Infertility Flashcards
What are the specific goals of evaluation of infertile male:
Identify:
- potentially correctable conditions
- irreversible conditions that are amenable to ART using sperm of male partner
- irreversible conditions not amenable → donor sperm or adoption
- life- or health-threatening conditions underlying or associated medical comorbidities
- genetic abnormalities or lifestyle and age factors that may affect male patient or offspring (esp is ART employed)
When should infertility be evaluated?
After 6 months of attempted conception when a female partner is > 35 yo.
For infertility evaluation whom should be evaluated and what is included evaluation?
GUIDELINE STATEMENT 1
initial fertility eval, both male and female partners should undergo concurrent evaluation
GUIDELINE STATEMENT 2
evaluation should include reproductive history and one or more semen analysis (if 2, at least 1 mo apart)
Reference limits for SA by WHO:
Semen volume → 1.5 mL
Total Sperm # → 39 milllion/ejaculate
Sperm Concentration → 15 million/mL
Vitality → 58%
Progresive Motility → 40%
Total Motility → 40%
Morphology Normal Forms → 4%
Types of sperm abnormalities:
Azoospermia → no sperm
Teratozoospermia → abnormal form (macrospermia - large, globospermia - round - could be WBC)
Necrozoospermia → dead sperm
Asthenozoospermia → reduced or absent or aberrant motility
Whom should evaluate men with abnormal SA?
GUIDELINE STATEMENT 3
men with one or more abnormal semen parameters should be evaluated by male reproductive expert:
complete H&P
directed tests as indicated
Evaluation of male should be considered particularly when couples have:
GUIDELINE STATEMENT 4
Failed ART or recurrent reproductive losses (RPL)
Clinicians should counsel infertile men or with abnormal SA of which health risks associated with abnormal semen parameters:
GUIDELINE STATEMENT 5
infertility or abnormal SA may be harbinger of medical dz
Proven: testicular cancer, mortality, charleston comorbidity index
Possible: DMII, , MS, chronic epididymtiis
Unclear: prostate cancer, melanoma, other cancer, STI, thyroid disorders
Infertile men with specific conditions should be informed of which associated health conditions?
GUIDELINE STATEMENT 6
pts with identifiable causes of infertility should be informed of relevant, associated conditions
Klinefelters: testosterone deficiency (possible perinatal disorders, anomalies, genetic disorders, respiratory disorders, CVD, endocrine, malignant neoplasms)
Cystic Fibrosis: tooth enamel defects, pulmonary, pancreatic
Hypospadias: urinary anomalies
Cryptorchidism: testicular cancer
Testosterone deficiency: DMII, metabolic disorder, CVD, HTN, all cause mortality, CVD mortality, alzheimer’s (possible PAD, rapid bone lose, lung and testicular cancer, CCI, prostate cancer)
Couples with advanced paternal age (>40) should be counseled of increased risk:
GUIDELINE STATEMENT 7
of health outcomes for their offspring
(germ line mutations, chromosomal abnormalities, birth defects, chondrodysplasia, schizophrenia, autism)
What are risk factors associated with male infertility that should be discussed and counseled:
GUIDELINE STATEMENT 8
lifestyle, medication usage, environmental exposures
(i.e. obesity, diet, alcohol, smoking, steroids, stress, pesticides, metals [lead, zinc, copper], chemicals)
current data on majority of risk factors are limited
Results from SA should be used to:
GUIDELINE STATEMENT 9
guide mgmt. of patient, greatest clinical significance when multiple abnormalities present (OR of infertility inc with more abnormal parameters)
What labs are important in infertile men and for what indications?
GUIDELINE STATEMENT 10
FSH and testosterone
Low T < 300 → LH, estradiol, prolactin
impaired libido, ED, oligozoospermia, azoospermia, atrophic testis, evidence of hormonal abnormality on PE
Azoospermic men should be evaluated with what tests and why?
GUIDELINE STATEMENT 11
semen volume, PE, FSH
differentiate obstruction vs. impaired production
(low volume, acidic pH → obstruction)
Patient with primary infertility and azoospermia or severe oligospermia (< 5 million sperm/mL) (non-obstructive) should have:
GUIDELINE STATEMENT 12
Karyotype and Y-chromosome microdeletion analysis
likely have elevated FSH and testicular atrophy (possible impaired sperm production)
Patients with vasal agenesis or idiopathic obstructive azoospermia should have? what should partner have if concern?
GUIDELINE STATEMENT 13
CFTR mutation carrier testing (5T allele) q31.2 of Ch. 7
GUIDELINE STATEMENT 14
Men with CFTR, partner should have genetic evaluation
What is NOT recommended in initial evaluation of infertile couple?
GUIDELINE STATEMENT 15
DNA fragmentation analysis
GUIDELINE STATEMENT 18
Antisperm antibody (ASA) testing
*trauma, mumps, testis malignancy, vasal obstruction, vasectomy, patency of genital tract
GUIDELINE STATEMENT 21
Scrotal US
GUIDELINE STATMENT 22
TRUS
What could increased round cells on SA indicate? What concentration is concerning? What should patients be evaluated for? How do you treat infertility due to chronic prostatitis?
GUIDELINE STATEMENT 16
>1 million/mL differentiate from WBC (pyospermia)
*special stains differentiate germ cells from somatic cells
GUIDELINE STATEMENT 17
pyospermia should be evaluated for infection
*chronic prostatitis, abx 6 weeks, dx by alkaline pH and leukocytes on SA
What is the utility for testing antisperm antibodies? How are they tested? How treated?
GUIDELINE STATEMENT 18
ASA should not be done on initial evaluation
When it would change treatment → (poor motility-isolated asthenospermia, agglutination, or abnormal post-coital test, or unexplained):
trauma, mumps orchitis, testis malignancy, vasal obstruction, vasectomy that disrupts the blood-testis barrier, or the patency of the male genital tract allowing sperm antigens or genital tract infections to generate ASA → can result in sperm agglutination in the semen
- Mixed agglutination: mix sperm with RBC coated in human Ab, ASA will cause linking and agglutination of RBC
- Immunobead assay: polysaccharide beads with rabbit anti-human Ab, beads bind to sperm containing ASA
TX: oral steroids, ART
When couples have RPL, what tests are appropriate?
