Prof. DR. Dr. Nukman Moeloek, SpAnddr. Silvia W Lestari, M.Biomed

Department of Medical Biology Faculty of Medicine, University of Indonesia

� Infertility� Hypogonadism� Hypogonadism� Sexual dysfunction� Male aging� Male contraceptive

� is the inability to conceive after at least oneyear of unprotected intercourse

� in men :-hormone disorders-hormone disorders-illness-reproductive anatomy trauma andobstruction-sexual dysfunction can temporarily orpermanently affect sperm and preventconception.

Both Couples need to be Both Couples need to be counseled and evaluated.counseled and evaluated.

HHISTORY TAKINGISTORY TAKING is initiated is initiated and followed with:and followed with:and followed with:and followed with:PHYSICAL EXAMINATION PHYSICAL EXAMINATION ::• Measuring the testicular volume • Checking for varicocele or any abnormality• Appointment for semen analysis

The search for the cause of infertility usually begins withthe maleà less complicated.

A thorough examination and a review of the man's medicaland surgical history are necessary à chronic disease,A thorough examination and a review of the man's medicaland surgical history are necessary à chronic disease,pelvic injury, childhood illness, abdominal or reproductiveorgan surgery, recreational drug use, and medications canaffect fertility.

Physical examination may detect testicular irregularities,evidence of hormonal disorders or evidence of testosteronedeficiency.

� General History includes any potential exposure to environmental toxins, either through occupation or hobbies.

� Medical History of any condition that would potentially affect erectile function, the testes, or the hormonal status of the patient It will also include a review of additional medical conditions for which the patient is being followed, including any condition that would require radiotherapy or chemotherapy.

� Surgical History during the male infertility visit focuses on any history of GU surgeries at any .point during the life of the male undergoing evaluation.

� Sexual History include the overall pattern of sexual activity , history of sexually transmitted infections asked about the used of lubricants

� Medication History Prescription drugs can affect sperm count, motility, and morphology, and the dose and duration of use should be documented

� Social History Cigarette smoking, excessive alcohol consumption, and consistent marijuana use are all known to be gonadotoxins

� Family History should include a discussion of testicular or other GU malignancies and specifically any cancer history, prostate or bladder problems in other family members.

� Female Partner History should include details of any previous pregnancies, menstrual cycle length, whether she is undergoing evaluation for fertility issues, and any medical or surgical management that has been necessary

� Assessing reproductive-fertility history is important; specialists typically inquire about the following:

� Early puberty (may result from hormonal disorder)� Late puberty (may result from Kallmann's syndrome)� Previous pregnancy� Previous pregnancy� Sexual intercourse timing (understanding ovulation)� STDs (can cause scarring, obstruction)� Use of lubricants (may kill sperm)

may detect testicular irregularities

(e.g., varicocele, absence of vas deferens, tumor)

evidence of hormonal disorders(e.g., underdeveloped reproductive organs,enlarged breast tissue),

or evidence of testosterone deficiency.

Male Reproductive SystemMale Reproductive System

OrchidometryOrchidometry

� Varicocele is a mass of enlarged and dilated veins that develops in the spermatic cord within the scrotal sac.

� If the valves that regulate bloodflow from these veins are congenitally (from birth) defective, causing swelling in the veins above and behind the testicles with resulting warming of the testes.

�� PempiniformPempiniform plexus plexus distended and distended and tortoustortous

�� Testes soft and Testes soft and depresseddepressed

�� Exposure to heat and Exposure to heat and metabolites affect metabolites affect sperm profilesperm profile

A varicocele can develop in one testicle or both,but in about 85% of cases it develops in the lefttesticle.

The left spermatic vein drains into the left renalvein, which transits between the superiorThe left spermatic vein drains into the left renalvein, which transits between the superiormesenteric artery and the aorta; causeincreased distal backpressure and dilation,resulting in formation of a varicocele.

