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CAUSES OF MALE

INFERTILITY
PRESENTED BY: LEONARD IMMANUEL NATHAN

OBJECTIVE
Understanding infertility in male.
Differentiate infertility & impotency.
To understand the causes of male infertility.

OUTLINE
Anatomy of the Male Reproductive System
Recap of Male Physiology
Causes of Male Infertility
A. Pre Testicular
B. Testicular
C. Post Testicular

Summary

INFERTILITY VS IMPOTENCY
Infertility: Inability to achieve conception despite one
year of frequent unprotected intercourse.
Impotence: Inability to develop or maintain an erection
of the penis during sexual activity in humans.

MALE HYPOGONADISM
DEFINITION: condition when the testis does not produce
enough male sex hormone( testosterone).
Two types:

I. Primary: also known as primary testicular failure


problem originates from the testes.

II. Secondary : problem arising from the hypothalamuspituitary axis.

CATEGORIES OF MALE INFERTILITY


Pre Testicular
Testicular
Post Testicular

1.) Pre Testicular


1. Hypothalamus-pituitary axis disorders which causes
infertility in men.
2. Three main disorders:
Congenital
Acquired
Systemic

i.) Congenital
Kallmanns Syndrome ( Hypogonadotropic Hypogonadism)
- primary GnRH deficiency less production of LH and FSH
no testosterone production.
Associated with inability to smell( anosmia).
Red-green color blindness.

ii) Acquired
Any hypothalamic or pituitary disease hypogonadotropic
hypogonadism infertility.
1. Tumours : Pituitary Macroprolactinoma
2. Infiltrative disease: Sarcoidosis, Tuberculosis,
Hemochromatosis.
3. Infundibulitis
4. Vascular lesions : Pituitary Infarction
5. Endocrinopathies: Hyperprolactinemia, Estrogen excess,
glucocorticoid excess, androgen excess.

1. Hyperprolactinemia caused by adenomas. Inhibits GnRH.


2. Estrogen excess due to estrogen therapy or testicular

tumour.
3. Glucocorticoid excess - glucocorticoid therapy , Cushings

Syndrome
4. Androgen overproduction : adrenal hyperplasia or tumours of

testis or adrenal glands. Exogenous testosterone use


suppresses spermatogenesis.
5. Drugs : Opioids and psychotropic drugs leads inhibit GnRH

secretion secondary hypogonadism infertility.

2.) Testicular
Can be in Genetic or Non- genetic in nature.
I. Genetics: Klinefelter Syndrome, Cryptorchidism.
II. Non Genetics: Drugs, Radiation, Trauma, Infections,
Varicocele.

i.)

Klinefelter Syndrome

Sex chromosome aneuploidy: with an extra X ( XXY)


chromosome.
These patients often have : 1.) Very small testes 2.)
Azoospermia

ii) Cryptorchidism
Most common genital problem encountered in
paediatrics.
Generally referred to Undescended testis.
Some cases partially reversible through
surgery( Orchiopexy)
Individuals have low sperm count, poor sperm quality,
lower fertility rates due to Impaired

iii) Varicocele
Dilatation of the pampiniform venous plexus within the
scrotum.
Seen in 40% of male infertility interferes with
thermoregulation.
Left testicle > right testicle.
Blocks the epididymis and vas deferens.
Seen in 10-15% of normal men and even higher
percentage in infertile man

iv) Drugs
Many drugs are associated with impaired
spermatogenesis or Leydig cell dysfunction.
Most importantly Alkylating agents. Ex:
Cyclophosphamide, Chlorambucil)
Anti Androgens Ex: Flutamide, Spironolactone,
Ketoconazole, Cimetidine.
Leads to: Testicular dysfunction by inhibiting androgen
production.

v) Infection
Viral Orchitis, especially MUMPS well recognized
cause of infertility.
Causative agent: Echovirus & Arbovirus.
Previous Sexually Transmitted Disease(STD): Chlamydia,
Gonorrhoea
Other infectious causes : Tuberculosis, Leprosy
These infections germinal cell damage male
infertility.

Other Causes
Testicular Cancer.

Testicular Torsion twisting of the testis and


spermatic cord ischemia.

3.) Post Testicular


Factors that do not allow the normal transport of sperm
through the ductal system.
Examples of sperm transport disorders are
1. Epididymal dysfunction ( drugs, infection)
2. Abnormalities of the vas deferens ( congenital absence,
Youngs syndrome, infection, vasectomy).
3. Seminal vesicle and prostate.
4. Ejaculatory duct disorders.

Sexual dysfunction :
1. Ejaculatory dysfunction, premature ejaculation, erectile

i) Abnormalities of vas deferens


Infection: Gonorrhoea, Chlamydia, Tuberculosis.
These infections causes obstruction of the vas
deferens
Ligation of vas deferens Vasectomy
1-2% have Bilateral Congenital Absence of vas deferens
I.

Due to mutations of CFTR gene

II. Mutations manifests other findings: Sinusitis, Bronchiectasis,


infertility (oligozoospermia).

Other Causes of Infertility


Smoking
- Environmental Toxin: cadmium, mercury,
lead
Obesity
Hyperthermia

Summary

Pre
Testicular

Testicular

Post
Testicular

Hypothalamus-pituitary
axis abnormality
Kallmann syndrome
Tumour
Infiltrative diseases
Lymphocytic
infundibulitis or
hypophysitis
Pituitary infarction
Drugs: opioids,
psychotropic drug
Hormonal:
hyperprolactinemia.
Excess: androgen,
estrogen, cortisol.

Problems arising from the


testes.
Klinefelter Syndrome
Cryptorchidism
Infections: Mumps,
leprosy, tuberculosis.
Gonorrhoea, Chlamydia.
Drugs: alkylating agents,
spironolactone,
ketoconazole,
Environmental: smoking,
hyperthermia, cadmium,
lead, mercury.
Trauma
Testicular Cancer
Testicular Torsion

Caused by obstruction in
the male ductal system.
Epididymal disorder
Congenital bilateral
absence of Vas Deferens
Vasectomy

References
Medscape
UpToDate
Davidsons Principles & Practice of Medicine(21st Edition)