How does testosterone excess affect sperm levels?
Excess testosterone -> decreased sperm
- Testosterone inhibits GnRH, LH/FSH via negative feedback
- Gonadotropins LH and FSH are needed for spermatogenesis
- Testosterone will not result in sperm
How does a varicocele affect sperm production?
Impairs sperm production
- Varicocele causes blood to pool
- More blood = increased testicular temperature
- -> impaired sperm production
Tx = surgical intervention or radiologic embolization
What causes Asherman's syndrome?
Uterine scarring, usually iatrogenic
Can interfere with fertility
How does marijuana affect sperm count?
Decreased, due to suppressed LH/FSH
How does prolactin excess affect sperm levels?
Prolactin inhibits hypothalamic GnRH secretion
- -> Decreased LH/FSH
- -> Decreased spermatogenesis
What is the prevalence of infertility?
What genetic testing should be ordered for men with congenital bilateral absense of the vas deferens?
CFTR mutation - likely that they are a carrier
Test BOTH partners
- Even if pt with CBAVD is negative for known CFTR mutations, they may be a carrier of an unidentified mutation; need to know CFTR status of partner
Carrier of CFTR mutation can have CBAVD without other symptoms
Which aspect of fertility is most affected by maternal age?
Ovarian reserve; we run out of eggs
Note: uterus largely unaffeted; donor eggs have the same success rate in older vs. younger uteri
Describe the clinical features of congenital bilateral absence of the vas deferens
- Missing vas deferens, distal 2/3 of epididymis, seminal vesicle
- Likely a carrier of CFTR mutation
List the 3 most common causes of infertility in a person with a uterus
- Anatomic anbnormality
- Uterine and/or fallopian tube
- Ovulatory dysfunction
- Decreased ovarian reserve (fewer eggs)
- Uterine and/or fallopian tube
Inability to conceive after one year of unprotected intercourse
Note: For female patients 35 and older, consider intervention after 6 months without conceiving - i.e. pt doesn't have to meet the strict definition of infertility to be treated for infertility
Which part of the hypothalamic/pituitary/gonadal axis is interrupted in hypothalamic amenorrhea?
Pulsatile GnRH secretions from the hypothalamus
Remember that both absent and continuous GnRH secretions will inhibit LH/FSH secretion
What is the most effective form of male contraception?
Pull out method and/or condoms have higher failure rates b/c may not always be properly executed
What is the best treatment option for a woman with bilaterally blocked fallopian tubes who wishes to conceive a child?
Age and ovarian reserve play a role in likelihood of success
Is a vasectomy immediately effective?
- Must check to make sure ejaculate has no sperm after a few months
- Surgery is a failure if any motile sperm persist at >6 months; repeat procedure
How long does it take after fever for sperm levels to return to normal?
Up to 3 months
If a pt has abnormal semen results <3 months after fever, rechek later
Sperm count below ___ is an indication for karyotype testing
Sperm count below 5 million is an indication for karyotype testing
What is the first line treatment for ovulation induction in a patient with PCOS?
Describe the MOA
- Oral non-steroidal aromatase inhibitor
- Decreased estrogen level -> brain releases more LH/FSH
List the steps of a complete evaluation for infertility in a person with a uterus
- Assess uterine cavity
- Document tubal patency
- Confirm ovulation
- Assess ovarian reserve
What is the MOA of clopiphene citrate?
Selective estrogen receptor modulator
- Blocks hypothalamic estrogen receptors
- This tricks the brain into thinking there isn't enough estrogen
- -> Increased LH and FSH
- -> induces ovulation
What is the most common genetic caues of azoospermia?
Klinefelter syndrome (47, XXY)
How will semen differ in retrograde ejaculation vs. ejaculatory duct obstruction?
Both: Low ejaculatory volume
- Retrograde ejaculation
Normal semen pH (≥7.2)
- Normal semen pH (≥7.2)
- Ejaculatory duct obstructiond
- Acidic semen pH => seminal vesicle secretions are not getting into the ejaculate
Prostate secretions are acidic
Seminal vesicle secretions are alkaline
At what age does fertility peak in a person with a uterus?
When does it begin to significantly decline?
20-24 years old
Significant decline begins at 30-32ish