evaluation of male infertility
TRANSCRIPT
Aboubakr Elnashar Benha University, Egypt
Evaluation of male
infertility
ABOUBAKR ELNASHAR
CAUSES Pretesticular:
Hypothalamic pituitary disease (Secondary
hypogonadism): 1-2%
Testicular:
Primary hypogonadism: 10-15%
Post-testicular defects
disorders of sperm transport: 10 to 20 %
Idiopathic:
Seminiferous tubule dysfunction: 60-80%
including microdeletions of the Y chromosome
ABOUBAKR ELNASHAR
CAUSES OF MALE INFERTILITY
I. Hypothalamicpituitary disorders
(GnRH; LH and FSH deficiency)
Congenital disorders
Congenital GnRH deficiency: Kallmann syndrome
Hemochromatosis
Multiorgan genetic disorders: PraderWilli syndrome,
Laurence Moon Beidl syndrome, familial cerebellar ataxia
ABOUBAKR ELNASHAR
Acquired disorders
Pituitary and hypothalamic tumors: macroadenoma,craniopharyngioma
Infiltrative disorders: sarcoidosis, histiocytosis,
tuberculosis, fungal infections
Trauma, postsurgery, postirradiation
Vascular: infarction, aneurysm
Hormonal: hyperprolactinemia, androgen excess, estrogen
excess, cortisol excess
Drugs: opioids and psychotropic drugs, GnRH agonists or
antagonists
Systemic disorders: Chronic illnesses, Nutritional
deficiencies, Obesity
ABOUBAKR ELNASHAR
II. Primary gonadal disorders
Congenital disorders
Klinefelter's syndrome (XXY) and its variants
(XXY/XY; XXXY)
Cryptorchidism
Myotonic dystrophy
Functional prepubertal castrate syndrome:
congenital anorchia
Varicocele
Androgen insensitivity syndromes
5 alphareductase deficiency
Y chromosome deletions
ABOUBAKR ELNASHAR
Acquired disorders
Viral orchitis: mumps, echovirus, arbovirus
Granulomatous orchitis: leprosy, tuberculosis
Epididymoorchitis: gonorrhea, chlamydia
Drugs: alkylating agents, alcohol, marijuana, antiandrogens,
ketoconazole, spironolactone, histamine2 receptor antagonists
Ionizing radiation
Environmental toxins: dibromochloropropane, carbon disulfide,
cadmium, lead, mercury,environmental estrogens and phytoestrogens
Hyperthermia
Immunologic disorders: polyglandular autoimmune disease
Trauma
Torsion
Castration
Systemic illness: renal failure, hepatic cirrhosis, cancer,
sickle cell disease, amyloidosis, vasculitis, celiac disease ABOUBAKR ELNASHAR
III. Disorders of sperm transport
Epididymal dysfunction: drugs, infection
Abnormalities of the vas deferens: congenital
absence, Young's syndrome, infection, vasectomy
Ejaculatory dysfunction: spinal cord disease,
autonomic dysfunction, premature ejaculation
IV. Unexplained male factor infertility
ABOUBAKR ELNASHAR
EVALUATION
History
Examination
Investigation
1. Conventional Semen analyses
2. Specialized Semen analysis
3. Endocrine testing
4. Genetic tests
ABOUBAKR ELNASHAR
A. History
Focuses on causes of infertility.
Personal:
Age, occupation, special habits
Present:
Type of infertility, duration
Sexual:
Frequency, erection, ejaculation, dysparunia, habits.
libido
ABOUBAKR ELNASHAR
Past:
Medical:
Chronic medical illness
Infections: mumps orchitis, sinopulmonary symptoms,
STI, and GUI (prostatitis)
Surgical:
inguinal and scrotal areas such as vasectomy,
orchiectomy, and herniorrhaphy
Trauma
Developmental:
testicular descent, pubertal development, loss of body
hair, or decrease in shaving frequency
ABOUBAKR ELNASHAR
Drugs and environmental exposures:
alcohol, radiation therapy, anabolic steroids,
cytotoxic chemotherapy, drugs that cause
hyperprolactinemia
exposure to toxic chemicals (e.g. pesticides,
hormonal disrupters)
School performance
determine if he has a history of learning disabilities
suggestive of Klinefelter's syndrome
ABOUBAKR ELNASHAR
PHYSICAL EXAMINATION
General:
Evidence of androgen deficiency
depend upon the age of onset.
during early gestation: ambiguous genitalia
late gestation: micropenis
Childhood: delayed pubertal development
Adulthood: decreased sexual function, infertility,
loss of secondary sex characteristics.
