Male reproductive physiology

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1 START Lecture Series Crown Conference Centre, Melbourne Feb 18 th 2017 Male reproductive physiology Prof Robert I McLachlan FRACP, Ph.D., AM Director, Clinical Research, Hudson Institute Consultant Andrologist, Monash IVF Program Director, Andrology Australia

2 Declaration Equity interest in Monash IVF Group

3 Male Reproductive Physiology Anatomy Hypothalamic-pituitary-testicular axis Spermatogenesis Epididymis, vas, seminal vesicles, prostate Male genetics: Y chromosome Semen testing Sperm DNA Male sexual function

4 ...OK, let s go!

5

6 Seminal fluid Delivery Sperm Testosterone

7 Hypothalamo-pituitary-testicular axis Hypothalamus GnRH Testosterone Estradiol Pituitary VIRILITY Behaviour Prostate Muscles Skin & Hair Lipids Bone marrow Inhibin B Testis LH, FSH FERTILITY

8 Dual functions of testis Spermatogenesis fertility Androgen virility Fertility Virility

9 Testicular interstitial tissue LEYDIG cells Testosterone 10nM 500 nm illustration:setchell 1994

10 Normal spermatogenesis requires development of Sertoli and germ cells under influence of fetal neonatal and pubertal gonadotrophin surges Seminiferous tubules spermiation Spermatids spermiogenesis Interstitium LH testicular T 50 x serum levels FSH Both act on Sertoli cells Spermatocytes meiosis Spermatogonia mitosis

11 structure of a sperm

12 sperm midpiece and tail

13 sperm midpiece and tail 1000 per heart beat 3,000 genes involved

14

15 Epididymis Secretes & absorbs various components Proteins added to sperm Highly androgen dependent Roles: sperm maturation sperm storage

16 Human Sperm-Oocyte Interaction Acrosome intact sperm Zona Pellucida-binding Acrosome reaction Intravitelline processing Zona Pellucida-penetration Oolemma fusion

17 Pulsatile GnRH from hypothalamic neurons nocturnal then throughout trigger of puberty unclear Rising LH Leydig cell testosterone secretion Metabolites of testosterone important Estradiol Dihydrotestosterone Onset of puberty

18 GnRH LH Testosterone : 3 hormones in one Amplification pathway (prostate, skin) Testosterone 5-7 mg/day 5a-reductase (5-10%) DHT Direct pathway (muscle) Androgen receptor Androgen receptor Hepatic oxidation & conjugation Renal excretion Inactivation pathway aromatase (0.2%) Estradiol Y Estrogen receptors Diversification pathway (brain, bone) D Handelsman

19 Pubertal Development: Tanner staging

20 Testicular volume Assessed using an orchidometer Normal testicular volume <3ml in childhood 4-14 ml in puberty ml in adulthood Asymmetry between testis is common (eg 15 vs 20 mls) Among men with testicular disorders, reduced testicular volume is paralleled with reduced spermatogenesis

21 Testis volume at spermache calculated based on onset of spermaturia % of boys Testicular volume (ml) Nielsen et al JCEM 1986, 62: 532

22 Delayed puberty Delayed puberty often represents transient activation of GnRH system: late bloomer, constitutional delay. Occasionally can permanent : range of medical and structural reasons. Hypogonadotrophic hypogonadism HH Congenital HH: Acquired: e.g. Kallmann s syndrome e.g. pituitary tumour

23 Congenital hypogonadotropic hypogonadism Sense of smell patient & relatives Formal testing, MRI olfactory bulb hypoplasia Young J JCEM 2012;97:

24 Congenital hypogonadotropic hypogonadism Sense of smell patient & relatives Formal testing, MRI olfactory bulb hypoplasia GnRH secretion or action GnRH neuronal migration Young J JCEM 2012;97:

25 Man with congenital GnRH deficiency To establish fertility : gonadotrophin therapy For virilization: testosterone (after 5 years) Courtesy of M Zitzmann, Munster

26 Gonadotrophin therapy to restore fertility in hypogonadotrophic hypogonadism (HH) Aim to mimic normal puberty : it takes time! hcg (LH) 4-6 months semen, testis volume, testosterone add FSH further 3-24 months Natural fertility (or ICSI)

