ALGORITME DIAGNOSIS INFERTILITY

The initial workup of the infertile couple consists of a semen analysis, detection of
ovulatory function by various methods, and evaluation of tubal patency by
hysterosalpingogram (HSG) with concomitant fluoroscopy. Further evaluation of
pelvic anatomy, either by laparoscopy and/or hysteroscopy may be considered as a
part of the initial workup if there is an abnormality on HSG or later if no cause for
infertility can be found. Purely diagnostic laparoscopy for the infertile woman is being
used less frequently as more couples are advanced on the ART earlier in the
evaluation. Other procedures such as Y chromosome mapping, anti-sperm
antibodies, sperm penetration assay (SPA), or other tests of sperm function may be
used in certain cases.

Complete Medical and Gynecologic History

The basic evaluation of an infertile couple is generally agreed on (Fig. 2) The

evaluation consists of a detailed history, physical examination, assessment of
ovulation, semen evaluation, as well as uterotubal assessment. In addition, follicle-
stimulating hormone (FSH), and estradiol levels obtained on the third day of the
menstrual cycle maybe useful in women older than 35.

FEMALE.

A thorough workup is based on an extensive history and physical examination. The

woman should be asked about the timing of her pubertal development and
menarche. Menstrual history should include cycle length, duration, and amount of
bleeding, associated dysmenorrhea, or premenstrual symptoms. A history of
spontaneous, regular, cyclic predictable menses is, in almost all women, consistent
with ovulation, while a history of amenorrhea or abnormal or unpredictable bleeding
suggests anovulation or uterine pathology. Previous pregnancies, abortions, and
birth control history are also documented. The patient should be asked about
dyspareunia or severe dysmenorrhea that may be linked to endometriosis. A history
of pelvic inflammatory disease, STD, ruptured appendix or other abdominal surgery,
and the past use of an intrauterine device may be associated with tubal disease. A
history of galactorrhea may be an indication of elevated prolactin levels, while a
history of pubertal onset of progressive hirsutism associated with oligomenorrhea
may indicate polycystic ovarian disease or other disorders of androgen excess.
Excessive weight loss or weight gain, excessive stress or exercise is often
associated with ovulatory disorders. Sexual, social, and psychological issues should
be explored. Any prior infertility evaluation, surgery, or medical therapy is essential
information and records, films, or surgical photographs should be sought and
carefully re-evaluated.
MALE

The male partner should be questioned about prior fertility, general health,
medications, genital surgery, trauma, infection, and impotence. A history of drug or
alcohol abuse, frequent hot-tub baths, excess stress, fatigue, or excessive or
infrequent coitus should be elicited. Medical conditions that may result in infertility
include diabetes (retrograde ejaculation), any serious debilitating disease, adult
mumps orchitis, or pituitary hypofunction

all may lead to hypogonadism. Herniorrhaphy, varicocele, and bladder neck

suspensions are surgical procedures that may potentially be associated with
infertili
ty.

Diagn
ostic
algorit
hm for
the
basic evaluation of the infertile couple. BBT, basal body temperature; EMB,
endometrial biopsy; FSH, follicle-stimulating hormone; HSG,
hysterosalpingogram.(Chantilis SJ, Carr BR: Evaluation and treatment of the infertile
couple. In Quilligan EJ, Zuspan F [eds]: Current Therapy in Obstetrics and
Gynecology. Philadelphia, WB Saunders, pp. 83–90, 2000.)

FEMALE FACTOR

Treatment algorithm for infertile couples with oligo-anovulation. TSH, thyroid-

stimulating hormone; PRL, prolactin; FSH, follicle-stimulating hormone; LH,
luteinizing hormone; IUH, intrauterine insemination with washed husband’s sperm;
IVF, in vitro fertilization.(Chantilis SJ, Carr BR: Evaluation and treatment of the
infertile couple. In Quilligan EJ, Zuspan F [eds]: Current Therapy in Obstetrics and
Gynecology, pp. 83–90. Philadelphia, WB Saunders, 2000.)
In women with known polycystic ovarian syndrome characterized by
hyperandrogenism and oligo-ovulation, fertility is a constant challenge. Two common
endocrine features of this disease are increased circulating LH and
hyperinsulinemia. For these women, if infertility is a problem, then recent evidence
indicates that weight loss and treatment with insulin agents may be successful in
inducing ovulation. Women who have a body mass index (BMI) higher than 27
should be encouraged to lose weight. This reduces the amount of circulating
androgens and promotes ovulation induction. Furthermore, insulin sensitizers such
as metformin have been shown to increase the number of ovulatory cycles in these
women, especially in conjunction with clomiphene.
Treatment algorithm for male factor infertility. SPA, sperm penetration assay; IUH,
intrauterine insemination with washed husband’s sperm; IVF, in vitro fertilization;
ICSI, intracytoplasmic sperm injection; IUD, intrauterine device.(Chantilis SJ, Carr
BR: Evaluation and treatment of the infertile couple. In Quilligan EJ, Zuspan F [eds]:
Current Therapy in Obstetrics and Gynecology, pp. 83–90. Philadelphia, WB
Saunders, 2000.)

