[Overview]
I. Definition of male infertility
According to the World Health Organization (WHO), a couple who has lived together for more than 1 year without using any contraception and whose female partner is infertile due to male factors is called male infertility. Male infertility is not an independent disease, but is the result of one or more diseases and factors. Wei Xinlin, Department of Male Medicine, Jiangning District Maternal and Child Health Clinic, Nanjing, Jiangsu Province
II. Etiology and diagnostic classification
According to WHO male infertility diagnostic procedure table, the diagnosis of male infertility etiology can be divided into 16 categories.
1, sexual dysfunction: including erectile dysfunction and ejaculatory dysfunction and other sexual problems such as too little sexual frequency or application of lubricant during intercourse causing infertility.
2, normal sexual function, based on sperm and seminal plasma examination abnormalities to determine the diagnosis of those who.
(1) male immune infertility
(2) Unexplained infertility
(3) Simple seminal plasma abnormalities
3, the cause of male infertility with a definite cause and abnormal semen quality classification
(1) Medical factors
(2) Systemic causes
(3) Congenital abnormalities such as Klinefelter’s syndrome, Y chromosome defect, cilia immobility syndrome, cryptorchidism
(4) Acquired testicular damage
(5) Varicose veins of the spermatic cord
(6) Infertility of male accessory gland infection
(7) Endocrine causes: hypothalamic lesions including hypotesticular dysfunction, Kallmann’s syndrome, selective LH deficiency, selective FSH deficiency; pituitary lesions including anterior pituitary insufficiency, hyperprolactinemia; exogenous or endogenous hormone level abnormalities, estrogen/androgen excess, glucocorticoid excess, hyper- or hypothyroidism
4. Other: male infertility that manifests as abnormal semen quality but has no definite etiology.
(1) Idiopathic oligospermia
(2) idiopathic weak spermatozoa
(3) idiopathic teratozoospermia
(4) obstructive azoospermia
(5) Idiopathic azoospermia
[Diagnostic points]
I. Medical history and physical examination
1. Medical history: A comprehensive understanding of family history, reproductive history, sexual history and other factors that may have an impact on fertility.
(1) Sexual history is an important element in the assessment of male infertility: consultation of sexual history provides a preliminary understanding of the presence of sexual dysfunction causing infertility.
(2) Past medical history: detailed information on the patient’s past fertility history should be obtained. If the semen analysis is abnormal, the focus should be on the history of fertility-related diseases, such as growth and development history, history of past diseases, etc. Among the fertility-related diseases or factors to be focused on, including the history of reproductive organ infections, trauma to the reproductive organs, history of surgery, history of endocrine diseases, diseases and factors affecting testicular spermatogenesis, sexual function and gonadal function, the application of drugs that have an impact on fertility, and bad habits, such as alcoholism, smoking, wearing tight pants, environment and occupation, etc.
2.Physical examination.
(1) General examination: focus on body shape and secondary sexual characteristics
(2) Examination of genital organs: focus on the presence of genital malformations, the location, hardness and size of testes, epididymis, vas deferens with or without nodules, scrotum with or without varicocele, sphingomyelia, etc.
(3) Anal finger examination, should pay attention to the size and hardness of the prostate, the presence of nodules and stones, suspected prostatitis should be made prostate massage fluid examination. For those who definitely have subclinical varicocele, scrotal thermometry and Doppler ultrasonography can be performed.
Laboratory tests
1.Semen analysis
The normal indicators of semen analysis are shown in the table.
Table: Semen analysis normal value range
Indicators
Normal value range
Color*
Milky white or off-white, may be light yellow if no semen is released for a long time
Volume*
2ml or more
PH*
7.2-8.0
Liquefaction*
Less than 60 minutes (usually 5-20 minutes)
Sperm density*
≥20×106/ml
Total sperm count*
≥40×106/per semen
Number of active sperm (within 60 minutes after collection)*
Ratio of spermatozoa with forward motion (class a and class b) ≥ 50%
or the percentage of spermatozoa with fast forward motion (class a) ≥ 25%
Survival rate*
≥75% sperm survival (Eosin Y staining method)
Morphology*
≥30% normal morphology (Pap stain or Richter stain)
Leukocyte count*
<1×106/ml
Note: The above standards are the normal values provided by the World Health Organization’s fourth edition of “Laboratory Testing Manual for Human Semen and Sperm-Cervical Mucus Interaction”.
2.Selective examination
According to the medical history, physical examination, semen examination results and risk factors, the following laboratory tests should be selected.
(1) Biochemical examination of semen.
(2) Microbiological examination of semen.
(3) Semen cytology examination.
(4) Endocrine examination.
(5) Immunological examination.
(6) Sperm function test.
(7) Chromosomal examination.
(8) Imaging examination.
(9) Post-coital test.
(3) Special examination
1. Vasectomy: In order to identify obstructive azoospermia or testicular spermatogenic dysfunction azoospermia, as well as to check the site, scope and cause of obstruction, vasectomy can be used.
2. Testicular or epididymal biopsy.
[Treatment options and principles]
I. Infertile couples participate in diagnosis and treatment together
II. Non-surgical treatment
1.Clear diagnosis of etiology, treatment for etiology.
2. For those whose etiology, pathology and pathogenesis are not clear after examination, empirical treatment can be used.
Third, surgical treatment
1.Surgeries that may improve testicular spermatogenesis such as high spermatic cord vein ligation and testicular descent fixation.
2.Surgery to relieve obstruction of the vas deferens.
3.Surgery to relieve other factors that cause semen not to enter the female reproductive tract normally, such as retrograde ejaculation and hypospadias surgery, etc.
4.Surgery for male infertility caused by other systemic diseases, such as pituitary tumor surgery and thyroid surgery, etc.
Assisted human reproductive technology
For infertile couples for whom the above treatment is ineffective, human assisted reproduction technology can be considered.
1.Artificial insemination of husband’s semen (AIH).
2. Artificial insemination of donor semen (AID).
3. In vitro fertilization embryo transfer technique (IVF-ET).
4. Single sperm intracytoplasmic injection (ICSI).