Infertility Testicles are bilateral ovoid structure, located within scrotum - PowerPoint Presentation

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Infertility

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Testicles are bilateral ovoid structure, located within scrotum

Testis weighs about 20 GM and has volume of 15-25 ml, small testicle when the volume is less than 12 ml

The testicular volume could be measured by ultrasound using ellipsoid formula(

lenghth

*width*thickness*,52)

Or could be measured using

prader

orchidometer

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testes have

both endocrine

and exocrine function. Both of these functions

are under

the control of the HPG axis

.

The endocrine function is the secretion of

testosteron

, the exocrine function is

spematogenesis

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Each testis has 200-300 lobule each lobule contain one or two seminiferous tubules

Seminiferous tubule contain germ cells and

sertoli

cell

The seminiferous tubules are surrounded by interstitial tissue which has

leydig

cell

Sertoli

cells line the seminiferous tubules and are linked by

tight junctions

. These

junction form

the basis for the

blood–testis

barrier. As a result of this tight junction barrier,

spermatogenesis occurs

in an immunologically privileged site

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FSH

bind to

Sertoli

cells and

induces production and

secretion of

androgen-binding protein.

this protein

binds testosterone

and lead

to

high level of testosterone within the seminiferous tubule and so stimulate spermatogenesis.

Nourish the developing sperms and so called nurse cell and has phagocytosis function consuming residual cytoplasm in spermatogenesis

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Spermatogenesis is a cyclic process that involves the

division of

spermatogonial

stem cells into elongated spermatids

.

In humans, an

entire

spermatogenic

cycle requires approximately 60–80

days

Interstitial

leydig

cell secret testosterone under control of LH

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Hypothalamic-pituitary-gonadal axis

Hypothalamus secretes GNRH ( gonadotropin releasing hormone), which stimulate the anterior pituitary to secrete FSH and LH

There is

rythmicity

and pulsatile secretion of GNRH, seasonal and circadian

rythmicity

and so the

testosteron

is higher in spring and on early morning

GNRH peak every 90-120 minutes (pulsatile )

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FSH and LH are only known to act on gonad

FSH is essential for

spermatogenesis.

LH stimulate

leydig

cell to secretes

testosteron

Testosteron

is the primary sex hormone, the biological effect include:

Growth of muscle and bone

Maturation of testis and penis in fetus

Secondary sexual characteristic at puberty (deepening of voice, facial and axillary hair

Testosteron

is important for normal sperm development and important for sexual function(libido, erection and ejaculation)

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Infertility:

is the inability of a sexually active, non-

contracepting

couple to achieve spontaneous pregnancy in one year

.

About 15% of couples

seek medical treatment for infertility

The chance of normal couple to conceive is estimated 20-25%/month

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Etiology

Idiopathic 25%

Varicocele

: dilatation of veins in

pampiniform

plexus of spermatic cord, found in 15% of general population

Mostly affect the left side, because the left internal spermatic vein enter the LT renal vein in right angle while the RT one drain into IVC

and compression of LT renal vein between aorta and SMA (nutcracker

effect),

which result

in increased hydrostatic pressure,

causing dilation

and tortuosity of these vessels.

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The

pampiniform

plexus surround the testicular artery and provide heat exchange mechanism to cool the artery and so keep the temperature of testis 2-4 below the core body temperature

In

varicocele

blood pooling

can cause

an increase

in scrotal temperature and thus impair spermatogenesis

.

Significant

varicocele

can affect the blood supply to the testicle and so causing hypoxic injury

retrograde flow

of

blood from

the renal and adrenal veins,

may contain

harmful substances to the testicle such as catecholamine.

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Clinical grading of

varicocele

(based on physical examination)

Grade1

palpable on

valsalva

grade 2 palpable without

valsalve

grade 3 visible

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Majority are asymptomatic, chronic heaviness or testicular pain, infertility

Indication of surgical repair: pain , infertility, testicular atrophy

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UDT or

cryptorchidism:failure

of one or both testicle to descend into the scrotum prenatally

Incidence in full term is 4% and mostly descend within one year

It is associated with increase risk of infertility and testicular tumor

Infertility occur because 1 improper environment for normal development 2 hyperthermia

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Antisperm

antibody: antibodies directed against sperm antigens

Caused by breakdown of blood testis barrier by infection , trauma , surgery (testicular surgery or vasectomy, tumor.

