1. Rational Investigations and
Management of Male Infertility
Dr Sujoy Dasgupta
MBBS (Gold Medalist, Hons)
MS (OBGY- Gold Medalist)
DNB (New Delhi)
MRCOG (London)
Advanced ART Course for Clinicians (NUHS, Singapore)
M Sc, Sexual and Reproductive Medicine (South Wales, UK)
Clinical Director and Consultant: Reproductive Medicine, Genome Fertility
Centre, Kolkata
Managing Committee Member, BOGS, 2022-23
Executive Committee Member, ISAR Bengal, 2022-24
Clinical Examiner, MRCOG Part 3 Examination
Winner, Prof Geoffrey Chamberlain Award, RCOG World Congress, London,
2019

2. Do we understand-
“Male Infertility?”

3. 1. Men’s fertility potential depends
on female factors
• Assessment of tests and treatments for the male is
challenging due to inconsistent endpoints and the
observation that many of these endpoints are
dependent upon and measured from the female
partner.
• Ideally, the endpoint for fertility trials should be "live
birth or cumulative live birth (WHO, 2021)

4. 2. We cannot treat
We bypass

5. 3. Reliance of Semen
“Reference Range”

6. Limitations of WHO Guideline
• 5 percentile and time-to-pregnancy (TTP) concept
• Not true reference values but recommends
acceptable levels.
• Day to day variation
• Functional ability of the sperms?

7. Sperm DNA
Fragmentation (SDF)
Infertile men with:
• Repeated IUI or IVF failure
• Recurrent spontaneous
miscarriages (ESHRE, 2018)
• Previous low fertilization,
cleavage or blastulation rate
• Varicocele with
normozoospermia
• Advanced male age (>40 y)
Significance of SDF
• Live birth after IUI/ IVF/
ICSI- ?
• Oocytes can repair the
damaged DNA
• Lack of standardization
• Lack of definitive treatment
4. Is “Routine” Semen Analysis ENOUGH?

8. 5. Can we rely on a “Semen” report?

10. Collection Method Masturbation Abstinence 4 days
Collection Complete Volume 2 ml
Colour Whitish Viscosity Normal
Liquefaction Time 45 minutes pH 7.6
Sperm Concentration 36 million/ ml
Total Motility 46% Progressive Motility 33%
Non progressive Motility 13% Immotile 54%
Motile Sperm Count 16.56 million/ ml TMSC 33.12 million
Normal Morphology 5% Abnormal Morphology 95%
Vitality 32% Round cells Nil
Impression- Normozoospermia
• Treated for “male factor” with antioxidants
• Unexplained subfertility
• Conceived with OI with hMG first cycle, delivered
6. Can we interpret properly?

11. Points to note in semen report
Volume 1.4 ml
Colour Whitish
Viscosity Normal
Liquefaction Time 45 minutes
pH 7.6
Sperm Concentration 16 million/ ml
Sperm count 39 million/ ejaculate
Total Motility 42%
Progressive Motility 30%
Non progressive Motility 12%
Immotile 58%
Normal Morphology 4%
Vitality 54%
Round cells Nil
1
2
3
4
5
6

12. 7. Male Infertility- Mild or Severe?
• TMSC= Total Motile sperm count =
• Sperm concentration x total volume x total motility
(16 mil/ml x 1.4 ml x 42%)
• TMSC >5/ 10/ 20 million

13. Mild Male Factor
• Investigations- NOT
usually recommended
• Antioxidants
• CC
• Other adjuvant
Lifestyle changes
1. Heat exposure to scrotum
2. Obesity
3. Food habit
4. Smoking
5. Alcohol
6. Anabolic steroids
7. Chronic scrotal fungal
dermatitis
(EUA, 2018; ASRM, 2020)

14. When to repeat semen analysis?
• Mild problems- After 3 months
• Severe problems- ASAP
(NICE, 2013; EUA, 2018; ASRM, 2020)

