ANDROLOGYANDROLOGY

Dr hab. Rafał KurzawaCLINIC of REPRODUCTION and

GYNECOLOGY

POMERANIAN ACADEMY of MEDICINE

Epidemiologia niepłodnościEpidemiologia niepłodności

Symptomatology of male infertility Symptomatology of male infertility

TYPE I TYPE I – erection problems – erection problems (0,3-7%)(0,3-7%) TYPE II TYPE II – azoospermia – azoospermia (0,9%-16%)(0,9%-16%) TYPE III – immunological infertility TYPE III – immunological infertility (3,4%-25%)(3,4%-25%) TYPE IV – abnormal seminal quality TYPE IV – abnormal seminal quality (23%-48%)(23%-48%) TYPE V TYPE V – idiopathic sperm dysfunction – idiopathic sperm dysfunction (0-25%)(0-25%)

Diagnosis Diagnosis

General examination General examination Semen analysis Semen analysis Other diagnostic tests: Other diagnostic tests:

– USGUSG– Hormonal diagnostic Hormonal diagnostic – Diagnostic tests for Assisted Reproductive Diagnostic tests for Assisted Reproductive

Technology Technology

TYPE I – erection problems TYPE I – erection problems (0,3-7%)(0,3-7%)

Normal ejaculation Normal ejaculation – Hypospermia (semen volume < 2,0 ml) – chronic prostatitis Hypospermia (semen volume < 2,0 ml) – chronic prostatitis – Impotence Impotence

Retrograde ejaculation Retrograde ejaculation – Neurogenic– DM, SM Neurogenic– DM, SM – Anatomical Anatomical – Jatrogenic – drugs, operations Jatrogenic – drugs, operations

disejaculation disejaculation – Functional – anorgazmiaFunctional – anorgazmia– Neurogenic – spinal injury Neurogenic – spinal injury – Jatrogenic – drugs, chemiotherapy, radiotherapy, operations Jatrogenic – drugs, chemiotherapy, radiotherapy, operations

TYPE II – azoospermia TYPE II – azoospermia (0,9%-16%)(0,9%-16%)

Pre-testicular causes Pre-testicular causes – Hypothalamic or pituitary disorder – LH, FSH deficiency, Hypothalamic or pituitary disorder – LH, FSH deficiency,

Kallman syndrome, trauma, tumors, inflammation, Kallman syndrome, trauma, tumors, inflammation, meningitismeningitis

Testicular causes Testicular causes – Primary testicular failure Primary testicular failure – Congenital – 47XXY, del Y, AZFCongenital – 47XXY, del Y, AZF– Acquired- mumps, testicular torsion, castrationAcquired- mumps, testicular torsion, castration– Jatrogenic – radiotherapy, chemiotherapy Jatrogenic – radiotherapy, chemiotherapy

Post-testicular causes Post-testicular causes – Congenital – CBAVD, CFCongenital – CBAVD, CF– Acquired – inflammations (gonorrhea) Acquired – inflammations (gonorrhea) – Jatrogenic – vasectomy, hernia operation Jatrogenic – vasectomy, hernia operation

Diagnostic tests for Assisted Diagnostic tests for Assisted Reproductive Technology- ICSI Reproductive Technology- ICSI

FSHFSH– If < 12IU – sperm biopsy If < 12IU – sperm biopsy

is effective in 80-90% is effective in 80-90% Blocked ejaculatory Blocked ejaculatory

duct duct (Micro-Epidydymal (Micro-Epidydymal Sperm Aspiration –Sperm Aspiration –MESE) MESE)

Other Other (Testicular Sperm (Testicular Sperm Extirpation- TESE, Extirpation- TESE, Testicular Sperm Testicular Sperm Aspiration- TESA) Aspiration- TESA)

TYPE III – immunological infertility TYPE III – immunological infertility (3,4%-25%)(3,4%-25%)

antisperm antibodies – antisperm antibodies – the immune system may the immune system may produce antibodies that produce antibodies that attack and weaken or attack and weaken or disable spermdisable sperm – Auto-immunological Auto-immunological

diseases diseases – Concequences of Concequences of

testicular trauma testicular trauma

Congenital Congenital – Undescended testicles Undescended testicles

Sexually transmitted Sexually transmitted disease (gonorrhoea) or disease (gonorrhoea) or testicular infection testicular infection (mumps) (mumps)

Vascular Vascular – Testicular torsion Testicular torsion – Varicocoeles Varicocoeles

Diseases: Diseases: – Thyroid faiure; Addison Thyroid faiure; Addison

disease, hepar diseases; disease, hepar diseases; DM, auto-immunological DM, auto-immunological diseases; diseases;

Environmental factorsEnvironmental factors– Drugs (sulfasalazine, T, Drugs (sulfasalazine, T,

chemiotherapy)chemiotherapy)– Temperature Temperature – Other factors (X-rays, lead, Other factors (X-rays, lead,

cigarette smoke, alcohol; cigarette smoke, alcohol; marijuana, frequently marijuana, frequently wearing tight-fitting pants wearing tight-fitting pants and underwear)and underwear)

Immunological Immunological – Testitis Testitis

Genetic Genetic – del Y, aberrations (count del Y, aberrations (count

and structure of and structure of chromosomes) chromosomes)

