INFERTILITY DIAGNOSIS

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2 INFERTILITY Infertility is the inability t cnceive after 12 mnths f unprtected intercurse. There are multiple causes f infertility and a systematic way t evaluate the cnditin. Let s lk at sme f the causes. DIAGNOSIS A semen analysis is used as the principal bjective parameter fr defining fertility in the male partner. This helps study sperm cunt and mtility amng ther factrs. Evaluatin gals It is imprtant t identify the desired gals f the evaluatin. T identify ptentially crrectable cnditins. T identify irreversible cnditins that may be amenable t assisted reprductin (ART). T identify irreversible cnditins thse are nt amenable t assisted reprductin (ART) and cunsel fr dnr inseminatin r adptin. When shuld the male be evaluated? Evaluatin f the male shuld ccur simultaneusly with that f the female partner after a year f regular but unsuccessful unprtected intercurse. This shuld include bth primary (wh have never cnceived) and secndary infertility (thse wh have cnceived in the past). Is there a female age which has higher risk f Infertility? Female risk factr fr infertility such as age ver 35 years Recent studies suggest that the best age f cnceptin is belw 28 years as female fertility starts a gradual decline after 28 years Basic clinical evaluatin f the male: Reprductive evaluatin f the male shuld be dne by an Andrlgist r a specialist in male reprductin. This is a specialized field and requires in-depth knwledge f anatmy and physilgy f the reprductive system. 1 f 10

3 Histry It is imprtant fr ne t underg a physical examinatin as needed Semen analysis - An advanced semen analysis is recmmended which assesses parameters beynd mtility, mvement f sperm, and mrphlgy. Semen analysis frms the crnerstne f evaluating male factr infertility. It is critical t btain a representative sample, analyzed at a labratry that rutinely perfrms semen analysis in rder t decide further management. At least tw semen samples must be btained, preferably abut a mnth apart with a 3-5 day abstinence perid prir t each sample. N decisin shuld be based n a single reprt since semen parameters fluctuate with time. Surgical interventin in particular must never be based n fewer than tw cnsistent reprts. The best f varius recent reprts is taken t be indicative f the fertility ptential f the man and shuld guide therapy. The sample shuld be cllected thrugh masturbatin in a wide-muthed, clean cntainer withut spillage. Smene reprting difficulty in semen cllectin r ne wh prduces yellw semen r scanty ejaculate shuld be asked t prvide a semen sample by vibratry stimulatin. 5% f Indian men have difficulty cllecting a semen sample by masturbatin. Smetimes they give a pseud-ejaculate (urethral secretins r urine) which is misleadingly reprted as shwing azspermia. Sample shuld be maintained at rm r bdy temperature till evaluatin. Samples must be examined within ne hur f cllectin. This is particularly relevant in India since a large number f labratries serve as cllectin centers fr larger labratries and there may be a delay in transprt f sample t the central labratry. Samples must be reprted by individuals qualified t evaluate them and wh perfrm such tests rutinely. The reprts must mentin the WHO criteria fr a nrmal semen analysis since n Indian criteria n nrmal semen sample exist. It is cmmn t see reprts frm reputed labratries quting incrrect nrmal r reference ranges. This is detrimental t the patient s perceptin f his prblem and is ften the basis fr prescribing unnecessary therapies. It is imprtant t understand that these are reference ranges and are neither necessary nr sufficient t prduce a pregnancy. They are used t guide therapy and prgnsticate utcme. CASA (cmputer assisted semen analysis): Rutine use is cntrversial because f lack f understanding f specificatins and limitatins. In the majrity it des nt ffer any clinical advantage ver a rutine semen analysis. 2 f 10