The diagnosis of male factor infertility often leads to poor treatment outcome.
However, with the emergence of ART, infertile couples with this problem have a
better chance of pregnancy. Although techniques of IVF together with
micromanipulation of gametes, such as intracytoplasmic sperm injection (ICSI), are
advancing at rapid speed, intrauterine insemination (IUI) with the husband’s sperm
still remains one of the treatment options available for couples diagnosed with male
factor infertility. Although clinicians may offer IUI to patients as one of several
possible options for the treatment of male factor infertility, patients often choose this
as the first line of treatment.

The use of IUI for the primary treatment of male factor infertility associated with
severe oligospermia or oligoasthenospermia remains controversial because of
extremely low pregnancy rates. For couples with severe oligospermia or those with
sperm-directed antibodies, IVF may be a better choice. Couples with mild to
moderate oligospermia, however, may be treated with IUI in conjunction with
menotropins for controlled ovarian hyperstimulation prior to IVF. In men with repeat
abnormal semen analysis, an enhanced SPA as well as referral to a urologist
specializing in male infertility may be considered. Y chromosome analysis may be
indicated in males with severe oligospermia. Persistent fertility can be treated with
IVF with consideration of ICSI or the use of donor sperm.

Treatment algorithm for unexplained infertility. hCG, human chorionic gonadotropin;

IUH, intrauterine insemination with washed husband’s sperm; IVF, in vitro
fertilization; GIFT, gamete intrafallopian transfer; IVF, in vitro fertilization.(Chantilis
SJ, Carr BR: Evaluation and treatment of the infertile couple. In Quilligan EJ, Zuspan
 F [eds]: Current Therapy in Obstetrics and Gynecology, pp. 83–90. Philadelphia, WB
Saunders, 2000.)

Timing of Testing

In the first month of evaluation, the use of condoms or barrier contraceptives is

suggested. On day 1 the woman begins the basal body temperature chart. An HSG
is scheduled for days 7 to 11 of the cycle to avoid menstruation and the possibility of
radiation exposure to a potential embryo. Home urine LH testing is begun on day 10
through 18. A serum progesterone level is obtained on day 21 or more accurately 7
days after the LH surge. An endometrial biopsy is taken on day 25 to 28, again most
accurately dated to LH surge. During this time a semen analysis is also obtained.

In the second month, a follow-up visit is scheduled. This may be done day 12 to 14
or after the LH surge at which time a postcoital test is performed if indicated. At this
time test results, HSG films, and other data is reviewed with the couple

Referensi :
Kakarla, N. B. K., 2008. Evaluation and Management of the Infertile Couple. Glob.
libr. women's med. (ISSN: 1756-2228) 2008; DOI 10.3843/GLOWM.10321

Patofisiologi Infertilitas (RZA)

More than 90% of male infertility cases are due to low sperm counts, poor sperm
quality, or both. The remaining cases of male infertility can be caused by a number
of factors including anatomical problems, hormonal imbalances, and genetic defects.

