MALE INFERTILITY AND
SEXUAL DYSFUNCTION
Presented at ASI Congress, Surabaya, August 20 -24, 2006
DEPARTMENT OF MEDICAL BIOLOGY AND ANDROLOGY
KM Arsyad
KMA MI & SD
LEARNING OBJECTIVES
1.
2.
3.
4.
Student be able to know and
understanding :
Infertile Couples,
The etiology of male Infertility
Sexual Function
Etiology of Male Sexual Dysfunction
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LEARNING CONTENTS:
1.
2.
3.
4.
5.
6.
7.
INTRODUCTION
INFERTILE COUPLES
THE ETIOLOGY OF MALE INFERTILITY
MANAGEMENT OF MALE INFERTILITY
SEXUAL FUNCTION
ETIOLOGY OF MALE SEXUAL DYSFUNCTION
MANAGEMENT OF MALE SEXUALDYSFUNCTION
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1.
1.ANDROLOGY
ANDROLOGY
2.
THE
2. THEROLE
ROLEOF
OFSEXUAL
SEXUAL
RELATIONSHIP
RELATIONSHIP
3.
BRANCHS
3. BRANCHSOF
OFMEDICINE
MEDICINE
RELATED
TO
INFERTILE
RELATED TO INFERTILECOUPLES
COUPLES
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1.1. ANDROLOGY
Term : andros & logos
DEFINISI :
Cabang ilmu Kedokteran mengenai
kesehatan SRP, mulai dari masa
perkembangan sampai masa dewasa
meliputi masalah infertilitas,
hipogonadism, disfungsi seksual pria,
Pria lansia dan kontrasepsi pria
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1.1. DEFINITION
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1.1. DEFINITION , CENTRAL TOPICS
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1.2. THE ROLE OF SEXUAL RELATIONSHIP :
PROCREATION
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PLEASUR
E
LOVE
1.3. THE BRANCHES OF MEDICINE RELATED TO
INFERTILE COUPLES
Infertile couples
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2.1.HUMAM REPRODUCTION
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2.3. REQUIREMENT FOR PREGNACY
MALE ASPECTS
1. The male must produce satisfactory numbers of
normal motile spermatozoa.
2. He must have patent conduits and potency to
ejaculate spermatozoa into the vagina,
3. The spermatozoa must reach to cervix, pass through
the cervical mucus, and ascend through the uterus
and oviduct at an appropriate time to encounter an
ovum,
4. The spermatozoa must be capable of penetrating and
fertilizing ovum,
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2.3. REQUIREMENT FOR PREGNACY
FEMALE ASPECTS
5. The female must release an ovum that has
access to a patent oviduct,
6. The fertilized ovum must move into the
uterus and find an endometrium prepared
for implantation.
7. The embryo must implant, develop normally,
and produce the glycoprotein gonadotropin
(HCG) to rescue the corpus luteum
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FACTORS AFFECTING REPRODUCTIVE PERFORMANCE :
1. Age of the Wife
2. Age of the Husband
3. Frequency of Intercourse, and
4. Duration of Coital Exposure.
Age
Mean Conception
Age
Conception
in less
Of wife
delay in months
of husband than 6
months(%)
16
12
<25
75
17
10
25 29
48
18
9
30 - 34
38
19
8
35 - 39
25
20
7
40 / >
23
21-23
6
Weekly freq.
Conceptions
in under
24
5
of intercourse 6 months
(%)
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6
<1
17 13
26
8
once
32
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2.2. Probability Of Infertile Couple
No
Treatment
Husband
Wife
Infertilty
1.
FERTILE
FERTILE
IDIOPATHIC
ART/ IMMUNOLOGIC
2.
FERTILE
SUBFERILE
WIFE FACTOR
WIFE
3.
FERTILE
STERILE
WIFE FACTOR
ADOPTION
4.
SUBFERTILE
FERTILE
HUSBAND FACTOR
HUSBAND
5.
SUBFERTILE
SUBFERTILE
BOTH
BOTH
STERILE
FERTILE
HUSBAND FACTOR
ART/CLONING
STERILE
SUBFERTILE
BOTH
ART/CLONING
8.
STERILE
STERILE
BOTH
ADOPTION
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2.1. INFERTILITY :
Infertility is defined as the failure of a
couple to achieve pregnancy after
unprotected intercourse,
Prevalence 8 % (50 80 Million population)
2 Million new Infertile couples each year
Male infertility has many causes from
hormonal imbalances, to physical
problems, to psychological and/or
behavioral problems,
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3. THE ETIOLOGY OF MALE INFERTILITY :
1.
2.
3.
4.
Hormonal
Imbalances,
Physical
Problems,
Psychological
Problems,
Behavioral
Problems,
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3.1.HORMONAL IMBALANCES :
Disorders on the
hypothalamus-pituitary
testis axis,
Hyperprolactinemia,
Hypogonadotropic
Hypopitutarism,
Panhypopituitafism,
Hypothyroidism,
Congenital Adrenal
Hyperplasia.
