Male Infertility, Varicocele, Vasectomy

Male Infertility
Normal physiology
Hypothalamus secrets LHRH
 Inhibited by prolactin (from pituitary) and testosterone (from Leydig cells)

LHRH stimulates anterior pituitary gland to produce LH and FSH

 FSH production inhibited by inhibin B and testosterone
 LH production inhibited by testosterone
 Anterior pituitary also secretes growth hormone, TSH, ACTH and prolactin
 Posterior pituitary secretes ADH and oxytocin (both synthesized in hypothalamus)

FSH and testosterone stimulate Sertoli cells to secret inhibin B and androgen-binding protein
LH stimulate Leydig cells to secrete testosterone

Function of Sertoli cells

 Regulate spermatogenesis
 Blood-testis barrier
 Secretion of inhibin B & androgen binding protein

Function of Leydig cells

 Located at interstitium
 Secretion of testosterone as endocrine and paracrine

Spermatogenesis
 About 70 days
 Spermatogonium (Adult stem cells, 2n)  mitotic division  Primary spermatocyte (2n)  First
meiosis  Secondary spermatocyte (1n) Second meiosis  Spermatid (Haploid
chromosome, 1n)  Spermatozoa (Haploid chromosome, 1n)

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Sperm maturation journey

 Spermatozoa formed in testis, entered epididymis
 Epididymal transit
o 2-6 days in human
o During transit in epididymis (motility 3% at caput, 60% at cauda), sperm undergo
maturation process
o Acquire motility and fertilizing ability
 In female reproductive tract
o Uterus secret enzymes (steroid binding albumin)
o Sperm acquires capacitation ability (hence, finally competent to fertilize the egg)

Basics of Infertility
WHO Definition of Infertility
 Inability for a sexually-active, non-contracepting couple to achieve spontaneous pregnancy
in one year

Primary infertility
 Failure to achieve first pregnancy
Secondary infertility
 Failure to achieve subsequent pregnancy

Epidemiology
 Normal couple pregnancy rate: 25% per month
 Pregnancy rate 1-3% per month in non-azoospermic couple, 30% will conceive eventually
 75% will conceive in half year, 85% of couples will conceive within 1 year  15% infertility

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 5% will remain unwillingly childless
 Male factor 30%, male + female factor 30%, female factor 40%

Prognostic factors
 Duration of infertility
 Primary or secondary infertility
 Results of semen analysis
 Age and fertility status of female partner
Female age is the single most important variable influencing outcome in assisted reproduction
Compared to woman aged 25 years old, fertility only 50% at 35 years old, 25% at 38 years old, 5%
at 40 years old

Etiology of male infertility

 Pre-testicular
o Hypothalamic disease
o Pituitary disease
 Testicular
o Varicocele
o Trauma
o Torsion
o Cryptorchidism
o Chemo / Radiation
o Genetic disorder
 Klinefelter syndrome
 Y-chromosome microdeletion
o Systemic disease
o Gonadotoxin
 Post-testicular
o Disorder of sperm transport
 Congenital bilateral absence of vas
 Acquired disorder (post vasectomy / STD / infection)
 Functional disorder (ejaculatory disorder)
o Disorder of sperm motility
 Congenital defect of sperm
 Immunological disorder

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 Infection

Prevalence
 All patients
o Idiopathic infertility 30% - Oligo-astheno-terato-zoospermia OAT
o Varicocele 15%
o Hypogonadism 10%
o Undescended testis 8.4%
o Obstruction 2.2%
 Azoospermic patients (10% of all infertile male)
o Non-obstructive 2/3
 Undescended testes 17%
 Hypogonadism 16% (Mainly Klinefelter syndrome)
 Idiopathic infertility 13%
 Varicocele 10%
 Causes of primary/secondary testicular failure
o Obstructive 1/3
 Vasectomy 5%
 CBAVD 3%

Approach to Infertility

What would you ask in history taking?

I would see the patient and his partner in my infertility clinic, preferably with his partner adequately
screened for female factors first.

I will confirm the duration of infertility, whether it is primary or secondary infertility. Enquire
about the sexual history to ensure proper and adequate attempts, history and methods of
contraception, erectile and ejaculatory function of the patient.
Past medical history focused on testicular pathology like epididymo-orchitis, mumps,
undescended testes, STD, torsion, trauma; endocrine and respiratory diseases e.g. cystic
fibrosis, Kartagener syndrome (causing immotility of sperm), history of inguinoscrotal /
retroperitoneal surgery / transurethral surgery, chemotherapy and radiotherapy or other
gonadotoxin.

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Family history of hypogonadism and genetic diseases were enquired.

Drug history focused on (anabolic) steroid and other hormones usage.

Social history: Smoking, drinking, hot bath

In physical examination,
Look for the habitus and degree of virilization, stigmata of Klinefelter syndrome and any
inguinoscrotal scar.
Examine the penis for any chordee, Peyronie’s disease and hypospadias.
Examine the testes for mass, position, size and consistency. Normal volume is 20ml (Prader
orchidometer).
Examine the epididymis for any induration or cyst.
Examine for any varicocele and palpate for the presence of vas deferens.
Perform DRE for the prostate and seminal vesicle

Kartagener syndrome
 AR
 Cilia dyskinesia
 Situs inversus, chronic sinusitis, bronchiectasis
 Moveable tail (flagella) of sperm also affected  Infertility

Investigation
Semen analysis
Collection
 Abstinence for 3-5 days (more than 7 days would lead to reduce motility)
 Obtain semen with masturbation
 Avoid use of condom with spermicide
 Avoid coitus interruptus
o Lost initial part of semen (lots of motile sperm), bacteria and acidic vaginal environment
that may contaminate the specimen
 Use wide mouthed container
 Specimen kept in body temperature
 Examined within 1-2 hours

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What is no sperm could be seen in the SA?
 If no spermatozoa are found in wet preparation, examine in concentrated specimen  20%
will find sperms
 Centrifugation at 3000rpm for 15 minutes
 Examine pellet under phase contrast optics at 200x magnification

If abnormal SA, what should do?