Sperm Abnormalities
Sperm abnormalities can be caused by a range of factors, including congenital birth
defects, disease, chemical exposure, and lifestyle habits. (See Risk Factors section.)
In many cases, the causes of sperm abnormalities are unknown.
Sperm abnormalities are categorized by whether they affect sperm count, sperm
movement, or sperm shape. They include:
 Low Sperm Count (Oligospermia). A sperm count of less than 20 million/mL is
considered low sperm. Azoospermia refers to the complete absence of sperm cells
in the ejaculate. Partial obstruction anywhere in the long passages through which
sperm pass can reduce sperm counts. Sperm count varies widely over time, and
temporary low counts are common. A single test that reports a low count may not be
a representative result.
 Poor Sperm Motility (Asthenospermia). Sperm motility is the sperm's ability to move.
If movement is slow or not in a straight line, the sperm have difficulty invading the
cervical mucus or penetrating the hard outer shell of the egg. If 60% or more of
sperm have normal motility, the sperm is at least average in quality. If less than 40%
 of sperm are able to move in a straight line, the condition is considered abnormal.
Sperm that move sluggishly may have genetic or other defects that render them
incapable of fertilizing the egg. Poor sperm motility may be associated with DNA
fragmentation and may increase the risk for passing on genetic diseases.
 Abnormal Sperm Morphology (Teratospermia). Morphology refers to shape and
structure. Abnormally shaped sperm cannot fertilize an egg. About 60% of the sperm
should be normal in size and shape for adequate fertility. The perfect sperm
structure is an oval head and long tail.

Retrograde Ejaculation
Retrograde ejaculation occurs when the muscles of the bladder wall do not function
properly during orgasm and sperm are forced backward into the bladder instead of
forward out of the urethra. Sperm quality is often impaired.
Retrograde ejaculation can result from several conditions:
 Surgery to the lower part of the bladder or prostate (the most common cause of
retrograde ejaculation)
 Diseases such as diabetes and multiple sclerosis
 Spinal cord injury or surgery
 Medications such as alpha blockers used for enlarged prostate glands, tranquilizers,
certain antipsychotics, or blood pressure medications may also cause temporary
retrograde ejaculation.
 Aging
Structural Abnormalities
Any structural abnormalities that damage or block the testes, tubes, or other
reproductive structures can affect fertility:
 Cryptorchidism. Cryptorchidism is a condition usually seen in newborn infants in
which the testicles fail to descend from the abdomen into the scrotum.
Cryptorchidism is associated with mild to severe impairment of sperm production.
 Hypospadias. Hypospadias is a birth defect in which the urinary opening is on the
underside of the penis. It can prevent sperm from reaching the cervix if not surgically
correct.
 Blockage in the Tubes that Transport Sperm. Some men are born with a blockage or
other problems in the epididymis or ejaculatory ducts, that later affect fertility. Some
men lack the vas deferens, the tube that carries sperm from the testicles out through
the penis. Low semen levels in ejaculate may be associated with structural
abnormalities in the tubes transporting the sperm.

Torsion:
Is a common problem affecting fertility that is caused by a supportive tissue
abnormality which allows the testes to twist inside the scrotum which is
characterized by extreme swelling. Torsion pinches the blood vessels that feed the
testes shut which causes testicular damage. If emergency surgery is not performed
to untwist the testes, torsion can seriously impair fertility and cause permanent
infertility if both testes twist.

Hormonal Deficiencies
Hypogonadism is the general name for a severe deficiency in gonadotropin-releasing
hormone (GnRH), the primary hormone that signals the process leading to the
release of testosterone and other important reproductive hormones. Low levels of
testosterone from any cause may result in defective sperm production.
Hypogonadism is uncommon and is most often present at the time of birth. It is
usually the result of rare genetic diseases that affect the pituitary gland. These
conditions may include selective deficiencies of the hormones FSH and LH, Kallman
syndrome, or panhypopituitarism, in which the pituitary gland fails to make almost all
hormones. Hypogonadism can also develop later in life from brain or pituitary gland
tumors or as a result of radiation treatments.

Hyperprolactinemia:
Elevated prolactin--a hormone associated with nursing mothers, is found in 10 to
40 percent of infertile males. Mild elevation of prolactin levels produces no
symptoms, but greater elevations of the hormone reduces sperm production,
reduces libido and may cause impotence. This condition responds well to the drug
Parlodel (bromocriptine).

Hypothyroidism:
Low thyroid hormone levels--can cause poor semen quality, poor testicular
function and may disturb libido. May be caused by a diet high in
iodine. Reducing iodine intake or beginning thyroid hormone replacement therapy
can elevate sperm count. This condition is found in only 1 percent of infertile men.

Congenital Adrenal Hyperplasia:

Occurs when the pituitary is suppressed by increased levels of adrenal

androgens. Symptoms include low sperm count, an increased number of immature
sperm cells, and low sperm cell motility. Is treated with cortisone replacement
therapy. This condition is found in only 1 percent of infertile men.

