MALE INFERTILITY

DR. DICKY FAIZAL IRNANDI, SP.AND

Nama : Dicky Faizal Irnandi
TTL : Madiun, April 1987
Jenis Kelamin : Laki-laki
Status : Menikah 1-1
Agama : Islam
Telp : 0852-30-0852-32
0838-345-555-05 (WA)
Email : dr.dicky.faizal@gmail.com
Riwayat Pendidikan :

Tanjung Balai Asahan Sumut  SDN 132407

Blitar  SLTPN 1
Malang  SMUN 3
Malang  Pend. Dokter FKUB 2005
Surabaya  Andrologi FKUA 2013

Perubahan akan bermakna bila perubahan itu

bermanfaat bagi dunia di sekitar kita
TUJUAN PEMBELAJARAN

Memahami langkah diagnosis fertilitas

Mampu menginterpretasikan dan menjelaskan analisis semen

Mampu menjelaskan manajemen terapi infertilitas

ANDROLOGY

The central topics of andrology are:

Andrology is defined as the branches (1) Infertility
of science and medicine dealing with
reproductive functions of the male (2) Hypogonadism
under physiological and pathological (3) male contraception
conditions (Statutes of the European
Academy of Andrology) (4) erectile dysfunction, and
(5) male senescence
SCOPE OF ANDROLOGY
PROBLEMS…

Women  gynaecologist

Men
• Family physicians
• (His wife’s) gynaecologist
• Urologist
• Endocrinologist
 THEN…
From the point of view of the afflicted
couple, a specialized interdisciplinary field
of reproductive medicine would seem to
offer a solution
The World Health Organization (WHO)
considers the couple as a single entity in its
definition of “reproductive health,” which it
defines as freedom from disease and
disturbances of reproductive functions,
both in the male and in the female
FRAMEWORK
Gynaecology

Center for
reproductive
medicine.

Andrology
 • The capability to • The probability of • A couple fails to
conceive or induce producing a live induce a pregnancy
a pregnancy birth arising from a within 1 year of
given menstrual regular unprotected
cycle intercourse

Fertility Fecundity Infertility

• No pregnancy at all • No further

has been achieved pregnancies have
occurred

THE TERMS… Primary Secondary

infertility infertility
INFERTILITY

Failure to conceive, 1 year unprotected intercourse

• Primer
• Sekunder
• Secara umum, ±15% pada populasi

Kontribusi partner

• Istri  40%
• suami + istri  25%
• Suami  25%
• Unexplained  10%
CAUSES OF MALE INFERTILITY

• Varicocele
Major causes
• Infection
(40%)
• Immunologic

• Endocrine
• Iatrogenic
Minor causes
• Systemic
(20%)
• Congenital
• Erectile dysfunction
Idiopathic (40%)
KAPAN KITA PERLU MELAKUKAN PEMERIKSAAN?

Infertilitas

• Primer
• Sekunder

Sebelum satu tahun, bila:

• Risiko tinggi infertilitas laki-laki  riwayat criptorchidisimus

• Usia istri > 35 tahun
• Cek potensi fertilitas suami
LANGKAH PEMERIKSAAN

Pemeriksaan Analisis Pemeriksaan Pemeriksaan

Anamnesis
fisik semen laboratorium tambahan
 ANAMNESIS

The patient medical history is used to identify risk factors and

behavior pattern that could have a significant impact on male
infertility
• Fertility History
• Investigation/treatment of infertility
• History of disease with possible adverse effect on fertility
• Pathology possibly causing testicular damage
• Other factors with possible influence of fertility
• Sexual Dysfunction
HISTORY OF DISEASE WITH POSSIBLE ADVERSE EFFECT
ON FERTILITY
PATHOLOGY POSSIBLY CAUSING TESTICULAR DAMAGE

Mumps, Orchitis Testicular injury Testicular Torsion

History of
Testicular maldescent
varicocele/varicocelectomy
 OTHER FACTORS WITH POSSIBLE ADVERSE EFFECT ON
FERTILITY
Environmental and/or occupational factors
• Heat
• Toxic factors (Pb)
• Others
Excess consumption of alcohol

Drug abuse

Tobacco smoking

Genetic abnormalities

Immunological factor (antisperm antibody)

 SEXUAL DYSFUNCTION
Average frequency of intercourse per month

1. Desire

2. Arousal

3. Erection

4. Ejaculation :
• An ejaculation
• Extra vaginal ejaculation
• Hypospadias
• Retrograde ejaculation
GENERAL EXAMINATION

Gynaecomastia Arm span

Obesity Virilization
PHYSICAL EXAMINATIONS

UG examination

• Penis
• Testis
• Epididymis
• Vas defferens
• Scrotal swelling
• Varicocele
• Inguinal
• Prostate gland & seminal vesicles
SEMEN ANALYSIS

