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There is a complex interplay between male sexual dysfunction and male factor infertility, including ejaculatory dysfunctions which are the most common male sexual dysfunction. It is divided into four categories: premature ejaculation (PE), delayed ejaculation (DE), retrograde ejaculation (RE), and anejaculation/anorgasmia (AE). Unfortunately, some of these ejaculatory dysfunctions are less studied and not as well understood. Various pharmacologic treatments and surgical procedures can be offered for patients with ejaculatory dysfunctions seeking fertility. These include the off-label use of SSRIs (selective serotonin reuptake inhibitors) for PE, surgical (testicular sperm aspiration, testicular sperm extraction, and microsurgical epididymal sperm aspiration) and nonsurgical methods (medications, positive predictive value, and electroejaculation) for patients with RE and AE. The interaction between chemical impulses and the modulation of the ejaculation process in an individual patient is necessary to conclude the clinical status of the patient and feasibility of the available treatment techniques. Ultimately, this can help in deciding the best sperm retrieval technique to increase pregnancy outcomes.
Donor insemination (DI) remains a very important treatment option with acceptable pregnancy rates. In order to optimize pregnancy rates with DI, careful consideration should be given to various aspects of this service, including the recruitment and screening of sperm donors, cryopreservation of semen, and the screening and management of recipients. This chapter examines these important aspects of treatment to consider how to optimize DI services in the future. Treatment using DI was initially designed to treat male factor infertility. However, DI remains a therapeutic option for male factor infertility when either too few or no sperm are obtained at surgical sperm aspiration. With the advent of intracytoplasmic sperm injection (ICSI) many assumed that DI would become a very limited treatment. Although the numbers of cycles have reduced considerably there has been an increasing trend for DI to be used for other groups of patients such as single women and lesbians.
Rational treatment of the infertile male requires a correct and complete etiological diagnosis. Varicocele develops during puberty, and it is the most common cause of male infertility with prevalence varying between 30 and 60 percent. Thermography, endovascular treatment, and transcatheter embolization are treatment options for varicocele patients. Male accessory gland infection (MAGI) may result from infestation by sexually transmitted pathogens. The prevalence of immunological infertility is related to that of the diseases initiating the antibody formation, but it is no more than 5 percent in our population. Idiopathic sperm deficiency probably results from the combination of unfavorable external and lifestyle factors which includes conditions like idiopathic oligozoospermia, asthenozoospermia, or teratozoospermia. Intrauterine insemination (IUI) is an effective mode of treatment but if IUI remains unsuccessful after a maximum of four cycles, intracytoplasmic sperm injection (ICSI) should be recommended.
This chapter deals firstly with the anatomy and physiology of male reproduction, and then gives an account of the aetiology and management of male factor infertility. The male reproductive system consists of the penis, testes, ejaculatory ducts and accessory sex glands. The testis produces the majority (6-7 mg/day) of testosterone, although a small amount is also produced by the adrenal glands. Spermatogenesis and synthesis of testosterone are under control of the anterior pituitary gland. Prior to investigating the infertile male, the clinician must ensure that the female partner has been thoroughly evaluated. The World Health Organization has defined the minimal semen parameters for fertility. These parameters are volume, pH, sperm concentration, total sperm number, motility and morphology. The surgical causes of male infertility include varicocele and cryptorchidism. The infertile male should be managed in a tertiary centre where appropriate facilities exist for microsurgery, assisted conception techniques and cryostorage of sperm.
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