Hypogonadotropic Hypopituitarism:

Low pituitary gland output of LH and FSH. This condition arrests sperm
development and causes the progressive loss of germ cells from the testes and
causes the seminiferous tubules and Leydig (testosterone producing) cells to
 deteriorate. May be treated with the drug Serophene. However, if all germ cells
are destroyed before treatment commences, the male may be permanently infertile.

Genetic Disorders
Certain inherited disorders can impair fertility. Examples include:
 Cystic fibrosis can cause missing or obstructed vasa deferentia (the tubes that carry
sperm).
 Polycystic kidney disease, a relatively common genetic disorder that causes large
cysts to form on the kidneys and other organs during adulthood, may cause infertility
as the first symptom if cysts develop in the reproductive tract.
 Klinefelter syndrome is marked by two X and one Y chromosomes (the norm is one
X and one Y), which causes low testosterone levels and abnormalities of the
seminiferous tubules, although most other male physical attributes are normal.
 Kartagener syndrome is a rare disorder that causes impaired sperm motility as well
as severe respiratory infections and a reversed position of the major organs.

Varicocele
A varicocele is an abnormally enlarged and twisted (varicose) vein in the spermatic
cord that connects to the testicle. Varicoceles are found in about 15% of all men and
in about 40% of infertile men, although it is not clear how much they affect fertility or
by what mechanisms. They can raise testicular temperature, which may have effects
on sperm production, movement, and shape.

A varicocele develops when the one way valves in these spermatic veins are
damaged causing an abnormal back flow of blood from the abdomen into the
scrotum creating a hostile environment for sperm development. Varicocoeles may
cause reduced sperm count and abnormal sperm morphology which cause
infertility. Variococles can usually be diagnosed by a physical examination of the
scrotum which can be aided by the Doppler stethoscope and scrotal ultrasound.

Age
 Age-related sperm changes in men are not abrupt, but are a gradual process. Aging
can adversely affect sperm counts and sperm motility (the sperm's ability to swim
quickly and move in a straight line). The genetic quality of sperm declines as a man
ages.

Sexually Transmitted Diseases

Repeated Chlamydia trachomatis or gonorrhea infections are the sexually
transmitted diseases most often associated with male infertility. Such infections can
cause scarring and block sperm passage. Human papillomaviruses, the cause of
genital warts, may also impair sperm function.

Lifestyle Factors
Nearly any major physical or mental stress can temporarily reduce sperm count.
Some common conditions that lower sperm count, temporarily in nearly all cases,
include:
 Testicular Overheating. Overheating, such as from high fevers, saunas, and hot
tubs, may temporarily lower sperm count.
 Substance Abuse. Cocaine or heavy marijuana use can temporarily reduce the
number and quality of sperm. Chemical compounds in marijuana may impair sperms'
ability to swim and also inhibit their ability to penetrate the egg. Anabolic steroid use
can shrink testicles and decrease sperm production. Heavy drinking may also impair
fertility.
 Smoking. Cigarette smoking may affect sperm quality.
 Obesity. Obesity may impair hormonal levels and adversely affect fertility.
 Bicycling. Prolonged bicycling may affect erectile function. Pressure from the bike
seat can sometimes damage blood vessels and nerves that are responsible for
erections. Mountain biking, which involves riding on off-road terrain, exposes the
perineum (the region between the scrotum and the anus) to more extreme shocks
and vibrations and increases the risk for injuries to the scrotum. A padded or
contoured bike seat set at the proper height and angle can help reduce this risk.
 Emotional Stress. Stress may interfere with certain hormones involved with sperm
production but doctors are not sure if stress plays an important role in infertility.

