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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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Page 1: ANDROLOGY Case Presentation Dr Rosalina  M.Ali 20 Sept 2013 Hospital  Ampang

ANDROLOGYANDROLOGYCase PresentationCase Presentation

Dr Rosalina M.AliDr Rosalina M.Ali20 Sept 201320 Sept 2013

Hospital AmpangHospital Ampang

Page 2: ANDROLOGY Case Presentation Dr Rosalina  M.Ali 20 Sept 2013 Hospital  Ampang

16% couples fail to conceive 16% couples fail to conceive after 1 year of trying.after 1 year of trying.

Male factor : 30%Male factor : 30% Combination male and female Combination male and female

factors : 40%factors : 40%

Page 3: ANDROLOGY Case Presentation Dr Rosalina  M.Ali 20 Sept 2013 Hospital  Ampang

Mdm N 33yo/ Malay Clerk/NKMIMdm N 33yo/ Malay Clerk/NKMI

Married for 4 yearsMarried for 4 years

Presented with history of primary Presented with history of primary infertilityinfertility

Menses Hx: Menarche 12yoMenses Hx: Menarche 12yo

Cycle 30-32days with 5 days flowCycle 30-32days with 5 days flow

No dysmenorrhea, no menorrhagiaNo dysmenorrhea, no menorrhagia

Latest pap smear on March 2013 Latest pap smear on March 2013 normalnormal

Social history :Non smoker, does not Social history :Non smoker, does not consume alcoholconsume alcohol

Family History : Nil in significanceFamily History : Nil in significance

Page 4: ANDROLOGY Case Presentation Dr Rosalina  M.Ali 20 Sept 2013 Hospital  Ampang

Examination : unremarkableExamination : unremarkable

Height 145, Weight 74 , BMI 35Height 145, Weight 74 , BMI 35 Investigation:Investigation:- MGTT 18/23 started on insulinMGTT 18/23 started on insulin- HSG :Irregular filling defect in right HSG :Irregular filling defect in right

uterine cornua. Possible uterine polyp uterine cornua. Possible uterine polyp or blood clots. Bilateral tubes patent.or blood clots. Bilateral tubes patent.

- Infectious screening : Non reactiveInfectious screening : Non reactive

Page 5: ANDROLOGY Case Presentation Dr Rosalina  M.Ali 20 Sept 2013 Hospital  Ampang

Hormonal profile:Hormonal profile:

TSH TSH 0.7990.799

T4T4 18.218.2

LH LH 4.5 IU/L4.5 IU/L

FSH FSH 6.3 IU/L6.3 IU/L

ProgesteroneProgesterone 30 nmol/L 30 nmol/L

EstradiolEstradiol 97 pmol/L97 pmol/L

ProlactinProlactin 11 Mu/L11 Mu/L

Page 6: ANDROLOGY Case Presentation Dr Rosalina  M.Ali 20 Sept 2013 Hospital  Ampang

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

Page 7: ANDROLOGY Case Presentation Dr Rosalina  M.Ali 20 Sept 2013 Hospital  Ampang

Family hx: no known medical illnessFamily hx: no known medical illnessyounger brother was married for 4 younger brother was married for 4 years before wife conceived.years before wife conceived.

Smokes 12 cigarettes ,now 3-4 Smokes 12 cigarettes ,now 3-4 cigarettes /daycigarettes /day

Never had hx of long exposure to Never had hx of long exposure to toxic material/ pesticidetoxic material/ pesticide

No hx of MumpsNo hx of Mumps

Page 8: ANDROLOGY Case Presentation Dr Rosalina  M.Ali 20 Sept 2013 Hospital  Ampang

Examination:Examination:

Normotensive, normal hair Normotensive, normal hair distributiondistribution

general examination unremarkablegeneral examination unremarkable

Testes – 2 masses felt over the right Testes – 2 masses felt over the right testes, separated from each othertestes, separated from each other

2 x 2cm, 2 x 3cm. Non tender2 x 2cm, 2 x 3cm. Non tender

R LR L

Page 9: ANDROLOGY Case Presentation Dr Rosalina  M.Ali 20 Sept 2013 Hospital  Ampang

Infectious screening : NRInfectious screening : NR

Hormonal profile (12/6/13)Hormonal profile (12/6/13)

FSH 15.8, LH 8.6FSH 15.8, LH 8.6

Testosterone 9.1Testosterone 9.1

Prolactin 143Prolactin 143

InvestigationInvestigation

Page 10: ANDROLOGY Case Presentation Dr Rosalina  M.Ali 20 Sept 2013 Hospital  Ampang

SFA : July SFA : July 20112011

-> -> azoospermiaazoospermia

08/04/20108/04/20133

27/6/20127/6/20133

PhPh 7.57.5 7.57.5

VolVol 2mls2mls 1.5mls1.5mls

Others NILOthers NIL

ImpImp AzoospermiaAzoospermia

Page 11: ANDROLOGY Case Presentation Dr Rosalina  M.Ali 20 Sept 2013 Hospital  Ampang

Scrotal U/S: No significant abnormalityScrotal U/S: No significant abnormality Biopsy (15/8/13)Biopsy (15/8/13)Right testes:Right testes:-> PESA : once aspiration (0.3cm-> PESA : once aspiration (0.3cm3) 3) no no

mature sample seen mature sample seen -> TESA : 3 biopsy samples 0.2cm-> TESA : 3 biopsy samples 0.2cmFirst and second biopsy showed no matureFirst and second biopsy showed no maturesperm seensperm seenThird biopsy only 1 mature sperm (grade Third biopsy only 1 mature sperm (grade

c) c) SeenSeen

Page 12: ANDROLOGY Case Presentation Dr Rosalina  M.Ali 20 Sept 2013 Hospital  Ampang

