Male infertility

• Prevalence• Normal/abnormal semen• Tests • Causes• management

EXTENT OF THE PROBLEM 50% of the contribution towards infertility is by men sperm dysfunction, azoospermia or ineffective coitus is a factor in 50% of infertile couples,thus placing andrology at the core of reproductive medicine

WHO semen parameter reference values

Semen parameters 4th edition 5th edition

Volume of ejaculate(ml)

≥2 ≥1.5

Sperm concentration (x106/ml)

≥20 ≥15

Total sperm count (x106)

≥40 ≥39

Motility (%) ≥50 progressive (a + b) ≥25 a only

≥40 total motility ≥28 progressive (a+b)

Morphology by Kruger strict criteria (%)

≥15 ≥4

Vitality (%viable) ≥75 ≥58

White blood cells (106/ml)

<1 <1

Sperm motility measurement

A rapid progressive motility

B sluggish or slowly progressive motility

C nonprogressive motility

D lack of motility

Semen quality: Kruger Strict Morphology value

• Reflects the percentage of sperms with “Perfect appearance”

• Useful in assisted reproduction

• Poor predictor of genetically normal sperm

Test Method Why? Problem

WBC assay

• Pap

• flow cytometry

• peroxidase test (widely used)

Leukocyto spermia-

• Abn motility

• morphology

• defective fertilization

Unconsistent results of leucocyto sperm & infertility;

immature germ cells resemble round cells

Test Method Why? Problem

ROS Quantificaton

Chemiluminescence (luminometer)

Excess can lead to sperm damage &infertility

ROS in 40% of subfertile men

inverse relation with rate of spon pregnancy

ROS• WBC • Sperm• prolong

ed semen processing

Test method Why? Problem

DNA fragmentation tests

• TUNEL

• comet assay

• acridine orange

• sperm chromatin

ass. with infertility, early embryo death, poor embryo development & poor implantation helpful

with rec. preg. loss, varicocele & ROS level

N range <30%

ASA detection

• Mixed agglutination

• immunofluorescence

• immunobead

• 13% subfertile

• useful if isolated defects in motility

• unexplained

• poor PCT

2.5% of fertile couples also test positive

Sperm Function

Hypo –osmotic swelling

Checks for sperm viability • D/D of immotile

cilia syndrome (ultrastructural defects in dynein) to select viable sperm in ICSI

Acrosome reaction assay

• Microscopy • acrosin

enzyme assay

• electron • Microscopy • immunocyt

ochemical • triple stain

Value ltd. With IVF –ICSI & ability of Kruger strict morphology

Sperm zona binding assay

SPERM penetration assay

Pts sperm incubated with “promiscuous” hamster ova

To predict IVF will have successful outcome

Time consuming requires intact hamster ova

GENETIC

Karyotype Sperm conc. <5 x 106 /ml

5% subfertile males will have chr. abn

15% in azoospermic

MC – Klinefelter (47,XXY) 1:500 male

Sequence abn. (pt mutations frameshift mutations & other submicroscopic deletions) cannot be id

Remarks : genetic counselling to discuss impact on future generation

Aetiology

• Pretesticular-10%

• Testicular-25%

• Post-testicular-40%

• Idiopathic-25%

Testicular

– Genetic • Klinefilter syndrome ( 10-15%)• Chromosome translocations• Y –microdeletions• Immotile cilia syndrome• XYY syndrome• Mixed gonadal dysgenesis

– Varicocele• Inflammatory

• Mumps orchits• Cryptorchidism

• Testiculartorsim• Gonadotoxins

Post -Testicular

Genetic– CFTR – mutations– 5 –alpha reductase deficiency– Persistent mullerian ducts– ADPKD – Prune belly syndrome

Sperm delivery disorders– Ductal obstruction (7-12%)

• Genital infection• Latrogenic • Walffian duct malformation• Mullerian duct cyst

– Ejaculatory problems Immunologic infertility

PRE - TESTICULAR

Genetic– Kallman’s syndrome– Congenital adrenal hyperplsia– B –thalesemia – Androgen receptor mutation– FSH/LH hormone or receptor defects

Pituitary disease

Goals of evaluation of infertile male

Identify reversible conditions Irreversible conditions – ART Genetic & chromosomal abnormalities

Where is the problem !1. Hormones from Brain2. In the Tests 3. In the Tubes4. Impotence

Ques1

Normal volume azoospermia

Ques 2

• Low ph• Low volume• Azoospermia

Any other factor?????

NOA and OA

• Spermatozoa are found in about 60% of patients with NOA.