Environmental Factors
Occupational or other long-term exposure to certain types of toxins and chemicals
(such as herbicides and pesticides) may reduce sperm count by either affecting
testicular function or altering hormone systems. Estrogen-like and hormone-
disrupting chemicals such as bisphenol A, phthalates, and organochlorines are
particular potential concerns. Chronic exposure to heavy metals such as lead,
cadmium, or arsenic may affect sperm quality. These chemicals generally affect men
who have long-term and intense occupational exposure to them. At this time, there is
no strong evidence supporting a serious harmful effect on fertility in men who have
normal limited exposure to these chemicals.
Medical Conditions
Medical conditions that can affect male fertility include any severe injury or major
surgery, diabetes, HIV, thyroid disease, Cushing syndrome, heart attack, liver or
kidney failure, and chronic anemia. Certain types of medications can impair sperm
production.
Infections in the Urinary Tract or Genitals. Infections that may affect fertility include
prostatitis (inflammation in the prostate gland), orchitis (in the testicle), semino-
vesculitis (in the glands that produce semen), or urethritis (in the urethra), perhaps
by altering sperm motility. Even after successful antibiotic treatment, infections in the
testes may leave scar tissue that blocks the epididymis.
Cancer and Its Treatments. Cancer treatments such as chemotherapy and radiation
can damage sperm quality and quantity, causing infertility. The closer radiation
treatments are to reproductive organs, the higher the risk for infertility. There is also
some evidence that male infertility is itself a risk factor for testicular cancer.

Infection and Disease:

Mumps, tuberculosis, brucellosis, gonorrhea, typhoid, influenza, smallpox, and

syphilis can cause testicular atrophy. A low sperm count and low sperm motility
are indicators of this condition. Also, elevated FSH levels and other hormonal
problems are indicative of testicular damage. Some STDs like gonorrhea and
chlamydia can cause infertility by blocking the epididimis or tubes. These
conditions are usually treated by hormonal replacement therapy and surgery in the
case of tubular blockage.

Erectile Disfunction (ED):

Also known as impotence, this condition is common and affects 20 million

American men. ED is the result of a single, or more commonly a combination of
multiple factors. In the past, ED was thought to be the result of psychological
problems, but new research indicates that 90 percent of cases are organic in
nature. However, most men who suffer from ED have a secondary psychological
problem that can worsen the situation like performance anxiety, guilt, and low self-
esteem. Many of the common causes of impotence include: diabetes, high blood
pressure, heart and vascular disease, stress, hormone problems, pelvic surgery,
trauma, venous leak, and the side effects of frequently prescribed medications (i.e.
Prozac and other SSRIs, Propecia). Luckily, many treatment options exist for ED
depending on the cause--these will be discussed in the treatment section.

Premature Ejaculation:
Is defined as an inability to control the ejaculatory response for at least thirty
seconds following penetration. Premature ejaculation becomes a fertility problem
when ejaculation occurs before a man is able to fully insert his penis into his
partner’s vagina. Premature ejaculation can be overcome by artificial insemination
or by using a behavioral modification technique called the “squeeze technique”
which desensitizes the penis.

Ejaculatory Incompetence:

This rare psychological condition prevents men from ejaculating during sexual
intercourse even though they can ejaculate normally through masturbation. This
condition sometimes responds well to behavioral therapy; if this technique does not
work, artificial insemination can be employed using an ejaculate from
masturbation.
Source:
1. Infertility in men | University of Maryland Medical
Center http://umm.edu/health/medical/reports/articles/infertility-in-
men#ixzz3JFXkTZIA
2. Infertility in men | University of Stanford

TREATMENT OF INFERTILITY (RIM)