The right spermatic vein drains directly into theinferior vena cava and develops a varicocele lessfrequently

Incidence and Prevalence

Incidence of varicocele is 10-20% and thecondition develops sometime aroundpuberty.

The sudden development of varicocele in anolder man may indicate a retroperitonealtumor blocking the spermatic vein,although this is quite rare.

� Testosterone production declines naturally withage.

� Low testosterone, or testosterone deficiency(TD), may result from disease or damage tothe hypothalamus, pituitary gland, or testiclesthat inhibits hormone secretion andtestosterone production, and is also known ashypogonadism.

Depending on age, insufficient testosterone productioncan lead to abnormalities in muscle and bonedevelopment, underdeveloped genitalia, anddiminished virility.

Testosterone is the androgenic hormone primarilyTestosterone is the androgenic hormone primarilyresponsible for normal growth and development ofmale sex and reproductive organs, including the penis,testicles, scrotum, prostate, and seminal vesicles.

It facilitates the development of secondary male sexcharacteristics. Additionally, normal testosterone levelsmaintain energy level, healthy mood, fertility, andsexual desire.

� Testosterone production increases rapidly atthe onset of puberty and decreases rapidlyafter age 50 (to 20–50% of peak level by ageafter age 50 (to 20–50% of peak level by age80).

� Recent estimates show that approximately 13million men in the United States experiencetestosterone deficiency and less than 10%receive treatment for the condition.

� Men with obesity, diabetes, or hypertension may be twice as likely to have low testosterone levels.

� Hypogonadism may be present at birth (congenital) � Hypogonadism may be present at birth (congenital) or may develop later (acquired). Causes of the condition are classified according to their location along the hypothalamic-pituitary-gonadal axis:

Primary, disruption in the testicles Secondary, disruption in the pituitary gland Tertiary, disruption in the hypothalamus

� Klinefelter syndrome.

� Congenital hormonal disorders such as e.g., Kallmann syndrome also may cause Kallmann syndrome also may cause testosterone deficiency.

� Other congenital causes include absence of the testes (anorchism; may also be acquired) and failure of testicles to descend into scrotum (cryptorchidism).

Klinefelter SyndromKlinefelter Syndrom

Semen Analysis

•An evaluation of spermatogenesis andspermiogenesis.

•Modern approach is to interpret with regard to:

• diagnosis of specific lesions; and• diagnosis of specific lesions; and• indicators of dysfunctional and/or functional potential.• Requires understanding of the relevance of spermpatho-physiology.

• In any case, the results must be accurate andreliable.

– Appearance/colour

– Odour

– Liquefaction

– Volume– Volume

– Viscosity

– pH

– Concentration

–Motility

–Morphology

– Total sperm count

– Other cell

� Azoospermia is the absence of sperm in the semen.Men with normal reproductive tracts and hormonesystems can have azoospermia due to a lack ofsperm-producing tissue in the testes or anobstruction. Obstructions can be viewed with x-ray.obstruction. Obstructions can be viewed with x-ray.The World Health Organization has establishedcriteria for normal sperm concentration,morphology, and motility. Total motile sperm count,which should be about 40 million, is calculated bymultiplying volume by concentration by motility.Sperm concentration <20million/mL is namedoligozoospermia.

� The semen fluid test looks at factors that may impede sperm performance. Abnormally thick semen may cause sperm to swim more slowly through cervical mucus, obstructing slowly through cervical mucus, obstructing fertilization. Abnormal sperm shape (70% or more of sperm in semen is abnormally shaped.

� The sperm penetration assay (SPA), or sperm-oocyte interaction test, examines the ability of sperm to penetrate the egg by combining it with a hamster egg. combining it with a hamster egg.

� The immunobead test looks at semen for the presence of antibodies that damage sperm

� The fructose test� The sperm chromatin integrity assay� The Y chromosome microdeletion assay

� A sexual dysfunction, refers to a problem during anyphase of the sexual response cycle that prevents theindividual or couple from experiencing satisfactionfrom the sexual activity.