 If abnormal, at least 2 samples are required each separating 3 months apart

Criteria
 WHO laboratory manual 5th edition 2010
 Values of percentiles of semen parameters from men whose partner became pregnant within 1
year of discontinuing contraception are tabulated
 Using 5th percentile as the new threshold

 Volume: 1.5ml
o 30% from prostate (Acidic)
o 60% from SV (Alkaline)
o 10% from testis
o Causes of low semen volume
 CBAVD
 Ejaculatory duct obstruction
 Retrograde ejaculation
 Low testosterone production
 Improper collection

 pH >7.2
o If no contribution from SV (e.g. CBAVD / Obstruction distal to SV)  Acidic

 Sperm concentration (million / mL)

o Oligozoospermia: Concentration of sperm <15 million/ml
o Special clearance: Immotile sperm < 100,000/ml

 Progressive motility
o Asthenozoospermia: Less than 32% of sperms are of Grade A motility (rapidly

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progressing >20um/second) or 40% Grade A + B
o Causes
 Anti-sperm antibodies
 Prolonged abstinence
 Infection (associated with leucocytospermia = high oxygen reaction species which
can damage sperm)
 Varicocele
 Immotile cilia syndrome
o Grading of sperm motility (all at 37oC)
Grading Motility Criteria
A Rapidly progressive
(>20µm/sec)
B Slowly progressive
(5 - 20µm/sec)
C Non progressive
(<5 µm/sec)
D Immotile

 Normal forms
o Teratozoospermia: <4% normal forms
o Normally, majority of sperm would have some minute abnormalities
o Dye test with methylene blue stain
 Kruger criteria
 Smooth, oval head
 Acrosome 40-70% of head volume
 No abnormalities of neck, mid-piece of tail

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o WHO criteria: More lenient, normal = at least 4% sperm normally shaped

o Kruger strict criteria: More strict, normal = at least 15% sperm normally shaped
o Men with normal fertility can have up to 85% abnormal morphology

 Fructose >13
o Secreted by SV, if obstruction distal to SV  Low level

 Pyospermia
o Differential diagnosis: Immature germ cells vs white cells
o Differentiate by monoclonal antibodies to white cells

 Sperm agglutination
o Check for anti-sperm antibodies (IgG and IgA bound to sperm)
o Condition associated with anti-sperm antibodies formation
 Vasectomy
 Testicular trauma / infection / cancer
 Varicocele
 Cryptorchidism

Blood
 FSH (1st line)
o FSH correlates with the number of spermatogonia
 When spermatogonia is absent, FSH is high (Usually 3x)

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 For Sertoli-cell only, FSH is usually elevated
 Maturation arrest, FSH is usually normal
o Normal FSH ~10mIU/ml
(KL Ho: >7 is abnormal already)
 Morning testosterone (1st line)
o ~10-38nmol/L, 270-1070ng/dL
o Testosterone exhibits a circadian rhythm, with peak in the early morning and trough level
in the late afternoon
 LH
o 2-12mIU/ml
 Prolactin
 Karyotype <10 million/ml for Klinefelter disease
 Y chromosome microdeletion < 5 million/ml
 CFTR testing in case of CBAVD
o If +ve: Check partner’s genetics & presence of bilateral kidneys

Testicular biopsy
Indication
 Obstructive azoospermia
o At least one vas, normal hormonal profile and normal testes volume
o To be done before reconstructive surgery  To rule out Sertoli cell-only syndrome /
Maturation arrest
 Non obstructive azoospermia
o Perform during TESE / micro-TESE in case of NOA to rule out TIN and predict success
rate in subsequent TESE

 Bouin’s solution: Picric acid, acetic acid, formaldehyde

 Other solution: Zenker’s solution or glutaraldehyde; Formalin should not be used
 Eppendorf tubes if sperm cryopreservation as well
 Johnson scores
1 No cells
2 Sertoli cell only
3 Spermatogonia
4 <10 Spermatocytes
5 Many spermatocytes

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6 <10 Spermatids
7 Many spermatids
8 <10 Spermatozoa
9 Many spermatozoa but disorganized epithelium
10 Complete spermatogenesis organized epithelium
 ≥ 8 will be adequate for IVF

Oligo-Astheno-Teratospermia (OAT)
Causes of OAT
 Idiopathic
 Varicocele
 Infection
 UDT
 Gonadotoxin
o Heavy metals (Lead, Cadmium, Mercury, Pesticides, Herbicides)
o Alcohol (Reduced sexual function)
o Smoking (Oxidative damage to sperm DNA)
o Heat
o Radiation/Chemotherapy
o Anti-sperm antibodies

Azoospermia
 1% of general male population
 10% of infertile male
 2/3 non obstructive, 1/3 obstructive

Non-obstructive azoospermia
 2/3 of azoospermia cases
 Usually high FSH, small testes
o Normal FSH in 40% of men with primary spermatogenic failure
o Exception: Maturation arrest (with normal FSH)

Management
 Sperm retrieval + ART
o Micro-TESE: > 50% success of sperm retrieval
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 Result of ICSI worse than OA: Birth rate 19% (compared with 28% in OA) and higher
miscarriage rate

Causes
 Undescended testis 17%
 Hypogonadism 16%
 Idiopathic 13%
 Varicocele 10%

Primary hypogonadism
 Caused by Leydig cell dysfunction, with elevated LH level
 Exogenous testosterone is not indicated because insufficient testicular testosterone could be
reached and this could suppress pituitary LH release
 Causes
o Commonest: Klinefelter Syndrome
o Testicular insults
 Infection / Trauma / Malignancy / Gonadotoxins / Heavy Metals / Alcohol /
Smoking / Heat / Chemoradiation / Anti-sperm antibodies
o Pre-testicular: Pituitary tumor such as hyperprolactinoma
o Genetics
 >15% have positive genetic studies
 Risk of transfer of abnormal genes to offspring
 Chromosomal abnormalities such as Klinefelter syndrome / Y-chromosome
microdeletions / Kallman syndrome
o Idiopathic

Klinefelter syndrome
 Most common sex chromosome abnormality (1 in 1000 male births)
 Not directly inherited (X chromosome could be coming from father or mother)
 47XXY or 46XY / 47XXY mosaicism, only seen in some of the cells

Clinical presentation
 Phenotype ranged from normally virilized man to one with stigmata of androgen deficiency
 Long arms and legs due to delayed epiphyseal closure
 Female hair distribution, gynecomastia, scant body hair

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 Small testes
 Associated with undescended testes

Need for long term follow up?