15. I n f e r t i l i t y

16. Antioxidants
Astaxanthin several-fold stronger antioxidant activity than vitamin E and b-carotene.
potent antiperoxidation activity.
Coenzyme Q10 Protects the cell membrane from lipid peroxidation.
improves Total Antioxidant Capacity (TAC) concentrations and decreased
Malondialdehyde (MDA) levels.
L-Carnitine increases fatty acid transport into sperm mitochondria which are needed for sperm
energy production.
Lycopene antiproliferative, immunomodulatory, and anti-inflammatory effects that promote cell
differentiation .
Vitamin B9 (Folic
Acid)
Protects against mutations and DNA strand breaks.
Regulates DNA methylation and gene expression
prevents abnormal chromosomal replication and mitochondrial DNA deletions.
Zinc role in signaling, enzymatic activities, sexual maturation and managing mitochondrial
oxidative stress.
improves chromatin integrity
Selenium Suppresses testicular toxicity and modulate DNA repair.

17. 8. Dilemma in managing severe male
factor
Collection Method Masturbation Total Motility 30%
Abstinence 4 days Progressive
Motility
16%
Collection Complete Non progressive
Motility
14%
Volume 1.5 ml Immotile 70%
Viscosity Normal Motile Sperm
Count
0.54 million
Liquefaction Time 45 minutes Normal
Morphology
1%
pH 7.6 Vitality 34%
Sperm
Concentration
1.2 million/ ml Round cells Nil

18. What next?
• Straightaway donor sperm IUI
• Antioxidants for 3 months and repeat test
• Investigate in details√
• History
• Physical Examination
• Hormone Assay
• Imaging
• Genetic Tests

19. Severe Male Factor is NOT ONLY a fertility
problem
• Diabetes
• Cardiovascular diseases
• Lymphoma, extragonadal
germ cell tumours, peritoneal
cancers
• Repeated hospitalization
• Increased mortality
• Testicular Cancer
Choy and Eisenberg, 2020; Bungum et
al., 2018; Eisenberg et al., 2013;
Jungwirth et al., 2018; Hotaling and
Walsh, 2009
Self-Testicular
Examination
•Atrophic Testes
•H/O undescended testicles
•Testicular microcalcification
(post-mumps or others)

20. Sperm abnormality may be the first
symptom of testicular cancer
• 31 yrs
• Came for IUI (D)
• Malignant teratoma-
treated by orchidectomy
and chemotherapy

21. Severe Male Factor- if not left
untreated ???
• Overall, 16 (24.6%) of 65
patients with severe
oligozoospermia developed
azoospermia.
• Two (3.1%)patients with
moderate oligozoospermia
developed azoospermia
• None of the patients with
mild oligozoospermia
developed azoospermia.

22. Revisiting History
• Age
• Duration of subfertility
• Previous pregnancy- can have secondary male
subfertility
• Lifestyle
• Occupation- Driving, IT, chemical industry (heavy
metal, pesticides)
• Medical history- Diabetes, Mumps, Cancer
• Surgical history- Hernia, Orchidopexy, Pituitary
Surgery, Bladder neck surgery
• Drug history- Sulphasalazine, Finesteride,
cytotoxic drugs, steroids
• Sexual history- Low libido, ED

23. Darren et al. Male infertility – The other side of the equation . 2017

24. Varicocele- always CLINICAL Diagnosis
(EUA, 2018)
• Subclinical: not palpable or
visible, but can be shown by
special tests (Doppler
ultrasound).
• Grade 1: palpable during
Valsava manoeuvre, but not
otherwise.
• Grade 2: palpable at rest, but
not visible.
• Grade 3: visible at rest

25. Surgery for Varicocele
(EUA, 2018)
• Grade 3 varicocele
• Ipsilateral testicular atrophy
• Pain
• Abnormal semen parameters
• No other fertility factors in the couple