GUIDELINE STATEMENT 19
Karyotype and sperm DNA fragmentation
In differentiating between obstructive and non-obstructive azoospermia is there a role for dx testicular bx?
GUIDELINE STATEMENT 20
NO
*predicted from clinical and lab tests without surgical dx biopsy
*FSH >7.6 and testis longitudinal axis < 4.6 → 89% chance of spermatogenic dysfunction
When should clinicians recommend TRUS for infertility?
GUIDELINE STATEMENT 22
Not on initial evaluation
In men with SA suggestive of ejaculatory duct obstruction (EDO) (i.e. acidic-pH < 7, azoospermic, semen volume < 1.5 mL, normal serum T, palpable vas deferens)
For isolated small or moderate right varicocele, is any other imaging indicated routinely?
GUIDELINE STATEMENT
NO, abdominal imaging for this sole indication
(only consider if large and non-reducible)
What abdominal imaging is recommended if vasal agenesis is present?
GUIDELINE STATEMENT 24
Renal US to evaluate for renal abnormalities
(male genital tract derive from Wolffian or mesonephric tract, paired which forms epididymis, vs, SV → anomalies can lead to renal anomalies)
When should surgical varicocelectomy be considered for infertility? When should it not?
GUIDELINE STATEMENT 25
in men attempting to conceive who have palpable varicocele, infertility, and abnormal semen parameters, except azoospermic men
GUIDELINE STATEMENT 26
men with non-palpable varicoceles detected solely on imaging
In men with clinical varicocele and non-obstructive azoospermia, what is recommended?
GUIDELINE STATEMENT 27
absence of evidence supporting varicocele repair
proceed to ART
How is sperm retrieval recommended in men with NOA? Should any pharmacologic manipulation be utilized prior to surgical intervention?
GUIDELINE STATEMENT 28
microdissection testicular sperm extraction (micro-TESE)
*micro-TESE → wide opening of tunica albuginea to allow exam of multiple regions of tissue, each oriented in centrifugal pattern to parallel blood supply, allowing extensive search of all testis areas with limited devascularization
GUIDELINE STATEMENT 45
Patients with NOA there is limited data supporting pharmacologic manipulation such as SERMs, AIs, and gonadotropins prior to sx intervention
Sperm surgically retrieved fro ICSI may be:
GUIDELINE STATEMENT 29
fresh or cryopreserved
Where may sperm be extracted in men with obstructive azoospermia?
GUIDELINE STATEMENT 30
Testis or epididymis
In men with aspermia, how may sperm collection be performed?
GUIDELINE STATEMENT 31
surgical sperm extraction, induced ejaculation (sympathomimetics, vibratory stimulation or electroejaculation)
Infertility associated with retrograde ejaculation may be treated with:
GUIDELINE STATEMENT 33
sympathomimetics and arlkalinization of urine with or without urethral catheterization, induced ejaculation, or surgical sperm retrieval
After vasectomy, what are options for couples desiring conception:
GUIDELINE STATEMENT 33
surgical reconstruction, surgical sperm retrieval, reconstruction with sperm retrieval for cryopreservation
Patients with vasal or epididymal obstructive azoospermia, what procedure may be successful in returning sperm to ejaculate:
GUIDELINE STATEMENT 34
microsurgical reconstruction
For infertile men with azoospermia and EDO, what are options to improve/assist in fertility?
GUIDELINE STATEMENT 35
transurethral resection of ejaculatory ducts or surgical sperm extraction (TESE, TESA, percutaneous epididymal sperm aspiration PESA)
(TRUS > 15 mm A/P diameter SV, dilated vasal ampula > 6 mm, prostatic cysts)
How may male infertility be managed through advances:
GUIDELINE STATEMENT 36
ART through IVF/ICSI
What should clinicians advise an infertile couple with low total motile sperm count on repeated SA?
GUIDELINE STATEMENT 37
IUI success may be reduced and treatment with ART (IVF/ICSI) may be considered
Patients with hypogonadotropic hypogonadism SHOULD be advised of what in regards to fertility?
GUIDELINE STATEMENT 38
determining and treating the baseline etiology for disorder is recommended
What can be used to treat infertile men with low testosterone?
GUIDELINE STATEMENT 39
Aromatase inhibitors (AIs), hCG, or selective estrogen receptor modulators (SERMs–Clomiphene)
or combination thereof
hCG is FDA approved, others are not
GUIDELINE STATEMENT 40
for men interested in current or future fertility, testosterone monotherapy should not be prescribed
Patients with hyperprolactinemia SHOULD be advised of what in regards to fertility?
GUIDELINE STATEMENT 41
evaluate and treat etiology accordingly
(decreased libido and/or impotence and/or testosterone deficiency with low/low normal LH → prolactin level)
*medications can inhibit dopaminergic inhibition of prolactin → elevated prl
opioids, antipsychotics, antidepressants, antiemetics, prokinetics, antihypertensives
hypothyroidsim, stress, elevated estrogen, CKD, chest wall injuries
Patients with idiopathic infertility should be counseled about treatment options:
GUIDELINE STATEMENT 42
use of SERMs has limited benefits relative to the results of ART
GUIDELINE STATEMENT 44
consider treatment using FSH analogue with aim to improve sperm concentration, pregnancy rate, live birth rate
(not FDA approved)
In regards to fertility, what should clinicians counsel patients about supplements:
GUIDELINE STATEMENT 43
supplements (antioxidants and vitamins) are questionable, inadequate to support specific agents for this purpose
What should clinicians discuss in regards to planned gonadotoxic therapies:
GUIDELINE STATEMENT 46
effects on decrease/altered sperm production prior to commencing therapy (chemo/RT)
GUIDELINE STATEMENT 47
pts undergoing chemo and/or RT should avoid pregnancy for at least 12 months after completing tx
GUIDELINE STATEMENT 48
encourage sperm banking, preferably multiple specimens, prior to commencement of tx
GUIDELINE STATEMENT 49
defer SA after gonadotoxic tx at least 12 (preferably 24) months after tx completed
Name high risk and intermediate risk gonadotoxins:
high risk: cyclophosphamide, ifosfamide, busulfan, chlorambucil, procarbazine, mechlorethamine, MOPP, CHOP
intermediate risk: cisplatin, carboplatin, oxaplatin, doxorubicin, taxanes, paclitaxel, docetaxel, cabazitaxel, ABVD, BEP
What risks regarding infertility should be discussed with patients undergoing RPLND?
