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U36 Urology
Infertility
Toronto Notes 2019
Normal Semen Values
• Volume: 2-5 mL
• Concentration: >15 million sperm/mL
• Morphology: 30% normal forms
• Motility: >40% adequate forward
progression
• Liquefaction: complete in 20 min
• pH: 7.2-7.8
• WBC: <10/HPF or <106 WBC/mL semen
Common Terminology on SA
• Teratospermia: Abnormal morphology • Asthenospermia: Abnormal motility
• Oligospermia: Decreased sperm count • Azoospermia: Absent sperm in semen • Mixed types: i.e. oligoasthenospermia
Mutation of cystic fibrosis transmembrane conductance regulator (CFTR) gene is associated with congenital bilateral absence of vas deferens and epididymal cysts, even if patient manifests no symptoms of CF
• obstructive
■ iatrogenic (surgery: see below)
■ infectious (gonorrhea, chlamydia)
■ trauma
■ congenital (absence of vas deferens, CF)
■ bilateral ejaculatory duct obstruction, epididymal obstructions
■ Kartagener’s syndrome (autosomal recessive disorder causing defect in action of cilia)
• endocrine(seeEndocrinology,E46)
• HPTA(2-3%)e.g.Kallmann’ssyndrome(congenitalhypothalamichypogonadism),excessprolactin,
excess androgens, excess estrogens
• other
■ retrograde ejaculation secondary to surgery
■ medications
■ prior exposure to chemotherapy or pelvic radiation
■ drugs: marijuana, cocaine, tobacco, alcohol
■ increased testicular temperature (sauna, hot baths, tight pants or underwear) ■ chronic disease: e.g. liver, renal
History
• ageofbothpartners
• medical:pastillness,DM,trauma,CF,geneticsyndromes,STIs,cryptorchidism
• surgical:vasectomy,herniorrhaphy,orchidopexy,prostatesurgery
• fertility:pubertalonset,previouspregnancies,durationofinfertility,treatments
• sexual: libido, erection/ejaculation, timing, frequency
• familyHx
• medications:cytotoxicagents,GnRHagonists,anabolicsteroids,nitrofurantoin,cimetidine,
sulfasalazine, spironolactone, α-blockers
• socialHx:alcohol,tobacco,cocaine,marijuana,schoolperformance/learningdisabilities(suggestiveof
Klinefelter syndrome)
• occupationalexposures:radiation,heavymetals
Physical Exam
• generalappearance:sexualdevelopment,gynecomastia,obesity,pubichair
• scrotalexam:size,consistency,andnodularityoftesticles;palpationofcordforpresenceofvasdeferens;
DRE; valsalva for varicocele
Investigations
• semen analysis (SA) at least 2 specimens, collected 1-2 wk apart • hormonal evaluation
■ indicated with abnormal SA (rare to be abnormal with normal SA)
■ testosterone and FSH
■ serum LH and prolactin are measured if testosterone or FSH are abnormal
• genetic evaluation
■ chromosomal studies (Klinefelter syndrome – XXY)
■ genetic studies (Y-chromosome microdeletion, CF gene mutation)
• immunologicstudies(antispermantibodiesinejaculateandblood) • testicularbiopsy
• scrotalU/S(varicocele,testicularsize)
• vasography(assesspatencyofvasdeferens)
Treatment
• assessmentofpartner • lifestyle
■ regular exercise, healthy diet
■ eliminate alcohol, tobacco and illicit drugs • medical
■ endocrine therapy (see Endocrinology, E46)
■ treat retrograde ejaculation
■ discontinue anti-sympathomimetic agents, may start α-adrenergic stimulation
(phenylpropanolamine, pseudoephedrine, or ephedrine) ■ treat underlying infections
• surgical
■ varicocelectomy (if indicated)
■ vasovasostomy (vasectomy reversal) or epididymovasostomy ■ transurethral resection of blocked ejaculatory ducts
• assistedreproductivetechnologies(ART)
■ refer to infertility specialist
■ spermwashing+intrauterineinsemination(IUI)
■ in vitro fertilization (IVF)
■ intracytoplasmic sperm injection (ICSI) after CF screening of patient and partner in patients with
congenital bilateral absence of vas deferens