ABOUBAKR ELNASHAR
General appearance
Eunuchoidal proportions (upper/lower body ratio
<1 with an arm span 5 cm >standing height):
androgen deficiency antedating puberty.
increased body fat and decreased muscle mass:
current androgen deficiency.
Skin
Loss of pubic, axillary, and facial hair,
decreased oiliness of the skin, and
fine facial wrinkling: long-standing androgen
deficiency.
Breasts
Gynecomastia suggests a decreased androgen to
estrogen ratio.
ABOUBAKR ELNASHAR
External genitalia
Tanner stage
Phallus and testes
Scrotum
Absence of the vas
Epididymal thickening
Varicocele
Hernia
•Varicocele
should be confirmed with the man standing and
performing a Valsalva maneuver.
ABOUBAKR ELNASHAR
Examination for Varicocele:
distension of the pampiniform venous plexus in the
spermatic cord.
3 grades:
1. Palpable during Valsalva s maneuvers.
2.Palpable without Valsalva s maneuver.
3. Visible distension
Varicocele assessment are not correlated with
pregnancy (ESHRE, 2009)
ABOUBAKR ELNASHAR
ABOUBAKR ELNASHAR
ABOUBAKR ELNASHAR
Testes:
Decreased volume of the seminiferous tubules can
be detected by measuring testicular size by Prader
orchidometer or calipers.
ABOUBAKR ELNASHAR
ABOUBAKR ELNASHAR
I. STANDARD SEMEN ANALYSIS
A. Macroscopic
1. Delayed liquefaction
2. Increased viscosity
3. Semen volume
4. pH
B. Microscopy
1. Agglutination
2. Concentration
3. Motility
4. Morphology
5. Round cells
6. Leukocytes
ABOUBAKR ELNASHAR
Semen analysis: WHO, 2010
:
:
Lower reference limit Parameter
1.5 ml Volume
7.2 pH
15 million/ml Concentration
39 million/ejaculate Total sperm number
40% or PR: 32%
Total motility: (PR+NP)
58% live spermatozoa Vitality
4% (strict criteria). Normal forms
ABOUBAKR ELNASHAR
Other threshold values
Peroxidase-positive leukocytes (106 per ml): <1.0
Mixed Antiglobulin Reaction (MAR) test (motile
spermatozoa with bound particles, %): <50
Immunobead test (motile spermatozoa with bound
beads, %) <50
Seminal fructose (ųmol/ejaculate): ≥13
Seminal neutral glucosidase (mU/ejaculate): ≥20 Seminal zinc (ųmol/ejaculate): ≥2.4
ABOUBAKR ELNASHAR
Collection:
After 2-7 d of sexual abstinence
at the doctor's office
Masturbation
If this is not possible:
condoms without chemical additives
delivered to the laboratory within 1 h
At least 2 samples collected 1-2 w apart & not more
than 3 months apart. marked variation of sperm production within one individual
Any systemic disease during sperm generation time (72 days for spermatogenesis & 14 days for transport through the
epididymis & vas): ±negative impact.
ABOUBAKR ELNASHAR
A. Macroscopic
1. Delayed liquefaction
liquifaction after 1 h
Due to:
chronic prostatitis
seminal vesiculitis
ABOUBAKR ELNASHAR
2. Increased viscosity= Hyperviscosity
length of the thread that forms on withdrawal of
a glass rod >2cm
Due to:
chronic prostatitis
seminal vesiculitis
Kartagner s syndrome : interfere with the semen analysis, in particular, evaluation of sperm motility. Treatment in the laboratory 1. passing the sample via a large gauge needle 2. diluting with a physiological solution 3. enzyme digestion before testing for sperm parameters
ABOUBAKR ELNASHAR
3. pH < 7
+Azoospermia Due to:
Dysgenesis of vas deferens,
seminal vesicles
epididymis
ABOUBAKR ELNASHAR
4. Semen volume Mean: 3.7 mL
lower limit: 1.5 mL
low volume+ azoospermia or severe
oligozoospermia
Genital tract obstruction
Congenital absence of vas deferens: diagnosed
by physical examination and low semen pH
Ejaculatory duct obstruction: diagnosed by dilated
seminal vesicles on transrectal US
ABOUBAKR ELNASHAR
ABOUBAKR ELNASHAR
ABOUBAKR ELNASHAR
Low semen volume+ normal sperm concentration
1. Semen collection problems: loss of a portion of
the ejaculate
Repeat semen sample collection after emptying
the bladder
2. Partial retrograde ejaculation
neuropathic disorders, including urogenital tract
surgery, sympathetic denervation, and diabetes
low semen volume+ low sperm concentration
Androgen deficiency: Endocrine assessment
ABOUBAKR ELNASHAR
B. Microscopic
1. Agglutination
Stick of motile spermatozoa to each other.