• Birth rates are lower in NOA vsOA (19% vs 28%)

• Fertilisation and implantation ratesare significantly lower

• Miscarriage rates are higher in NOAvs OA (11.5% vs 2.5%)

EUA-2010

• Men with non-obstructive azoospermia (NOA) can be offered a testicular sperm extraction with cryopreservation of the spermatozoa to be used for ICSI

• To increase the chances of positive sperm retrievals in men with NOA, TESE (single, multiple or microsurgical) should be used rather than TEFNA

Full evaluation

Endocrine evaluation Post ejaculatroy urinalysis TRUS ± seminal vesiculography Vasography Scrotal ultrasound Sperm function testing

Pct Sperm penetration/viability assay

Anti –sperm antibodies Semen culture Genetic screening

Testicular biopsy

Endocrine evaluation -indications

Sperm density < 10 million/ml Impaired sexual function Clinical findings s/o endocrinopathy

(Endocrine disorders are extremely uncommon in men with normal semen parameters)

TRUS -indications

Fructose negative azoospermia Low volume azoospremia Severe unexplained oligoasthenospremia DRE : abnormal

Genetic testing - indications

Sperm destiny < 5 million/ml Non -obstructive azoospermia Clinical suggestions

Medical therapy

• 5% of patients exhibit abnormal semen analyses for which no etiology can be identified (Greenberg et al , J.urol, 1978)

 Specific/Targetted• HH• hyperprolactinemia• Infections• Ejaculatory dysfunction

HH-Causes

• Congen– Kallman

• Acquired– pituitary tumors, – pituitary trauma, – Panhypopituitarism – anabolic steroid use

• The initial evaluation of patients with suspected HGH: MRI

•  

Gonadotropin for HH(<1%)

• Initial Mx : hCG ( 3000–6000 IU/wk)– until adequate serum T levels are

detected

• If sperm undetected after 6 mo • co-treatment with– hMG (75–150 U 2-3X/week) or– FSH (50–150 IU 3X/ week)

• 6 to 9 months for sperm to appear in the ejaculate, – therapy may be needed for 1 to 2 years.

• Treatment with hCG/hMG has also been reported to be effective in a patient who has anabolic steroid-induced azoospermia

• GnRH infusion pump(iv or sc): who do not respond to hCG/FSH

• effective treatment for non-pituitary Gn deficiency, both for inducing androgenization and spermatogenesis

• need for a 2-hour dosing : clinically unfeasible

• 8of 9 patients with idiopathic HGH were able to father a child with the use of pulsatile GnRH therapy (Crowley and Whitcomb 1990).

 

Men on anabolic steroids

• Stop Testosterone

• Full recovery can take over a year and may not return to pretreatment

• Prob: since their endogenous production is suppressed– may need some treatment

Steroid induced azoospermia

• hCG, Clomiphene, aromatase inhibitors

Testosterone/estradiol

Treatment

Normal(15:1) CC/hcg(3000IU alt day)

Altered Letrozole Blocks the aromatization

hormone replacement therapy is more cost-effective than sperm retrieval/ ICSI in these patients 

Hyperprolactinemia is a form of HGH

• An excess of prolactin inhibits the hypothalamic secretion of GnRH and has been implicated as a cause of reproductive and sexual dysfunction

• Routine screening of infertile men for hyperprolactinemia has not been shown to be useful

Causes

– pituitary tumor (macroadenoma or microadenoma)

– Hypothyroidism,– stress,–Medications : phenothiazines, tricyclic

antidepressants and some antihypertensives, medical illness, and idiopathic factors

greater than 250 ng/ml, macroadenoma

between 100 and 250 ng/ml

microadenoma

between 25 and 100 ng/ml pituitary stalk compression

0 to 25 ng/ml normal

Steroids– ASA pos: results inconsistent– aseptic necrosis of femur head

 • treatment of antisperm antibodies using

corticosteroids should not be prescribed routinely, but it can be considered in patients with antisperm antibodies and earlier failed fertilization during IVF or ICSI.

Androgens• contraindicated

Infections

54% of men who have leukocytospermia have no evidence of infection

positive semen cultures may be found in up to 83% of healthy men, and pathogens such as Ureaplasma urealyticum, Proteus mirabilis, Mycoplasma hominis, Escherichia coli, and Enterococcus are isolated in the same frequency in men who have leukocytospermia and men who do not

• Chlamydia trachomatis has been isolated frequently in asymptomatic men who have unexplained infertility and has been found to bind to and penetrate human sperm

• M hominis and U urealyticum :NGU; demonstrated to impair human sperm function in vitro

• E coli and U urealyticum have been reported to decrease sperm motility

• Other pathogens include Neisseria gonorrhoeae, Treponema pallidum, Mycobacterium tuberculosis, Haemophilus ducreyi, herpes simplex virus I and II, papillomaviruses, and Trichomonas vaginalis.

• MC are Streptococcus fecalis andEscherichia coli, respectively

• Also, Chlamydia trachomatis and Ureaplasma urealyticum are often involved

• antibiotic therapy acc.

• culture-negative patients should be treated with anti-inflammatory therapy and frequent ejaculation because empiric antibiotic therapy generally provides no benefit and may be harmful 

 

When is semen culture done?