4 Ejaculate vlume > 1.5 ml ph > 7.2 Sperm cncentratin (x106/ml) >15 % Mtility >40 type A+B r >32% type A % Nrmal mrphlgy >4% by Kruger s criteria WBC A. Semen pus cells <1 x 10 6 / ml Many labratries imprperly reprt all rund cells as white bld cells. A variety f assays are available t differentiate leukcytes (pus cells) frm immature germ cells. The clinician must make sure that the tw types f cells are differentiated. Mre than 1 mill/ml WBC is an indicatr f true infectin and merits treatment. This rughly crrespnds t >5 WBC/hpf. B. Azspermia The diagnsis f azspermia is made with extreme cautin because f its specific causes and management. The semen specimen must be centrifuged at 3000g fr at least 15 minutes and the pellet examined fr sperms Azspermia refers t ttal absence f sperm. The presence f even a single mature sperm changes the diagnsis t extreme ligspermia r cryptzspermia. Azspermia shuld be cnfirmed in a secnd semen analysis. Additinal investigatins fr assessment f Fertility prblems Hrmnal evaluatin Initial hrmnal evaluatin may cnsist f measurements f serum fllicle-stimulatinghrmne (FSH), luteinizing hrmne (LH), estradil, prlactin levels and teststerne levels depending n the sperm abnrmality. A single recent measurement is usually sufficient t determine a patient s clinical endcrine status. Many men with abnrmal spermatgenesis have a nrmal serum FSH, but a marked elevatin f serum FSH is clearly indicative f an abnrmality in spermatgenesis. Scrtal ultrasund and Dppler Is dne t check fr develpment f testis and fr presence f variccele. Specialized test f sperm functin Presently rutinely used t predict the fertilizing capacity f sperm and plan crrect management Sperm DNA testing is increasingly becming crner stne f male fertility treatment. 3 f 10

5 Management ptins fr men with sperm issues There are plenty f behavir management methds fr men wh suffer frm issues with sperm cunt etc. Life-style changes, avidance f heat expsure, txin expsure and stress Avidance f smking Medical treatment is dne after explaining all ptins and benefits / success scenaris If begun, such therapies shuld be mnitred fr effectiveness and success Cuples age and fertility status shuld be the primary cnsideratin fr suggesting a treatment mdality. Indicatins and techniques fr crrecting a variccele Variccelectmy shuld be advised nly if all the fllwing criteria are met: Dcumented infertility Detected variccele Presence f sperm abnrmality The female partner is fertile r has a crrectable abnrmality Discussed all available ptins with cuple and they are fine with the surgical ptin and can affrd t wait fr results Azspermia Azspermia refers t the ttal absence f sperm in the ejaculate. Additinal investigatins Testicular bipsy Vs Micr TESE In the era f Micr Testicular sperm extractin and facilities fr ART, Testicular bipsy is nt needed as with MICRO TESE sperm can be cllected and frzen. 4 f 10

6 Diagnstic algrithm AZOOSPERMIA LOW VOLUME, FRUCTOSE NORMAL VOLUME, FRUCTOSE + ABSENT VAS DEFERENS PALPABLE VAS DEFERENS FSH < 2X, TESTIS NORMAL FSH > 2X, TESTIS SMALL CBAVD TRUS Pst ejaculate urine fr sperms Teststerne N vasectmy, trauma, surgery Testicular Failure Ejaculatry duct bstructin Needle bipsy f Testis Retrgrade ejaculatin Hypgnadism Epididymal bstructin Testicular impairment 5 f 10

7 Assisted reprductin Assisted reprductin shuld be the primary treatment mdality in men with: Testicular failure with severe OATs r azspermia CBAVD All immtile sperms Partners wh have an indicatin fr ART ART shuld be advised in men wh: Have persistent azspermia r severe OATs after surgical crrectin f varicceles r bstructive azspermia Failed t cnceive spntaneusly after 3-6 mnths f empirical drug therapy f OATs r surgical treatment Are lder r have partners with advanced age FSH levels ver twice the upper limit f nrmal indicate testicular failure. Hwever, this des nt preclude fcal areas f spermatgenesis. Such a persn may still be a candidate fr Micr TESE-ICSI. 20% t 40% f men with testicular failure and azspermia will have a few areas f sperm prductin. These sperm are t few in number t appear in the ejaculate but can be retrieved frm the testis and used fr ICSI. Sperm prductin, especially in men with testicular failure may nt be hmgenus. Thus, a single bipsy may nt be representative f the whle testis. Several bipsies may be needed t identify an area f fcal sperm prductin, which is nt ideal and Micr TESE is better. Infertility is a cmmn issue faced by men and wmen the wrld ver. If yu r yur partner suffer frm it, it is very imprtant fr bth f yu t tackle the issue like a team. There are plenty f treatment and crrective measures available that help yu get ver yur cnditin if nt bypass it. 6 f 10

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