Infertility Testicles are paired structure within scrotum that has endocrine and reproductive - PowerPoint Presentation

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Infertility

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Testicles are paired structure within scrotum that has endocrine and reproductive function

Testis has volume of 15-25 ml

The testis is ovoid in shape and has

pedunculated

body at superior pole called appendix testis( ruminant of

mullerian

duct) and the epididymis attach to

posterolateral

aspect of testis

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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

The germ cell will form the sperm,

sertoli

cell is important for nutrition and form BTB

Leydig

cell secretes

testosteron

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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(process duration 72 D)

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

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It results from incompetent valve ,lead to retrograde flow and vein dilatation and so affect the scrotal temperature

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

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 :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

Sexual and reproductive: duration of problem, previous pregnancy, frequency and time of intercourse, use of lubricant

Partner history

Medical and surgical history of risk factor of infertility

Erectile and ejaculatory dysfunction

Examination for secondary sexual characteristic

Penile and testicular examination

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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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Teratospermia

: morphology less than 4%

Asthenospermia

: motility less than 40%

Oligospermia

: count less than 15 –10*6

Azospermia

: no sperm

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Hormon

profile :

testosteron

, LH, FSH, prolactin

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

Special test like

karyotyping for

klinefelter

s

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

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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

Assisted conception

IVF

, ICSI , IUI