Campbell Male Infertility 2021 Flashcards
Semen analysis should be done ___ days after ejaculation.
Increase probability of conception, frequency of intercourse: ___
Female fecundity declines after age: ___
1-2 days after ejaculation.
intercourse every day around the time of ovulation is likely the best strategy
Age 35
TRUE or FALSE
Cancer can negatively affect spermatogenesis, with or without spermatotoxic chemotherapy.
TRUE. Especially if the cancer is of testicular origin.
TICS
Toxins
Infectious/inflammatory disease
Childhood history
Sexual History
Toxins that interfere with spermatogenesis, sperm function, and sperm delivery
Antiandrogens: bicalutamide, flutamide, nilutamide Anti-HTN: spironolactone Anti-retroviral: indinavir Stavudine Corticosteroids or exogenous estrogen
Exogenous testosterone reduces spermatogenesis by: ___
Conversion to estradiol (by aromatase) –> inhibition of LH secretion by the pituitary –> reduces spermatogenesis
Opioid abuse can cause : __ which can negatively affect spermatogenesis.
Hypogonadotropic hypogonadism
Men should be encouraged to ___ before undergoing oncologic therapy.
Childhood RT doses of ___ lessened chances of having future offspring.
Crypopreserve sperm
7.5 Gy and above
Scrotal temperature is ___ below core body temperature, due to countercurrent heat exchange.
2-4 degrees Celsius
Consuming locally grown produce, effects:
Lower serum free testosterone, LH, and sperm concentration and normal sperm morphology
Hydrocele and hernia surgery during childhood can cause: ___
Vasal obstruction
** vasal occlusion as a result of inflammation associated with this material should be considered in an infertile man
Approximately ___ of men with torsion will have sperm counts below 20 mL/min.
36-39%
** Torsion disrupts intratesticular architecture inc. Sertoli cells in the blood-testis barrier –> 11% develop antisperm antibodies
Unilateral cryptorchidism, treated paternity rate: ___
Bilateral, treated, paternity rate: ___
96%
70%
Recommend orchidopexy before ___ age from a reproductive perspective.
10 years of age
Male obesity causes reproductive by: ___
overabundance of adipose cells that contain the enzyme aromatase –> peripheral conversion from testosterone –> elevated estradiol
Measurement of the testis: ___ cm is associated with spermatogenic impairment.
A volume of ___ mL is considered low
=< 4.6 cm
=< 20 mL
What is Meacham’s maxim?
Search for the vas as if perform- ing the first step of a vasectomy, bringing it to the surface of the skin.
If what is presumed to be the vas disappears from the examiner’s fingers three times, the clinician can be confident that the vas is absent.
If unilateral absence of vas deferens –> possibility of ___ and ___.
Consider doing a/an ___.
Wolffian duct development and renal agenesis
Consider doing a renal ultrasound
** In the US: cystic fibrosis gene mutation
Varicocele grading
Grade I, which is palpable only with the patient standing and performing a Valsalva maneuver
Grade II, which is palpable but not visible;
Grade III, a varicocele that is so large as to be visible by the examining physician through the rugae of the scrotum
Palpable seminal vesicles may suggest: ___
Engorgement and possible ejaculatory ductal obstruction
** seminal vesicles cannot typically be palpated
Endocrine evaluation should be done in men with ___
All men with infertility, even those in whom sperm density is greater than 20 million/mL
Lower limit for concentration of bioavailable testosterone
164 ng/dL
** 54.5 % of 300 ng/dL (54-68% bound to albumin)
Conditions with decreased SHBG (Sex Hormone–Binding Globulin)
Obesity Nephrotic syndrome Hypothyroidism Glucocorticoids, progestins, and androgenic steroid therapy Acromegaly Diabetes mellitus
Conditions with INCREASED SHBG (Sex Hormone–Binding Globulin)
Aging Hepatic cirrhosis and hepatitis Hyperthyroidism Anticonvulsant therapy Estrogen therapy Human immunodeficiency virus disease
Pituitary hypoandrogenism causes LH to ___.
Leydig cell hypoandrogenism causes LH to ___.
