Infertility: Male

Question 1

Lifestyle and environmental factors for male infertility

Answer 1

-Obesity (BMI 30+)
=Decreased spermatogenesis, erectile dysfunction
-Low BMI (<19)

-Cigarette smoking
=Decrease spermatogenesis, fertilising capacity

-Anabolic steroids/ recreational drug use
=Spermatogenesis

-Prescription drugs
=Sulfasalazine, cimetidine, phenytoin, sex steroid, hypotensive agent, opiates

-Alcohol
=Erectile dysfunction

-Heavy metals, insecticides, solvents

Question 2

History taking in subfertility

Answer 2

-Duration of subfertility
-Prior known/documented fertility
-Lifestyle
-Intercourse (timing, frequency, problems)
-History of STD/PID
-Current and past medical/ surgical illnesses

Question 3

Male factors of sexual dysfunction (erectile and ejaculatory)

Answer 3

-Psychosexual
-Medical and surgical illnesses
=vascular disease, MS, diabetes, spinal cord injury, obesity prostate disease and surgery, urethral surgery, endocrine
-Drugs
=α,β-blockers, alcohol, anabolic steroids, antidepressant , antipsychotic, opioids, cocaine

Question 4

Causes of abnormal semen analysis

Answer 4

-Medical and surgical illnesses / endocrinopathy
=Torsion, trauma, mumps, cryptorchidism, scrotal or inguinal surgery, brain tumour, systemic illness/infection, STD, chemotherapy, radiotherapy, vasectomy

-Drugs/ Occupational exposures (heat, chemical, radiation)

-Genetic
=CBAVD (CF mutation 70%), Y chromosome microdeletion, Klinefelter, autosomal defect

-Structural ( idiopathic/ congenital)
=Varicocele, Epidydimal obstruction (Young syndrome), Ejaculatory duct obstruction

-Idiopathic

Question 5

WHO 2010 criteria for semen analysis

Answer 5

-Volume (>/ 1.5ml)
-PH (>7.1)
-Sperm concentration (>/15 x 10^6)
-Total sperm count (>/ 39 x 10^6)
-Motility (within 60 min of ejaculation)
=Progressive (>/ 32%)
=Total (>/ 40%)
-Morphology (>/ 4%)
-Vitality (>/ 58% live)
-White blood cells (<1 x 10^6)

Question 6

Investigations of male subfertility

Answer 6

-History (detailed)
-Physical examination
=Focus on Genitourinary examination
-Laboratory evaluation
=2 semen analysis at least 6 weeks apart
=Sperm retrieval in urine sample
=STI screening/ C&S on semen
=Endocrine testing ( LH, FSH, PRL, Testosterone)
=Karyotype, Y chromosome microdeletion
=CF screening
-USS / Vasogram
-Surgical
=PESA /Testicular biopsy

Question 7

Surgical retrieval of semen

Answer 7

-PESA and TESE
-Open testicular biopsy

Question 8

Management of male subfertility (specialist)

Answer 8

-Expectant management
=Mild to moderate male factor

-Medical management
=Hypogonadotrophic hypogonadism
==HCG first then combined with FSH, In some cases GnRH
=Sexual dysfunction
==Psychosexual counselling, sildenafil, penile vibratory stimulation, electroejaculation, AIH

-Surgical management
=Reversal vasectomy
=Vasoepididymostomy/ TURED/balloon dilatation
=NOT for varicocoele

-Assisted reproduction
1. Intra uterine insemination (PR 6 – 17%) (Mild factor, Retrograde ejaculation)
2. Sperm donor (AID) (PR 5-15%)
3. ICSI (PR 5-50%)
4. Surgical sperm retrieval + ICSI
5. IVF with gamete donation

Question 9

Examination of male in subfertility

Answer 9

-Scrotum= Varicocele
-Size (volume) of the testes= Small testes associated with oligospermia
-Position of the testes= Undescended testes
-Prostate= Chronic infection