Male infertility Flashcards
- Typically endocrinopathies and Highly treatable
- May be associated with important medical problems (pituitary tumors, significant hypogonadism)
• Pre-testicular cause of male infertility
Most common and usually reversible
•Includes varicoceles, gonadotoxins, as well as primary testicular problems
Testicular infertility
Obstruction and Ejaculation disorders
Post-testicular
•28 yo male comes in for evaluation of inability to conceive with his 27 yo wife
- Past medical/surgical history is negative/No meds, drug allergies
- Minimal EtOH, no tobacco, no street drugs /ROS is negative Exam demonstrates:•Normal male body habitus/No gynecomastia/Circumcised penis without lesions
- Testes descended, 20 cc on right, 16 cc on left, no masses
- Vasa and epididymides palpable without abnormalities
- **Grade 3 left varicocele **
need to exam when standing
Pt has issues conceiving with wife, you see grade 3 left varicocele, what is your next step in a work up (youve gotten a detailed history)
Semen analysis
Four key workups when eval of the infertile male?
- Full history and physical exam
- Semen analysis (>2)
- Hormone studies to examine HPG axis (typically, total testosterone and FSH, reserve LH, estradiol, and prolactin if testosterone is low).
- Scrotal U/S if testicular abnormality identified
Key guidelines for standard semen analysis
>2 samples; will see flucuation
3-5 day abstinence
Collection: masturbation, coitus interruptus, condom
container free of spermatoxic agents
serum analysis
- Volume >
- Concentration >
- Motility >
- Volume > 1.5-2 mL
- Concentration > 20 million/mL
- Motility > 50%
Serum analysis
Total motile sperm >
• Total sperm >
• Absence of WBCs, RBCs, or bacteria
Total motile sperm >20 million
• Total sperm >40 million
• Absence of WBCs, RBCs, or bacteria
how long do we need to wait to see if intervention with sperm have worked?
- 70 days stem cell- spermatozoa
- 20 days transit epididymis
- **90 days to reflect change in SA **
What hormone testing is done for men with infertility?
FSH and testosterone
- If testosterone low, repeat in early AM, would also order ____, _____, _____
- Yield for significant endocrinology low if sperm concentration _____
LH, prolactin, estradiol
>10 million/cc
•Semen analysis demonstrates the following:
- Vol 3.5 mL (N>1.5 mL)
- Sperm concentration 8 million/mL (N>20)
- Sperm motility 35% (N>50%)
- Total motile sperm/ejaculate 9.8 million (N>20)
- Total testosterone 440 ng/dL (N=280-800) •FSH 5.6 IU (N=1.5-10.0)
of these which is concerning?
the low sperm motility
the normal testosterone and FSH tell us HPG axis is intact
How can varicocele cause infertility?
because increases the temperature of the sperm and the environment they are in.
most common causes of male infertility
varicocele and idiopathic
can have testicular failure or obstruction or cryptorchidism
- Countercurrent heat exchange keeps testis ___ cooler than body temp.
- Varicocele destroys this system, resulting in higher intra-testicular temp.
- Other co-factors, including hormonal and genetic abnormalities, important.
- However, correction of varicocele results in clinical improvement.
2-4o C
Pt has 2 yr history of trying to concieve with wife. non palpable epididymis and vasa on physical exam. Everything else normal.
SA:
volume: .5 ml (N>1.5ml)
pH 5.5 (N>7.2)
Sperm concentration 0 (N>20)
all other semem characteristics normal
what do we do next?
CFTR analysis when you see acidic, low sperm concentraiton and low sperm volume
80-90% CBAVD associated with mutation of at least one
Cystic Fibrosis Transmembrane-conductance Regulator (CFTR) gene
- Most cases of CBAVD are genetic in origin and are______
- Incidence ____of men presenting with infertility
autosomal recessive.
1-2%
- CFTR mutation common in general Caucasian population (~1 in 25)
- Of these men, most will have 2 mutations, with the second often on the _____
5T allele
CFTR mutation cause____ of the genital ducts during embryogenesis but________ is not impaired
involution
Spermatogenesis
You find that the cause of your pts infertility is due to CFTR mutation, what shoud you recommend for this patient?
Genetic counseling is essential including CTFR testing for both partners
CBAVD stands for
congenital bilateral absence of vas deferens, often associated with cystic fibrosis
YOur pt has absent epididymis and vas deferens thus can make sperm but not carrier fluid. He tests negative for CFTR, what associated anomaly would we expect to see in our pt?
renal agenesis/anomalies
gives rise to ureteral bud, as well as SV, vas deferens, lower 2/3 of epididymis
Mesonephric duct
•Defects in mesonephric duct early (6th week of gestation), leads to
agenesis of genital ducts and ipsilateral kidney
Your pt has CBAVD but negative for CFTR, what test is indicted next?
do a renal ultrasound; usually associated with renal agenesis dt defect in mesonephric duct early on (6th week of gestation)
What should be first step in evaluation of male fertility?
How many SA’s necessary to get baseline of semen parameters?
Detailed, yet focused, history and physical exam
need at least 2
most common disorder of chromosomal number in men, occuring in up to 1 in 500 live male births with triad of smal firm testes, azoospermia and gynecomastia
Klinefelters syndrome: XXY; some have mosaic
necessary for gonadal differentiaion. responsible for testis formaiton and spermatogeneis
Y chromosome; specifically the SRY gene on short arm of Y
Abnormal dilation of pampinform plexus of internal spermatic veins, typically occur on left side and may be bilateral
varicocele
It is recommended that all men with azoospermia or severe oligospermia (<2million/mL) be offered karyotypic and genetic testing, including eval of Y chromosome microdeletions