Left TestesLeft Testes : 2 biopsy taken showed : 2 biopsy taken showed

no mature sperm / spermatids were no mature sperm / spermatids were seenseen

Page 13: ANDROLOGY Case Presentation Dr Rosalina  M.Ali 20 Sept 2013 Hospital  Ampang

AGEAGE

POSTTESTICULAR

POSTTESTICULAR TESTICULARTESTICULAR

PRETESTICULAR

PRETESTICULAR

ENVIRONMENTOCCUPATION

LIFESTYLE

ENVIRONMENTOCCUPATION

LIFESTYLE

CAUSES OFMALE

INFERTILITY

CAUSES OFMALE

INFERTILITY

Page 14: ANDROLOGY Case Presentation Dr Rosalina  M.Ali 20 Sept 2013 Hospital  Ampang

AGEAGE

ENVIRONMENTALENVIRONMENTAL

OCCUPATIONALOCCUPATIONAL

LIFESTYLELIFESTYLE

Page 15: ANDROLOGY Case Presentation Dr Rosalina  M.Ali 20 Sept 2013 Hospital  Ampang

PRE TESTICULARPRE TESTICULAR

Hypothalamic diseaseHypothalamic disease

Pituitary diseasePituitary disease- - tumour, radiation, surgery, tumour, radiation, surgery,

hyperprolactinaemia, exogenous hyperprolactinaemia, exogenous hormonehormone

Page 16: ANDROLOGY Case Presentation Dr Rosalina  M.Ali 20 Sept 2013 Hospital  Ampang

TESTICULARTESTICULAR

CongenitalCongenital- genetic, chromosomal, Noonan genetic, chromosomal, Noonan

syndrome, cryptorchidismsyndrome, cryptorchidism

AcquiredAcquired- injury, varicocele, - injury, varicocele,

chemo/radiotherapy,chemo/radiotherapy, testicular testicular tumourstumours

Page 17: ANDROLOGY Case Presentation Dr Rosalina  M.Ali 20 Sept 2013 Hospital  Ampang

POST TESTICULARPOST TESTICULAR

CongenitalCongenital- cystic fibrosis, CAVD- cystic fibrosis, CAVD

AcquiredAcquired- vasectomy, infectionvasectomy, infection

Disorders of sperm fx & Disorders of sperm fx & motilitymotility

Sexual dysfunctionSexual dysfunction

Page 18: ANDROLOGY Case Presentation Dr Rosalina  M.Ali 20 Sept 2013 Hospital  Ampang

INVESTIGATIONINVESTIGATION

Semen AnalysisSemen Analysis Endocrine testEndocrine test Genetic evaluationGenetic evaluation ImagingImaging Testicular biopsyTesticular biopsy Other sperm function testsOther sperm function tests

Page 19: ANDROLOGY Case Presentation Dr Rosalina  M.Ali 20 Sept 2013 Hospital  Ampang

ClinicalClinical

ConditionConditionFSHFSH LHLH Testos-Testos-

teroneteroneProlactinProlactin

NormalNormal

SpermatogenesisSpermatogenesisNormalNormal NormalNormal NormalNormal NormalNormal

HypogonadotrophicHypogonadotrophic

HypogonadismHypogonadismLowLow LowLow LowLow NormalNormal

AbnormalAbnormal

SpermatogenesisSpermatogenesisHigh/NHigh/N NormalNormal NormalNormal NormalNormal

HypergonadotrophiHypergonadotrophic c

HypogonadismHypogonadism

HighHigh HighHigh Normal/Normal/

LowLowNormalNormal

Prolactin secreting Prolactin secreting tumourtumour

Normal/ Normal/ LowLow

Normal/ Normal/ LowLow

LowLow HighHigh

Basal hormone levels in various clinical status

Page 20: ANDROLOGY Case Presentation Dr Rosalina  M.Ali 20 Sept 2013 Hospital  Ampang
Page 21: ANDROLOGY Case Presentation Dr Rosalina  M.Ali 20 Sept 2013 Hospital  Ampang

WHO reference limits and 95% CI for WHO reference limits and 95% CI for semen parameterssemen parameters

PARAMETER REFERENCELIMIT

95% CI

Semen volume (ml) 1.5 1.4 -1.7

Sperm concentration (10 6/ ML)

15.0 12 -16

Total Number10 6/ ejeculate)

39.0 33 - 46

Total motility 40.0 38 - 42

Progressive motility 32.0 31 - 34

Normal forms (%) 4.0 3 - 4

Vitality (%) 58.0 55 - 63

Page 22: ANDROLOGY Case Presentation Dr Rosalina  M.Ali 20 Sept 2013 Hospital  Ampang

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

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

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

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

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

Page 23: ANDROLOGY Case Presentation Dr Rosalina  M.Ali 20 Sept 2013 Hospital  Ampang

ReferencesReferences

TOG 2013 volume 15:1-9TOG 2013 volume 15:1-9 NICE clinical guideline 156NICE clinical guideline 156

Assessment and treatment for Assessment and treatment for people with fertility problemspeople with fertility problems

Fertility & Sterility 2012 Vol 98, No 2 Fertility & Sterility 2012 Vol 98, No 2 August ASRMAugust ASRM

Page 24: ANDROLOGY Case Presentation Dr Rosalina  M.Ali 20 Sept 2013 Hospital  Ampang

THANK YOUTHANK YOU


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