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Taher A. Unpublished data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

diseaseGonadotropin

deficiency (Kallmann syndrome)

Isolated LH deficiency (“fertile eunuch”)

Isolated FSH deficiency

Congenital hypogonadotropic syndromes

Pituitary diseasePituitary insufficiency

(tumors, infiltrative processes, operation, radiation, deposits)

HyperprolactinemiaExogenous 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 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 motilityImmotile cilia syndromesMaturation defectsImmunologic infertilityInfection

Disorders of coitusImpotenceHypospadiasTiming 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

Open (Palomo procedure)

Laparoscopic

Inguinal (Ivanisevich procedure)Using Lense Loupe or

Microscope

Subinguinal

Improvement

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

Endocrinopathies

EAU Guidelines 2005

Only

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 systemDecrease 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 supplementAromatase inhibitorAntiestrogens

Cryptorchidism & Orchiopexy Histopathologic hallmarks

Decreased numbers of Leydig cells, Degeneration of Sertoli cellsDelayed disappearance of gonocytes, Delayed appearance of adult dark (Ad)

spermatogoniaFailure of primary spermatocytes to developReduced total germ cell counts

Cryptorchidism & Orchiopexy Also increase malignancy risk Treatment :

Orchiopexy in 1 year of age

Disorders of ejaculation

Failure of emission or ejaculationSymphatic 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 obstructionNormal volume, basic, fructosa positive

ejaculate

TRUS ( Trans rectal ultrasonografi)

Complete ejaculatory duct obstruction

Vasal obstruction

Most common etiology : post vasectomy Treatment

Modified single layer vasovasostomyTwo layer vasovasostomyVasoepidimostomy

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)

MESAMicrosurgical 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