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Questions and Answers
What is the definition of a varicocele?
A varicocele is defined as dilated testicular veins due to reflux of blood.
What factors might contribute to the development of a varicocele?
The etiology of a varicocele is probably multifactorial, involving incompetence of venous valves and anatomical differences between the left and right internal spermatic vein.
During a physical examination for male reproductive health, what key aspects should be assessed regarding the testes?
Key aspects include testis position (cryptorchidism), volume (normal is ~15-25ml), and firmness (normal is firm).
How is varicocele classified based on palpability during examination?
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Which examination techniques are used to diagnose a subclinical varicocele?
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What are the three main classifications of male infertility based on etiology?
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How can obstructive azospermia be differentiated from non-obstructive azospermia?
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What hormonal levels should be evaluated during a hormonal assessment in male infertility?
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What is one potential test procedure to assess for ductal or seminal vesicle obstruction?
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List two common pre-testicular causes of male infertility.
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What is the significance of performing a standard semen analysis in the evaluation of male infertility?
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Name a possible consequence of an undescended testicle in terms of fertility.
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What role does genetic counseling play in the evaluation of male infertility?
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What is the prevalence of varicocele in men with primary infertility?
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What defines a subclinical varicocele based on testicular size discrepancy?
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Under what condition should hormone testing be performed in subfertile men?
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What indicates a diagnosis of hypergonadotrophic hypogonadism in azoospermic patients?
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What is a common reason for performing genetic testing in men with severe oligospermia?
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What is the advised treatment approach for a subclinical varicocele?
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Which imaging technique is sensitive for evaluating the prostate and seminal vesicles?
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What should be measured if total testosterone level is found to be low?
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Study Notes
Male Infertility
- Male infertility is defined as the inability to conceive after 12 months of frequent intercourse.
- Causes of male infertility can be pre-testicular (hormonal), testicular, or post-testicular (obstruction).
- Pre-testicular causes include hormonal issues, head trauma, sarcoidosis, and tumors.
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Testicular causes include:
- Undescended testicles
- Radiation to the testicle
- Chemotherapy
- Varicocele
- Advanced age
- Viral orchitis
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Post-testicular causes are mainly due to obstruction of the reproductive tract, such as:
- Epididymal dysfunction
- Infection
- Vas deferens abnormalities
Evaluation of Male Infertility
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History includes:
- Duration of infertility
- Prior fertility
- Family history
- Chronic illness
- Acute febrile illness (Cirrhosis, CKD)
- Medications (anabolic steroids, spironolactone, corticosteroids, cimetidine)
- Diabetes
- Mumps
- Undescended testes
- Genital surgery
- Inguinal surgery
- Trauma
- Infections
- Erectile dysfunction (ED)
- Drug/tobacco use
- Frequent coitus
- Occupation
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Physical examination includes:
- Gynecomastia
- Obesity
- Sexual development
- Baldness pattern
- Testicular volume (4x3 cm)
- Testicular mass
- Undescended testes
- Spermatic cord (thick cord or normal)
- Epididymis (palpable or not, distended or not, epididymal cyst)
- Vas (present or absent)
- Prostate by PR exam (tender, hot?)
- Varicocele
- Hypospadias
Varicocele
- Definition: Dilated testicular veins due to reflux of blood.
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Diagnoses:
- Established by physical examination (in a warm room)
- Grade 1: Palpable with valsalva only
- Grade 2: Palpable without valsalva
- Grade 3: Large, visible varicocele
- Other modalities: Ultrasound, venography, doppler stethoscope
- Subclinical varicocele: Does not need repair
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Etiology: Probably multifactorial, including:
- The absence or incompetence of venous valves
- Anatomic differences (length, insertion) between the left and right internal spermatic vein
- Increased hydrostatic pressure
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Prevalence:
- General male population: ~ 15%
- Men with primary infertility: ~ 35%
- Men with secondary infertility: ~ 50-80%
- Bilateral varicoceles: ~ 15-50%
- Isolated right sided varicocele: ~ 15-50%
2021 WHO Criteria for Semen Analysis
- Sperm concentration: ≥ 15 million spermatozoa per mL
- Total sperm count: ≥ 39 million spermatozoa per ejaculate
- Progressive motility: ≥ 32 %
- Total motility: ≥ 40%
- Vitality: ≥ 58% alive
- Morphology: ≥ 4% normal forms
Scrotal Ultrasound
- Significant discrepancy in testis size
- Palpable abnormality
- Subclinical varicocele (> 3 mm subclinical - > 3.5 clinical)
- Subclinical varicocele needs no treatment
- Transrectal ultrasound:
- Sensitive for evaluating the prostate and seminal vesicles
- Should only be performed for azoospermia or low volume
- Used to evaluate for possible ejaculatory duct obstruction
Hormone Testing
- Hormone testing for all subfertile men is not necessary.
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Indicated when sperm concentration is less than 10 million per mL:
- Measurement of serum testosterone and (FSH) levels
- Adequate to assess the pituitary-testicular axis in most cases
- If total testosterone level is normal: No further endocrine testing is needed.
- If total testosterone level is low: Serum luteinizing hormone and prolactin levels should be checked to evaluate for a pituitary cause.
Evaluation of Azoospermia according to Hormonal Assessment
- If FSH and LH are increased (double that of normal) and the patient has azoospermia: Diagnosis is hypergonadotrophic hypogonadism (primary testicular failure).
- If FSH and LH are decreased and the patient has azoospermia: Diagnosis is hypogonadotrophic hypogonadism (secondary testicular failure).
Genetic Testing and Counseling
- Indicated for patients with azoospermia or severe oligospermia.
- The karyotype should be determined because of the increased incidence of karyotypic abnormalities in this population.
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Description
Explore the complex topic of male infertility, defined as the inability to conceive after 12 months of frequent intercourse. This quiz covers the various causes, including hormonal, testicular, and post-testicular factors, along with the necessary evaluations to assess fertility. Test your knowledge on this critical issue affecting many couples.