 FU needed as long-term hypogonadism, risk of breast cancer, testicular cancer (GCT and
Leydig cell tumor), extra-gonadal germ cell tumors, lung cancer and NH lymphoma

Hormonal profile
 Testosterone level normal or low (low in 50% cases), FSH and LH increased
 Indications of karyotyping: NVA, oligozoospermia <10 million/ml

Management
 Micro-TESE
o 30-50% spermatozoa can be found
o X chromosome or XY chromosome (10%) carrying sperm
 Testicular biopsy
o Sclerosis of tubules and Sertoli-cell only in non-sclerosed tubules
o Small hyalinized seminiferous tubules, pseudo-adenomatous clusters of Leydig
cells

o
 Regular monitoring
o Hypogonadism
 Higher risk of metabolic, cardiovascular diseases and venous thromboembolism
(Hence, be careful when starting testosterone replacement)
 Pre-implantation genetic analysis
o Increased genetic abnormality
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o 3-day embryo, at least 8 cells
o One cell is removed for analysis
o Pregnancy rate slightly lower than IVF alone

Y-chromosome microdeletion (Azoospermia factor AZF)

 Azoospermia factor: a region in long arm of chromosome Y, important in sperm formation
 10-15% of NOA
 9% of HK Chinese

Three subtypes
 AZFa (Sertoli cell-only)
o Virtually 0% sperm retrieval, FSH elevated usually
o Congenital Sertoli cell only syndrome: Failure of germ cell migration
o Acquired Sertoli cell only syndrome: Degenerative
o

 AZFb (Maturation arrest)

o Virtually 0% sperm retrieval, FSH normal
 AZFc
o Most common
o Severe oligozoospermia
o 60% success of sperm retrieval by TESE
o Increased risk of Turner syndrome (45 X) or transferal of YCMD to male
o Need proper counseling: If the offspring is male, he will surely carry the AZFc gene as
well

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 TESE should not be arranged for AZFa and AZFb mutation
 Indications for genetic testing: NVA, severe oligozoospermia (<5 millions/ml)

Kallmann syndrome
 Most common X-linked disorder in infertility practice
 X-linked recessive

Clinical presentation
 Isolated failure of gonadotrophin production with otherwise normal pituitary production
 Hypogonadotrophic hypogonadism and anosmia (loss of smell)
 Other features
o Unilateral renal agnesis
o Long arms and legs / craniofacial abnormalities / Gynecomastia / UDT / Micropenis /
small testis

Management
 Spermatogenesis can be induced by hormonal treatment

Obstructive azoospermia
 1/3 in azoospermia
 Normal sized testes, normal hormonal profiles

Workup
 TRUS
o For any absence of vas and SV
o Prostatic cyst / calcification and distended SV
 USG Scrotum for epididymis
 USG Kidney

Intra-operative vasogram
 When to perform?
o Intra-operative for
 Transurethral resection of ejaculatory duct: for confirming diagnosis and using
blue dye to confirm adequate resection

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 VE / VV: To ensure distal patency
o Due to risk for vasal scarring or obstruction, vasography should be performed in the
same time with reconstructive surgery
 How to perform?
o Microsurgical dissection and isolate the vas
o Hemitransect the vas with scalpel at the straight portion of vas
o Vas fluid examined under microscope to confirm presence of sperms
o Saline vasography: inject 0.5-1ml NS, look for any resistance
o 24G angiocath into distal vas (inject indigo carmine, Foley to BSB, confirm distal
obstruction with clear Foley urine)
o Fr 3 catheter into distal vas (injecting contrast for vasogram)

Results of ICSI better / Birth rate 28% in OA

Congenital Bilateral Absence of Vas Deferens

Absence of vas and seminal vesicles

Clinical picture
 Clinically: absence of vas and seminal vesicles
 Semen: Low pH, low volume, low fructose
 Radiological: Absence of SV / Vas / Epididymis on TRUS; USG showed unilateral renal
agenesis

Two main population

Majority: Associated with cystic fibrosis
Cystic fibrosis
Chromosomal abnormalities
 Cystic fibrosis transmembrane conductance regulator (CFTR gene); Chromosome 7p
 Most common mutation: delta F 508
 Autosomal recessive

Incidence
 Carrier 1 in 25; Incidence 1 in 2,000 in Caucasian, 1 in 350,000 in Japan

Pathophysiology

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 Chloride channel defect  prevent the usual flow of chloride ions and water into and out of the
cells  Thick mucus secretions that result in typical presentation with recurrent URTI
 Thick mucus clogs the tubes that carry sperm from testis (the vas deferens) as they are
forming, causing them deteriorate before birth

Clinical features
 CAVD is the most consistent features of CF patients (~98%)
 Respiratory symptoms: 50%
 Pancreatic enzyme deficiency / GI obstruction
 Salt tasting skin

Diagnosis
 Positive genetic testing, or
 Positive sweat chloride test plus COPD / Pancreatic insufficiency / positive family history

Genetic counselling
 Test partner for any gene mutation
 If positive  50% chance of inheritance
 If negative  0.4% chance of being a carrier of unknown mutation
 No need to test the male patient actually, bound to have the gene defect

Minority: Associated with Unilateral Renal Agenesis

 Genetic basis not well understood
 Men with CUAVD is usually fertile
 Unilateral absence of vas is usually associated with ipsilateral absence of kidney / ectopic
kidney  CFTR gene screening not indicated
 Unilateral absence of vas + normal kidneys  CFTR gene screening indicated

Management
 No reconstructive surgery as the obstruction is irreversible
 Sperm retrieval (PESA/MESA) + ART
 Genetic counseling

Ejaculatory duct obstruction

Causes

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 Congenital: Prostatic cysts / Mullerian cysts
 Acquired: Post-infective / Post-surgical
Prostatic utricle cysts Mullerian duct cysts
Age presents at 10s-20s presents at 20s-30s

Location always at level of verumonatum anywhere along the pathway of Mullerian duct

always midline (from scrotum to prostatic utricle)

Pathology Embryological remnant of Mullerian Focal incomplete regression of Mullerian

duct system (paramesonephtic) duct

Usually smaller <10mm larger

do NOT extend above prostate gland typically EXTEND above prostate gland

Relation with COMMUNICATES with urethra do NOT communicate with urethra

urethra

Association hypospadias do NOT associated with other GU tract

UDT abnormalities

unilateral renal agenesis

Clinical presentation / Signs and Symptoms

 Pain during ejaculation
 Distended SV (AP >15mm)
 Semen: Low volume, acidic pH

Management
Transurethral resection of EDO
 Intra-op trans-rectal injection of methylene blue and contrast to seminal vesicles, or,
intra-operative vasogram
 Resection of verumonatum, appearance of blue dyes confirm adequate resection
 Alternatives: Small-size ureteroscopy to SVs

