An update - causes, diagnosis and treatment of Male infertility by IVF Progeny an ivf-icsi center

       1.     Main causes of male factor infertility

Pretesticular

·       Hypothalamic  disease

 – Gonadorotrophin deficiency  (Kallam  syndrome)

·       Pituitary disease

-  Pituitary insufficiency (tumours, radiation, surgery )

-  Hyperprolactinaemia

-  Exogenous hormones ( anabolic steroids, glucocorticoid excess, hyper – or hypothyroidism )

          Testicular   

·       Congenital  

     Genetic  

     - Chromosomal (Kleinfelter syndrome 47 , XXY)

     - Y chromosome microdeletions

     - Noonan syndrome (male Turner syndrome 45 , XO)

          Other

          -   Cryptorchidism

·       Acquired

-         Injury ( orchitis, torsion, trauma )

-          Varicocele

-          Systemic diease ( renal failure, liver failure )

-          Chemotherapy , radiotherapy

-          Testicular tumours

-          Idiopathic

Post – testicular ( obstruction )

·       Congenital

-  Cystic fibrosis, Congenital of the vas deferens ( CAVD )

-  Young’s syndrome

·       Acquired

 - Vasectomy

 -Infection ( Chlamydia, gonorrhoea )

 - Iatrogenic vassal injury

·       Disorders of sperm function or motility

 - Immotile cilia syndrome

 - Maturation defects

 - Immunology infertility

 - Globozoospermia

·       Saxual  dysfunction

 - Timing and frequency

 - Erectile/ ejaculatory dysfunction

-Diabetes mellitus, multiple sclerosis, spinal cord/pelvic injuries

Regulation of spermatogenesis

The entire spermatogenic process, including transit in the ductal testicular system takes approximately 3 month .

 Male age

For this reason, the age of semen donors is limited to 40 or 45 years in some countries .

Environmental, occupational and lifestyle fectors

These include heat , X-rays, heavy metal (lead, mercury) . glycol ethers (highly volatile compound used as solvents ) and pesticides ; a well documented example being dibromochloropropane (DBCP) , a nematocide used in certain crops .

Pretesticular

Causes include craniopharyngiomas, surgery for pituitary tumours, kallmann syndromes and (GnRH) secretion (Prader- willi syndrome , Laurence- Moon-Biedl syndrome) . 

Testicular

Hypergonadotrophic hypogonadism result from testicular failure and leads to oligozoospermia and non- obstructive azospermia with elevated LH and FSH levels. Also the finding of normal testosterone and LH levels with an elevated FSH implies isolated spermatogenic failure without Leydig cell damage . Causes of testicular failure include bilateral crytorchidism, genetic disorders, systemic disease, (66%) the cause is unknown .

Post- testicular

Cause include surgical trauma and vasectomy , infection (Chlamydia gonorrhoea, tuberculosis), congenital bilateral absence of vas deferens (CBAVD).

2  Components of infertility history of the male

·       Medical history

Recent pyrexia/ illness

Systemic illness – diabetes mellitus, cancer, infection

 Genetic illness – cystic fibrosis, Klinefelter syndrome

·       Surgical history

 Undescended testes, orchidopexy

 Hernia repail

 Testicular trauma, torsion

 Pelvic, bladder or retroperitoneal surgery

·       Fertility history

 Previous pregnancies – with current and previous partners Duration of infertility

 Previous infertility of treatments

·       Sexual history

 Erection ejaculation problems

 Frequency of intercourse

·       Medication

Nitrofurantoin, cimetidine, sulfasalazine, sprionolactone, x-blockers, methotrexaryte, colchicines , antidepressant, phenothiazines, chemotherapy

·       Social history

  Alcohol, smoking, anabolic steroids, recreational drugs      Exposure to ionising radiation

 Chronic heat exposure

 Aniline dyes Pesticides

 Lead exposure

Physical examination

 Varicoceles are usually found on the left side and may associated with atrophy of the testis

Semen analysis

The entire ejaculate should be collected and the sample should be analysed  within an hour of collection because sperm motility decreases after ejaculation .

Fresh semen is coagulated  and liquifies 15-30 minutes after ejaculation . Low ejaculation volumes of <1.5 ml may not buffer against.

Endocrine tests

 FSH, LH, testostetrone nad prolactin should be measured in men with sperm counts of <5 x 10 ml -1  FSH reflected sperm production . Low testosterone levels with high FSH and LH indicate primary testicular failure whereas low testosterone levels in combination with low LH and FSH levels in defect with secondary hypogonadism .

Genetic evaluation

Klinefelter syndrome (47, XXY) is the most frequently detected sex chromosomal abnormality . as many as 10-15% of men with azoospermia and 5-10% of men with severe aligospermia have underlying micro – deletion in one or more gene regions implicated in spermatogenesis , on the long arm of the Y chromosome (Yq). AZFc micro- deletion have a good  prognosis for surgical sperm recovery whereas the prognostic value for sperm recovery in AZFa and AZFb micro – deletion .

Imaging

 Ultrasound can also be use full in the clinical diagnosis of varicocele, a renal ultrasound scan is recommended, as up to 30% of such men have a renal abnormality .

Testicular biopsy

 Biopsy can be done by an open or percutaneous needle approach and is used to obtain a small piece of testicular tissue for histological  examination .

·       Normal ( appropriate number of cella with complete spermatogenesis ).

·       Hypospermatogenesis ( all cell types present and in correct ratio but at reduse cell number )

·       Maruration arrest ( failure of spermatogenesis beyond a certain stege can be early or late )

·       Sertoli cell- only ( del Castillo) syndrome ( no germ cells ).

Other sperm function tests

These include the postcoital test the sperm penetration assay (SPA) and the hemizona assay (HZA) .

Sperm DNA fragmentation has been shown to be a robust sperm DNA tests such as the sperm chromatin structure assay (SCSA) the comet and the TUNEL .

Surgical sperm retrieval

 Testicular sperm aspiration  ( TESA) , testicular sperm extraction (TESE) and microsurgical TESE (micro-TESE). Sperm from the epididymis can be retrieved by microsurgical  (MESA) or percutaneous (PESA) epididymal sperm aspiration under local  anaesthetic .

Assisted reproduction

Indication include mild male factor infertility immunologic  infertility and mechanical problems of sperm delivery such as erectile dysfunction or hypospadias. NICE of oligozoospermia, however, specific semen criteria for its use have not been standardise . it has been  reported that IUI conception rates of  8-16% .
invitro fertilisation (ivf)& intracytoplasmic sperm injection Moreover  it has revolutionised the treatment of male factor infertility including oligospermia,asthenospermia,or following fertilisation failure.ICSI involves the micromanipulation and injection of a single sperm into the cytoplasm of the oocyte. it requires ovarian stimulation,oocyte retreival& sperm prepration as for ivf. average pregnancy rates of 33.0% per embryo transfer.