm aspiration
PESA:PESA: Percutaneous Epididymal sperm aspirationPercutaneous Epididymal sperm aspiration
TESE:TESE: Testicular sperm extractionTesticular sperm extraction

34. RESULTS OF ICSIRESULTS OF ICSI
Fertilization rate -Fertilization rate - 60-70%60-70%
Pregnancy rate –Pregnancy rate – 20-40%20-40% /Embryo transfer/Embryo transfer
Male partner having abnormal karyotype inMale partner having abnormal karyotype in
Y-Chromosome micro deletion should undergoY-Chromosome micro deletion should undergo
genetic counselling before ICSIgenetic counselling before ICSI

35. TREATMENT OF OLIGOASTHENOTERATOZOOSPERMIATREATMENT OF OLIGOASTHENOTERATOZOOSPERMIA
(OAT)(OAT)
Infective
* Antibodies
Immunological
* Corticosteroid
* Condom
Endocrinal
* GnRH
* hCG
* hMG
* Testosterone
* CC
* Bromocryptine
* Thyroxin
Idiopathic
* CC
* Empirical
*Antioxidants
If FailsIf Fails
* IUI
*ART

36. TREATMENT OF AZOOSPERMIA
Azoospermia
Obstructive
* Surgery
* Epididymal sperm
Aspiration (MESA, PESA)
IVF-ET
GIFT
ZIFT
ICSI
* TESE – ICSI
* TDI
Non obstructive
* TESE – ICSI
* TDI
Endocrinal (Rare)
* GNRH
* HCG
* HMG
* CC

37. Treatment of
Erectile and Ejaculatory
Dysfunction
Erectile Dysfunction
* Withdrawal of drugs
* Treatment of underlying cause
* Psychosexual therapy
* Local injection ,Vacuum pump
* Transurethral pellet ,Penile implant
* Sildenafil(Viagra),Tadalafil,Vardenafil
Ejaculatory Dysfunction
* Psychosexual therapy
* Vibrator
* Electro-Ejaculation
Retrograde Ejaculation
* Coitus in full bladder
* Alphaadrenergic or cholinergic
drugs
* Insemination with post-voided urine
after processing
Premature Ejaculation
* Use of condom
* Pelvic Floor exercise
* Squeeze techniques
* IUI with ejaculated sperm

38. CONCLUSION
 Male factor is involved up to half of infertile couples
 Thorough evaluation is needed to detect the
abnormality
 There are only few cases in practice where specific
drug therapy is indicated
 Though IUI is an effective procedure it has little role
in severe OAT.
 ICSI has revolutionized the management of male
infertility. But it is a very expensive procedure

39. CONCLUSION (Contd…)
 Sexual dysfunction should always be enquired and be dealt
with sympathy
 Vibrator and Viagra are two effective tools available in
ejaculatory and erectile failure
 More research is needed to know paracrine regulation of
spermatogenesis and to develop newer treatment to
improve sperm parameters in VIVO
 Irrespective of problems adoption of general measure is
important in achieving pregnancy