This article contains information compiled from various sources while preparing the thesis on the Male Factor in severe infertility. I hope it will enlighten you.
MALE FACTOR
The discovery of the causes of male infertility and the successful application of intracytoplasmic sperm injection (ICSI) in assisted reproductive techniques have revolutionized male infertility.
During clinical research, men should be examined systematically. . Evaluation; It includes anamnesis, physical examination and laboratory examination of the ejaculate. In a multi-center study conducted worldwide and including 32 clinics, only male factor appears to be the cause of infertility in 30-40% of infertile couples. 12% of men defined as infertile can achieve pregnancy within 4 years.
In male infertility, the first and basic test is spermiogram. There is confusion about normal values in the evaluation of semen parameters. Even in normally fertile men, semen values can vary greatly over time and fall below normal values. These changes create difficulties in defining normal values in semen analysis. Male reproductive system physiology should be taken into consideration when evaluating semen analysis.
MALE REPRODUCTIVE SYSTEM PHYSIOLOGY
The male reproductive system consists of testicles, epididymis, seminal vesicles, ejaculatory ducts, bulbourethral glands and urethra. occurs. In men, the testicles are under the control of Luteinizing Hormone (LH) and FSH secreted from the pituitary gland. Normal levels of both FSH and LH are required for normal sperm production. LH; It stimulates testosterone synthesis in Leydig cells and FSH stimulates inhibin synthesis in Sertoli cells. FSH and testosterone together stimulate spermatogenesis in the seminiferous tubules. While spermatogonia in humans turns into mature sperm in 75 days, this process begins in the Sertoli cells lining the seminiferous tubules in the testicle. Immature spermatogonia turn into spermatocytes as a result of mitotic division, and spermatocytes turn into spermatozoa containing 23 chromosomes through meiosis. (Spermiogenesis) The resulting spermatozoa then pass into the epididymis. Spermatozoa released from the Sertoli cell undergo maturation during their 12-21 day course in the epididymis. and becomes progressively more mobile. With ejaculation, mature spermatozoa are released from the vas deferens together with secretions from the prostate, vesiculoseminalis and bulbourethral glands. In this period, spermatozoa seem to have gained the ability to move and fertilize, but they do not have the capacity to fertilize. In order for the sperm to become fertile, a series of biochemical reactions called capacitation must first occur on the outer surface of the sperm. Although some of the capacitation occurs in men, some of it occurs in the female genital tract as sperm pass through the cervical mucus. Finally, the acrosome reaction is necessary to complete the fertilization capacity of the sperm. Acrosome; It contains proteolytic enzymes including acrosin, neuraminidase and hyalurinidase, which are necessary for sperm to penetrate the zona pellucida. After the sperm-zona pellucida unite, hardening occurs in the zona (cortical reaction) and the penetration of other sperm is prevented.
APPROACH STORY IN MALE INFERTILITY
Although women are generally held responsible for infertility, in a study conducted by the World Health Organization on the etiology of infertility on 7273 infertile couples in 1993, infertile couples, which are known to be 15% in the society. The female factor is seen as effective in 41%, the male factor alone is seen as effective in 24%, and the male and female factors appear together in the other 24% group. In other words, male problems may occur in approximately half of infertile couples. In the evaluation of couples applying for infertility consultation, the evaluation of the man must be done in the early stages of the research. Detailed anamnesis, physical examination and spermiogram are the basic evaluations in the evaluation of male infertility. Initial examinations should be rapid, non-invasive and economical, and focus on identifying potential risk factors that may affect the male partner's fertility.
DIAGNOSIS CLASSIFICATION FOR MALE INFERTILITY
• Sexual and/or ejaculatory dysfunction
• Immunological causes
• Isolated seminal plasma anomalies
• Iatrogenic
/> • Systemic causes
• Congenital anomalies
• Undescended testicle
• Karyotype anomalies
• Seminal vesicle and/or vas deferens congenital agenesis (Obstructive agenesis) cause of zoospermia)
• Acquired testicular destruction
• Varicocele
• Male accessory gland infection
• Endocrine causes
• Idiopathic azoospermia
• Idiopathic oligozoospermia
• Idiopathic asthenozoospermia
• Obstructive cryptozoospermia
• Obstructive azoospermia (Taken from the World Health Organization's "Standardized investigation and diagnosis of infertile couples" handbook.) The history will give very important information and clues to the physician regarding the identification of male infertility. . Childhood diseases such as cryptorchidism, testicular trauma, and testicular torsion negatively affect male fertility. It is well known that cryptorchidism affects male infertility through germ cell degeneration. Hormone levels and semen quality have a partial impact on fertility potential. An important factor in infertility is whether cryptorchidism is unilateral or bilateral. In studies conducted on adults who were operated on due to cryptorchidism in childhood, it was found that paternity rates were significantly lower in bilaterally cryptorchid men (65.3%) than in unilateral cryptorchids (89.7%) and in the control group (93.2%).
