AMIT K SHARMA UROLOGIST HSB MALE INFERTILITY AMIT K SHARMA UROLOGIST HSB

At the end of this talk 1.Understand the performance characteristics of Semen Analysis 2.Describe the role of semen analysis in prognosticating pregnancy, and consequently its utility in defining fertility

3.Understand the role of semen analysis as a marker for significant underlying disease 4.Provide evidence-based recommendations to your patients

Semen Analysis - Introduction Primary infertility affects approximately 15% of couples with male factor infertility accounting for 50% of cases Semen analysis has traditionally been the initial test of choice in the evaluation of the infertile male.

What is Semen? Sperm + Seminal Plasma Source Volume 1.Testis/vas <0.1 ml 2.Epididymis 3.SV 1.5-2.0 ml 4.Ampullae 5.Prostate 0.5 ml 6.Bulbourethral glands 0.1 ml 7.Glands of Littre 0.1 ml

collected at least 7 days between specimens Because the human spermatozoa show marked heterogeneity, at least two semen samples should be evaluated collected at least 7 days between specimens 3 months after any febrile illness. Samples are collected after a period of abstinence of greater than 48 h Specimens should be analyzed within 1 h of collection as semen liquefies at room temperature within 60 min

If the results of semen analysis are normal according to WHO criteria, one test should be sufficient If the results are abnormal in at least two tests, further andrological investigation is indicated

Natural conception may occur for men even when SA values are less than WHO reference ranges and, conversely, men with normal SA parameters may have difficulty initiating a pregnancy.

Biological Variation A 33 yo male with a 1 year history of infertility presents to your clinic today and provides a SA. History and physical are unremarkable. Partner is normal On questioning, he abstained for 1 day before providing a semen analysis

Volume 2.5 cc Concentration 15 million/ml Motility 60% Morphology 8%

Questions 1.Does the season matter? 2.Would have abstaining for longer time have made a difference? If so, how much of a difference? 3.Does it matter how many times he ejaculated last week

4.If he repeated the SA the exact same way several times, how much variation would there be? Would some of the parameters vary more than the others? 5.He’s 33 now. Would his results have been different last year

1. Does the season of collection matter? A: MAYBE (sperm maybe best in spring) 2. Would have abstaining for longer time have made a difference? A: DEFINITELY (by about 25% per day up to day 4) 3. Does it matter how many times he had intercourse last week? A: MAYBE (less than 1-2/7 days may maximize)

4. How much difference between could you expect with between 2 samples. A: A LOT (about 30-50% CV in all parameters between 2 samples) 5. Would his SA likely have been any different when he was younger? A: NO (except for the volume)

Definations Infertility is a disease defined by the failure to achieve pregnancy after 12 months or more of regular unprotected intercourse Fertility is defined by the actual production of live children Sterility is the absence of the capacity to reproduce

Conception rates Per cycle is 25% Per year 85% Therefore, 10-15% of couples meet the definition of infertility

INFERTILITY ≠ ABSENCE OF FERTILITY INFERTILITY ≠STERILITY INFERTILE OFTEN BECOME FERTILE

Prognostic Performance of SA for Pregnancy Starting at TIME 1 YEAR (i Prognostic Performance of SA for Pregnancy Starting at TIME 1 YEAR (i.e. Infertile) Approximately 29%of couples with concentrations of <20 x106/ml will conceive within 2 years of being declared ‘infertile’ (Collins Fertil Steril 1995)

Approximately 27% of couples with total motile counts <5 x106/ml will conceive within 2 years of being declared ‘infertile’ (Snick Human Reprod 1997) If the SA is within the reference range, the probability of conception is 50-70% within 2-3 years

Drawbacks There are still a significant proportion of patients with normal semen analyses but with unexplained infertility. A normal spermiogram does not necessarily correlate with fertility potential, because it does not assess sperm function. Standard semen analysis has been unable to detect some functional deficiency in about 40% of men presenting for sub-fertility

Semen analysis is not a diagnostic test for infertility or fertility Semen analysis parameters are crude prognosticators of fertility. Concentration and morphology are the strongest parameters.

Don’t rely on the ‘reference range’ on the SA report Even using everything which is currently measurable, only a small portion of the probability of future success can be prognosticated.