Success rate
 Patency 90% (65-95%) / SA improvement 60% / Pregnancy rate 30% (20-42%)

Complications
 Recurrent obstruction
 Chemical epididymitis
 Incontinence if sphincter injured

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 Retrograde ejaculation if bladder neck injured

Vas obstruction / Post vasectomy

 Post inguinal hernia repair vas injury
o Common site: inguinal region, retroperitoneum
o Very difficult to repair

Epididymal obstruction
 Most common cause of OA

Causes
 Congenital: Chronic sinopulmonary infection (Young’s syndrome)
 Acquired: Post-infection / Post-surgical

Management
 Vaso-epididymostomy
o Intraoperative vasogram to confirm distal patency
o Microscopic visualization of epididymal fluid to confirm proximal patency
o Microsurgical intussusception technique (Berger)
 3 double-armed 10-O nylon sutures into epididymis so that each suture forms 1
side of triangle
 Epididymal opening made between sutures
 Invaginating the epididymal tubule into vas


 Success rate: post-op 92% sperm positive in ejaculate
o Success rate of VE
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 Patency 70-80%
 Spontaneous pregnancy 20-40%
 Special case: Right testicular atrophy, OA at distal vas and epididymis of left side
o Consider VE with right vas and left epididymis
 Sperm retrieval
o PESA / MESA

Intra-testicular obstruction
 Reconstruction impossible
 TESE, micro-TESE

Varicocele
 OAT syndrome
o Idiopathic is the most common cause of OAT

Definition
 Dilatation of the veins in the pampiniform plexus of the spermatic cord

Epidemiology
 15% general male population
 10% adolescents
 90% decrease in motility
 40% primary infertility, 80% secondary infertility

Venous drainage of testis

 Internal spermatic vein (testicular vein) —> Left to renal vein, right to IVC

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 External spermatic vein (cremasteric vein) —> inferior epigastric vein
 Vasal vein (within the vas): becomes the remaining venous drainage after varicocelectomy
 Gubernacular vein —> superficial scrotal vein
 Subinguinal collaterals —> superficial system

Etiology of varicocele
 Incompetent vein valves in the internal spermatic veins
 Leading to retrograde venous flow, venous dilatation, tortuosity of pampiniform plexus

Why does left sided more common?

 Right angle insertion to left renal vein (right sided: oblique insertion)
 Longer vein
 Nutcracker phenomenon of left renal vein by SMA and aorta

Pathophysiology of varicocele causing impaired spermatogenesis

 Increase in testicular temperature (0.6 degree)
o Due to disruption of countercurrent heat exchange provided in pampiniform plexus
o Normally, testicular veins form pampiniform plexus, which is a meshwork of veins
encircling the testicular artery, so that the arterial blood is cooled before it reaches the

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testis
 Stagnation of blood causing testicular hypoxia  Testicular germ cell damage
 Reflux of renal and adrenal toxic metabolites which may alter spermatogenesis, damage sperm
DNA
 Pan-testicular defect with abnormal hormone production and spermatogenesis
 Cross-circulation  Affect contralateral side

Hudson’s classification
 Grade 3: Visible and palpable at rest
 Grade 2: Palpable without Valsalva maneuver
 Grade 1: Palpable with Valsalva maneuver
 Grade 0: Subclinical, only demonstrate by Doppler USG

Clinically significant varicocele in USG

 Maximum venous diameter > 3mm in the upright position and during Valsalva maneuver
 Venous reflux with duration > 2 seconds

Indications for treatment (EAU guideline)

 Grade 2-3 (Clinical) varicocele
 Abnormal SA
 Proven male infertility without reversible female factors

 In children and adolescents (EAU)

o Significant risk of over-treatment, as majority of boys with varicocele will have no fertility
problems in later life
o Only advised if
 Symptomatic
 Small testis size (2ml or 20% reduction compared with contralateral testis)
 Bilateral palpable
 Abnormal SA
 Additional testicular condition affecting fertility

Monitoring of patients with varicocele

 Young adult males with varicoceles and normal SA
o SA every 1-2 years

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 Adolescent males with varicoceles with normal testicular growth
o Annual objective measurement of testis size +/- SA

Evidence on the benefits of surgical intervention in varicocele

1. To improve both SA and spontaneous pregnancy rate

Meta-analysis of RCTs and observational studies

 Only clinical varicoceles showed that surgical varicocelectomy significantly improves
semen parameters and pregnancy rate.
 RCT in subclinical varicocele patients: ineffective in increasing pregnancy rate
 RCT in normal SA patients: no benefit

Marmar et al 2007
 Included RCTs and observational studies (5 studies only) involving only infertile men with
palpable varicocele and abnormal SA
 Odds of spontaneous pregnancy after varicocelectomy vs conservative treatment is 2.6-2.9

Baazeem EU 2011
 Clinical varicocele with infertility
 Spontaneous pregnancy rate: OR 3.04 / NNT 5.3; 13.9% (Control) Vs 32.9%

Cochrane review Kroese 2012

 Treatment of varicocele in men with otherwise unexplained subfertility may improve a couple’s
chance of pregnancy (OR 2.39 / NNT 7)

2. To reduce sperm DNA fragmentation and improve ART

 Intact sperm DNA integrity is important for normal fertilization and growth of embryo
 May be considered in couples planning for ART

3. To improve testosterone in hypogonadism patients

 Needed to be further evaluated by prospective EAU

Predictive factors of success for varicocelectomy

 Positive GHRH stimulation test

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 Normal FSH level
 Grade III varicocele
 Lack of testicular atrophy
 Total motile sperm count > 5 x 106
 No genetic defect identified

Management of varicocele
 Better perform genetic testing first

Radiological approach
 Retrograde / Antegrade sclerotherapy
 Retrograde embolization
 Efficacy
o Recurrence 10%
 Complications
o Hydrocele 0%, artery not affected
o Coil embolism

Surgical approach
 Retroperitoneal (Open: Palomo’s operation)
o Procedure
 Muscle splitting incision near ASIS
 Internal spermatic veins ligated at this level
 High ligation of internal spermatic veins, above the internal inguinal ring
o Recurrence 15%, hydrocele 10%, not artery preserving
o Miss varicocele collaterals
 External spermatic veins
 Peri-arterial veins
 Cremasteric veins
o Could not preserve lymphatics
 Laparoscopy
o Procedure
 Internal spermatic ring ligated high in the retroperitoneum (around 5cm above the
deep inguinal ring)
o Recurrence 2%, hydrocele 5%, not artery preserving

