in the name of godiacld.ir/dl/co/10/infertilityinmendrsoltanzadeh.pdf · m l f t i f tilit a d t t...
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In the name of GodIn the name of God
Dr Dr SoltanzadehSoltanzadeh MD,UrologistMD,Urologist
M l F t I f tilit A d T t tM l F t I f tilit A d T t tMale Factor Infertility And TreatmentMale Factor Infertility And Treatment
Male factor:Male factor:11 Pure 20%Pure 20%1.1. Pure 20%Pure 20%2.2. Both 30Both 30--40% 50%40% 50%
E al ationE al ationEvaluation:Evaluation:
HistoryHistoryPh/ExPh/ExPh/ExPh/ExLab dataLab data
G l f l ti i id tifi dG l f l ti i id tifi dGoals of evaluation is identified :Goals of evaluation is identified :
1.1. Reversible conditionReversible condition22 Irreversible causeIrreversible cause ARTART2.2. Irreversible cause Irreversible cause ARTART3.3. Irreversible cause Irreversible cause Donor insemination adoptionDonor insemination adoption
Si ifi t d l i th lSi ifi t d l i th l4.4. Significant underlying pathologySignificant underlying pathology5.5. Genetic abnormalityGenetic abnormality effect offspringeffect offspring
HistoHistoHistoryHistory
Infertility historyInfertility historySexual historySexual historySexual historySexual historyFamily historyFamily historyP t hi tP t hi tPast historyPast history
PMHPMHPMHPMH
Childhood Childhood DM DM ND ND INF INF Renal D Renal D Cancer Cancer Surgical Surgical Medication Medication GonadotoxinGonadotoxin
Ph sical E aminationPh sical E aminationPhysical Examination:Physical Examination:
HypospadiasHypospadias & & ChordeeChordeeTestis volumeTestis volumeTestis volumeTestis volumeVas & Vas & epididymisepididymisDREDREDREDRESitusSitus inversusinversusVirilizationVirilizationGeneral ExaminationGeneral ExaminationGeneral Examination General Examination
Basic Lab TestsBasic Lab TestsBasic Lab TestsBasic Lab Tests
semen Analysissemen Analysis
NumberNumberCollection: abstinenceCollection: abstinence
containercontainerMethodology : Physical characteristicsMethodology : Physical characteristicsgy ygy y
1.1. LiquefactionLiquefaction2.2. VolumeVolume3.3. CountCount4.4. MotilityMotilityyy5.5. WBCWBC6.6. MorphologyMorphology
CASACASA1.1. VelocityVelocityyy2.2. Flagellar beat frequencyFlagellar beat frequency3.3. Lateral head Lateral head
PHPHFructose Fructose
Ho monal assaHo monal assaHormonal assayHormonal assay
TestosteroneTestosteroneFSHFSHFSHFSHLHLHP l tiP l tiProlactineProlactine
Additional TestingAdditional TestingAdditional TestingAdditional Testing
Le koc te stainingLe koc te stainingLeukocyte stainingLeukocyte staining
11//3 3 RC RC WBCWBCIndication : RC :Indication : RC : 1010--1515% / HPF% / HPFIndication : RC : Indication : RC : 1010 1515% / HPF% / HPF
11**101066 /mL/mLi l t ii l t i papanicolaou stainpapanicolaou stain
peroxidaseperoxidase
Antispe mAntispe m AntibodAntibodAntispermAntisperm AntibodyAntibody
Semen c lt eSemen c lt eSemen culture:Semen culture:
Indication: pyospermia + clinical symptomIndication: pyospermia + clinical symptomMycoplasma genitaliumMycoplasma genitaliumMycoplasma genitaliumMycoplasma genitaliumChlamydia trachomatis (PCR)Chlamydia trachomatis (PCR)
DNA Integrity Testing:DNA Integrity Testing:DNA Integrity Testing:DNA Integrity Testing:Indications:Indications:
11 Unexplained infertilityUnexplained infertility1.1. Unexplained infertilityUnexplained infertility2.2. Repeated IVF failureRepeated IVF failure
