EVALUATION OF MALE INFERTILITY

Introduction

Definition:• Failure of conception after at least 12 months

of regular unprotected intercourse.Epidemiology:• Up to 50% of infertility is due to male factors.• An estimated 14–25% of couples may be

affected at some point in their reproductive years.

Pathophysiology

Failed fertilization of the normal ovum due to abnormalities of:

• morphology (teratozoospermia, <4% normal forms)• motility (asthenozoospermia, <40% motile sperm)• low sperm numbers (oligozoospermia, <15 x 106 per

mL)• absent sperm (azoospermia)• Abnormal epididymal function (defective spermatozoa

maturation or transport or induce cell death).

Pertinent History in Evaluation of the Infertile Male

• Infertility history• Sexual history• Past history (childhood/Medical

/Surgical/medication /gonadotoxins)• Family history

PHYSICAL EXAMINATIONGeneral Examination:• weight, height and arm span• secondary sexual development• signs of hypogonadism• GynaecomastiaGenital Examination:• Penis• Scrotum & testis• Epididymis• Spermatic cord• DRE of prostate.

LABORATORY EVALUATION

Basic investigations• Semen analysis• Hormone measurement: serum FSH, LH and

testosterone

Semen Analysis

• Collection and Timing

The semen analysis characteristics can be classified into two groups:

A. macroscopic B. microscopic.

Microscopic characteristics

Sperm AgglutinationCount and ConcentrationMotilityMorphologyViabilityNon-sperm Cells

Semen Analysis

CASA : computer assisted semen analysis• high precision and quantitative assessment of

sperm kinematics• provides data on sperm density, motility,

straightline and curvilinear velocity, linearity, average path velocity,

• amplitude of lateral head displacement, flagellar beat frequency, and hyperactivation.

Hormone measurement

Special investigations

• Anti sperm antibody test• Hypo osmotic swelling test• Sperm penetration assay • post coital test• Post-orgasmic urine analysis• Chromosomal / genetic studies

Imaging Studies

• Scrotal USS: to assess for testicular abnormalities and detection of varicocele.

• Transrectal USS: excellent definition of the prostate, seminal vesicles, ampulla of the vas deferens, and the ejaculatory ducts.

• is indicated for low ejaculate volumes, azoospermia (volume <1 mL) with acidic pH and negative semen fructose

• Abdominal Ultrasonography• Vasography: the vas deferens is punctured at

the level of the scrotum and injected with contrast.

• A normal test shows the passage of contrast along the vas deferens, seminal vesicles, ejaculatory duct, and into the bladder, which rules out obstruction

Testicular Biopsy

Two roles in the management of male infertility:1. diagnostic for the differentiation of

obstruction from nonobstructive testicular pathology

2. therapeutic for sperm harvest with the intention of use for ICSI.