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Male infertility Work up and Management overview

Male infertility Work up and Management overview. Dr. Anmar Nassir, FRCS(C) Canadian board in General Urology Fellowship in Andrology (U of Ottawa) Fellowship in EndoUrology and Laparoscopy (McMaster Univ ) Assisstent Prof Umm Al- Qura Consultant Urology KFSH & RC.

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Male infertility Work up and Management overview

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  1. Male infertilityWork up and Management overview Dr. Anmar Nassir, FRCS(C) Canadian board in General Urology Fellowship in Andrology(U of Ottawa) Fellowship in EndoUrology and Laparoscopy (McMaster Univ) Assisstent Prof Umm Al-Qura Consultant Urology KFSH & RC

  2. 8-15% of couplesMale = 50%

  3. Pituitary-Gonadal Axis

  4. LH & FSH • LH • Activate testicular T production from Leydig cells • Feed back inhibition by testosterone • FSH • Stimulate Sertoli cells & spermatogonial membranes • The major stimulator of seminiferous tubule growth during development • Feed back inhibition by inhibin from Sertoli cells

  5. Testosterone will initiate and maintain spermatogenesis • Sperm fertility maturation, achieved at the level of the distal corpus or proximal cauda epididymis.

  6. Physiology • Epididymis: • Maturation • Transport • Storage • Vas: • Transfer of sperm • Seminal vesicles (The main bulk of the ejaculate): • Secretory products: e.g. • fructose, prostaglandin, clotting factors • Ejaculation • Coagulation of semen • Prostate: • Liquifaction • Zn: antibacterial & sperm stabilization

  7. The scrotal temperature is is 2°C to 4°C below rectal temperature due to counter-current mechanism

  8. Anatomical Physiology Seminal vesicles  1.5 to 2.0 mL. Prostate  0.5 mL, Cowper's glands  0.1 to 0.2 mL, • Epididymis: • Maturation • Transport • Storage • Vas: • Transfer of sperm • Seminal vesicles (The main bulk of the ejaculate): • Secretory products: e.g. • fructose, • prostaglandin, • clotting factors • Ejaculation • Coagulation of semen • Prostate: • Liquifaction • Zn: antibacterial & sperm stabilization

  9. Evaluation ofInfertile patient

  10. Abnormalities in the woman are involved in approximately 75% of infertile couples. • 30% Ovulatory disorders • 25% fallopian tube abnormalities • 4% endometriosis • 4% cervical mucus abnormalities • 4% hyperprolactinemia • Conception rates drop more rapidly in the 35- to 39-year-old age group.

  11. Many of the genes that affect male reproduction, including the androgen receptor gene, are located on the X chromosome. • Therefore, family history should focus on the phenotype of the maternal uncles

  12. Impairing Spermatogenesis • Medications: • nitrofurantoin , • cimetidine , • sulfasalazine , • Anabolic steroid • Substances: • cocaine • marijuana • Nicotine • pesticides

  13. Infertility History

  14. Physical Exam

  15. Laboratory Assessment • Semen analysis X2 • Quantitation of leukocytes in semen • Lab: Baseline, gluc. , U/A • Hormonal assay FSH, LH, Prol, TSH, • Antisperm antibodies: semen or blood • Advanced sperm fertility tests

  16. Semen • The WHO (1999) defines the following reference values:

  17. Hormonal Evaluation

  18. Diagnostic Studies TRUS US scrotum Testicular biopsy

  19. Asthenospermia Pretesticular Testicular Posttesticular Endocrine Varicocele Antispermantibodies Environment Infection Febrile illness Partial ductal obst. Intrinsic defect

  20. Semen 3cc, 10m/cc, 34% motile, 29% normal morphology and 0.9(10x6) WBC. On scrotal exam : bag of worms Varicocele • 15% of the population • 35% of male with 1ry infertility • 75% of male with 2ry infertility • 40% bilateral • Varicocele repair: • 75% improvement of semen • 35% initiate pregnancy

  21. Varicocele • Semen samples from infertile men with varicoceles have demonstrated decreased motility in 90% of patients and sperm concentrations less than 20 million sperm/mL in 65%of patients.

  22. Improvement in seminal parameters is demonstrated in approximately 70% of patients after surgical varicocele repair. • Improvements in motility are most common, occurring in 70% of patients, with improved sperm densities in 51% and improved morphology in 44% of patients. • Conception rates have averaged 33% to 50% compared with 16% in the control group

  23. Treatment • Surgical: • Inguinal • Retroperitonial • Microscopic sub inguinal • Laparoscopic • Percutaneous venous occlusion

  24. Pyospermia • Round cells: WBCs and immature germ cells. • Semen Culture

  25. Semen: 0.9cc, 0.2m/cc,20% motile and negative post void sperm. ED Obstruction • TRUS Dilated Ej Duct. • TURED

  26. *CBAVD = congenital bilateral absence of the vas deference . Causes of Obstructive Azospermia *

  27. Testicular Biopsy • Diagnostic: • Obstruction vs • Sertoli Cell-only vs • maturation arrest • Therapeutic: Harvesting sperms for ICSI

  28. Indications for ICSI • Immunological infertility • Severe oligoasthenospermia • Obstruction azospermia • Nonobstruction azospermia • Anejaculation ? • pregnancy rate 30 - 60% • Live delivery / initial ICSI cycle 20-40%

  29. Risk of Congenital Anomalies with ICSI • 1.8% congenital anomalies • Miscarriage and congenital anomalies are same for ICSI and IVF

  30. Genetic Evaluation • CF gene • Karyotyping abnormality • Y-chromosome microdeletion

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