Male Infertility Causes Idiopathic male infertility 31 % Maldescended testes 7.8 % Urogenital infection 8.0 % Disturbances of semen deposition and sexual factors 5.9 %

General and systemic disease 3.1 % Varicocele 15.6 % Hypogonadism 8.9 % Immunological factors 4.5 % Obstructions 1.7 % Other abnormalities 5.5%

Classification I.Non obstructive infertility 60%: inadequate sperm production by the testes II. Obstructive infertility 38%: normal sperm production but there is a blockage in the genital tract III. Coital infertility 2%: normal sperm production and patent genital tract; however infertility is secondary to sexual dysfunction which impairs intromission or ejaculation.

Causes Of Non Obstructive Infertility Hormonal -Hypogonadotrophic Hypogonadism -Thyroid gland disorders -Hyperprolactinaemia Genetic - Y Chromosomal microdeletions,translocations and aneuploidy - KS

Varicocele Undescended testis Gonadotoxins Systemic illness Orchitis,torsion,trauma and tumours Autoimmune infertility

Severe Male Factor Infertility number < 1 m/ejaculate motility < 20% progression < 2/4 abnormal forms > 85%

Structural and chromosomal abnormalities found in 5 % infertile man and 14% azospermic man In addition to the SRY gene which is involved in determining the fate of the embryonic bipotential gonad, the Y chromosome also contains the ‘‘male-specific Y’’ (MSY) which contains chromosomal material not represented elsewhere in the genome and contains numerous genes involved in spermatogenesis

An AZFc microdeletion quantitatively impairs spermatogenesis however men with such deletion may be oligozospermic and even father children naturally Unlike AZFc microdeletion; AZFa and AZFb microdeletions are associated with azoospermia and complete spermatogenic failure and sperm will not be found in the testes of men with these deletions via surgical sperm retrieval (TESE)

Klinefelter syndrome (KS) is the most common example of a numerical abnormality KS is associated with primary testicular failure, patients present with hypogonadal features, azoospermia, gynecomastia,small sized testes and some may have learning difficulties.

Micro-TESE yields sperm in up to 50% of cases with a 30—50% pregnancy rate via ICSI The younger the age of male the better the TESE outcome, so it has been suggested that TESE should be performed on KS patients before the age of 35 years

How do Y deletions cause male infertility Code for proteins essential for spermatogensis

Causes of Obstructive Infertility Intratesticular obstruction Epididymal Obstruction CBAVD EDO Vasectomy-post hernia surgery, orchidopexy

Coital Infertility ED PE Penile deformities Anejaculation Retrograde Ejaculation

History Time the couple has been engaging in unprotected intercourse and how long they have been deliberately trying to conceive The frequency and timing of vaginal intercourse with respect to the female partner’s menstrual cycle should be assessed Technically, the infertility diagnosis only applies to couples engaging in unprotected vaginal intercourse at least twice a week on average for a year, although evaluation may occur earlier when the female partner is older than 35 years

Primary or secondary infertility Medical Conditions Lifestyle factors Medications Infection and inflammation Surgery Cystic fibrosis,Klienfelter Synd,Neuropathic conditions, Diabetes Mellitus,Hyperthroid Testosterone. Alpha reductasenitrofurantoin, cimetidine, sulfasalazine, spironolactone, colchicine, valproate, calcium channel blockers, lithium, chemotherapeutic agents and antimetabolites.

Family History Female factors female partner age(age greater than 35 years suggests greater likelihood of fertility impairment), menstrual cycle regularity, increased serum anti-mu¨llerian hormone or day 3 serum FSH and pregnancy history

Physical Examination -Secondary sexual characteristics -Penis -Testis -Epidydimis -Cord

Investigations SFA Hormonal Profile Ultrasound Scrotum & Testis TRUS

Male Reproductive Genetic profile Post orgasmic urine analysis DNA fragmentation Sperm Antibodies Klinefelter syndrome (47, XXY) The Y chromosome microdeletion assay uses polymerase chain reaction technology to assess for deletions in the portion of the Y chromosome critical for spermatogenesis. Screening for cystic fibrosis transporter gene mutations is essential in men with congenital bilateral or unilateral absence of the vas deferens.

Check for karyotype abnormalities and y- Microdeletions in any infertile man with a sperm concentration of < 5 x 105/ml, especially with azoospermia. Check an FSH, testoserone and PRL in every infertile male, regardless of the semen analysis.

