male infertility
Introduction
Introduction After marriage, the couple lived together for more than two years. No contraceptive measures were taken. The woman never became pregnant and was called infertility. According to reports, 10% to 15% of married couples have infertility. Infertility is called male infertility because of the man's cause. Male reproductive physiology activities mainly include a series of processes such as spermatogenesis, maturation, semen formation, ejaculation and spermatogenesis. Any factor interferes with any part of the above process. Both can affect fertility and cause male infertility. Male factors cause infertility to account for 20.6% of infertility.
Cause
Cause
Cause:
(1) abnormal semen
1. No sperm or too little sperm
When the sperm density in semen is less than 0.2 billion/ml, the chance of conception is reduced, and when it is less than 0.2 billion/ml, it causes infertility. This infertility can be divided into permanent and temporary, the former is found in congenital testicular developmental disorders or testicular, severe lesions of the seminal vesicle; the latter is more common in sexual life than frequency leads to primary failure of spermatogenesis, generally sperm reduction rather than total No sperm.
2. Poor sperm quality
Insufficient or dead sperm in semen (more than 20%), or poor sperm motility or more than 30% of abnormal sperm, often cause infertility.
3. Semen physical and chemical trait abnormalities
Normal semen quickly condenses into a jelly-like form after injection, and is completely liquefied in the next 15 to 30 minutes. If the semen does not coagulate after injection, or liquefaction is not always suggestive that the seminal vesicle or prostate has lesions. Bacterial and viral infections of the reproductive tract can also cause changes in semen composition to cause infertility. Infectious bacteria in semen greater than 103 / ml, non-pathogenic bacteria greater than 104 / ml can cause infertility.
(two) spermatogenic disorders
Testicular disease
Such as testicular tumor, testicular tuberculosis, testicular syphilis, testicular non-specific inflammation, trauma or testicular atrophy after testicular torsion, testicular abscess, etc., can cause spermatogenic dysfunction, infertility.
Chromosomal abnormalities
Sexual chromosome abnormalities can cause poor differentiation of testicular and other sexual organs, resulting in true hermaphroditism and congenital testicular hypoplasia. Autosomal abnormalities can lead to metabolic disorders in the gonads and spermatogenic cells.
3. Sperm dysfunction
Long-term consumption of cottonseed oil can affect sperm autoimmunity in sperm, and can also cause sperm dysfunction.
4. Local lesions
Diseases such as recessive varicocele and giant hydrocele affect the external environment of the testicle, or cause infertility due to temperature, pressure and other reasons.
(3) Sperm and egg binding disorders
Sperm obstruction
Such as congenital insemination of the lack of obstruction such as atresia, surgical ligation of the vas deferens, chronic inflammation of the spermatic tract and its surrounding tissues.
2. Retrograde ejaculation
Such as the bladder neck has been operated or damaged or scar contracture after surgery to deform the urethra, bilateral lumbar sympathectomy or rectal cancer after abdominal perineal surgery, genital nerve damage caused by diabetes, spermatic cyst hypertrophy, and Severe urethral stricture, certain drugs, such as adrenergic blockers, can cause sympathetic changes in the bladder.
3. External genital abnormalities
Such as congenital penile deficiency, such as penile too small, male pseudohermaphroditism, urethral fissure or hypospadia, acquired penile inflammation or injury, scrotal edema, giant testicular hydrocele.
4. Male sexual dysfunction
Impotence, premature ejaculation, no ejaculation, etc.
(four) systemic factors
1. Mental and environmental factors
Sudden changes in the living environment lead to long-term mental stress, high altitude, high temperature, super-strength work and radiation work.
2. Nutritional factors
Severe malnutrition, vitamin A, vitamin E deficiency, trace elements such as zinc, manganese deficiency, calcium and phosphorus metabolism disorders, mercury arsenic, lead, ethanol, nicotine, cottonseed oil and other toxic substances chronic poisoning, chemotherapy drugs and so on.