The treatment of infertility begins with basic treatments. These can include advice
(e.g., the timing of intercourse or reduction of stress factors), the administration of
drugs to enhance the reproductive cycle, and various procedures that treat
underlying causes of infertility. If the basic treatments fail, then treatment moves to
more advanced techniques including assisted reproductive technologies (ART).
The definition of ART according to the Center for Disease Control (CDC) is all fertility
treatments in which both eggs and sperm are handled. In general, ART procedures
involve surgically removing eggs from a woman’s ovaries, combining them with
sperm in the laboratory, and returning them to the woman’s body or donating them to
another woman. They do NOT include treatments in which only sperm are handled
(i.e., intrauterine—or artificial—insemination) or procedures in which a woman takes
medicine only to stimulate egg production without the intention of having eggs
retrieved.
For the purpose of this policy, assisted reproductive technologies (ART) includes any
means of attempting pregnancy that does not involve normal coitus (sexual
intercourse) and will be referred to as "artificial means of conception". The simplest
of these techniques is artificial insemination (AI). In this procedure, viable sperm is
mechanically injected into the vagina, cervix, or uterus. In vitro fertilization (IVF) is a
more advanced technology that involves surgically removing eggs from the woman’s
ovaries, combining them with sperm in the laboratory and, if fertilized, replacing the
resulting embryo into the woman’s uterus. Various types of transfers may occur to
replace the fertilized egg back into the female.
All services which are received as part of an IVF procedure are considered under the
same benefit as the IVF procedure. This can include office visits, drugs, lab and
pathology, surgical procedures, etc. Mechanically assisted fertilization (MAF) may
be performed as part of an IVF procedure. Such procedures include Zona "drilling"
or (PZD) where the zona pellucida of the oocyte is mechanically interrupted so as to
assist sperm entry, and intracytoplasmic sperm injection (ICSI).
Modifications of the IVF procedure include such procedures as GIFT (gamete
intrafallopian transfer), ZIFT (zygote intrafallopian transfer), PROST (pronuclear
stage transfer), TEST (tubal embryo stage transfer) and TET (tubal embryo transfer).
While many of the services received during these procedures are similar to IVF, in
GIFT, eggs and sperm are transferred to the fallopian tube where fertilization occurs.
In ZIFT, PROST, TEST, and TET, fertilized embryos are transferred at various
stages of development into the fallopian tube, either from the fimbrial end via
laparoscopy or through catheterization of the uterine end, the latter with or without
ultrasound guidance.
Basic Treatments
Once infertility has been established, the treatments for infertility begin. Depending
on the unique medical situation of an infertile couples’, the following treatments for
infertility may be considered medically necessary.
1) Infertility drugs:
a) Dopamine agonists (bromocriptine and cabergoline)
b) Clomiphene citrate
c) Gonadotropins:
Human chorionic gonadotropin (hCG)
Choriogonadotropin alfa (a biosynthetic [recombinant DNA-derived] chorionic
gonadotropin)
Human menopausal gonadotropins (hMG) (menotropins). Failure of clomiphene
citrate and other techniques of inducing ovulation should be documented.
Urofollitropin (human follicle stimulating hormone-FSH)
Recombinant (biosynthetic) FSH (follitropin alpha, follitropin beta)
Recombinant (biosynthetic) luteinizing hormone (lutropin alfa)
d) Low dose glucocorticoids (dexamethasone or prednisone)
e) Gonadotropin-releasing hormone (GnRH). Unresponsiveness to Clomiphene
Citrate should be documented.
f) Metformin for annovulation secondary to polycystic ovarian disease (PCOD).
2) Therapeutic Operative Procedures for the Female (Note: Benefits for reversal of
sterilization are not covered unless otherwise stated by the member benefit booklet.)
a) Therapeutic operative laparoscopy (e.g., treatment of endometriosis or
periadnexal adhesions)
b) Open surgical treatment in women with moderate or severe endometriosis
c) Salpingo-ovariolysis
d) Terminal salpingostomy
e) Fimbrioplasty
f) Uterotubal implantation
g) Tubocornual anastomosis
h) Balloon tuboplasty
i) Ovarian wedge resection
3) Therapeutic Operative Procedures for the Male (Note: Benefits for reversal of
sterilization are not covered unless otherwise stated by the member’s benefit
booklet.
a) Varicocelectomy
b) Transurethral resection of ejaculatory duct
c) Orchiopexy
d) Surgical correction of epididymal blockage for men with obstructive azoospermia:
Epididymectomy
Epididymovasostomy
Excision of epididymal tumors and cysts
Epididymostomy
C) Artificial Means of Conception
This includes any means of attempting pregnancy that does not involve normal
coitus.

