Optional Course, Year VI- General

Medicine
Clinical Embriology & Assisted Human
Reproduction

Male Infertility
Course 1

Asist. Univ. Dr. Raluca Tulin

Endocrinology/ Embryology Specialist
Profile: Anatomy
Embryology Department, UMF Carol Davila;

Male Infertility Bad News!!!

1. Couple Infertility
-affects 15% of couples in the
reproductive age
-40% of cases male factor
-40% of cases female factor
-20% of cases both
2. Men and women are equally
affected
3. Infertility affects all ethnicities
and races

Male Infertility Good news!!!

1. Andrologys addressability is
rising.
2. Assisted human reproduction
techniques have substantially
evolved
(offering
solutions
even to the most severe cases
of male infertility).
3. Almost all patients with male
infertility (90%) become able
to conceive their own child
through
assisted
human
reproduction techniques.

Causes of Male Infertility

Unexplained Infertility
- Idiopathic (modified
spermogram)
- Unexplained (normal
spermogram)

Causes of Male Infertility

Medication!!!
Medication
Antibiotics

Erythromycin, Gentamicin,
Neomycin, Nitrofurantoin,
Tetracycline

Antihyperten
sive Drugs

Alfa & Beta blockers, Calcium

blockers, Spironolactone,
Thiazide Diuretics

Chemotherap
y Drugs

Busulfan, Cisplatin,
Vinblastine, etc ...

Hormones

Anabolic steroids,
Antiandrogen, Estrogen,
Progesteron derived drugs,
Testosteron

Psychotherap
y Drugs

Lithium, IMAO, Fenotiazine,

Others

Alopurinol, Cimetidine,
Ciclosporin, Colchicine

Male Infertility Anamnesis +

Physical Examination
Duration of infertility (+ partner age + previous pregancies) ->
The most important factors in obtaining pregnancy
Frequency/Quality of sexual act
-

APP

(high

fever,

acute

infections,

surgery

of

urinary

bladder/prostate, surgery on pelvic or retroperitoneal area,

inguinal hernias surgically corrected, varicocele, prolonged
antibiotics treatment)
-- APP childhood (cryptorchidism, parotitis/orchitis)
- Medication, pesticides, radiations, smoking,
steroids, hot saunas

illicit drugs,

Male Infertility Lab Tests

-SPERMOGRAM (3-5 days of
abstinence)
-Halosperm Test
-Spermoculture + Urine Test
-Endocrynological Tests (FSH +
testosteron)
-Gene Tests (cariotip, microdeletion
cromozom Y AZF a,b,c and gene CFTR
mutation)
-Testicular/ Abdominal ultrasound
(ductus deferens, epididymis/ renal
agenesis).

Take home message !!!!!!!

Male

infertility

can

be

the

first

sign

towards

diagnosing other severe illnesses ( brain neoplasia,

bone

marrow

neoplasia,

endocrinopathies,

genitourinary infections, congenital malformations).

Testicular cancer is 50x more frequent in infertile
men.

Primordial Germinal Cells

Primordial Germinal Cells have
ectodermal origins (S2). Migrate
towards the vitelline yolk sac (S3)
and then intraembryonic, at gonadal
vein level, anteromedial of
mesonephros (L2 kidney) S4-S6.
Further development depends on
presence/absence of SRY gene.

Primordial Germinal Cells

Primordial Germinal Cells

1921 it has been demonstrated that men and

women have different karyotypes (46,XY) and
(46,XX), but only until 1950 it has been
demonstrated that the presence of cr Y stimulates

SRY Gene
Sex-determining Region

Master gene in testicular

formation. Formed of somatic cells of
gonads growth.
Discovered in 1990, Sinclair
SRY, TDF (testis determining
factor) protein, initiates male sex
determination. Mutations of this
gene are responsible for gonadal
dysgenesis (XY women or Swyer
syndrome)
Translocation of short arm of Y
chromosome containing SRY gene
on chromosome X determines
male XX syndrome.

