infertility due to extratesticular cause

Infertility due to extratesticular causes refers to male infertility that is not related to testicular problems, but rather to issues outside the testicles.

• Definition: Extratesticular causes of male infertility account for a significant proportion of cases, with approximately 15% of the total population affected (11).
• Causes: These causes can be attributed to various factors, including:
  • Genetic abnormalities: Chromosomal abnormalities, such as an extra X sex chromosome, can affect sperm production and transit (13).
  • Ejaculation disorders: Retrograde ejaculation or anejaculation due to surgical procedures on the retroperitoneum, bladder, or pelvis can cause infertility (14).
  • Medications: Certain medications, such as antihypertensives, α-blockers, thiazides, antipsychotic drugs, and antidepressants, can lead to ejaculation disorders and infertility (14).
• Symptoms: Infertility due to extratesticular causes may not always present with symptoms. However, some men may experience:
  • Oligospermia: A low sperm count, as seen in the case of a 27-year-old man who presented with primary infertility and oligospermia (count of 10 million/mL) (15).
• Diagnosis: Diagnosis is typically made through semen analysis, physical examination, and blood investigations. Scrotal ultrasonography may also be performed to rule out extratesticular varicocele or other abnormalities.

References:

(11) Male factors are crucial contributors to infertility amongst infertile couples. The overall incidence of infertility accounts for nearly 15% of the total population. (13) Read more about the testicular causes of male infertility, which affect normal sperm production by the testicle. (14) Retrograde ejaculation or anejaculation due to surgical procedures on the retroperitoneum, bladder, or pelvis may also cause infertility (Turek 2008). (15) A 27-year-old man who presented to the urology outpatient department of our hospital with primary infertility was referred for scrotal ultrasonography (USG).

Extratesticular Causes of Infertility

Infertility caused by extratesticular factors refers to conditions that affect the male reproductive system outside of the testicles, leading to difficulties in conceiving a child. Some common signs and symptoms of infertility due to extratesticular causes include:

• Dull testicular pain or aching: Larger spermatoceles (varicoceles) may cause mild to moderate symptoms, including dull testicular pain or aching in the scrotum [7].
• Enlarged veins in the scrotum: Enlarged veins in the scrotum, also known as varicoceles, can affect sperm production and motility, leading to infertility [11].
• Changes in hair growth patterns: Altered sexual desire or libido, changes in hair growth patterns, and other subtle symptoms may indicate underlying issues with fertility [13].

Other Extratesticular Causes

In addition to the above-mentioned symptoms, extratesticular causes of infertility can also include:

• Hydrocele: A long-standing extratesticular mass effect such as that resulting from a hydrocele may compromise testicular blood flow and result in atrophy, leading to infertility [9].
• Ejaculatory duct cysts: Cysts or blockages in the ejaculatory ducts can cause bilateral epididymal obstruction (EDO) and subsequent infertility [6].

Prevalence of Extratesticular Causes

It's worth noting that extratesticular causes account for a significant proportion of male infertility cases. According to some studies, approximately 85% of cases are due to identifiable causes such as tubal disease, ovulatory dysfunction, and male factor infertility (due to varicoceles, hydrocele, or other extratesticular factors) [3][5].

References:

[7] Symptoms · Pain. A dull, aching pain or discomfort is more likely when standing or late in the day. [11] Infertility causes for men and people assigned male at birth. [13] Signs of Potential Infertility in Men. [3] Most cases are multifactorial: Approximately 85% are due to identifiable causes such as tubal disease, ovulatory dysfunction, and male factor infertility (due to varicoceles, hydrocele, or other extratesticular factors). [5] Most cases are multifactorial: Approximately 85% are due to identifiable causes such as tubal disease, ovulatory dysfunction, and male factor infertility (due to varicoceles, hydrocele, or other extratesticular factors).

Infertility caused by extratesticular factors refers to conditions that affect fertility but are not related to testicular function or sperm production. Diagnostic tests for extratesticular causes of infertility typically focus on evaluating the female reproductive system, hormonal imbalances, and other potential factors.

Diagnostic Tests:

• Blood testing: This involves analyzing blood samples to check for hormonal imbalances, such as thyroid hormone levels, which can affect fertility [6]. Blood tests may also be used to evaluate genetic causes of infertility, including chromosome abnormalities [14].
• Ultrasound: Transvaginal or transabdominal ultrasounds are used to examine the female reproductive organs, including the ovaries, uterus, and fallopian tubes. This can help identify conditions such as endometriosis, polycystic ovary syndrome (PCOS), or tubal damage [13].
• Hysterosalpingography (HSG): This test involves injecting a dye into the fallopian tubes to visualize their shape and patency. It's often used to diagnose tubal blockage or other issues affecting fertility [12].