≥10%: suggestive but not conclusive of
immunological infertility.
Confirmed by:
tests for sperm surface antibodies.
ABOUBAKR ELNASHAR
2. Sperm concentration
Lower limit: 15 million/mL (95% CI 12-16)
However, some men with sperm counts considered to be low can be fertile, while others above the lower limit of normal can be subfertile and, for the purposes of fertilization in vitro, 10 million/mL or even less can be satisfactory
ABOUBAKR ELNASHAR
If only a few spermatozoa/HPF
Sensitivity of detecting spermatozoa can be
increased by labeling the spermatozoa with a
fluorescent nuclei stain
ABOUBAKR ELNASHAR
If only a few spermatozoa/HPF
Sensitivity of detecting spermatozoa can be
increased by labeling the spermatozoa with a
fluorescent nuclei stain and then counting the
spermatozoa using a deep chamber. The sensitivity is reduced to 2000 spermatozoa per mL ejaculate
If no spermatozoa are seen:
Centrifuge
whole pellet should be smeared on a slide and
examined for the presence of spermatozoa before
the diagnosis of azoospermia
ABOUBAKR ELNASHAR
1. Adequate motile sperm in the pellet: ICSI with
ejaculated spermatozoa.
2. Few spermatozoa in the ejaculate:
spermatogenesis in a few seminiferous tubules:
microdissection Testicular Sperm Extraction
(TESE) and the testicular spermatozoa used for
ICSI
ABOUBAKR ELNASHAR
3. Sperm motility
Progressive
non-progressive
immotile
At least 40%of spermatozoa should be motile
At least 32% should have progressive motility.
If sperm motility is poor: sperm vitality should be
assessed by
supravital stains or
hypoosmotic swelling test: determine whether
the majority of immotile spermatozoa are dead
The distinction between living, non-moving
sperm, and dead sperm influences the type of
ART ABOUBAKR ELNASHAR
4. Sperm morphology
Previously based mainly on
shape
Now also include:
Length
Width
width ratio
area occupied by the acrosome
neck and tail defects (“strict” criteria)
Strict criteria:
good predictive value in terms of fertilization in
IVF.
ABOUBAKR ELNASHAR
5. Round cells
not > 5 million/ml.
Due to:
1. Leukocytes
2. Immature germ cells: usually indicate disorders
of spermatogenesis.
3. Degenerating epithelial cells.
ABOUBAKR ELNASHAR
6. Leukocytes
Mainly polymorphonuclear leukocytes
frequently present in the seminal fluid.
Assessment by:
peroxidase stain
The peroxidase positive cells are counted using
the hemocytometer
Not ≥: one million/mL.
Increased WBC± :
genital infection/inflammation ±:
poor semen quality release of reactive oxygen
species from the leukocytes.
ABOUBAKR ELNASHAR
Prediction of fertility
The likelihood of infertility
increased with decreases in any of the 3
parameters: M, NM, C
Normal morphology had the greatest
discriminatory power.
ABOUBAKR ELNASHAR
II. SPECIALIZED SEMEN ANALYSIS
Not routinely performed
used to determine the cause of male infertility
1. Sperm autoantibodies
2. Semen biochemistry (semen fructose)
3. Semen culture
4. Sperm cervical mucus interaction tests 5. Sperm function tests
Computer aided sperm analysis
Acrosome reaction Zona free hamster oocyte penetration test Human zona pellucida binding test Sperm reactive oxygen species generation Sperm chromatin/DNA assays
ABOUBAKR ELNASHAR
1. Sperm autoantibodies 4 to 8%of subfertile men.
The presence of agglutination in the initial semen analysis
suggests sperm autoimmunity; this should be confirmed by
the
Mixed antiglobulin reaction (MAR)
Immunobead test, both of which detect sperm
surface antibodies.
ABOUBAKR ELNASHAR
2. Semen biochemistry
Rarely useful in clinical practice. Fructose
marker of seminal vesicle function.
Low or non-detectable:
congenital absence of the vas deferens and
seminal vesicles or
ejaculatory duct obstruction
ABOUBAKR ELNASHAR
3. Semen culture
Indicated: semen samples contain inflammatory
cells Results: usually not diagnostic.
