ANDROLOGYANDROLOGYCase PresentationCase Presentation
Dr Rosalina M.AliDr Rosalina M.Ali20 Sept 201320 Sept 2013
Hospital AmpangHospital 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%
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
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
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
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
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
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
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
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
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
Left TestesLeft Testes : 2 biopsy taken showed : 2 biopsy taken showed
no mature sperm / spermatids were no mature sperm / spermatids were seenseen
AGEAGE
POSTTESTICULAR
POSTTESTICULAR TESTICULARTESTICULAR
PRETESTICULAR
PRETESTICULAR
ENVIRONMENTOCCUPATION
LIFESTYLE
ENVIRONMENTOCCUPATION
LIFESTYLE
CAUSES OFMALE
INFERTILITY
CAUSES OFMALE
INFERTILITY
AGEAGE
ENVIRONMENTALENVIRONMENTAL
OCCUPATIONALOCCUPATIONAL
LIFESTYLELIFESTYLE
PRE TESTICULARPRE TESTICULAR
Hypothalamic diseaseHypothalamic disease
Pituitary diseasePituitary disease- - tumour, radiation, surgery, tumour, radiation, surgery,
hyperprolactinaemia, exogenous hyperprolactinaemia, exogenous hormonehormone
TESTICULARTESTICULAR
CongenitalCongenital- genetic, chromosomal, Noonan genetic, chromosomal, Noonan
syndrome, cryptorchidismsyndrome, cryptorchidism
AcquiredAcquired- injury, varicocele, - injury, varicocele,
chemo/radiotherapy,chemo/radiotherapy, testicular testicular tumourstumours
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
INVESTIGATIONINVESTIGATION
Semen AnalysisSemen Analysis Endocrine testEndocrine test Genetic evaluationGenetic evaluation ImagingImaging Testicular biopsyTesticular biopsy Other sperm function testsOther sperm function tests
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
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
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. .
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
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