INFERTILITY PRIA

INFERTILITY

THE DEFINITION of INFERTILITY

WHO manual for the  standardized investigation, diagnosis and management of the infertile male,WHO Cambridge  University, Press, 2000.

Infertility is defined as no conception after at least 12 months of unprotected intercourse

The time limit of 12 months is arbitary, but corres-

  -ponds with the fact that majority (approximately

  85%) of couples who achive pregnancy spontaneously

  will do so within 12 months

Frequency  . . . .         /weeks - month

Timing      . . . .           Regulated/not Around ovulationInterval

Management of male infertility

1. History - taking

2. Clinical assessment of male infertility

3. Laboratory and additional technical  investigation

4. Male diagnostic categories

5. Treatment

. HISTORY - TAKING

1. Infertility - primary

                        secondary

2. Duration of infertility

3. Previous investigations and / or treatment for infertility

4. History of disease with possible adverse effect on

   fertility

a. Fever : > 38.50 C ® ¯ spermatogenesis 6 months

b. Medical interventions

ä          chemotherapy

ä          hormone treatments

ä          anti hypertension - anti diuretic

ä          ulcus pepticum drugs

4. History of disease with possible adverse effect on fertility

c. History of surgery

ä          general anesthesia ®¯spermatogenesis 3-6 months

ä          cryptorchidy

ä          hydrocelectomy

ä          varicocelectomy

ä          testicular biopsy

ä          prostatectomy

ä          vasectomy

ä          hernia repair

d. History of urinary tract infection

ä          dysuria

ä          urethral discharge

ä          pyuria -  hematuria

ä          freq of micturation

                                      ¯

ä          number of occurences

ä          Treatments

e.Sexually transmitted diseases

ä          gonorrhoea

ä          syphilis

ä          chlamydia trachomatis

ä          lymphogranuloma venereum

ä          mycoplasma

ä          herpes genitalis

f. Epididymitis - orchitis

g. Other causes

â          mumps orchitis

â          testicular injury

â          testicular torsion

â          environmental/occupational and life style factors :

ü  ­ temperature

ü  heavy metals : lead, cadmium,mercury, carbon, disulphide

ü  pesticides, herbicides                                    

ü  alcohol

ü  tobacco/marihuana  

h. Sexual and ejaculatory function :

ä          penile deformity

ä          erectile impotence

ä          anejaculation

ä          premature ejaculation

ä          retograde ejaculation

i.                    Psychological problem

II. CLINICAL ASSESSMENT OF MALE INFERTILITY

A. Physical examination

    General examination

ä         height    : Klinefelter

ä         weight                : obesity, Turner

ä         blood pressure              : drugs

ä         body hair distribution : hypoandrogenism

ä         gynaecomastia              : hyperoestrogenism          

B. Inguinal : scar 

               inguinal lymphnodes

               hernia

II. CLINICAL ASSESSMENT OF MALE INFERTILITY

C. Genital

            1. Penis :         - phymosis

                        - epi/hypospadia,scar, induration,

                                    - size

            2. Urethra :- stricture

                                    - discharge

                                    - ulceration

            3. Scrotal sac swelling :

                                    - hernia,

                                    - hydrocele,

                                    - varicocele

                                    - tumor

             4. Testes :

ä          location : - incomplete descent : high, inguinal,                                         impalpable

                                    - ectopic testes

                                    - retractile

ä          testicular volume  : 1) Caliper             

                          2) Prader orchiometer

                                  3) Takihara orchidometer

                          4) USG

ä          tescicular consistency : normal/soft/hard

ä          Pain

              5. Epidydimis :

ä          Regular outline, soft

ä          Position

ä          Consistency

ä          Pain

ä          Cyste deformity

ä          Granulomata

              6. Vasa deferentia

ä          Thin, firm, cord like structure

                    ¯

   Agenesis - uni / bilateral

III. LABORATORY INVESTIGATION

A.Semen analysis

            WHO 80, 87, 92, 2000

â                     Seminal plasma

â                     Spermatozoa - concentration

                                    - motility

                                    - morphology

â          Other cells

B. Tests on blood and serum

â          Rutine blood tests

â          Specific test - chlamydia trachomatis

                           - HIV

                           - antisperm antibodies

â         Hormone determinations

          Hypothalamus - hypophyse - testicular axis

ü  FSH

ü  LH

ü  Testosteron

ü  Prolactin

ü  Oestradiol

ü  Inhibin B

C. Tests on urine

â                     Infection : chlamydia trachomatis

â           Retrograde ejaculation

D. Chromosome and genetic analysis

â         Sperm cons < 5-10.106/ml

â         Karyotyping

E. Additional technical investigations

      1.Scrotal thermography :

            Confirm : subclinical/grade I varicocele

            (N) < 360 C

      2.Pocket Doppler

            Doppler/colour Doppler USG

     3.Sela tursica radiography /CT-scan-hypothalamo-pituitary region

F. Testicular biopsy

â         Unexplained azoospermia

                      { Testicular volume - FSH (N) }

â         Testicular malignancy / Ca-insitu

â         ICSI

SEMEN CLASIFICATION

.A.  Seminal plasma

â         Colour

â           Odour

â           Coagulation/liquefaction

â           Viscosity (consistency)

â           pH (7.2 - 8.0)

â           Volume         *  Aspermia

                           (2-6 ml)        *  Hypospermia

                                                *  Polyspermia

B. Spermatozoa

â         Concentration :

                     (20-250.106/ml)

- Azoospermia

- Cryptozoospermia

- Extreme oligozoospermia

   (< 5.106/ml)

- Oligozoospermia

   (5 - 20.106/ml)

- Normozoospermia

   (20 - 250.106/ml)

- Polyzoospermia

   (> 250.106/ml)

-  Motility : asthenozoospermia

            a : > 25%

            a + b > 50%

  - Morphology : teratozoospermia

            > 30%

            Strict criteriae - Kruger’s  cirteriae

C. Others

â         Agglutination

â           Leucocyte < 1 x 106/ml

â           Bacteriae

â           Fungus : hypha / spora

â           Crystals

â           Debris

â           Protozoa

GOOD LUCK