26. In couples seeking fertility with ART, varicocele repair
• may offer improvement in semen parameters
• may decrease level of ART needed

27. Do you recommend varicocelectomy here?
• 35 yr- Azoospermia
• Lt undescended testis
• 19 yr age- Lt orchidopexy
• 21 yr age- left testicular cancer
(mixed germ cell Tx)→
orchidectomy, f/b 3 cycles of
chemotherapy (BPC)
• 33 yr age-Papillary Ca Thyroid→
Total thyroidectomy and neck LN
dissection f/b Radio-iodine. Now
on Eltroxin 150
• FSH 27.14, LH 6.69, Testosterone
336 ng/dl, E2 26.0 pg/ml.
• Female age 35

28. Cryptorchidism in adults
(EUA, 2018)
• In adulthood, a palpable undescended
testis should NOT be removed because it
still produces testosterone.
• Correction of B/L cryptorchidism, even in
adulthood, can lead to sperm production in
previously azoospermic men
• Perform testicular biopsy at the time of
orchidopexy in adult- to detect germ cell
neoplasia in situ

29. Cryptorchidism- bilateral in adults?
• 31 yr
• Azoospermia
• USG- Rt testis in lower abdomen, Lt testis in inguinal canal
• FSH 13.40. LH 6.87. Testo 6.89. E2 <10.

30. B/L cryoptorchidism in ADULTS!!!

31. Congenital bilateral absence of vas
deferens (CBAVD)
• CLINICAL diagnosis
• Semen- Volume <1.5 ml, pH <7.0, fructose negative
• TRUS
• Renal ultrasound
• Cystic fibrosis mutation (CFTR) testing (EUA, 2018; ASRM,2020)
• Partner testing
• Indian prevalence- 1:10,000- 1:40,000 (Kapoor et al., 2006;
Prasad et al., 2010)

32. CBAVD, TRUS, CFTR mutation
• TRUS-
• B/L agenesis of seminal vesicles
• Male partner- CFTR carrier
• Female partner- CFTR carrier

33. CBAVD is NOT uncommon
• CFTR negative • CFTR carrier
• Wife- normal
• CFTR refused
• CFTR carrier
• Wife- normal
• CFTR negative

34. Other congenital anomalies
Transverse testicular ectopia (TTE), or
crossed testicular ectopia (CTE)
Subcoronal Hypospadias

35. Importance of history and examination
Rt sided orchidopexy during appendicectomy at 18 yr
Subsequently Rt testis atrophied
Lt side operated after 6 months, could not be brought to scrotum,
biopsied, seen by MRI (not seen in USG)

36. Learning from mistake
• Secondary anejaculation and ED
• B/L abdominal testes
• 3 yr age- attempted Rt orchidopexy but
failed
• 13 yr age- Left sided orchidopexy
attempted but partial success.
• 32 yr age- B/L orchidectomy after
failed orchidopexy attempt
• 35 yr
• Left cryptorchidism (abdominal testis)
• Lt orchidectomy at 12 yr
• Testicular prosthesis
• Azoospermia

37. Imaging
Scrotal ultrasound
1. Clinically abnormal findings-
mass/ atrophy
2. Tight scrotum (Cremasteric
reflex)
3. Obese patient
• NOT for Varicocele detection
• NOT the replacement for
clinical examination
(EUA, 2018; ASRM, 2020)
Transrectal ultrasound (TRUS)
1. Low volume and pH of semen
2. Ejaculatory disorders
(EUA, 2018; ASRM, 2020)

38. “Abnormal” scrotal ultrasound
Epididymal cyst Microlithiasis

39. Hormone Evaluation
Sperm concentration <10 million/ml
Sexual dysfunction
Clinically suspected endocrinopathy
FSH, LH, testosterone, HbA1C
FSH, LH low
Testosterone low
Hypogonadotropic hypodonadism
Pituitary imaging
FSH high LH high
Testosterone low
Global testicular failure
LH normal
Testosterone normal
Spermatogenesis defect
LH high
Testosterone normal
Sublinical hypogonadism
PRL, TSH If clinically suspected

