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49 Cards in this Set
- Front
- Back
Would you do a scrotal US for a male who is infertile?
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almost never
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Proven Gonadotoxins
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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 |
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Smoking leads to the following...
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Lung CA (most common CA killer worldwide)
Bladder CA Renal cell CA Pancreatic CA ED COPD |
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Non-proven gonadotoxins
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Alcohol
Caffeine Cycling Running Briefs/Boxers Hot tubs Cell phones |
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Things unproven, but still advised to avoid if trying to baby-make
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medications
supplements |
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Are there foods, vitamins or derivatives that will boost sperm counts?
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no
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Diagnoses that will cause reduced reproductive potential
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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 |
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Does chicken pox have any role in this?
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no
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Spermatogenic axis
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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. |
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Androgenic axis
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GnRH stim pituit to secrete LH to stimulate leydig cells to make testosterone which feeds back to the pituit.
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Characteristics of hypogonadal man
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low energy, libido and poor erections.
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Best way to supplement testosterone
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Exercise, rest, reduce stress
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Hormone profile of someone on anabolic steroids
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very high testosterone, very low FSH and LH
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Hormone profile of someone who just stopped using steroids
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very high LH and FSH, low testosterone.
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Treatment of steroid induced azoospermia
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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) |
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If you get exogenous testosterone...
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there is inhibition so you won't be making sperm endogenously either. this is why these men are infertile.
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Penbis physical exam - things to look for
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Hypospadias (opening of reuthra at underside)
Peyronies disease - curvature may prevent vaginal intercourse Phimosis - Can't retract foreskin which impairs semen deliv to cervix |
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Testes physical exam
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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 |
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Bulk of testis is devoted to..
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.sperm producing. (seminiferous tubule)
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Increased CA incidence in...
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spermatogenic failure, cryptorchidism, prior testes CA
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what forms most of the fluid in the ejaculate?
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seminal vesicle.
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Obstruction of vas or epididymis
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not detectable on semen analysis, palpable with careful exam, can be unilat or bilat.
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congen absence of the vas
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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) |
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Spermatocele
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may obstruct epididymis
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hydrocele
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may have an effect on spermatogenesis
more freq in younger pts. |
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Varicocele
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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.) |
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Where does left spermatic vein drain?
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left renal vein
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where does right spermatic vein drain?
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IVC
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Common theme in this lecture
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history and physical is very important and you are treating the couple, not just the patient.
also, you are a doctor before a specialist. |
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Non-obstructive genetic causes of azoospermia
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Y chrom microdeletions
Karyotypic anomalies (e.g. Klinefelters) |
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Obstructive genetic causes of azoospermia
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congen bilat absence of vas def
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Y chrom
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Most is specific to the male. There is a pseudoautosomal region that pairs well with the X though
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Yq - most testis genes are located within...
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palindromes
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We have defined clinically a number of microlesions where DNA alterations mess up sperm production.
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asdf
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AZFa, AZFb, or AZFa/b microdeletions...
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If you have any of these 3, you don't need to operate and there will be no spermatogenesis
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AZFc microdeletions...
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Has spermatogenic potential and the child will have the same issues.
Do surgery on this pt. |
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Which AZF microdeletion is most common?
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c - the one to do surgery on
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Options for AZFc deleted men
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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. |
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Klinefelter syndrome
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47 XXY (pure) or
46XY/47XXY (mosaic) Some can be eunuchoid, but some can look completely normal and just look infertile. |
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Axes that fail in Klinefelters
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Spermatogenic - you get oligospermia or azoospermia
Androgenic axis - failure of virilization at puberty and less testosterone effect in adulthood. |
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Myths
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“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.” |
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In Klinefelter's, you pubertal development depends on...
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your leydig cell function
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46, XX male syndrome
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SRY present in genome (often on X chrom due to translocation) but XX sex chromosomes.
AZFa, b, c all absent. |
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Freq of genetic basis of non-obstruc azoospermia
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Y chromosomal microdeletions
13% Klinefelter Syndrome 5% - 10% Translocations 1% - 3% Y chromosomal aberrations Rare |
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Congen bilat absence of vas def
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No palpable vasa
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DDx of low volume and acidic azoospermia
(no seminal vesicle fluid in the ejaculate) |
Congen bilat absence of the vas - seminal vesicles are absent/atrophic
Bilat ejac duct obstructed - seminal vesicles are blocked. |
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cystic fibrosis and congen bilat absence of vas def
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A spectrum.
All pts with cystic fibrosis have absence of vas. But with more CFTR dysfunc, you get CF |
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CF mutation analysis
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must be obtained for all pts with vasal agenesis as well as their partners before undertaking treatment.
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Are all CBAVD related to CFTR though?
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no, the other way around.
5-10% have unilateral renal agenesis |