The Endocrine Society is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The Endocrine Society has achieved Accreditation with Commendation. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Develop a systemic approach to evaluation of patients with oligozoospermia.
Identify relevant health concerns in infertile men including androgen deficiency, sexual dysfunction and testis cancer. Use the endocrine and semen laboratory, genetic testing and medical imaging to diagnose and optimally manage oligizoospermic infertility. Discuss the application and success rates of modern ART procedures for the oligozoospermic patient. The Endocrine Society has reviewed all disclosures and resolved all identified conflicts of interest.
Kenneth Burman, M.
Samuel Dagogo-Jack, M. Silvio Inzucchi, M. Kieren Mather, M. Lynnette Nieman, M. Endocrine Society staff associated with the development of content for this activity reported no relevant financial relationships. A year-old Caucasian man and his year-old partner present with 6 months of primary infertility. She is gravida G 0, para P 0 with regular cycles and no history of reproductive tract disorders, pelvic infection, or surgery.
Having undergone a normal puberty and been well previously, he complains of lower libido over the past year. There is no past or family history of reproductive disorders, and he takes no medications or illicit drugs. On examination, he is well virilized but with a 2-cm right testicular mass confirmed on ultrasound with a smaller left testicular lesion also being noted, both suggestive of neoplasia.
A semen analysis reveals severe oligozoospermia: 0. A right orchidectomy is performed and a multifocal seminoma without vascular invasion is identified; there is no evidence of extratesticular spread. Subsequently a left orchidectomy that reveals a similar tumor. Two weeks later he is referred for androgen replacement therapy and address of their fertility concerns.
Clinical Management of Male Infertility | SpringerLink
For 1 in 7 couples, the failure to readily conceive is a profound concern 1. Male infertility affects approximately 1 in 20 men and is the sole or contributory factor in half of assisted reproductive treatments ARTs. Sperm density is a function of sperm output and dilution by androgen-dependent accessory gland secretions; total sperm output is more reflective of spermatogenic production rate, but most discourse refers to density. Oligozoospermia may occur in many reproductive or systemic disorders, and is often associated with poorer motility and morphology a surrogate marker of function , reflecting both qualitative and quantitative defects in spermatogenesis.
Semen analysis should comply with the World Health Organization guidelines 2 , and at least 2 samples should be obtained for analysis several weeks apart. Substantial intraindividual variation in semen quality can be seen, necessitating several analyses to obtain a clear picture.
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Sperm parameters have prognostic significance for conception across populations. Fluorescent labeling of sperm greatly increases the sensitivity of analysis and reduces the apparent incidence of azoospermia 8. The identification of even the occasional sperm is significant in pointing to the presence of active spermatogenesis, thereby increasing the chance of sperm recovery for intracytoplasmic sperm injection ICSI from semen or testicular tissue. Sperm cryopreservation is prudent in severe oligozoospermia in case of later azoospermia; without frozen sperm backup, such men otherwise face surgical testicular sperm extraction.
Clearly evaluation of the female partner may also reveal reproductive disorders that amplify the fertility defect of her partner, and an understanding of each partner's health and the frequency and timing of intercourse is critical in planning management. Comorbidities prevalent in infertile men must be sought because they may have profound implications for reproductive and general health. Furthermore, underlying genetic issues may profoundly impact treatment and its safety.
But this common phenotype must not be presumed because specific diagnosis will inform management and avoid serious diagnostic oversights; hypothalamo-pituitary disease is uncommon but represents the most treatable form of male infertility. The history focuses on the reproductive tract puberty, prior fertility attempts, genital infection, mumps, or surgery [especially for cryptorchidism or torsion], symptoms of androgen deficiency and general health systemic disease, malignancy, prescription or other drug use, occupational exposure, lifestyle.
In addition to a general examination, the degree of virilization and scrotal findings are considered.
Testicular volume is estimated by orchidometry or ultrasound normally 15—35 ml ; smaller volumes suggest testicular failure but are often within the normal range. The vasa and epididymides should be palpated and the presence of varicocele noted. Clinical features depend on the cause, its severity, and the age of onset. In chemotherapy-induced spermatogenic failure, the only feature may be reduced testicular volumes. In regard to serum FSH, in primary spermatogenic failure, sperm density and serum FSH are inversely related, reflecting reduced feedback by Sertoli cell inhibin B secretion Serum FSH helps to discriminate obstructive normal FSH from nonobstructive azoospermia elevated FSH ; a consensus value for the upper limit in reproductively normal young men across 7 immunoassays was 8.
Medical treatment of male infertility
The distinction from spermatogenic failure is important because surgical repair may restore natural fertility, or at least guarantee viable sperm for ICSI using testicular sperm extraction. Infertile men with primary spermatogenic disorders are at risk of coexisting androgen deficiency.
