Recalcitrant Male Infertility
Samah Gamal Abdelnasser Taha Mohammed;
Abstract
Summary
F
inally, we can summarize the expectation of causes of male infertility which is unresponding to traditional lines of treatment (medical-surgical) into:
1-Pre-testicular causes: (Stahl et al., 2012).
a- Congenital hypogonadotropic hypogonadism.
b-Pituitary pathology including tumors, infiltrative diseases and infarction.
c-Adrenal pathology including tumors and congenital adrenal hyperplasia.
d-Systemic infections including viral illnesses and tuberculosis.
e-Systemic malignancies.
f-Anabolic steroid abuse.
2- Testicular causes: (Stahl et al., 2012):
a-Varicocele
b-Klinefelter syndrome
c-Y chromosome microdeletions
d-Testicular cancer
e-Leydig cell or Sertoli cell tumors
f-Idiopathic testicular failure
g-Prior vascular or traumatic insults
h-Prior orchitis
i-Gonadotoxin exposure (chemotherapy, radiation, medications, heat).
3- Post-testicular causes: (Stahl et al., 2012)
a-Congenital, iatrogenic, or postinflammatory epididymal obstruction.
b-Congenital, iatrogenic, or postinfectious vasal obstruction.
c-Ejaculatory duct obstruction
d-Ejaculatory or sexual dysfunction
4- Recalcitrant male infertility (unexplained):
Possible factors that might explain the difficulties to conceive in UMI include the presence of antisperm antibodies, sperm DNA damage, elevated levels of reactive oxygen species (ROS) and sperm dysfunction) Alaa et al., 2012).
In order to overcome these difficulties, Alaa et al. (2012) conducted tests and found that Normal semen analysis results, as routinely assessed, do not guarantee fecundity. This premise is important for all clinicians involved in the management of the subfertile men. Currently, one of the chief objectives of male infertility research is to invent a diagnostic test that efficiently correlates with sperm fertilizing potential. Proper understanding of the in vivo process of human fertilization and sperm egg interaction in vitro is the key to imagine the sperm functional alterations with great influence on diagnosis and treatment of male infertility.
As regard therapeutic modalities, Pharmacologic therapy is only effective in a handful of known causes of male infertility. The pathophysiology behind these specific causes of male infertility is relatively well-defined and understood, which allowed for the development of specific pharmacologic agents to correct the problem. More research is needed to delineate the pathophysiology behind idiopathic male infertility in order to develop specific therapies. Based on current data, hormonal therapies in general are a poor choice for idiopathic male infertility due to questionable efficacy and restrictive cost. At present, anti-oxidants appear to be the best pharmacologic choice for empirical treatment of idiopathic male infertility due to their low cost, high availability, good safety profile and modest efficacy (Hamada et al., 2012).
Both pulsatile GnRH analogs and combined LH and FSH treatment are effective in reversing the basic hormonal defects in HH, resulting in successful manifestation of secondary sexual characteristics, testicular enlargement and induction of spermatogenesis. However, their therapeutic roles in idiopathic male infertility have not been reproducible. Furthermore, the devastating consequences of exogenous testosterone on infertile men, in the form of testicular atrophy and further deterioration of spermatogenesis, make it critical to avoid such practice (Hamada et al., 2012).
Dopamine agonists are effective in mitigating the pathologic consequences of hyperprolactinemia on semen parameters, hormonal profile and erectile function; however, no studies on improvement of pregnancy rates were conducted. Again, their role in idiopathic male infertility is limited (Hamada et al., 2012).
