1
Forth stage
Surgery
(urology)
Lec-x
د.محمد فوزي
11/310/2016
Infertility
Definition: The inability of a sexually active, non contracepting couples to achieve
pregnancy in one year
Definition
:
failure to conceive after 1 year of unprotected sexual intercourse
About 25% of couples do not achieve pregnancy within 1 year
It affects about 15% of couples
Roughly:
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40 % male factor
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40 % female factor
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20 % both male & female
Male reproductive physiology:
It depends on the hypothalamic (LHRH) – pituitary ( LH , FSH ) – gonadal axis
LH – laydig cell – TST
FSH – Sertoli cells
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Spermatogenesis is completed by meiotic division
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In the seminiferous tubules
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It takes 74 day
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Sperm maturation occurs in the epididymis
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Fertilization occurs in the ampullary portion of the fallopian tube during
the middle of the cycle
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Causes of male infertility
Pretesticular
I.
Hypothalamic diseases
Gonadotropin deficiency
( Kallmann syndrome
II.
Pituitary diseases
Pituitary insufficiency, Hyperprolactinemia
Testicular
1. Chromosomal causes
Klinefelter syndrome (47,XXY)
2. Other syndromes
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Noonan syndrome ( male Turner syndrome 45 ,X
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Sertoli-cell-only syndrome
3. Gonadotoxins
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Radiation
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Drugs ( calcium channel blockers , cimetidine , tricyclic antidepressants ,
nitrofurantoin , allopurinol )
4. Systemic diseases
renal failure, liver cirrhosis ,,,,
5. Testicular injury
orchitis , torsion , trauma,,
6. Cryptorchidism
7. Varicocele
8. Idiopathic
Post testicular
I. Reproductive tract obstruction
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Congenital blockages ( cystic fibrosis, idiopathic epididymal obstruction,
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Acquired obstruction ( vasectomy , groin surgery , infection )
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Functional obstruction ( sympathetic N. injury, pharmacologic)
II. Disorders of sperm function or motility
Immotile cilia syndrome, maturation defect, immunologic infertility, infection
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Evaluation of male infertility depends on
• History
• Physical exam.
• Semen analysis
• Hormonal assessment
Physical examination
Complete exam.adequate virilization , body hair , gynecomastias , scrotal exam.
Laboratory investigations
Urinalysis
Semen analysis
azoospermia (obsructive and non obsructive) ,Oligospermia, asthenospermia,
oligoasthenospermia
Volume: 2.0 ml or more
pH: 7.2 or more
Sperm concentration: 20 × 10^6 or more sperm/ml
Total sperm number: 40 × 10^6 or more spermatozoa per ejaculate
Motility: 50% or more
Morphology: 30% or more
White blood cells: Less than 1 million/ml
Hormonal analysis
Evaluation of the pituitary – gonadal axis .Includes: testosterone , FSH , LH , prolact
Adjunctive tests
Semen leukocyte analysis, antisperm antibody test, sperm penetration assay ,Chromosomal
study, Semen culture.
Radiologic study
• Scrotal U/S : size of testes.,varicocele
• TRUS :For obstruction of ejaculatory duct
• CT & MRI
• Vasography
Testicular biopsy In azoo spermia to difrentiate between obstructive and non-
obstructive azoospermia
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Treatment of male infertility
Surgical treatment
Varicocele
Vasovasostomy
Ejaculatory duct obstruction – TURED
Electro ejaculation – spinal cord injury
Sperm aspiration ( vasal aspiration , epididymal sperm aspiration , testis sperm
retrieval )
Orchidopexy
Pituitary ablation
Non-surgical treatment
Pyospermia – antibiotics + antioxidant vitamins ( A,C,E )
Coital therapy - timing & frequency ( every other day around ovulation )
Immunologic infertility – corticosteroids suppression, sperm washing, IUI ,IVF ,ICSI
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Medical therapy
Hyperprolactinemia - bromocriptine
Hypo / hyperthyroid
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Empiric medical therapy
25% of infertility is idiopathic
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Clomiphene: citrate anti estrogen – increase secretion of GnRH, LH,FSH
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Tamoxifen : anti estrogin
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Antioxidant therapy : Vit E , glutathi
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Assisted reproductive technologies
• Intrauterine insemination ( IUI) : immunologic infertility, low sperm quality,
hypospadias
• IVF & ICSI
• Gamete intrafallopian transfer ( GIFT )
A.L.Y