Male Infertility Evaluation PDF

Evaluation of the Male infertility  objectives Classify and list the causes of infertility Evaluation of male patient with infertility Interpretation of SFA How can differentiate between obstructive and non obstructive azospermia...

Evaluation of the Male infertility  objectives Classify and list the causes of infertility Evaluation of male patient with infertility Interpretation of SFA How can differentiate between obstructive and non obstructive azospermia oosperia.tk titties tesrom yfhegin inepidydris Spermatozoa nature vastaeterens oligospermin finconcentation iii esterase otrreei.EE  kleigkemtiriieYeron.tt Male infertility item inabilityto conceive PYysygairm after 12monthsoffrequent intercone Infertility classification (according to the :etiology) HyperproaciesÉÉÉiÉ tumorsradioth 1. Pre-testicular hormonal problem Headtraumasarcoidosis 2. Testicular - undescended testicle - radiation to the testicle - chemotherapy - varicocele Advanced age viral orchitis 3. Post-testicular : mainly obstruction IteFourion chemotherapy there Epidymaldysfunction infection Vasdeferensabnoredities retrograde In systemic Cirth tiiie renting fi WHO diagnostic categories for male infertility causes  Male Infertility: Evaluation History (Questionnaire) Physical examination Standard semen analysis Hormonal evaluation check LH, FSH and testosterone levels Genetic counseling and evaluation Imaging studies Doppler U/S of testicles -Transrectal Ultrasound (TRUS) for the prostate to see if the patient has ductal or seminal vesicle obstruction - Vasography Testis Biopsy  History - Male History 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) drugs/ Tobacco frequent coitus Occupation  Physical Examination Physical examination , gynecomastia,Obesity sexual development ,look for male /. 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)? infection ,check for varicocele ,Hypospadias Physical Examination Testis: -position (cryptorchid?) -volume (normal ~15-25ml)* -firmness (normal = firm) *Note: Normally, >70% of testis volume is from germ cells alone. Therefore, a soft and/or small testis is indicative of abnormal spermatogenesis Epididymis: -fullness -cystic changes Vas deferens: -congenital absence of vas (CAVD) Cystic fibrosis mutations Woolfian duct anomalies  Varicocele Varicocele: Definition: dilated testicular veins due to reflux of blood 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 used to diagnose a sub-clinical varicocele: ultrasound, venography, doppler stethoscope However, the subclinical varicocele does not require repair! Etiology: probably multifactorial The absence or incompetence of venous valves resulting in reflux of venous blood The anatomic differences (length, insertion) between the left and right internal spermatic vein. Increased hydrostatic pressure Varicocele: Prevalence in the general male population ~ 15% in men with primary infertility ~ 35% in men with secondary infertility ~ 50-80% bilateral varicoceles ~ 15-50% isolated right sided varicocele 2021 WHO criteria for semen analysis }PR progressive }Np PRtNP Vitality 7, 5 8 % alive > I milion I m f  Scrotal ultrasound Significant discrepancy in testis size – Palpable abnormality – ?Diagnosis of subclinical varicocele (> 3mm subclinical- > 3.5 clinical) Note :- subclinical varicocele needs no treatment Transrectal ultrasound – Sensitive for evaluate the prostate and seminal vesicles – Should only for azoo, low volume is indicated to evaluate for possible ejaculatory duct obstruction  Hormone testing for all subfertile men is not necessary. It is indicated when sperm concentration is less than 10 million per mL, measurement of the serum testosterone and (FSH) levels is indicated. The levels of serum testosterone and FSH are adequate to assess the pituitary- testicular axis in the majority of cases. If the total testosterone level is normal, no further endocrine testing is needed. If the total testosterone level is low, the serum luteinizing hormone and prolactin levels can be checked to evaluate for a pituitary cause. Evaluation of azospermia according to hormonal assement If FSH and LH increased ( double that of normal ) and the patient is azospermia the diagnosis is hyper gonadotrophicn hypogonadism: primary testicular failure If FSH and LH decreased and the patient is azospermia the diagnosis is hypo gonadotrophic hypogonadism ( secondary testicular failure) n  Genetic testing and counseling are indicated in patients In with azoospermia or severe oligospermia the karyotype should be determined because of the increased incidence of karyotypic abnormalities in this population. The most common karyptype abnormality is Klinefelter's syndrome Karyotypes – 5.8% of infertile men has chromosomal abnormalities ( vs 0.5% of fertilie population) – 16% in azoospermia – Klinefelter syndrome, xx male Yq microdelection – Not detected on routine karyotype testing – 3 distinct loci on the long arm Specific gene defects (C.F mutation) y microgention  testicular biopsy A diagnostic testicular biopsy is indicated only in men (azoospermia, a normal testicular volume and normal FSH). In patients with a non obstructive azospermia a testicular sperm extraction TESE with cryopreservation of the spermatozoa to be used for ICSI can be done In order to increase the chances of positive sperm retrievals in men with non- obstructive azoospermia testicular sperm extraction (TESE, either single, multiple or microsurgical) should be used rather than testicular fine needle aspiration (TESA).