27 Causes of male infertility Spermatogenesis 60% - idiopathic genetic - acquired drugs, toxins infection Endocrine <1% gonadotropin deficiency congenital acquired Obstruction 30% congenital BCAV acquired vasectomy STI Intercourse erectile & ejaculatory - anatomical psychosexual

28 Laboratory investigations in male infertility Semen analysis Oligospermia = low sperm density Azoospermia = no sperm seen Serum FSH Serum LH & Testosterone Testicular histology Genetic testing

29 Semen volume ~2ml, ph 8.0 Testis 5% Seminal vesicle Seminal vesicles ~60% Prostate 30% Prostate Bulbourethral gland Vas deferens Bulbourethral 5% Epididymis

30 2/22/2017 Basic Fertilty plus IVF

31 Troop number and speed must be combined with appropriate deployment and individual quality Sperm concentration and motility Appearance (morphology) weak surrogate for ability

32

33 Semen analysis is important but only a rough guide to fertility World Health Organization reference ranges population distributions associated with conception A poor result must be repeated in 6 weeks Rough prediction of natural fertility potential Sperm number (total, motile) and morphology Semen analysis does not test sperm function!

34 % pregnant Background rate of natural fertility in idiopathic male infertility is significant 100 normal 80 Significant variables: x x 10 6 severity of semen defect duration of infertility female age & reproductive status - compounding effect Years azoospermia modified from Baker et al 1986

35 FSH range in normal fertile men FSH levels in azoospermic men undergoing testis biopsy Serum FSH (IU/L) Schoor et al J Urol

36 Classic Androgen deficiency Primary (high LH) impaired Leydig cell function Klinefelter s syndrome 47, XXY 1:600 men Infertile men Secondary (low LH) hypothalamo-pituitary disease pituitary tumours

37 Evidence of androgen deficiency or impaired Leydig cell function in infertile men Testosterone LH T/LH 12% 15% Many cases of androgen deficiency unrecognised Education of GP and fertility specialists - RTAC Long term follow up of infertile men Andersson, A.-M. JCEM 2004

38 Complete spermatogenesis In a man with zero sperm count (azoospermia), this biopsy patterns suggests Obstruction His FSH will be normal

39 Sertoli-cell-only pattern (germ cell aplasia) this patterns has many causes A low serum inhibin B will result allowing a raised FSH

40 Histological reporting McLachlan et al. Hum Reprod :2-16 Normal Germ cell maturation arrest spermatocyte stage Ewa Rajpert-De Meyts ICA Barcelona 2009 * Fixative: never use formalin: Bouin s preferred

41 Sertoli cell only tubule spermatids

42 Chromosomal anomalies in infertile men McLachlan & O Bryan JCEM 2010 Incidence in infertile men 4-5% ( 8-10 X normal) Review of 11 studies : 9766 azoo/oligospermic men sex chromosomal 4.2% (0.14%) autosomal 1.5% (0.25%) Johnson Fertil & Steril 1998 Relationship to severity azoospermic men 13.7% numerical - Klinefelter oligospermic men 4.6% translocations, inversions Only a minority are clinically suspected Van Assche Hum Reprod 1996

43 Y chromosome structure predisposes to a b deletions of entire AZF regions c c Intrachromosomal recombination between homologous repetitive sequences a b c c a b c c Courtesy C Krausz

44 Yq microdeletions - ~5% of severe Yp infertility Yq AZFa AZFb AZFc Alternative Terminology AZFa P5/proximal-P1 (AZFb) P5/distal-P1 P4/distal-P1 AZFc (b2/b4) gr/gr McLachlan & O Bryan JCEM in review

45 Yq microdeletions - ~5% of severe infertility Yp Yq AZFa AZFb AZFc Alternative Terminology AZFa P5/proximal-P1 (AZFb) P5/distal-P1 P4/distal-P1 AZFc (b2/b4) gr/gr Spermatogenic profile Azoospermia Sertoli cell only Germ cell arrest Azoo/oligozoospermia HypoS genesis

46 PCR-based Yq assessment routine in unexplained infertility and sperm densities < 5 million/ml 1 Explanation of infertility

47 PCR-based Yq assessment routine in unexplained infertility and sperm densities < 5 million/ml 1 Explanation of infertility 2 Transmission to sons infertility Cram Fertil Steril 2000 Sex chromosomal aneuploidy Foresta JCEM 2004 Opportunity for PGD sex selection is rarely taken

