Complex Infertile Cases approach and management. Dr. Anmar Nassir, FRCS(C) Canadian board in General Urology Fellowship in Andrology (U of Ottawa) Fellowship in EndoUrology and Laparoscopy (McMaster Univ) Assisstent Prof Umm Al-Qura
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Dr. Anmar Nassir, FRCS(C)
Canadian board in General Urology
Fellowship in Andrology (U of Ottawa)
Fellowship in EndoUrology and Laparoscopy (McMaster Univ)
Assisstent Prof Umm Al-Qura
Consultant Urology King Khalid National Guard Hospital
The hypothalamo-pituitary-gonadal axis provides pulsatile secretion of GnRH
The seminiferous tubules have a combined length of approximately 250 meters.
The scrotal temperature is is 2°C to 4°C below rectal temperature due to counter-current mechanism
A, The pattern shown by spermatozoa taken from proximal regions of the epididymis is characterized by a high-amplitude, low-frequency beat producing little forward movement.
B, In contrast, tail movement in a large proportion of spermatozoa from the cauda epididymis is characterized by low-amplitude, rapid beats that result in forward progression.
▪ The sperm tail has outer dense fibers, rich in disulfide bonds,
Sperm fertilizing ability was assessed using zona pellucida-free hamster eggs and by changes in motility, which increases in the distal regions of the human epididymis.
The process of spermatogenesis and spermiogenesis takes approximately 64 days in humans and results in a haploid germ cell that acquires natural ability to fertilize oocytes during epididymal transport.
(The main bulk of the ejaculate):
Seminal vesicles 1.5 to 2.0 mL.
Prostate 0.5 mL,
Cowper's glands 0.1 to 0.2 mL,
Before the ejaculation of the major portion of the ejaculate, a small amount of fluid from the glands of Littre and the bulbourethral glands is secreted.
(pregnancy rate of 1% to 3% per month )
A basic, simple, cost-effective evaluation of both the male and female partners should be initiated at the time of presentation.
Many of the genes that affect male reproduction, including the androgen receptor gene, are located on the X chromosome.
Pregnancy rates in normal fertile couples are 20% to 25% per cycle compared with 1% to 3% in infertile couples.
Abnormalities in the woman are involved in approximately 75% of infertile couples.
Antisperm antibodies: semen or blood
Advanced sperm fertility tests
Most prolactin-secreting tumors in men are macroadenomas (tumors greater than 1 cm)
Patients with small (atrophic) testes have either primary or secondary testicular failure. Serum hormone testing including testosterone , LH, FSH, and prolactin is done to differentiate between the two as well as to identify both functioning and nonfunctioning pituitary tumors. Patients with small testesand FSH concentrations greater than two to three times normal have severe germ cell failure, and the prognosis for natural conception is poor. A testicular biopsy should only be performed in these patients if testicular sperm retrieval combined with IVF is being considered, and this is often performed in conjunction with egg retrieval in the spouse.
Patients with azoospermia due to testicular failure should be offered genetic testing to rule out chromosomal abnormalities such as Klinefelter's syndrome and microdeletions of the Y chromosome. Patients with secondary testicular failure may be treated with hormone therapy, whereas primary testicular failure is almost always irreversible.
Complete absence of sperm motility or cases with motilities less than 5% to 10% should be evaluated by a sperm viability assay. Necrospermia exists when the nonmotile sperm are not viable. The finding of a high fraction of viable sperm in the presence of low or absent sperm motility suggests an ultrastructural abnormality, such as that found in primary ciliary dyskinesia (PCD, formerly called immotile cilia syndrome) and Kartagener's syndrome (PCD associated with situs inversus).
.A, Normal vasogram; note contrast agent in bladder.
B, Vasogram depicting left ejaculatory duct obstruction.
C, Normal seminal vesiculogram, again note contrast agent in bladder.
D, Seminal vesiculogram demonstrates complete left ejaculatory duct obstruction.
1- Structural chromosomal disorder
2-Syndromes affecting the HPGAxis.
3- Syndromes affecting the androgen biosynthesis and /or action.
4-Syndromes affecting function of the ductal system
5- Syndromes affecting sperm transportation.
6- Syndromes with variable RSAxis effects.
Contain Genes for gonadal Differentiation Into a Testis
Gene Required for Full Spermatogenesis
The majority of Y chromosome microdeletions that have been associated with azoospermia or severe oligospermia occur in one of three nonoverlapping regions of the long arm of the Y chromosome designated as AZFa (proximal), AZFb (middle), and AZFc (distal)
Although most studies have examined patients with idiopathic azoospermia or severe oligospermia, a 7% prevalence of Y chromosome microdeletions has been reported in patients with nonidiopathic severe male factor infertility
There is currently no treatment to improve spermatogenesis in patients with Y chromosome microdeletions; however, these patients are candidates for IVF with ICSI.
Improvement in seminal parameters is demonstrated in approximately 70% of patients after surgical varicocele repair.
During chemotherapy, most patients demonstrate elevations of serum FSH levels that correlate with the development of azoospermia. Those patients in whom FSH levels decline demonstrate a return of spermatogenesis, whereas those in whom FSH levels remain elevated are unlikely to recover
Preexisting spermatogenic defects in the contralateral testis are found in 25% of testicular cancer patients
Semen quality will usually return to baseline within 2 years after radiation therapy for seminoma.
A meta-analysis of all controlled studies for idiopathic male infertility has failed to reveal significant efficacy of currently available treatments
Therefore, we do not recommend GnRH therapy in patients with idiopathic infertility owing to its high cost and lack of efficacy.
These medications are more effective if given for a period of at least 7 to 10 days before planned ejaculation,