� Research suggests that sexual dysfunction iscommon (43% of women and 31% of men reportsome degree of difficulty), it is a topic that manypeople are hesitant to discuss.

� Fortunately, most cases of sexual dysfunction aretreatable, so it is important to share the concernswith the partner and doctor.

� Sexual dysfunction can be a result of a physical orpsychological problem.

� Physical causes:Diabetes, heart and vascular (blood vessel) disease,neurological disorders, hormonal imbalances,chronic diseases such as kidney or liver failure, andchronic diseases such as kidney or liver failure, andalcoholism and drug abuse.In addition, the side effects of certain medications,including some antidepressant drugs, can affectsexual desire and function.

� Psychological causes:These include work-related stress and anxiety,concern about sexual performance, marital orrelationship problems, depression, feelings of guiltand the effects of a past sexual trauma.

� The most common sexual problems in men are ejaculation disorders, erectile dysfunction and inhibited sexual desire. and inhibited sexual desire.

� There are different types of ejaculation disorders, including:

� Premature ejaculation: This refers to ejaculation that occurs before or soon after penetration.that occurs before or soon after penetration.

� Inhibited or retarded ejaculation: This is when ejaculation is slow to occur.

� Retrograde ejaculation: This occurs when, at orgasm, the ejaculate is forced back into the bladder rather than through the urethra and out the end of the penis.

� In some cases, premature and inhibitedejaculation are caused by psychological factors,including a strict religious background that causesthe person to view sex as sinful, a lack of attractionfor a partner and past traumatic events.for a partner and past traumatic events.

� Premature ejaculation, the most common form ofsexual dysfunction in men, often is due tonervousness over how well he will perform duringsex. Certain drugs, including some anti-depressants,may affect ejaculation, as can nerve damage to thespinal cord or back.

� Retrograde ejaculation is common in males withdiabetes who suffer from diabetic neuropathy(nerve damage). This is due to problems with thenerves in the bladder and the bladder neck thatnerves in the bladder and the bladder neck thatallow the ejaculate to flow backward.

� In other men, retrograde ejaculation occurs afteroperations on the bladder neck or prostate, or aftercertain abdominal operations. In addition, certainmedications, particularly those used to treat mooddisorders, may cause problems with ejaculation.

� Also known as impotence, erectile dysfunction isdefined as the inability to attain and/or maintain anerection suitable for intercourse.

� Causes of erectile dysfunction include diseases affectingblood flow, such as :blood flow, such as :-atherosclerosis (hardening of the arteries)-nerve disorders-psychological factors, such as stress, depression, andperformance anxiety (nervousness over his ability tosexually perform)-injury to the penis

� Chronic illness, certain medications, and a conditioncalled Peyronie's disease (scar tissue in the penis) alsocan cause erectile dysfunction.

� Previously: psychogenic factors> organic factors

� Now : organic factors > psychogenic factors

� Inhibited desire, or loss of libido, refers to a decreasein desire for, or interest in sexual activity. Reduced libidocan result from physical or psychological factors.

� It has been associated with low levels of the hormone� It has been associated with low levels of the hormonetestosterone.

� It also may be caused by :-psychological problems, such as anxiety anddepression-medical illnesses, such as diabetes and high bloodpressure-certain medications, including some anti-depressants-and relationship difficulties.

� The doctor likely will begin with a thorough historyof symptoms and a physical exam. He or she mayorder other tests to rule out any medical problemsthat may be contributing to the dysfunction. Thedoctor may refer you to other doctors, including andoctor may refer you to other doctors, including anandrologist or urologist (a doctor specializing in theurinary tract ), an endocrinologist (a doctorspecializing in glandular disorders), a neurologist (adoctor specializing in disorders of the nervoussystem), sex therapists, and other counselors.

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