Male%20infertility Treatment

• Treatment involves psychotherapy, medical management, surgical treatment, & different assisted reproductive techniques
• Goals of treatment include restoration of sexual function & fertility, & to obtain & maintain virility
• Treatment of male infertility should be started as soon as diagnosis has been established, especially if the female partner is >35 years old
• Patients should be informed of the possible risks & benefits that can be acquired from various treatments prior to initiation
• Pharmacologic management of male infertility may be applicable for patients diagnosed w/ hypogonadotropic hypogonadism, & sexual dysfunction
• There are still no proven medical treatment for infertility caused by Y chromosome microdeletions, Sertoli cell only syndrome, & Germ cell arrest at primary spermatocyte or earlier stage
• Testosterone replacement is not recommended as androgen replacement therapy for men w/ hypogonadism who are seeking treatment for infertility
  
  • Gonadotropins (hCG, hMG) & GnRH should be used instead
    
    
    

• Eg Doxycycline, Erythromycin, Norfloxacin, Trimethoprim
• May be used for men positive for leukocytes in their semen w/ identified infection
• Infection eradication aims to reduce the causative organisms contained in the semen & prostatic secretions, control inflammation, & improve sperm parameters for fertility purposes

• Eg Clomipramine, Desipramine, Fluoxetine, Imipramine, Paroxetine, Sertraline
• Treatment option for patients w/ premature ejaculation
• Effectively delays ejaculation, w/ effects seen a few days to 2 weeks after start of daily treatment

• Eg Brompheniramine, Ephedrine
• May be used in men w/ retrograde ejaculation or delayed ejaculation

• Potent selective serotonin re-uptake inhibitors (SSRI) that has been especially designed as an on-demand oral treatment for premature ejaculation
• Studies have shown that Dapoxetine significantly improved time to ejaculation
• Clinical trials have shown that if taken 1-2 hours before intercourse it was effective from the first dose on IELT & increased ejaculatory control, decreased distress, & increased satisfaction

• Eg Bromocriptine, Cabergoline
• Used for patients w/ hypogonadotropic hypogonadism secondary to hyperprolactinemia caused by pituitary adenomas 
• Mechanism of action: ergot alkaloid that binds to & stimulates dopamine receptors on lactotroph cells to inhibit prolactin secretion
• May also cause shrinkage of adenomas & restoration of gonadal function

• Eg Prednisone
• Used for patients w/ sperm autoimmunity

• Used to treat prepubertal cryptorchidism to induce testicular descent
• Descended testis after treatment w/ hCG may reascend later in life
• Used to stimulate spermatogenesis in men w/ hypogonadotropic hypogonadism when given w/ menotropins
  • Also considered as a treatment option for unexplained infertility

• hMG contains a combination of FSH & LH derived from human postmenopausal urine
• Used in combination w/ hCG for spermatogenesis stimulation
• Effectively stimulates sperm production in men w/ hypogonadotropic hypogonadism

• Eg Gonadorelin
• Also known as follicle-stimulating hormone-releasing hormone (FSH-RH), luteinizing hormone-releasing hormone (LH-RH), gonadoliberin, luliberlin
• Pulsatile GnRH is used as an alternative option to hCG for men w/ hypogonadotropic hypogonadism due to hypothalamic disease
• Used to replace GnRH in the system, thereby initiating stimulation of the pituitary gland to produce LH & FSH; LH & FSH production in turn stimulates testosterone production for spermatogenesis

• Eg Lidocaine, Prilocaine
• Several studies have shown that topical desensitizing agents help in delaying ejaculation by reducing the sensitivity of the glans penis
• Reduced vaginal sensation due to residual topical anesthetics limits the use of this treatment option

• Eg Sildenafil, Tadalafil, Udenafil, Vardenafil
• Oral phosphodiesterase-5 (PDE5) inhibitors should be offered as a 1st-line therapy for erectile dysfunction
• Have proven efficacy & safety in both non-selected populations of men w/ erectile dysfunction & in specific subgroups of patients (eg men w/ DM & those who have had a prostatectomy)
• Contraindicated in patients taking nitrates
• Sexual stimulation is still required
• Works peripherally; inhibits phosphodiesterase type 5, which is found in the penile tissue
  • Increases smooth muscle relaxation in the corpora cavernosa & enhances penile rigidity

