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Male Infertility Diagnosis and new Treatment


Semir A. S. Al Samarrai

 

Definition

Infertility is the inability of a sexually active, non-contracepting couple to achieve pregnancy in one year. 

About 15% of the couples do not achieve pregnancy within one year and seek medical treatment for infertility. Less that 5% remain unwillingly childless. 

The unogenital expert should examine any male with fertility problems for urogenital abnormalities, so that appropriate treatment could be given. Simultaneously assessment of the female partner is preferable, even if abnormalities are found in the male, because in one of four couples who consult with fertility problems, both male and female partners have abnormalities (25%)

The reasons for a reduction in male infertility are: 

  • Congenital Factors (Cryptorchidism and Testicular Dysgenesis)
  • Acquired Urogenital abnormalities (Obstruction of the Vas Deferens, or Ejaculatory Duct)
  • Urogenital Tract Infection
  • Increase Scrotal Temperature (e.g. as a consequence of Varicocele Testis)
  • Endocrine Disturbances,- TDS (Testosterone Deficiency Syndrome), Estrogen Excess
  • Thyroid Abnormalities
  • Genetic Abnormalities
  • Immunological Factors
  • Exogenous Factors (exogenics toxins, irradiation, lifestyle factor, obesity withy abdominal fat)
  • Idiopathic (40-50% cases)


Diagnosis

1.) Semen Analysis: One test should suffice:
A. if the results are abnormal the semen analysis should be repeated 
B. it is important to distinguish between:

1.) Oligozoospermia (<15 milliom spermtozoa/ml)
2.) Athenozoospermia (<40% motile spermatozoa)
3.) Teratozoospermia (<4% normal form) 

Quite often all three pathologies occur simultaneously as oligo-asteno-teratozoospermia (OAT) syndrome.

In extreme cases of OAT syndrome (<1 million spermatozoa/ ml), just as with azoospermia; there is an increased incidence of genetic abnormalities and obstruction of the male genital tract. 


2.) Hormonal Investigation: 

Endocrine malfunctions are more prevalent in infertile male than in the general population, but are still quite uncommon. Hormonal screening can be limited to determining follicle stimulating hormone (FSH), Luteinizing hormone (LH), and testosterone level in case of abnormal semen parameters. In man diagnosed with azoospermia or extreme OAT, it is important to distinguish between obstructive and non- obstructive causes. A criterion with reasonable predictive value for obstruction is a normal FSH with bilaterally a normal testicular volume. However, 29% of men with normal FSH appear to have defective spermatogenesis. 

3.) Microbiological Assessment: 


Indication for this assessment include abnormal urine samples, urinary tract infection (Prostatitis), male accessory gland infections (MAGI) and sexually transmitted diseases (STD's).

The clinical implications of white blood cells detected in a semen sample are as yet undetermined. However, in combination with a small ejaculate volume, this may point to a (partial) obstruction of the ejaculatory ducts cause by a (chronic) infection at the prostate or seminal vesicles. Genital infections may instigate the production of the spermatotoxic free oxygen radicals. Gonorrhoea and Chlamydia trachomatis can also cause obstruction of the genital tract. 

4.) Genetic Evaluation:

By taking extensive family history and carrying out Karyotype analysis, a number of andrological fertility disorders can be detected. This will not only yield a diagnosis, but also allow few appropriate genetic counselling. This is very important with the advent of intra intracystoplasmic sperm injection (ICSI), because the fertility disorders and possibly the corresponding genetic defect may be transferred to the offspring. 

Chromosomal abnormalities are more common in male with OAT are with azoospermia, the most common sex chromosome abnormality is Klinefelter's Syndrome (47 XXX), which affect 10 % of men diagnosed with azoospermia. 

In case of azoospermia or OAT, deletions in the azoospermic factor (AZF) region of the Y- chromosome can occur and testing is advised. The prevalence of Y- deletions is considerable (around 5%) in this group of patients. The presence of Y deletions means that the defect will be passed on to sons who will also be then infertile. 

