Infertility Part 2 (male)-
Primary care
Dr ZharifHussein
O&G Specialist MetroIVF
-Special interest in infertility-
History
Duration of infertility and prior fertility.
• Sexual history – coital frequency and timing.
• Childhood illnesses and developmental history such as viral rchitis or cryptorchidism.
• Infections such as epididymitis or urethritis, including STIs.
• Genital trauma or prior pelvic or inguinal surgery.
• Gonadal toxin exposure such as prior radiation therapy/chemotherapy, recent fever, or heat
exposure.
• Family history of birth defects, mental disability, reproductive failure, or cystic fibrosis.
• Medical and surgical history.
• Drug history, over-the-counter and recreational drugs.
• Agents such as heat, X-rays, metals, and pesticides – evidencesuggestive of a harmful effect.
Therefore, enquire about occupation; e.g., radiotherapists, engine drivers, diggers,
agricultural workers, chemists, laboratory workers, painters
If the first semen analysis (SA) is abnormal, repeat it in 3 months after the initial
analysis to allow time for the cycle of spermatozoa formation to be completed (not
mandatory and can be done earlier if it generates anxiety).
• A single-sample analysis will falsely identify about 10% of men as abnormal, but
repeating the test reduces this to 2%.
• If azoospermia or severe oligozoospermia is detected, repeat the test as soon as
possible
Semen analysis
Normal SA ---> Unexplained subfertility/ female factor
Abnormal SA
Full evaluation – examination and investigations
• If the sperm concentration is ≤ 5 × 10/ml, impaired sexual function or
other clinical findings suggestive of any specific concern from history.
• Azoospermia – complete absence of sperm from the ejaculate (1% of all
men and in approximately in 15% of infertile men).
Examination
• Secondary sexual characteristics – body habitus, hair distribution, and
gynaecomastia.
• Examination of the penis; location of the urethral meatus; testis size (normal
volume > 19 ml),mass, and consistency; presence of a varicocele; presence and
consistency of vasa and epididymides.
General advice
• Alcohol consumption of 3–4 units per day is unlikely to affect fertility. Excessive
alcohol intake is detrimental to semen quality.
• There is an association between smoking and reduced semen quality (although
the impact of this on male fertility is uncertain), and stoppingsmoking will improve
general health.
• BMI of > 29 – likely to have reduced fertility.
• There is an association between elevated scrotal temperature and reduced
semen quality, but it is uncertain whether wearing loose-fitting underwear
improves fertility.
Investigations
• Serum FSH and testosterone levels. If the testosterone level is low, repeat total and free
testosterone, LH, and prolactin levels.
• Scrotal USS – if, on palpation, scrotum is difficult or inadequate to assess, or a testicular mass is
suspected
Low FSH and testosterone
Pre-testicular – secondary testicular failure
Hypogonadotropic hypogonadism.
• Bilateral testicular atrophy, low semen volume, low LH levels.
• Congenital abnormalities such as Kallmann syndrome.
• Acquired – functioning and nonfunctioning pituitary tumours.
• Perform serum prolactin levels and pituitary CT or MRI.
High FSH and normal/low testosterone
Testicular – primary testicular failure
Bilateral testicular atrophy, low semen volume.
• Chromosomal abnormalities found in 7% of male infertility. Sex chromosome aneuploidy is
most common (Klinefelter syndrome in 2/3 cases). Karyotype all patients with non-obstructive
azoospermia and severe oligospermia (sperm count: < 5 × 10/ml).
• Y-chromosome microdeletions – may be found in 10–15% of men with azoospermia or severe
oligozoospermia. Prognostic significance – with deletions in AZFa or AZFb regions, sperm are
normally not found, whereas up to 80% with AZFc deletions may have retrievable sperm. (AUA)
• Counsel regarding inheritance of the compromised fertility potential in male offspring.
Normal FSH and testosterone
Post-testicular – 40%
Erectile/ejaculatory
• Anejaculation.
• Retrograde ejaculation – perform a post-ejaculatory urinalysis.
• Erectile dysfunction
Obstructive
Vasal agenesis
Obstruction
Vasal agenesis
Congenital bilateral absence of the vas deferens
• 70% of men with CBAVD and no clinical evidence of cystic fibrosis have an abnormality of CFTR gene.
(Almost all males with clinical cystic fibrosis have CBAVD).
• Seminal vesicle hypoplasia or agenesis – owing to embryological association between the vasa and seminal
vesicles.