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o Advantages
 Minimally invasive, deal with bilateral pathologies
o Serious morbidity: Bowel injury, nerve injury
o (Do not mention it in examination due to a small but significant risk of bowel or
vascular injury in laparoscopy)
 Inguinal
o Still first choice for children as the size of vessels are too small in subinguinal region
o Double ligation of spermatic veins and external cremasteric veins
o Recurrence 10%, hydrocele (<10%) as unable to identify and preserve the
lymphatics
 Microsurgical subinguinal (Gold standard)
o Simultaneously introduced by Marmar and Goldstein
o Procedure
 Small transverse incision below inguinal ring
 Dissection under microscope
 Micro-doppler / ICG identification of testicular artery
 Ligate internal spermatic vein, cremasteric vein, gubernacular veins and
sub-inguinal collaterals
 Preserving testicular artery and lymphatics
o Advantages
 Minimal recurrence (<1%) : Able to tackle external spermatic collateral,
gubernacular vein
 Better preservation of lymphatics and testicular artery under microscope: Minimal
hydrocele and testicular artery injury
 Preserve vasal vein (the only venous return after varicocelectomy)
 Small incision  Less pain, fast recovery
 External oblique aponeurosis not opened  less pain
o Disadvantages
 Tedious, time-consuming, requires microscope and special training

Al-Said RCT 2008

 Open vs Laparoscopic vs Microsurgical subinguinal
 Microsurgical subinguinal has the advantages of
o Much lower recurrence rate (3% vs 11% in open vs 17% in laparoscopy)
o SA parameters much improvement

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Male Infertility, Varicocele, Vasectomy
o Pregnancy rate at 1 year similar
o Complications: Hydrocele rate 0%

Outcome of MSV
 90% technical success
 70% patients have improvement in SA parameters (between 3 – 12 months post op)
o Small incision  Less pain
o Better ligate vein and avoid lymphatic injury
 Spontaneous pregnancy (from Goldstein series)
o From 30-40% (Consider FEMALE FACTOR) at 1 year
o 70% at 2 years

Complications of MSV
 Recurrence <2%
 Testicular artery injury 1%
 Hydrocele 0%
 Hematoma

Meta-analysis for different options in varicocelectomy

Summary
 Recurrence rate
o 1% microsurgical
o <10% all others
o 10% embolization and Palomo
 Pregnancy rate
o 40% microsurgical
o ~30% all others

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Male Infertility, Varicocele, Vasectomy
 Hydrocele rate
o <1% microsurgical and embolization
o <10% all others

Venous return after varicocelectomy: Vasal vein

 Vasectomy / Vasoepididymostomy are contraindicated for varicocelectomy
 Otherwise venous congestion  Testicular ischemia

Bilateral varicocele
 Do bilateral varicocelectomy
 One Japan study support bilateral varicocelectomy better than unilateral varicocelectomy

How to prevent testicular artery injury during varicocele?

 Microsurgery
 Micro-doppler USG
 Use of ICG in varicocelectomy

Scenario: Normal volume azoospermia + Varicocele

 Differential diagnosis: Obstruction (Proximal), testicular failure, varicocele
o Obstruction: FSH normal, normal testes
o Testicular failure: FSH high, T low, small testes
o Varicocele: FSH is usually high +/- small testes
 Genetic testing before varicocele surgery
 Varicocele repair is in general NOT recommended (In azoospermia)
o Even sperms return after surgery, it is usually transient
o Unlikely to improve SA to an extent that IUI is feasible
o <10% had sufficient number of motile sperm to avoid TESE
o More than 50% of those who showed initial benefit would return to azoospermic status 1
year late
 Sperm retrieval + ART is recommended

Anejaculation
Definition
 Complete absence of both antegrade or retrograde ejaculation
 “True anejaculation” = failure of emission with normal orgasm

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Different from Anorgasmic = Psychogenic, cannot achieve orgasm

Causes
 Ejaculatory duct obstruction
 Neurological (SCI / DM autonomic neuropathy / Pelvic Surgery)
 Psychogenic
 Drug induced
o Thiazide diuretics
o TCA / SSRI
o Alcohol
 Congenital: Mullarian duct obstruction
 Infection: Urethritis

Treatment
 No treatment for idiopathic causes
 Mechanical technique
o 1st line: Vibro-stimulation applied to penis, to evoke ejaculatory reflex
o Electro-ejaculation with rectal probe under GA
 Treat infertility

Clinical approach to azoospermia

Low volume azoospermia
 CBAVD
o Semen volume <1.5 mL and with an acidic pH and low fructose level
o Examination showed absence of vas deferens
o TRUS showed absence of SV
 Ejaculatory duct obstruction (EDO)
o Semen volume <1.5 mL and with an acidic pH and low fructose level
o Examination showed presence of vas deferens
o TRUS showed dilated SV / Prostatic or Mullerian cyst
 Retrograde ejaculation
o Post-ejaculate urine (>10 sperm/HPF)
o Causes
 Anatomical: Post TURP / TUBNI

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Male Infertility, Varicocele, Vasectomy
 Neurological: DM / multiple sclerosis / post retroperitioneal surgery
o Alkalization of urine
 Sodium bicarbonate 1g the night before and 1g in the morning of sperm collection
 Liverpool solution: NaCl + NaHCO3
 50% success rate
o Pseudoephedrine (sympathomimetic) to help close the bladder neck
 50% success rate
o Empty bladder before masturbation
o Obtain post ejaculate urine and send to lab ASAP
 Failure of emission / ejaculation
o Electro-ejaculation with rectal probe under GA / Vibro-stimulation with percutaneous
device e.g. Viberect
 Especially useful in DM / SCI patients
 Watch out for autonomic dysreflexia
o Use of rectal probe to stimulate the peri-rectal, peri-prostatic sympathetic nerves
o Pre-med: Pseudoephedrine 7-10 days to facilitate antegrade ejaculation, potassium
citrate to alkalinize the urine
o Collect both antegrade ejaculate and retrograde ejaculate with mineral oil lubricated
catheter
o