GUIDELINE STATEMENT 50
aspermia
GUIDELINE STATEMENT 51
obtain post-orgasmic UA for men with aspermia
*ejaculation if reflex involving interplay of somatic, sympathetic, and parasympathetic pathways
Emission: sympathetic spinal cord reflex, fail to deposit sperm into prostatic urethra
Expulsion: antegrade flow through combined sympathetic and somatic pathways (urethral muscles and bladder neck closure), sympathetic nerve damage → failure of bladder neck to contract, semen can pass retrograde to bladder
Lumbar sympathetics T10-L2
Men persistently azoospermic after gonadotoxic therapies, best treatment option?
GUIDELINE STATEMENT 52
TESE
What are important questions to ask at an initial male infertility visit?
- (C) Childhood/birth issues illness/issue (viral orchitis or cryptorchidism)
- (M) ED, low libido, ejaculatory problems, prior fertility
- (F) Family hx of reproductive failure, birth defects, MR, or CF
- (I) Epididymitis or urethritis
- (T)Genital Trauma or prior pelvic or inguinal surgery
- (E) Gonadotoxin exposures such as RT, chemo, meds/supplements, recreational drugs (cannabis), use of lubricants
- (N) Prior neoplasia such as testicular cancer
What elements of PE are important for infertility evaluation?
- Masses on DRE
- Penile Abnormalities
- Presence of varicocele
- Secondary sex characteristics (body habitus, hair distribution, gynecomastia)
- Testis size and consistency
- Presence of consistency of Vas Deferens
What instructions should be given to patient prior to collecting SA for fertility?
- If case of febrile illness, should wait 2 months after illness resolved
- Period of abstinence 2-7 days prior
- Semen can be collected by masturbation or by intercourse using special collection condom that do not contain substances detrimental to sperm
- Semen can be collected at lab or home, should be kept room/body temp during transport and examined w/in 1 hour
What elements of physical exam would suggest obstructive azoospermia?
- Absence of vas deferens
- History of inguinal/scrotal surgery (usually b/l)
- Hx of urethritis
- Low fructose levels in ejaculate
- Low volume ejaculate
- Midline mass felt on DRE
- Normal FSH
- Normal testis size
- TRUS findings: enlarged SV or ejaculatory ducts, midline prostatic cyst in urethra
What genetic conditions result in azoospermia and how do you test for them?
- CF mutation, b/l absence of vas deferens → CFTR (5T allele)
- Klinefelters Syndrome → Karyotype (47, XXY)
- Structural Chromosomal disorders → Karyotype (translocation)
- Y chromosome microdeletions → Y chromosome microdeletions assay (A/B no sperm, C sometimes)
Acceptable medications to treat hypogonadism in those desiring fertility? Unacceptable?
Acceptable
- Aromatase inhibitors (AIs: Anastrozole, Letrozole) → prevent conversion of testosterone to estradiol, thus decreasing negative feedback of estrogen at pituitary/hypothalamus level, thereby enhancing indirectly LH and FSH excretion from anterior pituitary
- hCG injection (2500-5000 IU 1-3 x week for 12-15 weeks) → biological activity of LH, directly stimulating testes to produce testosterone
- Selective estrogen receptor modulators (SERMs: Clomiphene citrate 25-50 mg/day x 3-6 mo, Tamoxifen) → blocks negative feedback of estrogen at pituitary/hypothalamus level, thereby enhancing indirectly LH and FSH excretion from anterior pituitary, increased LH/FSH should increase T production and spermatogenesis
Unacceptable
- Exogenous testosterone → increases negative feedback on hypothalamus and pituitary, resulting in low gonadotropins and low testicular testosterone which can inhibit spermatogenesis
Appropriate sperm extraction for NOA?
- Micro-TESE
- TESA (testicular sperm aspiration)
- TESE
- Testicular mapping (multiple percutaneous bx according to template)
Appropriate sperm extraction in patient who had prior vasectomy (obstructive azoospermia)?
- MESA (microsurgical epididymal aspiration)
- PESA (percutaneous epididymal sperm aspiration)
- TESA
- TESE
- Vasal sperm extraction (during vasovasostomy)
How do you properly examine for varicocele?
- Scrotum should be warm (warm room, hands, heating pad)
- Determine testis size and consistence
- Examine prone and standing
- Examine during a Valsalva maneuver
What are grades of varicoele?
Grade 1 → palpable only with patient performing Valsalva
Grade 2 → palpable w/o Valsalva
Grade 3 → visible through scrotal skin
What are common theories of varicocele pathophysiology on fertility?
**hyperthermia → pampiniform plexus encircle testicular arteries, counter-current exchange to cool arterial blood reaching testis, varicoceles may affect this and elevate temperature, affect enzymatic function?
**hypoperfusion leading to hypoxia → increase in venous pressure elicits compensatory vasoconstriction in pre-capillary arterioles as mechanism to down-regulate arterial flow
**increased ROS → DNA fragmentation
**reflux of metabolic toxins from adrenal and/or kidney → toxic on testis?
**testicular hormonal imbalance → Leydig cell dysfunction and decreased intratesticular T
What would you do if you found a right sided Grade 3 varcicocele?
RP imaging to r/o mass causing obstruction of right internal spermatic vein
Indications for varicocele repair in infertile male? in general?
- semen abnormalities (oligoasthenozoospermia)
- palpable varicocele
- infertility (> 1 year attempting)
- female has normal fertility and young
Also:
- Adolescents with objective evidence of reduced ipsilateral testicular flow
- Adult men with palpable varicocele and abnormal SA not currently attempting but possibly in future to improve or stabilize semen parameters
- Pain, sx may not relieve pain (heaviness/dull ache, exacerbated by strenuous activity), if conservative measure prove inadequate
What are the methods of varicocele repair?