Anti-estrogens were tried in many studies on idiopathic male infertility as single agents or in combination with other agents and they generally have limited therapeutic benefits. To combat idiopathic and obesity-related hyperestrogenemia, several aromatase inhibitors were tested resulting in modest improvement in hormonal profile without substantial effects on pregnancy rates. In addition, long-term use of these medications may lead to development of osteoporosis and
F
inally, we can summarize the expectation of causes of male infertility which is unresponding to traditional lines of treatment (medical-surgical) into:
1-Pre-testicular causes: (Stahl et al., 2012).
a- Congenital hypogonadotropic hypogonadism.
b-Pituitary pathology including tumors, infiltrative diseases and infarction.
c-Adrenal pathology including tumors and congenital adrenal hyperplasia.
d-Systemic infections including viral illnesses and tuberculosis.
e-Systemic malignancies.
f-Anabolic steroid abuse.
2- Testicular causes: (Stahl et al., 2012):
a-Varicocele
b-Klinefelter syndrome
c-Y chromosome microdeletions
d-Testicular cancer
e-Leydig cell or Sertoli cell tumors
f-Idiopathic testicular failure
g-Prior vascular or traumatic insults
h-Prior orchitis
i-Gonadotoxin exposure (chemotherapy, radiation, medications, heat).
3- Post-testicular causes: (Stahl et al., 2012)
a-Congenital, iatrogenic, or postinflammatory epididymal obstruction.
b-Congenital, iatrogenic, or postinfectious vasal obstruction.
c-Ejaculatory duct obstruction
d-Ejaculatory or sexual dysfunction
4- Recalcitrant male infertility (unexplained):
Possible factors that might explain the difficulties to conceive in UMI include the presence of antisperm antibodies, sperm DNA damage, elevated levels of reactive oxygen species (ROS) and sperm dysfunction) Alaa et al., 2012).
In order to overcome these difficulties, Alaa et al. (2012) conducted tests and found that Normal semen analysis results, as routinely assessed, do not guarantee fecundity. This premise is important for all clinicians involved in the management of the subfertile men. Currently, one of the chief objectives of male infertility research is to invent a diagnostic test that efficiently correlates with sperm fertilizing potential. Proper understanding of the in vivo process of human fertilization and sperm egg interaction in vitro is the key to imagine the sperm functional alterations with great influence on diagnosis and treatment of male infertility.
As regard therapeutic modalities, Pharmacologic therapy is only effective in a handful of known causes of male infertility. The pathophysiology behind these specific causes of male infertility is relatively well-defined and understood, which allowed for the development of specific pharmacologic agents to correct the problem. More research is needed to delineate the pathophysiology behind idiopathic male infertility in order to develop specific therapies. Based on current data, hormonal therapies in general are a poor choice for idiopathic male infertility due to questionable efficacy and restrictive cost. At present, anti-oxidants appear to be the best pharmacologic choice for empirical treatment of idiopathic male infertility due to their low cost, high availability, good safety profile and modest efficacy (Hamada et al., 2012).
Both pulsatile GnRH analogs and combined LH and FSH treatment are effective in reversing the basic hormonal defects in HH, resulting in successful manifestation of secondary sexual characteristics, testicular enlargement and induction of spermatogenesis. However, their therapeutic roles in idiopathic male infertility have not been reproducible. Furthermore, the devastating consequences of exogenous testosterone on infertile men, in the form of testicular atrophy and further deterioration of spermatogenesis, make it critical to avoid such practice (Hamada et al., 2012).
Dopamine agonists are effective in mitigating the pathologic consequences of hyperprolactinemia on semen parameters, hormonal profile and erectile function; however, no studies on improvement of pregnancy rates were conducted. Again, their role in idiopathic male infertility is limited (Hamada et al., 2012).
Anti-estrogens were tried in many studies on idiopathic male infertility as single agents or in combination with other agents and they generally have limited therapeutic benefits. To combat idiopathic and obesity-related hyperestrogenemia, several aromatase inhibitors were tested resulting in modest improvement in hormonal profile without substantial effects on pregnancy rates. In addition, long-term use of these medications may lead to development of osteoporosis and
Other data
| Title | Recalcitrant Male Infertility | Other Titles | عقم الرجال المستعصى | Authors | Samah Gamal Abdelnasser Taha Mohammed | Issue Date | 2014 |
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