Professional Documents
Culture Documents
Case
Puan RH, 31 year old housewife
Presented to GOPD in 1995 with history of
primary infertility after 5 years of marriage
Shes a healthy lady
Shes married to a 38 year old lorry driver
who smokes 20 cigarettes per day for
almost 20 years
Cont. history
He had history of Gonorrhoea in 1987 with
multiple attacks and had been treated by GP
He had no other medical or surgical illness
This is his second marriage in which his first
marriage lasted for 5 years without any
children
Currently his first wife remarried another man
and shes pregnant
Cont.examinations
Wife normal
Husband: Genitalia: Both testis appears
atrophic and soft
R testis : 2.5x1.5 cm
L testis : 3.0x2.0 cm
Volume less than 10 mls
Cont.investigations
Seminal fluid analysis : AZOOSPERMIA
Repeated 3 times : AZOOSPERMIA
Post SI urine for sperm negative
LH/FSH level : HIGH
Cont. diagnosis
TESTICULAR FAILURE
He was referred to urologist and testicular
biopsy performed in 1997
NO SPERM SEEN
MANAGEMENT : this couple was advised
for ADOPTION
INTRODUCTION
INFERTILITY : failure to conceive within
12 months of unprotected intercourse.
50% of normal couples conceive within 5
months and 85% within 12 months
Second pregnancy occur sooner which is
50% within 2 months
Current
estimates suggest about 6% of men
between the ages of 15 and
50 are infertile.
A man will eject nearly 200 million
sperm. However, because of the natural
barriers in the female reproductive tract
only about 40 sperm will ever reach the
vicinity of an egg
EPIDEMIOLOGY
Most fecund couples conceive soonest
because the chances of conception decline
with the duration of infertility
5% of couples desiring children have none by
the end of their reproductive life
Male infertility may be the largest single
cause of human infertility and it responsible
for one third of all primary infertility
EPIDEMIOLOGY - cont
Male factor also responsible for 20% of
secondary infertility and 20% of primary
infertility that involve both partners
AZOOSPERMIA is found in
approximately 10% of infertile couples
Table 1.
Postinfectious obstruction
Cystic fibrosis
Vasectomy
Ejaculatory dysfunction
Premature ejaculation
Retrograde ejaculation
Table 2. Possible
Environmental
Increased pollution
Heavy metals (lead, mercury, arsenic, etc.)
Organic solvents
Pesticides (DDT, PCBs, DBCP, etc.)
Dietary
Increased saturated fats
Reduced intake of fruits, vegetables, and whole grains
Reduced intake of dietary fiber
Increased exposure to synthetic estrogens
Table 4. Causes
Increased stress
Lack of sleep
Overuse of alcohol, tobacco, or marijuana
Many prescription drugs
Exposure to radiation
Exposure to solvents, pesticides, and other toxins
AZOOSPERMIA- CAUSES
ABSENT SPERMATOGENESIS
OBSTRUCTIVE AZOOSPERMIA
RETROGRADE EJACULATION
Absent Spermatogenesis
Obstructive azoospermia
Congenital - absence of vas deferens
Acquired - bilateral epididymo-ochitis or
trauma
Retrograde ejaculation
Congenital- anomalies at the bladder neck
or urethral valves
Neurological abnormalities
Previous surgery
Idiopathic
INVESTIGATION
MALE
FEMALE
OVULATION
HORMONAL
BOM
BBT
TUBAL
HSG
LAP
MALE
SFA X 3
AZOOSPERMIA
POST SI URINE
+ve
-ve
LH/FSH
RETROGRADE
EJACULATION
REDUCED
HYPOTHALAMIC
PITUITARY
NORMAL
OBSTRUCTION
INCREASED
TESTICULAR
FAILURE
INVESTIGATION
SEMINAL FLUID ANALYSIS (SFA) - is the
gold standard
Specimen preferably produced after 3 days of
abstinence
Specimen collected by masturbation into wide
mouthed sterile container
Specimen should be protected from
temperature fluctuation
INVESTIGATION- cont
Specimen should reached the lab within 1-2
hours of ejaculation
Specimen must be thoroughly mixed before
examinations under the microscope
INVESTIGATION- post SI
urine
The presence of sperm will make the urine TURBID
On centrifugation and examination under
microscope, there will be numerous sperms
Treatment- Crich and Jequier 1978 suggest to
ejaculate with full bladder
Alkalinizing the urine prior to ejaculation by
ingestion of NaHCO3 then collect and centrifuge
the urine for AIH
INVESTIGATION- hormone
FSH/LH
REDUCED in hypogonadotrophic hypogonadism
eg. Kallmans syndrome
NORMAL in patients with obstruction anywhere
from the seminiferous tubules to the opening of
the ejaculatory ducts into the prostatic urethra
INCREASED in testicular failure eg. Klinefelters
syndrome
MANAGEMENT- obstruction
Refer to urologist
Vasovasostomy, vasoepididymostomy
Testicular biopsy- presence of sperm
Fertility following surgery usually poor
ART can be offered
MANAGEMENThypogonadotrophic
Gonadotrophic
hypogonadism
injections to promote
spermatogenesis ( Wu 1985)
ART also can be offered
MANAGEMENT- testicular
failure
In severe cases in which the sperm is absent
totally from the testicular biopsy,
ADOPTION OR ART WITH DONOR
SPERM
In milder forms in which minimal amount
of sperm is present in the testicular biopsy,
ART can be offered
General Measures:
Maintain scrotal temperatures between
94-96o F.
