Male Infertility and Impotence

1. Male Infertility and Impotence

2. Definition • Infertility is “inability to conceive after one year of conjugal life without use of contraceptive methods.” • The term "primary infertility" is applied to “the couple who has never achieved a pregnancy.” • "secondary infertility" implies that “at least one previous conception has taken place.”

3. origin of problem: • 35% female • 35% male • 20% both partners • 10% unexplained

4. Major Causes

5. Etiology of Male Infertility Multi-factorialPrevalence • Varicocele 35% • Idiopathic 25% • Infection/injury – genito-urinary tract 10% • Genetic/systemic disease 10% • Endocrine 1 - 5% • Immunologic 1 - 5% • Obstruction 1 - 5% • Developmental 1 - 5% • Lifestyle: smoking, diet, heat ???%

6. Aetiological Classification • 1.Disorders of spermatogenesis: • A)Hormanal • Hypothalamic disorder • Pituitary secretion of FHS and LH • Hyperprolactinaemia causing Impotence or diminished libido. • B) Primary testicular disorders: • Idiopathic, Varicocele • Chromosomal defect, i.e. klinefilter’s syndrome • Crytorchism

7. Drugs,radiations • Orchitis (traumatic,mumps, TB,gonorrhoea) • Chronic illness • Immunological disorders • . • 2) Duct obstruction: • Congenital absence, inflammatory block, surgical trauma, • 3)Accessory glands disorders:Prostitis, vasiculitis, congenital absence of vas in cystic fibrosis.

8. 4.Disorders of sperms and vesicular fluid: Sperms antibodies and low fructose in seminal plasma. • Sperms acrosome defect • Zona pellucida binding defect • Zona penetrations defect • Oocyte fusion defect • 5. Sexual dysfunctions: • Low frequency coitus- wrong time • Impotence, hypospadias • Premature Ejaculation, retrograte ejaculation

9. 6.Psychological factors and environmental factors like smoking,alcohol consumption,tobacco chewing,diabetes, • Drugs: antihypertensive,antipsycotis,sex steroids, chemotherapy, beta-blockers, spirolactone,oestrogen

10. Unexplained Cervical/mucus Endometrial/uterine Pelvic/peritoneal Tubal Developmental/genetic 10% 2-3% 2-3% 5-10% 30-50% 40% Female Infertility Etiologies

11. Other Etiologies • PID • Cx conization/cautery • Smoking • IUD • Endometriosis • Genetics

12. Aetiology • 1.dyspareunia and vaginal causes • 2.Congenital defect in the genital tract. • 3.infection in the lower genital tract. • 4.Cervical factors • 5.Uterine causes • 6.Tubal factors • 7.Ovaries • 8.Peritoneal causes • 9.Chronic ill health – especially thyroid dysfuntion

13. The Most Important Factor in the Evaluation of the Infertile Couple Is: HISTORY

14. History-General • Both couples should be present • Age • Previous pregnancies by each partner • Length of time without pregnancy • Sexual history • Frequency and timing of intercourse • Use of lubricants • Impotence, anorgasmia, dyspareunia • Contraceptive history

15. Male Infertility: Evaluation • History (Questionnaire) • Physical examination • Standard semen analysis • Hormonal evaluation • Genetic counseling and evaluation • Imaging studies

16. History-Male • History of pelvic infection • Radiation, toxic exposures (include drugs) • Mumps • Testicular surgery/injury • Excessive heat exposure (spermicidal)

17. Physical Exam-Male • Size of testicles • Testicular descent • Varicocoele • Outflow abnormalities (hypospadias, etc)

18. Male Factors-Semen Analysis • Collected after 3 days of abstinence • Evaluated within one hour of ejaculation • If abnormal parameters, repeat twice, 2 weeks apart

19. Semen Analysis:World Health Organization Guidelines Fresh sample (to lab within 30 mins.) –most sperm in initial ejaculate Male should be abstinent for 48 to 72 hours 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

