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Andrology > Infertility > Flashcards

Infertility Flashcards

1
Q

Action of FSH

Normal level

A

semniferous tubules secrete inhibin from sertoli cells and produce sperm

2-12 IU/L

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2
Q

Action of LH

Normal level

A

leydig cells produce testosterone

2-9 IU/L

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3
Q

maturation of sperm

time taken

A

1) primary spermatocytes 46 chromosome

2) second meiotic division to form spermatids 23 chromosome
3) spermatozoa

process takes 72 days

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4
Q

structure of sperm
head
body
tail

A

head contains nucleus and acromosome capn with vesicles containing lytic enzyme
body contains mitochondria and contractile filaments extending into tail
tail

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5
Q

testosterone
normal level
bound to SHBG %

A

normal range in males is about 270-1070 ng/dL with an average level of 679 ng/dL

60% bound to SHBG
38% bound to albumin
2% is free

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6
Q

Definition infertility

A

Failure of conception after 12 months of regular unprotected sex
Infertility is defined by the inability of a sexually active, non-contraceptive couple to achieve spontaneous pregnancy within 1 year

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7
Q

chance of conception per month healthy couple and per year

A

20-25% per month
75% 6 months
90% one year

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8
Q

% couples affected infertility

A

14-25% couples affected at some point

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9
Q

frequency of intercourse during ovulation recommended

A

once a day

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10
Q

Normal sperm parameters

A

Volume = > 1.4 ml
Total sperm number (10^6 ejaculate) 39 million
Concentration (10^6/ml) 16 million/ml
Total mobility (progressive and non progressive) 42%
Progressive mobility = 30%
Morphology % normal forms = 4
PH = >7.2
Peroxidase positive leucocytes <1 million
Seminal fructose (micromole/ejaculate) = >13

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11
Q

scrotal temp vs body temp

A

2-4 degrees lower

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12
Q

drugs affecting fertility

irreversible affect

A 
Testosterone
Anabolic steroids
ADT
Chemotherapy
Opiates
5ARI
Alpha blockers

some antibiotics, spironolactone, cimetidine, nifedipine, sulfasalazine, and colchicine

Marijuana
Alcohol
Smoking

Sulfasalazine Azathioprine, Mycophenolate mofetil and Methotrexate

Testosterone, Sulfasalazine, Anabolic steroids, Cyproterone acetate, Opioids, Tramadol, GhRH analogues and Sartan - AgII receptor antagonists

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13
Q

increased risk of testicular cancer with infertility HR compared with fertile control subjects

A

3.3 to 11.9 HR

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14
Q

incidence testicular cancer

A

3-10 new cases per 100,000 males per year

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15
Q

sperm maturation time testes and epididymis transit time

A

64 days completes

5-10 days of epididymal transit time

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16
Q

incidence varicocele normal population and infertile

% with improved parameters after varicocele treatment

A

15% in general population, and 40% in infertility clinics

Improved semen parameters in approx. 70% of patients after repair

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17
Q

EAU recommendations varicocele

A

Treat in adolescents with ipsilateral reduction in volume

Clinical varicocele with abnormal semen and good female reserve

Failed assisted reproductive techniques/miscarriage

Do no treat varicocele in infertile men who have normal semen analysis and in men with subclinical varicocele

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18
Q

microdeletions

A

One of three non overlapping regions of Y chromosome
AZF a, b, c
AZFa – Sertoli only, rare 5%
AZFb – maturation arrest
Azoospermic factor c – severe oligozoospermia, can find sperm in 10-15%
Transmitted to male offspring, need genetic counselling before ART

19
Q

CBAVD
found in % infertility and OA
semen volume and PH indicators

A

CBAVD is found in 2% men with infertility and is present in 6% with obstructive azoospermia
>95% of men with CF have CBAVD
particularly those with a semen volume < 1.0 mL and acidic pH < 7.0.

20
Q

CUAVD

A

Congenital unilateral absence of the vas deferens (CUAVD) is usually associated with ipsilateral absence of the kidney (26% with UAVD there is absent kidney on ipsilateral side) and probably has a different genetic causation

21
Q

indications karyotype

A

karyotype analysis is currently indicated in men with azoospermia or oligozoospermia (spermatozoa < 10 million/mL)

22
Q

treatment retrograde ejaculation

A

pseudoephrine, Sudafed over the counter, try 60mg one tablet for a week, and an hour before do another semen analysis (120mg orally 90 minutes before ejaculation)
success rate 58%
Imiprimine 25mg
Centrifugation and resuspension (using sodium bicarbonate orally 1hr before), pregnancy rate 15%
Collegen injection into bladder neck
Acupuncture 68%

23
Q

incidence azoospermia

A

1-3% male population

10-15% of male infertile population

24
Q

Causes azoospermia OA

A

Epididymal obstruction is most common cause of OA affecting 30-67% of azoospermic men

Other sties of obstruction are intra testicular 15%, ED obstruction 1-5% and vas deferens

