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Evaluation of infertile men: Mini-review

Article · November 2016

DOI: 10.1016/j.apjr.2016.10.006

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Asian Pacific Journal of Reproduction 2016; ▪(▪): 1–3 1

56
Contents lists available at ScienceDirect 57
58
Asian Pacific Journal of Reproduction 59
60
journal homepage: www.apjr.net 61
62
1 63
2 Review http://dx.doi.org/10.1016/j.apjr.2016.10.006 64
3 65
4 Evaluation of infertile men: Mini-review 66
5 67
6 Q3 Mohannad AbuFaza1, Ibrahim A. Abdelazim1,2*, Hossam S. Osman1, Dareen A. Alsharif1 68
7 1
Department of Obstetrics and Gynecology, Ahmadi Hospital, Ahmadi, Kuwait 69
8 2 70
Department of Obstetrics and Gynecology, Ain Shams University, Cairo, Egypt
9 71
10 72
11 Q2 A R TI C L E I N F O ABSTRACT
73
12 74
13 Article history: Evaluation of infertile couple indicated because of failure of conception for one year of
Received 30 Jul 2016 unprotected intercourse, and indicated for the infertile couple because of failure of 75
14 76
Received in revised form 22 Oct 2016 conception for 6 months of unprotected intercourse if the female partner is above 35
15 77
Accepted 24 Oct 2016 years.
16 78
Available online xxx Initial male partner evaluation includes: 1) thorough reproductive history, and at least
17 one semen analysis. 79
18 If the initial male partner evaluation showed any abnormality, complete assessment 80
19 Keywords:
needed. 81
20 Men
Conclusion: Initial assessment of the infertile male include; thorough reproductive 82
21 Infertility
history, and at least one semen examination. Endocrine assessment indicated for males 83
22 Review
with abnormal semen analysis. Post-ejaculatory urine analysis performed in males having 84
23 <1 mL ejaculation volume, except in congenital bilateral absent vasa deferentia 85
24 (CBAVD), and hypogonadism. Genetic testing for cystic fibrosis transmembrane 86
25 conductance regulator (CFTR) mutations offered to male with CBAVD before IVF. 87
26 Males with severe oligozoospermia and/or non-obstructive azoospermia are at risk of 88
27 genetic abnormality, and must offered karyotype and Y-chromosome testing before IVF. 89
28 90
29 91
30 92
31 93
32 94
33 1. Introduction drug allergies; 5) previous sexually transmitted infections; 6) 95
34 exposures to environmental or chemical gonadal-toxins. 96
35 A previously fertility male, may acquire a secondary disease 97
2. Semen analysis
36 causing secondary infertility. Initial male partner evaluation 98
37 include; thorough reproductive history and at least one semen 99
38 Semen analysis is a basic step in infertile male assessment,
analysis. If the initial male evaluation showed any abnormality,
and the physician should provide the male partner with the 100
39 complete male assessment needed [1,2]. 101
40 proper instructions for semen collection such as pre-examination
Methods of complete male evaluation include; 1) complete
abstinence interval [3]. 102
41 history, examination, and semen analysis by a male reproduction 103
42 Semen should collected at the laboratory or at home by inter-
specialist; 2) endocrine evaluation; 3) post-ejaculatory urine
course or by masturbation using special condoms not containing 104
43 analysis; 4) ultrasound; 5) specific semen and sperm tests; 6) 105
44 toxic sperm materials. If the semen sample collected at home, the
genetic testing [1,2].
sample should transferred to the laboratory for examination within 106
45 History and examination of the male partner include; 1) coital 107
46 1 h, and kept at body temperature during transfer [4].
frequency; 2) duration of infertility; 3) medical disorders (upper
Semen examination report should provides information about 108
47 respiratory diseases, diabetes mellitus); 4) previous surgery, and 109
48 the volume of the semen sample, the concentration of the sperm,
viability, motility, and the morphology of the sperms in the sample. 110
49 111
50 According to world health organization definitions, lower limit
of normal semen sample should contains: 1.5 mL volume, 15 × 106 112
51 *Corresponding author: Ibrahim A. Abdelazim, Obstetrics and Gynecology, Ain
113
52
Shams University, Egypt and Consultant at Ahmadi Hospital, Kuwait Oil Company spermatozoa/mL (total sperm number 39 × 106 spermatozoa/
(KOC), Kuwait. ejaculate), 40% of the sperms of the sample motile (32% forward 114
53 Tel: +965 66551300 115
54 E-mail: dr.ibrahimanwar@gmail.com progressive motility), 4% of the sperms of the sample with normal
Peer review under responsibility of Hainan Medical College. morphology with absent of agglutination in the sample [5]. 116
55 117
2305-0500/© 2016 Hainan Medical College. Production and hosting by Elsevier (Singapore) Pte Ltd. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).