3. Endocrine diseases
Such as pituitary dwarfism, obesity, reproductive incompetence syndrome, hypopituitarism, congenital gonadal non-development, congenital spermatogenic syndrome, hyperprolactin, pituitary tumor or intracranial infection, birth injury.
Examine
an examination
Semen analysis
It is an important and simple method to measure male fertility. The normal normal value of semen in China is: semen volume 26ml/time, liquefaction time<30 minutes, pH value 7.28.0, normal sperm density value>20×106/ Ml, sperm activity rate 60%, vitality a level > 25%, or vitality (a + b) > 50%, sperm deformity < 40%. Use masturbation or sperm extractor, use special glass bottles, do not use plastic cups or condoms to collect, the specimen should not be sent for more than 1 hour, the temperature should be kept at 25 ~ 35 °C, and the abstinence time should be 3 to 5 days. Since the number of sperm and the quality of sperm often change, the average should be checked three times in a row.
2. Urine and prostatic fluid examination
Urine leukocytosis can indicate infection or prostatitis. After ejaculation, a large number of sperm can be considered for retrograde ejaculation. Prostate fluid microscopic examination of white blood cells > 10 / HP, should be done in bacterial culture of prostatic fluid.
3. Determination of reproductive endocrine hormones
Including testosterone, testosterone T, LH, FSH and other reproductive endocrine hormones. Combined with semen analysis and physical examination, it can provide the reason for identifying infertility. Such as T, LH, FSH are low, can diagnose secondary hypogonadism; simple T decline, LH normal or high, FSH increased can be diagnosed as primary gonadal failure; T, LH normal, FSH increased The diagnosis was selective seminiferous epithelial insufficiency; T, LH, and FSH were all increased, and the diagnosis was androgen tolerance syndrome.
4. Anti-sperm antibody examination
Immune infertility accounts for 2.7% to 4% of male infertility. WHO recommends a mixed antiglobulin response test (MAR method) and an immune strain test. Not only can anti-sperm antibodies be detected in the serum and secretions of infertile couples, but also whether these antibodies can bind to sperm and distinguish which antibody binds to which region of sperm. The percentage of microemulsion droplets to active sperm binding in the antiglobulin mixed reaction assay should be less than 10%. In the immunization test, the microemulsion droplet coated with IgA or IgG antibody is mixed with the sample sperm, and the antibody binds to IgA or IgG on the surface of the sperm. The key to the success of this trial is that sperm should be able to move. Immunization strains can be considered positive if they are combined with more than 50% of active sperm. In cases with positive results, 75% of sperm often show IgA or IgG. The interpretation of these antibody test results should be very careful, because some patients contain antibodies, but does not affect their fertility.
Diagnosis
Differential diagnosis
It should be differentiated from the following symptoms:
1. Sperm abnormal sperm abnormality refers to the amount of sperm, qualitative abnormalities, deformities, etc., is a kind of semen abnormality.
2. Sperm rare and oligozoospermia are men whose sperm count is lower than normal healthy fertility. It is now considered that the number of sperm is less than 20 million per ml for oligozoospermia. However, clinically, there are often changes in sperm motility, poor forward motility, and high sperm deformity. This is called weak azoospermia, which is a more common condition of male infertility.
3. Decreased sperm quality The decrease in sperm quality means that the number of sperm, survival rate, activity capacity, density, etc. are reduced at the same volume level.
General procedure for diagnosing male infertility: First of all, it should be clear whether male infertility or female infertility, or both have infertility; if it is male infertility, it should be clear whether male is infertile or relatively infertile. Infertility or secondary infertility; finally, the cause of male infertility should be identified. The examination and diagnosis methods for male infertility generally have detailed medical history, physical examination, laboratory examination, imaging examination, and other examinations.
First, medical history
A detailed and complete collection of medical history is an important basis for determining the diagnosis. Generally, you should ask from the following aspects:
1. Marriage and childbearing history Marriage age and time; whether the wife and wife have been married before; whether they have been pregnant or have given birth to their children and their specific time; the wife's health status, what kind of gynecological examinations have been done; couples' feelings and cohabitation.