Recurrent miscarriageRecurrent miscarriage3.3. Recurrent miscarriageRecurrent miscarriageRisk factors:Risk factors:
1.1. SmokingSmoking2.2. ToxinsToxins3.3. CancerCancer4.4. feverfever
Ult a st ct al e al ationUlt a st ct al e al ationUltra structural evaluation:Ultra structural evaluation:
Indication: < Indication: < 55--1010%%MitochondriaMitochondriaMitochondriaMitochondriaOuter dense fiberOuter dense fiberMi t b lMi t b lMicrotubulesMicrotubules
Radiologic e al ationRadiologic e al ationRadiologic evaluation:Radiologic evaluation:
VasographyVasographyVesiculographyVesiculographyVesiculographyVesiculographyTRUSTRUSV hV hVenographyVenographyScrotal USScrotal USAbdominal USAbdominal US
Ac osome eactionAc osome eactionAcrosome reaction:Acrosome reaction:
Differentiation of acrosome intact from Differentiation of acrosome intact from reactedreactedUnexplained infertilityUnexplained infertilityICSIICSIICSIICSI
Sperm Penetration Assay:Sperm Penetration Assay:R f ZPR f ZPRemove of ZPRemove of ZPScoring :Scoring :% of ova% of ova 1010 3030%%1.1. % of ova % of ova 1010--3030%%
2.2. Num of sperm/ovaNum of sperm/ovaEvaluation of :Evaluation of :Evaluation of :Evaluation of :
1.1. CapacitationCapacitation22 Acrosome reactionAcrosome reaction2.2. Acrosome reactionAcrosome reaction3.3. Fusion oolemaFusion oolema44 Incorporation into ooplasmIncorporation into ooplasm4.4. Incorporation into ooplasmIncorporation into ooplasm
Unexplained infertilityUnexplained infertilityGood sperm but low numberGood sperm but low numberGood sperm but low numberGood sperm but low numberAbnormal Abnormal ICSIICSI
Hemizona AssayHemizona AssayS i t tiS i t ti1.1. Sperm zona interactionSperm zona interaction
2.2. ICSIICSI3.3. Not indicatedNot indicated
Reactive Oxygen TestingReactive Oxygen TestingROS/TACROS/TACSperm Viability AssaySperm Viability AssaySperm Viability AssaySperm Viability Assay
1.1. Eosin YEosin Y22 Trypan blueTrypan blue2.2. Trypan blueTrypan blue3.3. HOSTHOST
Genetic TestingGenetic TestingGenetic Testing:Genetic Testing:
Prevalence increase with SC Prevalence increase with SC Karyotypic abnormalityKaryotypic abnormalityKaryotypic abnormalityKaryotypic abnormalityY chromosome MDY chromosome MDG t ti (AZF)G t ti (AZF)Gene mutation (AZF)Gene mutation (AZF)
Indication: sever oligospermiaIndication: sever oligospermianon obs. azoospermianon obs. azoospermia
Testicular biopsy:Testicular biopsy:p yp yIndicationIndicationNormal: obs.AzoospermiaNormal: obs.AzoospermiaHypospermatogenesis: all germinal elementHypospermatogenesis: all germinal elementoligo>azoooligo>azooM t ti t t t tidM t ti t t t tidMaturation arrest : spermatocyte or spermatidMaturation arrest : spermatocyte or spermatid
azoo>oligoazoo>oligoGerm cell aplastia : normal to small size testisGerm cell aplastia : normal to small size testisGerm cell aplastia : normal to small size testisGerm cell aplastia : normal to small size testis
regionalregionalEnd stage testis : Tubular & Pretubular SclerosisEnd stage testis : Tubular & Pretubular Sclerosisgg
germ cell germ cell ––sertoly sertoly ±±l dl dleydig leydig ±±
Diso de of spe matogenesisDiso de of spe matogenesisDisorder of spermatogenesisDisorder of spermatogenesis
Pit ita diseasePit ita diseasePituitary disease :Pituitary disease :
Time of onsetTime of onsetTestis size & consistencyTestis size & consistencyTestis size & consistency Testis size & consistency EthiologyEthiology