Inguinal ligation (Ivanissevich procedure): incise over inguinal crease, incise external oblique aponeurosis, avoid ilioinguinal nerve, mobilize cord, dissect out cord and identify dilated spermatic veins, cut, clamp, ligate (usually 3), preserve testicular artery, close in layers
Laparoscopic varicocelectomy
Optimal magnification
Percutaneous venous occlusion (embolization)
RP high ligation (Palomo procedure): incise over internal inguinal ring, incise external oblique aponeurosis, spit internal oblique muscle, push peritoneum medial, clamp, cut, ligate (usually 3), preserve testicular artery, close in layers
Subinguinal ligation: make subinguinal incision, mobilize cord, ligate all veins, leave 2-3 lymphatics, preserve testicular artery, close in layers
Describe complications of varicocele embolization:
- Epididymo-orchitis
- injury at puncture site (bleeding, false aneurysm, inadvertent cannulation of femoral artery)
- pampiniform plexus phlebothomosis and phlebitis
- radiation exposure
- skin infection
- spasm/dissection/perforation of venous tract
- contrast allergy reaction
Describe complication of varicocelectomy:
- Hematoma
- Hydrocele formation
- Injury to vas deferens: if done perform VV with 9-0 or 10-0 nylon sutures
- skin/wound infection
- testicular artery injury (testicular atrophy): can use vasodilator such as paparverine or 0.25% mepivacaine
- failure (varicocele persistence/recurrence): can be caused by missing a vein or by compression of L renal vein on SMA “nut cracker syndrome”
What is a “stress pattern” on SA?
consists of low count, poor motility, and poor morphology
consistent with varicocele but represent abnormal testicular function w or w/o varicocele
How do you follow efficacy of varicocelectomy done for infertility
Q3 mo semen analysis for 1 year
Risk factors for infertility:
- Loss of libido
- Reduction or loss of accessor glands
- Cryptorchidism
- Leydig cell hyperplasia
- Sertoli cell only
- DSD
- CF
- Retrograde ejaculation
- Anejaculation
How is an infertile FEMALE evaluated:
- H&P
- Hormonal profile
- Basal body temp
- Hysterosalpingogram
- Post-coital test
- Laparoscopy
What is sperm penetration assay (SPA)?
post coital testing in cases of hyperviscous semen, unexplained infertility, low or high volume specimens with good density
microscopic exam of cervical mucus shortly before ovulation w/in hours of intercourse to ID presence of sperm in mucus (normal >10-20 sperm/hpf with progressive motility)
How do you treat vasal or epididymal obstruction
VV
vasoepididymostomy
epididymal sperm extraction
How do you retrieve sperm from bladder?
- alkalinize urine 1 day before w/ NaHCO3
- Empty bladder to urethral cath
- rinse bladder with LR, leave 2 mL in bladder
- Masturbation
- Patient voids or sperm harvested with catheter
- concentrated w/centrifugation or ART
How can fructose guide determination of type of azoospermia?
Negative Fructose → low ejaculate volume, seminal vesicle fluid not present
(EDO, primary/secondary testicular failure, b/l congenital absence vas, ejaculatory dysfunction)
Positive Fructose → retrograde ejaculation, b/l vasal obstruction, incomplete specimen collection since SV secretions presents
Algorithm for Azoopermic male:
CF in regards to infertility shows which symptoms?
Male infertility (99%)
absent/defective vas deferens, epididymis, or SV
Dihydrotestosterone is produced from:
A. PSA
B. Luteinising hormone (LH)
C.Dehydroepiandrosterone(DHEA)
D. Follicle-stimulating hormone (FSH)
C.Dehydroepiandrosterone(DHEA)
Diabetes-induced erectile dysfunktion may benefit from chronic vardenafil therapy through effect on:
A. Down regulation of Caveolin receptors
B. Signal transduction upregulation of suppressin-3
C. Increase in vasoactive intestinal polypeptide expression
D. The endothelial NOS: Caveolin-1 ratio (eNOS/Caveolin-1)
D. The endothelial NOS: Caveolin-1 ratio (eNOS/Caveolin-1)
What is NOT a mechanism by which diabetes can result in erectile dysfunction?
A. Atherosclerosis
B. Ischaemic priapism
C. peripheral neuropathy
D. Endothelial dysfunction
B. Ischaemic priapism
The most important gene for male genital development is:
A. amh
B. azf
C. cftr
D. sry
D. sry
Which is a secondary form of hypogonadism?
A. Klinefelters syndrome
B. Kallmans syndrome
C. Adrenal insufficency
D. Prolactinoma
B. Kallmans syndrome
Which is the correct order of the spermatogenesis process?
- Spermatozoa
- Spermatids
- Primary spermatocyte
- Spermatogonium
- Secondary spermatocyte
A. 3-5-4-2-1
B. 4-3-5-2-1
C. 4-2-3-5-1
D. 3-5-2-4-1
B. 4-3-5-2-1
Spermatogonium Primary spermatocyte Secondary spermatocyte Spermatids Spermatozoa
What diagnostic measure is needed to confirm a diagnosis of azoospermia?
A. At least 1 centrifuged semen specimen
B. At least 2 centrifuged semen specimens
C kariotype analysis
D. Spermiogram is usually enough
B. At least 2 centrifuged semen specimens
What term is used to denote a state in which semen analysis shows motile spermatozoa to be lower than 32%?
A. Cryptozoospermia
B. Oligozoospermia
C. Tragozoospermia
D. Asthenozoospermia
D. Asthenozoospermia
How many layers comprise the tunica albuginea of the penile corpora cavernosa?
A. 1
B. 2
C. 3
D. 4
B. 2
Which area of the central nervous system is responsible for activating an erection?
A. Cerebral cortex
B. Nucleus paragigantocellularis
C. Preoptic medial area
D. Hypothalamic paraventricular nucleus
D. Hypothalamic paraventricular nucleus
Which pharmaceutical has the longest half-life?
A. Avanafil
B. Vardenafil
C. Tadalafil
D. Sildenafil
C. Tadalafil
Which is the most common cause of male infertility?
A. Varicocele
B. Testicular dysgenesis
C. Urogenital infections
D. Obstruction of the seminal path
B. Testicular dysgenesis
Which is adviced for monitoring patients who are on testosterone therapy for male hypogonadism?