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3.2. PHYISICAL PROBLEMS :
Varicocele,
Damaged
Sperm Ducts :
congenital, or acquired,
Infection and Diseases,
Retrograde Ejaculation,
Torsion.
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3.2.1. INFECTION and DISEASES :
1.
2.
3.
4.
5.
6.
7.
Sexual transmitted diseases.
Orchitis,
Accessory glands infection (MAGI),
Diseases with high fever,
TBC
Diabetes Mellitus
Others systemic diseases affected to
Liver or Kidney function,
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3.3.PSYCHOLOGICAL PROBLEMS :
The
term mental illness covers a
broad range of disorders cause
psychological, personality or
behavioral symptoms,
1) Neuroses, stress, depression
2) Psychoses,
3) Sexual deviation.
4) Drug uses for mental therapy
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3.4. BEHAVIORAL PROBLEMS :
Occupational
diseases,
Lifestyle (Alcoholism, Smoking,
Drug addiction, etc)
Tight underwear
Pollution (air, water and food)
Handphones, Laptops
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ETIOLOGIC
ETIOLOGIC FACTORS
FACTORS INFLUENCES
INFLUENCES SPERM
SPERM
FREE RADICAL
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Laboratory Assays for
Evaluation of Human Semen
No Lab Test
Parameters
1.
Seminal fluid volume, Sperm count, motility,
Morphology, Viability, Leukocytes in semen,
Routine
Evaluation
Sperm antibodies
2.
3.
Function
Membrane integrity, Sperm-cervical mucus
interaction, CASA, Capacitation, Acrosome
reaction, Zona pellucida binding, Zona
pellucida penetration, Oocyte-sperm fusion
Sperm
Function
HOST, Postcoital test, SPA, Acrosome reaction
tests, , HemiZona Assay, IVF
Specialized
Sperm
Assays
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NILAI NORMAL SPERMIOGRAM
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NOMENKLATUR SPERMIOGRAM
1. NORMOZOOSPERMIA = Ejakulat normal sesuai
sesuai nilai baku,
2. OLIGOZOOSPERMIA = Konsentrasi sperma
kurang
dari nilai baku,
3. ASTHENOZOOSPERMIA = Motilitas sperma
kurang
dari nilai baku,
4. TERATOZOOSPERMIA = Morfologi sperma kurang
dari nilai baku,
5. OLIGOASTHENOTERATO ZOOSPERMIA = Ketiga
variabel baku
abnormal,
MI & SD
6. AZOOSPERMIA = tidakKMAadanya
sperma di dalam
ejakulat,
27
4. MANAGEMENT OF INFERTILE MAN
Pemeriksaan Andrologi.
Anamnesa
Treatment ?
Pemeriksaan fisik :
Diagnosa Kausatif ?
1. Umum
2. Khusus /
Reproduksi
Analisis Semen
Rutin
Kualitas Sperma
Uji sperma khusus
Pemeriksaan Penunjang
lainnya
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TERAPI SUAMI DAN PASANGAN
(PIA)
FAKTOR PRIA
BISA DIOBATI
T E R A PI :
GAG A L
I ST R I
NORMAL
1)EMPIRIK
2)KAUSATIF
I ST R I
ABNORMAL
TUGAS TULIS ; MACAM MACAM ART/TRB
FAKTOR
ISTRI
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SUKSES RATE ART/TRB
T R B / ART
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4. SEXUAL FUNCTION CYCLES:
1.
2.
3.
4.
Sexual Response cycle has 4 phases :
Excitement, Plateau, Orgasmic, Resolution .
Male Sexual Function has 4 components :
libido,
erection,
ejaculation,
orgasm.
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5. SEXUAL RESPONSE CYCLE
4 Phases :
1. Excitement
2. Plateau
3. Orgasmic
4. Resolution
Keempat rentetan siklus reaksi
seksual diatas merupakan satu siklus yang lengkap
Plateau
phase
Penetrasi
(Fore play )
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Orgasmic
phase
Resulution
Phase
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NEURAL PATHWAYS THAT INFLUECES SR
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Disorders of Sexual Responses
on Male
No
Disorder of Functions*
Syndrome
Pathology
1)
Disorder of interest or libido
2)
Disorder of excitement or
arousal
3)
Disorder of orgasm
4)
5)
Pain related disorder
Fear/anxiety related disorder
Inhibited sexual desire ,Low sexual interest
Erectile dysfunction
Anorgasmia, Premature ejaculation, Delayed ejaculation
Ejaculatory pain, Erectile dysfunction
(performance anxiety)
sexual phobia
Kok Lee Peng, Psychosexual Counseling.1999
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6. MALE SEXUAL DYSFUNCTION :
Male sexual dysfunction is a problem with 1 of
the 4 main components of male sexual
function (libido, erection, ejaculation, orgasm)
that interferes with interest in or ability to
engage in sexual relations.