48 PCR-based Yq assessment routine in unexplained infertility and sperm densities < 5 million/ml 1 Explanation of infertility 2 Transmission to sons infertility Cram Fertil Steril 2000 Sex chromosomal aneuploidy Foresta JCEM 2004 Opportunity for PGD sex selection is rarely taken 3 Prognostic for sperm retrieval from testis biopsy

49 Bilateral congenital absence of the vas BCAV Ureter Seminal vesicle Prostate Vas deferens Testis Bladder Absent Wolffian duct derivatives mildest form of cystic fibrosis Corpora cavernosa 1-2% of male infertility CFTR mutations >80% heterocompound heterozygotes Glans penis Female CFTR status

50 Sperm DNA testing: Rationale Conventional WHO semen parameters have limited ability to predict fertility: better tests needed Sperm DNA integrity new diagnostic category: predict reproductive outcomes targeted therapies may be possible implications for health of offspring

51 Sperm DNA testing: current status Lack of predictive value of current testing do NOT support routine clinical use Practice Committee of the American Society for Reproductive Medicine. Fertil Steril : 86:S35-7 Collins JA et al Fertil Steril ;89:823 De Jonge et al, Fertil Steril :260-6.

52 Sperm DNA testing: current status Lack of predictive value of current testing do NOT support routine clinical use On occasion... Practice Committee of the American Society for Reproductive Medicine. Fertil Steril : 86:S35-7 Recurrent IVF failure Poor embryonic development Recurrent miscarriage Collins JA et al Fertil Steril ;89:823 De Jonge et al, Fertil Steril :260-6.

53 Male: variable (follows general health), gradual and modest Female Male Decline in reproductive hormones and function Female : invariable (unaffected by health), sudden, severe

54 Male: variable (follows general health), gradual and modest Female Male Lower conception rates Increasing autosomal dominant disease Reduced sperm DNA quality Poorer ART outcomes Decline in reproductive hormones and function Female : invariable (unaffected by health), sudden, severe

55 Erectile dysfunction Is a consistent or recurrent inability to attain and / or maintain a penile erection sufficient for satisfactory sexual activity and intercourse

56 MATeS: Erectile dysfunction Erectile dysfunction (% of all men) moderate ED severe ED all ages ~21% of all men reported moderate to severe erectile dysfunction. Erectile function declined with age

57 Sinusoid anatomy Deep dorsal vein Helicine arteries Tunica albuginea Cavernosal artery Capillary vessels 2001PW 2001PW 2-8

58 FLACCID OUTFLOW Tunica albuginea Cavernosal smooth muscle lacunar space INFLOW ERECT OUTFLOW Subtunical vein elongation lacunar space INFLOW

59 FLACCID OUTFLOW Tunica albuginea Cavernosal smooth muscle lacunar space INFLOW ERECT OUTFLOW Subtunical vein elongation It s all about relaxation! lacunar space INFLOW

60 SEXUAL STIMULATION Endothelial cell Cavernous nerve L-Arginine O 2 Contraction adrenergic Non-adrenergic Non-cholinergic GTP NO Guanylyl cyclase Cialis Approved Product Information 5 GMP Smooth muscle cell cgmp PDE 5 PDE5 inh cgmp specific protein kinase K + Ca 2+ Decreased Ca 2+ Relaxation

61 Pathogenesis of erectile dysfunction Organic examples Vascular cardiovascular disease Neurological diabetic, spinal cord Hormonal testosterone prolactin Structural penile damage Drug induced anti-hypertensive, anti-depressants Psychogenic Mixed

62 ED associated with co-morbid disease lifestyle risk factors (BMI, sedentary lifestyles) co-morbid conditions (cardiovascular, diabetes). ED is an early warning sign of cardiovascular disease, due to the common risk factors and pathophysiology mediated through endothelial dysfunction. Risk of CV event onset of ED = smoking = family history CVD

63 Disorders of Ejaculation Premature ejaculation Behavioural & counselling Drug therapy (SSRIs) Reducing penile sensation Delayed ejaculation Difficulty in achieving orgasm + ejaculation Treat androgen deficiency Psychosexual counselling Anejaculation Complete absence of ejaculation Vibrostimulation or electro ejaculation Anorgasmia Inability to reach orgasm Psychosexual Medication change

64

65 Autonomic nerves: Retroperitoneal surgery Diabetes

66 Thank you!

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