MALE INFERTILITY

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Presentation Transcript

MALE INFERTILITY : 

MALE INFERTILITY DR. AJANTA PANDE (SAMANTA) DR. ARINDAM PANDE

Slide 2: 

DEFINITION ANATOMY AND PHYSIOLGY ETIOLOGIES EVALUATION TREATMENT

Definition of Infertility : 

Definition of Infertility Infertility is defined classically as the inability to conceive after 1 year of unprotected and regular intercourse. This definition is based on the cumulative probability of pregnancy.

Slide 4: 

Male factor– 20% May extend from 30-40%, as contributory factor

Slide 5: 

+SRY Testis Sertoli cells Leydig cells Wolfiann duct MIS Testosterone Vas deferens,SV, epididymis DHT XX Genital tubercule Ext. genitalia, prostate Overview of sexual differentiation in the male (modified from Male Reproductive Biology, eds Lipshultz, Howards)

REGULATION OF H-P-T AXIS : 

REGULATION OF H-P-T AXIS

Slide 7: 

SEMINIFEROUS TUBULE AND SPERMATOGENESIS Testis: -Seminiferous tubules Germ cells Sertoli cells -Interstitium Leydig cells macrophages, endothelial cells Spermatogenesis ~74 days in humans (epididymal transit ~15 days) Clinical correlate: Need to wait 3 months after any intervention (medical or surgical) to see a change in semen quality

Slide 8: 

Maturation of Germ Cells Spermatogenesis: orderly differentiation of immature germ cells to mature spermatozoa 1. Mitotic phase quantitative phase 2. Meiotic phase generation of haploid spermatid 3. Spermiogenesis differentiation of spermatid

SPERM TRANSPORTATION : 

SPERM TRANSPORTATION Liquifaction Capacitation Acrosome reaction Cortical reaction

Etiology of male infertility : 

Etiology of male infertility PRETESTICULAR TESTICULAR POST TESTICULAR

PRETESTICULAR : 

PRETESTICULAR ENDOCRINE Hypogonadotrophic hypogonadism Hyperprolactinemia DM Hypothyroidism Androgenic steroid abuse Coital disorders Erectile dysfunction Ejaculatory failure

TESTICULAR : 

TESTICULAR GENETIC Klienfelter syndrome, Y chromosome deletion, Immotile cilia syndrome CONGENITAL Cryptorchidism ORCHITIS Infective Traumatic ANTISPERMATOGENIC AGENTS VASCULAR Torsion Varicocele IMMUNOLOGIC IDIOPATHIC

POST TESTICULAR : 

POST TESTICULAR OBSTRUCTIVE Epididymal Vasal EPIDIDYMAL HOSTILITY ACCESSORY GLAND INFECTION Prostitis Seminal vesiculitis IMMUNOLOGIC Post vasectomy idiopathic

FREQUENCY OF ETIOLOGIES : 

FREQUENCY OF ETIOLOGIES

HOW TO APPROACH? : 

HOW TO APPROACH?

HISTORY : 

HISTORY Age Duration of marriage Contraception practice Coital frequency and timing Occupation Addiction Drug history Medical history Operative history

GENERAL EXAMINATION : 

GENERAL EXAMINATION Height Weight Thyroid Breast Secondary sexual character

LOCAL EXAMINATION : 

LOCAL EXAMINATION Scrotal volume (N=15-35ml) Testicular volume (N=15-25ml) Epididymis palpation Presence of varicocele P/R examination

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SEMEN ANALYSIS Semen Parameters Normal range (WHO) Volume (>2mL) Sperm density (>20 million/mL) Sperm motility (>50%) Sperm morphology (>15% normal forms) Leukocyte density (<1 million/mL) pH >7.2 Viscosity <3(scale 0-4) Immunobead/MAR <10% coated Need at least 2 S/As (because parameters are highly variable) S/A is not a measure of fertility but fertility potential

ABNORMALITIES : 

ABNORMALITIES Oligozoospermia Asthenozoospermia Teratozoospermia Olgoasthenoteratozoospermia Azoospermia Aspermia Leucocytospermia Necrozoospermia

HORMONAL STUDY : 

HORMONAL STUDY Serum TSH high hypothyroid Testosterone low

CONTD.. : 

CONTD..

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Genetic Evaluation Karyotype analysis Abnormal karyotype in ~3-5% of infertile men Klinefelter’s (47 XXY); 1-2% of infertile men Y- chromosome micro-deletions 7-10% of infertile men vs. ~2% of fertile men Cystic Fibrosis (CF) gene mutations Carrier frequency; ~80% in CBAVD vs. ~30% of infertile vs. ~4% fertile men Pryor et al, 1997, Oates et al, 1992, Mak & Jarvi, 1997 Genetic evaluation is recommended in all infertile men with severe semen parameters in order to assess and prevent possible iatrogenic transmission of genetic mutations

OTHER INVESTIGATIONS : 

OTHER INVESTIGATIONS Fructose content of seminal fluid (If absent-Congenital absence of seminal vesicle, Partial duct obstruction, Both) Semen culture (If pus cells in microscopy) Urologic evaluation Transurerthral or transcrotal USG Scrotal thermography

Assess Expectations for Male Infertility Treatment : 

Assess Expectations for Male Infertility Treatment What treatments were previously recommended? Were they followed correctly? What results were obtained?