Precautions during sample collection to prevent
skin contamination.
The yield of semen culture may be improved by
performing a prostatic massage before sample
collection.
ABOUBAKR ELNASHAR
4. Sperm-cervical mucus interaction
identifies whether the problem is in the sperm or in
the cervical mucus
The postcoital test :
female partner is in the preovulatory phase of the cycle. The number and motility of sperm in the cervical mucus is assessed 9 to 24 h after SI The in vitro tests
the slide or the capillary tests
performed on sperm and cervical mucus from the infertile couple together with donor semen and cervical mucus. These so-called "crossed tests"
ABOUBAKR ELNASHAR
5. Sperm function tests
Routine:
Impractical and costly
Selective
when the standard semen analysis is normal or near
normal
ABOUBAKR ELNASHAR
Computer-aided sperm analysis: CASA
Assess:
1. sperm concentration
2. morphology.
3. Motility: Quantitative measurement = sperm
kinematics
sperm velocity (curvilinear, straight line, average path)
Amplitude of lateral displacement
other derived functions.
ABOUBAKR ELNASHAR
Useful in:
identifying men with unexplained infertility, predicting
in vivo and in vitro fertilizing capacity, and in
toxicology studies.
Accuracy depend upon:
technology
analytic conditions, and
technical training of the operators.
ABOUBAKR ELNASHAR
Sperm reactive oxygen species
Generation of reactive oxygen species may be a cause of sperm dysfunction and a predictor of fertilization in vitro. Reactive oxygen species lead to lipid peroxidation of the sperm membrane and are also deleterious to sperm motility. This is still regarded as a research test and is not often used for diagnosis of a specific sperm defect.
ABOUBAKR ELNASHAR
ASSESSMENT OF SDF
Test Principle Method
TUNEL
ISNT
Incorporation of probes
at the site of damage
Direct
SCSA
SCD
Comet
Susceptibility of DBs to
denature in acid
solution
Indirect
Aniline blue
Toluidine blue
Incorporation of probes
to nuclear proteins
Chromatin
incorporation
(Feijo and Esteves, 2014)
ABOUBAKR ELNASHAR
ABOUBAKR ELNASHAR
Normal= 10
Fragmented= 4
DFI= 4X100/10+4
=28.5%
normal
normal
normal
normal
normal
normal
normal
normal
normal
fragmented
fragmented
fragmented
fragmented
normal
≥30: male infertility
15-30: RM.
≤15: Excellent to Good fertility potential
ABOUBAKR ELNASHAR
ABOUBAKR ELNASHAR
There is insufficient evidence to recommend the
routine use of SDF testing in evaluation and
treatment of infertile couple level C
?????????
For diagnostic test
1. Results must be reproducible
2. Applicable to a given patient
3. Change management of patient
IV. ENDOCRINE TESTS
1. Serum testosterone (T)
Morning T
In men with borderline values:
Repeat
FT
ABOUBAKR ELNASHAR
2. Serum LH and FSH
Indication:
T is low
Interpretation:
high FSH and LH: primary hypogonadism
low or normal: secondary hypogonadism.
low LH + low sperm counts +well-androgenized:
exogenous anabolic or androgenic steroid abuse.
ABOUBAKR ELNASHAR
3. Prolactin
Indication:
low T
normal to low LH
4. Inhibin low serum inhibin concentrations may be an even more sensitive test of primary testicular dysfunction than high serum FSH concentrations, provided the assay is specific for inhibin B
ABOUBAKR ELNASHAR
ABOUBAKR ELNASHAR
IV. GENETIC TESTS
ICSI:
Men with severe oligozoospermia and
azoospermia to father children
Genetic risks:
1. Cystic fibrosis conductance regulator (CFTR)
gene,
2. Somatic and sex chromosome abnormalities
3. Microdeletions of the Y chromosome
ABOUBAKR ELNASHAR
ABOUBAKR ELNASHAR
OBSTRUCTIVE AZOOSPERMIA
Azospermia+Normal testicular volumes + Normal
FSH, and LH and T
1. Bilateral congenital absence of the vas:
physical examination
low fructose level in the semen.
2. Ejaculatory duct obstruction
Transrectal US:
dilated seminal vesicles.
Patients with obstructive azoospermia: urologist
specialized in infertility for further evaluation and tt.
ABOUBAKR ELNASHAR
ABOUBAKR ELNASHAR