Practical guide lines for evaluation of male infertilty.
•Als PPTX, PDF herunterladen•
7 gefällt mir•569 views
a practical approach to a male patient of infertilty.
Empfohlen
Empfohlen
Weitere ähnliche Inhalte
Was ist angesagt?
Was ist angesagt? (20)
Ähnlich wie Practical guide lines for evaluation of male infertilty.
Ähnlich wie Practical guide lines for evaluation of male infertilty. (20)
Kürzlich hochgeladen
Kürzlich hochgeladen (20)
Practical guide lines for evaluation of male infertilty.
- 1. Evaluation of Male Infertility-Practical tips and tricks. Dr. Sadashiv Bhole MS MCh DNB FAMASI Consultant Urologist, Robotic Surgeon Seven Star Hospital, Nagpur. Sagarika Bhole,NKPSIMS, Nagpur
- 2. Definition Infertility Failure to conceive after one year of unprotected intercourse. Primary infertility Patient has never conceived. Secondary infertility History of previous conceptions.
- 3. Prevalance of male infertility • Sole cause in 20 % to 30% • Contributing cause in 20 to 40 %
- 4. Causes of male infertility Pre-testicular causes Testicular causes Post-testicular causes
- 5. Pre-testicular causes • Hypothalamic disease (1-2%) • Gonadotrophin deficiency (Kallman syndrome) • Pituitary disease • Pituitary insufficiency (tumours, radiation, surgery) • Hyperprolactinaemia • Exogenous hormones (anabolic steroids, glucocorticoid excess,hyper- or hypothyroidism)
- 6. Testicular causes (30-40%) Congenital • Genetic • Chromosomal (Kleinfelter syndrome 47, XXY) • Y chromosome microdeletions • Noonan syndrome (male Turner syndrome 45, XO) • Other • Cryptorchidism Acquired • Injury (orchitis, torsion, trauma) • Varicocele • Systemic disease (renal failure, liver failure) • Chemotherapy, radiotherapy‐ • Testicular tumours • Idiopathic (40-50%)
- 7. Post-testicular -obstruction(10-20%) Congenital • Cystic fibrosis, congenital absence of the vas deferens (CAVD) • Young’s syndrome Acquired • Vasectomy • Infection (chlamydia, gonorrhoea) • Iatrogenic vas injury Disorders of sperm function or motility • Immotile cilia syndrome • Maturation defects • Immunological infertility • Globozoospermia Sexual dysfunction • Timing and frequency • Erectile/ ejaculatory dysfunction • Diabetes mellitus, multiple sclerosis, spinal cord/pelvic injuries
- 8. Infertility evaluation in men • Duration of more than 1 year. • Earlier in men with suspected factors. • Age • Fertility decreases with age . • Fall in androgens in aging men.
- 9. OPD VISIT • Both partners should be seen together • Privacy and sufficient clinical time • Classical history taking with emphasis on exploring a couple’s anxieties • Counseling is very important and essential
- 10. Recent pyrexia/ illness • diabetes mellitus, cancer, infection Systemic illness • Cystic fibrosis, Klinefelter syndrome Genetic disorders MEDICAL HISTORY
- 11. SURGICAL HISTORY Undescended testes, orchidopexy Hernia repair Testicular trauma, torsion Pelvic, bladder or retroperitoneal surgery
- 12. FERTILITY HISTORY • with current and previous partners Previous pregnancies Duration of infertility Previous infertility treatments
- 13. Erection or ejaculation problems Frequency of intercourse Use of lubricants SEXUAL HISTORY
- 14. MEDICATION HISTORY Nitrofurantoin Colchicine Methotrexate Cimetidine Sulfasalazine Spironolactone A –blockers Amiodarone Antidepressants Phenothiazines Chemotherapy
- 15. Social history Alcohol Smoking Anabolic steroids Recreational drugs Exposure to ionising radiation Chronic heat exposure Aniline dyes Pesticides Lead exposure
- 16. • Each stage in the investigation and treatment of infertility should be fully explained to the couple. • Written information in a range of languages should be available where appropriate. • Environmental factors can affect fertility and therefore an occupational history should be taken.
- 17. Physical Examination Systematic evaluation Secondary sexual characters Abdominal examination Inguinal areas Urethral meatus Penile anatomy Scrotum Testes
- 18. General Examination Height Weight BMI Blood Pressure Gynaecomastia Distribution and thickness of body hair Examination for varicocele in standing position Palpation of vas is mandatory DRE Signs of androgen deficiency
- 19. Examination of external genitalia Tanner stage-Pubic hair Tanner 5 Penile length-above 3.5 cm Scrotal skin –Pigment with rugosity Testicular volume-normal above 15ml. STAGE I STAGE II STAGE III STAGE IV STAGE V
- 20. Orchidometer
- 21. Diagnostic tests • Tests which have an established corelation with pregnancy • Tests which are not consistently correlated with pregnancy • Tests which seem NOT to correlate with pregnancy Diagnostic tests for infertility were classified into following three categories by ESHRE Capri workshop in 2000
- 22. Tests which have an established correlation with pregnancy Semen analysis Tubal patency test by HSG or Laparoscopy Mid luteal serum progesterone for the diagnosis of ovulation
- 23. Tests which are not consistently correlated with pregnancy Zona free hamster egg penetration tests Post-coital test Antisperm antibodies assays
- 24. Tests which seem NOT to correlate with pregnancy Endometrial dating Varicocoele assessment Chlamydial testing MAY HAVE A ROLE IN SPECIAL SITUATIONS
- 25. Semen Analysis • The male partner should normally have two semen analyses performed during the initial investigation. • Laboratories that perform semen analysis should undertake this according to recognised WHO methodology. • Laboratories should also practice internal quality control and belong to an external quality control scheme
- 26. Semen analysis Volume of semen Ph Components of Semen evaluation Fructose levels in semen Abnormal forms
- 27. Sperm Analysis Sperm count Sperm motility Sperm morphology Sperm Vialibility Sperm DNA fragmentation Components of semen evaluation
- 28. Interpretation of semen analysis • Oligoasthenospermia in bilateral varicocele. • Fructose absence in EJ duct obstruction. Poor Volume is seen in Retrograde Ejaculation Seminal Vesicles Agenesis Ejaculatory Duct Obstruction.
