Male Infertility

Question 1

What is the definition of infertility?

Answer 1

Inability to achieve pregnancy after one year of unprotected sexual intercourse.

Question 2

What percentage of infertility is due to male vs female factors?

Answer 2

50% female only
20% male only
30% male and female

Question 3

What is the most common cause of male infertility?

Answer 3

Varicocele

Question 4

What is the most common cause of low ejaculatory volume?

Answer 4

incorrect collection

Question 5

What is Azoospermia?

Answer 5

No sperm in the ejaculate

Question 6

What is Aspermia?

Answer 6

No ejaculate

Question 7

What is oligospermia?

Answer 7

Sperm concentration

Question 8

What is asthenospermia?

Answer 8

less than 40-50% sperm motility

Question 9

What is teratospermia?

Answer 9

abnormal sperm morphology

Question 10

What is the classification of causes of azoospermia?

Answer 10

Pre-testicular
Testicular
Post-testicular

Question 11

What are the risk factors for obstructive azoospermia?

Answer 11

Surgery/instrumentation
GU infections
CF/CBAVD

Question 12

What are the risk factors for non-obstructive azoospermia?

Answer 12

Gonadotoxin
Cryptorchidism
Torsion
Orchitis

Question 13

Medical conditions that may cause infertility?

Answer 13

Prostatitis, Orchitis, febrile illness
Hormonal disorders (hypogonadism, Thyroid disorders)
Cirrhosis
Diabetes
Myotonic dystrophy
Young's, Kartageners, CF, CBAVD

Question 14

What genetic anomalies may lead to infertility?

Answer 14

Karyotype abnormalities (6%)
CFTR mutations
Y chromosome microdeletions: AZF a, b, and c (10-15%)

Question 15

What should be included in the reproductive history?

Answer 15

The reproductive history should include

1) coital frequency and timing;
2) duration of infertility and prior fertility;
3) childhood illnesses and developmental history;
4) systemic medical illnesses (e.g., diabetes mellitus and upper respiratory diseases) and prior surgeries;
5) sexual history including sexually transmitted infections;
6) gonadal toxin exposure including heat.

Question 16

What should you look for on physical exam when working up male infertility?

Answer 16

Visual fields
Skin pigmentation
Thyroid exam
Gynecomastia/galactorrhea
Liver exam
Secondary sexual characteristics, tanner stage
Testicular size, consistency, Vas, epididymis, vericocele
Sphincter tone/Prostate

Question 17

What is normal ejaculate volume?

Answer 17

1.5-5 ml

Question 18

What is normal semen pH?

Answer 18

> 7.2

Question 19

What is normal sperm concentration?

Answer 19

> 20 million/ml

Question 20

What is a normal total sperm count?

Answer 20

> 40 million/ejaculate

Question 21

What is normal sperm motility?

Answer 21

> 40-50%

Question 22

What is the normal amount of progressively motile sperm?

Answer 22

> 32%

Question 23

What is the normal forward progression scale?

Answer 23

> 2 out of 4

Question 24

What is normal morphology percent for semen analysis?

Answer 24

> 4%

Question 25

What is normal sperm agglutination for a semen analysis?

Question 26

what is normal viscosity/consistency for a semen analysis?

Question 27

What is the normal concentration of leukocytes in a semen analysis?

Question 28

What is the normal value for the immunobead test which looks at the normal percent of motile sperm adhered to particles?

Question 29

What is the normal value for a sperm vitality test?

Answer 29

> 58%

Question 30

What is the normal value for fructose in a semen analysis?

Answer 30

> 13 umol/ejaculate

Question 31

What is the initial minimum workup for male infertility?

Answer 31

History, physical exam, and 2 semen analyses at least 1 month apart.

Question 32

What is the next step if the vas deferens are present bilaterally?

Answer 32

Examine the Semen volume

Question 33

What is the next step if the vas is absent unilaterally?

Answer 33

Get renal ultrasound (11% have renal anomalies) and CFTR testing.

Question 34

What is the next step if there is azoospermia and bilateral absence of the vas deferens?

Answer 34

Workup for CF

Question 35

What are the treatment options for CBAVD with no CF?

Answer 35

CFTR, and genetic testing LH, FSH, Testosterone Renal ultrasound

Question 36

What are the treatment options for CBAVD?

Answer 36

Donor insemination Adoption SR with ICSI

Question 37

What is the next step if vas are present but semen volume is

Answer 37

Post ejaculation urinalysis: If sperm in urine --> retrograde ejaculation No sperm in urine --> TRUS to look for EDO

Question 38

What is the treatment for EDO?

Answer 38

Trans urethral resection of ejaculatory ducts (TURED)

Question 39

What is the next step if vas are present and semen volume is > 1.5ml?

Answer 39

Evaluate the rest of the semen analysis: If semen analysis is abnormal get a hormone workup

Question 40

What if Semen analysis if completely normal?

Answer 40

1. Workup female partner 2. Post coital test 3. If normal post coital sperm function test

Question 41

What is the next step if shaking or low motility sperm are seen on post coital test?

Answer 41

Test for anti-sperm antibodies

Question 42

What is next step if no sperm are seen in mucus of post coital test?

Answer 42

evaluate coital technique | Consider intrauterine insemination

Question 43

What is the next step in patient with vas, abnormal semen analysis, but normal hormone evaluation?

Answer 43

Evaluate for ejaculation: If ejaculation absent --> anejaculation If ejaculation is present --> test for anti-sperm antibodies, rule out vericoele.

Question 44

What are the indications for an endocrine evaluation for male infertility?

Answer 44

An endocrine evaluation should be performed if there is: 1) an abnormal semen analysis, especially if the sperm concentration is less than 10 million/ml; 2) impaired sexual function; or 3) other clinical findings suggestive of a specific endocrinopathy.

Question 45

How should and endocrine evaluation for male infertility be conducted?

Answer 45

minimum initial hormonal evaluation should consist of measurements of serum (FSH) and serum testosterone levels. If the testosterone level is low, a repeat measurement of total and free testosterone (or bioavailable testosterone), as well as determination of (LH) and prolactin levels should be obtained

Question 46

Low T, Low/normal LH, Low/normal FSH, normal prolactin?

Answer 46

Hypogonadotropic hypogonadism

Question 47

Normal T, normal LH, High/normal FSH, normal prolactin?

Answer 47

abnormal spermatogenesis

Question 48

Low T, High FSH, High LH, normal prolactin?

Answer 48

Hypergonadotropic hypogonadism (i.e. testicular failure)

Question 49

Low T, low/normal FSH, Low/normal LH, high prolactin?

Answer 49

Prolactinoma