Please cite this article in press as: AbuFaza M, et al., Evaluation of infertile men: Mini-review, Asian Pacific Journal of Reproduction (2016), http://dx.doi.org/10.1016/j.apjr.2016.10.006
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2 Mohannad AbuFaza et al./Asian Pacific Journal of Reproduction 2016; ▪(▪): 1–3

1 Detailed sperm morphology is not needed except after failed that may cause infertility. Trans-rectal ultrasound can diagnose 63
2 in-vitro-fertilization (IVF) and before intra-cytoplasmic injec- seminal vesicles, prostatic and ejaculatory ducts abnormalities. 64
3 tion (ICSI) [6]. Scrotal ultrasound can diagnose varicocele, absent vasa and 65
4 Sperm concentration 48 million/mL, motility 63%, and testicular lesions [10]. 66
5 morphology 12% usually seen in normal fertile male. Sperm 67
6 concentration <13.5 million/mL, motility<32%, and 3.5. Specific semen and sperm tests 68
7 morphology <9% normal usually seen in sub-fertile male [7]. 69
8 Specific semen and sperm tests include: 1) Identification of 70
9 3. Complete assessment of the infertile male leukocytes in the semen sample; increased white blood cells 71
10 (WBCs) count in semen associated with decreased motility, and 72
11 If the initial assessment of the male partner showed abnor- function of the sperms. The immature germ cells and WBCs 73
12 mality in the semen sample a complete male assessment needed. appear as round cells under microscopic wet-mount examina- 74
13 The complete assessment of the male partner includes; 1) tion. WBCs cells can differentiated from the immature germ 75
14 Thorough reproductive history and thorough examination per- cells by the immuno-histo-chemical staining [11]. 76
15 formed by male reproduction specialist; 2) endocrine evaluation; 2) Antisperm antibodies (ASA); Infertile couple due to ASA 77
16 3) post-ejaculatory urine analysis; 4) ultrasound; 5) specific typically treated with ICSI. ASA suspected when there is iso- 78
17 semen and sperm tests; and 6) genetic testing. lated asthenospermia with normal semen parameters, and normal 79
18 sperm concentration. ASA developed after break in blood-testis 80
19 3.1. Thorough reproductive history and thorough barrier as after trauma, testicular biopsy or vasectomy. ASA in 81
20 examination performed by male reproduction specialist the serum or in the seminal fluid detected using indirect antibody 82
21 agglutination test. ASA bound to the sperms detected using 83
22 Thorough history should includes; 1) Thorough evaluation of immuno-bead test [12,13]. 84
23 the whole body systems; 2) family history of infertility; 3) use of 3). Sperm viability. Assessed by mixing semen with eosin 85
24 anabolic steroids. dye (eosin dye test). Viable sperm remain colorless after mixing 86
25 General physical examination includes; 1) Thorough genital with eosin dye, while non-viable sperm will take up the eosin 87
26 examination; penis, testes, epididymides, and both vasa; 2) the stain [14,15]. 88
27 reproduction specialist examining an infertile male should 4). Sperm DNA fragmentation; The term “DNA fragmenta- 89
28 comment on presence or absence secondary sexual character tion” means no repairable damage of the DNA of the sperm. 90
29 and/or varicocele and perform per rectal examination if needed. This damage of the sperm DNA detected by 1) Direct tests, 91
30 The reproduction specialist can diagnose the congenital including single-cell electrophoresis (Comet), and terminal 92
31 bilateral absent vasa deferentia (CBAVD) by general and scrotal deoxy-nucleotide transferase–mediated dUTP nick-end labeling 93
32 examinations. (TUNEL) [16–18]. 2) Indirect tests, including sperm chromatin 94