40. Stories of Hypo/Hypo
• 29 yr, Azoospermia
• Delayed puberty
• Anosmia
• MRI- B/L olfactory bulb absent
• Genetic tests advised, Lost to F/U.
•32 yr, Azoospermia
•sudden loss of body hair, low libido
•Nonfunctioning Pituitary macroadenoma →
Endoscopic surgery H/P Lymphocytic hypophysitis
•Started hCG f/b hMG by endocrinologist
•Sperm conc 1-2/ hpf
• 30 yr, Azoospermia
• 17 yr age, sudden testicular atrophy
• B/L testes 6 cc each

41. Role Of Medical Therapy
(EUA, 2018, ASRM, 2020)
Hypogonadotropic
hypodonadism
•hCG 2000-5000 IU 3 times a week
•If hCG alone cannot restore spermatogenesis, FSH is
added 75-150 IU 3 times a week
•Serum testosterone and semen analysis every 1–2 months
•Usual time to recover 6 – 12 months (may take 24
months)
•Natural conception vs ART?
Idiopathic Male
infertility
CC
Tamoxifen
Letrozole
hCG
All empirical
Evidences?
Testosterone
supplementation
Strongly CONTRAINDICATED
Feedback inhibition on FSH, LH→ secondary
hypogonadism
Aromatase
inhibitors (Letrozole,
Anastrozole)
If T:E2 ratio <10 (T- ng/dl, E2- pg/ml)

42. Antioxidants in severe male
factor?

44. Smits RM, Mackenzie-Proctor R, Yazdani A, Stankiewicz MT, Jordan V, Showell MG. Antioxidants for
male subfertility. Cochrane Database Syst Rev. 2019;3(3):CD007411. Published 2019 Mar 14.
• may improve live birth rates
• clinical pregnancy rates may also increase.
• Overall, there is no evidence of increased risk of
miscarriage, however antioxidants may give more
mild gastrointestinal upsets
• Subfertilte couples should be advised that overall, the
current evidence is inconclusive.

45. • In some studies, AS was found to be beneficial in
reversing OS-related sperm dysfunction and improving
pregnancy rates.
• The most commonly used preparations, either as
monotherapy or in combination as multi-AS, were: vitamin
E (400 mg), carnitines (500–1000 mg), vitamin C (500–
1000 mg), CoQ10 (100–300 mg), NAC (600 mg), zinc (25–
400 mg), folic acid (0.5 mg), selenium (200 mg), and
lycopene (6–8 mg).
• Still debatable due to the heterogeneity in study designs
and the multifactorial genesis of infertility.

46. TMSC PR/CYCLE
 10–20 million 18.29%
 5–10 million 5.63%
 <5million 2.7%
Guven et al, 2008;Abdelkader & Yeh, 2009
Hamilton etral., 2015
Criteria TMSC Treatment
Pre wash TMSC > 5 million IUI
Pre wash TMSC 1 - 5 million IVF
Pre wash TMSC <1 million ICSI
Male factor- IUI, IVF or ICSI?

47. TMSC <5 mil/ml and IUI
• Counsel before IUI
1. Double Ejaculate Kucuc et al., 2004; Oritz et al., 2016
2. “Trial IUI”- Post wash- IMSC Ombelet et al., 2014
3. IMSC >1 mil/ml → Further IUI
4. IMSC <1 mil/ml → ICSI

48. ICSI with Ejaculate vs Testicular sperms

49. 9. Azoospermia- what to do?
• Straightaway donor sperm IUI
• Testicular FNAC

50. Surgical Sperm Retrieval (SSR) in
Azoospermia (OA>NOA)

51. Predictors of sperm retrieval?
• FSH
• Testicular Size
• LH, Testosterone
• BMI
• AMH- semen, serum
• Inhibin B- semen, serum
• Age
• Ultrasound parameters
• No reliable positive prognostic factors
guarantee sperm recovery for patients
with NOA
• The ONLY negative prognostic
factor is the presence of AZFa
and AZFb microdeletions.

