Male infertility

Question 1

Radiation risk for sperm production decline

Answer 1

0.15 Gy

Question 2

Radiation risk for azoospermia

Answer 2

0.5 Gy

Question 3

Most important downstream product of SRY

Answer 3

SOX9
AMH synthesis depends on SOX9

Question 4

When do sertoli cells start making AMH?

Answer 4

6 weeks
Sertoli cells are the only cells that make SRY

Question 5

Male abnormal FSH level

Answer 5

> 7.4 mIU/L

Question 6

Role of FSH in men

Answer 6

Upregulates LH receptors on leydig cells
stimulates ABP production

Question 7

Cryptorchidism/mumps

Answer 7

testicular atrophy

Question 8

STDs

Answer 8

ductal obstruction

Question 9

DM/neurological disorder

Answer 9

retrograde ejaculation

Question 10

CF

Answer 10

absent VD

Question 11

pubertal delay

Answer 11

endocrinopathy and impaired spermatogenesis

Question 12

DDX low volume on SA

Answer 12

failed emission, incomplete collection, short abstinence, CBAVD, EDO, hypogonadism, retrograde ejaculation

Question 13

Retrograde ejaculation

Answer 13

consider if volume is < 1 mL
pretreat to alkalinize bladder
give sudafed to close bladder neck
In men with very low or no volume + AZO, any sperm in PEU indicates retrograde ejaculation
In men with low volume oligospermia, higher sperm numbers are required

Question 14

What does low motility indicate

Answer 14

testicular dysfunction
sperm ab
infection
varicoceles
prolonged abstinence

Question 15

What does poor morphology mean

Answer 15

poor quality of sperm
associated with varicocele and testicular failure
reflects ability to fertilize oocyte

Question 16

When to do endocrine evaluation in men?

Answer 16

sperm conc < 10 mill/mL
sexual dysfunction (low libido)
findings c/w hypoTSH, hyperprolactin etc

if hypo hypo –> MRI

Question 17

NOA

Answer 17

severe deficiency in spermatogenesis due to HP or primary testicular dysfunction

Question 18

Kallman

Answer 18

failure of migration of GnRH and olfactory neurons causing delayed puberty, anosmia

X linked recessive: most common, anosmin !, KAL,
AD: FGFR1
also AR forms

Question 19

Klinefelter Syndrome

Answer 19

results from non-disjunction of XX or XY during gametogenesis
Affected individuals also lead to T deficiency, Osteoporosis, metabolic syndrome, T2DM, gynecomastia, breast cancer, extra gonadal germ cell tumors

Question 20

Can Y chromosome microdeletions be detected with karyotype?

Answer 20

No, need PCR to diagnose

Question 21

Surgical correction for OA

Answer 21

microsurgical reconstruction of vas or epididymis
transurethral reconstruction of ED (TURED)
sperm retrieval techniques

Question 22

What is the CFTR gene?

Answer 22

produces protein responsible for chloride transport across cell membranes
mutations result in abnormal chloride and water transport
Leads to thick mucous secretions that are thick and sticky
thick mucous clogs vas deferens and leads to deteriorations

Question 23

PESA

Answer 23

percutaneous epididymal sperm aspiration with needle

for OA
No microsurgery, local anesthesia, fast and repeatable, minimal discomfort
few sperm retrieved and hematoma risk

Question 24

MESA

Answer 24

microsurgical epididymal sperm aspiration with incision

open surgical approach using microscopy to identify individual epididymal tubules and extracts large number of sperm directly from tubules

Large # of sperm, best prep rates, good for sperm cryo
Microsurgery required
post-op discomfort
higher cost

Question 25

TESA

Answer 25

percutaneous testicular sperm aspiration with needle

no microsurgery, local anesthesia, fast and repeatable
few sperm retrieved
hematoma risk
risk testicular atrophy

Question 26

TESE

Answer 26

conventional or microsurgical testicular sperm extraction with incision for NOA

local anesthesia, minimal discomfort
few sperm retrieved
risk testicular atrophy

Question 27

MicroTESE

Answer 27

highest sperm retrieval rates for NOA

Question 28

Where do WHO parameters come from?

Answer 28

represent 5th percentile lower reference limit for men who had a partner achieve a pregnancy within 12 months

Question 29

Dosing of hcg for oligospermia

Answer 29

3000 IU of hcg twice weekly

Question 30

Meds for oligospermia

Answer 30

3000 IU hcg twice weekly
add on clomid 50 bc sometime high hcg can suppress FSH
try FSH 75 twice weekly

Question 31

DNA fragmentation tests

Answer 31

Comet
TUNEL
SCSA

Question 32

DNA frag testing

Answer 32

> 30
DNA fragmentation is associated with worse pregnancy rates and higher rates of miscarriage
No prospective studies showing a benefit of DNA fragmentation testing to improve outcomes
DNA fragmentation may be useful for couples with failed IVF cycles and if high DNA frag could consider ICSI with surgically extracted sperm
Prospective cohort of 100 couples with high DNA fragmentation testicular sperm yielded higher live birth rates compared to ejaculated sperm
Decreased abstinence (more frequent ejaculation) may help limit sperm DNA damage

Question 33

When is DNA frag warranted

Answer 33

Varicocele (maybe)
Elevated in 50%
Most helpful when on the fence about varicocele repair
Borderline to normal SA
Moderate varicocele and SA within normal ranges
After repair, post-op abnormal SDF is very poor predictor of natural and assisted conception
No evidence to get in subclinical varicocele
RPL
MA of 13 prospective studies showed higher SDF rates in males
Mechanism of how increased DFI contributes is unknown
ASRM did NOT recommend in 2012
RCT (Mansour et al) showed lower SAB rates after varicocele repair
History of poor IVF outcome
Recurrent blastulation failure
Paternal genome activated between 4 and 8 cell stage, high DNA damage may manifest in later stages of embryonic development