33 structure, to identify the abnormal structure of the chromatin, 95
34 3.2. Endocrine evaluation and increased liability of DNA of the sperms to denaturation. 96
35 DNA damage of the sperms is common in infertile males, 97
36 Endocrine disorders are uncommon in males with normal and males with decreased reproductive ability. ICSI with 98
37 semen analysis. Endocrine evaluation is needed for male with; 1) retrieved sperms through testicular aspiration or testicular biopsy 99
38 <10 million/mL sperm concentration; 2) sexual dysfunction; 3) is the best treatment for males with abnormal ejaculated sperm 100
39 history or examination findings suggestive of endocrinopathy. DNA integrity [19,20]. 101
40 The initial hormonal evaluation includes: serum follicle 102
41 stimulating hormone, and total serum testosterone (T). If the 3.6. Genetic testing 103
42 total serum T level is < 300 ng/mL, more evaluation is needed, 104
43 and includes morning total serum testosterone and free serum Males with severe oligozoospermia and/or non-obstructive 105
44 testosterone, prolactin, and luteinizing hormone, to identify the azoospermia are at risk of genetic abnormality, and must 106
45 source of abnormal total testosterone level [8]. Carter et al., offered karyotype and Y-chromosome testing before IVF [21]. 107
46 suggests that the serum inhibin B level are lower in infertile Cystic fibrosis transmembrane conductance regulator (CFTR) 108
47 male, and related with the sperm parameters better than the gene mutations seen in eighty percent (80%) of the males 109
48 follicle stimulating hormone [9]. diagnosed as CBAVD. CFTR gene mutations increased among 110
49 azoospermia males, CBAVD, and men with vasa agenesis. 111
50 3.3. Post-ejaculatory urine analysis Chromosomal abnormalities seen in 10%–15% of the azoo- 112
51 spermic males. Sex chromosomal abnormalities (Klinefelter 113
52 Low volume or absence of the semen in the sample suggests syndrome) constitute 2/3 of chromosomal abnormalities found 114
53 incomplete collection, obstruction of the ejaculatory duct, in infertile males. Balanced chromosomal translocation is also 115
54 retrograde ejaculation, or CBAVD. In order to exclude the high in infertile males [21]. 116
55 possibility of retrograde ejaculation; a post-ejaculatory urine Males with non-obstructive azoospermia, or severe oligo- 117
56 analysis performed in males having <1 mL ejaculation volume, zoospermia should have chromosomal study before using their 118
57 except in CBAVD and hypogonadism. sperm for IVF [22]. 119
58 Y-chromosome micro-deletions seen in 16% of infertile males 120
59 3.4. Ultrasound with azoospermia or severe oligospermia. Y-chromosome micro- 121
60 deletion detected with PCR testing to visualize the whole Y 122
61 The male genital tract can easily and accurately imaged using chromosome length. Most deletions causing oligozoospermia or 123
62 ultrasound. Ultrasound can detect male genital tract abnormalities azoospermia occur in the Y-chromosome long arm known as the 124

Please cite this article in press as: AbuFaza M, et al., Evaluation of infertile men: Mini-review, Asian Pacific Journal of Reproduction (2016), http://dx.doi.org/10.1016/j.apjr.2016.10.006
 APJR118_proof ■ 12 November 2016 ■ 3/3

Mohannad AbuFaza et al./Asian Pacific Journal of Reproduction 2016; ▪(▪): 1–3 3

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Please cite this article in press as: AbuFaza M, et al., Evaluation of infertile men: Mini-review, Asian Pacific Journal of Reproduction (2016), http://dx.doi.org/10.1016/j.apjr.2016.10.006

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