A. Perform a DEXA scan every year
B. Measure Hematocrit, testosterone and PSA at 3,6 and 12 months and thereafter annually
C. Measure PSA, SHBG, LH and testosterone every 6 months
D. Measure PSA and testosterone at 3 and 6 months and thereafter annually, and perform a DEXA scan after 1 year
B. Measure Hematocrit, testosterone and PSA at 3,6 and 12 months and thereafter annually
What is the proportion of male-infertility-associated factors volontary childless couples?
A. 5-10% of the cases
B. 20-30 % of the cases
C. 40-50 % of the cases
D. 60-70 % of the cases
C. 40-50 % of the cases
What is the prevalence of varicocele in the general adult population?
A. 6%
B. 12%
C. 18%
D. 24%
B. 12%
Question 1: Topic - Vasal Fluid and Surgical Procedures
Clinical Vignette: A 42-year-old male presents for a vasectomy reversal. During the procedure, the surgeon notices that the vasal fluid is “copious, crystal clear, and watery.” What is the recommended surgical procedure?
A) Vasovasostomy
B) Vasoepididymostomy
C) Either Vasovasostomy or Vasoepididymostomy
D) None, abandon the procedure
Correct Answer: A) Vasovasostomy
In-depth Explanation:
A) Vasovasostomy: The correct answer. According to the table, when vasal fluid appears “copious, crystal clear, and watery,” it suggests the absence of sperm, and a vasovasostomy is recommended.
B) Vasoepididymostomy: Incorrect. This procedure is typically recommended when vasal fluid is either scant or appears like thick white toothpaste.
C) Either Vasovasostomy or Vasoepididymostomy: Incorrect. The table specifies vasovasostomy for this appearance of vasal fluid.
D) None, abandon the procedure: Incorrect. The table provides a recommended surgical procedure based on the fluid’s appearance.
Question 2: Topic - Vasal Fluid and Intraoperative Evaluation
Clinical Vignette: During a vasectomy reversal, a urologist encounters vasal fluid that is “scant and without any granuloma at the vasectomy site.” What would an intraoperative evaluation of aspirate likely reveal?
A) No sperm or sperm heads
B) Sperm with tails, including short tails, motile or nonmotile
C) Fluid with occasional grapelike clusters of sperm heads
D) Many sperm heads, often with acrosome visible
Correct Answer: A) No sperm or sperm heads
In-depth Explanation:
A) No sperm or sperm heads: Correct. The table indicates that “scant fluid, no granuloma at vasectomy site” is associated with no sperm or sperm heads.
B) Sperm with tails, including short tails, motile or nonmotile: Incorrect. This finding is associated with “copious, cloudy thin, water-soluble” fluid.
C) Fluid with occasional grapelike clusters of sperm heads: Incorrect. This is related to “any fluid.”
D) Many sperm heads, often with acrosome visible: Incorrect. This finding corresponds to “copious, creamy yellow, water-insoluble” fluid.
Memory Tool: “No granule, No gamete. Scant fluid with no granuloma means no sperm.”
Reference Citation: Based on paragraph referring to TABLE 67.2.
Rationale for the Question: Understanding intraoperative findings based on vasal fluid can inform surgical decisions.
Clinical Vignette: A 35-year-old male is undergoing vasectomy reversal. The vasal fluid is described as “copious, creamy yellow, and water-insoluble.” What would an intraoperative evaluation of aspirate likely reveal?
A) Many sperm heads, often with acrosome visible
B) No sperm
C) Fluid with occasional grapelike clusters of sperm heads
D) Barbotage fluid reveals sperm, usually with tails, often motile
Correct Answer: A) Many sperm heads, often with acrosome visible
In-depth Explanation:
A) Many sperm heads, often with acrosome visible: Correct. According to the table, “copious, creamy yellow, water-insoluble” fluid is associated with many sperm heads, often with the acrosome visible.
B) No sperm: Incorrect. This finding is linked with “copious, crystal clear, watery” fluid.
C) Fluid with occasional grapelike clusters of sperm heads: Incorrect. This is associated with “any fluid.”
D) Barbotage fluid reveals sperm, usually with tails, often motile: Incorrect. This finding corresponds to “scant fluid, granuloma present at vasectomy site.”
Memory Tool: “Creamy and Yellow, say Hello to many a Sperm Fellow!”
Reference Citation: Based on paragraph referring to TABLE 67.2.
Rationale for the Question: Recognizing intraoperative findings from the vasal fluid’s appearance is important for real-time surgical decision-making.
Clinical Vignette: During a vasectomy reversal, the urologist notices “scant fluid with a granuloma present at the vasectomy site.” What is the recommended surgical procedure?
A) Vasovasostomy
B) Vasoepididymostomy
C) Either Vasovasostomy or Vasoepididymostomy
D) None, abandon the procedure
Correct Answer: A) Vasovasostomy
In-depth Explanation:
A) Vasovasostomy: Correct. The table suggests vasovasostomy for “scant fluid, granuloma present at vasectomy site.”
B) Vasoepididymostomy: Incorrect. This procedure is suggested for scant fluid without a granuloma or with other characteristics like thick white toothpaste-like appearance.
C) Either Vasovasostomy or Vasoepididymostomy: Incorrect. The table specifies vasovasostomy for this specific fluid appearance and condition.
D) None, abandon the procedure: Incorrect. The table provides a recommended procedure based on the fluid’s characteristics.
Memory Tool: “Granuloma is grand for Vasovasostomy, no second thoughts!”
Reference Citation: Based on paragraph referring to TABLE 67.2.
Rationale for the Question: This question tests whether the examinee can correctly identify the surgical procedure based on both the vasal fluid and additional features like granuloma.
Clinical Vignette: A urologist performs a vasectomy reversal and finds that the intraoperative evaluation of aspirate reveals “sperm with tails, including short tails, motile or nonmotile.” What is the recommended surgical procedure?
A) Vasovasostomy
B) Vasoepididymostomy
C) Either Vasovasostomy or Vasoepididymostomy
D) None, abandon the procedure
Correct Answer: A) Vasovasostomy
In-depth Explanation:
A) Vasovasostomy: Correct. The table specifies that when aspirate shows “sperm with tails, including short tails, motile or nonmotile,” a vasovasostomy is recommended.
