Male infertility

Male infertility - the absence of pregnancy with a regular sexual life without protection for 1 year; disease caused by diseases of the reproductive system of men, which leads to disruption of generative and copulatory functions and classified as infertile (infertile) condition.

[1], [2], [3],

Epidemiology

About 25% of married couples do not reach pregnancy within 1 year, among them 15% of couples are treated for infertility, but still less than 5% of married couples remain childless. Approximately 40% of cases occur in male infertility, 40% in female, and 20% in mixed.

[4], [5], [6], [7],

Causes of the male infertility

• hypogonadism;
• inflammatory diseases of the reproductive system;
• chronic systemic diseases;
• toxic action (medical preparations, irradiation, toxins, etc.);
• obstruction of the ducts of the epididymis or vas deferens;
• antegrade ejaculation;
• gonads agenesis, serto-cell syndrome
• varicocele
• genetic disorders.

[8], [9], [10], [11]

Pathogenesis

Pathogenesis is caused by a decrease in the number, mobility, changes in the morphology of spermatozoa, which leads to disruption of the process of their penetration into the egg.

[12], [13], [14], [15], [16], [17],

Forms

There are primary and secondary male infertility. In the case of primary infertility, a man never became pregnant, with secondary infertility, at least one pregnancy from a given man was already. In men with secondary infertility, as a rule, prospects for restoring fertility are better. The classification developed by WHO (1992) is now recognized.

By the nature of changes in the level of gonadotropins in the blood are distinguished:

• hypogonadotropic;
• hypergonadotrophic;
• normogynadotropic.

In addition, there are:

• excretory (for violation of the passage of the ejaculate on the sexual path):
• obstructive;
• retrograde ejaculation
• Immunological (with an increase in the level of antisperm antibodies),
• idiopathic (with a decrease in the parameters of the ejaculate unclear genesis).

Diagnostic categories according to the World Health Organization

Code	Disease	Code	Disease
01	Psychosexual disorders	09	Infection of the genitals
02	Causes of infertility not revealed	10	Immunological factor
03	Isolated pathological changes in seminal plasma	Eleven	Endocrine causes
04	Iatrogenic causes	12	Idiopathic oligozoospermia
05	Systemic diseases	13	Idiopathic asthenozoospermia
06	Congenital malformations of the reproductive system	14	Idiopathic teratozoospermia
07	Acquired testicular disorders	15	Obstructive azoospermia
08	Varicocele	16	Idiopathic azoospermia

[18], [19], [20], [21], [22], [23], [24]

Diagnostics of the male infertility

Diagnosis of the disease based on the evaluation of  spermatogenesis  by examining the ejaculate obtained after 3-5 days of sexual abstinence. To diagnose a single-time study is not enough. In the analysis of the ejaculate, the number of spermatozoa is estimated, their mobility, and an evaluation of the morphology of the spermatozoa is also mandatory.

In all cases, a hormonal examination should be performed to determine the level of LH, FSH, prolactin, testosterone, estradiol in the blood.

Patients who have an increase in FSH are unpromising for medical treatment.

[25], [26]

Treatment of the male infertility

Male infertility should be treated with strict pathogenetic methods.

Male infertility due to hypogonadotropic hypogonadism

Assign gonadotropins:

Gonadotrapine chorionic intramuscular injection 1000-3000 units once every 5 days, 2 years

+

(3 months after the start of therapy)

Menotropins intramuscularly 75-150 IU 3 times a week.

The dose of HG is selected strictly individually, under the control of testosterone levels in the blood, which should always be within the limits of normal indices (13-33 nmol / l). To stimulate spermatogenesis, menotropics (menopausal gonadotropin) are added not earlier than 3 months after the administration of HG. Combined therapy with gonadotropins is performed for at least two years.

Evaluation of efficacy against spermatogenesis is not performed in raps less than 6 months after initiation of combined therapy with gonadotropins.

Male infertility due to other causes

In those cases where hypogonadism is due to prolactinoma, dopamine agonists are prescribed.

With infectious lesions of the genitals shows antibiotic therapy, which is prescribed taking into account the sensitivity of microflora.

In the immunological form of pathology, it is possible to perform immunosuppressive therapy with GCS

When varicocele and obstructive form of the disease requires surgical intervention.

Evaluation of treatment effectiveness

Evaluation of the effectiveness of treatment is conducted no earlier than 3 months after the start of treatment based on the  analysis of the spermogram. The maximum duration of treatment should not be more than three years; With continued infertility for three years, artificial insemination is necessary.

[27], [28], [29], [30]

Complications and side effects of treatment

In rare cases, it is possible to increase the mammary glands, fluid retention and electrolytes, the appearance of acne vulgaris, which disappear after treatment

[31], [32], [33], [34], [35]

Errors and unreasonable appointments

Most often in the treatment of this condition, there are errors due to the wrong choice of the drug.

In the treatment, especially idiopathic, many methods of drug treatment that do not have rational pathophysiological prerequisites-the so-called "empirical therapy" -are still used (often quite long, simultaneously or sequentially).

When evaluating appropriate therapeutic approaches, it is necessary to follow the principles of evidence-based medicine, which requires controlled studies.

Unreasonable appointments include:

• Gonadotropin therapy with normogonadotropic form of pathology;
• androgen therapy in the absence of androgen deficiency. Testosterone and its derivatives suppress pituitary secretion of gonadotropins, thus leading to suppression of spermatogenesis. A large percentage of patients receiving androgens showed azoospermia;
• the use of selective estrogen receptor modulators (clomiphene, tamoxifen), which are drugs with a potential carcinogenic effect in the idiopathic form of pathology;
• use of aromatase inhibitors. (testolactone), kallikrein, pentaxifillin, which are ineffective in this pathology;
• the use of dopamine receptor agonists (bromocriptine) in the idiopathic form of pathology (effective only in infertility due to hyperprolactinemia);
• the use of somatotropin, which leads to an increase in the volume of the ejaculate, causes hypertrophy of the prostate gland, but does not affect the amount and mobility of spermatozoa;
• the use of phytopreparations, the effectiveness of which in this pathology is not proved.

[36]

Forecast

The effectiveness of treatment is low and is less than 50%.

[37], [38]