1. Abnormalities
in the Production of Competent Sperm
2. Abnormalities
in Reproductive Tract Transport of
Sperm
3. Abnormalities
in Anterograde / Onward Ejaculation
4. Immunologic,
Endocrine and Infection Factors
1. Abnormalities in the Production of
Competent Sperm
Testicular Damage/Maldevelopment - Poor
spermatogenesis / Poor sperm function.
1.
Males may
have these conditions following mumps
orchitis, cryptorchidism, or in
association with Klinefelter's syndrome.
Males with the latter genetic
abnormality (XXY) usually have small
testes and azoospermia. Exposure to
radiation or to industrial or
environmental toxins, marijuana and
alcohol use, smoking, drugs, including
cimetidine, spironolactone, nitrofurans,
sulfasalazine, erythromycin,
tetracyclines, anabolic steroids, and
chemotherapeutic agents, can depress
sperm quantity and quality.
Resumption of spermatogenesis has been
reported to occur within 2 years
following discontinuation of anabolic
steroids; however, it is not known
whether all individuals will return to
normal function. Exposure to
diethylstilbestrol in utero has been
suggested, but not proven, as a cause of
male infertility.
2.
Approximately 20%
to 40% of infertile males, depending on
the zeal of the search, have a
varicocele, usually on the left side
because of the direct insertion of the
spermatic vein into the renal vein. A
small-randomized trial in Germany
observed a significant increase in sperm
concentration in the treated group up to
30--35% pregnancy rate. The same change,
however, was noted in the nonoperated
group, and the pregnancy rates in both
the operated and nonoperated groups were
the same.
[Back to Top]
2. Abnormalities in Male Reproductive
Tract Transport of Sperm (obstructive
abnormalities of Vas Deferens or
Epididymis).
Obstructive Azoospermia (absence
of spermatozoa in the semen)
1. Previous
Vasectomy, failed vas reversal,
obstruction of the vas deferens &
iatrogenic damage to the vas deferens or
epididymis.
2. Congenital
bilateral absence of the vas deferens
(screening for cystic fibrosis mutations
should be considered).
[Back to Top]
3. Abnormalities in Anterograde /
Onward Ejaculation (retrograde
ejaculation, anejaculation)
1. Retrograde Ejaculation
In retrograde ejaculation, the part
of the bladder that normally closes
during ejaculation (the bladder
neck) remains open, causing the
ejaculatory fluid to travel backward
into the bladder. Common causes of
retrograde ejaculation include
diabetes, spinal cord injuries,
certain drugsΦ, and some
surgical operations (including major
abdominal or pelvic surgery--one of
the most common causes is
transurethral resection of the
prostate).
A doctor makes the diagnosis of
retrograde ejaculation by finding a
large amount of sperm in a urine
sample. About one third of men with
retrograde ejaculation improve after
treatment with drugs that close the
bladder neck (such as
pseudoephedrine, phenylephrine,
chlorpheniramine, brompheniramine,
or imipramine). However, most of
these drugs can increase heart rate
and blood pressure, which can be
dangerous in men with high blood
pressure or heart disease. Diabetes,
some neurologic diseases, or
occasionally following prostatectomy
or pelvic lymphadenectomy, there can
be retrograde ejaculation into the
bladder.
The presence of sperm in the bladder
can be determined by examining a
post-ejaculation urine sample.
Φ
Neurologic ejaculatory dysfunction
can be caused by β-blockers,
phentolamine, methyldopa,
guanethidine, and reserpine.
2.
Spinal Cord Injury, paraplegia,
quadriplegia and anejaculation
The
nerves that are responsible for
carrying the signal for ejaculation
exit the spinal cord and course
along the aorta at the posterior
part of the abdomen. These nerves
are most commonly injured after
spinal trauma resulting in
paraplegia (paralysis of both legs
and often other structures in the
lower part of the body) or
quadriplegia (the
inability to move all four limbs or
the entire body below the neck),
major bowel or vascular surgery, or
surgery for testicular cancer.
In the past,
men with ejaculatory dysfunction
were considered infertile because
they couldn't ejaculate and
impregnate their wives even though
they did produce sperm within their
testicles. Penile vibratory
stimulation (PVS) employs a custom
designed mechanical vibrator (store
bought vibrators don't work for most
patients) that is applied to the
underside of the glans penis and set
to vibrate at designated frequency
and wave amplitude. This technique
only works in patients with an
intact ejaculatory reflex arc and
the results are dependent on the
level of spinal cord injury.
Electroejaculation is performed with
a device known as an
electroejaculator.
Electroejaculation must be performed
under general anesthesia in all
patients who have abdominal and
perirectal sensation.
[Back to Top]
4. Other
conditions including Immunologic, endocrine
and infectious factors
affecting multiple components of
fertility.
1. Immunology Disorders
(anti-sperm antibodies):
The presence of both IgG and IgA
antisperm antibodies are measured on the
sperm surface. The results are given in
terms of the number of motile sperm
affected by antisperm antibodies.
Surface antibodies may affect both
movement of the sperm and the ability of
the sperm to bind and fertilize the
oocyte. Results are clinically
significant and positive if more than
50% of sperm are affected by either
class of antibody. IgA antibodies are
considered of greater clinical
significance than IgG. Antisperm
antibodies often are associated with
testicular surgery (i.e., vasectomy,
vasectomy reversal) or trauma.
2. Endocrine Disorders:
Thyroid, gonadotropins, prolactin, and
testosterone may occasionally uncover
unsuspected abnormalities. FSH levels
are elevated with germ cell aplasia, and
testosterone levels are decreased in men
who are hypogonadotropic.
Hyperprolactinemia is commonly
associated with impotence, and in the
absence of impotence, measuring a
prolactin level is unlikely to aid in
the diagnosis. Infusion of gonadotropin-releasing
hormone (GnRH) can stimulate secretion
of gonadotropins, and there have been
occasional reports of the usefulness of
this treatment as well as the
administration of gonadotropins in males
who have an isolated gonadotropin
deficiency.
3. Urogenital Infections,
Reactive Oxygen Species, Misc.
Infection in the genitourinary tract,
including those caused by Mycoplasma,
Ureaplasma, gonorrhea and chlamydia
should be treated. Increased levels of
reactive oxygen species can cause damage
to the sperm membrane. Substances such
as peroxidase and hydrogen peroxide can
be released by abnormal sperm and by
white blood cells, and when elevated
levels of leukocytes are present in the
semen (with or without a positive
culture), treatment with vitamin E and
glutathione is advocated.
[Back to Top]
To make an appointment, please call us
TODAY at
615-321-8899.
|