B) Vasoepididymostomy: Incorrect. This is typically recommended when the vasal fluid is either scant or thick and white like toothpaste.
C) Either Vasovasostomy or Vasoepididymostomy: Incorrect. The table is clear about recommending vasovasostomy for this specific sperm finding.
D) None, abandon the procedure: Incorrect. The table provides a specific surgical procedure based on these sperm findings.
Memory Tool: “Tails tell tales; Vasovasostomy prevails!”
Reference Citation: Based on paragraph referring to TABLE 67.2.
Rationale for the Question: This question focuses on identifying the correct surgical procedure based on intraoperative sperm findings, crucial for clinical decision-making.
Clinical Vignette: A patient is undergoing a vasectomy reversal. The vasal fluid appears to be “scant white thin fluid.” What would the intraoperative evaluation of aspirate likely show?
A) No sperm or sperm heads
B) Fluid with occasional grapelike clusters of sperm heads
C) Barbotage fluid reveals sperm, usually with tails, often motile
D) Many sperm heads, often with acrosome visible
Correct Answer: A) No sperm or sperm heads
In-depth Explanation:
A) No sperm or sperm heads: Correct. The table indicates “scant white thin fluid” is associated with no sperm or sperm heads.
B) Fluid with occasional grapelike clusters of sperm heads: Incorrect. This finding is related to “any fluid.”
C) Barbotage fluid reveals sperm, usually with tails, often motile: Incorrect. This corresponds to “scant fluid, granuloma present at vasectomy site.”
D) Many sperm heads, often with acrosome visible: Incorrect. This is associated with “copious, creamy yellow, water-insoluble” fluid.
Memory Tool: “Scant and white, sperm out of sight!”
Reference Citation: Based on paragraph referring to TABLE 67.2.
Rationale for the Question: This tests the examinee’s ability to predict intraoperative findings from the vasal fluid description, key in choosing the right course of action.
Clinical Vignette: A 40-year-old man is undergoing a vasectomy reversal. The vasal fluid is described as “scant fluid with a granuloma present at the vasectomy site.” What would barbotage fluid likely reveal?
A) Many sperm heads, often with acrosome visible
B) No sperm or sperm heads
C) Fluid with occasional grapelike clusters of sperm heads
D) Sperm, usually with tails, often motile
Correct Answer: D) Sperm, usually with tails, often motile
In-depth Explanation:
A) Many sperm heads, often with acrosome visible: Incorrect. This finding is associated with “copious, creamy yellow, water-insoluble” fluid.
B) No sperm or sperm heads: Incorrect. This is typically associated with “scant white thin fluid” or “copious, thick white toothpaste-like” fluid.
C) Fluid with occasional grapelike clusters of sperm heads: Incorrect. This corresponds to “any fluid.”
D) Sperm, usually with tails, often motile: Correct. According to the table, barbotage fluid in “scant fluid, granuloma present at vasectomy site” reveals sperm that are usually tailed and often motile.
Memory Tool: “Granuloma with scant? The sperm aren’t absent; they dance!”
Reference Citation: Based on paragraph referring to TABLE 67.2.
Rationale for the Question: This question aims to evaluate the examinee’s understanding of how additional findings like a granuloma could affect the intraoperative evaluation of aspirate.
Clinical Vignette: During a vasectomy reversal, the surgeon finds any kind of fluid during the intraoperative evaluation. What is the appearance of the aspirate likely to reveal?
A) No sperm or sperm heads
B) Many sperm heads, often with acrosome visible
C) Fluid with occasional grapelike clusters of sperm heads
D) Sperm with tails, including short tails, motile or nonmotile
Correct Answer: C) Fluid with occasional grapelike clusters of sperm heads
In-depth Explanation:
A) No sperm or sperm heads: Incorrect. This typically corresponds to “scant white thin fluid” or “copious, thick white toothpaste-like” fluid.
B) Many sperm heads, often with acrosome visible: Incorrect. This is associated with “copious, creamy yellow, water-insoluble” fluid.
C) Fluid with occasional grapelike clusters of sperm heads: Correct. The table specifies that any fluid could have this appearance.
D) Sperm with tails, including short tails, motile or nonmotile: Incorrect. This corresponds to “copious, cloudy thin, water soluble” fluid.
Memory Tool: “Any fluid type, look for grape-like!”
Reference Citation: Based on paragraph referring to TABLE 67.2.
Rationale for the Question: The question gauges understanding of how the description “any fluid” impacts intraoperative sperm findings.
Clinical Vignette:
You are consulting a 35-year-old man with obstructive azoospermia. You’re discussing surgical sperm retrieval options.
Multiple Choice:
A. MESA is suitable for nonobstructive azoospermia
B. MESA requires local anesthesia
C. MESA allows a large number of sperm to be harvested
D. MESA has a high complication rate
Correct Answer:
C. MESA allows a large number of sperm to be harvested
In-Depth Explanation:
A. Incorrect. MESA is not indicated for nonobstructive azoospermia.
B. Incorrect. MESA requires anesthesia and microsurgical skills.
C. Correct. MESA allows a large number of sperm to be harvested for cryopreservation.
D. Incorrect. MESA, being a microsurgical procedure, has a lower complication rate.
Memory Tool:
“MESA means Many Eggs, So Amazing!” to remember that a large number of sperm can be harvested.
Specific Reference Citation:
Table 67.4, Advantages of MESA
Rationale for Question:
This question tests the examinee’s understanding of the advantages of the MESA procedure, which is critical for clinical decision-making.
Clinical Vignette:
A 38-year-old male patient is concerned about potential complications related to sperm retrieval techniques.
Multiple Choice:
A. PESA does not require microsurgical skills
B. PESA is highly successful in obtaining sperm
C. PESA is ideal for nonobstructive azoospermia
D. PESA requires general anesthesia
Correct Answer:
A. PESA does not require microsurgical skills
In-Depth Explanation:
A. Correct. PESA does not require microsurgical skills.
B. Incorrect. PESA has variable success in obtaining sperm.
C. Incorrect. PESA is not indicated in nonobstructive azoospermia.
D. Incorrect. PESA requires only local anesthesia.
Memory Tool:
“Plain and Easy, Skip Anesthesia” to remember that PESA requires only local anesthesia and no microsurgical skills.
