Flashcards in Disorders of Male Reproduction Deck (35):
What percentage of inability conceive can be contributed to male infertility?
40-50% of couples with infertility, the male is the sole cause or contributes to the cause of infertility
Describe the cells and their respective products that are stimulated by LH and FSH.
FSH stimulates stertoli cells that produce sperm
LH stimulates Leydig cells that produce testosterone
Contrast the presentation of pituitary disease in pre-puberty v. post puberty.
pre-pubertal: dx due to growth retardation, delayed puberty or adrenal and thyroid deficiency, *testes are small and soft*
post-pubertal: symptoms of specific hormone deficiency/excess, mass effects or symptoms of underlying process, testosterone is low and Gn levels are inappropriately low, *testes are small and firm*
What are the features of Kallman Syndrome?
congenital hypogonadotropic hypogonadism, with anosmia presenting with delayed puberty; cryptorchidism and gynecomastia
What are the treatments used in Kallman Syndrome?
testosterone replacement used to achieve virilization, if fertility is desired, exogenous gonadotropins are used (more difficult regimen, more expensive)
What sources can cause androgen excess and what is the result?
exogenous anabolic steroid (abuse)- all administered testosterone is a male contraceptive
both lead to testicular hypo function by lowering FSH and LH via negative feedback
Will someone with congenital adrenal hyperplasia have a high or low ACTH? What is the tx for CAH?
21-hydroxylase deficiency results in decreased cortisol synthesis and an increase in ACTH (steroids are shunted to androgen pathway)
patients can be treated with glucocorticoids and Gn secretion will resume
What are possible causes of excess estrogen?
tumors in the adrenal cortex
Stroll or Leydig cells of the testis
Hepatic dysfunction, excess alcohol use
obesity- peripheral aromatase
How is AIS inherited? What would you expect for LH and testosterone levels?
elevated LH and testosterone levels (no feedback)
FSH are normal or high
(broad range of phenotypes from phenotypic females to phenotypic males)
What would you expect of hormone levels in a patient with Klenfelter's syndrome? What are common features?
syndrome of hypogonadism: low testosterone, elevated FSH and LH, high estrogen/testosterone ratio (not absolute estrogen); small firm testis and azoospermia
variable phenotypes, long limbs, breast development
Are patients with Klinefelter's Syndrome able father children?
no therapy available to improve spermatogenesis
microsurgical testicular sperm extraction (TESE) has been performed and sperm have been used in IVF with ICSI
What chromosomal deletions can lead to infertility and what are the features of this syndrome?
deletions in the long arm of the Y chormosome AZFa, AXFb and AZFc occur de novo and are not inherited (unless through IVF)
males are phenotypically normal without other known problems; sperm are found in 50% of men with AZFc with testicular biopsy (are candidates for IVF, ICSI), sperm are never seen in patients with AZFb variant
Describe the TESE procedure.
can be done in-office
cord block is usually used for anesthesia
IV sedation can be given to relax patient
What are the sequalae of cryptorchidism?
low sperm counts in 50% with bilateral, 25% in unilateral; the higher the testis, the more severe the testicular dysfunction
germ cells absent in 20-40% of inguinal testes and 90% of intra-abdominal testes, although 80-90 with surgically corrected unilateral cryptorchidism or 30-50% with corrected bilateral cryptorchidism
How common is varicocele?
abnormal toruosity and dilation of the testicular veins is seen in 15-20% of all men and in 40% of men presenting with infertility
*most common correctable cause of male infertility
Why are 90% of varicoceles left-sided?
left sided varicoceles are associated with pattern of drainage through left renal artery and associated with Nutcracker phenomenon (left renal vein compressed between super mesenteric artery and the aorta)
unilateral right-sided varicoceles are uncommon and can be caused by thrombus or occlusion of the vena cava or in situs inversus
What are possible causes of orchitis?
mumps in 30% of patients if contracted after puberty may result in permanent testicular atrophy (interstitial edema and mononuclear edema
What is the sequalae of mumps related orchitis?
severe bilateral orchitis due to damage of infection may result in hypergonadotropic hypogonadism and gynecomastia
TESE with IVF/ICSI may be attempted for azoospermic patients
List possible environmental/drug related gonadotoxins.
chemotherapy (testicular cancer, Hodgkin's disease, bone and soft tissue sarcoma, lymphoma and leukemia)
workplace chemicals and solvents: alkylating agents, vinca akyloids, antimetabolites
Chemotherapy for which cancers is most likely to result in sterility?
80-100% sterility of patients with Hodgkin's and most treated with cisplatin-based chemo for testis cancer will be azoospermatic
note radiation exposure above a certain amount usually results in azoospermia and recovery is dose related and can take more than 5yr to return (Leydig cells are relatively radio resistant)
When should sperm banking be offered for someone undergoing cancer treatment?
before and not during chemotherapy or radiation; efforts to protect spermatogenesis during chemotherapy have been disappointing
What is the result of heavy marijuana use on fertility?
decreased serum testosterone
decreased sperm concentration
(cocaine has also been correlated with decreased sperm counts)
What prescription meds can effect male fertility?
spironolactone: detrimental to semen quality through anti-androgen activity
CCB: causes a reversible functional defect in sperm
antibiotics: unclear data as a possible cause of infertility
sulfasaline: reversible defects in sperm concentration and motility
cimetidine: degeneration of germ cells
opioid use: stops pulsate GnRH
How does alcohol effect male fertility?
excess consumption affects both the testes and the liver:
testicular atrophy in chronic alcoholics (total T levels may be normal but free T is low due to elevated SHBG
ED and gynecomastia
fecundity has not been proven
How does tobacco smoke effect fertility?
DNA binding carcinogens are found in sperm and embryos from smoke, cadmium and nicotine are present in creased amounts in semen (causes decreased sperm motility)
Does unilateral obstruction effect fertility?
unilateral obstruction only effects fertility if there is a contralateral testicular pathology
What is the mechanism of disease in CBVD and possible treatments.
congenital bilateral absence of the vas deferens, is associated with mutation in the CFTR gene; most men with clinical CF are often azoospermic
tx: surgical sperm retrieval combined with IVF/ICSI after genetic testing, microsurgical epididymal sperm aspiration (MESA)
What is the classic presentation of CBAVD?
low-volume, azoospermic, acidic ejaculates (alkaline fluid normally form seminal vesicles)- hypoplasia of the seminal vesicles is also possible or problems with ejaculation
Describe two processes that could interfere with ejaculation.
dysfunction of the peristaltic function of the vas deferens- i.e. due to RPLND or spinal cord injury
failure in closure of the bladder neck (retrograde ejaculation- examine urine for sperm)
What interventions are available for patients with spinal cord injury and dysfunction in ejaculation?
intervention depends on the level of the spinal cord injury
above T10- penile vibratory stimulation (70% successful)
lower spinal cord- electrical stimulation
What are the conditions for which electroejaculation is indicated?
spinal cord injury
retroperitoneal lymph nod dissection
Where are the most common places of ductal obstruction? How is it treated?
either in the epididymis or vas deferens
treatments for ductal obstruction, specifically reversal of vasectomy include vasovasotomy and epididymovasostomy
What are the most common causes and possible treatments for immunologic infertility?
introduced with torsion or trauma
immune suppression with corticosteroids is not particularly effective, often semen processing and IVF/ICSI is used
How does primary ciliary dyskinesia effect fertility?
causes a flagellar abnormaility that cause immobile sperm and if accompanied by situs inverses is considered Kartagener's (AR)