Clones

Risk of transmission of chromosomal or genetic disease.

Inability to conceive after 1 year of unprotected sexual intercourse. 15% of couples. 40-50% : a male factor 40 -50%: a female factor Idiopathic: large proportion (25-50% of cases) Factors influencing the prognosis in infertility Causes of Male Infertility Pre-testicular Testicular Post-testicular

29% of men with a normal FSH appear to have defective spermatogenesis Pretesticular causes of infertility

Hypothalamic disease – Isolated gonadotropin deficiency (Kallmann's syndrome) – Isolated LH or FSH deficiency – Congenital hypogonadotropic syndrome Pituitary disease – Insufficiency (tumor, infiltrative processes, operation, radiation) – Hyperprolactinemia – Hemochromatosis – Exogenous hormones Testicular

Testicular causes of infertility

Chromosomal anomalies (Klinefelter's syndrome, XYY syndrome, Y microdeletions) Noonan's syndrome (Turner's syndrome) Myotonic dystrophy Bilateral anorchia Sertoli-cell-only syndrome Gonadotoxins (drugs, radiation) , trauma, systemic disease Defective androgen synthesis or action Cryptorchidism, varicocele Klinefelter’s Syndrome 47XXY

Affects 10% of men diagnosed with . Post-testicular

Post-testicular causes of infertility Disorders of transport – Congenital disorders (CAVD, ED obs, PCKD) – Acquired disorders (vasectomy, op., inf) – Functional disorders (nerve inj., drug) Disorders of sperm motility or function – Congenital defects of the sperm tail (Kartagener’s syndrome) – Maturation defects – Immunologic disorders – – Infection Evaluation of Male Infertility History and PE. Laboratory studies: 1. . 2. Hormonal evaluation. 3. Radiological investigation. 4. Chromosomal studies. 5. Testicular biopsy. 6. Immunological studies. 7. Sperm function tests. Genital examination ➢ Penis ➢ Testis size > 4.6 cm (3.6-5.5 cm, Vol:18.6 ml) ➢ ➢ Vas deferens ➢ Spermatic cord –varicocele ➢ Semen Analysis: cornerstone (WHO 2010 vs 1999) Collection: abstinence interval :48-72 hrs. Volume >1.5 (2.0) ml (), pH >7.2 Concentration> 15 (20) M/ml, total count > 39M. Motility: Total motility (PR + NP) >40% (asthenospermia) Progressive motility (PR)> 32% (Gr. A+B > 50% or Gr. A>25%). Morphology > 4% (teratospermia). Viability >58%(75%), WBC < 1 M/ml Liquefaction, viscosity. *Computer-assisted Semen Analysis (CASA): has not been documented give a more accurate prognosis or to affect treatment

Radiological Investigation

Scrotal US color duplex US. Gonadal Venography. Transrectal US, abdominal US Seminal vesiculography and vasography. CT or MRI of pelvis (rare)

Testicular Biopsy

In azoospermia men with normal sized testes and normal FSH. – Distinguish between obstructive and non- obstructive azoospermia (spermatogenic failure). As part of a therapeutic process in patients with clinical evidence of non- obstructive azoospermia who decide to undergo ICSI. – About 50–60% of men with non-obstructive azoospermia have some seminiferous tubules with spermatozoa that can be used for ICSI. Testicular Biopsy

Percutaneous needle biopsy; Open biopsy; Fine needle biopsy. Evaluation: 1. touch imprints (cytopathological examination). 2. histopathological examination. 3. DNA flow cytometry.

Infertile men TSGH CASA X 2 Hx, PE, U/A (vas) Azoospermia

Post-ejaculate U/A Fructose test Sperm(+) (-) TRUS or Vasography

TRUS Testicular size, FSH, LH, Testosterone

Testes: small, FSH > 2N Testes: N or Small FSH, testosterone < N, FSH: N to 2N LH: N or

EAU Guidelines on Male Infertility (European Urology 48 (2005) 703–711)

Aetiology and distribution(%) of male infertility among 7057 men

No demonstrable cause 48.5 Sexual factors 1.7 Urogenital infection 6.6 Congenital anomalies 2.1 Acquired factors 2.6 Varicocele 12.3 Endocrine disturbances 0.6 Immunological factors 3.1 Idiopathic abnormal semen (OAT syndrome) 26.4 Other abnormalities 3.0 Surgical Treatment of Male Infertility Varicocelectomy. Vasovasostomy. Vasoepididymostomy. TUR of ejaculatory duct. Sperm retrieval technique. Artificial (3/200). Electroejaculation. Ablation of pituitary adenoma. Other operation (orchiopexy, torsion). Varicocele The most common cause of correctable male infertility Incidence: 15% ( 8 - 22.9%) Left side predominant: 78 - 95% Bilateral varicocele: 2 - 70%

Varicocele

Male infertility : 30 - 40% with varicocele Varicocele ablation: 51-70% with improved Pregnancy rate after op: 32.2% ( 35 - 63% ) (Michael H. 1995; 65 studies, 6983 patients) Treatment of varicocele to achieve pregnancy in infertile partnerships remains controversial. (EAU guidelines, 2011) High Ligation of ISV Microsurgical Varicocelectomy Laparoscopic varix ligation Gonadal Venography and Embolization of ISV

Chart Title

Azoospermia Ejaculatory dysfunction

Retrograde ejaculation Anejaculation

Sympathomimetic agents Electroejaculation or AIH (EEJ) and ART Electroejaculation (Pregnancy per ouple:37%) Ejaculatory Duct Obstruction (5% of Azo) Symptoms: – Postcoital pain, , infertility Treatment: TURED – 65-70% improve semen quality – 30% pregnancy Vasovasostomy (preg. <50% after 8 years interval) Vasoepididymostomy pregnancy rates (20–30%) Vasoepididymostomy

Schoysman, 1986 Silber, 1989 End to side End to end Patent: 21%(117/565) Patent:77% (146/190) Pregnancy: Pregnancy: Corpus--50% Corpus--72% Caput---18% Caput---43%

Pregnancy rates (20–30%). Combine epididymovasostomy with MESA, and cryopreserve the harvested spermatozoa for ICSI. Assisted Reproductive Techniques

Various Insemination Techniques Candidates for Sperm Retrieval

Reproductive tract obstruction: – Congenital: CAVD – Acquired: infection, trauma, or previous failed reconstruction. As an alternative to surgical reconstruction.

PESA & MESA CAVD

1-2% of infertility cases. 80% detectable CF mutation. CF: 99% with CAVD. The most common autosomal recessive genetic disorder in the US and is fatal. 15% renal malformations. Hypogonadism Incidence of endocrine disease in male infertility: 0.9-8.6%. (Greenberg, 1978; Dubin, 1971) Hypogonadotropic (hypothalamic or pituitary origin) – Idiopathic form (IHH) – Kallmann's syndrome Hypergonadotropic Treatment: – Androgen replacement (Virilization) – Gonadotropin therapy (spermatogenesis) * Idiopathic Infertility

Abnormal CASA – Up to 25%

Hx, PE and hormones: normal. Management – Either empirical medical therapy or ART A meta-analysis of all controlled studies – Failed to reveal significant efficacy of currently available treatments (EAU guidelines 2012). 要有目標去追求