Idiopathic [46%] Idiopathic [46%]

TYPE IV – abnormal sperm quality TYPE IV – abnormal sperm quality (23%-48%) (23%-48%)

Obraz morfologicznyObraz morfologiczny

Treatment Treatment

Risk factor elimination Risk factor elimination Give up smoking Give up smoking Testicular temperatue decreaseTesticular temperatue decrease Regular sexual intercourses (2-3 per Regular sexual intercourses (2-3 per

week) week) Antioxydants Antioxydants

– Vitamin E, C, Zinc Vitamin E, C, Zinc Tetracicline Tetracicline

– Chlamydia Trachomatis infection Chlamydia Trachomatis infection

Treatment (pharmacotherapy)Treatment (pharmacotherapy)

Risk factor elimination Risk factor elimination Hormonal treatment Hormonal treatment

– Testosterone Testosterone – hCGhCG – FSH FSH – C.C, tamoxyphen C.C, tamoxyphen

Varicose veins in the spermatic Varicose veins in the spermatic cord cord

Physical examination Physical examination – I I Valsalva test examination ( or during Valsalva test examination ( or during

cough) cough) – II II large veins during palpation large veins during palpation – IIIIII visible varicouse veins visible varicouse veins

Other diagnostic test Other diagnostic test – Semen analysis (SA) Semen analysis (SA) – USG USG

Treatment Treatment – Operation Operation – ART.: IUI, IVF, ICSI ART.: IUI, IVF, ICSI

Diagnostic and therapeutic algorithm Diagnostic and therapeutic algorithm (female)(female)

Sperm analysis

O, A, T, OA, OT, TA, OAT

grave O, A, T, OA, OT, TA, OAT

azoospermia Testicular cells?

TESE, MESA

Treatment: operation, CC, hMG (FSH)

ICSI

IUI

Sperm analysis- Sperm analysis- recommendation by WHOrecommendation by WHO

– General female infertility diagnostic test- SAGeneral female infertility diagnostic test- SA– sterility sterility – sample should be delivered to laboratory in 60 sample should be delivered to laboratory in 60

min. after ejaculation min. after ejaculation – abstinence min. 48 hours max. 7 days abstinence min. 48 hours max. 7 days – the next semen analysis between 7 days and the next semen analysis between 7 days and

3 months 3 months

Seminal quality, cytology and Seminal quality, cytology and sperm quantitation sperm quantitation

– liquefactionliquefaction

– viscosity viscosity

– volumevolume

– colorcolor

– pHpH

– smellsmell

– Sperm count Sperm count – Sperm motion analysis Sperm motion analysis – WBC count (pyospermia) WBC count (pyospermia) – Spermatozoa count Spermatozoa count – Antisperm antibodies Antisperm antibodies – Sperm morphology Sperm morphology – Microbiology Microbiology

Semen analysis Semen analysis

– Microscope Microscope – Makler counting chamber Makler counting chamber – Immunobead test (IgG, IgA or IgM)Immunobead test (IgG, IgA or IgM)

– CASA CASA (computer-assisted sperm analysis)(computer-assisted sperm analysis)

Sperm motion analysis Sperm motion analysis 0- 0- immotile immotile 1- weak movement with no forward progression 1- weak movement with no forward progression 2- weak to moderate forward progression 2- weak to moderate forward progression 3- good forward progression; active tail movement 3- good forward progression; active tail movement 4- rapid forward progression; vigorous tail movement 4- rapid forward progression; vigorous tail movement

Seminal quality- ranges Seminal quality- ranges

–Liquefaction < 60 minutes Liquefaction < 60 minutes

–Volume > 2 ml Volume > 2 ml

–Color- gray to white opalescent fluid Color- gray to white opalescent fluid

–pH 7,2 – 8,0 pH 7,2 – 8,0

IMMUNOBEAD TEST IMMUNOBEAD TEST

Microscopic polyacrylamide spheres, ranging in Microscopic polyacrylamide spheres, ranging in size from 2 to 10 um, coated with anti-human size from 2 to 10 um, coated with anti-human immunoglobins against human IgG, IgA or IgMimmunoglobins against human IgG, IgA or IgM

Normal sperm rangeNormal sperm range

Motility Motility >50% 4 or 3 ; or >25% 4>50% 4 or 3 ; or >25% 4 Sperm count Sperm count >20>20··101066/ml/ml WBC count WBC count <10<1066/ml/ml Spermatozoa Spermatozoa <5<5··101066/ml/ml Autoagglutinating Autoagglutinating <10%<10% Immunebead testImmunebead test <10%<10% Sperm morphology Sperm morphology >30% normal forms >30% normal forms

(WHO); 5-14% strict criteria (Kruger)(WHO); 5-14% strict criteria (Kruger)

Definitions of „abnormal” counts Definitions of „abnormal” counts

NormozoospermiaNormozoospermia Oligozoospermia Oligozoospermia << 2020··101066/ml/ml AstenozoospermiaAstenozoospermia <50% 4 or 3 ; or <25% <50% 4 or 3 ; or <25%

44 TeratozoospermiaTeratozoospermia <30% <30% Azoospermia Azoospermia no sperm no sperm