A morning serum T is performed, and a subnormal level is confirmed along with serum LH. Low-undetectable serum gonadotropin and T levels with or without persistent hyperprolactinemia require evaluation for secondary testicular failure. Asymptomatic cases with mild LH elevations do not warrant T treatment 14 , but follow-up seems prudent given that the natural history of Leydig cell dysfunction is unknown.
Importantly, even in those with overt symptomatic androgen deficiency, and for whom T therapy provides substantial benefit, treatment should be deferred until fertility issues have been addressed because it will suppress gonadotropin levels and spermatogenesis. When fertility is not immediately sought, sperm cryopreservation allows T replacement to be commenced.
Testicular cancer risk is elevated 2-fold by infertility per se and 5- to fold with a prior history of cryptorchidism; orchidopexy in early life reduces but doesn't eliminate this risk Careful testicular examination is essential and educating the patient about self-examination is reasonable. Given the low prevalence of testicular cancer, testicular ultrasonography is recommended only in those with abnormal findings or those at risk, ie, prior cryptorchidism or testicular cancer 16 , In those facing a second orchidectomy, sperm cryopreservation prior to castration must be offered and, if the semen quality is too poor, sperm retrieval attempted from uninvolved areas of the surgical specimen and cryopreserved if possible.
Infertile men have an 8- to fold higher prevalence of chromosomal anomalies than fertile men and often exhibit no other phenotypic features Fertility may be normal, but interference with spermatocyte chromosomal pairing results in azoospermia or, more often, oligozoospermia. Only a minority of sperm has an unbalanced chromosomal complement, yet there is a significantly increased risk of offspring with trisomy 21 or 13, or of uniparental disomy in relation to chromosomes 14 and 15, that result in bone and growth disorders. Reciprocal translocations between autosomes or sex chromosomes and an autosome occur in 0.
The breakpoints may interrupt genes important for spermatogenesis, causing meiotic arrest or sperm that are chromosomally unbalanced. Chromosomal inversions may be harmless, but adverse outcomes may be seen depending upon the chromosome, position, and extent. Microdeletions of the long arm of the Y chromosome Yq involve the azoospermia factor AZF regions that contain multiple copies of spermatogenic genes Due to high homology between palindromic sequences, intrachromosomal recombination and deletions of 0.
Yq microdeletions are the most common identifiable genetic cause of spermatogenic failure. PCR-based detection before ART provides the couple with a clear diagnosis, the knowledge of vertical transmission of subfertility to male offspring, and the option of female embryo selection. Single genetic defects causing spermatogenic failure eg, myotonic dystrophy , sperm motility, or functional disorders are emerging but collectively account for a small minority of oligozoospermia and have not entered routine practice 18 , Many patients will have an established diagnosis of congenital eg, Kallmann's syndrome or acquired HH resulting from childhood or adult-onset disease pituitary adenoma, surgery, radiotherapy, trauma, hemochromatosis and be receiving T treatment.
But others will have escaped recognition and present with infertility, usually accompanied by features of androgen deficiency. This diagnosis is suggested by the finding of low-undetectable gonadotropin and T, with or without persistent elevated prolactin. Gonadotropin levels can be in the normal range but can be inappropriate for the clinical setting eg, a low serum T and also require consideration of disorders causing HH.
Hyperprolactinemia of any cause adenoma, drug related, idiopathic may induce HH and affect fertility. Toggle navigation. Subscribe Register Login.
Solutions to Male Infertility
Your Name: optional. Your Email:. Colleague's Email:. Separate multiple e-mails with a ;. Thought you might appreciate this item s I saw at Clinical Obstetrics and Gynecology. Send a copy to your email. Some error has occurred while processing your request. Please try after some time. Louis, Missouri Correspondence: Sherman J. Evaluation and Treatment of Male Infertility.
Find all citations by this publisher default. Or filter your current search. Type: Book, Review. Abstract This chapter provides a comprehensive overview of the clinical, "hands-on" approach to the diagnosis and treatment of male infertility. It is a resource of evidence-based information for those who are practicing in this fascinating field as reproductive endocrinologists, fertility specialists, urologists, gynecologists and general practitioners.
This chapter has been revised with a particular focus on current challenges in the management of severe male infertility.
The chapter gives an overview of the genetic and chromosomal contribution to abnormal sperm production and covers the latest advances in the investigation of the topical DNA fragmentation and newest sperm selections strategies. Therapeutic interventions are presented in detail, mainly in the areas of sperm retrieval, varicocele repair and intra-cytoplasmic sperm injection, including potential complications and extreme challenges as complete failed fertilization.
Various approaches to fertility preservation are described, including advances in prepubertal fertility preservation.