20. Semen Analysis Abnormal semen results • Azospermia • Oligospermia • Athenospermia • Teratospermia

21. Normozoospermia Normal ejaculate Asthenozoospermia Teratozoospermia Azoospermia Aspermia Normal ejaculate Sperm concentration <20 × 106 /ml <50% spermatozoa with forward progression <30% spermatozoa with normal morphology No spermatozoa in the ejaculate No ejaculate Sperm Terms

22. Hormonal and others • GnRH • FSH • LH • TSH • Prolactin level • Rule out genetic diseases. • Chromosomal study • Immunological study

23. Imaging Studies • Transrectal Ultrasound (TRUS) • Vasography • Testis Biopsy

24. Transrectal Ultrasound (TRUS) Ejaculator ductal stones Seminal vesicle dilatation.

25. Vasography • Indication • Assessment of vasal obstruction or ejaculatory duct obstruction. • An inguinal vasal obstruction should be suspected in an azoospermic patient with normal spermatogenesis and a history of prior inguinal or scrotal surgery.

26. Testis Biopsy • Indication • Distinguishing between obstruction and testicular failure. • Identification of mature sperm for ICSI

27. Treatment- Male Factor • Hypogonadotrophism:-GnRH • Ligation Retrograde ejaculation • Testosterone for spermatogenesis • Clomiphene 50 mg daily for 3 months for oligospermia. • Empierical medical therapy by administration of vit.c , B 12, folic acid. • Varicocele:- surgical treatment • Obstruction:-short-cut operation • IVF/IUI :- last option.

28. Female Infertility: Evaluation • History (Questionnaire) • Physical examination • Ovarian factor • Tubal factors • Hormonal analysis • Immunological test • Postcoital test

29. History-Female • Previous female pelvic surgery • PID/Infection • Medical diseases:-TB, diabetes,STD • IUD use/MR done • Ectopic pregnancy history • Proven fertility • Endometriosis

30. History-Female • Irregular menses, amenorrhea, detailed menstrual history • Vasomotor symptoms • Stress • Weight changes • Exercise • Cervical and uterine surgery

31. Physical Exam-Female • Pelvic masses • Uterosacral nodularity • Abdominopelvic tenderness • Uterine enlargement • Thyroid exam • Uterine mobility • Cervical abnormalities

32. Ovarian factors • Fern test • Endometrial biopsy in secretory phase • Serial USG • Serum progesterone • Laparoscopy • D & C.

33. Tubal factor Tubal patency test by:- • Tubal insufflation test • Hystero-salphingo-graphy • Laproscopy dye insufflation test • Hydrotubation

34. Hormonal Immunological • FSH • LH • Estrogen • Progesterone • TSH • Prolactin • Testosterone • Antisperm antibody

35. Treatment for female factor • Anovular :- clomiphene citrate bromocriptine • D&C:- histopathology, bacteriology • Reconstructive surgery:- developmental defect • Surgery:- tubal block • If all method fails, then go for….

36. Assisted Reproductive Technologies • Intrauterine Insemination(IUI) • In Vitro Fertilization(IVF) • IVF and Intra Cytoplasmic Injection of Sperms(ICSI)

37. Intrauterine insemination (artificial insemination) • definition: Artificial introduction of semen into the vagina, cervix or uterus by means other than coitus to produce pregnancy is called artificial insemination. • sperm can come from husband or donor or pool donor.

38. IUI, cont’d. • 6000 babies / year born in US. as result of artificial insemination INDICATION OF ARTIFICIAL INSEMINATION:- • Impotent husband. • Sterile husband. • Husband suffering from hereditary disease. • Rh-incompatibility between husband and wife.

39. In vitro fertilization • test - tube babies” • 1st performed in 1978 (Louise Joy Brown) • often performed on infertile women with tubal blockage

40. Test tube babies/ in-vitro fertilization Techniques:- • The ovum is removed from ovary through abdominal wall and is fertilized with the sperm in a small laboratory dish in artificial medium.. • At the stage of blastocyst, the embryo is return to uterus through cervix. • Blastocyst is implanted in endometrium.

41. Artificial insemination in laboratory disc Blastocyst