Infertility

Question 1

Action of FSH

Normal level

Answer 1

semniferous tubules secrete inhibin from sertoli cells and produce sperm

2-12 IU/L

Question 2

Action of LH

Normal level

Answer 2

leydig cells produce testosterone

2-9 IU/L

Question 3

maturation of sperm

time taken

Answer 3

1) primary spermatocytes 46 chromosome

2) second meiotic division to form spermatids 23 chromosome
3) spermatozoa

process takes 72 days

Question 4

structure of sperm
head
body
tail

Answer 4

head contains nucleus and acromosome capn with vesicles containing lytic enzyme
body contains mitochondria and contractile filaments extending into tail
tail

Question 5

testosterone
normal level
bound to SHBG %

Answer 5

normal range in males is about 270-1070 ng/dL with an average level of 679 ng/dL

60% bound to SHBG
38% bound to albumin
2% is free

Question 6

Definition infertility

Answer 6

Failure of conception after 12 months of regular unprotected sex
Infertility is defined by the inability of a sexually active, non-contraceptive couple to achieve spontaneous pregnancy within 1 year

Question 7

chance of conception per month healthy couple and per year

Answer 7

20-25% per month
75% 6 months
90% one year

Question 8

% couples affected infertility

Answer 8

14-25% couples affected at some point

Question 9

frequency of intercourse during ovulation recommended

Answer 9

once a day

Question 10

Normal sperm parameters

Answer 10

Volume = > 1.4 ml
Total sperm number (10^6 ejaculate) 39 million
Concentration (10^6/ml) 16 million/ml
Total mobility (progressive and non progressive) 42%
Progressive mobility = 30%
Morphology % normal forms = 4
PH = >7.2
Peroxidase positive leucocytes <1 million
Seminal fructose (micromole/ejaculate) = >13

Question 11

scrotal temp vs body temp

Answer 11

2-4 degrees lower

Question 12

drugs affecting fertility

irreversible affect

Answer 12

Testosterone
Anabolic steroids
ADT
Chemotherapy
Opiates
5ARI
Alpha blockers

some antibiotics, spironolactone, cimetidine, nifedipine, sulfasalazine, and colchicine

Marijuana
Alcohol
Smoking

Sulfasalazine Azathioprine, Mycophenolate mofetil and Methotrexate

Testosterone, Sulfasalazine, Anabolic steroids, Cyproterone acetate, Opioids, Tramadol, GhRH analogues and Sartan - AgII receptor antagonists

Question 13

increased risk of testicular cancer with infertility HR compared with fertile control subjects

Answer 13

3.3 to 11.9 HR

Question 14

incidence testicular cancer

Answer 14

3-10 new cases per 100,000 males per year

Question 15

sperm maturation time testes and epididymis transit time

Answer 15

64 days completes

5-10 days of epididymal transit time

Question 16

incidence varicocele normal population and infertile

% with improved parameters after varicocele treatment

Answer 16

15% in general population, and 40% in infertility clinics

Improved semen parameters in approx. 70% of patients after repair

Question 17

EAU recommendations varicocele

Answer 17

Treat in adolescents with ipsilateral reduction in volume

Clinical varicocele with abnormal semen and good female reserve

Failed assisted reproductive techniques/miscarriage

Do no treat varicocele in infertile men who have normal semen analysis and in men with subclinical varicocele

Question 18

microdeletions

Answer 18

One of three non overlapping regions of Y chromosome
AZF a, b, c
AZFa – Sertoli only, rare 5%
AZFb – maturation arrest
Azoospermic factor c – severe oligozoospermia, can find sperm in 10-15%
Transmitted to male offspring, need genetic counselling before ART

Question 19

CBAVD
found in % infertility and OA
semen volume and PH indicators

Answer 19

CBAVD is found in 2% men with infertility and is present in 6% with obstructive azoospermia
>95% of men with CF have CBAVD
particularly those with a semen volume < 1.0 mL and acidic pH < 7.0.

Question 20

CUAVD

Answer 20

Congenital unilateral absence of the vas deferens (CUAVD) is usually associated with ipsilateral absence of the kidney (26% with UAVD there is absent kidney on ipsilateral side) and probably has a different genetic causation

Question 21

indications karyotype

Answer 21

karyotype analysis is currently indicated in men with azoospermia or oligozoospermia (spermatozoa < 10 million/mL)

Question 22

treatment retrograde ejaculation

Answer 22

pseudoephrine, Sudafed over the counter, try 60mg one tablet for a week, and an hour before do another semen analysis (120mg orally 90 minutes before ejaculation)
success rate 58%
Imiprimine 25mg
Centrifugation and resuspension (using sodium bicarbonate orally 1hr before), pregnancy rate 15%
Collegen injection into bladder neck
Acupuncture 68%

Question 23

incidence azoospermia

Answer 23

1-3% male population

10-15% of male infertile population

Question 24

Causes azoospermia OA

Answer 24

Epididymal obstruction is most common cause of OA affecting 30-67% of azoospermic men

Other sties of obstruction are intra testicular 15%, ED obstruction 1-5% and vas deferens