Isolated Hypogonadotrpic Hypogonadism :Isolated Hypogonadotrpic Hypogonadism :Isolated Hypogonadotrpic Hypogonadism :Isolated Hypogonadotrpic Hypogonadism :
Congenital or IdiopathicCongenital or IdiopathicXL > AD AR & Mutation (XL > AD AR & Mutation (3030%)%)XL > AD,AR & Mutation (XL > AD,AR & Mutation (3030%)%)SymptomsSymptomsHCG FSHHCG FSH G RHG RH T t tT t tHCG, FSH, HCG, FSH, GnRHGnRH, Testosterone , Testosterone ,,clomipheneclomiphene
Isolated FSH DeficiencIsolated FSH DeficiencIsolated FSH DeficiencyIsolated FSH Deficiency
Normal size testisNormal size testisOligo or AzooOligo or AzooOligo or AzooOligo or AzoohMGhMG
And ogen E cessAnd ogen E cessAndrogen Excess:Androgen Excess:
CAH CAH 21 21 Hydroxilase >Hydroxilase >Adrenal & Testicular TumorAdrenal & Testicular TumorAdrenal & Testicular TumorAdrenal & Testicular TumorExogenousExogenousMRI CT USMRI CT USMRI , CT , USMRI , CT , US
Est ogen e cessEst ogen e cessEstrogen excess :Estrogen excess :
Testicular Testicular SertoliSertoli Cell TumorCell TumorLeydigLeydig Cell TumorCell TumorLeydigLeydig Cell TumorCell TumorObesity ,hepatic Obesity ,hepatic disdisG tiG ti ED T ti At hED T ti At hGynecomastiaGynecomastia , ED , Testis Atrophy, ED , Testis Atrophy
P olactin E cessP olactin E cessProlactin Excess:Prolactin Excess:
TumorTumorStress Medication IdiopathicStress Medication IdiopathicStress , Medication , IdiopathicStress , Medication , IdiopathicED & InfertilityED & InfertilityL t di dL t di dLater diagnosedLater diagnosedRuled out Hypothyroidism Ruled out Hypothyroidism
Th oid Abno malitTh oid Abno malitThyroid Abnormality:Thyroid Abnormality:
Hyper & HypoHyper & Hypo
A d I iti it S dA d I iti it S dAndrogen Insensitivity SyndromeAndrogen Insensitivity Syndrome
XLXLPhenotype male to femalePhenotype male to femalePhenotype male to femalePhenotype male to femaleAzoo or OligoAzoo or Oligo
Genetic S nd omesGenetic S nd omesGenetic SyndromesGenetic Syndromes
Chromosomal disordersChromosomal disordersklineFelterklineFelter’’s Syndromes SyndromeXXY PXXY P 11//6006001.1. XXY , P XXY , P 11//600600
2.2. Pure or mosaicismPure or mosaicism3.3. AzoospermiaAzoospermiapp4.4. Tubular sclerosisTubular sclerosis5.5. GenicomastiaGenicomastia
B b d kB b d k6.6. Barbody karyotypeBarbody karyotype7.7. 50 50 fold higher risk of breast cancerfold higher risk of breast cancer88 MosaicismMosaicism ICSIICSI8.8. Mosaicism Mosaicism ICSIICSI
XX MaleXX MaleXX Male:XX Male:
Similar to klinfelter syndromeSimilar to klinfelter syndromePortion of Y ch or SRY genePortion of Y ch or SRY genePortion of Y ch or SRY genePortion of Y ch or SRY geneazooazoo
XYY S nd omeXYY S nd omeXYY Syndrome:XYY Syndrome:
Tall , AggressiveTall , AggressiveOligo or AzooOligo or AzooOligo or AzooOligo or AzooARTART
Y ch omosome mic o deletionY ch omosome mic o deletionY chromosome micro deletion:Y chromosome micro deletion:
Not inheritedNot inheritedAZFcAZFc >> AZFbAZFb AZFaAZFaAZFcAZFc > > AZFbAZFb , , AZFaAZFaART & genetic counseling ART & genetic counseling
Bilate al Ano chiaBilate al Ano chiaBilateral Anorchia:Bilateral Anorchia:
Infection , Vascular or torsionInfection , Vascular or torsionTestosteroneTestosteroneTestosterone Testosterone
UDTUDTUDT:UDT:
11//3 3 bilateralbilateralDependent to testis levelDependent to testis levelDependent to testis levelDependent to testis levelUnilateral corrected Unilateral corrected fertility fertility 8080--9090%%Bil t l t dBil t l t d f tilitf tilit 3030 5050%%Bilateral corrected Bilateral corrected fertility fertility 3030--5050% % Retractile Testis Retractile Testis M h iM h iMechanismMechanism
