Role of Urology in Treatment of Male Infertility

1. Nur Rasyid Department of Urology Faculty of Medicine University of Indonesia Role of Urology in Treatment of Male Infertility

2. Introduction • US & Europe : 20% are unable to conceive • 50% : male factor • Urologist : first specialist visit for man factor

3. Aetiology EAU Guidelines 2005

4. Causes of male infertility in RSCM Taher A. Unpublished data

5. Aetiology • Pretesticular • Testicular • Post Testicular

6. Pre Testicular • Hypothalamic disease • Gonadotropin deficiency (Kallmann syndrome) • Isolated LH deficiency (“fertile eunuch”) • Isolated FSH deficiency • Congenital hypogonadotropic syndromes • Pituitary disease • Pituitary insufficiency (tumors, infiltrative processes, operation, radiation, deposits) • Hyperprolactinemia • Exogenous hormones (estrogen-androgen excess,glucocorticoid excess, hyper- and hypothyroidism) • Growth hormone deficiency

7. Testicular • Chromosomal (Klinefelter syndrome [XXY], XX sex reversal, XYY syndrome) • Noonan syndrome (male Turner syndrome) • Myotonic dystrophy • Vanishing testis syndrome (bilateral anorchia) • Sertoli-cell-only syndrome (germ cell aplasia) • Y chromosome microdeletions (DAZ) • Gonadotoxins (radiation, drugs) • Systemic disease (renal failure, liver failure, sickle cell anemia) • Defective androgen activity • Testis injury (orchitis, torsion, trauma) • Cryptorchidism • Varicocele • Idiopathic

8. Post Testicular • Reproductive tract obstruction • Congenital blockages • Congenital absence of the vas deferens (CAVD) • Young syndrome • Idiopathic epididymal obstruction • Polycystic kidney disease • Ejaculatory duct obstruction • Acquired blockages • Vasectomy • Groin surgery • Infection • Functional blockages • Sympathetic nerve injury • Pharmacologic • Disorders of sperm function or motility • Immotile cilia syndromes • Maturation defects • Immunologic infertility • Infection • Disorders of coitus • Impotence • Hypospadias • Timing and frequency

12. Varicocele • Most common correctable cause • Occur 15 % of the general population • Up 35 % of men being evaluated for primary infertility • Up to 80 % of men with secondary infertility • Incompetent venous valve • Associated a progressive and time-dependent deterioration in testicular function

14. Varicocele Repair • Retroperitoneal • Open (Palomo procedure) • Laparoscopic • Inguinal (Ivanisevich procedure) • Using Lense Loupe or Microscope • Subinguinal

15. Improvement • Semen quality improvement : 60 – 80 % • Pregnancy rate : 20 – 60 %

16. Endocrinopathies Only EAU Guidelines 2005

17. Endocrinopathies • Disorder of production or secretion of GnRH • Disorders of pituitary function • Disorders of testosterone synthesis and function

18. Disorder of production or secretion of GnRH Disorders of pituitary function Disorders of testosterone synthesis and function

19. Disorder of production or secretion of GnRH • Low levels of FSH and LH • Kallmann’s syndrome • Hormonal replacement with hCG

20. Disorders of pituitary function • Pituitary mass • Direct compression of the portal system • Decrease FSH/LH secretion  hypogonadotropic hypogonadism • Must performed imaging to find pituitary adenoma • Sugical, radiation and medical (cabergoline, bromocriptin) treatment

21. Disorders of testosterone synthesis and function • Defect enzym for systhesis testosterone • Defect Androgen receptor • Exogenous androgen  reversible in 6 month to 1 year • Treatment • Testosterone supplement • Aromatase inhibitor • Antiestrogens

22. Cryptorchidism & Orchiopexy • Histopathologic hallmarks • Decreased numbers of Leydig cells, • Degeneration of Sertoli cells • Delayed disappearance of gonocytes, • Delayed appearance of adult dark (Ad) spermatogonia • Failure of primary spermatocytes to develop • Reduced total germ cell counts

23. Cryptorchidism & Orchiopexy • Also increase malignancy risk • Treatment : • Orchiopexy in 1 year of age

24. Disorders of ejaculation • Failure of emission or ejaculation • Symphatic nerves injury • Retrograde ejaculation • Medication, prior surgery to bladder neck

26. Disorders of ejaculation • Treatment • Neurogenic problem : simpathomimetic agents  enhance emission and close bladder neck (successful in 50 % cases) • Post ejaculate-urine specimen • Vibratory stimulation under anaesthesia • If all above fail  IVF / ICSI

27. Obstruktif Azoospermia • Tidak adanya spermatozoa dan sel spermatogenesis pada semen dan urine pasca ejakulasi yang disebabkan oleh sumbatan bilateral pada duktus seminalis

28. Obstruction Depend level of obstruction • Complete ejaculatory duct obstruction • Low Volume, acidic, fructose negative ejaculate • Vasa or epididimis obstruction • Normal volume, basic, fructosa positive ejaculate

29. TRUS ( Trans rectal ultrasonografi)

30. Complete ejaculatory duct obstruction

31. Vasal obstruction • Most common etiology : post vasectomy • Treatment • Modified single layer vasovasostomy • Two layer vasovasostomy • Vasoepidimostomy

32. Modified single layer vasovasostomy

33. Two layer vasovasostomy

34. Vasoepididimostomy

35. Congenital bilateral absence of the vas deferens • Sperm harvested from • Epididymis (MESA) • Testis (TESE) •  ICSI

36. PercutaneousEpididymal Sperm Aspiration (PESA)

37. MESAMicrosurgical Epididymal Sperm Aspiration

38. BIOPSI TESTIS

39. Testis Biopsy / TESE

40. ART (ICSI)

41. Conclusion • Each infertility case must be examine carefully to select spesific treatment • Urologist has a pivotal role in surgery treatment for infertility cases