Swyer syndrome
Female XY
Santhi Soundarajan,
1981
Indian Athletewinner
of 11 international
medals
2006- Asia Games
revoked her Silver
Medal she didnt
pass the feminine test

Other genes involved in sex

differentiation
SOX 9 gene (chromosome 17)- regulates gene
transcription of AMH hormone
Gene that codes AMH hormone (chromosome 19)
Gena for Fgf9 (fibroblast growth factor)
seminiferous tubules
WT 1 gene (chromosome 11)
SF 1 gene (chromosome 9)
DAX 1 gene (chromosome X)- antagonises SRY
action its mutation: hypoplasia andrenal
kongenital and hypogonadotropic hypogonadism

Sexual Differentiation in
Males
Genetic sex at fecundation
Gonadal sex (testicles or ovary) S6 ( until
then the embryo is in non-differentiation stage
of gonadal sexualisation bipotential gonads
Genital sex (genital ducts OGE) under the
influence of testosterone secreted starting
S7/s (absence of testosterone: bipotential
gonads ovary) until S8 sexual nondifferentiation of genital ducts stage
S12- genital sex distinguished at ultra-sound

Intrauterine Sexualisation

Spermatogenesis
Starts at puberty (testicular cords become
seminiferous tubules) it never ends
At Contorted seminiferous tubules level
100 mil spz/day (IN COMPARISON WITH 1
OVOCIT/month)
Hormone controlled (GnRH, LH, FSH, Testosterone,
Inhibina) and through temperature control (-2C for
man and -8C at mouse)
Testicule volume - 18cm3 (5*2*3) ! 30g -0.08% of
body weight

At Blue Whale test volume -500Kg

Why have a car if you dont have

roads?

800-1600 seminiferous tubules/testicle

aprox 600m/testicle

Spermatogeneza
Mitosis of the
spermatogonia

16 days

Up to the primary
spermatocytes

First meiosis

24 days

For the division of the

primary spermatocytes
to formsecondary
spermatocytes

Second meiosis

A few hours

Spermiogenesis

24 days

Total

~64 days

For engendering
the spermatids
Up to the
completed sperm cells

A chimps testicle is 10x bigger

than a humans

Spermatogenesis
Adjustment

Male Contraception
Condom
Vasectomy the male vas deferens are severed and then
tied/sealed; reversible but a small portion can still have children
EXP- Analogue nontoxic Adjudin (substance that disrupts sperm
maturity) can be useful in blocking spermatogenesis
EXP -No hormones pill which is capable to induce a dry orgasm.
The man can still orgasm (erection is not affected) but the substance
prevents sperm production. This is administered 4-6 hours before
sexual intercourse and fertility effect is reversible after 12-24 hours.
EXP -Hormonal in study combination
Progesterone (3doses/month) reduces spermatogenesis +
Testosterone (implant changed every 4 months) maintains
potency
Hormonal treatments have side effects: nausea,
headaches, icterus.
Long term, prostate issues may appear.
In addition, disadvantage of long latency period until it
can take effect (3 months).

Coming soon!
2017
Vasalgel injection of a nontoxic polymer in
the deferent duct (local anaesthetic). 10 years
protection. Cancelling the effect is made
through the injection of a polymer dissolvent..

Chemical castration brings

infertility
Clinical use:
Hormone-dependant cancer: prostate, breast
cancer
Prison (pedophiles, sexual abusers)
Used methods:
1. Antiandrogens (cyproterone acetate)
2. Depo-Provera (injection every 3months)
first in 1966 USA.
Side effects:
1. Ginecomastia, osteoporosis, CV illnesses

Testosterone Substitution
NOT IN INFERTILITY
Inactive oral; Preparations IM (esteri)

 Length difference between index finger and ring finger

depends on testosterone level the fetus has be exposed to
If ring finger is longer than index finger, then this shows a
higher testosterone concentration, and if shorter, then this
shows a lower testosterone concentration, which means
that even other features may be more feminine (source:
Live Science)

Clinical use:
IMPOTENCE Vs INFERTILITY
INFERTILITY

IMPOTENCE
(52% 40-70 years)

Reduced capacity of conceiving a

child

Incapacity of having complete

sexual intercourse

Cystic fibrosis

Medication

Mumps in postpuberty

Neurological illness

Drug abuse, smoking

Trauma

Genetically illness (Kalmann,

Klinefelter)

High cholesterol

Toxines

Arterial hypertension

Infections, Testicular Trauma

Diabetes

Drugs ; Endocrine Disruptors

(non-biodegradable)