Va icoceleVa icoceleVaricocele:Varicocele:
Prevalence: L Prevalence: L 9090% ; bilateral % ; bilateral 1010%%Secondary > PrimarySecondary > Primaryy yy yHigher T & reflux of metabolites &Impaired Higher T & reflux of metabolites &Impaired venous drainagevenous drainageMotility > SC > MorphologyMotility > SC > MorphologyDiagnosisDiagnosisggGradingGradingSurgical approachSurgical approachSurgical approachSurgical approachSuccessful predictorsSuccessful predictors
O chitisO chitisOrchitis:Orchitis:
MumpsMumps3030% at puberty% at puberty3030% at puberty% at puberty1010--3030% bilateral% bilateralI fI f 22b &b & G RHG RHInfInf αα22b & b & GnRHGnRHTESATESASyphilis, Gonorrhea , Leprosy , Syphilis, Gonorrhea , Leprosy , MononucleosisMononucleosis
Chemothe apChemothe apChemotherapy:Chemotherapy:
Spermatogonia & SpermatocytesSpermatogonia & SpermatocytesDose & AgeDose & AgeDose & AgeDose & AgeAlkylating >Alkylating >H d kiH d ki ’’ (MOPP & COPP)(MOPP & COPP) NOVPNOVPHodgkinHodgkin’’s (MOPP & COPP)s (MOPP & COPP) NOVPNOVPRecovery : Recovery : 44yySperm banking & contraceptiveSperm banking & contraceptive
RadiationRadiationRadiation:Radiation:
Dose & AgeDose & AgeRecoveryRecovery 22yyRecovery Recovery 22yy¼¼ permanentpermanentC t tiC t ti 66 2424Contraceptive Contraceptive 66--24 24 mm
Drug & MedicationDrug & MedicationMarijuana: Marijuana: pyospermiapyospermia. . Tes.genicomastiaTes.genicomastia , SC , SC CocainCocain : : morphology,motilitymorphology,motility & SC& SCSpironolactoneSpironolactone : ( : ( aldostronealdostrone antagonist)antagonist)
antiandrogenantiandrogen effect effect SC SC Ca channel blocker : functional defectCa channel blocker : functional defectCa channel blocker : functional defect Ca channel blocker : functional defect DES : UDT & Cyst of DES : UDT & Cyst of epididymepididymNitrofurantoinNitrofurantoinNitrofurantoinNitrofurantoin,,Gentamycin,Erythromycin,TetracyclineGentamycin,Erythromycin,Tetracycline: : gonadotoxicgonadotoxic & function& functionCimetidinCimetidin : germ cell: germ cellCimetidinCimetidin : germ cell: germ cellSulfazalazineSulfazalazine: SC & motility: SC & motilityAlcohol :Alcohol : peritubularperitubular fibrosis & germ cellfibrosis & germ cellAlcohol : Alcohol : peritubularperitubular fibrosis & germ cellfibrosis & germ cell
free free testesSmoking : female > maleSmoking : female > male
Idiopathic infe tilitIdiopathic infe tilitIdiopathic infertility:Idiopathic infertility:
3030% of patients% of patients2626% pregnancy rate% pregnancy ratep g yp g yGnRHGnRHGonadotropinsGonadotropinsGo adot op sGo adot op sClomiphenClomiphen & & TamoxifenTamoxifen & & TestolactoneTestolactone & & AnastrozoleAnastrozoleAndrogensAndrogensThyroxineThyroxine ,, argininarginin ,, corticostroidscorticostroids,, VitVit A,E,CA,E,CThyroxineThyroxine , , argininarginin , , corticostroidscorticostroids, , VitVit A,E,CA,E,CL L CarnitineCarnitine & & KallekreinKallekrein
Spe m deli e diso de sSpe m deli e diso de sSperm delivery disorders:Sperm delivery disorders:
DuctalDuctal obstructionobstructionCBAVD ICSI + Genetic counselingCBAVD ICSI + Genetic counselingCBAVD , ICSI + Genetic counselingCBAVD , ICSI + Genetic counselingEjEj. . DuctalDuctal Obstruction : TUREDObstruction : TUREDVV d fd f && idid lidid l bbVas Vas deferendeferen & & epididymalepididymal obs.obs.
