Download - Kramer Male Infertility
-
7/30/2019 Kramer Male Infertility
1/68
Current Management of Male Infertility
Andrew Kramer, MD, MBAAssistant Professor, Department of Surgery,
Division of Urology
University of Maryland School of Medicine
Diagnostic and Genetic Considerations
-
7/30/2019 Kramer Male Infertility
2/68
Outline:
Male Reproductive Anatomy
Male Reproductive History and Physical
Exam
Interpretation of the Semen Analysis
Selected Cases
Conclusion
-
7/30/2019 Kramer Male Infertility
3/68
-
7/30/2019 Kramer Male Infertility
4/68
-
7/30/2019 Kramer Male Infertility
5/68
-
7/30/2019 Kramer Male Infertility
6/68
-
7/30/2019 Kramer Male Infertility
7/68
-
7/30/2019 Kramer Male Infertility
8/68
-
7/30/2019 Kramer Male Infertility
9/68
-
7/30/2019 Kramer Male Infertility
10/68
-
7/30/2019 Kramer Male Infertility
11/68
-
7/30/2019 Kramer Male Infertility
12/68
-
7/30/2019 Kramer Male Infertility
13/68
-
7/30/2019 Kramer Male Infertility
14/68
-
7/30/2019 Kramer Male Infertility
15/68
-
7/30/2019 Kramer Male Infertility
16/68
-
7/30/2019 Kramer Male Infertility
17/68
-
7/30/2019 Kramer Male Infertility
18/68
-
7/30/2019 Kramer Male Infertility
19/68
-
7/30/2019 Kramer Male Infertility
20/68
-
7/30/2019 Kramer Male Infertility
21/68
-
7/30/2019 Kramer Male Infertility
22/68
-
7/30/2019 Kramer Male Infertility
23/68
3 Cases:
1. Obstructive Azoospermia
2. Nonobstructive azoospermia
3. Inability to ejaculate
-
7/30/2019 Kramer Male Infertility
24/68
A couple presents withinability to have children
-
7/30/2019 Kramer Male Infertility
25/68
HPI:
Male: 34
2 yrs of unprotected intercourse
No children from previous relationships
-
7/30/2019 Kramer Male Infertility
26/68
Exam:
Testes scrotally located and of normalsize and consistency
No vasa palpable
Only caput of epididymis present
-
7/30/2019 Kramer Male Infertility
27/68
Semen Analysis:
Azoospermia
-
7/30/2019 Kramer Male Infertility
28/68
Semen Analysis:
Volume: 0.5cc
Count: 0
pH: 6.5
-
7/30/2019 Kramer Male Infertility
29/68
-
7/30/2019 Kramer Male Infertility
30/68
One Cause of ObstructiveAzoospermia
(congenital bilateral absence ofthe vas deferens)
* Caused by Mutations in CF genes
-
7/30/2019 Kramer Male Infertility
31/68
Transmission Pattern:
F508/F508
Clinical CF
F508/5T
CBAVD
F508/+
carrier
5T/+
carrier
Male
Female
F508
F508
+
5T
-
7/30/2019 Kramer Male Infertility
32/68
Clinical manifestation depends onthe amount of CFTR dysfunction
-
7/30/2019 Kramer Male Infertility
33/68
-
7/30/2019 Kramer Male Infertility
34/68
CBAVD: obstructive azoospermia
CF gene is located on chromosome 7
Encodes a membrane protein called CFTR
(CF transmembrane conductanceregulator) that regulates Cl- balance
When abnormal, ion and water transport
across epithelial cells is altered causingtenacious sections
Thickett, K., Stableforth, D. et al. Awareness of infertility in men with cystic fibrosis. Fertility and Sterility.
Vol 76(2). August 2001, pp 407-408.
-
7/30/2019 Kramer Male Infertility
35/68
Cystic Fibrosis Transmembrane Conductance Regulator
...
