MALE INFERTILITY: TREATMENT

BABALOLA R N
 OUTLINE

• NON-SURGICAL

• SURGICAL

• ASSISTED REPRODUCTIVE TECHNIQUES

• CONCLUSION
 Introduction
• The nature of male infertility, as well as the
possible cause, should be sought out
– Identify reversible causes
– Identify patients with specific sperm retrieval
needs
– Ensure partner is adequately evaluated
– Treatment can include non-surgical and surgical, in
conjunction with artificial reproductive techniques
 DEFINITION OF TERMS
• TURED- Transurethral resection of ejaculatory ducts
• EDO – Ejaculatory duct obstruction
• MESA – Microsurgical epididymal sperm aspiration
• PESA – Percutaneous epididymal sperm aspiration
• TESA – Testicular sperm aspiration
• TESE – Testicular sperm extraction
• IVF – In-vitro fertilization
• ICSI – Intra-cytoplasmic sperm injection
 Non- Surgical
• Leukocytospermia)
– broad-spectrum antibiotics doxycycline and
trimethoprim–sulfamethoxazole
Coital Therapy
• Simple counseling on issues of coital timing,
frequency, and gonadotoxin avoidance can
improve fertility.
– Avoid coital lubricants
 Non-surgical
• Hyperprolactinemia—
– Bromocriptine; trans-sphenoidal surgery
• Clomiphene citrate
– Increased testosterone production, and may
improve spermatogenesis
Antioxidant Therapy
• Up to 40% of infertile men have increased
levels of reactive oxygen species
– Treatment with scavengers of these radicals may
protect sperm from oxidative damage.
– Glutathione, Vit A, C, E, fish oils

• Drugs for ED – PDE 5 inhibitors

 Oligo-astheno-teratozoospermia
• Spermatotoxins
– Eliminate
• Cigarrette, marijuana, cannabis, alcohol, valproic acid,
anabolic steroids, cimetidine, spironolactone, Ca2+
channel blockers, colchicine, dilantin
• Medical therapy
– Clomiphene, hCG, tamoxifen, pentoxifylline, folinic
acid, (carnitine for motility disorders)
SURGICAL TREATMENTS
 PENILE & TESTICULAR DISORDERS

• Urethroplasty

• Hypospadias repair

• Epispadias repair

• Orchidopexy

• Varicocelectomy
 Low-semen-volume azoospermia
Semen <1.5ml
• Ejaculatory duct obstruction
– Intraprostatic cyst – Excision of the roof of the cyst
(TUR)
– Trans-urethral resection of the ejaculatory duct
• Vasal aplasia
– Microsurgical epididymal sperm aspiration /
Percutaneous epididymal sperm aspiration
TURED
 Normal semen volume azoospermia

• Primary testicular failure

– Testicular sperm aspiration OR testicular sperm
extraction (open surgical biopsy)
• Approx 50% of azoospermic men will have some sperm
in their testis, useful for ICSI
• Secondary testicular failure
– hCG stimulates virilization (Leydig cell →
testosterone)
 Normal semen volume azoospermia

• Epididymal and vasal obstruction

– Causes include vasectomy, infection, congenital,
trauma, previous surgery
– Vasectomy reversal
• Vaso-vasostomy or vaso-epididymostomy
• MESA is carried out if reconstruction is not
possible
VASECTOMY REVERSAL
 Anejaculation
• Spinal cord injury (above T10)
– Lower cord intact, with the sympathetic
innervation to the seminal vesicle & bladder neck
– Penile vibratory stimulation
• Normal ejaculatory reflex is stimulated and antegrade
ejaculation occurs
• Sperm is then retrieved for either home cervical
insemination, IUI, IVF or ICSI
 Anejaculation
• Spinal cord injury (below T10)
– Interruption of the pathway from the integration
centre to the sympathetic nuclei, thus penile
vibration will not work
–Electro-ejaculation
–Direct sperm retrieval
Treatment: Retrograde ejaculation
• Neurologic cause
– α–sympathomimetic agents (pseudoephedrine)
• Anatomic cause
– Optimize semen and urine for IUI
• Alkalinize urine (NaHCO3), make urine dilute, collect
urine immediately after ejaculation and extract sperm
• If sperm has poor quality, empty bladder (catheter) and
instill sperm medium into bladder before ejaculation
 Assisted Reproductive Techniques
• Sperm Retrieval Methods

• Fertilization

• Implantation
 Assisted Reproductive Techniques
• Vasal aspiration
• Epididymal aspiration
– Microsurgical epididymal aspiration
• Sperm are directly collected from a single, isolated epididymal tubule
• Epididymal tubule is then closed with fine, microscopic suture, and
the sperm are processed.
– Percutaneous epididymal sperm aspiration (PESA) – palpable
epididymis
• Epididymal sperm are not as mature as vasal sperm; as a
consequence, epididymal sperm require ICSI to fertilize
the egg
 Assisted Reproductive Techniques
• Testicular sperm extraction (TESE)
– A small piece of testis tissue is taken in a manner
similar to that of a regular testis biopsy.
• Testicular sperm aspiration (TESA)
– When spermatogenesis is known or suspected to
be normal, or is reduced but uniformly distributed
throughout the testicle
 Reproductive Techniques
• Intra-uterine insemination
– At time of ovulation, sperm is extracted and concentrated from
semen, and inserted into the uterus via a trans-cervical catheter