Specific Reference Citation:
Table 67.4, Disadvantages of PESA
Rationale for Question:
The question evaluates your understanding of the limitations and requirements of the PESA procedure, a key point in patient counseling and treatment selection.
Clinical Vignette:
You are advising a 40-year-old male patient with obstructive azoospermia on surgical sperm retrieval methods.
Multiple Choice:
A. TESA requires microsurgical skills
B. TESA is ideal for nonobstructive azoospermia
C. TESA uses local anesthesia
D. TESA provides a large quantity of sperm
Correct Answer:
C. TESA uses local anesthesia
In-Depth Explanation:
A. Incorrect. TESA does not require microsurgical skills.
B. Incorrect. TESA yields poor results in nonobstructive azoospermia.
C. Correct. TESA uses local anesthesia.
D. Incorrect. TESA results in a small quantity of sperm obtained.
Memory Tool:
“TESA - Totally Easy, Simply Anesthetic” to remember that TESA uses local anesthesia.
Specific Reference Citation:
Table 67.4, Advantages of TESA
Rationale for Question:
This question aims to assess the examinee’s familiarity with the advantages of TESA, critical information for treatment planning and patient discussions.
Clinical Vignette:
You are considering sperm retrieval options for a 30-year-old patient with nonobstructive azoospermia.
Multiple Choice:
A. TESE is not indicated for nonobstructive azoospermia
B. TESE has a high complication rate
C. TESE requires anesthesia and microsurgical skills
D. TESE can be performed with local anesthesia
Correct Answer:
C. TESE requires anesthesia and microsurgical skills
In-Depth Explanation:
A. Incorrect. TESE is the preferred technique for nonobstructive azoospermia.
B. Incorrect. TESE has a low complication rate if performed microsurgically.
C. Correct. TESE requires anesthesia and microsurgical skills.
D. Incorrect. TESE requires anesthesia, but the table does not specify that it can be performed with local anesthesia.
Memory Tool:
“TESE Treats Elusive Sperm Effectively” to remember that it is ideal for nonobstructive azoospermia.
Specific Reference Citation:
Table 67.4, Advantages and Disadvantages of TESE
Rationale for Question:
This question tests the examinee’s understanding of the TESE technique, especially when it comes to nonobstructive azoospermia, making it essential for clinical decision-making.
Infertility is attributable to male factor in __% of cases
50
Blood-testis barrier is made up of ____ cells
sertoli
____ cells produce testosterone stimulated by ___ hormone
Leydig…. LH
Sertoli cells are stimulated by ____ hormone
FSH
Semen composition
Seminal vesicles - ___ cc, fructuose, alkaline
Prostate - ____ cc, acidic
Testes - ____ cc
SV - 1.5cc
Prostate - 0.5cc
Testes - 0.1cc
History taking in infertility exam
Prior fertility • Libido/sexual function • Testis pain or swelling • Cryptorchidism • Prior inguinal or scrotal surgery • Brothers’ fertility history
Medications that affect fertility
Calcium channel blockers Gout medications • Cimetidine • Sulfasalazine • Exogenous testosterone
Physical exam for infertility
Body habitus (Klinefelters)
Hair distribution
Gynecomastia
GU exam - testicular size, palpable vas deferens, cryptorchidism, varicoceles
absence of sperm in ejaculate
Azoospermia
Azoospermia with FSH < 7.6 & testes > 4.5 cm
obstructive azoospermia
Low sperm count
Low volume
Low pH
No fructose
Ejaculatory duct obstruction
Endocrine labs for initial infertility workup
AM Testosterone & FSH
Low T
High FSH
High LH
Primary hypogonadism (i.e. testicular failure)
Low T
Low FSH
Low LH
Secondary hypogonadism (hypothalmic issue)
Exogenous testosterone replacement down regulates ___ which down stream leads to inhibition of spermatogenesis
GnRH
Treatment for Hypogonadotrophic Hypogonadism
hCG to stimulate leydig cells
FSH to stimulate sertoli cells
Azoospermia, low T, elevated fsh, atrophic testes
Klinefelter (47XXY)
Imaging for ___ anomalies should be offered in those with unilateral vasal agenesis or CBAVD
renal
Grade ___ varicocele is palpable only with valsalva
I
Grade ___ varicocele is palpable without valsalva
II
Grade ___ varicocele is visible on exam
III
Criteria to intervene on varicocele
Infertility, testicular size differential
Male factor infertility is the cause of couple’s infertility in ___% of cases
50%
Pediatric history pertinent including ___ or ____
torsion
bilateral UDT (50-65% fertility despite pexy before 1 y.o.)
Intercourse ____ around ovulation should be adequate for conception
q48hrs
Abnormal semen parameters can be present for up to ____ s/p febrile illness
3 months
Exogenous ___ impairs spermatogenesis
steroids and testosterone
It can take up to ____ months to see normal sperm in patients on long term T
3-12 months
Recreational drugs that impair sperm include ___, ___, and ____
smoking, MJ, and opioids
Critical physical exam component is palpation of bilateral ____
vas deferens
Unilateral absence of vas deferens should prompt ____
ipsilateral renal imaging
Bilateral absences of vas deferens should prompt ____
CFTR genetic testing
Bilateral absences of vas deferens should prompt ____
CFTR genetic testing
Normal size of adult testes
___ cc volume
___ cm length
20cc volume
4cm length
size of testes is correlated with sperm production
Variocele Grading
1 = Palpable with \_\_\_\_ 2 = Palpable with \_\_\_\_ 3 = Visible
1 = Valsalva 2 = Standing only 3 = Visible
At least ___ semen analyses should be collected
2
Men should abstain from sex for between __ to ___ days before a semen analysis
2-7
Low volume semen can be due to ____ collection
incorrect
Low volume, acidic, azoospermia
Ejaculatory duct obstruction
Bilateral vas deferens absence
Small testicular volume with azoospermia suggests a ____ cause
non-obstructive
Low semen volume
1.5
Low sperm concentration
10
Low normal forms
4
____ is useful test with low volume or absent ejaculate
post-ejaculate urinalysis
Testosterone & FSH levels are indication when sperm concentrations are
<10 million
Testosterone & FSH levels are indication when sperm concentrations are
<10 million
Draw T & FSH before ___ AM
10
When FSH > ___ , impaired spermatogenesis exists
> 7
Testosterone deficiency is defined by two AM levels,
<300
Check ____ in patients with low T and concurrent obesity, elderly, HIV, or liver dz
sex hormone binding globulin
All mean with severe oligospermia,
<5 million
Most common genetic abnormality leading to infertility is ___
Klinefelter Syndrom (47 XXY)
Microdeletions in ___, ____, and ____ result in complete abscence of spermatogenesis
AZFa, AZFb, AZFb/c
Non-obstructive azoospermia have ___ semen volumes and ___ pH of ejaculate
normal & normal
Transrectal u/s should only be used to diagnose ____
ejaculatory duct obstruction
Azoospermia, palpable vas, normal testes size, and low semen volume
Ejaculatory duct obstruction
When is sperm DNA fragmentation analysis recommended in male infertility workup?