• Low semen volume – since majority of semen is derived from seminal vesicles.
• Both partners – genetic counselling and test for CFTR gene. Failure to identify a CFTR abnormality in a
man with CBAVD does not rule out the presence of a mutation, as many mutations may not be detected by
routine testing methods; therefore, test the spouse for CFTR gene abnormalities because she may be a carrier.
• In patients who have CBAVD and CFTR mutations, the prevalence of renal anomalies is extremely rare.
Therefore, imaging of the kidneys with USS or CT scan is only indicated in men with CBAVD with no
mutations in CFTR.
Unilateral vasal agenesis
• Transrectal USS (TRUS) – to evaluate the ampullary portion of the contralateral vas deferens and the
seminal vesicles, because unilateral vasal agenesis can be associated with contralateral atresia of the vas
deferens or seminal vesicle, leading to obstruction azoospermia.
• There is a strong association between unilateral vasal agenesis and ipsilateral renal anomalies; therefore,
organize USS or CT scan of the kidneys.
Obstruction
Epididymal/vasal obstruction
• Vasa and testes are normal, semen volume normal.
* Bilateral epididymal obstruction – identified only by surgical
exploration.
* Vasal obstruction – vasectomy (most common), severe genitourinary
infections, iatrogenic.
• Vasography – to diagnose whether the obstruction is in vas deferens or
ejaculatory ducts. It should not be done unless reconstructive surgery is
undertaken at the same surgical procedure.
Ejaculatory duct obstruction
• Semen volume low (< 1.0 ml).
• Seminal pH low and fructose low, as the seminal vesicle secretions are
alkaline and contain fructose.
• TRUS – minimally invasive and avoids the risk of vasal injury associated
with vasography.
• With or without seminal vesicle aspiration and seminal vesiculography –
determine the anatomical site of the obstruction.
• Vasography.
Treatment
Pre-testicular
Gonadotrophins
Testicular
• Surgical sperm retrieval (SSR)
by TESA/TESE and ICSI.
• Donor sperm (DI).
Post-testicular
Obstructive
Microsurgical reconstruction
SSR and ICSI
Ejaculatory/erectile
Erectile dysfunction
Anejaculation
Retrograde ejaculation
Referencee
1. WHO Laboratory Manual for the Examination and Processing of Human Semen, Fifth edition, 2010.
2. Fertility: Assessment and Treatment for People with Fertility Problems. NICE Clinical Guideline 11, February 2004. Please also refer to updated guide-
lines from Feb 2013.
3. The Evaluation of the Azoospermic Male. AUA Best Practice Statement; Revised, 2010.
4. British Fertility Society Guidelines for Practice. Impact of Chlamydia trachomatis in the reproductive setting. Hum Fertil (Camb) 2010;13(3):115–125.
5. AUA Guidelines on the Pharmacological Management of Premature Ejaculation. J Urol 2004:172(1):290–294.
6. Guideline on the Management of Erectile Dysfunction. AUA Diagnosis and Treatment Recommendations, 2005.
7. ASRM. Evaluation of azoospermic man. Fertil Steril 2008;90:S74–77.
8. ASRM. Genetic considerations related to ICSI. Fertil Steril 2008;90:S182–184.
9. ASRM. ICSI. Fertil Steril 2008;90:S187.
10. The Management of Obstructive Azoospermia. AUA Best Practice Statement; Revised, 2010.
11. The Optimal Evaluation of the Infertile Male. AUA Best Practice Statement; Revised, 2010.
12. ASRM. Report on vericocele and subfertility. Fertil Steril 2008;90:S247–249.
13. ASRM. Sperm retrieval for obstructive azoospermia. Fertil Steril 2008;90:S213–218.
14. ASRM. The clinical utility of the sperm DNA integrity testing. Fertil Steril 2008;90:S178–180.
15. ASRM. The management of infertility due to obstructive azoospermia. Fertil Steril 2008;90:S121–124.
16. Report on varicocele and infertility. AUA Best Practice Policy, Reviewed, 2011.
17. ASRM. Vasectomy reversal. Fertil Steril 2008;90:S78–82
Thank you
O&G tutorial
By Drzharif
Fbpage: drzharif, youtube channel: drzharifhussein instagram:zharifhussein
Email: drzharifhussein@gmail.com / Whatsapp only : 01120758634 (office hours 8am-5pm)