52. Problems with indiscriminate FNAC
Case 1-
• Repeat test showed SC 3-4
sperms/ hpf
Case 2-
• Repeat semen analysis- 58
mil/ml, TM 48%
Case 3-
• Azoospermia- one occasion
• FNAC- B/L maturation
arrest
• FSH 0.22, LH 0.34, Testo
549
• Pituitary MRI- normal
• Started hMG
• After 6 months- 2 mil/ml

53. Problems with indiscriminate FNAC
• LH 30.10, FSH 43.70, E2 38.48, Testo 432

54. Problems with indiscriminate FNAC
• B/L testes- 6 cc each
• FNAC- B/L
maturation arrest
• FSH 37.2, LH 24.4,
Testo 245.53, E2 37,
ratio <10
• Not keen for IVF-ICSI

55. Problems with indiscriminate FNAC
• 37 yr
• Inguinal hernia operated
Rt sided- 2 yr ago and
Lt sided15 yr ago
• B/L testes- 18 cc each
• FSH 5.96. LH 4.74.
Testo 212. Estradiol
14.22.
• FNAC- Sertoli Cell
Only

56. FNAC- role?
• Isolated foci of
spermatogenesis
ASRM, 2020
• Consider TESA in
indeterminate cases- NOT
NECESSARY
FSH >7.6 <7.6
Testicular long axis (cm) <4.6 >4.6
89% chance of NOA 96% chance of OA

57. If previous FNAC was done
(Schwarzer, 2013)
Diagnosis Chance of sperm retrieval
(Micro-TESE >> TESE)
Sertoli-cell-only syndrome
(Germ cell hypoplasia)
32%
Maturation arrest 66.7%
Hypospermatogenesis 100%
Tuberous sclerosis 33.3%
Mixed atrophy 95.2%

58. Genetic testing
• Sperm
concentration <5
million/ml
• Azoospermia
• Testicular atrophy
• Elevated FSH
• Karyotyping
• Y chromosome
Microdeletion (YCM)
• CFTR testing in
CBAVD

59. In presence of genetic defect
• Sperm Aneuploidy testing by FISH
• PGT-SR (previously- PGD)
• Prenatal invasive testing (EUA, 2018; ASRM,
2020)

60. Klinefelter’s Syndrome

61. Translocation
45, XY rob (14, 21), (q10, q10) 46,XY,t(3;6)(p21;p23)
Robertsonian Translocation Reciprocal Translocation

62. Alternative- Prenatal testing
46,XY22ps+
• Oligospermia →Azoospermia
• YCM normal
• Spermes obtained by TESA
Amniocentesis
• Normal Karyo & CMA
• Live born by 34/40

63. Genetic Abnormalities ≠ Advanced intervention
46,XY,15ps+
46,X,Y,q+
46,X,inv(Y)(p11.q11)
46,X,inv(Y)(p11.2q11.2)

64. Look for type of YCM

65. Y chromosome Microdeletion (AZF)

66. • 39 yr
• FSH 25.4, LH 12.6, Estradiol 14, Testo 61.
Sometimes nothing can be done

67. Medical Therapy in Idiopathic
Azoospermia
• To improve the chance
of sperm retrieval
(Alkandari and Zini, 2021; Kumar,
2021; Holtermann et al., 2022).
• Sometimes, can lead to
appearance of sperms in
the ejaculate (Alkandari and
Zini, 2021; Kumar, 2021).
• hCG
• FSH
• CC
• Tamoxifen
• Letrozole
• Antioxidants??
(Agarwal A, Majzoub A, 2017)

