Male Infertility: Causes, Diagnosis, Treatment & Semen Analysis Guidelines

What is Male Infertility?

1. Infertility: It occurs when one year of unprotected intercourse does not lead to conception.

2. Subfertility: The couples who exhibit decreased reproductive efficiency.

3. Fecundability: It is a probability of achieving pregnancy within a single menstrual cycle.

4. Fecundity: The probability of achieving live birth within a cycle.

What is Spermatogenesis?

• During embryogenesis, there are approximately 300 thousand spermatogonia in each gonad. Each undergoes mitotic division, and by puberty there are 600 million spermatogonia in each testis.
• Sperm production takes place in seminiferous tubules within the testis. The complete spermatogenesis takes about 70 days to complete.
• Adult males produce 100-200 million sperm each day.
• Leydig cells produce testosterone (which, along with FSH, stimulates spermatogenesis).
• Maturation of sperm takes place in epididymis, and transport of sperm is via vas deferens.

Semen Analysis

• To prove male infertility, semen analysis is done. For proper semen analysis, the person should refrain from sexual activity (abstinence) for 2-3 days. The short interval of abstinence decreases the sperm density and semen volume.
• Longer abstinence intervals increase the proportion of dead, immotile, and morphologically abnormal sperms.
• Abnormal sperm count can only be analyzed at least after 4 weeks.
• Semen specimens should be collected in a clean container or can also be collected in a silastic condom, which does not contain any anti-spermicidal agents.
• Semen samples should be examined within an hour after collection.

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Guidelines for Semen Analysis

Semen Analysis Conclusions 

If the ejaculate volume and pH are:

• Low or absent: CBAVD (congenital absence of vas deferens), ejaculatory duct obstruction, hypogonadism, retrograde ejaculation (TORP done for BPH).
• High volume (>5 ml): Inflammation of accessory gland
• Seminal vesicle secretions are alkaline and contain fructose.

The ejaculatory duct obstruction leads to acidic semen (prostate secretions) and has no sperm or fructose.

What are the Abnormalities Found in Sperm?

1. Oligozoospermia: reduced sperm count
2. Asthenozoospermia: reduced sperm motility (<32%)
3. Teratozoospermia: increased abnormal sperm count
4. Oligoasthenoteratozoospermia-sperm variables are subnormal
5. Azoospermia: no sperm present in the semen
6. Aspermia—no ejaculation
7. Leukocytospermia: increased WBC count in semen

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Define the Causes of Male Infertility?

Pretesticular:

Hypothalamic pituitary disease (secondary hypogonadism). It counts for 1-2%

Hypothalamic Pituitary disorders include: (Pre-testicular)

1. Idiopathic isolated gonadotropin deficiency

2. Kallmann syndrome

3. Single gene mutations

4. Hypothalamic and pituitary tumors

5. Infiltrative disease

6. Hyperprolactinemia

7. Drugs

8. Chronic systemic illness and malnutrition

9. Infections of the glands

10. Obesity.

Testicular

Primary Hypogonadism. It is a reason for 10-15% of the cases.

Primary gonadal disorders: (Testicular) 

1. Klinefelter syndrome

2. Y chromosome deletions

3. Cryptorchidism

4. Varicoceles

5. Infections

6. Drugs

7. Radiation

8. Environmental

9. Gonadotoxicity

10. Chronic illness

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Post-testicular Defects:

Problem of ejaculatory duct and disorders of sperm transport. It is the reason for 10-20% of the cases.

1. Disorders of sperm transport: (post-testicular) 
2. Epididymal obstruction or dysfunction
3. Infections obstructing vas deferens
4. Vasectomy
5. Kartagener syndrome
   • Triad of bronchiectasis, situs inversus, male infertility.
   • There is primary ciliary dysfunction.
6. Ejaculatory dysfunction
7. Young syndrome

Evaluation of Male Infertility

The evaluation of male fertility is very important because of the following reasons:

• It helps identify and correct the specific cause
• It helps in the identification of the individuals whose fertility cannot be corrected but could be overcome by IUI (intrauterine insemination) and ART (assisted/artificial reproductive techniques).
• To identify genetic abnormalities
• To identify any medical condition that requires special attention.
• To identify the individuals whose infertility can neither be corrected nor overcome with ART, in whom adoption or donor sperm are considered.

History of Male Infertility 

• Duration of infertility and previous infertility
• Coital frequency and sexual dysfunction
• Any previous evaluation or treatment of infertility
• Childhood illness (mumps, orchitis, cryptorchidism) and developmental history
• Previous surgery and its outcome, systemic medical illness
• History of exposure to STD
• Exposure to environmental toxins
• Current medications and allergies
• Occupational exposure to tobacco, alcohol, and other drugs.