Male Sexual Dysfunction:
Dysfunction of Libido,
Erectile Dysfunction,
Ejaculatory Dysfunction,
Orgasmic Dysfunction
1.
2.
3.
4.
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6.1. DYSFUNCTION of LIBIDO :
Hormonal
imbalance :
eq :Hypogonadism, Hyperprolactinemia,
Physical Problems :
eq : Diabetes, Anemia, etc
Psychological Problems :
eq Stress, Sexual deviation, etc
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6.2. ERECTILE DYSFUNCTION
A man who is unable to develop or sustain an
erection sufficient for penetrative sexual
intercourse is usually or traditionally labeled
impotent- a word that not only has pejorative
implication, but also takes little account of the
complex process of male sexual function.
Erectile Dysfunction (ED) is the inability to
achieve or maintain a hard, erect penis sufficient
for sexual intercourse.
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6.2.1. PREVALENCE AND RISK OF
ERECTILE DYSFUNCTION
Prevalence
:
5% among 40 years olds
10% among 60 years olds
15% among 70 years olds
Risk Factors :
Diabetes Mellitus, Hypertension,
Hyperlipidaemia, Depression, Smoking,
Hypothyroidism, Chronic Renal Failure,
Hypogonadism and Hyperprolactinemia.
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6.2.2. CAUSES OF ED :
1.
2.
3.
4.
5.
6.
7.
Psychogenic,
Psychiatric
Neurogenic,
Endocrine,
Arteriogenic,
Venous,
Drugs
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6.2.2.1.CAUSES OF
PSYCHOGENIC ED
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6.2.2. CAUSES OF ARTERIOGENIC ED :
1.
2.
3.
4.
5.
1.
Hypertension,
Smoking,
Diabetes Mellitus,
Hyperlipidemia,
Peripheral vascular disease,
CAUSES OF VENOUS ED :
Functional impairment of the venoocclusive mechanism
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6.2.2.3. CAUSES OF ENDOCRINE ED :
1.
2.
3.
Hormonal deficiency
low testosterone
Raised SHBG,
High Prolactin
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6.2.2.4. CAUSES OF NEUROGENIC ED :
1.
2.
3.
4.
5.
6.
7.
Trauma,
Myelodysplasia,
Intervertebral disc lesion,
Multiple Sclerosis,
Diabetes mellitus,
Alcohol,
Pelvic Surgery.
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6.2.2. 5. CAUSES OF DRUG ED :
1.
2.
3.
4.
5.
6.
7.
8.
Major tranquilizer,
Anticholinergics,
LH-RH analogues
Anti Androgen
Antihypertension,
Antidepressant
Anxioloytic,
Psychotropic drugs.
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6.3. EJACULATORY DYSFUNCTION :
Unejaculation
Retrograde
ejaculation
Damaged ducts :
Congenital Duct and Accessory glands Agenesis
Acquired duct obstruction
Premature
ejaculation :
Short Frenulum
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6.4. ORGASMIC DYSFUNTION :
Physical
Problems:
Anatomical anomaly
(Hypo/epispadia),
Psychological Problems
Behavioral Problems (Lifestyle)
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7.The Management of MSD :
History ( to confirm that the patient is
suffering from SD, to assess the severity of
the condition, to identify a possible underlying
aetiology)
Physical examination (secondary sexual
characteristics, blood pressure, abdominal
aneurysm, external genitalia and prostate,
lower limb pulses).
Clinical investigation ( urine, serum glucose,
serum testosterone,SHBG, probating,
creatinine, thyroid hormones, fasting lipid
profile, PSA)
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. DIAGRAM GOAL ORIENTED TREATMENT
OPTION
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CONCLUSION :
Infertility
is inability of man to
conceive his wife,
The causes of infertility could
interfere male sexual function and
also the role of sexual relationship,
A full history and thorough clinical
examination of the patient can help to
elucidate the cause of MSD,
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REFERENCES :
1.
2.
3.
4.
5.
Biology, 5th Ed. Campbell,NA,Reece,JB, Mitchel,LG,
Addison Wesley Longman, Inc., New York 1999.
page. 913 - 935
Richardson,D Overview:What do we tell our patient?,
dalam: The Assessment and Treatment of Erectile
Impotence, editors :Stricker,P.,Richardson,D. Excerpta
Medica,Australia, 1992
Nieschlag,
E.,
Behre,H.M.,
Andrology,
Male
Reproductive
Health
and
Dysfunction,
Springer.Berlin,2000.
Kok Lee Peng
Psychosexual Counseling, 7th
Workshop & Seminar on Male & Female Sexual
Dysfunction, Singapore, 20-21 March 1999.
Carani,C.,Granata,ARM.,Faustini,M.,and Marrama,P.
Prolactine and Testosterone : their role in male sexual
function, Int. J. of Andrology, 19: 48 54,1996.
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Prof David de Kretser
King and Queen
Seatle, Washingon, USA
Brisbane, Australia
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