1. Infertility Def.: The inability of a sexually active, non contracepting couples to achieve pregnancy in one year Def : failure to conceive after 1 year of unprotected sexual intercourse About 25% of couples do not achieve preg. within 1 year It affect about 15% of couples Roughly : 40 % male factor 40 % female factor 40 % female factor 20 % both male & female 20 % both male & female

2. Male reproductive physiology It depends on the hypothalamic (LHRH) – pituitary ( LH, FSH ) – gonadal axis LH – laydig cell – TST FSH – Sertoli cells Spermatogenesis is completed by meiotic division In the seminiferous tubules It takes 74 day Sperm maturation occurs in the epididymis Fertilisation occurs in the ampullary portion of the fallopian tube during the middle of the cycle

3. Causes of male infertility Pretesticular Pretesticular - Hypothalamic diseases - Hypothalamic diseases Gonadotropin deficiency ( Kallmann syndrome ) Gonadotropin deficiency ( Kallmann syndrome ) - Pituitary diseases - Pituitary diseases Pituitary insuficiency Pituitary insuficiency Hyperprolactinemia Hyperprolactinemia

4. Testicular Testicular - Chromosomal causes Klinefelter syndrome (47,XXY) Klinefelter syndrome (47,XXY) - Other syndromes Noonan syndrome ( male Turner syndrome 45,X ) Noonan syndrome ( male Turner syndrome 45,X ) Sertoli-cell-only syndrome Sertoli-cell-only syndrome - Gonadotoxins Radiation Radiation Drugs ( calcium channel blockers, cimetidine, tricyclic antidepressants, Drugs ( calcium channel blockers, cimetidine, tricyclic antidepressants, nitrofurantoin, allopurinol ) nitrofurantoin, allopurinol )

5. - Systemic diseases renal failure renal failure liver cirrhos liver cirrhos - Testicular injury orchitis, torsion, trauma orchitis, torsion, trauma - Cryptorchidism - Varicocele - idiopathic

6. Post testicularPost testicular - Reproductive tract obstruction … Congenital blockages ( cystic fibrosis, idiopathic epididymal obstruction, … Congenital blockages ( cystic fibrosis, idiopathic epididymal obstruction, … Acquired obstruction ( vasectomy, groin surgery, infection ) … Acquired obstruction ( vasectomy, groin surgery, infection ) … Functional obstruction ( sympathetic N. injury, pharmacologic) … Functional obstruction ( sympathetic N. injury, pharmacologic) - Disorders of sperm function or motility immotile cilia syndrome,maturation defect,immunologic infertility, infectio immotile cilia syndrome,maturation defect,immunologic infertility, infectio

7. evaluation of male infertility depends on evaluation of male infertility depends on History History Physical exam. Physical exam. Semen analysis Semen analysis Hormonal assessment Hormonal assessment

8. Physical examination Complete exam., adequate virilization, body hair, gynecomastias, scrotal exam. Laboratory investigations Urinalysis Urinalysis Semen analysis Semen analysis azoospermia (obsructive and non obsructive) azoospermia (obsructive and non obsructive) Oligospermia, asthenospermia,oligoasthenospermia Volume: 2.0 ml or more pH: 7.2 or more Sperm concentration: 20 × 10^6 or more sperm/ml Total sperm number: 40 × 10^6 or more spermatozoa per ejaculate Motility: 50% or more Morphology: 30% or more White blood cells: Less than 1 million/ml Volume: 2.0 ml or more pH: 7.2 or more Sperm concentration: 20 × 10^6 or more sperm/ml Total sperm number: 40 × 10^6 or more spermatozoa per ejaculate Motility: 50% or more Morphology: 30% or more White blood cells: Less than 1 million/ml

9. Hormonal analysis Evaluation of the pituitary – gonadal axis Includes : testosterone, FSH, LH, prolact Adjunctive tests semen leukocyte analysis, antisperm antibody test, sperm penetration assay Chromosomal study Semen culture

10. Radiologic study Scrotal U/S Scrotal U/S size of testes.,varicocele size of testes.,varicocele TRUS TRUS For obstruction of ejaculatory duct CT & MRI CT & MRI Vasography Vasography Testicular biopsy In azoo spermia to difrentiate between obstructive and non obstructive azoospermia

11. Treatment of male infertility Surgical treatment Surgical treatment Varicocele Varicocele Vasovasostomy Vasovasostomy Ejaculatory duct obstruction – TURED Ejaculatory duct obstruction – TURED Electroejaculation – spinal cord injury Electroejaculation – spinal cord injury Sperm aspiration ( vasal aspiration, epididymal sperm aspiration, testis sperm retrieval ) Sperm aspiration ( vasal aspiration, epididymal sperm aspiration, testis sperm retrieval ) Orchidopexy Orchidopexy Pituitary ablation Pituitary ablation Non surgical treatment Non surgical treatment Pyospermia – antibiotics + antioxidant vitamins ( A,C,E ) Pyospermia – antibiotics + antioxidant vitamins ( A,C,E ) Coital therapy - timing & frequency ( every other day around ovulation ) Coital therapy - timing & frequency ( every other day around ovulation ) Immunologic infertility – corticosteroids suppression, sperm washing, IUI,IVF,ICSI Immunologic infertility – corticosteroids suppression, sperm washing, IUI,IVF,ICSI

12. Medical therapy Medical therapy - Hyperprolactinemia - bromocriptine - Hypo / hyperthyroid Empiric medical therapy Empiric medical therapy 25% of infertility is idiopathic 25% of infertility is idiopathic - Clomiphene: citrate anti estrogen – increase secretion of GnRH, LH,FSH - Tamoxifen : anti estrogin - Antioxidant therapy : Vit E, glutathi

13. Assisted reproductive technologies Assisted reproductive technologies Intrauterine insemination ( IUI) : immunologic infertility, low sperm quality, hypospadias Intrauterine insemination ( IUI) : immunologic infertility, low sperm quality, hypospadias IVF & ICSI IVF & ICSI Gamete intrafallopian transfer ( GIFT ) Gamete intrafallopian transfer ( GIFT )