Vasectom e e salVasectom e e salVasectomy reversal :Vasectomy reversal :
66% of men who have undergone % of men who have undergone vasectomyvasectomyyySecondary ep.obs (Secondary ep.obs (6262%% 1515yo)yo)Sperm & fluid copious and clearSperm & fluid copious and clearSperm & fluid copious and clearSperm & fluid copious and clear
Vasoepid mostomVasoepid mostomVasoepidymostomy:Vasoepidymostomy:
VasectomyVasectomyInfectionInfectionInfectionInfectionCFCF
End to End End to End AnastomosisAnastomosis
End to Side End to Side AnastomosisAnastomosis
Ejaculatory problems:Ejaculatory problems:Distinguish from Distinguish from anorgasmiaanorgasmiaPharmacologic therapy:Pharmacologic therapy:Pharmacologic therapy: Pharmacologic therapy:
1.1. Normal B.NNormal B.N2.2. EmissionEmission
PsuedoephedrinePsuedoephedrine 60 60 mg QIDmg QIDpp g Qg QImipraminImipramin 25 25 mg BDmg BDCyclicCyclicRecovery of spermRecovery of sperm
11 Fluid intakeFluid intake1.1. Fluid intakeFluid intake2.2. Sodium bicarbonateSodium bicarbonate3.3. Media into bladderMedia into bladder
SCISCI1.1. Vibration Vibration 7070% UMN% UMN2.2. TT11--TT6 6 BCR or Hip RBCR or Hip R3.3. TT77--TT12 12 both reflexboth reflex
Electro ejaculation:Electro ejaculation:Electro ejaculation:Electro ejaculation:1.1. SCISCI2.2. RPLNDRPLND3.3. MSMS
A iA i d fl id fl i b Tb T444.4. Autonomic Autonomic dysreflexiadysreflexia above Tabove T44
Spe m f nction diso deSpe m f nction diso deSperm function disorderSperm function disorder
Immunologic infertility Immunologic infertility SppressSppress AbAb :: corticostroidcorticostroid:: high dose cyclichigh dose cyclicSppressSppress AbAb : : corticostroidcorticostroid: : high dose cyclichigh dose cyclic
low dose low dose longtermlongterm3030 4040%%3030--4040%%
Processing technique : Processing technique : chymotripsinchymotripsinICSIICSI
Ult a st ct al Abno malitUlt a st ct al Abno malitUltra structural Abnormality:Ultra structural Abnormality:
Electron microscopyElectron microscopyOuter dense fiberOuter dense fiberMicrotubulMicrotubulMicrotubulMicrotubulMitochondriaMitochondriaConnecting pieceConnecting pieceAc osomeAc osomeAcrosomeAcrosome
Immotile cilia syndrome ARImmotile cilia syndrome ARDysplasia fibrous sheath (stump tail Dysplasia fibrous sheath (stump tail synsyn) I,II) I,IIRound head sperm: Round head sperm: acrosomeacrosome & & cytoskeletalcytoskeletal Pr (Pr (--) I,II) I,IIConnecting piece : pin headConnecting piece : pin headConnecting piece : pin headConnecting piece : pin headICSIICSI