B8.010 Prework 1: Evaluation of Male Infertility Flashcards
definition and incidence of infertility
inability to achieve pregnancy with times intercourse for at least 1 year
10-15% of married couples are affected
sperm head
nucleus: takes DNA to egg
acrosome: contains enzymes that allow the sperm to enter the egg
sperm tail
propels sperm
steps of spermatogenesis
- spermatogonial cell multiplication and proliferation at the base of the seminiferous tubules produce primary spermatocytes
- primary spermatocytes undergo meiotic division to form secondary spermatocytes
- a second meiotic division produces haploid round spermatids
spermiogenesis
4th step of spermatogenesis where remodeling of nuclear and cytoplasmic components render spermatozoa
steps required for male normal fertility
healthy sperm production
normal ejaculation
adequate sperm number and sperm morphology
normal sperm function: motility
general alterations involved in male infertility
- defective sperm production
- reproductive tract obstruction
- sexual disorders, erectile, and ejaculatory dysfunctions (delayed, premature, and retrograde ejaculations)
* *great amount is idiopathic**
relevant components of medical history to infertility diagnosis
sexual history, coital frequency and timing
duration of infertility and prior fertility
childhood illnesses and developmental history
systemic medical illnesses
prior surgeries
toxin/lifestyle exposures/habits
medications
diagnostic testing for male infertility
sperm analysis, blood tests, imaging
low volume of semen
test for obstructions or retrograde ejaculation
no sperm
testicular biopsy
sperm number, morphology, and function defects
hormonal tests
check for varicocele, hormones
steps of semen analysis
- confirm length of abstinence (2-5 days)
- produce semen sample (on site preferred)
- perform basic semen analysis, minimum of 2 samples should be analyzed
normal volume of ejaculate
> 1.5 mL
color of ejaculate
whitish, opalescent
ejaculate liquefaction
complete within 30 min
ejaculate pH
7.2-8.0
infection = basic pH
obstructive azoospermia = acidic pH
normal total sperm #
> 39 million
normal sperm concentration
> 15 mil per mL
normal sperm vitality
> 75%
distinguish live/dead with cell dyes
normal sperm morphology
> 4% normal
normal total motile sperm
> 40 million
normal total sperm motility
> 40%
normal total progressive sperm motility
> 32%
normal WBCs in sperm
<1 mil
more = chronic inflammation
aspermia
no ejaculate
hypospermia
low ejaculate volume
azoospermia
no spermatozoa in ejaculate
oligospermia
< 15 mil sperm/ ejaculate
asthenozoospermia
low sperm motility
teratospermia
low sperm motility
CASA
computer sperm analysis for sperm motility
can measure total and different patterns of sperm motility in multiple spermatozoa simultaneously
when to do an endocrine evaluation
if an abnormal semen analysis
if impaired sexual function
if other clinical findings of endocrinopathy
if patient is taking testosterone or anabolics
tests for male endocrine evaluation
FSH, LH, T, prolactin
genetic testing for male infertility
karyotype
Y chromosome microdeletion (AZF)
cystic fibrosis testing
klinefelter (XXY, hypogonadism)
transrectal US
images prostate, seminal vesicles and vas deferens
rule out obstructive infertility
scrotal US
for varicocele, epididymal abnormalities, undescended testis
anti-sperm antibodies
presence indicates autoimmune infertility
absent seminal fructose
indicates seminal vesicle issues, or duct obstruction
sperm-zona binding test
hemizona assay
measures binding to isolated ZP and this is compared to normal donor sperm
sperm penetration test
measured with hamster oocytes freed of ZP
medications which can cause male infertility
T replacement therapy anabolic steroid use chemotherapy certain antifungal meds some ulcer drugs recreational drugs
idiopathic male infertility
65+% of infertile males
environmental causes of male infertility
industrial chemicals
heavy metal exposures
radiation or xrays
overheating the testicles
ejaculation issues
retrograde ejaculation caused by diabetes, spinal cord injuries, medications, and surgery of the bladder, prostate, or urethra
genetic causes of male infertility
chromosomal defect/genetics klinefelters syndrome CF kallmanns kartageners
other pathological causes of male infertility
infection: orchitis, epididymitis, STIs hormone imbalances DM hypothyroidism undescended testicles varicocele testis tumors antisperm antibodies
what is a varicocele
dilation and tortuosity of the internal spermatic veins (pampiniform plexus) that drain the testis and are within the spermatic cord
testicular venous drainage
veins of pampiniform plexus ascend and pass along the inguinal canal
merge to form the testicular vein, which opens on the R into the IVC (at an acute angle) and on the L side into the L renal vein (at a right angle)
development of varicocele
commonly develops during puberty
affects 15% of males
most are L sides, 1% right sides and 1% bilateral
40% of men with primary infertility
presentation of varicocele
most asymptomatic, sometimes scrotal pain
most common symptom is infertility
“bag of worms”
labs associated with varicocele
volume is at normal levels
sperm count is reduced <15 mil sperm/ejaculate
normal morphology is below 4%
sperm motility is reduced
no infection of the male reproductive tract
pathophys of infertility in varicocele
associated infertility appears to be due to alteration of spermatogenesis and the function of Leydig cells, secondary to the increase in testis temperature, venous pressure, and hypoxia
varicocele treatment
surgical hydrocelectomy offers the most definitive treatment
indications for varicocele surgery
female partner has normal fertility or a reversible cause of infertility
varicocele is palpated or corroborated by ultrasound
male partner has one or more abnormal semen parameters
varicocele surgery goals and outcomes
ligation of the internal spermatic veins with preservation of the lymphatics
70% of cases have improvement of the semen quality and 30-35% natural pregnancy rates
complications of varicocele surgery
testicular hydrocele
occlusion of internal spermatic lymphatic channel during vein ligation during varicocele surgery
lack of drainage and fluid accumulation in scrotum
treatment for obstructive, undescended testis, or varicocele causes of infertility
surgery
treatment for absence of ductal system
sperm retrieval from testis or epididymis
- IVF
- ICSI
low sperm quality but good numbers
intrauterine insemination