Pituitary: LH decreases
Leydig cell dysfunction: LH is elevated to varying degrees
FSH + testis size by caliper orchidometer
Obstructive azoospermia: ___
Non-obstructive: ___
Obstructive: FSH =< 7.6 IU/L, testis long axis > 4.6 cm
Non-obstructive (spermatogenic dysfunction): FSH > 7.6 IU/L, testis long axis <=4.6 cm
Total testosterone to estradiol ratio of ___ is suggested to indicate reproductive dysfunction.
< 10:1
Initial endocrine screening for male reproductive dysfunction
In the morning: Total testosterone SHBG Albumin LH and FSH (pituitary) Estradiol (evaluate aromatization)
Lower parameter for sperm concentration: ___
Upper parameter: ___
Lower: 13.5 million/mL (lower, likely infertile)
Upper: 48 million/mL (greater than this, likely fertile)
__ day/s of abstinence optimal for assessing bulk semen parameters.
1 day only
Threshold value for seminal hypovolemia: ___
If aspermia or seminal hypovolemia –> perform ___ and ___ to detect retrograde ejaculation
1.0 mL
Post-ejaculatory UA
TRUS (assess obstruction)
Necrozoospermia
The condition describing a large number of nonliving sperm
Conditions associated with antisperm antibody formation
vasectomy testis trauma orchitis cryptorchidism testis cancer varicocele
Pyospermia threshold (WHO)
1 million/mL
Genetic disorders affecting the 9 + 2 architecture of cilia (9 peripheral pairs + 2 central pairs of microtubules)
Immotile cilia syndrome
Primary cilia dyskinesia (PCD)
Kartagener syndrome: nearly totally immotile but metabolically active
Karyotyping should be perfomed in all males with: ___
Azoospermia from spermatogenetic dysfunction Severe oligospermia (< 5 million sperm/mL)
Recommend Y chromosomal microdeletion assessment to: ___
Azoospermic men before surgical sperm extraction (to counsel on likelihood of retrieval)
**AZFa and AZFb deletions can cause significant pathology = low likelihood of sperm retrieval
Globozoospermia
A preponderance of sperm with round heads, a condition referred to as globozoospermia, indicates deficient acrosome formation.
TX: IVF with ICSI
Varicocele imaging
Don’t rely on ultrasound as a necessary diagnostic tool
Varicoceles become palpable at 2.7-3.6 mm
Tx of varicoceles < 3.0 mm = does not improve seminal outcomes
Fluid, contrast or otherwise, should NEVER be injected into the vasal lumen in the direction of the epididymis because: ___
It will rupture the delicate epididymal tubules
**vasography has been replaced by TRUS and MRI
Most commonly identified genetic cause of male infertility
Klinefelter syndrome (47, XXY)
** results in azoospermia, small testes, and elevated gonadotropin levels
Leydig cell dysfunction: if azoospermia + low testosterone + elevated LH: treatment is ___ if patient desires paternity
Surgical sperm extraction
Kallman syndrome
Decreased pituitary function + anosmia
TX: LH replacement with HCG
FSH replacement with recombinant FSH (rFSH) or hMG
Treatment of incomplete form of hypogonadotropic hypogonadism
Anti-estrogenic agents to stimulate the pituitary:
Clomiphene citrate
Tamoxifen
Anastrozole
Letrozole
In general, mild elevations of prolactin in the range of 20 to 50 μg/L do not warrant further evaluation; if prolactin is significantly elevated, ___ is indicated
Cranial MRI
Varicoceles negatively affect male reproductive function by: ___
Increase in intratesticular temperature secondary to interruption in the countercurrent heat exchange provided in the pampiniform plexus with opposing flow vectors in a central arterial system and surrounding veins
Obstruction of the ejaculatory ducts:
< 5% of men with azoospermia
Suspect if < 1.0mL volume semen
Imaging: TRUS, MRI, chromotubation, hydarulic measurements
TRUS-guided SV aspiration: =>3 sperm per high-powered field - suggestive of obstruction
TX: TURED if amenable
Treatment for retrograde ejaculation
Synephrine, pseudoephedrine, ephedrine, or phenylpropanolamine, with approximately one in four patients achieving antegrade ejaculation