Sperm DNA fragmentation analysis is used for specific indications such as recurrent pregnancy loss.
What are Selective Estrogen Receptor Modulators (SERMs), and how are they used in male infertility?
SERMs like Clomiphene are recommended for idiopathic oligozoospermia.
What is the stance on antioxidant therapy in the management of male factor infertility?
Evidence supports the use of antioxidant supplements in specific cases, with caution against overuse due to a lack of robust evidence.
What are the considerations for testosterone therapy in male infertility with low testosterone?
Testosterone therapy is considered for patients with low testosterone, weighing the risks and benefits.
What is the guideline’s stance on genetic testing in male infertility workup?
Genetic testing, including sperm DNA fragmentation analysis, chromosomal abnormalities, and Y-chromosome microdeletions, is recommended for specific indications.
What hormonal treatments are suggested for abnormal semen parameters in male infertility?
The guideline recommends testosterone therapy for patients with low testosterone and Selective Estrogen Receptor Modulators (SERMs) like Clomiphene for idiopathic oligozoospermia.
What does the document define as the timing for the initial evaluation of infertility?
: Infertility is defined as the failure to conceive after 1 year of unprotected sexual intercourse, and couples should be evaluated by a fertility specialist at that point.
What does the document recommend for men in couples experiencing recurrent pregnancy loss (RPL)?
The document recommends that men in couples with RPL be evaluated with a karyotype and SDF analysis.
What does the 2020 guideline recommend regarding the initial evaluation of infertility in couples?
The 2020 guideline recommends concurrent assessment of both male and female partners as part of the initial infertility evaluation.
What are the potential consequences of advanced paternal age in relation to fertility and offspring health?
Advanced paternal age can contribute to genetic mutations, chromosomal abnormalities, worsened semen parameters, an increased rate of miscarriage, and greater morbidity in offspring, including associations with certain malignancies and neuropsychiatric conditions.
What is the recommended evaluation timing for couples where the female partner is 35 or older?
The recommendation is for couples to be evaluated after 6 months of failure to conceive if the female partner is 35 or older.
Age-related decline in ovarian reserve and oocyte quality leads to the recommendation for earlier evaluation.
Earlier evaluation is recommended due to age-related decline in ovarian reserve and oocyte quality.
What challenges are associated with women aged 35 or older in terms of fertility?
There is a decline in fertility potential and an increased time to conception in women of this age.
What is new about the 6-month time interval for evaluation in the AUA/ASRM guideline?
The specific time interval of 6 months for evaluation had not been previously explicitly stated in the AUA/ASRM guideline.
What does the 2020 guideline recommend regarding the concurrent assessment of male and female partners?
The 2020 guideline recommends that male and female partners undergo concurrent assessment as part of the initial infertility evaluation, focusing on abnormal semen parameters or concerns for male factor infertility.
When is male evaluation specifically recommended in infertility cases?
Male evaluation is recommended for couples with failed assisted reproductive technology (ART) cycles or recurrent pregnancy losses (RPLs), defined as 2 or more losses.
Why is emphasizing male partner evaluation in infertility cases important?
Emphasizing male partner evaluation is important because it is often delayed or altogether overlooked.
What did a 2019 study by Samplaski et al reveal about male infertility evaluation?
The study revealed that only 4.8% of men seen at centers specializing in male infertility had previously undergone an evaluation by a reproductive urologist.
What disparity does the text highlight between couples treated with ART and men evaluated by a reproductive urologist?
Despite 17% of couples being treated with ART, only 4.8% of men were evaluated by a reproductive urologist.
Who are the main referring parties for men in male infertility evaluations?
Approximately 60% of men were referred by reproductive endocrinologists, and 20% by primary care providers.
Why is a definitive recommendation for the timely evaluation of the male partner necessary?
It is necessary to effect improvements in clinical practice.
What specific changes are highlighted in the 2020 guideline regarding male infertility?
The 2020 guideline emphasizes the association of medical comorbidities with male infertility and specifically discusses advanced paternal age.
How is advanced paternal age defined in the context of male infertility?
Advanced paternal age is defined as a male partner aged 40 years or older.
What genetic factors are associated with advanced paternal age?
Advanced paternal age contributes to more de novo genetic mutations and chromosomal abnormalities.
How does advanced paternal age affect semen parameters?
Advanced paternal age leads to worsened semen parameters.
What are the broader health implications of advanced paternal age on offspring?
It is associated with an increased rate of miscarriage, greater offspring morbidity, and likely associations with some childhood malignancies, rare musculoskeletal syndromes, and neuropsychiatric conditions such as schizophrenia and autism spectrum disorders.
What are the primary considerations in the evaluation of male infertility, leading to the discussion of genetic testing?
Physical examination and semen analysis are paramount, and based on these, hormonal evaluation may be warranted as part of the fertility evaluation.
For which conditions is genetic testing advised?
For which conditions is genetic testing advised?
When is testing for Y chromosome microdeletions recommended?
In specific clinical scenarios, including nonobstructive azoospermia and severe oligospermia.
When is CFTR mutation analysis recommended?
For men with congenital bilateral absence of the vas deferens (CBAVD).