68. Disclaimer
• Written consent from all the patients

69. Semen analysis
Mild problem Severe problem
1. Lifestyle changes
2. Antioxidants
1. History
2. Physical Exam
3. Repeat semen ASAP
4. Hormonal evaluation
Low FSH, LH
Pituitary imaging
hCG/ FSH
supplementation
High FSH
Karyotype
YCM
ICSI
TESA for azoospermia
Donor sperms
Repeat semen after 3 months
Normal hormones
Cannot afford ICSI
No sperms in TESA
S/O obstruction
Idiopathic
Obstructive Azoo
TRUS
CFTR test for CBAVD
Pituitary failure Testicular failure

70. Semen analysis
Mild problem Severe problem
1. Lifestyle changes
2. Antioxidants
1. History
2. Physical Exam
3. Repeat semen ASAP
4. Hormonal evaluation
Low FSH, LH
Pituitary imaging
hCG/ FSH
supplementation
High FSH
Karyotype
YCM
ICSI
TESA for azoospermia
Donor sperms
Repeat semen after 3 months
Normal hormones
Cannot afford ICSI
No sperms in TESA
S/O obstruction
Idiopathic
Obstructive Azoo
TRUS
CFTR test for CBAVD
Pituitary failure Testicular failure

71. Semen analysis
Mild problem Severe problem
1. Lifestyle changes
2. Antioxidants
1. History
2. Physical Exam
3. Repeat semen ASAP
4. Hormonal evaluation
Low FSH, LH
Pituitary imaging
hCG/ FSH
supplementation
High FSH
Karyotype
YCM
ICSI
TESA for azoospermia
Donor sperms
Repeat semen after 3 months
Normal hormones
Cannot afford ICSI
No sperms in TESA
S/O obstruction
Idiopathic
Obstructive Azoo
TRUS
CFTR test for CBAVD
Pituitary failure Testicular failure

72. Semen analysis
Mild problem Severe problem
1. Lifestyle changes
2. Antioxidants
1. History
2. Physical Exam
3. Repeat semen ASAP
4. Hormonal evaluation
Low FSH, LH
Pituitary imaging
hCG/ FSH
supplementation
High FSH
Karyotype
YCM
ICSI
TESA for azoospermia
Donor sperms
Repeat semen after 3 months
Normal hormones
Cannot afford ICSI
No sperms in TESA
S/O obstruction
Idiopathic
Obstructive Azoo
TRUS
CFTR test for CBAVD
Pituitary failure Testicular failure

73. Semen analysis
Mild problem Severe problem
1. Lifestyle changes
2. Antioxidants
1. History
2. Physical Exam
3. Repeat semen ASAP
4. Hormonal evaluation
Low FSH, LH
Pituitary imaging
hCG/ FSH
supplementation
High FSH
Karyotype
YCM
ICSI
TESA for azoospermia
Donor sperms
Repeat semen after 3 months
Normal hormones
Cannot afford ICSI
No sperms in TESA
S/O obstruction
Idiopathic
Obstructive Azoo
TRUS
CFTR test for CBAVD
Pituitary failure Testicular failure

74. Non-targeted investigations ?
• Delayed puberty
• Testo 100.86. FSH 28.33. LH 13.65. E2 27.83
• Testosterone injection started at puberty - sec sex charac, voice, genital size
improved
• MRI pitutary microadenoma
• GH, TSH, Cortisol, PRL, - all normal

75. Targeted female investigations
• If no risk factors for
tubal block- 3 cycles of
IUI, then tubal patency
test
• If risk factors- tubal
patency first
•Ovaries
•Tubes- IUI or IVF/ICSI?

76. 1. Meticulous semen analysis in a standard laboratory
2. Physical examination and rational investigations
3. Avoid non-evidence based drugs for long time
4. Antioxidants- May be useful in mild problem
5. Antioxidants- Not reliable in severe problem
6. Donor sperm is NOT the only solution
7. IUI or IVF/ICSI- depends on the overall assessment
Take Home Messages

77. Treatment burden for MALE
infertility falls on FEMALE