Male infertility General Practice Perspective

Siya SharmaConsultant

Gynaecologist & ObstetricianKings Lynn GP Update on Women’s Health

14-9-20131

My Interest Areas

• Infertility Management, Reproductive Medicine, IVF

• Laparoscopic & Hysteroscopic Surgery • Ovulatory and Menstrual disorders

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Aims of the sessionTo discuss • Male infertility aspects relevant to general

practice• Diagnosis and Treatment options

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Q - Permanently sterile men ?A – 1%

Do We Know?

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Myths

1. A man with azoospermia cannot become a biological father

- “donor sperm or adoption are the only choices”

2. A man who has had chemotherapy before, is sterile and cannot father a child

3. “Your FSH is too high: we will never find sperm”

4. A man with oligo-astheno-teratozoospermia (OAT) does not need to see a urologist / andrologist

– “his sperm can be used for IVF and ICSI”

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Infertility – Factors & Incidence

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(Hull MG, et al. BMJ 1985;291:1693–7. School of Public Health, University of Leeds, The management of subfertility. Effective Health Care 1992;1(3):1–240. Thonneau P, et al. Hum Reprod 1991;6:811–6.

Male Infertility Incidence

• Male infertility is a factor in ¼ to ½ (25 - 50%) of subfertile couples

•Main reasons abnormal semen quality- sexual dysfunction

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Male Infertility-Specific Causes

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Seminiferous tubule dysfunction 60-80%

Post-testicular abnormalities, defect & blocks 10-20%

Primary hypogonadism 10-15%

Secondary hypogonadism (Hypothalamic-pituitary disorders) 1-2%

Male Infertility - Aetiology

Category Examples

Primary gonadal

disorders

Congenital Acquired

•Y-chromosome abn.

•Klinefelter syndrome

•Androgen insensitivity

•5-reductase deficiency

•Haemochromatosis

•Cryptorchidism

•Anorchia

•Varicocoele

•Viral orchitis

•Epididymo-orchitis

•Drugs / toxins

•Radiation

•Hyperthermia

•Trauma / torsion

•Immunological

•Systemic illness

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Category Examples

Hypothalamic-pituitary disorders

Congenital Acquired

•Kallmann syndrome

•IHH – idiopathic hypogonadotropic hypogonadism

•Multi-system disorders:

- Prader-Willi syndrome

- Laurence-Moon-Biedl

syndrome

•Haemochromatosis

•Pituitary tumours

•Hypothalamic tumours

•Hormone-related:

- Hyperprolactinaemia

- Androgen

- Estrogen

- Cortisol

•Infiltrative disorders

•Vascular

•Drugs

•Chronic illness

•Nutritional deficiency

•Obesity

Male Infertility - Aetiology

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Testosterone concentration in testis/testes

Q – More or Less than bloodA - MoreQ – How many times moreA - 20-100 times more

Brain Storming

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Sexual function• Pubertal development

• Coitus – Frequency (2-3/week), timing

• Libido – do you have desire for coitus?

• Erectile function – do you have normal erections ?

• Ejaculatory function – do you ejaculate ?

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Past Surgical History

13Varicocoele Cryptorchidism Trauma

Torsion

Inguinal SurgeryScrotal

Medical history

•Diabetes mellitus

•Neurological disease

•Hypothalamic-pituitary disorders

•Cancer survivors

•Viral orchitis14

Medical history

•Hyposmia / anosmia – Kallmann Syndrome

•Headaches/visual disturbance – Prolactinoma

•Recurrent respiratory infections – Cystic Fibrosis

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Mechanism Examples

Gonadotoxins

(impair spermatogenesis)

•Sulfasalazine•Methotrexate•Cytotoxic

chemotherapy

•Colchicine•Nitrofurantoin

Erectile dysfunction •Beta-blockers•Thiazide diuretics

•Metoclopramide

Ejaculatory failure •Alpha-blockers•Anti-depressants

•Phenothiazines

Antiandrogenic •Spironolactone •Cimetidine

Hypothalamic-pituitary

suppression

•Testosterone•Anabolic steroids

•Drugs → prolactin•GnRH analogues

Drugs of misuse •Cannabis•Heroin

•Cocaine

Drugs Impairing Male Fertility

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Personal History

•Alcohol > 3-4 units/day detrimental to semen quality

•Smoking - reduces semen quality- impact on male fertility is uncertain

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Environmental factors

•Heavy metals•Organic solvents•Pesticides / herbicides•Phytoestrogens•Radiation•Heat

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Male – Physical Examinations

• General

• Genitalia

– Meatus normal?

