Definitionrefers to a male's inability to causepregnancyin a fertile femaleIn humans it accounts for 40-50% ofinfertility. Male infertility is commonly due to deficiencies in the semen, and semen quality is used as a surrogate measure ofmalefecundity.Infertility is a widespread problem. For about one in five infertile couples the problem lies solely in the male partner (male infertility).

Pre-testicular causesPre-testicular factors refer to conditions that impede adequate support of the testes and include situations of poor hormonal support and poor general health including:

Hypogonadotropic hypogonadismdue to various causesObesityincreases the risk of hypogonadotropic hypogonadism.Animal models indicate that obesity causes leptin insensitivity in thehypothalamus, leading to decreased Kiss1expression, which, in turn, alters the release ofgonadotropin-releasing hormone(GnRH).Drugs,alcoholStrenuous riding (bicycle riding,horseback riding)Medications, including those that affect spermatogenesis such aschemotherapy,anabolic steroids,cimetidine,spironolactone; those that decrease FSH levels such asphenytoin; those that decrease sperm motility such assulfasalazineandnitrofurantoinGenetic abnormalities such as aRobertsonian translocation

Tobacco SmokingMale smokers also have approximately 30% higher odds of infertility. There is increasing evidence that the harmful products of tobacco smoking kill sperm cells.Therefore, some governments require manufacturers to put warnings on packets. Smoking tobacco increases intake of cadmium, because the tobacco plant absorbs the metal. Cadmium, being chemically similar to zinc, may replace zinc in the DNA polymerase, which plays a critical role in sperm production. Zinc replaced by cadmium in DNA polymerase can be particularly damaging to the testes.

DNA DamageCommon inherited variants in genes that encode enzymes employed in DNA mismatch repair are associated with increased risk of sperm DNA damage and male infertility.As men age there is a consistent decline in semen quality, and this decline appears to be due to DNA damage.(Silva et al., 2012). These findings suggest that DNA damage is an important factor in male infertility.

Testicular FactorsTesticular factors refer to conditions where the testes produce semen of low quantity and/or poor quality despite adequate hormonal support and include:

AgeGenetic defects on theY chromosomeY chromosome microdeletionsAbnormal set of chromosomesKlinefelter syndromeNeoplasm, e.g.seminomaIdiopathicfailureCryptorchidismVaricocele(14% in one study)TraumaHydrocele

MumpsMalariaTesticular cancerDefects inUSP26in some casesAcrosomaldefects affecting egg penetrationIdiopathic oligospermia- unexplained sperm deficiencies account for 30% of male infertility.

Post-testicular causes Post-testicular factors decrease male fertility due to conditions that affect the male genital system after testicular sperm production and include defects of the genital tract as well as problems inejaculation:

Vas deferensobstructionLack ofVas deferens, often related to genetic markers forCystic FibrosisInfection, e.g.prostatitisRetrograde ejaculationEjaculatory duct obstructionHypospadiasImpotence

SpermatogenesisSertoli cellthis is the only place in the testes where the spermatozoa are producednourishes the developing sperm cellsAlso called as nurse cellThe strongest intercellular barriers in the bodyblood-testis barrierGerm cells:primary spermatocytesspermatogoniasecondary spermatocytesSpermatid

Cycleswithin the human testis: 60 dayssperm maturation: 10-15 days

Diagnosis of Male InfertilityHistoryDuration of infertility; earlier pregnanciesSexual history, timing and frequency, lubricantsMedical and surgical history- fever, acute infection, surgical procedure of bladder, pelvis, herniaChildhood diseases: mumps, cryptorchidismMedication, radiation, tobacco, cocaine, marijuana, androgenic steroids, hot tubs Family history

Physical examinationBody hairGynecomastia is a commonendocrine disorder in which there is a benign enlargement of breast tissue in malesTestis: size and consistencyEpididymis; vas deferensVaricoceleThis occurs when the veins in the testicular cord (around the vas deferens) become engorged with blood. Other abnormalities

GYNECOMASTIA

VARICOCELE

Laboratory testsUrinalysisSemen analysisSemen collection: 48-72 hours of sexual abstinenceSeminal fructose and post ejaculate urinalysisFructose: derived from the seminal vesicleHormone assessmentFSH and testosterone

Diagnostic TestsRadiologic testingScrotal ultrasoundCT scan or MRI of the pelvisTestis biopsy is a test to remove a small sample of tissue from one or bothtesticlesand examine it under a microscope to evaluate a man's ability to father a child.Vasographyis anX-ray studyof thevas deferensto see if there is blockageFine-needle aspiration mapping of the testesSemen culture

Mapping of testes

Sperm Mapping

Treatment of male infertility (Surgical treatments)Vasovasostomy or epididymovasostomyliterally connection of thevasto the vasEjaculatory duct obstruction TURED (Transurethral Resection of the Ejaculatory Ducts )is performed to treat obstructive male infertility conditionsSperm aspiration: vas deferens, epididymis, or testicle.Orchidopexy: within two years of ageis asurgeryto move an undescendedtesticleinto thescrotum and permanently fix it thereTesticular torsionoccurs when thespermatic cord(from which thetesticle is suspended) twists, cutting off the testicle's blood supply, a condition calledischemia

Surgical management of male infertilityTestis biopsy

Surgical management of male infertilityVasography:

Surgical management of male infertilityVasography

Surgical management of male infertilityVasovasostomy

Surgical management of male infertilityVasovasostomy

Surgical management of male infertilityVasoepididymostomy

Surgical management of male infertilityTransurethral resection of the ejaculatory ducts (TURED)

Treatment of male infertility (Nonsurgical treatments)Pyospermia (is a condition in which there is an unusually high number of white blood cells in the semen)evaluate the patient for sexually transmitted diseases, penile discharge, prostatitis, or epididymitisCoital therapyImmunologic infertilityCorticosteroid suppression, sperm washing, IUI, IVF, and ICSI.

Medical therapy

Hyperprolactinemia; hypothyroidism; congenital adrenal hyperplasia; testosterone excess/ deficiency: Kallmann syndrome, HCG, FSHEmpiric medical therapy clomiphene citrate: antiestrogen, increase secretion of GNRH, FSH, and LH. Low sperm count antioxidant therapy: vit E growth hormone

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