• On-demand oral doses of Tramadol was comparable to Dapoxetine in delaying ejaculation in patients w/ premature ejaculation
• Delays ejaculation by stimulation of the m-opioid receptors & serotonin production in the CNS

• Eg low-dose Testosterone, Mesterolone
• Have been used w/ the assumption that these may cause “rebound” spermatogenesis stimulation & epididymal sperm maturation

• Have been used for the management of unexplained/idiopathic infertility
• Further studies are needed to prove the efficacy of Clomiphene citrate & Tamoxifene in the management of infertility in male patients
• Mechanism of action: blocks the negative feedback of estrogens in the hypothalamic-pituitary axis, thereby increasing the secretion of FSH, LH & testosterone
• Studies have shown significant increases in sperm concentration & motility & increased conception rates in couples given Clomiphene citrate therapy

 Supplements

• Eg antioxidants, vitamin & mineral supplements (Eg Carnitine, Cinnoxicam, Coenzyme Q10, Kallikrein,Pentoxifylline, Selenium, Vitamin E, Vitamin C, Zinc)
• Oxidative stress may be contributory to the semen quality during spermatogenesis, for w/c several studies have cited that antioxidant intake may help in infertility
• May improve pregnancy rates & live births in subfertile males
• Further studies are needed to prove the efficacy of different supplements for male infertility

Psychotherapy & Behavioral Therapy

• May help men w/ sexual dysfunction especially those w/ delayed ejaculation & anorgasmia
• Goals of psychotherapy in men & couples suffering from sexual dysfunction are:
  
  • Help men develop sexual skills that will enable them to delay ejaculation or achieve an orgasm while broadening their sexual scripts, increasing sexual self-confidence & diminishing performance anxiety
  • Focus on resolving psychological & interpersonal issues that may have precipitated, maintained or be the consequence of the symptom for the man, partner or couple
• Psychotherapy offers men, women & couples benefit, including the development of sexual skills, address ejaculation dysfunction improving relationship concerns & sexual self-confidence

• Techniques used to initiate pregnancy in couples w/ the male partner diagnosed w/ moderate-severe oligospermia & azoospermia
• May be used for patients w/ azoospermia in semen analysis but positive for sperm extracted from the seminiferous tubules
• Should be considered for couples w/ persistent infertility despite radical treatments

• Involves direct injection of a single sperm into the cytoplasm of an oocyte
• Treatment option for male infertility secondary to sperm autoimmunity, very severe oligospermia, asthenospermia, teratospermia, & non-obstructive azoospermia
• Indications: <2 million motile sperm/ejaculate, <5% normal sperm morphology, <5% sperm w progressive motility, positive sperm autoantibodies

• Involves direct placement of washed sperm into the upper uterine cavity prior to ovulation
• May be considered for couples unable to conceive due to retrograde ejaculation or mild male infertility
• May also be considered in couples w/ cervical mucus-antisperm antibodies

• May be considered for couples unable to conceive due to retrograde ejaculation or moderate oligospermia
• Amniocentesis or pre-implantation genetic diagnosis may be considered if previously diagnosed w/ autosomal abnormality

• Sperm is obtained from men w/ obstructive azoospermia & is used to fertilize the partner’s ova during assisted reproduction

• Eg Microsurgical Epididymal Sperm Aspiration (MESA), Percutaneous Epididymal Sperm Aspiration (PESA), Testicular Sperm Aspiration (TESA)
• May be considered for men w/ CBAVD

• Used to retrieve sperm in men w/ retrograde ejaculation for possible use in ART on the day of ovulation
• May be considered if w/ spinal cord injury & after treatment failure

• Technique of choice for patients w/ non-obstructive azoospermia as part of ICSI during testicular biopsy, w/ the obtained spermatozoa cryopreserved
• Procedure used to effectively retrieve sperm from the testis or epididymis
• May be considered for men w/ CBAVD & Klinefelter syndrome
• The only procedure that allows sperm retrieval in patients w/ intratesticular obstruction

• Vibrostimulation is the 1st-line therapy for men w/ anejaculation due to spinal cord injury but w/ intact lumbosacral spinal cord segment
  • May also be used in delayed ejaculation & retrograde ejaculation
• Electroejaculation is used if vibrostimulation fails to retrieve sperm

• Artificial insemination w/ donor sperm may be considered by couples w/ male-factor infertility who have failed w/ other assisted reproductive techniques