Infertility

Background
• Generally defined as inability of a couple to
conceive within a certain period of time, 1 year or
more, despite having regular unprotected sex.
• Primary infertility – one has never conceived
before
• Secondary infertility – one has conceived at some
point in the past
• Unexplained infertility - Fertility testing has not
found a reason that a person or couple is unable to
get pregnant.
 Risk Factors
• Many of the risk factors for both male and
female infertility are the same. They include:
– Age – fertility reduces with increasing age
– Tobacco use
– Alcohol use
– Marijuana use
– Being overweight and underweight
– Exposure to environmental toxins or hazards
– STI’s
 Causes
• We will approach the causes under the
following subtopics;
– Production
– Storage
– Delivery
 Male Infertility
1. Production:
– Hypothalamus
– Anterior Pituitary
– Testes
 Hypothalamic-Pituitary-Gonadal Axis
• The hypothalamic pituitary gonadal axis is comprised of the
hypothalamus, the pituitary gland (both anterior and posterior portions)
and the testes.
• The hypothalamus secretes gonadotrophin releasing hormone (GnRH) in a
pulsatile fashion, which enters the hypophyseal portal system in order to
reach the anterior pituitary gland.
• This stimulates the anterior pituitary gland to secrete two hormones vital
for reproduction, follicle-stimulating hormone (FSH) and luteinizing
hormone (LH), as well as adrenocorticotropin, growth hormone, prolactin,
and thyroid-stimulating hormone(TSH) whose roles in reproduction at
normal physiologic levels are poorly understood
• LH and FSH act on cells in the testes including
Leydig, Sertoli and germ cells. Leydig cells are
the testosterone producing cells in the
testicle, while Sertoli cells produce inhibin B.
• Both hormones feedback onto the anterior
pituitary and the hypothalamus. Testosterone,
once released into the peripheral circulation
may be converted to estradiol by the enzyme
aromatase, which can have effects on fertility.
• Any derangements in any of these steps can
have tremendous impact on male fertility.
Hypothalamic-Pituitary-Gonadal Axis
 Male Infertility
 Hypothalamus
– Congenital abnormalities of hypothalamus
• e.g. Kallman’s syndrome
– Starvation, stress or severe illness
– Tumors
– Head injury
– Inflammation (sarcoidosis)
– Infection (tuberculosis)
– Drugs: marijuana
 Male Infertility
• Pituitary
• Endocrine: thyroid, prolactin
• Tumors
• Inflammation: sarcoidosis, meningitis
• Infarction
• Trauma
• Drugs: anabolic steroids
 Male Infertility
• Testes:
• Congenital: Klinefelters (47, XXY), developmental
disorders, undescended testis
• Disorders of gonadal steroidgenesis
• Infection: chlamydia, prostatitis, mump orchitis
• Autoimmune disorder
• Tumors; chemo/Radiotherapy
• Drugs / alcohol
• Trauma to the testes
• Vascular: testicular torsion
 Male Infertility
• 2. Storage:
– Temperature
• Rise in scrotal temperature – bath tubs and saunas
• Occupation
• Varicocoele – enlargement of scrotal veins
 Male Infertility
 3. Delivery:
Impotence/Ejaculation
○ Neurogenic: medications (alpha adrenergic blockers, chemotherapy
medications, beta blockers, SSRIs, diuretics, CNS stimulants and depressants )
○ Endocrine: diabetes
○ Cardiac-related conditions
○ Congenital: absence vas deferens (CF)
○ Hypospadia
○ Vasectomy
○ Psychological problems
 Retrograde ejaculation
 Male Infertility
 Diagnosis
 History:
Previous children
Infections: prostatitis, STD, mumps orchitis
Trauma to head or testicles
Surgery to testicles or hernia
Occupation (sitting, bio hazards)
Chemo or Radio therapy
Ethanol or Smoking
Medication
Medical history (DM, HTN)
Previous investigations
 Male Infertility
• Physical examination
– Anatomy
– Testicular size
– Varicocele (valsalva)
 Male Infertility
• Investigations:
– semen analysis
• Abstain 2-4 days prior
• At least 2 samples over different period of time
– If abnormal:
• Blood work: FSH, LH, TSH, testosterone, PRL
• Testicular U/S
• Chromosomal analysis
– Biopsy
 Semen analysis

pH scale 7.2 to 8.0 pH

Semen volume 1.5 to 7.6 milliliters

Sperm concentration (density) 15 to 259 million per milliliter

Sperm morphology 4 to 48 percent

Sperm motility 40 to 81 percent

Time to liquefaction 15 to 30 minutes after collection

Vitality 54 to 97%
< 1 million/mL
WBC
 Male Infertility
• Interventions:
– Treat underlying causes
– Intrauterine Insemination (IUI)
– Intracytoplasmic Sperm Injection (ICSI)