Male factor infertility aetiology:
A. Imperfect spermatogenesis:
• Local causes:
1) Congenital: undescended testis, no spermatogenesis.
2) Traumatic:
• Direct trauma: to the testis.
• Surgical trauma: injury of the blood supply of the testis.
• Thermal trauma:
* Varicocele: (the commonest cause of male infertility).
*Frequent hot baths.
*Tight clothes & nylon underwear.
3) Inflammatory: TB orchitis & mumps exposure after puberty.
4) Vascular: varicocele & irradiation (EAO).
5) Miscellaneous: Klinefelter’s syndrome (47 XXY).
6) Tumors: bilateral tumors destroying both testes.
• General causes:
1) Endocrinal causes: especially hyperprolactinemia & uncontrolled DM.
2) Non-endocrinal: excessive smoking & alcoholism.
B. Obstruction in transport (must be bilateral)(obstructive azoospermia):
1) Congenital: aplasia & hypoplasia of the vas deferens.
2) Traumatic:
Accidental: vas ligation during repair of inguinal hernia.
Surgical: bilateral vas ligation for permanent sterilization.
3) Inflammatory: gonorrhea & chlamydia.
4) Neoplastic: prostatic tumours closing the vas (very rare).
5) Miscellaneous: immotile cilia syndrome (all sperms are immotile).
C. Failure of semen deposition in the vagina:
1) Erection problems: impotence: *(90%): psychological. *(10%): organic e.g. DM.
2) Ejaculation problems: Premature ejaculation before penetration.
Retrograde ejaculation: e.g. long standing diabetic neuropathy & after prostatectomy.
Congenital anomalies of the penis e.g. hypospadius & epispadius.
D. Causes in the seminal fluid:
1) Anti-sperm antibodies (Autoimmune disorder destroying sperms).
2) Volume: increased or decreased. 3) Viscosity: too viscid semen.
Def.: failure of liquefaction of semen within ½ hour after ejaculation at room temperature.
Treatment: ↑water intake & mucolytic.
Male factor infertility Diagnosis:
A. History:
1) Age.
2) Previous marriage & its results (children).
3) Radiation exposure.
4) Recreation agents: smoking & alcohol.
5) Occupation: exposure to heat & prolonged standing suggests varicocele.
6) Operations: for hernia & varicocele.
7) Diseases: *gonorrhea & mumps. *DM.
8) Drugs: tranquilizers.
B. Examination:
1) General examination:
Height, body built & gynecomastia: Klinefelter’s syndrome.
Endocrinal diseases e.g. thyroid disorders.
Chronic diseases e.g. TB.
2) Local examination:
Penile abnormalities e.g. hypospadius.
Testicular abnormalities e.g. varicocele & undescended testis.
Prostatic abnormalities: by digital rectal examination.
C. Investigations:
Routine: semen analysis (semenogram).
Precautions:
1) In reliable laboratory.
2) Abstinence: no intercourse for 4 days before taking the sample.
3) Collected by masturbation or coitus interruptus.
4) Examined within one hour after taking the sample.
5) Repeat after 2 weeks. if semen analysis is abnormal or borderline.
Normal values:
1) Volume: 2-5 ml/ejaculate.
2) Reaction: alkaline (7.4).
3) Count: Total > 39 millions (> 15 millions/ml is normal).
4) Motility:
*quantitative: total > 40% motile (a + b > 32 %)
*qualitative: normally forward & progressive.
5) Vitality: at least 60 % are viable 4 hours after ejaculation.
6) Morphology: strict criteria 4% (four percent) considered normal.
7) Pus cells :< 3-5/HPF.
Abnormal findings:
1) Abnormal volume:
Aspermia: no ejaculate.
Hypospermia: < 1.5 ml.
Hyperspermia: > 6.8 ml (may be due to prostatitis).
2) Abnormal count:
Azoospermia: no sperms.
Oligospermia: < 15 millions /ml.
Polyspermia.
3) Abnormal vitality:
Asthenospermia: weak sperms.
Teratospermia: ↑ abnormal forms.
Necrospermia: dead sperms.
4) Abnormal components Presence of RBCs.
Presence of pus cel
Fractional semen analysis: (done only if needed).
a) Fructose in semen 🙁 normal=120-240 mg/dl).
*Secreted from seminal vesicles.
*Essential for sperm nutrition.
b) PGs in semen:
*Secreted from seminal vesicles & prostate.
*Essential for sperm motility.
Additional: (according to suspected cause).
1) Doppler U/S: for varicocele.
2) Testicular biopsy:
Precautions:
a. After written consent.
b. Must be bilateral & multiple to detect any localized pathology.
Indication: azoospermia.
Value: it differentiates between obstructive azoospermia & productive azoospermia (no spermatogonia).
3) Hormonal study: serum PRL , serum testosterone & thyroid functions.
4) Chromosomal study: for suspected Klinefelter’s syndrome.
5) Immunological tests:
Male factor infertility Treatment :
Treatment of the cause; e.g.
Medical treatment: *Bromocriptine for ↑PRL.
Clomiphene to stimulate spermatogenesis.
Surgical treatment: for varicocele.
Assisted reproductive techniques:
Indications: oligospermia or asthenospermia.
Procedure: AIH & if failed IVF or ICSI is done