- 29. Labs… Blood sugar Serum creatinine FSH LH SerumTestosterone TSH
- 30. LAB TESTS TESTOSTERONE LOW <300 ng/dl NORMAL 300-800 ng/dl HIGH FSH LAB TESTS HIGH LH SR. PROLACTIN INDICATES LEYDIG CELL DAMAGE INDICATES SEMINI FEROUS-TUBULE DAMAGE ALSO IMP TESTOSTERONE HIGH FSH HIGH LH SR. PROLACTIN
- 31. FSH MORE THAN 2-3 TIMES NORMAL VALUE PRIMARY TESTICULAR FAILURE LOW TESTOSTERONE <300 ng/ml HIGH SERUM OESTRADIOL Tamoxifen LOW TESTOSTERONE LOW LH CLOMIPHONE CITRATE 25MG OD
- 32. Radiology • USG Scrotum with colour doppler. • TRUS
- 33. Surgically correctable conditions • Vasectomy reversal- Patency rates decline with time • Bilateral varicocele Open Goldsteins approach Laparoscopic repair. • 40 % results are expected in properly selected patients.
- 34. Surgical treatment of Varicocele Benefits Fertility restoration Spontaneous pregnancy Fertility Improvement Sperm retrieval in Azoospermia Fertilty Improvement ICSI outcomes
- 35. • There is no evidence that semen quality and pregnancy rates improves in men with normal sperm count after surgical treatment of a clinically apparent varicocele • The benefits of the treatment of a varicocele in oligozoospermic men is less certain
- 36. Surgically correctible causes of infertility Obstructive azoospermia VEA VV anastomosis TURED
- 37. Surgically correctible causes of infertility Reconstructive surgery for hypospadias and penile deformities.
- 38. MISCONCEPTION Correction of crypto orchidism in adults DOES NOT restore fertility.
- 39. Testicular biopsy should be performed in the context of a patient with a normal hormonal status and Azoospermia.
- 41. Antioxidants in the therapy of male infertility Ubidecarenone Carotenoids(lycopene) Omega 2 fatty acids Carnitine Vit E & Vit C Selenium Glutathione N –Acetyl Cysteine Pentoxiphylline Zinc Vit B12
- 42. Oxidative stress • Oxidative stress(OS) is the imbalance between the production of reactive oxygen species(ROS) by the spermatozoa and leucocytes & the antioxidant capacity of seminal plasma
- 43. 1) The primary source or ROS in infertile patient is immature spermatozoa. 2) OS can damage the DNA of the spermatozoa and prevent them from fertilising the egg. 3) Reactive oxygen species includes oxygen ions, free radicals and peroxides. CAUSES- OXIDATIVE STRESS
- 44. Ubidecarenone • Also known as Coenzyme Q10,Ubiquinone, Coenzyme Q and abbreviated to CoQ10,CoQ,Q10 or Q • Component of electron transport chain and participates in aerobic cellular respiration generating energy as ATP.
- 45. Oxidants in male infertility WHEN Always HOW Co Enyme Q10 Vit C 500 mg Vit E 400 IU Folic Acid 2 mg Zinc 25 mg Selenium 26 mcg Minimum 2 months (initiation of sperm production to ejaculation) WHEN HOW HOW LONG
- 46. • Bromocriptine is an effective treatment for sexual dysfunction in men with hyperprolactinaemia. • Intrauterine insemination is an effective treatment where the man has mild abnormalities of semen quality. • Infection of the male genital tract should be treated if present, but there is no evidence that this will improve fertility. KEY POINTS
- 47. • IVF and ICSI are effective treatments for men with moderate to severe semen abnormalities • ICSI has made it possible for men with only few sperms to become fathers • Sperms for ICSI can be obtained by TSA or directly from testicular biopsy as well as aspiration from epididymis.
- 48. TAKE HOME MESSAGE Semen analysis is most informative initial investigation in male. Antioxidants helpful to decrease oxidative stress. Treatment effect should be noted more than 60 days later. Treatment of clinical varicoceles prior to ICSI may be beneficial for patient subgroups of severe oligo asthenospermia. Surgical and endocrinological abnormalities should be identified and corrected for optimal results.