Congenital causes epididymal obstruction as CBAVD, detached epididymis in UDT

25
Q

causes NOA

A 
UDT
Infective – STI, UTI, mumps
Torsion
Hormonal - hypogonadism
Testicular tumours
Varicocele
26
Q

UDT and GCT

A

In 5-10% of testicular cancers there is history of UDT
Risk of GCT 3.6 to 7.4 x higher than general population
2-6% of all men with history of UDT will develop testicular cancer
Even with early orchidopexy still harbour higher risk of GCT

27
Q

indications ART

A

Surgically unable to reoncstruct eg congenital absence of vas
Men with few viable sperm in ejaculate
Azoospermic men with varicoceles - as half will achieve enough sperm to have IVF with ICSI after varicocele repaired
Men with non obstructive azoospermia

28
Q

success rate ICSI

A

Indicated in cases of severe male factor infertility
In couples with prior failed IVF
Or in cases of sperm with significant fertilising ability defects
In 2006 ICSI represented 47% of all IVF treatments in UK
Success rates pregnancy rate 20-37% per cycle
36% in women <35 years
10% in women > 40 years

29
Q 
Klinefelters 
features
chromosone
incidence
hormone profile
A 
1 in 650 live male births
47XXY
tall stature, long extremities, absent frontal balness, 
fewer chest hairs, wide hips, narrow shoulders
breast development
small testicles and penis
high FSH
low testosterone
Azoospermia
30
Q

Kallman syndrome

A 
facial asymmetry
UDT
anosmia
pituitary dysfunction
colour blindness
31
Q

azf c

chance of finding sperm on tese

A

Seen in 60% of cases of microdeletions

Can find sperm on TESE in 50%

32
Q

OA vs NOA ratio

Azoospermia in general pop vs infertile men

A

60% NOA, 40% OA

general population 1%, infertility 10-15% azoospermia

33
Q

NOA vs OA FSH, testicular size and volume

A

OA
normal testis
normal FSH
low semen volume

treatment: reconstruction or SSR/ICSI

NOA
small testis
raised FSH
normal volume
treatment: SSR (microtese, icsi), hormonal
34
Q 
Causes of OA: volume, ph, fructose, urine
Vasal/epididymal
EDO
Retograde ejaculation
Antegrade loss ejaculation
A

Vasal/epididymal: normal volume and fructose and PH
EDO: low volume <1.5cc, acidic low PH and low fructose
Retograde ejaculation: low/none volume, more than 10 sperm phf in urine
Antegrade loss ejaculation: none volume, no sperm in urine and normal PH and fructose

35
Q

treatment of retograde ejaculation pseudofed dosing

A

60-120mg 1-2 hours before ejaculation 7-10 days before ovulation
can also add / exchange in imipramine 25mg

36
Q

AD treatment (risk of electroejaculation and injury above T6)

A 
BP >20 above baseline or above 150
sit up 
loosen tight clothing, remove stimulus
nifedipine  IR 10mg sublingual or chew
1-2 sprays GTN, repeat after 30 mins
monitor BP a few hours for rebound hypertension
37
Q

pros of embolisation varicocele

A

can treat both sides
no risk arterial injury hydrocele
low learning curve

cons
chronic pain
migration coils
unable to access R>L
radiation
38
Q

papers for varicocele treatment

A 
Evers MA 
Lancet
No benefit
however flawed analysis
when choose clinically significant varicoceles with semen impaired pregnancy rate is 36% vs 20%

Abel Meguid SR
OR 3.04, NNT 5
spont pregnancy rate 32% vs 13%

39
Q

varicocele incidence gen pop vs primary infertility vs secondary infertility

A

15% gen pop
35% primary infertility
75% secondary infertility

40
Q

vasectomy reversal paper

A

Belker 1991
< 3 years patentcy 97%, pregnancy 76%
>5 years, patency 71%, pregnancy 30%
9-14 years, 80% patency 44% pregnancy

41
Q

semen quality orchidectomy papers

A

Rives 2012
semen quality

Peterson JCO 1999

50% drop in semen parameters post orchidectomy
10% will become azoospermic post orchidectomy
10% will be azoospermic before orchidectomy

42
Q

LH and FSH level

lab

A

LH 1.3-8.0mlU/ml

FSH 1.6-11.0mIU/ml

43
Q

causes of SV obstruction

A

Congenital atresia
Stone
Stenosis due to infection
Inflammation

44
Q

doing TURED

A

Joint procedure with radiology under GA

Appropriately consented pt – aware of risk of failure (early/ late- due to recurrent obstruction), small risk incontinence and retrograde ejaculation, recurrent chemical epididymitis
Transrectal probe to guide needle into dilated SV
Aspirate fluid for SA. If sperm – excludes proximal obstruction Fill SV with methylene blue
Place resection scope, and resect veru/ ejaculatory ducts, until see flush of blue into urethra. Preserve BN and sphincter
Use transrectal probe to ensure decompression of cyst and both SV’s
If no sperm on aspirate of SV, needs vasogram to exclude proximal obstruction.
May require Epididmovasostomy/ vasovasostomy/ or SSR with TESE dependent on level of obstruction

Andrology (6 decks)

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