• men who have overt signs of GU infections (eg, cystitis, urethritis, or prostatitis), semen and urine cultures are performed

• In asymptomatic infertile men who have leukocytospermia or in cases of truly unexplained infertility, semen cultures can be considered and appropriate antibiotic treatment instituted depending on the organism isolated

Schiff et al, Endocrinol Metab Clin N Am (2007) 313–331

Ejaculatory dysfunction

failure of emission or retrograde ejaculation. Reported causes are

spinal-cord injury, diabetes mellitus, retroperitoneal surgery, multiple sclerosis, and bladder-neck and prostate surgeryPsychogenic idiopathic.

• α sympathomimetic medication ephedrine, pseudoephedrine, imipramine, and phenylpropanolamine.

• IF unsuccessful or C/I, vibratory simulation or electroejaculation.

• Electroejaculation- the application of transrectal electrical current to stimu- late the pelvic nerves---results in approximately 90% of patients producing a semen specimen

Emperic therapy

For empiric pharmacologic therapy---treatment should last at least 3 to 6 months to incorporate a full 74-day spermatogenic cycle

• Advise the couple: – inconsistent response to therapy – low conception rate vs. ART– Lack of a significant improvement sor no

pregnancy after at least two spermatogenic cycles may be an indication to proceed with ART.

EMPERIC Therapy

1. Antiestrogens• Clomiphene citrate MC drug for idiopathic

oligospermia. The rationale for its use is based – on the drug’s ability to bind estrogen receptors,

causing antiestrogen and, to a lesser extent, estrogen effects. This removes the negative feedback inhibition of estrogen at the hypothalamic and pituitary levels, increasing GnRH, LH, and FSH secretion and stimulating testosterone production and spermatogenesis.

–

Due to the peripheral conversion of T, estrogen levels may increase above normalTherefore, monitoring of serum testosterone and estradiol is required to make sure levels do not rise to detrimental levels.

• therapy with clomiphene may be more advantageous in men – who have mild oligospermia and – low serum gonadotropins or – increased estrogen

• Therapy is less likely to be efficacious– who have elevated baseline gonadotropins – in men who have remarkably abnormal

semen analyses or testicular biopsies

Physiological Role of ROS 

• Induces acrosome reaction

• Mediates activation and capacitation

• Needed for membrane fluidity

• Bind and traverse the zona pellucida

• Fuse with the oocyte membrane

 

de Lamirande et al, Hum Reprod, 1995

Why Spermatozoa Susceptible to High Levels of ROS ?

  

• Possess significant ability to generate ROS

• Contains extremely high concentration of polyunsaturated fatty acids (PUFA)

• Exhibit no capacity for membrane repair

• Limited amount of cytoplasmic defensive enzymes

de Lamirande et al, Hum Reprod, 1995 Alvarez et al, Mol Reprod Dev, 1995 MacLeod, Am J Physiol, 1943

List of the Antioxidants• Ascorbic acid (Vit. C) • - tocopherol (Vit. E) •  tocopherol (Vit. E) plus selenium •  Glutathione •  L-Carnitine plus L-acetyl-carnitine •  Coenzyme Q10 • Lycopene •  Picnogenol •  N-acetyl-cysteine •  Vit. A and Vit. E • Pentoxifylline • Selenium • Shao-Fu-Zhu-Yu-Tang •  Astaxanthin • Lepidium meyenii • -linolenic acid and lignans •  Vit. C and E, lycopene, selenium, folic acid, garlic oil plus zinc • Morindae officinalis extract

Advantages of antioxidants

• Improvement in sperm motility and motion kinetics

• Increase in sperm count in AZ or OA patients •  Decrease in abnormal spermatozoa •  Reduction in PUFA in sperm membrane •  Suppression of ROS production •  Reduction in sperm DNA fragmentation •  Improvement in sperm viability •  Improvement in oocyte fertilization rate •  Improvement in pregnancy rate (few studies)

Cochrane Review for “Antioxidants for Male Subfertility 2011”

• Analysis of 34 RCT involving 2876 couples.

• The study evaluated the effect of oral antioxidant supplementation for male partners of couples undergoing ART

• Pooled findings support increases in live births and pregnancy rates with the use of antioxidants by the male partner (P<0.0001).

• However, the evidence for improvement in semen parameters is not substantial.

Conclusions

Antioxidants3 main issues need to be addressed before anti-oxidant therapy becomes routine medical care for the infertile couple: • Present diagnostic tests for oxidative stress are

– cumbersome and – expensive and – not available.

• Without the availability of a “quick and easy” test for OS, many doctors are unwilling/more than willing to offer empirical antioxidant therapy.

• Development of such assays for sperm OS are urgently required

 

• Pressing need for large multi-centre trials using a single anti-oxidant or combination therapy to confirm that pre-conception supplementation can boost live birth rates.

• Without such a definitive trial, antioxidant therapy will be relegated to the “promising but never proven” basket of medical treatments, never receiving widespread medical support

• Finally, research suggests that OS to sperm DNA may result in miscarriage and possibly even affect the health of the next generation.

• If such inter-generational effects of sperm oxidative damage are confirmed, – pre-conception antioxidant supplementation for

the male will become standard medical practice, just as pre-conception folate supplementation for the prevention of neural tube defects is standard care for women

thankyou