Male infertility Flashcards
Radiation risk for sperm production decline
0.15 Gy
Radiation risk for azoospermia
0.5 Gy
Most important downstream product of SRY
SOX9
AMH synthesis depends on SOX9
When do sertoli cells start making AMH?
6 weeks
Sertoli cells are the only cells that make SRY
Male abnormal FSH level
> 7.4 mIU/L
Role of FSH in men
Upregulates LH receptors on leydig cells
stimulates ABP production
Cryptorchidism/mumps
testicular atrophy
STDs
ductal obstruction
DM/neurological disorder
retrograde ejaculation
CF
absent VD
pubertal delay
endocrinopathy and impaired spermatogenesis
DDX low volume on SA
failed emission, incomplete collection, short abstinence, CBAVD, EDO, hypogonadism, retrograde ejaculation
Retrograde ejaculation
consider if volume is < 1 mL
pretreat to alkalinize bladder
give sudafed to close bladder neck
In men with very low or no volume + AZO, any sperm in PEU indicates retrograde ejaculation
In men with low volume oligospermia, higher sperm numbers are required
What does low motility indicate
testicular dysfunction
sperm ab
infection
varicoceles
prolonged abstinence
What does poor morphology mean
poor quality of sperm
associated with varicocele and testicular failure
reflects ability to fertilize oocyte
When to do endocrine evaluation in men?
sperm conc < 10 mill/mL
sexual dysfunction (low libido)
findings c/w hypoTSH, hyperprolactin etc
if hypo hypo –> MRI
NOA
severe deficiency in spermatogenesis due to HP or primary testicular dysfunction
Kallman
failure of migration of GnRH and olfactory neurons causing delayed puberty, anosmia
X linked recessive: most common, anosmin !, KAL,
AD: FGFR1
also AR forms
Klinefelter Syndrome
results from non-disjunction of XX or XY during gametogenesis
Affected individuals also lead to T deficiency, Osteoporosis, metabolic syndrome, T2DM, gynecomastia, breast cancer, extra gonadal germ cell tumors
Can Y chromosome microdeletions be detected with karyotype?
No, need PCR to diagnose
Surgical correction for OA
microsurgical reconstruction of vas or epididymis
transurethral reconstruction of ED (TURED)
sperm retrieval techniques
What is the CFTR gene?
produces protein responsible for chloride transport across cell membranes
mutations result in abnormal chloride and water transport
Leads to thick mucous secretions that are thick and sticky
thick mucous clogs vas deferens and leads to deteriorations
PESA
percutaneous epididymal sperm aspiration with needle
for OA
No microsurgery, local anesthesia, fast and repeatable, minimal discomfort
few sperm retrieved and hematoma risk
MESA
microsurgical epididymal sperm aspiration with incision
open surgical approach using microscopy to identify individual epididymal tubules and extracts large number of sperm directly from tubules
Large # of sperm, best prep rates, good for sperm cryo
Microsurgery required
post-op discomfort
higher cost
TESA
percutaneous testicular sperm aspiration with needle
no microsurgery, local anesthesia, fast and repeatable
few sperm retrieved
hematoma risk
risk testicular atrophy
TESE
conventional or microsurgical testicular sperm extraction with incision for NOA
local anesthesia, minimal discomfort
few sperm retrieved
risk testicular atrophy
MicroTESE
highest sperm retrieval rates for NOA
Where do WHO parameters come from?
represent 5th percentile lower reference limit for men who had a partner achieve a pregnancy within 12 months
Dosing of hcg for oligospermia
3000 IU of hcg twice weekly
Meds for oligospermia
3000 IU hcg twice weekly
add on clomid 50 bc sometime high hcg can suppress FSH
try FSH 75 twice weekly
DNA fragmentation tests
Comet
TUNEL
SCSA
DNA frag testing
> 30
DNA fragmentation is associated with worse pregnancy rates and higher rates of miscarriage
No prospective studies showing a benefit of DNA fragmentation testing to improve outcomes
DNA fragmentation may be useful for couples with failed IVF cycles and if high DNA frag could consider ICSI with surgically extracted sperm
Prospective cohort of 100 couples with high DNA fragmentation testicular sperm yielded higher live birth rates compared to ejaculated sperm
Decreased abstinence (more frequent ejaculation) may help limit sperm DNA damage
When is DNA frag warranted
Varicocele (maybe)
Elevated in 50%
Most helpful when on the fence about varicocele repair
Borderline to normal SA
Moderate varicocele and SA within normal ranges
After repair, post-op abnormal SDF is very poor predictor of natural and assisted conception
No evidence to get in subclinical varicocele
RPL
MA of 13 prospective studies showed higher SDF rates in males
Mechanism of how increased DFI contributes is unknown
ASRM did NOT recommend in 2012
RCT (Mansour et al) showed lower SAB rates after varicocele repair
History of poor IVF outcome
Recurrent blastulation failure
Paternal genome activated between 4 and 8 cell stage, high DNA damage may manifest in later stages of embryonic development
