SPERM DNA FRAGMENTATION Clinical threshold value of DNA Fragmentation Index is 30%, that means 70% are normal. Has role in deciding to go for ICSI in patients who have high fragmentation DIAGNOSTIC CATEGORIES After evaluation we should be able to segregate the patients into different categories depending on cause and what treatment we can offer. Broadly we have can segregate into categories: Medical/ Surgical treatment Will help May Help or improve chances of success in ART Will not help MEDICAL AND SURGICAL MANAGEMENT OF MALE INFERTILITY MEDICAL THERAPYSPECIFIC Endocrine Disorders Ejaculatory Disorders Genital Tract Infections EMPIRICAL THERAPY Treatments for Idiopathic Male infertility AROMATASE INHIBITORS Empirical antioxidant treatment Vitamin C and E Carotenoids and Lycopene Folate Carnitine and N-acetylcysteine Selenium Clomiphene citrate and aromatase inhibitors Lifestyle complimentary treatments Environmental exposure prevention Obesity prevention Coital Lubricants Eastern approaches-Acupuncture Pyospermia: evaluate the patient for sexually transmitted diseases, penile discharge, prostatitis, or epididymitis Coital therapy Immunologic infertility Corticosteroid suppression, sperm washing, IUI, IVF, and ICSI. COMPLIMENTARY TREATMENTS Lifestyle complimentary treatments Environmental exposure prevention Obesity prevention Coital Lubricants Eastern approaches-Acupuncture Nonsurgical treatments Pyospermia: evaluate the patient for sexually transmitted diseases, penile discharge, prostatitis, or epididymitis Coital therapy Immunologic infertility Corticosteroid suppression, sperm washing, IUI, IVF, and ICSI. Ejaculatory Duct obstruction PESA-Percutaneous Epididymal Sperm Aspiration Micro-TESE : Testicular Sperm Extraction (involves a small incision and snipping off some tissue from inside the testicle. Micro TESE- Surgical Approach MANAGEMENT The management of infertility should take place in a dedicated infertility clinic staffed by an appropriately trained professional team of Andrologists with facilities for investigating and managing problems in both partners. SCI International Hospital M-4, Greater Kailash-1, New Delhi-110048 www.scihospital.com

1. Dr. Vishal Dutt Gour
MBBS, MS, M.Ch (Urology)
Urologist and Male Infertility Specialist
SCI International Hospital, New Delhi
EVALUATION AND DIAGNOSIS
OF
MALE INFERTILITY

2. Male Infertility is common and a widespread
problem in which a male is unable to make a
fertile female pregnant even after unprotected
intercourse for a year.
Incidence rising over last few decades:
 20% of infertile couples-Male infertility is the
sole cause .
 40-50% of cases- Male infertility is
contributing factor.

3.  Sexual and Reproductive History: Timing of
intercourse
 Genitourinary infections: Prostatitis,
Epididymitis, Orchitis
 Childhood illness and development history:
Delayed Puberty, Crytorchidism,
Gynecomastia
 Past Surgical History: Bladder Neck surgery,
Hernia, Hydrocele, Testicular trauma/
torsion

4.  Systemic Medical illnesses: DM,
Multiple Sclerosis, Post RT – CT,
Febrile illness.
 Medications, recreational drugs and
gonadotoxin exposure:
Anabolic Steriods, Nitrofurantoin,
Chronic Alcohol and Drug Abuse,
Smoking
 Family History

5. General Examination
 Eunoichoid appearance, Secondary Sexual
Characters, gynecomastia
Genital Examination
 Testis-size and consistency
 Epididymis rule out past evidence of
infection, turgidity in obstruction
 Varicocle
 Vas deferens look for places of atrophy,
CBAVD

6. Semen Analysis:
 Cornerstone of Lab evaluation of the
infertile male.
 Two samples during different
spermatogenic cycles.
 Semen Analysis with history and
physical examination guides us for
future evaluation planning.

