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

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

Aetiology EAU Guidelines 2005

Causes of male infertility in RSCM Taher A. Unpublished data

Aetiology Pretesticular Testicular Post Testicular

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

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

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

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

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

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

Endocrinopathies Only EAU Guidelines 2005

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

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

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

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

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

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

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

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

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

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

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

TRUS ( Trans rectal ultrasonografi)

Complete ejaculatory duct obstruction

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

Modified single layer vasovasostomy

Two layer vasovasostomy

Vasoepididimostomy

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

Percutaneous Epididymal Sperm Aspiration (PESA)

MESA Microsurgical Epididymal Sperm Aspiration

BIOPSI TESTIS

Testis Biopsy / TESE

ART (ICSI)

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