Tests of Spermatozoa DNA damage

Factors that can contribute to increased sperm DNA fragmentation include smoking, testicular hyperthermia, increase in seminal reactive oxygen species due to the presence of seminal leukocytes in response to infection and presence of varicocele In men who are at increased risk for elevated sperm DNA fragmentation or aneuploidy due to lifestyle factors, advanced age or varicocele and in men who have undergone previous failed IVF cycles these factors should be evaluated to determine the best future treatment options.

FSH levels and testicular longitudinal axis provide an accurate means to distinguish between NOA and OA without biopsy A patient with FSH ≥7.6 mIU/ml and testicular longitudinal axis ≤4.6 cm has an 89% chance of having spermatogenic dysfunction as a cause of azoospermia rather than OA Conversely, a man with FSH <7.6 mIU/ml and testis longitudinal axis >4.6 has a 96% likelihood of having OA Diagnostic biopsy before surgical sperm retrieval purely to discriminate OA from NOA is no longer recommended

Analysis Finding Conclusion Ejaculate volume Low (< 1.5 mL) Post ejaculation urine (retrograde ejaculation) TRUS (absence of vas deferens) Hormonal evaluation (hypogonadism), ,meds High (>5 mL) Likely contaminant Semen quality Does not coagulate TRUS (ejaculatory duct obstruction) Does not liquefy Hormonal analysis Sperm density Oligospermia (< 15 million per mL) Severe oligospermia (< 5 million per mL) TRUS (partial ejaculatory duct obstruction) Antisperm antibody evaluation Hormonal analysis Physical examination for varicocele,toxins,environment,chemorad,orchitis Azoospermia Sperm centrifuged to verify azoospermia Postejaculation urine (retrograde ejaculation) Hormonal evaluation Testicular biopsy (testicular failure) TRUS (ejaculatory duct obstruction) Motility Decreased Antisperm antibodies Physical examination for varicocele

Medical Treatment -may be effective in the following cases: Hypo-gonadotropic hypogonadism may be treated with FSH/LH preparations Combination of human chorionic gonadotropin (hCG) and FSH therapy for 6—24 months results in testicular growth in almost all and spermatogenesis in 80—95% of patients without undescended testis

Coital infertility e.g. sympathomimetic drugs such as pseudo-ephedrine, vibrator and electrojaculation for anejaculation and sympathomimetic drugs

Clomiphene citrate which is a selective oestrogen receptor modulator (SERM) has also been used successfully in patients with the adult onset form of idiopathic hypogonadotropic hypogonadism Chronic prostato-vesiculitis is associated with impaired semen parameters, elevated ROS and increased DNA fragmentation. It is diagnosed by the finding of pyospermia; ≥106 peroxidasepositive white blood cells (WBCs) per millilitre of ejaculate.

Surgical Treatment Of Infertility Vas reversal Varicocele Surgery Surgical Sperm Retrieval

Varicocele Dilatation of the pampiniform plexus of spermatic veins Incidence 12% of men in the general population 25-35%with infertility 90% left sided, 10% on right NB- renal cell carcinoma

Grading of varicocele I palpable during valsalva II palpable on standing III visible on standing Bag of worms

Indications of Treatment? In the context of male factor infertility two indications for treatment; Patients with grade II/III varicoceles associated with a reduction in ipsilateral testicular volume ?Abnormal semen parameters in subfertile men including oligozoospermia <20x 106/ml, poor motility <50% progression, abnormal sperm morphology

Indications Surgical Sperm Retrieval Nonobstructive azoospermia(NOA) Obstructive azoospermia not amenable to reconstruction as in CBAVD Coital infertility due to anejaculation

PESA TESA MESA TESE Micro TESE

Azoospermia - The patient produces semen containing no sperm Oligozoospermia - sperm concentration is low, less than 15 million per ml Asthenozoospermia: < 32% motile spermatozoa Teratozoospermia: < 4% normal forms

Oligoasthenoteratozoospermia (sometimes referred to as OATS) – combination of the above Necrospermia - all sperm are dead Pyospermia or leucospermia - presence of large number of white blood cells in the semen, often associated with an infection

Prognostic factors for male infertility • duration of infertility; • primary or secondary infertility; • results of semen analysis;(Conc. & Morph) • age and fertility status of female partner

Summary Male infertility should be treated in a specialized unit Assisted conception techniques have revolutionized management Obstruction is a treatable cause of male factor infertility Even those with primary testicular failure can achieve paternity

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