Testicular insult before puberty does not induce antibodies

It mainly affect sperm motility and capacitation

Treat by steroid or assisted fertility

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Endocrine disorder:

Hypogonadotropic

hypogonadism

:

congenital 1

kallman

syndrome which syndrome of decrease gonadotropin releasing hormone from the hypothalamus

Associate with loss of smell (anosmia)

Present with delayed puberty or infertility

2 idiopathic congenital cause (no anosmia)

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Acquired cause :

Pituitary infiltrative disease

Hyper

prolactinemia

Brain trauma

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Hypergonadotropic

hypogonadism

:

1 Genetic cause such as

klinfelter

syndrom

(

xxy

)

It,s

sign and symptom vary between boys

Small firm testicle , tall ,

gynecomastia

,

azospermia

and infertility

2

aquired

cause: testicular injury like torsion,

trauma ,

bil

mumps

orchitis

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Intercourse problems

lubricants used during sexual intercourse may negatively affect the sperms

Erectile dysfunction

Ejaculatory dysfunction: retrograde ejaculation or

anejaculation

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Obstruction:

1 BAVD which associate with cystic fibrosis

2 Epididymitis

3 Vasectomy or

vasal

injury in inguinal surgery

4 Prostatic cyst

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Medications

Antiandrogen

like

flutamide

5 alpha

reductase

inhibiters like

finasteride

Spironalacone

: diuretic which has weak estrogenic effect

Alcohol ,

cannabies

, opioid decrease the level of testosterone and so affect fertility

Chemotherapy :

impaire

spermatogenesis, the effect is time and dose dependent, we usually advice for cryopreservation of sperm before chemotherapy

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Thermal toxicity like certain occupational exposures , laptop use

Radiation: affect spermatogenesis

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History and examination

Reproductive

history: duration of problem, previous

pregnancy

, Female evaluation

Medical and surgical history of risk factor of infertility

Sexual history

:

libido, quality of erection, intercourse

frequency and timing,

use of

lubricant

Medication history

Fever or acute infection can decrease testis function

and

semen quality. the impact of such insults may

not be observable in the semen until at least 2 months

after the

event.

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Occupational History

Professions at risk of affecting fertility, such as direct and prolonged

exposure to

high temperatures (e.g., kitchen work) and

exposure

to

gonadotoxic

agents (

pesticides).

Lifestyle

Risk

Factor: Smoking ,

excessive alcohol

and coffee

intake

, recreational drugs

,elevated

body mass index (BMI)

,

and low physical activity

also have been

linked to impaired male fertility; modifying such risk factors may have

a positive

impact on male fertility.

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physical evaluation

:

evaluation of secondary

sexual characteristics,

presence of

gynecomastia

, penis inspection

with attention

to location of the external urethral meatus, and digital rectal

examination of

the prostate

.

A detailed evaluation of the scrotal content is of paramount importance.

Testes should

be assessed for bilateral presence, location

,size

(according to

Prader

orchidometer

,

consistency, and presence of

nodules. Bilateral presence of deferent ducts should be

ascertained. The

presence of

varicocele

, and its grading

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Assesment

1 seminal fluid analysis:

Parameter Lower reference limit (range)

Semen volume (mL) 1.5 (1.4-1.7)

Total sperm number (106/ejaculate) 39 (33-46)

Sperm concentration (106/mL) 15 (12-16)

Total motility (PR + NP) 40 (38-42)

Progressive motility (PR, %) 32 (31-34)

Vitality (live spermatozoa, %) 58 (55-63)

Sperm morphology (normal forms, %) 4 (3.0-4.0)

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The lower acceptable numbers represent the

fifth percentile

of this group. In other words, fewer than 5 % of the men who fathered

achild

in the past year had semen parameter measurements below these cutoffs.

This implies

that having better or worse numbers does not necessarily mean that a

man will

or will not be able to father a child.

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Teratospermia

: morphology less than 4%

Asthenospermia

: motility less than 40%

Oligospermia

: count less than 15 –10*6

Azospermia

: no sperm

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Leukocytes are normally present in the seminal

fluid

, but a

concentration above

1 × 10 6 /mL

Is

considered

abnormal ,higher

than normal white blood cell may indicate infection

.

Fructose is a carbohydrate that is secreted in

high

concentration from

the seminal vesicles and is normally

present in

the ejaculate.

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Hormon

profile

:Although a minimum initial hormonal evaluation consists of FSH and total

serum testosterone

, the concomitant assessment of LH, prolactin, and estradiol permits one

to obtain

a more comprehensive picture of the endocrine status of the patient

Normal level of

testosteron

is 300ng/dl, 40% of testosterone is tightly bound to globulin, 58% loosely bound to albumin, 2% is free

Biologically active testosterone include the last two forms

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Special test like karyotyping for

klinefelters

and genetic mapping for y chromosome

microdeletion

done in case of severe

oligospermia

or

azospermia

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Scrotal ultrasound : for detection of testicular size and abnormality, detection of

varicocele

TRUS: to detect ejaculatory duct obstruction, the finding that indicates that on TRUS are increase diameter of seminal vesicle, midline prostatic

cyst,low

ejaculate volume, acidic and low fructose ejaculate

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Testicular biopsy: diagnostic to discriminate obstructive

azospermia

from testicular failure, and therapeutic to achieve sperm for IVF

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Treatment

Treat reversible cause

Avoid risk factor for infertility like smoking and excessive alcohol, recreational drugs

Exercise and increase physical activity

Surgical correction of obstructive

azospermia

Sperm retrieval

and Assisted conception

IVF , ICSI , IUI