205. Male Infertility

Question 1

Lab Testing that suggests low fertility

Semen Analysis results suggesting low fertility

what is cryptozospermia?

What can pH tell you about semen?

Answer 1

Labs: Serum FSH + T

• if T low, measure with added LH/PRL
• if FSH low, measure with added LH/PRL
• if pt obese, check serum E (more aromatase in adipose)

Semen Analysis:
Ejaculate Volume > 1.5mL
Sperm Conc > 15million/mL
Motility >40%
Normal Morphology >4% (abnormal shape is NOT abnormal genetics)
reference range is NOT cut points - low %ile can still be fertile!

Cryptozospermia: rare; sperm in seminal fluid - need to centrifuge sample

pH: normal > 7.2
Prostate secretions are ACIDIC
Seminal Vesical secretions are BASIC
Azospermia will have ACIDIC secretions

Question 2

What are 5 non-pharm ways to optimize male reproductive health?

Answer 2

1. Improve timing of intercourse with ovulation (best 2 days before ovulation - give sperm time to get to tubes)
2. Reduce offending meds: T supplements (suppress FSH), Spironolactone (suppress libido), Bblockers/thiazides (E.D.), a-blockers/SSRIs (ejaculatory dysfx)
3. Reduce fever: fever decreases sperm count, motility, morphology, DNA integrity (recovery in 4-8 weeks after systemic fever resolves)
4. Decrease tobacco use (cessation best): causes less sperm conc, motility, morphology, fx (more sperm DNA damage, aneuploidy)
5. Less drug use: Marijuana (less LH and T secretion, less semen conc, motility, fx), Cocaine (impaired spermatogenisis via VC)

Question 3

What 4 Hormone Diseases cause male infertility? How do you treat it?

Answer 3

1. Hypogonadotropic Hypogonadism: Congenital Kallman’s syndrome (no GnRH migration, anosmia, cleft palate), Acquired pituitary trauma; isolated FSH/LH deficiency;
   mech: less LH/FSH secretion;
   tx: hCG (LH analog), FSH replacement tx (EASY)
2. HyperPRL: pit adenoma, hypothyroid, stress, drugs, liver disease;
   mech: inhibits hypothalamic secretion of GnRH
   tx: bromocriptine, cabergoline, surgery
3. E Excess: Adrenal/Testicular Tumors, liver failure, obesity (higher aromatase in fat)
   mech: high E inhibits LH/FSH secretion
   tx: underlying condition, aromatase inhibitors (anastrozole, letrozole, exemstane)
4. Androgen Excess: most commonly endogenous steroids, CAH, adrenal/testicular tumor
   mech: inhibit GnRH secretion
   tx: stop use of anabolic steroids, tx underlying condition

Question 4

What are the mechanisms and tx of fertility for these conditions:

1. Varicocele
2. Obstructive Azospermia
3. CBAVD

Answer 4

Varicocele: dilated veins near testicle raise temp, decrease sperm quality

• bag of worms appearance
• 13.4% prevalence, 37% of infertile pts
• mech: testicular hyperthermia
• tx: radiographic embolization of veins, surgical ligation

Obstructive Azospermia: vasal obstruction of vas deferens (congenital or acquired) or epididymal obstruction (congenital or acquired)
tx: microsurgical reconstruction (vasovasostomy, epididymovasostomy - bypass block)

CBAVD: missing both vas deferens, distal 2/3 epididymus, seminal vesicles

• CFTR gene mutation testing (CBAVD is sx of CFTR mutation carrier!)
• may have small pockets of complete spermatogenesis in seminiferous tubules (may find fertility)
• tx: surgery to retrieve sperm in setting of IVF/ICSI (IVF does not work because sperm not motile)

Question 5

What genetic malformations may be found in infertile male

Answer 5

1. Klinefelter Syndrome (47 XXY): most common genetic cause of azospermia; CP - small, firm testis, gynecomastia, azospermia (50-60% may find viable sperm!)
2. Y Ch testings for microdeletions - no sperm if complete AZFa or AZFb microdeletion
3. Test partner for CFTR mutation carrier even if pt has CBAVD with no CFTR carrier gene - CBAVD pt may have undocumented CFTR mutation

Question 6

What are 4 forms of male contraception

Answer 6

1. Abstinence
2. Pull Out Method (Coitus Interruptus): 27% pregnancy rate when not properly executed
3. Condoms: 18% pregnancy rate when not properly used, helps PREVENT some STDs
4. Vasectomy: vasal division, excision of vasal segment, mucosal cautery (seal tube), fascial interposition; clearance occurs when single semen sample has zero sperm, or <100k nonmotile sperm/mL at 4mo post procedure
   Failed vasectomy if sperm persist >6mo post-procedure = need repeat vasectomy