• In-vitro fertilization
– Incubation of harvested oocytes and processed spermatozoa in
a culture medium
– Fertilized oocytes (embryos) are then transferred into the
uterus, others are cryopreserved
– Recommended when sperm is of adequate quality after a failed
IUI
• Intra-cytoplasmic sperm injection
– Delicate micro-manipulation to place an individual
spermatozoon into the cytoplasm of an harvested
oocyte
– Bypasses all fertilization barriers
– Particularly useful in sever oligospermia or when
the spermatozoa are funtionally deficient (such as
gotten from TESE, MESA etc)
UNIT EXPERIENCE
 UNIT EXPERIENCE
• 92 patients
• Mean age – 37±7 years
– Jeje et al, 2016
• Type of fertility
– Primary – 49 patients
– Secondary – 43 patients
 AGE DISTRIBUTION
60

50

40

30

20

10

0
20-29 30-39 40-49 50-59
 OCCUPATION
Occupation
Business Civil Servant Artisans Others
23%
29%

18%
31%
 History
• Family history of infertility
– Yes – 2
– No – 90
• Frequency of intercourse
– <1 per week – 17.3%
– 1-2 per week – 15.34%
– 3 or more – 67.3%
• Previous groin surgeries
– Yes – 16
– No – 76
• Other relevant history
– Previous orchidopexy for testicular torsion – 7
– Perineal trauma/testicular atrophy – 1
– Orchidopexy for undescended testis – 1
– Recurrent testicular pain - 1
 Examination
• Most (95%) of the patients had masculine
appearance, 7 (7.6%) had gynecomastia
• 24 (26%) patients had testicular
hypotrophy/atrophy on examination
• Varicoceles were seen in 40(43.5%) of patients
 VARICOCELE

Both
25%

No varicocele
57%
Left
15%

Right
3%
 SEMINAL FLUID ANALYSIS
• Available in 82 patients
• Only 9 patients had normal SFA
• Oligospermia was the leading anomaly on
SFA, present in 37 (45.1%) of the patients
– Owolabi et al, 2011
– Ikechebelu JI, 2003
• Azoospermia was commoner in primarily
infertile males while oligospermia was
commoner in secondarily infertile males,
though this relationship did not attain
statistical significance (p=0.412)
 SEMINAL FLUID ANALYSIS
30
20
10
0
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m rm rm rm lS rm rm rm
er e e e a e e e
o sp o sp o sp o sp rm o sp o sp o sp
o ig o o o zo zo zo
Az O l o z o z N o o o
e n rat ecr e n rat
a sth o te N
A sth Te
o en
il g h
O a st
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O
 SPERM CULTURE
No growth Staph aureus Klebsiella
E coli Contaminants
7% 7% 2%
38%

47%
• Ultrasound abnormalities
– Pampiniform plexus dilatation – 40
– Microlithiasis – 9
– Testicular atrophy - 15
– Epididymal cyst – 8
– Intra-abdominal testis - 1
HORMONAL PROFILE (50 patients)

• Only 11 of the 50 patients had normal

hormonal profiles
• Hyperprolactinemia was the commonest
homonal abnormality, present in 22 (44%) of
the patients, followed by hyper-gonadotrophic
hypogonadism (13 patients, 26%)
 Hormonal Profile
25
20
15
10
5
0
H tin H LH ia ne al
FS la
c FS d em ro rm
ed o Lo
w an tin te No
va
t pr H la
c os
e d FS st
El an ro te
H ted er
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 Further investigations
• Vasography ( 16 patients)
– Patent vas - 13
– Obstructed – 3
• Testicular biopsy(13 patients)
– Absent spermatogenesis - 5
– Spermatogenesis arrest – 2
– Normal spermatogenesis - 6
• 1 patient had in addition interstitial fibrosis
 Treatment
• Vitamin A/C/E- 48 patients
• Varicocelectomy – 32 patients
• Referral for ART - 16 patients
• Antibiotics – 14 patients
• Neurosurgical referral
• ED treatment
• Couples counselling - coital Rx
 CONCLUSION
• Male fertility has significant psycho-social and emotional
consequences for the couple
• Patients in our unit were assessed and managed
accordingly
• With advancements in assisted reproductive techniques,
chances of fertility have been improved in previously
“hopeless” situations
 THANKS FOR
YOUR ATTENTION
• Ikechebelu JI, Adinma JI, Orie EF, Ikegwuonu SO.
High prevalence of male infertility in
southeastern Nigeria. J Obstet Gynaecol. 2003
Nov;23(6):657-9.
• AT Owolabi, OB Fasubaa, SO Ogunniyi. Semen
quality of male partners of infertile couples in Ile-
Ife, Nigeria.Nig J Clin Pract. 2013; 16(1): 37-40