MALE INFERTILITY TREATMENT

Counselling
‘Lifestyle’ factors can impair semen quality, e.g. heavy smoking, alcohol abuse, use
of anabolic steroids, extreme sports (marathon training, excessive strength sports),
and an increase in scrotal temperature through thermal underwear, sauna or hot tub
use, or occupational exposure to heat sources. A considerable number of drugs can
affect spermatogenesis.
Medical (hormonal) treatment
Antioxidant treatment (folic acid, vitamin E, zinc, selenium) have a positive influence
on semen quality and some improvement of spontaneous pregnancy rates. No
studies have confirmed that hormonal therapies, such as human menopausal
gonadotrophin (HMG)/human chorionic gonadotrophin (HCG), androgen, anti-
estrogens (clomiphene and tamoxifen), prolactin inhibitors (bromocriptine) and
steroids, have improved pregnancy rates in men with idiopathic OAT. However,
some primarily endocrinological pathologies can be treated medically, including:
• Low testosterone: clomiphene citrate 50 mg/day or tamoxifen 20 mg/day
• Hypogonadotrophic hypogonadism: start HCG 1500 IU subcutaneously 3
times per week, and add HMG or FSH 75–150 IU intramuscularly 3 times per week,
until spermatogenesis occurs
• Hyperprolactinaemia: dopamine agonists.
In patients with sperm autoantibodies, high-dose corticosteroids, although effective,
are not recommended because of serious side-effects.
Surgical treatment
Varicocele
The treatment of varicocele is a controversial subject, mainly based on whether there
is an actual need to treat varicocele in infertile men. There is evidence of improved
semen parameters after successful varicocele treatment. Current information
supports the hypothesis that in some men, the presence of varicocele is associated
with progressive testicular damage from adolescence onwards and consequent
reduction in fer-tility. Although treatment of varicocele in adolescents may be
effective, there is a significant risk of over-treatment. In cases of normal semen
analysis and in men with a subclinical varicocele, there appears to be no benefit from
treatment compared with observation. Varicocele repair, however, seems effective in
couples in whom the men hasoligozoospermia, a clinical varicocele and otherwise
unexplained infertility.
Microsurgery/vasovasostomy and epididymovasostomy
Only urologists with experience in microsurgery should undertake these procedures
using an operating microscope. The likelihood of initiating pregnancy is inversely
proportional to the obstruction interval and becomes less than 50% after 8 years.
Other important prognostic factors are the quality of the semen after the procedure
and the partner’s age. In approximately 15% of men who have undergone a
successful vasovasostomy, sperm quality deteriorates to the level of azoospermia or
extreme oligospermia within 1 year.
Sometimes an epididymal obstruction coexists, especially in men with a long interval
between vasectomy and vasovasostomy. In these men a vaso-epididymostomy is
indicated. Considering that a vaso-epididymostomy has a limited effect on pregnancy
rates (20–30%), it is advisable to combine this procedure with microsurgical
epididymal sperm aspiration (MESA), and cryopreserve the harvested spermatozoa
for ICSI. The indications for vaso-epididymostomy include obstructions at the level of
the epididymis in the presence of a normal spermatogenesis (testicular biopsy). Poor
sperm quality and sometimes sperm antibodies after successful vasectomy repair
may prevent spontaneous pregnancy and assisted reproduction is indicated.
MESA/TESE
MESA in combination with ICSI is indicated in men with obstructive azoospermia
when reconstruction (vasovasostomy, vaso-epididymostomy) cannot be performed
or is unsuccessful. An alternative would be percutaneous aspiration of spermatozoa
from the caput epididymis (PESA). If a MESA or PESA procedure does not produce
spermatozoa, testicular sperm extraction (TESE) can be applied. In about 50–60% of
men with non-obstructive azoospermia (NOA), spermatozoa can be found in the
testis. Some authors recommend taking several testicular samples, while others
advocate microsurgical harvesting of spermatozoa. So far, no clinical or laboratory
parameter has been shown to be useful in predicting sperm harvesting in men with
NOA. In case of AZFa and AZFb microdeletions, no spermatozoa can be retrieved.
Transurethral incision of ejaculatory ducts or midline prostatic cyst
Distal obstructions of the genital tract are commonly caused by infections of the
prostatic urethra and the accessory glands or by a cyst in the midline of the prostate.
Treatment of the obstruction by transurethral incision of the cyst or the ejaculatory
ducts (TURED) may lead to an increase in semen quality and, occasionally,
spontaneous pregnancy. Long-term results, however, are disappointing.
Retrograde ejaculation & Anejaculation
Treatment of retrograde ejaculation is basically aimed at removing the cause of the
disorder or harvesting spermatozoa from the urine after orgasm. Anejaculation can
be treated by vibrostimulation or electro-ejaculation techniques. It is possible to
induce ejaculation in around 90% of patients with spinal cord injuries. However, the
semen quality is often poor with a low number of motile spermatozoa and increased
rates of DNA fragmentation. This accounts for the disappointing results of assisted
reproduction techniques in these men. Testicular sperm extraction (TESE), in-vitro
fertiliation and ICSI are often required.
REFERENCE
1. A. Jungwirth, T. Diemer, G.R. Dohle, A. Giwercman, Z. Kopa, C. Krausz,
H.Tournaye Guidelines For The Investigation And Treatment Of Male
Infertility. The European Association Of Urology At Their Website -
Http://Www.Uroweb.Org. (Text Update February 2012) Eur Urol 2012
Jan;61(1):159-63