SM_205b: Male Fertility Flashcards
Male infertility has ____, ____, and ____ causes
Male infertility has pre-testicular, intrinsic testicular, and post-testicular causes
Infertility examination of men involves ____, ____, and ____
Infertility examination of men involves history, physical examination, and appropriate lab testing
Normal testis size is ____ and ____
Normal testis size is > 4 cm x 2 cm and x 20 cc
Lab testing for male testing involves ____
Lab testing for male testing involves serum FSH and testosterone with other testing as indicated
- If testosterone is low, consider LH and prolactin
- If FSH is low, consider LH and prolactin
- If patient is obese, consider estradiol
Describe normal semen analysis
Semen analysis
- Ejaculate volume: > 1.5 mL
- Sperm concentration: > 15 million sperm / mL
- Sperm motility: > 40%
- Sperm normal morphology: > 4% Kruger
Describe additional sperm parameters
Additional sperm parameters
- If no sperm, centrifuge sample: cyrptozospermia
- Normal pH ≥ 7.2: prostate secretions are acidic, seminal vesicle secretions are alkaline
- Low ejaculate volume and normal pH: think incomplete collection or retrograde ejaculation
- Low ejaculate volume and acidic pH: think ejaculatory duct pathology or congenital bilateral absence of the vas deferens
Describe Kruger morphologic criteria
Kruger morphologic criteria (normal)
- Smooth oval head
- Acrosome is 40-70% of volume of head
- No abnormalities of neck, midpiece, or tail
- No cytoplasmic droplets more than half the size of the head
Highest probability of conception occurs is ____ occurring when intercourse occurs on ____
Highest probability of conception occurs is 0.3 occurring when intercourse occurs on day of ovulation
Describe medication effects on male reproductive health
Medication effects on male reproductive health
- Endocrine axis: testosterone
- Libido: spironolactone
- Errectile function: beta blockers, thiazide diuretics
- Ejaculatory function: alpha blockers, antidepressants
Fever impacts semen parameters such as ____ and ____
Fever impacts semen parameters such as sperm count / motility / morphology and sperm DNA integirty
- Return to pre-febrile baseline: motility and morphhology at 4 weeks, sperm count at 8 weeks
- If patient has fever within 3 months prior to semen testing, consider repeating 4-8 weeks later before making final treatment recommendations
Tobacco, marijuana, and cocaine ____ impact male fertility
Tobacco, marijuana, and cocaine detrimentally impact male fertility
- Tobacco: decreased semen parameters, impaired sperm function, increased sperm DNA damage and aneuploidy, hormonal changes
- Marijuana: suppresses LH and testosterone secretion, impairs semen parameters, impairs sperm function
- Cocaine: impaired spermatogenesis, vasoconstriction
Treatment of infertile male involves ____, ____, ____, and ____
Treatment of infertile male involves
- Counselling to optimize male reproductive health
- Identifying medically treatable conditions
- Identifying surgically treatable conditions
- Identifying serious associated health problems
Describe medical management of hormone deficiency contributing to male infertility
Hormone deficiency contributing to male infertility
- Hypogonadotropic hypogonadism: congenital (Kallman’s syndrome: anosmia, cleft palate, cryptorchidism), acquired (pituitary trauma)
- Isolated LH deficiency
- Isolated FSH deficiency
- Mechanism: low levels of gonadotropin secretion
- Treatment: hCG and FSH replacement therapy, treat underlying medical condition
Hyperprolactinemia causes male infertility by ____
Hyperprolactinemia causes male infertility by inhibiting hypothalamic secretion of GnRH
- Pituitary adenoma, hypothyroidism, stress, liver disease, phenothiazines and tricyclic antidepressants
- Additional testing: pituitary MRI
- Treatment: bromocriptine, cabergoline, surgery
Estrogen excess causes male infertility by ____
Estrogen excess causes male infertility by inhibiting gonadotropin secretion
- Adrenal or testicular tumors, liver failure, obesity (testosterone / estradiol ratio < 10/1)
- Treat underlying condition, possible role for aromatase inhibitors (anastrozole, letrozole, exernstane)
Androgen excess causes male infertility by ____
Androgen excess causes male infertility by inhibiting gonadotropin secretion
- Exogenous source (anabolic steroids) most common, endogenous source (adrenal or testicular tumors), congenital adrenal hyperplasia
- Treatment: stop use of anabolic steroids, treat underlying medical condition, cortisol replacement for CAH
Varicocele is particularly common in ___ males
Varicocele is particularly common in infertile males
- Grade I: palpable on exam only with Valsalva
- Grade II: palpable on exam without Valsalva
- Grade III: visible on exam
Varicocele causes infertility through ____
Varicocele causes infertility through testicular hyperthermia
- Treatment: radiographic embolization, surgical ligation
Obstructive azoospermia causes infertility due to ____ or ____
Obstructive azoospermia causes infertility due to vasal obstruction or epididymal obstruction
- Treatment: microsurgical reconstruction, vasovasostomy, epididymovasostomy
Describe congenital bilateral abscence of the vas deferens
Congenital bilateral abscence of the vas deferens
- Also typically missing distal 2/3 of epididymis and seminal vesicle
- Retrieved sperm generally used in setting IVF / ICSI
- CFTR gene mutation testing
Nonobstructive sperm retrieval techniques include ____
Nonobstructive sperm retrieval techniques include microdissection testicular sperm extraction
- Testicular sperm extraction
- Testicular percbiopsy
- Testicular sperm aspiration
Single biopsy is often ____ for finding sperm
Single biopsy is often not enough for finding sperm
- Heterogeneous histology of seminiferous tubules with scant pockets of complete spermatogenesis amid a majority of abnormal tubules
Micro-TESE has ____ sperm retrieval rate and ____ clinical pregnancy rate
Micro-TESE has 50-60% sperm retrieval rate and 40-60% clinical pregnancy rate
Klinefelter syndrome is ____ genotype and presents with ____, ____, and ____
Klinefelter syndrome is 47 XXY genotype and presents with small firm testes, gynecomastia, and azoospermia
- Most common genetic cause of azoospermia
- Accounts for 2/3 of chromosomal abnormalities in infertile men
___ chromosome may have ___ in infertile men
Y chromosome may have microdeletions in infertile men
- Microdeletions found in 10-15% of azoospermic men and 3-10% oligospermic men
- Deletions in long arm of Y chromosome
- No sperm will be found if complete AZFa or AZFb microdeletion
Cystic fibrosis (CFYR) involves ____
Cystic fibrosis (CFYR) involves congenital bilateral abscence of the vas deferns
- Typicallty absent vas deferns and absence of seminal vesicles
- Congenital unilateral or bilateral abscence of vas deferns
- Partner must be tested even if patient (-) testing
- CBAVD semen analysis: low ejaculate volume, acid pH semen, azoospermia
Describe forms of artificial contraception
Artificial contraception
- Abstinence
- Pull out methods
- Barrier methods
- Contraceptive pill
- Intrauterine devices
- Surgical sterilization
Vasectomy involves ____, ____, ____, and ____
Vasectomy involves vasal division, excision of vasal segment, mucosal cautery, fascial interposition
- Can recanalize
Clearance from contraception given after vasectomy if ____ or ____
Clearance from contraception given after vasectomy if
- Single semen sample shows no sperm
OR
- Fresh well-mixed noncentrifuged sample shows no sperm of < 100,000 nonmotile sperm/mL at > 4 months post-procedure
If any motile sperm persist at > 6 months after vasectomy, ____
If any motile sperm persist at > 6 months after vasectomy, procedure should be deemed a failure and a repeat vasectomy should be offered
