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Subfertile Man
Dr .Ashraf Fouda
Ob/Gyn. Consultant
Damietta General Hospital
E. mail : ashraffoda@hotmail.com
Infertilityaffects
15 % of couples,
and
50 % of male infertility
is potentially
correctable.
Evaluation of the
subfertile man requires:
1. A complete medical
history,
2. Physical examination, and
3. Laboratory studies.
The main purpose of
the male evaluation is
to
identify and
treat correctable
causes of subfertility.
In
addition,
many men seek an
explanation
for their condition,
which can be discovered
during their evaluation.
The male fertility
evaluation can
uncover significant medical
and genetic pathology
that could affect the
patient's health or that
of his offspring.
Although pregnancies can
be achieved without any
evaluation other than a
semen analysis,
This test
alone is insufficient
to adequately evaluate
the male patient.
Treatment of correctable
male-factor pathology is :
1. Cost effective,
2. Does not increase the risk of
multiple births, and
3. Can spare the woman
invasive procedures and potential
complications
associated with assisted
reproductive technologies.
Appropriate evaluation
and treatment
of the subfertile
man are critical in
delivering suitable care
to the
infertile couple.
Infertility,
defined as the inability
to conceive after
one year of
unprotected intercourse,
affects
15 % of couples.
Male subfertility
is one of the
most rapidly growing
fields in medicine,
with dramatic advances
in diagnosis and treatment.
Although infertility
(or subfertility)
is often attributed
to female
causes, fertility is a two-
person phenomenon.
Successful conception depends on
many complicated events,
including :
1. Satisfactory sexual and ejaculatory
function,
2. Appropriate timing, and a
3. Complex set of interactions
between the male and the female
reproductive tracts.
Male and female factors
coexist in about one third of cases,
while one third of cases are
secondary to male factors only.
Therefore, evaluation of
both partners is critical,
and the woman's gynecologic
evaluation should proceed
simultaneously with the man's.
Causes of Male Subfertility
Another common
correctable cause of male
subfertility is
obstruction,
which may occur
after a vasectomy.
Causes of Male Subfertility
Less common correctable causes
include :
1.Ejaculatory dysfunction,
2.Infection,
3.Medications, and
4.Hormonal deficiency
Causes of Male Subfertility
When the sum of these
correctable causes
is calculated,
it becomes apparent that
more than one half of cases
of male subfertility
are potentially correctable.
Causes of Male Subfertility
The specific corrective
treatments such as
vasectomy reversal and
varicocele ligation
are more cost effective than
empiric treatment with
assisted reproductive
technologies.
Causes of Male Subfertility
Furthermore, correction of
underlying male factors can:
1. Allow for natural conception,
2. Does not carry an increased risk of
multiple births, and
3. Spares the woman invasive
procedures and the potential
complications of these therapies.
Causes of Male Subfertility
Recent advances, particularly
in molecular genetics, have
improved our understanding of
some forms of male subfertility.
A significant proportion of
male subfertility currently is
unexplained.
Causes of Male Subfertility
About13 % of men with
nonobstructive azoospermia
(i.e., no sperm in the semen because
of low or absent sperm production)
have been shown to
have Y-
chromosome microdeletions,
Causes of Male Subfertility
About 70 % of men with
congenital bilateral
absence of the vas deferens
are carriers of
cystic fibrosis mutations.
)ICSI(
The most significant advance in the
treatment of severe male infertility is
in vitro fertilization with
intracytoplasmic sperm injection (ICSI).
With this technique, a single sperm is
injected directly into the oocyte.
Only one viable sperm per egg
is required for ICSI, and a precise
diagnosis is not required to achieve
conception.
)ICSI(
When using sperm from men
with known or presumed
genetic infertility, it must be
assumed that any male offspring
also will be infertile.
Y-chromosome microdeletions
from the father are inherited
by the sons when ICSI is used.
There does not appear
to be an increased risk
of major malformations
in children born from
ICSI compared with
the general
population.
Counseling
about these potential
genetic issues
is a critical part
of the male fertility
evaluation.
Evaluation
The main goals of evaluating
the subfertile man are to
identify correctable causes
of infertility
and to help him and his partner
to conceive by the
most natural, least invasive
means possible.
Evaluation
In addition,
the evaluation
may uncover significant
underlying
medical or genetic
pathology.
Evaluation
Subfertility may be related
to an underlying
malignancy,
such as a
testicular or pituitary
tumor.