Evaluation of Infertility
Medical history (childhood illnesses, cryptorchidism, chronic
treatment, family medical history, illicit drugs, smoker, previous
infections, working in toxic environment)
Clinical tests (rectal exam, inguinal scars, OGE test varicocele
(left>right), epididymis, vas deferent)
Hormonal dosage (FSH, LH, PRL, Testosterone,
freeTestosterone, PRL, Estradiol, AMH)
Specific Tests (testicular ultra sound, transrectal, abdominal,
spermogram, MAR test, Halosperm)
Urine test determining of sperm cell =retrograde ejaculation
Accessory glandes markers
a. zinc, citrate or cholesterol for prostate
b. fructose, prostaglandin, bicarbonate for seminal vesicles
c. alpha-glucosidase, glycerylphosphorylcholine, L-carnitine for
epididymis

AMH in Males
Indicator of presence/functionality of Sertoli cells
Indications:

Sexual ambiguity;
Pseudohermaphroditism
Hermaphroditism
Cryptorchidism
Female testicle
Azoospermia (adult)

Low azoospermia NON-OBSTRUCTIVE

MARKER of AZOOSPERMIEI NON-OBSTRUCTIVE (testicular
tissue affected)

Prolactin in Infertility
Indications : In Men:
ginecomastia, infertility, azoospermia, exposure to pituitary gland
tumours (microadenome and macroadenome) si breast tumours

Real Hyperprolactinemia (increase of prolactin monomers)

False Hyperprolactinemia (presence of prolactin dimers and
polimers (macroprolactinemia) which are biological
inactive or with a reduced activity (it is the case of lab
Hyperprolactinemia without image showing)
Results:
Real HiperPRL Recovery Coefficient >60%
pseudoHiperPRL- R<40%
Uncertain -40%-60% chromatography gel filtrated

PEG (polyethyleneglycol) will enable mcaroprolactins and

biologic monomers will stay active (the ones which recover)

Seminoma / epididymitis

SPERMOGRAM

Human spermatozoon has a small size. Therefore, enzymes, such as the

acrosin, are important for human sperm penetration into the oocyte

Spermogram Results
Values following test

Normal values

Volume: ml
Colour: opalescent
pH:
Liquefying: complete
Time to liquefy: 15min
Viscosity: normal
Concentration: mil/ml
Total no. of spz in sample: mil
Motility a+b: %
Motility a+b+c: %

1,5ml
Opalescent
7,2-8,0
Complete: distinguished drops
20 min
Normal
15 x 106 /ml or
39 x 106 in sample
32%
40%

Morfology
Values following test
Normal forms: %
Abnormal forms: %

Normal values
> 4% normal forms
(according to WHO 2010)

Leucocyte: 1%

1% leucocyte

Spermogram
Results:

NORMOSPERMIA normal values

Oligozoospermia = low concentration of sperm
Hypospermia = sperm volume < 1,5 Ml
Aspermia = absence of sperm
Azoospermia = absence of sperm cells
Pyospermia = presence of leucocyte in sperm
Hematospermia = presence of red cells in sperm
Astenozoospermia = motility < 40%
Teratozoospermia = > 96% of sperm cells have abnormal
shapes
Necrozoospermia = unviable sperm cells
OligoAstenozoospermia = mobile sperm cells < 15 mil./mL
and motility < 40%
OligoAstenoTeratozoospermia (OAT)

MAR Test
(Mixed Antiglobulin Reaction)
Direct MAR test is done to detect antisperm antibodies of the IgA class in human semen.
The presence of antisperm antibodies can interfere with sperm function and zona binding
and the acrosome reaction.
Antisperm antibodies. The presence of antisperm antibodies which react with antigenes
present on sperm cells is considered typical and specific towards immunological infertility.
These antibodies can be found in approx. 8% of infertile men.
Limitations. Direct MAR testing can only be done on mobile sperm cells. Samples with low
concentration or low mobility can deliver a false negative result.
Interpretation reference values.
When antispermatic antibodies are present, the mobile sperm cells will tie the latex
particles forming agglutinate, in a proportion (percentage) which is correlated directly with
the severity of the immunological reaction.
Reference values:
< 10% - negativ;
10 39% - intermediary (suspicion of infertility of immunological cause);
> 40% - positive (very high probability of infertility of immunological cause).

Halosperm is a diagnosis test based on the

technique of chromatin dispersal of the sperm cell nucleus
Fragmentation of sperm cell DNA (SDF)

Factors that can influence broken sperm cell DNA: some medication, toxins,
fever, smoking, drugs, infections, age, long abstinence.

