CUA Guideline: The workup and management of azoospermic males 2015

Question 1

what percentage of infertilities is attributed to male factor?

Answer 1

50%

Question 2

broadly speaking what are three categories of azoospermia?

Answer 2

pre-testicular (2%) - hypogondotropic hypogonadism Testicular (40-90%): maturation arrest(Azf-B), sertoli cell only(Azf-a), reduced spermatogenesis(Azf-c) post-testicular ( 7-50%)– obstruction or ejaculatory dysfunction, normal spermatogenesis but obstructive azoospermia or ejaculatory dysfunction another way is to think of Low volume, N volume

Question 3

what are three forms of assistive reproductive technologies?

Answer 3

Timed insemination( or Intrauterine insemination) in-vitro fertilization( oocytes are incubated with sperms in a dish ) intracytoplasmic sperm injection( ICSI)

Question 4

how many semen analysis are needed to confirm azoospermia in men>

Answer 4

two

Question 5

what should be done if on history you find out someone is on medicine that is potentially gonadotoxic?

Answer 5

take them off and repeat semen analysis in 3-6 months

Question 6

what is low semen volume azoospermia and what does it mean?

Answer 6

<1.5ml volume. could mean three things 1) abN SV or obstruction 2) ejaculatory duct obstruction 3) failure of emission or retrograde ejaculation

Question 7

what should you do in someone with low volume azoospermia?

Answer 7

examine them( look for vas) do a urinalysis of post ejaculate urine for presence of sperm( diabetic men can have this)

Question 8

how do you treat retrograde ejaculation?

Answer 8

take them off the alpha blocker they are on put them on pseudoephedrine or other alpha agonists

Question 9

what if you dont find sperm in post ejaculate UA of a guy with low volume azoo?

Answer 9

do imaging: look for ejaculatory duct obstruction( SV>1.5cm) absence of SV

Question 10

What are findings that may be associated with CF?

Answer 10

absence of Vas, absence of SV, ED cysts

Question 11

who should get a renal US

Answer 11

unilateral or bilateral absence of the Vas

Question 12

how is pretesticular normal volume azoospermia diagnosed?

Answer 12

low LH, FSH, T either low or Normal

Question 13

what does it mean if a guy has N volume, high FSH, high LH, small testis?

Answer 13

not obstructive, probably testicular failure( I am guessing)

Question 14

what if a guy has N semen volume, N FSH and LH?

Answer 14

could be obstructive, non-obstructive, need a biopsy in this setting

Question 15

you will find the algorithm for management of low volume azoo here

Answer 15

Question 16

who should be referred for genetic counselling or testing?

Answer 16

hypogonadotropic hypgondaism,

absence of vas or obstruction of it or ejaculatroy structures( screen both man and partner for CF)

Men with testicular failure( look for y-chromosome microdeletions)

Question 17

You will find the algorithm for Normal volume Azoo here

Answer 17

Question 18

how do you treat hypogondotropic hypogondaism?Low FSH and Lh

Answer 18

GnRH analogue

or LH/FSH analogue ( b-hcg)

Question 19

how do you treat retrograde ejacualtion?

Answer 19

try and make it anerograde with pseudophed

if it doesnt work can try and get sperm from bladder and use it for ART(ICSI or IVF, not sure if enough for IUI)

Question 20

how do you treat obstructive azoospermia?

Answer 20

1) sperm retrieval and ICSI( percutaneous, open, miscoscopic aspiration from epidydimis, open biopsy of testis)
2) microsurgical vasoepididmostomy, also take sperm at the same time in case it doesnt work
3) TUR ejaculatory duct. Use TRUS to guide your TUR, warn patient of complications

Question 21

what should you do for men with non-obstructive azoo( testicualr failure with some sperm production or otherwise- like AZF-C)

Answer 21

micro-TESE

Question 22

what can be offered to SCI patients with failure to ejcaulate?

Answer 22

vibrostimualtion or electroejaculation\BOTH can cause autonomic dysreflexia.

Question 23

what is the role of varicocelectomy in men with azoospermia ?

Answer 23

CONTROVERSIAL

can offer it to men with testicular failure, warn them it may not work and might need ICSI

Question 24

Is the use of androgens recommended for men with azoospermia?

Answer 24

No it is CONTRAINDICATED