HPMI Update

Male Infertility - Dr Andrew Hedges

Overview

• 2nd largest cause of infertility in couples

• 1 in 20 men = low sperm

• 1 in 100 = no sperm

Why

• Blocked / absent vas deferens

• Low production / poor movement

How sperm

• Pre-testes (Pit / Hypo) - LH / FSH

• Testes (Genes, Undescended, Mumps)

• Post-testes (Vasectomy, Infection, Cysts, Age)

History

• Developmental + Puberty

• Medical, surgical and reproductive

  • Trauma

  • Torsion

  • Undescended

• Infections

  • STD, Respiratory (CF), Urinary

• Medications

  • Anabolics, Chemotherapy

• Occupation and habits

• Family reproductive history

Lifestyle

• Smoking

  • Toxic

  • Cadmium binds to sperm DNA within 30s = very toxic

  • Transgenerational evidence that DNA damage may cause greater burden of disease in offspring

  • Low chance of successful IVF pregnancy

• Alcohol

  • Hard to quantity acceptable safe lower limit

  • Binge drinking = Formaldehyde measurable in semen the following day

  • Today’s sperm affected by habits over last 8 to 10 weeks

  • Leads to obesity

• BMI

  • Insulin resistance > hormonal changes

  • Higher fat tissue = converting androgens to oestrogens

  • Obesity = inflammation = oxidative stress + sperm damage

• Steroids

  • Anabolic = Inhibit sperm production

  • Stopping anabolics = hard, lead to fatigue

• Environmental

  • Herbicides / fungicides

  • Vigilence with PPI for spray weeds etc

  • Fungicides e.g. mildrew treatment in fruit trees

  • MDF banned as causes cancers

  • Fuels, thinners, oils, coal dust

  • Heat

  • Non-ionising radiation

    • Cancer treatments

    • Mobile phones = reduces sperm count

  • Over exercise

Exam

• Secondary sex characteristics

• Penis, urethral meatus

• Palpate testes and measure size, testicular consistency for cancers

• Varicocoele

• Presence of vas and epididymus

Semen Analysis

• Normal

  • Volume > 1.5mL

  • pH > 7.2

  • Conc > 15 million / mL

  • Total > 39 mil

  • Motility > 32% progressive

  • Morphology > 47%

  • Antisperm AB < 50%

• Minimum x 2 samples

  • Abstain 2 to 5 days

  • Collection to analysis 30 minutes

• pH

  • Prostatic fluid acidic

  • Seminal vesicles alkalive

• Non sperm cells

  • RBC

  • Leukocytes = inflammation

Results

• Normal

• No sperm

• Low sperm

• Significant abnormality

Investigations

• Blood tests

  • Testosterone, LH, FSH, TFT, PRL

  • Genetic testing

    • CF

    • Karyotype

    • Y-Chromosome gene deletion

• Ultrasound

  • Tumour and blockage

Sperm

• Small

• Limited repair mechanisms

Typical

• Older men

• Chronic medical issues

• Obese

• Oxidative stress

Treatment

• No sperm

  • Hormonal therapy

    • Gonadotrophins

    • Androgens

    • Aromatose inhibitors

  • Antioxidants

    • CoQ10

    • Selenium

  • ICSI

  • Freeze for back up

  • Extended sperm search

Vasectomy reversal

• Best results under 8 years

Donor sperm

• Own

• Donor pool

Referral

• Semen analysis x 2 if able

• Genetic test if you want