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Physical Examinations for Male Infertility

• Examination of penis:
  • Proximal hypospadias, penile hypospadias, or penoscrotal hypospadias—no proper implantation of sperm in the vagina.
  • Examine Peyronie's disease.

• Palpation of testes and measurement of their size
• Presence and consistency of both vasa and epididymis
  • Palpation of vas deferens helps to rule out congenital absence of vas deferens.
• Presence of any varicocele: Most common treatable cause of male infertility—varicocele.
• Secondary sexual characteristics, hair distribution, and breast development
• Digital rectal examination (DRE): examination of the seminal vesicles: Seminal vesicles are not usually palpable on DRE.

• Prader orchidometer: Used for checking volume of testes.
• Seager orchidometer: To measure length of testis.

Other Investigations for Male Infertility Include 

• Absence of fructose: can be due to congenital absence of seminal vesicle, partial duct obstruction.
• Semen culture 
• Urologic evaluation
• Endocrine evaluation (LH, FSH, Testosterone) usually done for abnormal semen analysis
  • Elevated FSH, LH normal or low testosterone: Primary Testicular failure
  •  Low FSH, LH, Low Testosterone: Hypogonadotropic hypogonadism 
  • Normal FSH, LH, testosterone: Normal or primary testicular failure

Genetic Evaluation

1. Mutations within Cystic fibrosis Transmembrane conductance regulator (CTFR gene)

2. Chromosomal anomalies resulting testicular dysfunction—Klinefelter syndrome

3. Y chromosome deletions associated with abnormalities of spermatogenesis.

• Transrectal ultrasonography: indicated in the diagnosis of severe oligospermia or azoospermia (obstruction of ejaculatory duct). It is less invasive. Primarily done to visualize seminal vesicles.
• Renal Ultrasonography: unilateral or bilateral vasal agenesis
• Transscrotal ultrasonography: to confirm physical findings or to detect non-palpable varicocele.
• Testis biopsy for azoospermia. (When the testicular biopsy shows normal spermatogenesis, obstruction to the vas deferens is suspected.).
• Vasography helps to visualize the vas deferens and detect any blockages or abnormalities.

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Drugs that Impair Male Infertility

1. Impaired spermatogenesis: Sulfasalazine, methotrexate, nitrofurantoin, colchicine, chemotherapy

2. Pituitary suppression: Testosterone injections, GnRH analogues

3. Anti-androgenic effects: Cimetidine, spironolactone

4. Ejaculation failure: Alpha blockers, antidepressants, phenothiazine

5. Erectile dysfunction: beta blockers, thiazide, metoclopramide.

Treatment of Male Infertility

1. Hypogonadotropic hypogonadism: Secondary hypogonadism

Pulsatile GnRH, hCG, hMG, Testosterone, Clomiphene Citrate, and Tamoxifen.

2. Hypergonadotropic to hypogonadism : Primary hypogonadism or Primary testicular failure

• IVF/ICSE, Donor sperm, Adoption
• Androgen, FSH, Clomiphene.
• Hyperprolactinemia-Dopamine agonists
• Strict control of DM, hypothyroid

Pretesticular Treatment 

1. Erectile Dysfunction: PDE5 inhibitor (Sildenafil)

2. For ejaculatory problems (Retrograde ejaculation): Imipramine, Pseudoephedrine/Ephedrine, Phenylpropanolamine

3. Retrograde Ejaculation, Neurogenic impotence, severe hypospadias: Intrauterine insemination (IUI)

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Surgical Treatment for Male Infertility

1. Vasovasostomy

2. Vasoepididymostomy

3. Transurethral resection of ejaculatory ducts

4. Varicocele repair

5. Orchiopexy

6. Vibratory stimulation and ejaculatory ejaculation.

Surgical Management 

• Cryptorchidism: Orchidopexy at 1 year of age
• Varicocele: High ligation of internal spermatic vein
• Gonadal failure: surgical retrieval of spermatozoa, followed by ICSI.

Questions

Absence of fructose in sperm and palpable seminal vesicles/seminal vesicles are enlarged on TRUS

Diagnosis is: Ejaculatory Duct Obstruction

Treatment is: TURED (TransUrethral Resection of Ejaculatory Duct)

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Hope you found this blog helpful for your NEET SS Surgery urology preparation. For more informative and interesting posts like these, keep reading PrepLadder’s blogs.