The document discusses various causes and treatments for male infertility. It covers endocrine disorders like hypogonadotropic hypogonadism, hyperprolactinemia, congenital adrenal hyperplasia, and anabolic steroid abuse. It also discusses conditions like pyospermia (leukocytospermia), antisperm antibody infertility, retrograde ejaculation, and anejaculation. For each condition, it provides details on diagnostic criteria and potential medical therapies aimed at improving sperm parameters and fertility outcomes.

2. Medical Therapy in Male Infertility 9 th Royan Int. Congress G. Pourmand, MD Urology Research Center, Medical Sciences/University of Tehran Aug. 2008

8. Reproductive Hazards in the Workplace TYPE OF EXPOSURE OBSERVED EFFECTS Decreased Sperm Count Abnormal Morphology Altered Sperm Trasnfer Altered Hormones/Sexual Performance Lead + + + + Dibromchloropropane + Carbaryl(Sevin ® ) + Ethlyene bromide + + + Plastic production (Sterene and acetone) + Ethylene glycol monoethyl ether + Welding + + Mercury vapor + Heat + + Military radar + Radiation (Chernobyl) + + + + Carbon disulfide + (From Carbone D, Thomas AJ: Medical therapy – Specific. AUA Postgraudate Course, 92 nd Annual Meeting of the AUA, New Orleans, LA, April 1997) (AUA, 1999)

9. Drug-induced Infertility SUPPRESSION OF HPG AXIS DIRECT GONADOTOXICITY IMPAIRED FERTILIZATION Anabolic steroids Ketoconazole Calcium channel blockers Cimetidine Sulfasaralazine Colchicine DES Valproic acid Nitrofurantoin Cyclosporine Sprironolactone Minocycline Phenothiazine Allopurinol

10. Chronic Conditions Associated with Male Infertility Diagnosis Percent of Infertility Mechanism Spinal cord injury Uremia Chronic liver disease Sickle cell anemia Myotonic dystrophy Cystic fibrosis 95 >50 >50 >50 80 90 Elevated scrotal temperature Hypogonadism Hypogonadism Hypogonadism Testicular atrophy Absence of vasa

12. Algorithm for the workup of isolated abnormalities in semen parameters Predominance of Single Abnormal Parameters Motility/ Forward progression TRUS Antibody test Endocrine evaluation Positive Semen processing Negative High(>1ml) Low(<1ml) Viscosity: hyperviscous Morphology: rare transient Density: Oligospermia <20×10 6 ml/cc volume Endocrine evaluation Varicocele Sperm washing Sperm washing: AIH Infection ART Steroids retry AIH, ART Varicocelecotomy Appropriate treatment Collection error Abnormality of sex glands AIH Mechanical None of above ED obstruction Retrograde ejaculation Urine centrifugaton Specific therapy TURED Specific or empirical medical therapy Specific or empirical medical therapy Empirical medical therapy Specific therapy

13. Evaluation of Oligospermic Men Normal serum testosterone, LH, FSH Oligospermic Azoospermic Varicocele No varicocele Idiopathic oligospermia Varicocelectomy Moderate & Severe oligospermia Mild oligospermia ICSI-IVF AID adoption Intrauterine insemination (after “swim-up” or Percoll) failed * ; Empirical therapy * * * *

14. Evaluation of Azoospermic Men Normal serum testosterone, LH, FSH Oligospermic Azoospermic Post ejaculation urine specimen Assess ejaculatory process by Hx and P/E Sperm absent Evidence for retrograde ejaculation Sperm present Semem fructose Re-exam Vas No evidence for retrograde ejaculation Retrograde ejaculation Neurologic exam negative positive Congenital absence of seminal vesicle Exploration, vasogram and/or Testicular biopsy Obstruction of ductal system absent present Obstruction of ED Testicular failure TRUS

15. Johnsen score 10 Full spermatogenesis 9 Many late spermatids, sloughing 8 Few late spermatids 7 No late spermatids, many early spermatids 6 Few early spermatids, arrest of spermatogenesis at the spermatid stage 5 No spermatids, many spermatocytes 4 No spermatids, few spermatocytes, Arrest of spermatogenesis 3 Spermatogonia only 2 No germ cells, Sertoli cells only 1 No seminiferous epithelial cells

26. Endocrine disorder 4. Anabolic steroid abuse Anabolic steroid abuse Hypogonadotropic Hypogonadism Anabolic steroid stop If not normalized · hCG 2,000 IU IM Spermatogenesis promotion hCG 3,000 IU IM · Tamoxifen 10mg 2×/day Normalized < 3month · recombinant FSH 75~150 IU H-P-G axis negative feedback mechanism

27. Endocrine disorder 5. Hypothyroidism ◈ Not recommended for screening test in asymptomatic pt. ◈ Treatment: Thyroid hormone pill (Levothyroxine sodium, T4) once a day, preferably in the morning. Initial dose: 25 mcg qd, p.o., Maintenance : 100~400 mcg/day

29. Endocrine disorder 7. Hyperestrogenemia Inhibition of conversion of androgen to estrogen ◈ Use Brand name Dose Testolactone Teslac ® (Bristol-Meyers Squibb) 50mg~100gm/day Anastrozole Arimidex ® (AstraZeneca) 1mg /day Letrozole Femara ® (Novartis) 2.5mg/day ◈ Treatment : Aromatase inhibitor ◈ Diagnosis: 1. Serum E2 > 50pg/dl 2. T (ng/dl) / E2 (pg/dl) ratio < 10

31. Pyospermia, Leukocytospermia Urethritis (most common) Prostatitis Epididymitis Seminal vesiculitis Leukocyte ↑ ROS↑* Sperm motility ↓ & fertility ↓ Causative or Empirical Antibiotics Diagnosis: * Semen analysis * Endtz test * Pap smear * Giemsa stain * Peroxidase stain * IHC stain(monoclonal Ab) Diagnosis (WHO) : leukocyte in sperm >1×10 6 /ml * ROS ; Reactive Oxygen Species

32. Pyospermia Treatment Chlamydiae trachomatis : Doxycycline 100mg, bid 10days or Ciprofloxacin 400mg, bid 10days or Tetracycline 500mg, bid 10days Neisseria gonorrhea : Ceftriaxone 250mg, i.m. qd 후 Doxycycline 10mg, bid 10days Alternative treatment If, hypersensitive to cephalosporin Spectinomycin 2g, i.m. If, hypersensitive to tetracycline Erythromycin 500mg, qid 10days Unknown Cause Ciprofloxacin, trimethoprim-sulfamethoxazole, bid 2~12wk

33. Detection test for Antisperm Ab (WHO guidelines ; Normal<10%) SpermMAR test (WHO guidelines ; Normal<20%) Indirect Immunobead Test, IBT(×400)

36. Retrograde Ejaculation Anatomic Y-V plasty Open prostatectomy Transurethral resection of prostate Transurethral incision of bladder neck Neurologic Retroperitoneal LN dissection DM Pharmacologic Pelvic surgery Spinal cord injury Idiopathic ◈ Cause