Male Infertility

Male Infertility ( Summary of TOG+ excerpts from NICE Guidance)

Incidence – 

Male factor alone- 30% of infertile couples. 

Male factor + female factor- 40% 

Normal Semen Parameters- WHO Reference Limits

Semen volume                      1.5 mL

Sperm concentration            15.0 x 106/ml

Total number                         39.0 x 106/ejaculate

Total motility (PR+NP,%)       40.0 %

Progressive motility (PR,%)   32.0

Normal forms (%)                   4.0

Vitality (%)                              58.0

Causes of Male Factor Infertility- 

  1. Pretesticular
  2. Testicular
  3. Post -Testicular
  1. Pre-testicular ( Rare- less than 1 % of male infertility) 
  1. Hypothalamic Disease- Gonadotrophin deficiency (Kallman syndrome)
  2. Pituitary disease- Pituitary insufficiency (tumours, radiation, surgery), Hyperprolactinaemia, Exogenous hormones (anabolic steroids, glucocorticoid excess, hyper- or hypothyroidism)

2. Testicular: Congenital, Acquired

Testicular Congenital-  a. Genetic b. Other

Testicular Congenital  ( Genetic)

‐ Chromosomal (Kleinfelter syndrome 47, XXY)

‐ Y chromosome microdeletions

‐ Noonan syndrome (male Turner syndrome 45, XO)

Testicular – Congenital, Other

‐ Cryptorchidism

Testicular-  Acquired- 

‐ Injury (orchitis, torsion, trauma)

‐ Varicocele

‐ Systemic disease (renal failure, liver failure)

‐ Chemotherapy, radiotherapy

‐ Testicular tumours

‐ Idiopathic

3. Post-testicular (obstruction):Congenital, Acquired, Disorders of sperm function or motility, Sexual dysfunction

Post testicular Congenital

‐ Cystic fibrosis, congenital absence of the vas deferens (CAVD)

Post Testicular – Acquired

‐ Vasectomy

‐ Infection (chlamydia, gonorrhoea)

‐ Iatrogenic vasal injury

Disorders of sperm function or motility

‐ Immotile cilia syndrome

‐ Maturation defects

‐ Immunological infertility

Sexual dysfunction

‐ Timing and frequency

‐ Erectile/ ejaculatory dysfunction

‐ Diabetes mellitus, multiple sclerosis, spinal cord/pelvic injuries

HISTORY- 

  1. Age
  2. Fertility history- Previous pregnancies – with current and previous partners, Duration of infertility, Previous infertility treatments
  3. Sexual history- Erection or ejaculation problems, Frequency of intercourse
  4. Medical History 
  5. Surgical History
  6. Medications( including supplements / OTC drugs) 
  7. Social- smoking, alcohol, drugs, anabolic steroids, occupational exposure(s)

EXAMINATION

General Appearance

Height, Weight, BMI

BP

Any reduced hair growth, gynecomastia. 

Scrotal examination

Epididymis

Penile and prostate examination

TESTS- 

  1. Semen analysis
  2. Endocrine tests
  3. Genetic analysis
  4. Imaging
  5. Testicular biopsy

Semen analysis–

Clear instructions for collection, transport etc to be given. 

To be done after abstinence of 72 hours. Sample should be analyzed within an hour of collection. 

                If semen analysis shows-

Normal counts– No need to repeat

                If low count- repeat after 3 months. 

                If azoospermia– repeat sample earlier. 

Endocrine tests

If count is less than 5 X 109 /mL-  FSH, LH, testosterone and prolactin should be measured. 

Also indicated in impaired sexual function or if signs of endocrine disease. 

Genetic analysis

To be done cases of severe oligospermia or azoospermia. 

In CBAVD / non palpable vas deferens — Test for cystic fibrosis carrier status. 

Klinefelter syndrome (47, XXY) is the most frequently detected sex chromosomal abnormality. Yq microdeletions are present in about 15% of men with azoospermia and 10% of men with severe oligospermia. 

Imaging

Scrotal ultrasound-

  • if any testicular tumor is found on examination.
  • to look for varicocele. 

Renal imaging to be done in absent vas. 

TESTICULAR BIOPSY

For diagnosis of severe oligospermia and azoospermia. 

  • Can facilitate sperm recovery for ICSI.

TREATMENT

  1. Medical
  2. Urological surgery
  3. ART

Primary testicular failure- No treatment. If about to undergo chemotherapy- offer option of semen preservation. 

MEDICAL

Gn Rh / Gonadotropins- for Pretesticular 

 If any specific hormonal condition- specific treatment. 

Urological surgery

  1. Varicocele- NICE Guidance mentions that varicocele surgery should not be offered because it does not improve fertility rates. 

There is some evidence of improved semen parameters but not of increased pregnancy rates. 

  1. Surgical sperm retrieval
  2. Vasectomy reversal

ASSISTED REPRODUCTION

  1. IUI – Upto 6 cycles of unstimulated IUI can be offered. 

Indications-  immunologic infertility and mechanical problems of sperm delivery( erectile dysfunction or hypospadias). May have a role in mild male factor infertility ( see below)

Fresh sperm is associated with higher conception rates than frozen–thawed sperm. 

Intrauterine insemination, even using frozen–thawed sperm, is associated with higher conception rates than intracervical insemination. 

Indications of IUI according to NICE- 

  • Inability / difficulty in having vaginal intercourse ( using partner or donor sperm) 
  • conditions that require specific consideration in relation to methods of

conception (for example, after sperm washing where the man is HIV positive)

  • people in same-sex relationships.

If such groups do not conceive after 6 cycles of unstimulated IUI, then tubal patency should be tested. If there is evidence of normal ovulation, tubal patency and semenalysis, offer a further 6 cycles of unstimulated intrauterine insemination before IVF is considered. 

Monthly conception rate- 8 to 16%

  1. IVF + ICSI

With ICSI, pregnancy rate is about 33% per embryo transfer. 

NICE recommendation for mild male factor infertility- advise them to try to conceive for a total of 2 years (this can include up to 1 year before their fertility investigations) before IVF will be considered. Do not routinely offer intrauterine insemination ( Exceptional circumstances may be considered) 

Offspring born to couples using ICSI have higher incidence of chromosomal anomalies. 

Subscribe to Free Daily Quiz

Leave a Reply