Male Infertility Flashcards
What is the definition of infertility?
Inability to achieve pregnancy after one year of unprotected sexual intercourse.
What percentage of infertility is due to male vs female factors?
50% female only
20% male only
30% male and female
What is the most common cause of male infertility?
Varicocele
What is the most common cause of low ejaculatory volume?
incorrect collection
What is Azoospermia?
No sperm in the ejaculate
What is Aspermia?
No ejaculate
What is oligospermia?
Sperm concentration
What is asthenospermia?
less than 40-50% sperm motility
What is teratospermia?
abnormal sperm morphology
What is the classification of causes of azoospermia?
Pre-testicular
Testicular
Post-testicular
What are the risk factors for obstructive azoospermia?
Surgery/instrumentation
GU infections
CF/CBAVD
What are the risk factors for non-obstructive azoospermia?
Gonadotoxin
Cryptorchidism
Torsion
Orchitis
Medical conditions that may cause infertility?
Prostatitis, Orchitis, febrile illness Hormonal disorders (hypogonadism, Thyroid disorders) Cirrhosis Diabetes Myotonic dystrophy Young's, Kartageners, CF, CBAVD
What genetic anomalies may lead to infertility?
Karyotype abnormalities (6%) CFTR mutations Y chromosome microdeletions: AZF a, b, and c (10-15%)
What should be included in the reproductive history?
The reproductive history should include
1) coital frequency and timing;
2) duration of infertility and prior fertility;
3) childhood illnesses and developmental history;
4) systemic medical illnesses (e.g., diabetes mellitus and upper respiratory diseases) and prior surgeries;
5) sexual history including sexually transmitted infections;
6) gonadal toxin exposure including heat.
What should you look for on physical exam when working up male infertility?
Visual fields Skin pigmentation Thyroid exam Gynecomastia/galactorrhea Liver exam Secondary sexual characteristics, tanner stage Testicular size, consistency, Vas, epididymis, vericocele Sphincter tone/Prostate
What is normal ejaculate volume?
1.5-5 ml
What is normal semen pH?
> 7.2
What is normal sperm concentration?
> 20 million/ml
What is a normal total sperm count?
> 40 million/ejaculate
What is normal sperm motility?
> 40-50%
What is the normal amount of progressively motile sperm?
> 32%
What is the normal forward progression scale?
> 2 out of 4
What is normal morphology percent for semen analysis?
> 4%
What is normal sperm agglutination for a semen analysis?
what is normal viscosity/consistency for a semen analysis?
What is the normal concentration of leukocytes in a semen analysis?
What is the normal value for the immunobead test which looks at the normal percent of motile sperm adhered to particles?
What is the normal value for a sperm vitality test?
> 58%
What is the normal value for fructose in a semen analysis?
> 13 umol/ejaculate
What is the initial minimum workup for male infertility?
History, physical exam, and 2 semen analyses at least 1 month apart.
What is the next step if the vas deferens are present bilaterally?
Examine the Semen volume
What is the next step if the vas is absent unilaterally?
Get renal ultrasound (11% have renal anomalies) and CFTR testing.
What is the next step if there is azoospermia and bilateral absence of the vas deferens?
Workup for CF
What are the treatment options for CBAVD with no CF?
CFTR, and genetic testing
LH, FSH, Testosterone
Renal ultrasound
What are the treatment options for CBAVD?
Donor insemination
Adoption
SR with ICSI
What is the next step if vas are present but semen volume is
Post ejaculation urinalysis: If sperm in urine –> retrograde ejaculation
No sperm in urine –> TRUS to look for EDO
What is the treatment for EDO?
Trans urethral resection of ejaculatory ducts (TURED)
What is the next step if vas are present and semen volume is > 1.5ml?
Evaluate the rest of the semen analysis:
If semen analysis is abnormal get a hormone workup
What if Semen analysis if completely normal?
- Workup female partner
- Post coital test
- If normal post coital sperm function test
What is the next step if shaking or low motility sperm are seen on post coital test?
Test for anti-sperm antibodies
What is next step if no sperm are seen in mucus of post coital test?
evaluate coital technique
Consider intrauterine insemination
What is the next step in patient with vas, abnormal semen analysis, but normal hormone evaluation?
Evaluate for ejaculation:
If ejaculation absent –> anejaculation
If ejaculation is present –> test for anti-sperm antibodies, rule out vericoele.
What are the indications for an endocrine evaluation for male infertility?
An endocrine evaluation should be performed if there is: 1) an abnormal semen analysis, especially if the sperm concentration is less than 10 million/ml;
2) impaired sexual function; or
3) other clinical findings suggestive of a specific endocrinopathy.
How should and endocrine evaluation for male infertility be conducted?
minimum initial hormonal evaluation should consist of measurements of serum (FSH) and serum testosterone levels. If the testosterone level is low, a repeat measurement of total and free testosterone (or bioavailable testosterone), as well as determination of (LH) and prolactin levels should be obtained
Low T, Low/normal LH, Low/normal FSH, normal prolactin?
Hypogonadotropic hypogonadism
Normal T, normal LH, High/normal FSH, normal prolactin?
abnormal spermatogenesis
Low T, High FSH, High LH, normal prolactin?
Hypergonadotropic hypogonadism (i.e. testicular failure)
Low T, low/normal FSH, Low/normal LH, high prolactin?
Prolactinoma