STRUCTURALOBSTRUCTION FUNCTIONAL OBSTRUCTION

DISTAL PROXIMAL Bladder neck Loss of antegrade

(Vasal/ epididymal) (EDO) -1% (retrograde ejaculation
ejaculation) (SCI)

FSH Normal Normal Normal Normal

Testes Normal Normal Normal Normal

Semen volume/ count Normal Low (<1.5cc) Low/ none None

Azoospermia Azoospermia Azoospermia Azoospermia

(complete block)

Fructose/pH Normal/ normal Low/ acidic Normal/ normal none

Post-ejaculate Urinalysis Normal Normal > 10 sperm / hpf No sperm

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Normal volume azoospermia
 Spermatogenic failure
o Check FSH
 Varicocele / Undescended testis
 Proximal obstruction

*Endocrine correction of

hypogonadotropic hypogonadism

(Pulsatile LHRH),

hyperprolactinemia (Dopamine agonists),

or testicular failure (Clomid / HCG / HMG)

If no abnormality found in SA…

 Female factors
 Coital problems
 Acrosomal defect
 Acrosome is an organelle over the anterior half of the head in the spermatozoa, it
contained hyaluronidase and arocin for digestion of the outer membrane of ovum

Causes of anti-sperm antibodies

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Male Infertility, Varicocele, Vasectomy
 Found in 10% of infertile men
 Acquired or congenital ductal obstruction (Unilateral or bilateral)
 Vasectomy
 Testicular / Epididymal infection
 Testicular torsion/ trauma
 Cryptorchidism
 Varicoceles
o Antibodies in serum are NOT conclusive
o Most sensitive / accurate method: Test for anti-sperm antibodies in semen
o “ImmunoBead” test – Detects IgA (from genital tract mucosal surface) IgG (blood) to
sperm

Treatment options
 Not for surgery / ART
o Remained childless
o Adoption
o Donor insemination
 Scrotal exploration +/- Reconstructive surgery for OA
 Varicocelectomy for varicocele
 Sperm retrieval + Assisted reproductive technique (ART)

How to choose between ART and reconstruction?

Favours ART
 Age of female partner >37 years old
 Coexisting female factors requiring IVF  ART
 Fear potential complications of reconstruction (GA ~ 4 hours)
 Likelihood for success with sperm retrieval / ICSI is greater than with surgical treatment

Favours reconstruction
 Multiple children wanted
 Cost effectiveness
 Nature process to conceive

Reasons for reconstructive surgery over direct sperm retrieval and ART?
 Allow couples to have offspring in a natural manner

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Male Infertility, Varicocele, Vasectomy
 Obviates the need for sperm retrieval for every other child they want to have
 More cost effective by Schlegel’s analysis
 Reconstructive procedure is relatively safe (reduces possible risks of ART such as OHSS)

Assisted Reproductive Technology

Types of ART
 Small significant fetal malformation (6%) compared with normal pregnancy (4%)
 Intrauterine insemination (IUI)
o 5-10 million sperms, sperm must be processed to remove prostaglandin and bacteria
o Used to bypass cervical mucus
o Indications
 Deposition abnormalities (hypospadias)
 Severe dyspareunia
 Several psychosexual abnormality
o Pregnancy up to 30% for 4 cycles, multiple gestations up to 30%
 In vitro fertilization (IVF)
o 0.1-0.5 million sperms
o 4% malformation, less than ICSI, conflicting evidence vs normal population
o Steps
 Gonadotropins are used to recruit multiple oocytes, ova are harvested before
ovulation with use of ultrasound-guided needle aspiration
 Mixing sperms with the oocytes
 After fertilization, the embryos are incubated for 2-3 days in culture and placed
into uterus transcervically
o 30% successful implantation rate and clinical pregnancy
 Intra-cytoplasmic sperm injection (ICSI)
o Indication
 Severe male factor infertility
 Failed prior regular IVF cycle
 Sperm showed significant defect in fertilizing ability
o One sperm
o 6% malformation
o Clinical pregnancy rate 30%

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o MCQ: Pregnancy rate 37% for 35 years old, 10% for >40 years old

Complications of ART
 Medication-related
o Ovarian hyper-stimulation syndrome (OHSS)
 Ovarian enlargement due to multiple ovarian cyst and acute fluid shift to
extracellular third space
 Mild 20% / Moderate 5% / Severe 1%
 Mild: N, V, D, ovarian enlargement (5-12cm)
 Moderate: Ascites
 Severe: Hypovolemia, hydrothorax, hemo-concentration
o Ovarian torsion
 Retrieval procedure-related (rare)
o Female
o Male
 ART procedure-related
o Multiple births
o Pre-term delivery
o Low birth weight
o Increased risk of malformation to 6%
 Genetic-related
o Transfer of abnormal genes e.g. YCMD to son

 Pre-implantation genetic diagnostic

o At least when embryo has 8 cells, corresponding to 3-day embryo
 Embryonal transfer
o Single embryo transfer vs Double embryo transfer
o In general, single embryo transfer preferred
 Similar success rate
 Less risk of multiple pregnancy
o NICE guideline (Depends on)
 Quality of embryo
 Age of mother
 Number of times of IVF

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Sperm retrieval
Goals
 Best-quality sperms
 Adequate number of sperms
 Minimize damage to reproductive tract

Conventional TESE = Testicular Sperm Extraction

 Multiple random biopsies
 Excision of large volume >500mg
 T, FSH, testis volume, age and cryptorchidism NOT predictors of TESE outcome
(Tam PC: FSH is predictor of TESE outcome)
 Transverse incision to avoid vessel injury
 Increased efficacy
o FNA map-directed TESE, TESA  TESE on positive spot
o Perfusion-guided TESE
o Clomid before TESE (LE: 3)
 Success rate according to histology of testicular biopsy
o Hypospermatogenesis: 80%
o Maturation arrest 47%
o Sertoli cell-only syndrome 23%
 Testicular biopsy at the same time
o To rule out TIS
o Obtain histology for counseling of chance of success in further TESE
 Can result in permanent damage to the testis (risk of hypogonadism as much testicular tissue is
extracted)

TESA = Testicular Sperm Aspiration

 Not much indication, usually performed by non-urologists
 Low success rate
o Usually failed in NOA

Microdissection TESE
 Equator incision on testes to avoid vessel injury  Nearly bivalve the testis
 Dilated seminiferous tubule  Spermatogenesis active regions
 Minimal amount (10mg) of testicular tissue with maximal sperm yield (unlike conventional

