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ANDROLOGY Case Presentation Dr Rosalina M.Ali 20 Sept 2013 Hospital Ampang

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ANDROLOGY Case Presentation Dr Rosalina M.Ali 20 Sept 2013 Hospital Ampang. 16% couples fail to conceive after 1 year of trying. Male factor : 30% Combination male and female factors : 40%. Mdm N 33yo/ Malay Clerk/NKMI Married for 4 years Presented with history of primary infertility. - PowerPoint PPT Presentation
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ANDROLOGY ANDROLOGY Case Presentation Case Presentation Dr Rosalina M.Ali Dr Rosalina M.Ali 20 Sept 2013 20 Sept 2013 Hospital Ampang Hospital Ampang
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  • ANDROLOGYCase Presentation

    Dr Rosalina M.Ali20 Sept 2013Hospital Ampang

  • 16% couples fail to conceive after 1 year of trying.Male factor : 30%Combination male and female factors : 40%

  • Mdm N 33yo/ Malay Clerk/NKMIMarried for 4 yearsPresented with history of primary infertility

    Menses Hx: Menarche 12yoCycle 30-32days with 5 days flowNo dysmenorrhea, no menorrhagiaLatest pap smear on March 2013 normalSocial history :Non smoker, does not consume alcoholFamily History : Nil in significance

  • Examination : unremarkable Height 145, Weight 74 , BMI 35Investigation:MGTT 18/23 started on insulinHSG :Irregular filling defect in right uterine cornua. Possible uterine polyp or blood clots. Bilateral tubes patent.Infectious screening : Non reactive

  • Hormonal profile:TSH 0.799T418.2LH 4.5 IU/LFSH 6.3 IU/LProgesterone 30 nmol/LEstradiol97 pmol/LProlactin11 Mu/L

  • Mr M.S 38yo/ Malay male- hx of ? Epilepsy during childhood, last attack was at the age 15yo, not on any follow up or medication- no allergies- Past surgical hx: appendicectomy done in 2009 under GA, no hx of genitourinary surgery- coital history is adequate- no erectile/ ejaculatory problem

  • Family hx: no known medical illnessyounger brother was married for 4 years before wife conceived.Smokes 12 cigarettes ,now 3-4 cigarettes /dayNever had hx of long exposure to toxic material/ pesticideNo hx of Mumps

  • Examination:Normotensive, normal hair distributiongeneral examination unremarkableTestes 2 masses felt over the right testes, separated from each other2 x 2cm, 2 x 3cm. Non tender

    R L

  • Infectious screening : NR

    Hormonal profile (12/6/13)FSH 15.8, LH 8.6Testosterone 9.1Prolactin 143

    Investigation

  • SFA : July 2011 -> azoospermia

    08/04/201327/6/2013Ph7.57.5Vol 2mls1.5mls Others NILImpAzoospermia

  • Scrotal U/S: No significant abnormalityBiopsy (15/8/13)Right testes:-> PESA : once aspiration (0.3cm3) no mature sample seen -> TESA : 3 biopsy samples 0.2cmFirst and second biopsy showed no maturesperm seenThird biopsy only 1 mature sperm (grade c) Seen

  • Left Testes : 2 biopsy taken showedno mature sperm / spermatids were seen

  • AGE

    ENVIRONMENTAL

    OCCUPATIONAL

    LIFESTYLE

  • PRE TESTICULARHypothalamic diseasePituitary disease- tumour, radiation, surgery, hyperprolactinaemia, exogenous hormone

  • TESTICULARCongenitalgenetic, chromosomal, Noonan syndrome, cryptorchidismAcquired- injury, varicocele, chemo/radiotherapy, testicular tumours

  • POST TESTICULARCongenital- cystic fibrosis, CAVDAcquiredvasectomy, infectionDisorders of sperm fx & motilitySexual dysfunction

  • INVESTIGATIONSemen AnalysisEndocrine testGenetic evaluationImagingTesticular biopsyOther sperm function tests

  • Basal hormone levels in various clinical status

    ClinicalConditionFSHLHTestos-teroneProlactinNormalSpermatogenesisNormalNormalNormalNormal

    HypogonadotrophicHypogonadismLowLowLowNormal

    AbnormalSpermatogenesisHigh/NNormalNormalNormal

    Hypergonadotrophic HypogonadismHighHighNormal/LowNormalProlactin secreting tumourNormal/ LowNormal/ LowLowHigh

  • WHO reference limits and 95% CI for semen parameters

    PARAMETERREFERENCELIMIT95% CISemen volume (ml)1.51.4 -1.7Sperm concentration (10 6/ ML)15.012 -16Total Number10 6/ ejeculate)39.033 - 46Total motility40.038 - 42Progressive motility32.031 - 34Normal forms (%)4.03 - 4Vitality (%)58.055 - 63

  • A more specified measure is motility grade, where the motility of sperm are divided into four different grades:

    Grade a: Sperm with progressive motility. These are the strongest and swim fast in a straight line. Sometimes it is also denoted motility IV.

    Grade b: (non-linear motility): These also move forward but tend to travel in a curved or crooked motion. Sometimes also denoted motility III.

    Grade c: These have non-progressive motility because they do not move forward despite the fact that they move their tails. Sometimes also denoted motility II.

    Grade d: These are immotile and fail to move at all. Sometimes also denoted motility I.

  • ReferencesTOG 2013 volume 15:1-9NICE clinical guideline 156Assessment and treatment for people with fertility problemsFertility & Sterility 2012 Vol 98, No 2 August ASRM

  • THANK YOU


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