2. Sexual life history asks patients about sexual desire, frequency of sexual intercourse, whether or not sexual orgasm; whether the penis is erect and inserted into the vagina, whether it can ejaculate and semen shot into the vagina; how to position and posture of sexual intercourse; whether there is masturbation habit.
3. Whether the past medical history has suffered from male germline tuberculosis. (especially epididymal tuberculosis) and other non-specific chronic inflammation; whether there are infectious diseases such as mumps in childhood; whether there is a history of congenital diseases such as de-plugging; whether there is genital trauma and surgical history; Or history of exposure to toxic chemicals; whether to work in a high temperature environment; whether there is excessive smoking and drinking, long-term consumption of cottonseed oil; long-term use of antihypertensive drugs.
4. Whether family parents are close relatives; whether there are congenital and hereditary diseases; the health and fertility of parents and siblings.
Second, physical examination
Including height, weight, posture, shape, degree of obesity, whether the distribution of body hair is sparse, whether the skin is dry and rough, the distance between the two arms, the laryngeal node and the development of the breast, etc., these tests are important for assessing the male fertility. External genital examination should pay attention to the development of the penis, the location and size of the urethral opening. When the scrotum is examined, the patient should take the standing position, pay attention to whether the scrotum is swollen, the size, position and texture of the testis, the size and texture of the epididymis and the testicular connection. There are no songs in the spermatic veins. Prostate and seminal vesicle examination often through the rectal examination, pay attention to its size, texture, with or without induration, at the same time can do prostate massage, take the prostate fluid to the laboratory for examination.
In the examination of external genital organs, measuring the size of the testicles is of great significance for the evaluation of male fertility. Soft warfare is usually accompanied by a decrease in spermatogenesis, and soft and small testes often indicate a poor prognosis. Testicular measurements can usually be made with a self-made star pill model, and the models are numbered 1 to 20, and then the model is placed in a measuring cup containing an aqueous solution to measure the volume of different models. The size of the model number represents the volume of different cubic centimeters. . If the testicular volume is less than 11 Cm3, it often indicates poor testicular function.
Third, laboratory inspection
1. Blood and urine examination Blood and urine routine examination, anti-streptolysin "O" determination, blood sugar, urine sugar determination, syphilis serum reaction determination to exclude diabetes, syphilis and other diseases that may be related to male infertility.
Suspected urogenital tract inflammation can be used for urinary bacterial culture, prostatic fluid or sperm culture. Male infertility caused by endocrine causes may be related to hormone levels such as urinary 17-hydroxycorticosteroid, 17-ketosteroid, blood follicle stimulating hormone (FSH) interstitial cell stimulating hormone (LH) cold ketone, prolactin Wait. Sometimes the test must be stimulated with clomiphene citrate, GNRH stimulation test. HCG stimulation test, etc. to understand the physiological function of the hypothalamic-pituitary-gonadal axis. Some male infertility is associated with the development of an anti-sperm autoimmune response. Inflammatory tube obstruction, testicular injury or inflammation, adhesion rate and epididymal gland infection can form anti-sperm antibodies in vivo. Qualitative or quantitative determination of anti-sperm antibodies in patient serum by immunological methods such as sperm agglutination test, sperm cytotoxicity test, sperm brake test, and indirect immunofluorescence test.
2. Semen examination Semen examination is an important check item for the diagnosis of male infertility. It can reflect the quality of sperm produced by the testes, the smoothness of the spermatic tract and the secretory function of the epididymis. The following items should be strictly observed when collecting semen: 1 Do not allow sexual intercourse within 3~7 days before collecting semen. 2 Collect semen by masturbation. 3 Collect semen in the glass specimen bottle and disable the condom collection. 4 pay attention to the insulation at about 35 ° C, and send inspection within lh. Semen composition is affected by many factors, such as age, health, environmental factors, and frequency of sexual life. Therefore, it is not possible to make a diagnosis based on an abnormality in one of the semen examination results, and it is necessary to perform 3 semen examinations at regular intervals. According to the relevant literature, the normal values of semen analysis are shown in Table 7-9-2.