GENERAL TREATMENT : 

GENERAL TREATMENT Education- coital frequency and timing Avoidance of substance/drug abuse Weight reduction Avoidance of hot bath/tight underwear

PRETESTICULAR(ENDOCRINE).. : 

PRETESTICULAR(ENDOCRINE).. Hypogonadotropic hypogonadism- Pulsatile GnRh, hCG, hMG, Testosteron, Clomiphen citrate, Tamoxifen Eugonadotropic hypogonadism- Aromatase inhibitor(Anastrazole) Hypergonadotropic hypogonadism- IVF/ICSE, Donor sperm, Adaptation Idiopathic- Androgen, FSH, Clomiphen Hyperprolactinemia- Dopamine agonists Strict control of DM, Hypothyroid

ART Treatments for Infertility : 

ART Treatments for Infertility American Society for Reproductive Medicine. 2003. American Society for Reproductive Medicine. 2001. IVF with embryo transfer Gamete intrafallopian transfer (GIFT) Zygote intrafallopian transfer (ZIFT) Cryopreservation Intracytoplasmic sperm injection (ICSI)

IVF with Embryo Transfer : 

IVF with Embryo Transfer Egg and sperm are retrieved from couple, donor(s), or both Combined in a petri dish, incubated for 2–5 days If fertilization and cleavage occurs, embryo is transferred through a catheter to uterus

Gamete Intrafallopian Transfer (GIFT) : 

Gamete Intrafallopian Transfer (GIFT) Oocytes retrieved via laparoscopy Oocytes and sperm placed in same catheter Injected directly into the fallopian tube via laparoscopy Embryo travels through the fallopian tube to the uterus for implantation

Zygote Intrafallopian Transfer (ZIFT) : 

Zygote Intrafallopian Transfer (ZIFT) Combines techniques used in IVF and GIFT Ova are placed in a petri dish with sperm If fertilization occurs, the zygote: Is injected into fallopian tube Travels through tube to uterus Implants in uterus

Cryopreservation : 

Cryopreservation Sperm or embryos are preserved by freezing for replacement in subsequent cycles Photo source: http://www.dcmsonline.org

Intracytoplasmic Sperm Injection (ICSI) : 

Intracytoplasmic Sperm Injection (ICSI) A single sperm is injected directly into the cytoplasm of the oocyte Increases probability of fertilization American Society for Reproductive Medicine. 2004. Photo source: www.fertilitycentre.ca

PRETESTICULAR(COITAL DISORDERS).. : 

PRETESTICULAR(COITAL DISORDERS).. Erectile dysfunction- PDE5 Inhibitor (Sildenafil) Retrograde ejaculation, Neurogenic impotence, Severa Hypospadius- Intrauterine insemination (IUI) For ejaculatory problems phenylephrin or imipramine may be tried

IUI----intrauterine insemination : 

IUI----intrauterine insemination Send sperms directly into the uterine cavity First choice for male immunological infertility

IUI----intrauterine insemination : 

IUI----intrauterine insemination

POST TESTICULAR.. : 

POST TESTICULAR.. Prior vasectomy (most common cause)- microsurgical vasovasostomy (better if less than 5 years) Epididymal or vasal obstruction -MESA -PESA -TESE -TESA/FNA -ICSI

Obstructive Azoospermia (OA):Management Options : 

Obstructive Azoospermia (OA):Management Options Reconstructive surgery (vasal, epididymal) Resection of ejaculatory duct (cyst) Sperm retrieval from site proximal to obstruction Genetic counseling for CF patients

TESTICULAR.. : 

TESTICULAR.. Cryptorchidism- Orchidopexy at 2-3 year of age Varicocele- High ligation of internal spermatic vein Gonadal failure- Surgical retrieval of spermatozoa, followed by ICSI

Counseling couple : 

Counseling couple The use of skills that enable a client to recognize and identify his (sic) own problems, and the ability to help client find his own solution or resolution. The Human Fertilization and Embryology Authority (HFEA) state in their code of practice that three sorts of counseling must be available at licensed treatment center. These are: Support counseling Implications counseling Therapeutic counseling

Success rates "take home baby rate" : 

Success rates "take home baby rate" One of the first questions that most people ask is "what is the chance for success?" The best estimate is that the birth of a live baby occurs in approximately 15-25% of women in whom embryos are transferred into the uterus. Success varies with many factors, including the number of embryos that are transferred. The major hurdles to success are implantation after embryo transfer and early pregnancy loss.

Success rates "take home baby rate" : 

Success rates "take home baby rate" Pregnancy complications tend to be higher with ART pregnancies, primarily because of the much higher rate of multiple pregnancy. Twins occur in about 25% of ART pregnancies versus 1-2%of spontaneous pregnancies. The risk of more than a twin pregnancy is less than 5%.

Conclusion : 

Conclusion Male infertility is multifactorial Hormones, physiology, environment, anatomy and DNA all play a role It is the delicate balance of all of these factors that must be weighed in order to optimize male fertility Every evaluation is different and every treatment strategy is geared toward the individual patient and circumstance and must always take into account the female partner

Slide 44: 

THANK YOU