Repro - 1-19 - Male Infertility

Front 1

Would you do a scrotal US for a male who is infertile?

Back 1

almost never

Front 2

Proven Gonadotoxins

Back 2

Smoking - decreases sperm function and increases offspring risk of pediatric CA (in both mother and father)
If mother smokes, child also at greater risk of bilateral cryptorchidism.

Obesity - reduces sperm density

Marijauna - reduces sperm function and increases risk of testis CA

Anabolic steroids

Front 3

Smoking leads to the following...

Back 3

Lung CA (most common CA killer worldwide)
Bladder CA
Renal cell CA
Pancreatic CA
ED
COPD

Front 4

Non-proven gonadotoxins

Back 4

Alcohol
Caffeine
Cycling
Running
Briefs/Boxers
Hot tubs
Cell phones

Front 5

Things unproven, but still advised to avoid if trying to baby-make

Back 5

medications
supplements

Front 6

Are there foods, vitamins or derivatives that will boost sperm counts?

Back 6

no

Front 7

Diagnoses that will cause reduced reproductive potential

Back 7

Cryptorchidism - less sperm production (either uni or bilat)

Hernia repair (vasal blockage)

Torsion - loss of one testis and dysfunction of the remaining one

Mumps - only as an adult is a rare cause of infertility

Pubertal delay

Front 8

Does chicken pox have any role in this?

Back 8

no

Front 9

Spermatogenic axis

Back 9

GnRH tells pituit to secrete FSH to stimulate sertoli cells to nurture developing sperm cells.

Inhibin is secreted by these and acts back on the pituitary.

Front 10

Androgenic axis

Back 10

GnRH stim pituit to secrete LH to stimulate leydig cells to make testosterone which feeds back to the pituit.

Front 11

Characteristics of hypogonadal man

Back 11

low energy, libido and poor erections.

Front 12

Best way to supplement testosterone

Back 12

Exercise, rest, reduce stress

Front 13

Hormone profile of someone on anabolic steroids

Back 13

very high testosterone, very low FSH and LH

Front 14

Hormone profile of someone who just stopped using steroids

Back 14

very high LH and FSH, low testosterone.

Front 15

Treatment of steroid induced azoospermia

Back 15

Stop anabolics
Wait for pituit to respond (months)
Wait for spermatogenesis to return
Don't give FSH or LH
Do not do immediate intracytoplasmic sperm injection (ICSI)

Front 16

If you get exogenous testosterone...

Back 16

there is inhibition so you won't be making sperm endogenously either. this is why these men are infertile.

Front 17

Penbis physical exam - things to look for

Back 17

Hypospadias (opening of reuthra at underside)

Peyronies disease - curvature may prevent vaginal intercourse

Phimosis - Can't retract foreskin which impairs semen deliv to cervix

Front 18

Testes physical exam

Back 18

check to ensure testes are descended

size is normal (they will be small in non-obstructive azoospermia, normal in pbstructive)

consistenct (soft in non-obstruc, normal in obstructive)

rule out testes CA

Front 19

Bulk of testis is devoted to..

Back 19

.sperm producing. (seminiferous tubule)

Front 20

Increased CA incidence in...

Back 20

spermatogenic failure, cryptorchidism, prior testes CA

Front 21

what forms most of the fluid in the ejaculate?

Back 21

seminal vesicle.

Front 22

Obstruction of vas or epididymis

Back 22

not detectable on semen analysis, palpable with careful exam, can be unilat or bilat.

Front 23

congen absence of the vas

Back 23

unilat may have solitary kidney.

bilat is called congenital bilateral aplasia of the vas deferens.

(i think he said you will have a low volume of ejaculate and then you can just dx with physical exam)

Front 24

Spermatocele

Back 24

may obstruct epididymis

Front 25

hydrocele

Back 25

may have an effect on spermatogenesis

more freq in younger pts.

Front 26

Varicocele

Back 26

dilated pampiniform plexus (veins)
Dx made by physical exam (NOT semen analysis, hormonal studies or US)

commonly caused by spermatogenic deficiency.

Tx - surgery. improves chances of all kinds of pregnancy (natural, IVF, etc.)

Front 27

Where does left spermatic vein drain?

Back 27

left renal vein

Front 28

where does right spermatic vein drain?

Back 28

IVC

Front 29

Common theme in this lecture

Back 29

history and physical is very important and you are treating the couple, not just the patient.

also, you are a doctor before a specialist.

Front 30

Non-obstructive genetic causes of azoospermia

Back 30

Y chrom microdeletions

Karyotypic anomalies (e.g. Klinefelters)

Front 31

Obstructive genetic causes of azoospermia

Back 31

congen bilat absence of vas def

Front 32

Y chrom

Back 32

Most is specific to the male. There is a pseudoautosomal region that pairs well with the X though

Front 33

Yq - most testis genes are located within...

Back 33

palindromes

Front 34

We have defined clinically a number of microlesions where DNA alterations mess up sperm production.

Back 34

asdf

Front 35

AZFa, AZFb, or AZFa/b microdeletions...

Back 35

If you have any of these 3, you don't need to operate and there will be no spermatogenesis

Front 36

AZFc microdeletions...

Back 36

Has spermatogenic potential and the child will have the same issues.

Do surgery on this pt.

Front 37

Which AZF microdeletion is most common?

Back 37

c - the one to do surgery on

Front 38

Options for AZFc deleted men

Back 38

Do not use their sperm

Use their sperm for ICSI
and get a Normal girl or AZFc deleted boy

Preimplantation Genetic Diagnosis
Transfer only female embryos so no boys will be born.

Front 39

Klinefelter syndrome

Back 39

47 XXY (pure) or
46XY/47XXY (mosaic)

Some can be eunuchoid, but some can look completely normal and just look infertile.

Front 40

Axes that fail in Klinefelters

Back 40

Spermatogenic - you get oligospermia or azoospermia

Androgenic axis - failure of virilization at puberty and less testosterone effect in adulthood.

Front 41

Myths

Back 41

“Your Testosterone is too high to be a Klinefelter.”

“You’re too well virilized to be a Klinefelter.”

“You hold a Bachelor’s Degree, you cannot be a Klinefelter.”

Front 42

In Klinefelter's, you pubertal development depends on...

Back 42

your leydig cell function

Front 43

46, XX male syndrome

Back 43

SRY present in genome (often on X chrom due to translocation) but XX sex chromosomes.

AZFa, b, c all absent.

Front 44

Freq of genetic basis of non-obstruc azoospermia

Back 44

Y chromosomal microdeletions
13%
Klinefelter Syndrome
5% - 10%
Translocations
1% - 3%
Y chromosomal aberrations
Rare

Front 45

Congen bilat absence of vas def

Back 45

No palpable vasa

Front 46

DDx of low volume and acidic azoospermia

(no seminal vesicle fluid in the ejaculate)

Back 46

Congen bilat absence of the vas - seminal vesicles are absent/atrophic

Bilat ejac duct obstructed - seminal vesicles are blocked.

Front 47

cystic fibrosis and congen bilat absence of vas def

Back 47

A spectrum.

All pts with cystic fibrosis have absence of vas. But with more CFTR dysfunc, you get CF

Front 48

CF mutation analysis

Back 48

must be obtained for all pts with vasal agenesis as well as their partners before undertaking treatment.

Front 49

Are all CBAVD related to CFTR though?

Back 49

no, the other way around.

5-10% have unilateral renal agenesis