CF Gene
Chromosome # 7
CFTR
-
7/30/2019 Kramer Male Infertility
36/68
Management:
Family counseling
MESA: microsurgical epididymalsperm aspiration
Congenital Bilateral Absence of the Vas Deferens
-
7/30/2019 Kramer Male Infertility
37/68
EpididymalRemnant
Congenital Bilateral Absence of the Vas Deferens
-
7/30/2019 Kramer Male Infertility
38/68
-
7/30/2019 Kramer Male Infertility
39/68
Infertility: Part II
-
7/30/2019 Kramer Male Infertility
40/68
Infertility x 5 yrs
Husband: 45 Wife: 38
Wife has 2 children from a prior marriage
-
7/30/2019 Kramer Male Infertility
41/68
Physical Exam:
Testes measure 1.5cm x 1.5cm in size,slightly soft
Vasa and epididymides feel normal
No varicocele
-
7/30/2019 Kramer Male Infertility
42/68
Semen Analysis:
Volume: 3cc
Count: 0
Color: clear
pH: 8.1
-
7/30/2019 Kramer Male Infertility
43/68
Hormone Studies:
FSH: 15.2 (normal 2-20)
LH: 5.1
Testosterone: 344 Prolactin: 8.5
Estradiol:
-
7/30/2019 Kramer Male Infertility
44/68
Genetic Testing:
Karyotype: abnormalities range from 10-
15% in azoospermic men; Klinefeltersyndrome most common
Y-chromosome microdeletions: 13% ofmen with azoo or severe oligospermia
Oates, RD. Genetic considerations in the treatment of male infertility. Infert Reprod Med Clin NAmerica. Vol 13 (2002) 551-585.
-
7/30/2019 Kramer Male Infertility
45/68
Y Chromosome
Short arm: SRY--acts as an architecturaltranscription factor instigating male
development Long arm: Contains genes critical to
spermatogenesis
-
7/30/2019 Kramer Male Infertility
46/68
-
7/30/2019 Kramer Male Infertility
47/68
-
7/30/2019 Kramer Male Infertility
48/68
-
7/30/2019 Kramer Male Infertility
49/68
-
7/30/2019 Kramer Male Infertility
50/68
-
7/30/2019 Kramer Male Infertility
51/68
-
7/30/2019 Kramer Male Infertility
52/68
47, XXY Klinefelters Karyotype
-
7/30/2019 Kramer Male Infertility
53/68
-
7/30/2019 Kramer Male Infertility
54/68
-
7/30/2019 Kramer Male Infertility
55/68
-
7/30/2019 Kramer Male Infertility
56/68
-
7/30/2019 Kramer Male Infertility
57/68
-
7/30/2019 Kramer Male Infertility
58/68
Infertility: Part III
-
7/30/2019 Kramer Male Infertility
59/68
Married for 9 years with nopregnancies
Husband: 38 Wife: 37
PMH: 1985 testicular CA on left, s/porchiectomy, RPLND, and chemotherapy(cisplatinum/vinblastine/bleomycin)
-
7/30/2019 Kramer Male Infertility
60/68
Ejaculatory Dysfunction:
Two Types:
Retrograde Ejaculation (backwards flow ofejaculate)
Anejaculation (failure of emission)
-
7/30/2019 Kramer Male Infertility
61/68
Retrograde Ejaculation Diagnosis:
1. Void to completion
2. Ejaculation (collection any antegrade)
3. Void to completion ASAP: look at
sample for seminal fluidthen spin to 1cc,analyze pellet
-
7/30/2019 Kramer Male Infertility
62/68
Anejaculation/Failure of Emission:
Failure of sympathetic nervous system dueto:
-Spinal cord injury
-RPLND (sympathetic nerve injury)
-D.M.
-
7/30/2019 Kramer Male Infertility
63/68
-
7/30/2019 Kramer Male Infertility
64/68
Summary:
Evaluation of the
Infertile Male
-
7/30/2019 Kramer Male Infertility
65/68
Goal of Evaluation:
1. Identify correctable causes
2. Identify irreversible causes that may beamenable to ARTs
3. Irreversible conditions which are notamenable to ARTs but donor sperm may be anoption
4. Reveal genetic abnormalities that may affecthealth of offspring if ARTs were to be used
Sharlip, Ira and Jarow, Jonathan et al. Best practice policies for male infertility.Fertility and Sterility, Volume77(5). May 2002. 873-882.
-
7/30/2019 Kramer Male Infertility
66/68
Azoospermia: Etiology
1. Pretesticular: endocrine
2. Testicular: disorders of spermatogenesisintrinsic to testes (non-obstructive)
3. Post-testicular: ejaculatory dysfunction orobstruction of sperm delivery to meatus(obstructive)
Pre and Post testicular are often treated,primary testicular causes can still achievefertility
-
7/30/2019 Kramer Male Infertility
67/68
Remember:
Always evaluate patients as a couple
Perform the womans workup
simultaneously to the mans Just because one member of the couple is
abnormal does NOT mean the other one is
normal: both warrant a full workup
Th E d
-
7/30/2019 Kramer Male Infertility
68/68
The End
Andrew Kramer, MD, MBA
Division of Urology, Department of Surgery