8. LOW
EJACULATE
VOLUME
AZOOSPERMIA
OLIGO
ASTHENOSPERMIA
NORMAL BUT
INFERTILE
ASTHENOSPERMIA

9. A. Medications
B. Retroperitoneal or bladder neck injury
C. Ejaculatory duct obstruction
D. Diabetes mellitus
E. Spinal cord injury
F. Psychologic disturbances
G. Idiopathic
H. Incomplete collection

10. A. Hypogonadotropic hypogonadism
1. kallmann’s syndrome
2. pituitary tumor
B. Spermatogenic abnormalities
1. chromosomal abnormalities
2. Y chromosome microdeletions
3. Gonadotoxins
4. Varicocele
5. Viral orchitis
6. Torsion
7. Idiopathic
C. Ductal obstruction
1. Congenital bilateral absence of the vas deferens
2. Vasal obstruction
3. Epididymal obstruction
4. Ejaculatory duct obstruction

11. A. Varicocele
B. Cryptorchidism
C. Idiopathic
D. Drugs, heat, toxins
E. Systemic infection
F. Endocrinopathy

12. A. Gynaecologic abnormality
B. Abnormal coital habits
C. Acrosomal defects
D. Antisperm antibodies
E. Unexplained

13. A. Spermatozoal structural defects
B. Prolonged abstinence
C. Idiopathic
D. Genital tract infection
E. Antisperm antibodies
F. Varicocele
G. Partial obstruction

14.  Identify endocrinologic disorders that
affect male reproduction.
 Gain prognostic information.
 Done for severe oligospermia/
azoospermia and when you have
clinical doubts.

15. CLINICAL
STATUS
FSH LH TESTOSTERONE
NORMAL OR
OBSTRUCTION
N N N
ISOLATED
SPERMATOGENI
C FAILURE
N N
TESTICULAR
FAILURE
N or
HYPOGONADOT
ROPIC
HYPOGONADISM

16.  Azoospermic patients 10-15%,
oligospermic 4-5% and 1% of
normospermic show abnormalities
 Y chromosome microdeletion and
karyotyping.
 Deletions in the AZFc are most
frequently identified while AZF a &b
have poor prognosis in sperm
retrieval.

17. Scrotal Ultrasonography: Mainly to
confirm varicocele
TRUS: Azoospermic patient with
suspicion of Ejaculatory Duct
Obstruction
Abdominal Ultrasonography in cases
with absent vas

18.  Clinical threshold value of DNA
Fragmentation Index is 30%, that
means 70% are normal.
 Has role in deciding to go for ICSI in
patients who have high fragmentation

19.  The purpose of history, physical
examination, laboratory testing,
imaging, special tests help place the
patient in different diagnostic
classifications and plan further
treatment.
 Large no. of patients fall into the
idiopathic category.

20. After evaluation we should be able to
segregate the patients into different
categories depending on cause and what
treatment we can offer.
Broadly we have can segregate into categories:
Medical/ Surgical treatment
 Will help
 May Help or improve chances of success in
ART
 Will not help

22. SPECIFIC
THERAPY
EMPIRICAL
THERAPY
MEDICAL THERAPY
Endocrine
Disorders
Ejaculatory
Disorders
Treatments
for Idiopathic
Male infertility
Genital Tract
Infections
ANTIOXIDANTS AROMATASE
INHIBITORS

24. Empirical antioxidant treatment
 Vitamin C and E
 Carotenoids and Lycopene
 Folate
 Carnitine and N-acetylcysteine
 Selenium
 Clomiphene citrate and aromatase
inhibitors

25.  Lifestyle complimentary
treatments
 Environmental exposure
prevention
 Obesity prevention
 Coital Lubricants
 Eastern approaches-Acupuncture

26.  Pyospermia: evaluate the patient
for sexually transmitted diseases,
penile discharge, prostatitis, or
epididymitis
 Coital therapy
 Immunologic infertility
 Corticosteroid suppression, sperm
washing, IUI, IVF, and ICSI.

27. Microsurgical
Varicocelectomy
Transurethral resection of
the ejaculatory ducts
Surgical sperm retrieval Reconstructive surgery
Obstructive-PESA
Non Obstructive-Micro
TESE
VEA-Vasoepididymostomy
VVA- Vasovasostomy

28. Higher success rate- Disappearance of
Varicocele.
Lower complication rate- No hydrocele
formation.

30. Incision

31. Transurethral resection of the ejaculatory ducts

33. Micro TESE-
Surgical Approach
Micro-TESE : Testicular Sperm Extraction (involves a
small incision and snipping off some tissue from inside
the testicle.

34. VEA-Vasoepididymostomy

35.  VVA-Vasovasostomy

36. The management of infertility should take
place in a dedicated infertility clinic
staffed by an appropriately trained
professional team of Andrologists with
facilities for investigating and managing
problems in both partners.

37. SCI International Hospital
M-4, Greater Kailash-1, New Delhi-110048
www.scihospital.com