The normal value of semen analysis is 1.5.6.OInl, the number of spermatozoa with active sperm is >0. The spermatozoa >0.60 (in vivo staining method), the sperm density is >20 X 106/Inl, agglutination sperm, normal morphology sperm >0.50, white blood cells, such as semen volume less than 2ml, when the sperm activity rate drops significantly, it is necessary to analyze some chemical components in the semen to understand the function of the accessory gonads. At the same time, sperm morphology examination can be performed. There is information on the clinical significance of semen chemical analysis and sperm morphology examination results. The significance of semen chemical analysis and sperm morphology test results are normal and suspicious.
Acid phosphatase>6.9 4.2-6.9, zinc bm processing) 1.2-3.8 o.8-1.1, magnesium pupa oil) 2.7-10.3 2.1-2.8, fructose h see him) 6.7-8.3 4.4-6.6, sperm morphology , normal >0.40 0.3-0.4 , sperm head indefinite 0.50, sperm segment missing 0.25, sperm tail missing 0.25
3. Testicular biopsy
When the sperm count is less than 25 million / ml, there is an indication for testicular biopsy. This test identifies azoospermia or oligozoospermia because of loss of testicular spermatogenesis or sequelae. Testicular biopsy can be performed by puncture or scrotal incision. There are several cases of spermatogenic dysfunction:
(1) Supporting cell syndrome (sperm epithelial dysplasia) Almost all of the fine tubules do not see spermatogenic epithelium and only support cells, the diameter of the tube is slightly reduced, most of the other normal, is caused by congenital abnormalities, no Treatment indications.
(2) Sperm maturity disorder: Sperm development is arrested in the stage of primary spermatocytes, secondary spermatocytes or sperm cells, and cannot develop into sperm.
(3) Low spermatogenic function: There are normal germ cells in each stage of the spermatic tubule, but the number is reduced, the structure of the spermatogenic epithelium is disordered, the immature sperm cells are shed in the small lumen, and the nuclear abnormalities of individual cells change.
(4) Klinefelter Ssyndrome (Klinefelter Ssyndrome), the diameter of the small tubule becomes smaller, there is only supporting cells in the germ cell, the basement membrane of the refined tubule is thickened or glassy, the interstitial cells are hyperproliferated, and the chromosome is 47,XXY .
(5) Degenerative hypogonadism: The fine convoluted tubule is very small, and no spermatogenic cells and mesenchymal cells are similar to the 7-month fetal testicular biopsy specimen.
(6) Fertility sperm cells occur normally but the number of mesenchymal cells decreases.
(7) Hypothyroidism: In addition to the spermatogenic cells in the basal part of the seminiferous tubule wall, the other spermatogenic cells are separated from the spermatogenic epithelium to the lumen before maturation, and the spermatogenic epithelial arrangement is disordered.
(8) infertility caused by varicocele: the epithelium of the refined tubule is not fully mature, there is a transparent change, the fibroplasia of the conjunctiva, the epithelial epithelial shedding or disorder.
Fourth, image inspection
For those suspected of having obstruction or deformity, the vas deferens can be obtained by vas deferens. The angiographic route has two methods: retrograde intubation angiography and vas deferens angiography.
Five, other inspections
1. The sperm climbing test is used to understand the vitality of sperm, which is a more objective test. Generally, the plastic tube sperm nutrient solution is used for climbing height test. If the sperm climbs below 3cm, it is not normal.
2. The test of sperm penetration in the cervix fluid test to determine the speed of sperm in the cervix fluid is a technique for evaluating the quality of sperm. The cervical sputum is gently sucked into the tube before and after ovulation with a cervical straw, and then transferred to the person. In the special capillaries, one end is plugged with arable soil, the other end is placed in the semen specimen room, and placed in a 37 ° C incubator for 60 minn, and the farthest distance of sperm penetration is examined under a low power microscope.
