Male Infertility.

DR. WAEL ABUISNENEH

Male Infertility
Male infertility is an urgent problem
in all countries of the world. According to
world data reproductive potential of the male
population decreasing, and the number of
infertile couples tends to an increase. The
annual congresses of the European
associations of urologists allocate sessions for
discussions on fertility issues.
Introduction:

Male infertility is the inability of a woman to

fertilize.

A marriage is considered infertile if, within a

year of regular intercourse without the use of
contraception, pregnancy does not occur.

female infertility 30%

male infertility 30%
combined female and male infertility 25%
unknown cause of infertility 15%
World map containing percentages of infertility cases per region that are due to
male factor. This figure demonstrates rates of infertility cases in each region
studied (North America, Latin America, Africa, Europe, Central/Eastern Europe,
Middle East, Asia, and Oceania) due to male factor involvement.
Classification of male infertility

Primary infertility - a man has never been able

to fertilize

Secondary infertility - there was at least one

pregnancy from this man.
Types of male infertility:

• secretory;

• Excretory (obstructive);

• Autoimmune (immunological);

• combined;

• Relative.
 Secretory form of male infertility:
This form when the testicles, for various reasons, does not produce
healthy motile spermatozoa in an amount sufficient to fertilize an
egg.
The reasons:
-Primary hypogonadism : (damage directly to the testicles - congenital
dysgenesis, cryptorchidism, orchitis, varicocele, torsion, trauma…)
- Secondary hypogonadism (as a result of damage to the central nervous system,
primarily the hypothalamic-pituitary region - neuroinfection, pituitary tumors,
trauma….)
 - Excretory form of male infertility
(obstructive form)

With this form of infertility, the normal maturation of

spermatozoa in the testicles is preserved, but there is an
obstacle on the way of the spermatozoon from the
testicles to the urethra.
The reasons:
• diseases and malformations of the urethra and
accessory sex glands
• adhesion left after an inflammatory or infectious
process, a scar after surgery
• tumor of genital or nearby organs
 Autoimmune form of male infertility:
It develops as a result of damage to the hematotesticular barrier. The
testicular tissue becomes unprotected from the body's immune system,
antisperm antibodies appear that paralyze the activity of spermatozoa. The
spermatozoon consists of over 2,000 different antigens responsible for
specific reactions. Specific anti-sperm antibodies can be detected on any
of these proteins.

Causes of damage to the hematotesticular barrier:

• injury to testicular tissue;
• inflammatory diseases;
• impaired patency of the vas deferens
ways
Etiology:
 Infectious-toxic factor
1) microorganisms have a direct and immediate damaging effect on
spermatozoa;
2) change the rheological and chemical components of the ejaculate;
3) the infection causes inflammation and cicatricial obstructive processes in the
vas deferens;
4) emerging immunological reactions with the appearance of antisperm
antibodies make it impossible for sperm to move to the egg
 Varicocele - varicose veins of the
spermatic cord
• It occurs in 15% of the total male population and in 40% of
infertile men
• Impaired fertility in patients with varicocele occurs in 20-80% of
cases
• 13% of men who become ill during adolescence become infertile
Reactive oxygen and nitrogen
species generation in infertile
men with varicocele.
Three components can release
ROS in men with varicocele
under heat and hypoxic stress:
the principal cells in the
epididymis, the endothelial
cells in the dilated
pampiniform plexus and the
testicular cells (developing
germ cells, Leydig cells,
macrophages and peritubluar
cells). Abbreviation: ROS,
reactive oxygen species
Varicocele-induced sperm
biochemical pathways of ROS
generation.In the mitochondria,
heat and hypoxic stress can
directly activate complex III of
the electron transport chain to
release ROS. NO, generated
from testicular and endothelial
cells in the testis with
varicocele, can nitrosylate
complexes I and IV to promote
excessive release of ROS by
complex III. In the sperm tail,
where glycolytic units are
present, NO can nitrosylate
glyceraldehyde-3-phosphate
dehydrogenase, contributing to
intracellular acidification
through reducing the ratio of
NADH to NAD+ and reducing
the production of lactate.
Abbreviations: ROS, reactive
oxygen species; SOD,
superoxide dismutase.
Occupational and habitual intoxications

• Contact with industrial poisons (lead, mercury,

manganese, phosphorus, carbon disulfide,
ethyleneamine, ammonia, benzene, granosan,
organic peroxides….);
• The use of certain drugs: sulfonamides, a
number of antibiotics, nitrofurans;
• Radiation damage;
• Alcohol and tobacco abuse.
Genetic infertility•
In 5-20% of all patients with impaired spermatogenesis, chromosomal
abnormalities are detected, primarily sex chromosomes
• With azoospermia, chromosome anomalies are detected in 20% of cases,
and with oligozoospermia - about 7% of cases.
• In 10-15% of cases of idiopathic azoospermia and 5-10% of cases of severe
oligozoospermia in men, microdeletions are found in the AZF locus
(chromosome Y).
 Diagnostics:
• Collection of complaints and anamnesis;
• General examination, urogenital examination, examination by
a geneticist (according to indications)
• Spermogram,
• Hormonal screening (FSH, LH, TSH, T3, T4)
• Infection screening
• Clinical and biochemical blood tests
• Prostate specific antigen (PSA)
• Ultrasound of the pelvic organs and thyroid gland
• Thermography of the scrotum
• Medical genetic study
• Skull examination (MRI or CT)
• Testicular biopsy
• Uroflowmetry
Treatment:
• Stage 1: elimination of the factor that inhibits spermatogenesis;
• Stage 2: selection of stimulating drugs that improve the total number and
motility of spermatozoa, or surgical treatment
-with hypogonadotropic hypogonadism - gonadotropins (pregnyl)
-estrogen antagonists - clomiphene and tamoxifen
-with congenital adrenal hyperplasia - glucocorticoids,
- with testosterone deficiency - the introduction of this hormone.
- with hyperprolactinemia - bromocriptine or cabergoline,
- with retrograde ejaculation not associated with surgical interventions on the
neck of the bladder, the antidepressant imipramine or its agonists.
-antioxidants (androdose)
- patients who underwent prostate surgery (TUR) endoscopic injection of
collagen proximal to the seminal tubercle.
-surgical treatment consists in eliminating the varicocele or restoring the
patency of the vas deferens through vaso- or vaso-epididymo-anastomosis;
• Stage 3: with the ineffectiveness of the first two - the use of (reproductive
technologies).
In vitro fertilization (IVF)

Fertilization of the egg in 60-70% of cases, development of the embryo in 90% of cases.
intracytoplasmic sperm injection
Success rate - 70%
Extraction of spermatozoa from the testicle or its
epididymis – carried out in the absence of spermatozoa in the
ejaculate
Artificial insemination