– Any scars?

– Testes – size/volume, consistency, location/symmetry, masses

– Can you feel vas deferens?

– Is epidiymis full?

– Does the patient have a varicocoele?

• DRE – Digital rectal examination for prostate

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Male - Anatomy

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• Laboratory investigations of infertile male

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• Semen analysis

– Abstinence 3-5 days

– Specimen pot

– Transportation to lab

– Repeat analysis if abnormal (need minimum of two analyses, three months apart)

Male – Lab Investigations

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WHO 2010 Semen AnalysisCriteria Lower Reference Value (5th

percentile, 95%CI)

Semen volume (mls) 1.5 (1.4–1.7)

Total sperm number (106 per ejaculate)

39 (33–46)

Sperm concentration (106 per ml) 15 (12–16)

Total motility (PR + NP, %) 40 (38–42)

Progressive motility (PR, %) 32 (31–34)

Vitality (live spermatozoa, %) 58 (55–63) 23

WHO 2010 Semen AnalysisCriteria Lower Reference Value (5th

percentile, 95%CI)

Sperm morphology (normal forms, %) 4 (3.0–4.0)

pH ≥7.2

Peroxidase-positive leukocytes (106 per ml)

<1.0

MAR test (motile spermatozoa with bound particles, %)

<50

Immunobead test (motile spermatozoa with bound beads, %)

<50

Seminal zinc (umol/ejaculate) ≥2.4

Seminal fructose (umol/ejaculate) ≥13

Seminal neutral glucosidase (mU/ejaculate)

≥20 24

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Q – What % of men have sperm quality below the threshold thought compatible with normal fertility (conception within one year) ?A - 20%

Quiz

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Azoospermia

What to do next if azoospermia is revealed

• Endocrine assessment– FSH

– Testosterone (8-9 am, circadian cycle)

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Consider following when azoospermia is revealed

• Genetic screen in NOA - no spermatogenesis– Karyotyping, – Y deletions – CF – CBAVD– Hypogonadotrophic hypogonadism– Haemochromatosis – erectile disorders,

loss of libido29

Consider referral in azoospermia

Whom to refer ?• Andrologist or• Urologist with andrology interest

• Geneticist when indicated

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Azoospermia

• With low volume

• With normal volume

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Azoospermia

• ObstructiveObstructive

• Non-ObstructiveNon-Obstructive

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Low volume, acidic azoospermia

• Volume < 1cc

• Ph < 7.2

• Azoospermia

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Low volume acidic azoospermia• Testes - normal in size & consistency• FSH - normal• Spermatogenesis - normal (OA)• Low vol indicates no SV contribution

• Diagnosis by: - Vasal palpation - TR USS - Fructose assay not required

EDOEDO

CBAVDCBAVD

Normal Volume Azoospermia• Seminal Vesicles are present• Ejaculatory ducts are open• Differential diagnosis

- Non Obstructive

Azoospermia (NOA)

(spematogenic failure)

- Obstructive

Azoospermia (OA)

(Blockage of vas or

epididymis) 35

Normal volume Azoospermia

• Making a diagnosis ofOA• Testis - normal in size & consistency• Epididymes – full & firmNOA• Testis - small in size• Epididymes – Normal

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Azoospermia

• Azoospermia - semen volume and pH are the key for diagnosis

– Low volume, acidic pH

• CBAVD, EDO

– Normal volume alkaline

• NOA, blockage of vas or epididymis

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Male InfertilityTreatment Options

• Conservative• Medical• Surgical• ART

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Treatment in azoospermia• Non Obstructive - spematogenic

failure,variable

- Sperm extraction (testicular biopsy)

• Obstructive - Blockage of vas or epididymis

- Reconstruction- Sperm aspiration

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Q -Infertile couples undergoing IVF - male factor is solely implicated in ? A - 20% of cases Q – and is contributory in up to ?A - 50%

Quiz

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Any Questions Please?

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