Congenital causes epididymal obstruction as CBAVD, detached epididymis in UDT

Question 25

causes NOA

Answer 25

``` UDT Infective – STI, UTI, mumps Torsion Hormonal - hypogonadism Testicular tumours Varicocele ```

Question 26

UDT and GCT

Answer 26

In 5-10% of testicular cancers there is history of UDT Risk of GCT 3.6 to 7.4 x higher than general population 2-6% of all men with history of UDT will develop testicular cancer Even with early orchidopexy still harbour higher risk of GCT

Question 27

indications ART

Answer 27

Surgically unable to reoncstruct eg congenital absence of vas Men with few viable sperm in ejaculate Azoospermic men with varicoceles - as half will achieve enough sperm to have IVF with ICSI after varicocele repaired Men with non obstructive azoospermia

Question 28

success rate ICSI

Answer 28

Indicated in cases of severe male factor infertility In couples with prior failed IVF Or in cases of sperm with significant fertilising ability defects In 2006 ICSI represented 47% of all IVF treatments in UK Success rates pregnancy rate 20-37% per cycle 36% in women <35 years 10% in women > 40 years

Question 29

``` Klinefelters features chromosone incidence hormone profile ```

Answer 29

``` 1 in 650 live male births 47XXY tall stature, long extremities, absent frontal balness, fewer chest hairs, wide hips, narrow shoulders breast development small testicles and penis high FSH low testosterone Azoospermia ```

Question 30

Kallman syndrome

Answer 30

``` facial asymmetry UDT anosmia pituitary dysfunction colour blindness ```

Question 31

azf c | chance of finding sperm on tese

Answer 31

Seen in 60% of cases of microdeletions | Can find sperm on TESE in 50%

Question 32

OA vs NOA ratio | Azoospermia in general pop vs infertile men

Answer 32

60% NOA, 40% OA | general population 1%, infertility 10-15% azoospermia

Question 33

NOA vs OA FSH, testicular size and volume

Answer 33

OA normal testis normal FSH low semen volume treatment: reconstruction or SSR/ICSI ``` NOA small testis raised FSH normal volume treatment: SSR (microtese, icsi), hormonal ```

Question 34

``` Causes of OA: volume, ph, fructose, urine Vasal/epididymal EDO Retograde ejaculation Antegrade loss ejaculation ```

Answer 34

Vasal/epididymal: normal volume and fructose and PH EDO: low volume <1.5cc, acidic low PH and low fructose Retograde ejaculation: low/none volume, more than 10 sperm phf in urine Antegrade loss ejaculation: none volume, no sperm in urine and normal PH and fructose

Question 35

treatment of retograde ejaculation pseudofed dosing

Answer 35

60-120mg 1-2 hours before ejaculation 7-10 days before ovulation can also add / exchange in imipramine 25mg

Question 36

AD treatment (risk of electroejaculation and injury above T6)

Answer 36

``` BP >20 above baseline or above 150 sit up loosen tight clothing, remove stimulus nifedipine IR 10mg sublingual or chew 1-2 sprays GTN, repeat after 30 mins monitor BP a few hours for rebound hypertension ```

Question 37

pros of embolisation varicocele

Answer 37

can treat both sides no risk arterial injury hydrocele low learning curve ``` cons chronic pain migration coils unable to access R>L radiation ```

Question 38

papers for varicocele treatment

Answer 38

``` Evers MA Lancet No benefit however flawed analysis when choose clinically significant varicoceles with semen impaired pregnancy rate is 36% vs 20% ``` Abel Meguid SR OR 3.04, NNT 5 spont pregnancy rate 32% vs 13%

Question 39

varicocele incidence gen pop vs primary infertility vs secondary infertility

Answer 39

15% gen pop 35% primary infertility 75% secondary infertility

Question 40

vasectomy reversal paper

Answer 40

Belker 1991 < 3 years patentcy 97%, pregnancy 76% >5 years, patency 71%, pregnancy 30% 9-14 years, 80% patency 44% pregnancy

Question 41

semen quality orchidectomy papers

Answer 41

Rives 2012 semen quality Peterson JCO 1999 50% drop in semen parameters post orchidectomy 10% will become azoospermic post orchidectomy 10% will be azoospermic before orchidectomy

Question 42

LH and FSH level | lab

Answer 42

LH 1.3-8.0mlU/ml | FSH 1.6-11.0mIU/ml

Question 43

causes of SV obstruction

Answer 43

Congenital atresia Stone Stenosis due to infection Inflammation

Question 44

doing TURED

Answer 44

Joint procedure with radiology under GA Appropriately consented pt – aware of risk of failure (early/ late- due to recurrent obstruction), small risk incontinence and retrograde ejaculation, recurrent chemical epididymitis Transrectal probe to guide needle into dilated SV Aspirate fluid for SA. If sperm – excludes proximal obstruction Fill SV with methylene blue Place resection scope, and resect veru/ ejaculatory ducts, until see flush of blue into urethra. Preserve BN and sphincter Use transrectal probe to ensure decompression of cyst and both SV’s If no sperm on aspirate of SV, needs vasogram to exclude proximal obstruction. May require Epididmovasostomy/ vasovasostomy/ or SSR with TESE dependent on level of obstruction