Functional test of Artificial

Investigation of
male reproductive insemination
male infertility
system services

Male Surveillance of
contraceptive changing human Forensic medicine
trials fertility
SEMEN…

• Count, • Fluid (zinc, citric

morphology, acid, acid
vitality, motility phosphatase,
Prostaglandins,
fructose)
Testicular Activity and
functions & Tract production of
patency accessory glands
SEMEN EVALUATION (ROUTINE ANALYSES)
MACROSCOPIC MICROSCOPIC

• Coagulum • Aglutination
• Liquefactions • Sperm Density
• Color • Sperm Count
• Volume • Sperm Motility
• Smell • Sperm Viability/Vitality
• Viskositas • Sperm Morphology
• pH • Leukocytes count
• Round cells counts
• Epitel, crystals and other found on
specimen
SEMEN EVALUATION (ADDITIONAL TESTS)

Testing for antibody coating of spermatozoa

• Mixed antiglobulin reaction (MAR) test

Interactions between spermatozoa and cervical mucous

• In-vivo post coital test

Biochemical analyses of assessor sex organ function

• Measurement of Zinc, Fructose, Neutral alpha-glucosidase, in Seminal plasma

Computer Aided Sperm Analyses (CASA)

REFERENCE LIMITS FOR SEMEN
CHARACTERISTICS
SPERMATOZOA
MORPHOLOGY

IF > 50% AbN =

TERATOZOOSPERMIA
SEMEN ANALYSIS INTERPRETATION
CONCERN OF SEMEN ANALYSIS
 HORMON ASSAY

Indications:
• Sperm concentration <5 million/mL
• Impaired sexual function
• Sugesttivespecific endocrinopathy
Hormon Assay
• FSH : Azoospermia/oligozoospermia
• Testosteron: Hypoandrogenism& sexual dysfunction
• Prolactin: sexual dysfuction
• LH: not routine
• Estradiol: Gynaecomastia
GENETIC ANALYSIS

• Azoospermia: Non-obstructif azoospermia(NOA) &

Indication: CBAVD
• Severe Oligozoospermia (Extreme Oligozoospermia)
• Y Chromosom (microdeletion/RBM)  AZFa, AZFb,
AZFc(550 bp), DAZ(400 bp)  PCR
• Chromosom karyotype  Sex chromosom and
Genetic Testing autosom
• Cystic fibrosis gene mutations CFTR gene → ♂
CBAVD & ♀
 ADDITIONAL TECHNICAL INVESTIGATION
Scrotal thermography  Subclinical Varicocele

Doppler thermography  Subclinical Varicocele

USG
• Trans Rectal USG (TRUS)  Azoospermia: ejaculatory duct obstructive
• Scrotal USG  Scrotal examination difficult testiscular mass
Imaging Hypothalamo-Pituitary region
• Hyperprolactinemia  tumor
• Gonadotrophin deficiency  FSH ↓↓
Testicular Biopsi
• Indication: tumor or Ca In Situ (CIS)
MANAGEMENT OF MALE INFERTILITY

Conventional Management:

• Medical
• Surgical
• Psychological

ART (Assisted Reproductive Technology)

 CONVENTIONAL MANAGEMENT (MEDICAL)
Causal (base on pathophisiology) :
• Sexual & ejaculatory dysfunction:
Treatment Erectile Dysfunction
and underlying disease
• Endocrine cause: Hormon FSH
(hMG)), HCG (LH analog), GnRH
• Systemic cause
• MAGI: Antibiotic 10-14 days
• Immunological cause
Empirical (base on hypothetical) :
• Stimulation of spermatogenesis
• Improvement of epididymal
function
• Improvement of sperm transport
• Stimulation of sperm
metabolism: Antioksidant, Co
EnzymQ
CONVENTIONAL MANAGEMENT (SURGICAL)

Microsurgical
reconstruction of the Varicocelectomy:
Vasovasostomy:
vas/epididymis (TURED) in Varicocele with abnormal
vasectomy
case of ejaculatory/duct semen parameters
obstruction
CONVENTIONAL MANAGEMENT (PSYCHOLOGICAL)

Time of
Lifestyle Obesity
coitus

Environment Female
Underwear
(polutan) Factor
ASSISTED REPRODUCTIVE TECHNOLOGY (ART)

Intra- • Intra Uterine Insemination (IUI)

• Gamete Intra Fallopian Transfer (GIFT)
corporeal
Extra- • In-vitro Fertilization (IVF) = conventional
• Intra-cytoplasmic Sperm Injection (ICSI)
corporeal
DAFTAR PUSTAKA

• Nieschlag, E. and Behre, H. eds., 2013. Andrology: Male Reproductive Health and Dysfunction. Springer
Science & Business Media.
• World Health Organization, 2010. WHO laboratory manual for the examination and processing of
human semen.