1. Role of Urology in Treatment of Male Infertility
Nur Rasyid
Department of Urology
Faculty of Medicine
University of Indonesia

2. Introduction US & Europe : 20% are unable to conceive
50% : male factor
Urologist : first specialist visit for man factor

3. Aetiology
EAU Guidelines 2005

4. Causes of male infertility in RSCM
Taher A. Unpublished data

5. Aetiology
Pretesticular
Testicular
Post Testicular

6. Pre Testicular Hypothalamic disease Pituitary disease
Gonadotropin deficiency (Kallmann syndrome)
Isolated LH deficiency (“fertile eunuch”)
Isolated FSH deficiency
Congenital hypogonadotropic syndromes
Pituitary disease
Pituitary insufficiency (tumors, infiltrative processes, operation, radiation, deposits)
Hyperprolactinemia
Exogenous hormones (estrogen-androgen excess,glucocorticoid excess, hyper- and hypothyroidism)
Growth hormone deficiency

7. Testicular
Chromosomal (Klinefelter syndrome [XXY], XX sex reversal, XYY syndrome)
Noonan syndrome (male Turner syndrome)
Myotonic dystrophy
Vanishing testis syndrome (bilateral anorchia)
Sertoli-cell-only syndrome (germ cell aplasia)
Y chromosome microdeletions (DAZ)
Gonadotoxins (radiation, drugs)
Systemic disease (renal failure, liver failure, sickle cell anemia)
Defective androgen activity
Testis injury (orchitis, torsion, trauma)
Cryptorchidism
Varicocele
Idiopathic

8. Post Testicular Disorders of sperm function or motility
Reproductive tract obstruction
Congenital blockages
Congenital absence of the vas deferens (CAVD)
Young syndrome
Idiopathic epididymal obstruction
Polycystic kidney disease
Ejaculatory duct obstruction
Acquired blockages
Vasectomy
Groin surgery
Infection
Functional blockages
Sympathetic nerve injury
Pharmacologic
Disorders of sperm function or motility
Immotile cilia syndromes
Maturation defects
Immunologic infertility
Infection
Disorders of coitus
Impotence
Hypospadias
Timing and frequency

12. Varicocele Most common correctable cause
Occur 15 % of the general population
Up 35 % of men being evaluated for primary infertility
Up to 80 % of men with secondary infertility
Incompetent venous valve
Associated a progressive and time-dependent deterioration in testicular function

14. Varicocele Repair Retroperitoneal Inguinal (Ivanisevich procedure)
Open (Palomo procedure)
Laparoscopic
Inguinal (Ivanisevich procedure)
Using Lense Loupe or Microscope
Subinguinal

15. Improvement Semen quality improvement : 60 – 80 %
Pregnancy rate : 20 – 60 %

16. Endocrinopathies
Only
EAU Guidelines 2005

17. Endocrinopathies Disorder of production or secretion of GnRH
Disorders of pituitary function
Disorders of testosterone synthesis and function

18. Disorder of production or secretion of GnRH
Disorders of pituitary function
Disorders of testosterone synthesis and function

19. Disorder of production or secretion of GnRH
Low levels of FSH and LH
Kallmann’s syndrome
Hormonal replacement with hCG

20. Disorders of pituitary function
Pituitary mass
Direct compression of the portal system
Decrease FSH/LH secretion  hypogonadotropic hypogonadism
Must performed imaging to find pituitary adenoma
Sugical, radiation and medical (cabergoline, bromocriptin) treatment

21. Disorders of testosterone synthesis and function
Defect enzym for systhesis testosterone
Defect Androgen receptor
Exogenous androgen  reversible in 6 month to 1 year
Treatment
Testosterone supplement
Aromatase inhibitor
Antiestrogens

22. Cryptorchidism & Orchiopexy
Histopathologic hallmarks
Decreased numbers of Leydig cells,
Degeneration of Sertoli cells
Delayed disappearance of gonocytes,
Delayed appearance of adult dark (Ad) spermatogonia
Failure of primary spermatocytes to develop
Reduced total germ cell counts

23. Cryptorchidism & Orchiopexy
Also increase malignancy risk
Treatment :
Orchiopexy in 1 year of age

24. Disorders of ejaculation
Failure of emission or ejaculation
Symphatic nerves injury
Retrograde ejaculation
Medication, prior surgery to bladder neck

26. Disorders of ejaculation
Treatment
Neurogenic problem : simpathomimetic agents  enhance emission and close bladder neck (successful in 50 % cases)
Post ejaculate-urine specimen
Vibratory stimulation under anaesthesia
If all above fail  IVF / ICSI

27. Obstruktif Azoospermia
Tidak adanya spermatozoa dan sel spermatogenesis pada semen dan urine pasca ejakulasi yang disebabkan oleh sumbatan bilateral pada duktus seminalis

28. Obstruction Depend level of obstruction
Complete ejaculatory duct obstruction
Low Volume, acidic, fructose negative ejaculate
Vasa or epididimis obstruction
Normal volume, basic, fructosa positive ejaculate

29. TRUS ( Trans rectal ultrasonografi)

30. Complete ejaculatory duct obstruction

31. Vasal obstruction Most common etiology : post vasectomy Treatment
Modified single layer vasovasostomy
Two layer vasovasostomy
Vasoepidimostomy

32. Modified single layer vasovasostomy

33. Two layer vasovasostomy

34. Vasoepididimostomy

35. Congenital bilateral absence of the vas deferens
Sperm harvested from
Epididymis (MESA)
Testis (TESE)
 ICSI

36. Percutaneous Epididymal Sperm Aspiration (PESA)

37. MESA Microsurgical Epididymal Sperm Aspiration

38. BIOPSI TESTIS

39. Testis Biopsy / TESE

40. ART (ICSI)

41. Conclusion
Each infertility case must be examine carefully to select spesific treatment
Urologist has a pivotal role in surgery treatment for infertility cases