Evaluation
If the only evaluation
is a semen analysis,
underlying pathology
can be missed.
History and Physical
Examination
Because nearly
all commercially
available lubricants are
spermatotoxic,
their use is discouraged.
History and Physical Examination
Use of:
1. Prescription or
2. Drugs and
3. Exposure to environmental toxins
also can
impair fertility
History and Physical
Examination
Anosmia may
suggest an underlying
hypothalamic etiology
(such as Kallmann's syndrome)
or a pituitary etiology,
History and Physical
Examination
Frequent respiratory infections
are a feature of :
1. Young's syndrome:
(e.g., chronic sinusitis, bronchiectasis,
obstructive azoospermia) and
2. Kartagener's syndrome:
(e.g., primary ciliary
dyskinesia/immotile cilia, chronic
sinusitis, bronchiectasis, situs inversus).
History and Physical
Examination
1. Headaches,
2. Visual field disturbances, or
3. Galactorrhea
should prompt an investigation
for a tumor of the central
nervous system.
Clues to the Diagnosis of Male Infertility
Clinical clue Possible diagnosis
Clinical clue Possible diagnosis
History and Physical Examination
A thorough examination
can identify underlying causes
of subfertility.
Abnormal distribution of hair
and fat can suggest an
underlying endocrinopathy,
such as
hypogonadotropic hypogonadism.
History and Physical
Examination
The position and size
of the urethral meatus
should be noted because
severe hypospadias
can impair
sperm deposition
near the cervix.
History and Physical Examination
The levels of
serum testosterone and FSH
are adequate to assess the
pituitary-testicular axis
in the majority of cases.
Laboratory Evaluation
If the
total testosterone level is normal,
no further endocrine
testing is needed.
If the
total testosterone level is low,
the serum luteinizing
hormone and prolactin
levels can be checked to evaluate
for a
pituitary cause.
Laboratory Evaluation
When testosterone is merely
borderline or only slightly low,
supplementation should be avoided
unless the man is
significantly symptomatic
(i.e., erectile dysfunction,
markedly decreased energy level,
lack of libido).
Laboratory Evaluation
Testosterone supplementation
will actually
lower the sperm concentration
in such men because it can
cause
pituitary suppression
of gonadotropins.
Laboratory Evaluation
Ifthe FSH level is elevated,
it suggest end-organ
(testicular) failure.
A low level may indicate an
underlying FSH deficiency,
such as occurs with
hypogonadotropic hypogonadism.
Evaluation of the Subfertile Man
Laboratory Evaluation
More specialized testing
may be required based on the
outcome of this initial evaluation .
These tests require
referral to a center with
clinical and laboratory expertise
in the field of
reproductive medicine.
Laboratory Evaluation
For example, men with
low ejaculate volume
(less than 1 mL) should
have a post-ejaculatory urine
sample analysis to rule out
retrograde ejaculation.
Azoospermia
Azoospermic men can undergo
testicular biopsy
to evaluate the
level of sperm production
and differentiate between
testicular failure
and obstruction (i.e.,
normal sperm production)
Azoospermia
In patients with azoospermia:
1. Low semen volume
(less than 1 mL), and
2. A normal FSH level,
Transrectal ultrasonography
is indicated to evaluate for
possible
ejaculatory duct obstruction.
Azoospermia
Azoospermia
Genetic testing and counseling
are indicated in specific instances.
In patients with
azoospermia or severe oligospermia,
the karyotype should be determined
because of the increased incidence
of karyotypic abnormalities
in this population.
Azoospermia
Men with
congenital absence
of the vas deferens,
either unilateral or
bilateral,
may be carriers of cystic fibrosis.
These men should have
abdominal ultrasonography
to check for
renal agenesis.
Azoospermia
The outcome of the initial evaluation can
help guide treatment.
If correctable causes are found,
specific corrective treatment is offered.
If no correctable problem exists,
the couple may wish to pursue treatment
with assisted reproductive technologies
(ART) such as intrauterine insemination
and (ICSI) .
Azoospermia
An alternative to (ART)
is empiric treatment with
clomiphene citrate ,
although
few convincing data
show benefit.
Some reproductive
subspecialists advocate
abandoning
the male evaluation,
with the exception
of the semen analysis.
Whether this is an efficient approach to
conception,
is debatable,
But denying the man an evaluation,
including an opportunity to
learn the cause of his problem and
the chance
for specific corrective therapy,
seems inappropriate