Male subfertility Defined as the inability to conceive

Male subfertility

Defined as the inability to conceive after 1 year of regular unprotected sexual intercourse. ØIt affects approximately 15% of couples. ØRoughly : 40% male factor 40% femal factor 20% both

Male reproductive physiology The HPG axis. Hypothalamic–pituitary–testicular axis The hypothalamus secretes gonadotrophin-releasing hormone (Gn. RH). This causes pulsatile release of anterior pituitary gonadotrophins, called folliclestimulating hormone (FSH) and luteinizing hormone (LH), which act on the testis. §FSH stimulates the seminiferous tubules to produce sperm § LH acts on Leydig cells to produce testosterone

The Testis v. Endocrine : leydic cell produce testesteron Testestron coverated to dihydrotesterone By action of 5 alpha-raductase v. Exocrine : The seminiferous tubules---Spermatogenes is produce sperm

Spermatogenesis Is a complex process by which primitive, totipotent stem cells divide to either renew themselves or produce daughter cell that become spermatozoa. • The duration of entire spermatogenesis is 74 days. • Germ cells are replicate by meioses

Management History q Duration of sub fertility q. Earliar prgnencies with same or ather partner q. Sexual histry q. General medical and surgical history q. Childhood disease like mumps q. Cryptorchidism q. Exposure to medications and chimical q. Family history

Physical examination § Degree of virilization §Gynecomastia §Testicular size and consistancy §Status of epididymis §Varicocele §Penis and prostate

Laboratory GUE : infection, glucosuria, hematuria. Semen analysis is the primary source of information on sperm production & reproductive tract patency. sample collection, sexual abstinence duration 2 -7 day. WHO considered the minimum criteria for normal semen quality. o volume : 1. 5 -5 ml o concen, : 20 million/ml and more o motility: >50% progression score : 2 (scale 1 -4) morphology : >30% Other semen parameters §Fructose absent in semen-- Seminal vesicle agenesis §Retrograde ejaculation

Hormone assessment §Evaluation the HPG axis §LH, FSH, testesteron and prolactine §Estradiol §FSH and testesteron may be sufficient Indication low sperm less than 10 million Impairment of sexual function Other endocrinopathy (thyroid dis. )

Adjunctive tests Semen leukocyte analysis. pyospermia >1 million leukocyte/ml. Antisperm antibody (ASA) test. Mainly used in unexplained sub fertility

Hypoosmotic swelling (HOST) test differentiate immotile from dead sperm (necrospermia). Sperm –cervical mucus interaction Chromosomal studies like Cystic fibrosis mutation testing Radiologic testing qscrotal ultrasound q. Venograghy q. TRUS Testicular biopsy and vasography Now use for sperm retrieval for ICSI in azoospermia

Causes of male infertility Pretesticular causes hypothalamic disease Like gonadotropin deficiency pituitary disease pituitary insufficiency Hyperprolactinemia exogenous hormones

Testicular causes v chromosomal like klinefelter syndrome vgonad toxins like radiation v systemic disease vtestis injury v cryptorchidism vvaricocele vidiopathic

Posttesticular causes q. Reproductive tract obstruction • Congenital blockage like idiopathic epididymal obstruction • Acquired blockage q. Vasectomydisorder of sperm function or motility immotile cilia syndrome qdisorder of coitus impotence

Treatment Surgical treatment üVaricocelectomy üvaso-vasostomy üejaculatory duct obstruction (TURED). üelectroejaculation (spinal cord injuries).

Nonsurgical treatment §Pyospermia treated by Doxycycline & trimethoprimsulfa + antioxidant like vit. A, E, & C §Coital therapy : coitus every other day around time of ovulation §Immunologic infertility treated like steroids §Medical therapy : to treat specific hormonal abnonmality Hyperprolactinemia Hypo-hyperthyrodism Hormonal deficiency

Empiric Medical Therapy Ø Antiestrogen : like Clomiphene citrate Ø Antioxidant therapy ØGrowth hormone ASSISTED REPRODUCTIVE TECHNOLOGIES ØIntrauterine Insemination ØIn Vitro Fertilization ØInteracytoplasmic sperm injection ICSI