Other Tests:

• Luteinizing hormone (LH) testing: Urinary LH tests can predict ovulation before it occurs, helping define the times of greatest fertility [11].
• Progesterone testing: Blood progesterone levels are often checked to evaluate ovulation and hormonal balance.

These diagnostic tests help identify extratesticular causes of infertility in both men and women. However, it's essential to note that some cases may remain unexplained despite thorough evaluation (unexplained infertility).

Treatment Options for Infertility Due to Extratesticular Causes

Extratesticular causes of infertility, which affect about 10-20% of infertile males, are mainly due to an impairment of sperm delivery or ejaculatory dysfunctions [2]. While there are specific treatment options available for these conditions, drug treatment is not the primary approach. However, certain medications may be used in conjunction with other treatments to address underlying issues.

• Antisperm antibodies: In some cases, antisperm antibodies can cause infertility due to extratesticular causes. Treatment options include using medications that reduce the production of these antibodies or using assisted reproductive technologies like IUI (Intrauterine Insemination) [8].
• Gonadotrophins: Gonadotrophins, such as HMG and HCG, have been used to treat certain cases of extratesticular infertility. These medications can stimulate the production of sperm or improve sperm quality [7].

Other Treatment Options

While drug treatment may not be the primary approach for extratesticular causes of infertility, other treatments like IUI, IVF (In Vitro Fertilization), and surgical interventions may be considered depending on the underlying cause and individual circumstances.

• IUI: Intrauterine insemination involves placing sperm directly into the uterus to facilitate fertilization [4].
• IVF: In vitro fertilization is a more advanced treatment option that involves fertilizing an egg with sperm outside the body, followed by implantation of the embryo in the uterus [4].

Key Considerations

When considering treatment options for infertility due to extratesticular causes, it's essential to consult with a healthcare professional to determine the best course of action. This may involve a combination of medical treatments, lifestyle changes, and assisted reproductive technologies.

References:

[2] Extra-testicular causes affect about 10–20% of infertile males and are mainly due to an impairment of sperm delivery or ejaculatory dysfunctions. [7] A well-documented case has shown that in at least some cases the condition can be reversed and fertility restored by treatment with gonadotrophins (HMG and HCG). [8] The following tests or procedures are proven and medically necessary for diagnosing or treating Infertility: Antisperm antibodies.

The differential diagnosis of infertility due to extratesticular causes involves identifying various conditions that can affect male fertility, excluding those related to testicular function.

According to the search results, some of the possible causes of infertility due to extratesticular causes include:

• Urethral abnormalities: A urethral web, anterior urethral valves, anterior urethral diverticulum, and strictures can obstruct sperm transport, leading to infertility [2].
• Obstructed ejaculation: Strictures anywhere along the path of the urethra can cause obstructed ejaculation, resulting in infertility [2].
• Varicocele: A varicocele is a swelling of the veins that drain the testicle and can affect sperm production and transport, leading to infertility [7].
• Genital tract obstruction: Obstruction in the genital tract, such as atresia or stenosis, can prevent sperm from reaching the ejaculatory ducts, resulting in infertility [7].
• Cryptorchidism: Undescended testes can lead to infertility due to impaired spermatogenesis and increased risk of testicular torsion [7].

Other conditions that may be considered in the differential diagnosis of extratesticular causes of infertility include:

• Hormonal imbalances: Hormonal imbalances, such as hypogonadism or hypergonadotropic hypogonadism, can affect sperm production and transport [14].
• Obstructive or nonobstructive blockages: Blockages in the reproductive tract, either obstructive or nonobstructive, can prevent sperm from reaching the ejaculatory ducts, resulting in infertility [14].

Imaging studies, such as ultrasonography with color Doppler, can be useful in evaluating the scrotum and identifying individual lesions, thereby reducing the list of differential diagnoses [15].

It's essential to note that a comprehensive evaluation, including medical history, physical examination, and laboratory tests, is necessary to determine the underlying cause of infertility due to extratesticular causes.

References:

[2] - A urethral web, anterior urethral valves, anterior urethral diverticulum, and strictures can obstruct sperm transport, leading to infertility. [7] - The major causes for male infertility include varicocele, genital tract obstruction, testicular failure, cryptorchidism, idiopathic, gonadotoxin exposure, ... [14] - Azoospermia can be due to pre-testicular, testicular, and post-testicular causes and may result from various underlying factors, including hormonal imbalances, obstructive or