5.) Ultrasonography:

Ultrasonography is a useful tool for locating interscrotal defects. Colour Doppler Ultrasound of the scrotum can detect a Varicocele testis in around 30% of infertile males. Testicular Tumours can be found in 0.5% of infertile men, and testicular microcalcification (a potentially pre-malignant condition) are detected in around 2-5% of infertile males; especially patients diagnosed with history of cryptochordism. Transrectal utrasonography (TRUS) is indicated in men with a low volume of ejaculate (<1.5ml) to exclude obstruction of the ejaculatory ducts caused by a midline prostatic cyst or stenosis of the ejaculatory ducts. 
6.) Testicular Biopsy: 

Indication for performing a diagnostic testicular biopsy could be azoospermia or extreme OAT in the presence of normal testicular volume and normal FSH levels. The biopsy is aimed as a differentiating between testicular insufficiency and obstruction at the male genital tract. Pathological classifications are: tubular sclerosis, sertoli cell only syndrome, maturation arrest (incomplete spermatogenesis, not beyond the spermatocyte stage.) hypospermatogenesis, carcinoma in the situ of the testis. 

Treatment: 

1.) Counselling:

Sometimes, certain lifestyle factors may be responsible for poor semen quality: for example, heavy smoking, alcohol abuse, use of anabolic steroids, extreme sport (marathon training, excessive strength sports); and an increase scrotal temperature through thermal underwear, sauna, or hot tub use or occupational exposure to heat sources. A considerable number of drug can affect the spermatogenesis. 

2.) Medical (Hormonal) Treatment:

Some primarily endocrinological pathologies can be treated medically, including: 

  • Low Testosterone,
  • Hypogonadotrophic Hypogonadism
  • Hyperprolactenemia.
3.) Surgical Treatment:

Varicocele Testis: There is an evidence of improved semen parameters after successful Varicocele treatment. (Laparoscopic Varicocelectomy)

Current information supports the hypothesis that in some men, one presence of Varicocele is associated with progressive testicular damage from adolescence onwards and consequent reduction in the fertility. Varicocele repair, however, maybe effective in men who have subabnormal semen analysis, clinical Varicocele and otherwise unexplained infertility. 

Transurethral incision of the ejaculatory ducts or midline Prostatic cyst: Distal obstructions at the genital tract commonly caused by infections of the Prostatic urethra and the accessory gland, or by a cyst in the midline of the prostate, this treatment at the obstruction may lead to an increase semen quality and occasionally, spontaneous pregnancy, long term results, however, are disappointing. 

4.) Sexual Dysfunction:

For the treatment of sexual dysfunction there are only certain types of ED have the potential to be cured with specific treatments: 

Hormonal causes of ED: 

Testosterone replacement therapy is effective but should only be used after other endocrinological causes for testicular failure have been excluded.

Erectile Dysfunction: 

The use of pro-erectile drugs (PDES) inhibitors is very important in achieving erectile function by different causes of ED. Most men with ED will be treated with treatment options that are not caused specific. This approach requires a structured treatment strategy that depends on efficacy, safety, invasiveness and cost as well as patient and Partner satisfaction. 

Disorders of ejaculation: 

Retrograde ejaculation and an ejaculation can occur in neurological, such as multiple sclerosis, diabetes mellitus (neuropathy) and spinal cord injuries; following prostate surgery and bladder neck surgery and during antidepressant therapy. The treatment of retrograde ejaculation is basically aimed at removing the cause of the disorder or harvesting spermatozoa from the urine after orgasm. An ejaculation can be treated by vibrostimulation or electro- ejaculation techniques. Drug treatment can be effective by taking. Pseudoephedrine this medicine should be taken before the sexual intercourse.

Bibliography:

1.)The European Association of Urology (EAU) and International Urology Clinical Guideline 2010 

2.)WHO- Male Infertility Guideline World-Health-Organization-Laboratory Manual for Examination of Human Semen 3rd edition: New York Cambridge University Press 1992

Correspondence:

Prof. Dr. SAMIR AHMED SALIM AL SAMARRAI, Professor Doctor of Medicine- Urosurgery, Andrology, and Male Infertility; Dubai Healthcare City, Dubai, United Arab Emirates.

Mailing Address: Dubai Healthcare City, Bldg. No. 64, Al Razi Bldg., Block D, 2nd Floor, Dubai, United Arab Emirates, PO Box 15376

Email: fmcalsam@emirates.net.ae

 

Correspondence:
Prof. Dr. SEMIR AHMED SALIM AL SAMARRAI
Professor Doctor of Medicine-Urosurgery, Andrology, and Male Infertility
Dubai Healthcare City, Dubai, United Arab Emirates.
Mailing Address: Dubai Healthcare City, Bldg. No. 64, Al Razi building, Block D,
2nd floor, Dubai, United Arab Emirates, PO box 13576
Email: fmcalsam@emirates.net.ae