Low levels of inhibin B, which is secreted from Sertoli cells and regulates FSH secretion, and high levels of FSH are associated with a high risk of infertility.
Undescended testicle may lead to decreased spermatogenesis in the future, functions are impaired in untreated cryptorchid testicles after puberty, and post-puberty tests are associated with a high risk of infertility. They cannot benefit from correction.
50-70% of men with untreated unilateral undescended testicles are azoospermic or oligozoospermic. On the other hand, all men with untreated bilateral undescended testicles are infertile.
Although the responsible mechanisms are not fully understood, the following etiologies are discussed.
• Decrease in the number of tubules containing spermatogonium
• Toxic effect on the other testicle
br /> • Stimulation of anti-sperm antibody production
• Presence of variable levels of hypogonadotropic hypogonadism
• Epididymal malformations
Undescended testicle surgery should be performed in men after puberty up to the age of 32. However, the possibility of death due to surgery in a patient with undescended testicles after the age of 32 is high. It is higher than ignity.
Testicular trauma or testicular torsion may result in testicular atrophy. Abnormal semen findings develop in 30-40% of affected men. Testicular insufficiency and erectile dysfunction occur especially in diabetic patients with vascular involvement. Retrograde ejaculation is observed in these patients. Retrograde ejaculation is also a problem for patients who have undergone retroperitoneal or prostate surgery. The diagnosis of this condition, which occurs as a result of the sphincter in the bladder neck not closing during ejaculation and semen being ejaculated into the bladder, is made by detecting sperm in the urine sample taken after ejaculation.
Spermatogenesis may be impaired in cancer patients due to reasons such as chemotherapy and radiotherapy. Knowing such a situation is important in informing the patient and determining the type of treatment. Urinary system infections or sexually transmitted diseases should also be questioned in detail, as they may cause infertility with partial or complete obstructions as a result of pyospermia. Any systematic disease or uremia can disrupt spermatogenesis by affecting testicular function. Considering that spermatogenesis is completed in approximately 70 days and spermatozoa pass to the testicles and epididymis after 2 weeks, abnormal sperm analysis findings may be detected up to three months later. In order to get accurate results, spermiograms should be repeated at least every three months.
Familial infertility history brings to mind possible syndromes such as cystic fibrosis, Kallman syndrome, androgen insensitivity.
Smoking, alcohol, drug use, exposure to environmental toxins may also occur. It may cause infertility by affecting spermatogenesis.
PHYSICAL EXAMINATION
In physical examination, it would be appropriate to start with a general physical examination along with detailed examination of the genital organs. Because systemic diseases and any factor that may affect general health can negatively affect sperm production.
General appearance, penis size, characteristics of male secondary sex characters, urethral opening showing abnormal localization, testicular size and consistency, pretesticular structures should be noted in the examination.
br /> Small penis size can be a stimulus for hypogonadism. Angulation or curvature of the penis; will cause pain It may cause infertility due to both difficulty in erection and difficulty in coitus. Redness or discharge in the urethral meatus may be a sign of infection.
The size of the testicles, whether they are in the scrotum, and their consistency should also be evaluated. Testes consist of approximately 85-90% seminiferous tubules. These regions are the structures where sperm production takes place, and in cases of significant atrophy, they often cause defective spermatogenesis. This is why normal testicular sizes are important. Normal testicle length should be 4 cm and its volume should be more than 2 ml on average.
The presence of varicocele is an important issue that must be emphasized. Varicocele is defined as dilatation of the panfiniform plexus. This plexus is the terminal part of the internal spermatic vein that drains the testicle. Varicocele is more common on the left side because the left gonadal vein is longer. Because the left spermatic vein opens perpendicular to the left renal vein.
During the examination, room 20-22. It should be at C temperature. The patient must stand for 5 minutes before the examination. At low room temperatures, the scrotum will retract, making palpation difficult. Clinically palpable varicocele may cause testicular atrophy and deterioration in semen parameters. In general, the incidence of varicocele in men is 4-23%, while this rate is found to be 20-40% in the infertile group. Varicocele is the most common treatable cause of male infertility. Although the relationship between varicocele and sperm production is debated, one study found that the decrease in sperm concentration and motility in patients with varicocele was greater than in those without varicocele.
Varicocele repair, which includes ligation of the internal spermatic vein, provides improvement in semen parameters and testicular size. In a randomized controlled prospective study conducted by Madgar in 1995, it was shown that pregnancy rates increased by 76% in the varicocelectomy group.
Sperm parameters may be within normal limits in many patients with varicocele. Other studies report that fertile cases with varicocele with normal sperm parameters will pose a risk for infertility problems in the future.
In a study conducted by the World Health Organization (WHO), the incidence of varicocele was higher in men with abnormal sperm parameters than in men with normal sperm parameters.
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