Method consists in gentle breaking the DNA while forming a halo

around the sperm head.
Indications of the Halosperm test
Infertile men with varicocele have a high percentage of sperm with
broken DNA. The test indicates the degree of this affection.
In Infections (particularly with Chlamydia Trachomatis and
Mycoplasma), the test allows the validation of the antibiotic
efficiency and choosing the best samples for assisted human
reproduction.
Interpretations reference values.
SDF<30% normal;
SDF>30% severe DNA breaking

AZOOSPERMIA
OBSTRUCTIVE

NON-OBSTRUCTIVE

Obstr. Epididymis (post-infectiuous,

post- surgery)

Idiopathic

Obstruction deferent vas

Cryptorchidism

Obstruction ejaculatory duct (prostatic Mumps, drugs

cysts, post-infectiuous, post-surgery)
Irradiate (af cel sertoli)
Sclerosis seminiferous
tubules

Genetic Causes
Chromosome anomalies: present in 5-10% of men with
oligozoospermia and 10-15% of those with azoospermia; the best
known anomaly is Klinefelter syndrome (47, XXY); - for AZOO nonobstructive
Microdeletions of Y chromosome: present in 10-18% patients with
severe oligo-or azoospermia; AZF (Azoospermia Factor)cu
localisation Yq11.23 - for AZOO non-obstructive
Muatations of cystic fibrosis gene (CFTR): transmits autosomalrecessive; several mutations can determine: bilateral congenital
absence of the vas deferens (CBAVD), unilateral absence of it
without pulmonary or pancreatic manifestations (CUAVD) or
obstruction of the vas deferens; for AZOO obstructive

Absence of bilateral vas deferens

Missing palpation, dilated epididymis

Determining alfa-glucosidase sperm
L-carnitine sperm
Glicerolfosfoclorid sperm
Cystic fibrosis gene mutation (CFTR)
blood

AZF (Azoospermia Factor)localised

in Yq11.23

Transmitted to male

AZF microdeletions long arm Cr Y

(AZFa, AZFb, AZFc)
-vein blood collection--

Deletion of the entire AZFa region leads to SCO Sertoli-Cell-OnlySyndrome and to the impossibility to collect mature sperm cells from
the testicular tissue
Complete deletion AZFb and AZFbc stopping the maturity process
of spermatogonia leads to azoospermia. The same as in the case of
complete deletion AZFa, ICSI assisted reproduction technique is not
recommended. They can be counseled by the specialist doctor,
recommending alternatives (for example sperm donors).
Deletion of AZFc region (b2/b4) is associated with clinical and
histological phenotypes and in general will be compatible with
residual spermatogenesis. Deletion AZFc can be encountered in men
with azoospermia or severe oligoazoopermia and in rare cases, they
can be transmitted to male descendants. Also, patients with AZFc
deletions can benefic from ICSI; their male children will present
AZFc deletions.

Cryptorchidism

Affects 3% of new borns and 30% of

premature new borns
80% unilateral - 20% bilateral
80% inguinal canal 20% abdominal
Etiology- unknown
Testicule hypotrophy
HIGH RISK infertility and testicular cancer

Varicocele
Incidental -10-20%
Dilation pampiniform plexus veins
Infertility and stopping testicular growth
Affected Spermatogenesis;
Oxidative stress apoptosis
Acrozomial flaws

Worlds oldest man:

Antonio Todde (1889
2002,
112ani)
His recipe
for longevity:
Just love your brother and drink
a good
glass of wine every day!

Old aging is associated with the rise of LH, FSH

and SHBG and lowering of testosterone
concentration
Volume, motility and morphology will modify in
time- there are no relevant studies with regards
to concentration

Hormonal Values and Treatment

HyperPRL on infertile man Bromocriptine,
Lisuride (2.5-60mg/zi) ergot derivates
Hypotestosterone hCG (Pregnyl) or LH or
recombinant LH
TESTOSTERONE IS NOT ADMINISTERED FOR
INFERTILITY

Fertility after neoplasm treatment

After radiotherapy 1 year

(normospermia)
16% become oligozoospermical
20% become azoospermical
Spermatogenesis can improve in the
following 5 years.

Clinical Use
Choosing the right assisted
reproduction method

Azoospermia --- donor

OligoAstenoTeratozoospermia --- IVF cuICSI
Normospermia ---Insemination (IUI)
MAR positive (over 40%)---ICSI
Halosperm positive (SDF over 30%)---ICSI or
IVF