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Male Infertility, Varicocele, Vasectomy
TESE, which is a blind procedure)
 Less hematoma and reduction in testis size (more meticulous opening of TA and less bleeding)
 Less interference in testicular function
 If failed, check testosterone level & previous biopsy  If not SCO syndrome or maturation
arrest  May increase testosterone level if low, fair chance of getting sperm next time, should
be performed 6 months later (Success rate better >6 months vs <6 months after initial TESE)

PESA / MESA – Percutaneous or microsurgical epididymal sperm aspiration

 Indication for sperm aspiration
o Obstructive azoospermia at epididymis / CBAVD
 PESA
o Indication
 CBAVD
 Prior vasectomy refusing reversal
o Advantages
 Local anesthesia
 No need microsurgical instrument
o Disadvantages
 Further reconstruction not possible
 Risk of bleeding and haematoma
o Success rate is ~90%
 MESA
o Advantages
 Best tubules can be selected
 With chronic obstruction, optimal sperm quality is found in proximal epididymis
 Less complications (allow meticulous haemostasis)
 Success rate is ~100%
o Disadvantage
 Need microsurgical treatment

Vasal aspiration of sperm / seminal vesicle aspiration

 Distal obstruction / ejaculatory failure
 Using TRUS guidance

Sperm preservation

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Male Infertility, Varicocele, Vasectomy
 Preserve sperm: Human tubule solution
(Not Bouin’s solution which is for testicular biopsy)

Two approaches
 Fresh cycle
o Fresh sperm can be used
o Risk of ovarian hyper-stimulated but no sperm found  Solved by donor sperm in foreign
countries
 Cryopreserved
o Cryopreserved sperm is as good as fresh sperm

Cryopreservation
 Enzymatic or chemical activity is effectively stopped
 Need of cryoprotectant (e.g. Glycerol) to prevent ice formation (Inherent toxicity of
cryoprotectant)
 Freezing: Cooling to typically -80oC with solid CO2 or -196oC with liquid nitrogen
o Slow programmable freezing
 Lethal intracellular freezing can be avoided if cooling is slow enough to permit
sufficient water to leave the cell during progressive freezing of ECF
 Typically 1oC per minute
o Vitrification
 Better post thaw motility and cryosurvival
 Thawing at 40oC

Vasectomy
I will see the patient with his partner in my clinic. I will ask about the sexual history of the patient,
including the marital status, number of children and their health status, plus the method of
contraception and explore the reason for vasectomy.

In addition, I will enquire about any previous surgery on inguinoscrotal region.

In physical examination, I will specifically inspect for scar, laxity of the scrotum, confirm the
presence of vas and rule out other scrotal pathology.

I will explain vasectomy should be considered as irreversible and the procedure and possible

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Male Infertility, Varicocele, Vasectomy
complications of vasectomy and the need to continue contraception until azoospermia
Then I will introduce other contraceptive methods and give the patient a brochure of vasectomy and
see him 2 weeks later.

Contraindication: Chronic scrotal pain

Consent for vasectomy

 Advised to consent with the presence of partner
 LA/GA procedure
 Alternatives
 Efficacy
 Complications
o Hematoma 2%
o Early failure (Surgical error) 1 in 200
o Late failure (Recanalization) 1 in 2000
o Scrotal pain, numbness 5%
o Sperm granuloma 10%
o Anti-sperm antibodies 70%

Vasectomy procedure
 LA/GA
 Bilateral small incision over the vas
 Isolate the vas from cord vessels and fix the position with three-finger technique and control
with vasectomy clamp
 Vas is further dissected from cord vessels
 Vas is transected and 1cm is removed and sent for presence
o Send: To confirm vas is transected
o Not send: No additional information, still need sperm clearance, save the vas for 3
months till sperm clearance then can discard
 Mucosal ends are occluded by intraluminal cautery (reduce recanalization to 0.5%) and
separated in different fascial plane (Fascial interposition - FI)
 AUA best practice
o Mucosal cautery MC is the most effective component
1. Bilateral MC without FI and ligatures nor clips
2. Bilateral MC + FI without ligatures nor clips

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Male Infertility, Varicocele, Vasectomy
3. Abdominal end MC + FI
4. 3cm non-divisional extended electrocautery (Marie Stopes International) are good
method ~0.5% patency
 Skin is closed

After vasectomy
The patient should continue his current contraceptive method.
According to British Andrology Society (2016), SA should be done 12 weeks after vasectomy and
after at least 20 ejaculations. Examine samples within 4 hour of production, if non-motile sperm are
observed, further samples must be examined within 1 hour of production. Assessment of a single
sample is acceptable to confirm vasectomy success if azoospermia.

Special clearance (BAS 2016)

Two consecutive SA showing sperm counts less than 100,000/ml with non-motile sperm at least 7
months after vasectomy.
Risk of pregnancy is believed no more than recanalization after two consecutive azoospermic
samples
 Goldstein 10 years FU 10% patients with non-motile sperm, risk of pregnancy 0.05%

What to do if failed vasectomy

 Confirm the presence of sperm by SA x 2
 Explained the quoted risk is 1 in 2000
 Offer scrotal exploration to identify the vas and further occlusion
 Alternative contraceptive methods should be given

Post vasectomy chronic orchialgia

Chronic (> 3 months) genital pain that develop immediately or several years after vasectomy

History and exam to rule out other causes of orchialgia e.g. infection, varicocele, referred pain from
spine / ureteric stone, torsion, tumor

Pathophysiology
 Testicular back pressure
 Over-full epididymis
 Chronic inflammation and fibrosis

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Male Infertility, Varicocele, Vasectomy
 Sperm granuloma
 Nerve entrapment

Nervous supply of scrotum

Ilioinguinal nerve (L1), Genitofemoral nerve (L1-L2)

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Male Infertility, Varicocele, Vasectomy

Investigation
 Urinalysis
 USG scrotum
 CTU / MRI spine
 Spermatic cord blockade (Diagnostic tool) cause pain relief
o 20ml 0.25% Marcaine (Bupivacaine) into spermatic cord at the level of pubic tubercle

Medical Management
 Analgesics (NSAIDs)
 Antibiotics (Quinolone / Doxycycline – high penetrance) x 4 weeks
 Antidepressants e.g. Amitriptyline / Nortriptyline
o Inhibit norepinephrine release at first and second order neuron
 Anticonvulsants e.g. Gabapentin
o Calcium channel modulator in CNS to reduce neuropathic pain
 Nerve blockade with local anaesthesia
 Single injection or in a series with or without steroids

