Male Infertility

Male Infertility


ETIOLOGY:

CAUSE FEATURE
Genetic
  • XXY
  • Mutation of short or long arm Y chromosome

Disorders of spermatogenesis

 

Hormonal (pretesticular):

  • Hypothalamic disorder, Kallman’s syndrome. 
  • Pituitary secretion of FSH, LH.
  • Hyperprolactinaemia 
  • Hypothyroidism, adrenal gland disorder & diabetes.

Primary testicular disorders (testicular):

  • Idiopathic, varicocele, absent germ cells( Sertoli cell only syndrome)
  • Chromosomal defect
  • Cryptorchidism.
  • Drugs, radiation
  • Calcium channel blocker
  • Anticonvulsants
  • Antihypertensives
  • Spironolactone 
  • Cimetidine.
  • Orchitis
  • Chronic illness.
  • Immunological disorders (5%).
  • Immotility due to absence of dynein arms.
  • Absent cilia in Kartagener’s syndrome (15%).

Ejaculatory Duct obstruction:

Clinical diagnosis of ejaculatory duct obstruction is based on a triad:

  • Small ejaculate volume
  • Azoospermia
  • Absence of seminal fructose.
  • Congenital:
  • Failure of testes to descend down in the scrotum(Degeneration of the epithelium of seminiferous tubules)
  • Inflammatory block
  • Surgical trauma
  • Young’s syndrome with sinusitis and bronchiectasis
  • DNA fragmentation of sperm
  • Antibodies to genital infection

 Accessory gland disorders

  • Prostatitis
  • Vesiculitis
  • Congenital absence of vas in cystic fibrosis

Disorders of sperms and vesicular fluid

  • Sperm antibodies and low fructose in seminal plasma.
  • Immotile cilia syndrome /Kartagener’s syndrome(infertility(due to immotile sperm), situs inversus, chronic sinusitis, and bronchiectasis).
  • Sperm acrosome defect.
  • Zona pellucida binding defect.
  • Zona pellucida penetration defect.
  • Oocyte fusion defect
 Sexual dysfunctions
  • Low-frequency coitus—wrong time, low libido.
  • Impotence, hypospadias.
  • Premature ejaculation.
  • Retrograde ejaculation.

Psychological and environmental factors

  • Smoking
  • Alcoholism:Liver dysfunction causes increased estrogen and decreased testosterone leading to testicular atropy leading to infertility
  • Tobacco 
  • Diabetes
  • Drugs:
  • Antihypertensive
  • Antipsychotics
  • Cimetidine,
  • Sex steroids 
  • Chemotherapy
  • Nitrofurantoin
  • Beta-blockers,
  • Spironolactone
  • Oestrogen
 Obesity 
 Chronic illness 

 INVESTIGATIONS:

 HISTORY:

  • Coital frequency and timing related to ovulation
  • Occupation
  • Habit of smoking, alcohol, tobacco and drugs
  • History of TB , STD, diabetes and chronic illness
  • H/O surgery(hernia or scrotum)
  • Any coital problem: Premature and retrograde ejaculation, failure to ejaculate
General examination:
  • Height(Kallman and Klinefelters syndrome)
  • Weight and obesity (Hormonal defects)
  • The secondary sex characters
  • Thyroid enlargement, enlarged breasts and hirsutism

Local examination:

  • Penis
  • Scrotum
  • Surgical scars

Special investigations:

  • Semen analysis:Counts below 20 million/mL
  • Hormonal assays.
  • Postcoital test/Sims’ or Huhner’s test
  • Miller–Kurzrok test
  • Sperm penetration test
  • Transrectal ultrasonography: IOC for ejaculatory duct obstruction 
  • Seminal vesicle aspiration:IOC for ejaculatory duct obstruction 
  • Semen–cervical mucus contact test
  • Testicular biopsy
  • Immunological tests.
  • Patency of vas.
  • Chromosomal study. 
MANAGEMENT:

Education:

  • sexual counselling
  • coital position
  • masturbation
  • Substance abuse:Avoidance of tobacco (smoking, chewing), moderation in consumption of alcohol and avoidance of drug abuse.
  • Reduce heat around the scrotum.
  • Correct endocrinopathies
  • Surgical:
  • Varicocele: microsurgery the gold standard
  • Surgical correction of the undescended testes
  • Obstruction in the vas by vaso-vasal or vaso-epididymal anastomosis

Antibiotics:

  • Doxycycline
  • In epididymo-orchitis, prostatitis & STD

Premature ejaculation:

  • Selective serotonin reuptake inhibitors
  • Dapoxetine

Hormonal therapy:

  • HCG
  • Testosterone
  • FSH
  • Clomiphene: hypogonadal infertility
  • Letrozole: hypogonadal hypopituitarism
  • Human menopausal gonadotropin:In  pituitary inadequacy
  • GnRH—is indicated in hypothalamic failure
  • Tamoxifen
  • Dexamethasone
  • Sildenafil (Viagra)
  • Artificial insemination
  • Chronic medical disorder.
  • Oligospermia after sperm washout.
  • Impotency—ejaculatory failure.
  • Premature & retrograde ejaculation
  • Hypospadias
  • Antispermal antibodies
  • Unexplained infertility
  • Genetic and chromosomal abnormalities
  • HIV-positive male or female
  • IVF:
  • Indicated in retroperitoneal lymphnode disection followed by surgery for cancer
  • Microtesticular aspiration of sperm with In Vitro Fertilization can help this couple to achieve pregnancy. 
  • (Intracytoplasmic injection is a form of IVF)
Exam Question
 
  • Male infertility occurs if the sperm count is less than 20 million / ml
  • Infertility is a common feature in Sertoli cell only syndrome, because There is no germ cells in this condition
  • Transrectal ultrasound and seminal vesicle aspiration are investigations which help in confirmation of the  diagnosis of Ejaculatory Duct obstruction
  • Degeneration of the epithelium of seminiferous tubules is the cause of infertility in patient with  failure of testes to descend down in the scrotum
  • Patient with Kartagener’s syndrome is diagnosed to have Immotile sperm
  • Liver dysfunction causes increased estrogen and decreased testosterone leading to testicular atropy leading to infertility
  • Kartagener’s syndrome includes  Male infertility, Situs inversus & Bronchiectasis Sinusitis
  • Most common cause of surgically treatable male infertility is Varicocele
Don’t Forget to Solve all the previous Year Question asked on Male Infertility

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