Management of Male

Infertility
Ricky Adriansjah, dr., SpU(K)
SMF UROLOGI Subdiv. Urologi Andrologi
RUMAH SAKIT HASAN SADIKIN
FK UNIVERSITAS PADJAJARAN
BANDUNG
CURICULUM VITAE

• Nama lengkap : Ricky Adriansjah, dr, SpU(K)

• Tempat/tgl. lahir : Balikpapan, 22 Juli 1970
• Pekerjaan : Departemen Urologi subdiv. Andrology Infertility
RS.Dr.Hasan Sadikin, Bandung
• 1996 Lulus dokter umum FK UKI
• 2007 Lulus dokter Spesialis Urologi FK UI
• 2015 Memperoleh Konsultan Urologi Andrologi
ORGANISASI
• Anggota IAUI (Ikatan Ahli Urologi Indonesia)
• Anggota INASAU (Indonesian Society of Andrology Urology)
• Anggota EAU (European Association of Urology)
• Anggota ESAU (EAU Section of Andrology Urology)
• Anggota ASRM (American Society for Reproductive Medicine)
• Anggota SIU (Societe Internationale D’Urologie)
• Anggota UAA (Urological Association of Asia)
• Anggota ISSM (International Society for Sexual Medicine) dan
APSSM (Asia Pasific Society for Sexual Medicine)
• Anggota ASI (Asosiasi Seksologi Indonesia)
• Anggota PERFITRI (Perhimpunan Fertilisasi InVitro Indonesia)
• According to WHO 2014, 20% of infertile couple was
supported by male.
• 1-2% is AZOOSPERMIA
• 45-81% is secondary infertility
• 19-41% suffer from VARICOCELE and affected sperm
quality
Definition
• Azoospermia is absence of spermatozoa in ejaculation
• Aspermia is complete absence of antegrade ejaculation
Concentration
• According to the World Health Organization’s (WHO) 2010 criteria,
sperm concentration should be less than 15 million spermatozoa per
milliliter to get a diagnosis of oligospermia.
• Classified by:
• Mild oligospermia: 14-5 million sperm/ml
• Moderate oligospermia: 5-1 million sperm/ml
• Severe oligospermia: <1 million sperm/ml

• Cryptozoospermia is distinguished after centrifuge samples and less

than 500.000/ejaculate
Total Sperm Number
• Sperm Concentration x Ejaculation Volume
• According to WHO 2010 ≥ 40%
Motility
• Motility is graded from a to d, according to the World Health Organisation
(WHO) Manual criteria, as follows.
• Grade a (fast progressive)
• sperms are those which swim forward fast in a straight line - like guided
missiles.
• Grade b (slow progressive)
• sperms swim forward, but either in a curved or crooked line, or slowly (slow
linear or non linear motility).
• Grade c (nonprogressive)
• sperms move their tails, but do not move forward (local motility only).
• Grade d (immotile )
• sperms do not move at all.
• According WHO there are two type for Asthenospermia (low motility
sperm)
• Progressive Motility sperm ≥ 32% (a+b)
• Total Motility Sperm ≥ 40% (a+b+c)

• Low Morphology sperm called Teratospermia

Morphology
Paradigma
• Pretesticular
• Testicular
• Post testicular
Pretesticular
• Relatively rare
• Include endocrine abnormality
• Known as secondary testicular failure
• Congenital or acquired
• Commonly involve pituitary (Kallman, Klinefelter 47XXY)
• Varicoceles
Testicular
• Primary testicular failure
• Nowadays known as Azoopermia Spermatogenic
Dysfunction (ASD)
• History of chemotherapeutic or mumps infection, or any
gonadotoxic exposure (smoking, alcohol, radiation)
Post Testicular
• Obstruction of the sperm delivery pathways or ejaculatory
dysfunction (Obstructive Azoospermic)
• Ejaculatory Duct Obstruction (Fructose in sperm analyses
negative or low)
Problems in daily practice
• Azoospermia :
• Non obstructive (Azoospermia Spermatogenic Dysfunction/
PTF)
• Obstructive
• Decrease of Sperm quality :
• Varicocele
• Ejaculatory disorder : Retrograde Ejaculation
•
 Sperm
Analysis

Bahan Dasar Pabrik Transport

Buruk Buruk Azoosp

Azoosp
Anamnesis
• History of:
• Androgen deficiency (ED, low libido, depression, hair growth)
• Exposure of gonadotoxin such as chemo, radiation, smoking
• Trauma or inguinal surgery
• Infection such as mumps, epididymoorchitis, orchitis.
• Heat exposures, toxic environment, life style, occupation
(minefield)
• UDT
Physical Examination
• Patient should be in warm room and standing either supine
positions
• Emphasis on overall androgenization such as hair
distribution, penile development, scrotal rogation
• Absence or presence of gynecomastia
• Absence of vas deferens, epididymis
• Number of testicles and Volume of testicle, consistency,
length axis, neoplasm
• Examine also with Valsalva maneuver
Laboratory
• At least 2 semen analysis with 2-3 days of abstinence with 3
weeks differences
• Analysis with low volume, examine post ejaculate urinalysis.
• Endocrine lab such as LH, FSH and Total T morning sample
should be taken
• If Total T is too low, takes Prolactin samples
Do we need testicular biopsy?
• Biopsy is not NEEDED ANYMORE prior to IVF just to
distinguish NOA and OA
Schoor et al FSH and TLA
NOA or ASD for FSH>7.6 mIU/ml with
Testicle length axis TLA<4.6cm 98
96%
96
OA for FSH<7.6 with TLA> 4.6cm
94

92

90 89%

88

86

84
percentile

NOA OA
Management
• NOA:
• Microdissection TESE
• OA:
• Vasovasostomy or vasoepididymostomy
• PESA or MESA
• TURED (Ejaculatory Duct Obstruction)
MESA TESE 45

40
• 2013 adalah data di RSHS
35
• Pertengahan 2014
30
BFC berdiri
25
MESA/TESE
20
Gagal
15

10

0
2013 2014 2015 2016 2017
VARICOCELE
 Testicular
temperature ↑

Oxidative stress
Varicocele and ↑
Infertility
Naughton et al. Pathophysiology
of varicoceles in male infertility.
Hum Reprod Update Reactive Oxygen Gonadotoxic
2001;7(5):473–81 Species (ROS) ↑ factors ₊

Sperm DNA
Fragmentation ↑
 ▪ Couples are twice (1.8x) as likely to become
DNA pregnant with regular IVF methods if the TUNEL
fragmentation DNA fragmentation index(DFI) is less than 30%
▪ Evenson et al indicates DFI more than 30% was
How low can associated with increased miscarriages and
spontaneous abortion
we go ▪ Better achievement for spontaneous pregnancy
is less than 20% as a threshold
Semen Analysis Result
2013 - 2015

Concentration Motility Morphology

Varicocele in Azoospermia
• Varicocele with azoospermia semen analysis:
• Consider Primary Testicular Failure (Hypergonad
Hypogonadism FSH ↑, T ↓).
• Do at once varicocele repair with sperm retrieval.
• Remember that quality of sperm needs time to recover
after repair (6-12 months), consider wife’s age
• Kubilay Inci et al 2013 found:
– the value of varicocelectomy in NOA pts still remains
controversial but it was significantly improved the successful
rate of sperm retrieval surgery.
Terima kasih