Avoid exposure to free radicals.
Identify and eliminate environmental
pollutants
Stop or reduce all drugs, especially
anti-hypertensives,
antineoplastics such as
cyclophosphamide, and antiinflammatory
drugs such as sulfasalazine
dietary
vitamin C plays a critical role in protecting
against sperm damage
and that low dietary vitamin C levels were
likely to lead to
infertility.
Nutritional Supplements:
Multiple vitamin and mineral
Vitamin C - 1,000-3,000 per day in
divided doses
Vitamin E - 600-800 IU per day
Beta-carotene - 100,000-200,000 IU
per day
Folic acid - 400 g per day
Vitamin B12 - 1,000 g per day
Zinc - 30-60 mg per day
Botanical Medicines:
Panax ginseng (three times per day dosages)
High quality crude ginseng root - 1.5-2 g/d 3x/d
Standardized extract (5% ginsenosides) 500mg 3x/d
The dosage of ginseng is related to the ginsenoside
content. The typical dose (taken one to three times
daily)
should contain a saponin content of at least 25 mg of
ginsenoside
Rg1 with a ratio Rg1 to Rb1 of 2:1. For example,
for a high quality ginseng root powder containing
5% gin
ARTIFICIAL
REPRODUCTIVE
InTECHNIQUE
the couple with infertile man especially
ART - cont
Success in the arena of ART has been
spectacular for those having donor
insemination and less so with IVF and
GIFT
Most advances have occurred this century
especially micromanipulation technique
ART- micromanipulation
technique
ART- PZD
The principles is making a hole in the Zona
pellucida by methods - zona drilling,
cracking or cutting by - acidified medium or
a sharp glass neddle
Intention is to permit weakly motile
spermatozoa to gain access to the oolemma
ART- SUZI
A process in which one or more
spermatozoa are inserted into the
perivitalline space
This procedure sometimes will end up with
polyspermy
ART- ICSI
This is the latest micromanipulative
technique and the method of choice for
patient with severe male infertility
It is a process of injecting a spermatozoon or
sperm head directly into the ooplasm
ICSI has transformed the treatment of severe
male infertility during the past 2 years
ICSI - cont
The method has become increasingly
successful and now offers the hope of
having children to many man with virtually
no spermatozoa
In centres expert in ICSI, the fertilization
rate can be as high as with good sperm and
the pregnancy rates can be as high as with
standard IVF for other indications
ICSI - cont
Current development now include the use of
immature epididymal sperm and immature sperm
obtained by testicular biopsy
The source of sperm doesnt effect the pregnancy rate
ejaculated epididymal testicular
cycle
2572
128
120
transfers
93%
91%
90%
preg/cycle 34%
39%
36%
CONCLUSION
Male infertility has been neglected until the
past few decades
Now that female infertility has been defined
and in many instances treated successfully, it
is timely to focus on the male
While most causes of male infertility are
incurable, there have been major advances in
basic knowledge and research which will
CONCLUSION- cont
foster development of better diagnostic and
therapeutic measures
Failure of conventional IVF has lead to
attempts to broach the barrier of zona
pellucida by micromanipulative methods
Success has been infrequent but fertilization
(20%) and pregnancy rate (5%) are
improving
CONCLUSION- cont
With these techniques, polyspermy is
common (10%)
ICSI has been reported to produce higher
fertilization rates (50%) even with severe
sperm abnormalities, zero motility and total
teratospermia
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