Surgical Management
 Vas reversal – 75% success rate (Myers)
 Epididymectomy – 10-80% success rate
o Only if the pain is localized to the epididymis
o Poor results with epididymectomy for treatment of chronic orchialgia
 Micro-denervation of spermatic cord – 80% success rate
o Testis-sparing procedure for both psychological / physiological condition
o Divide all the structures with neural fibers, but to preserve arteries, lymphatics (to prvent
hydrocele) and vas deferens
o Key selection measure is a positive yet temporary response to spermatic cord block
o Complications: persistent pain, haematoma, hydrocele, testicular atrophy,
hypogonadism
 Orchidectomy 20-70% success rate
o When all other measures including MDSC failed
o Pain resolution better with inguinal approach than scrotal approach

Alternative method to vasectomy

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Male Infertility, Varicocele, Vasectomy
RISUG (Reversible inhibition of sperm under guidance)
Polymer gel
Vasalgel
USA product, not yet commercialized
Inject percutaneously to vas
Blocks or filters out sperms
Reverse with sodium bicarbonate injection

Vasectomy reversal
 5% of men with vasectomy (10% regret after vasectomy)
 Secondary epididymal obstruction
o Silber
o Epididymal blow-out phenomenon
o Increases with time of obstruction

Approach to vasectomy reversal

 Reproductive history (Including partner’s age and fertility), explore the reason of vasectomy
reversal
 Physical examination
o Size, consistency of testis
o Epididymis
o Palpable vas (Sperm granuloma)
o Vasal gap
o Groin scar (Second site of obstruction)
 Semen analysis
 FSH if testis is small
 Likelihood of success
o Experience of surgeon
o Time since vasectomy
 Secondary epdidymal obstruction rarely occurs within 4 years of vasectomy,
present in >60% of patients after 15 years of vasal obstruction
 Reasons for secondary epididymal obstruction
 High intraluminal pressure after vasectomy
 Rupture of delicate epididymal tubule
 Secondary obstruction in the epididymis

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Male Infertility, Varicocele, Vasectomy
o Partner age and fertility status
o Quality of fluid in proximal vas at the time of surgery

Treatment options
 Remained childless
 Adoption
 Donor insemination
 Scrotal exploration +/- Reconstructive Surgery

How to perform scrotal exploration?

 GA / supine position
 Microsurgical technique
 Bilateral 1.5cm longitudinal incision made over vas
 Previous vasectomy site and vasal gap identified
 Dissection of vas proximally and distally until sufficient length for cut ends to slightly overlap one
another, both ends transect to normal area
 Few drops of fluid from testicular end vas saved and examined to decide for VV / VE

Important steps for successful reversal

 Sufficient mobilization of both ends to prevent any tension on the anastomosis
 Peri-vasal adventitia must remain intact as stripping of the adventitia surrounding the cut ends
increase risk of stricture due to impaired blood supply
 Precise approximation of both ends is mandatory to avoid sperm leakage with formation of
sperm granuloma

o Vasovasostomy
o Average patency rate 89%, Average pregnancy rate 72%
o Factors affect success rate

Vasectomy related

 Time since vasectomy

 Vasovasostomy Study Group 1991 Belker
o <3 years 97% patency, 76% pregnancy
o 3-8 years 88% patency, 53% pregnancy

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Male Infertility, Varicocele, Vasectomy
o 9-14 years 79% patency, 44% pregnancy
o >15 years 71% patency, 30% pregnancy
 Use of surgical clips
 Presence of granuloma
 Sperm granuloma at the testicular end of the vas suggested that the
sperm have been leaking at the vasectomy site
 This vents the high pressure away from epididymis
 Improved patency rate

Reversal related
 Surgical technique and skill
 Microsurgical technique better than macrosurgical
Vasovasostomy Study Group 1991 Belker
o Sperm seen in ejaculate: 85% vs 40%
o Pregnancy rate: 50% vs 20%
 Two-layer similar to modified one layer
o Modified one layer technique
 Full thickness 9/O nylon suture at posterior
 3 anterior suture
 Anastomosis support by 9/O nylon seromuscular layer
 Level of obstruction
 More distal the better (thanks to larger lumen)
o Proximal length >2.7cm: Related to release of pressure
 Proximal vas condition
 Clear copious fluid with sperms from proximal vas +/- sperm in
microscopy VV
o Copious fluid with motile sperm: 94% sperm in ejaculate
after VV
o No sperm in vasal fluid: 60%
 Thick / Toothpaste-like / Absent vas fluid despite irrigation with NS
 VE

Female factor
 Age and fertility status of partner
 Female age > 40, rate of pregnancy decreases from 50% to 14%

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Male Infertility, Varicocele, Vasectomy

o Save sperm obtained if any for cryopreservation during operation or during FU

(~30% re-stenosis rate)
o Intra-op vasogram to ensure distal patency
o Use indigo carmine (Not methylene blue as toxic to sperm)
 Case study: Bilateral abrupt obstruction at inguinal level
 DDx: CBAVD with incomplete penetrance, post-surgery
 Reconstruction has to be abandoned

o Vasoepididymostomy
 20% of cases
 Intussusception technique end-to-side (Berger)
 Three suture triangulations intussusception
 Two sutures longitudinal intussusception (Peter Chan)
 Vas 400 micrometers
 Epididymal tubule 150 micrometers
 Better success with anastomosis to body rather than tail of epididymis
 Outcome
 Patency 50-70%
 Pregnancy 40%
 Delay sperm at 6 months: 20%
 ART should not be used until 2 years

Post operative care for reconstructive surgery

o Avoid excessive physical activity and ejaculation x 2 weeks
o Outcome
 Most patients have sperm within 4 weeks
 No sperm by 6 months considered a failure
 Average time to pregnancy 1 year
o Sperm retrieval + Assisted reproductive technique (ART)
 In vitro fertilization
 Intra-cytoplasmic sperm injection ICSI

Vasography
 Indications

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Male Infertility, Varicocele, Vasectomy
o Azoospermia
o Complete spermatogenesis with many spermatids on testicular biopsy
o At least one vas palpable
 No need vasography during testicular biopsy unless immediate reconstruction is planned
 Complications
o Stricture of the vas
o Injury to vasal blood supply / Haematoma
o Sperm granuloma

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