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MRCOG PART 2 SBAs and EMQs

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EMQ1480
SBA2068
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Male Infertility

Male Infertility Posted by Nibedita R.
Critically evaluate investigation and treatment options for male infertility.

Careful history including previous parenthood, social, occupational and psychosexual history should be obtained. Mumps orchitis or trauma can cause infertility due to atrophic changes. Medical disorders like diabetes and chronic renal disease can cause infertility from ejaculatory dysfunction or impotence. Surgeries like hernia repair, orchidopexy, bladder neck surgery and vasectomy reversal causes obstructive azoospermia or antisperm antibody. Lifestyle factors like recreational drugs, excessive smoking and alcohol have direct effects on fertility. Occupational exposure to heavy metals, toxins and high temperature can reduce sperm count. Certain drugs like salfasalazine, calcium channel blockers, betablockers, nitrofurantoin and chemotherapeutic drugs affect fertility adversely.
Carrier of cystic fibrosis gene is associated with congenital absence of vas deferens. Family history of subfertility may indicate genetic cause.

Examination of secondary sexual characteristics (male pattern of pubic hair, axillary hair and testicular enlargement according to tanner staging, hoarse voice and facial hair) and absence of secondary sexual characteristics indicate primary hypogonadotropic hypogonadism. Testicular examination for size, consistency and tenderness to exclude atrophy, mass and vericocele.

Semen analysis (according to WHO criteria) is the primary investigation, although, a poor predictor of sperm function and male subfertility. Sample has to be sent to a specialist laboratory, which is also attached to the specialist clinic to which couple would be referred. Patient should be instructed to abstain for 2-5 days before the sample is produced, the method of collection and submission to the laboratory.
If the result is abnormal, RCOG recommend a repeat test after 3 months.
Blood test: FSH, LH, Prolactin and Testosterone.
Karyotyping is indicated if severe deficit of semen quality or non-obstructive azoospermia. Couple should be offered appropriate genetic counselling and testing.

Life style changes should be given importance in primary care. Men with poor quality sperm should be advised to wear loose fitting underwear and avoid occupational situations that might cause testicular hyperthermia. Hypogonadotropic hypogonadism should be treated with weekly injection of gonadotropin to improve fertility. No evidence that treatment with steroids for antisperm-antibody is beneficial and may cause complications like hypertension and aseptic necrosis of femoral head.

Couples with duration of infertility >3 years, age of the female partner >35 years or ejaculate constantly showing azoospermia or severe oligozoospermia, should be referred immediately to specialist infertility clinic.

The couple should be counselled regarding treatment options available and costs implications. They should be involved in decision-making. Verbal information should be supported with written information.

In mild oligozoospermia, up to six cycles of intrauterine insemination can be attempted to improve fertility. If failed, or in severe olgozoospermia, invitro-fertilisation and embryo transfer should be offered for 3 cycles. Screening for infections like HIV, hepatitis B and hepatitis C should be done before IVF. In severe oligozoospermia, surgical sperm recovery from epididymis or testicular biopsies and Intra-cytoplasmic sperm injection is effective option available with success rates comparable with IVF (20%). Sperm can be cryopreserved for several cycles of ICSI. However, the possibilities of increased incidence of congenital anomalies, development delay and sex chromosome abnormalities should be counselled prior to the procedure.

In obstructive azoospermia, fertility can be restored by surgical correction if appropriate expertise available. Otherwise surgical sperm recovery and IVF produce similar success.

In non-obstructive azoospermia with testicular failure, the prognosis is poor with low sperm recovery rate (20% ? 60%); appropriate counselling is necessary and the option of donor sperm discussed. Donor insemination remains a less expensive option offering pregnancy rates of 10% per cycle in women less than 40 years of age.

Couple should be counselled at all stages of their treatment to alleviate anxiety and psychological stress and should be provided with information of fertility support group.

Posted by Iman B.
Before starting any investigation, a good history should be taken from the patient, for any occupational hazards, as sites of excessive heat or radiation, or previous urogenital surgery, any drug abuse, any genital pathology, and previous history of STDs and a systemic illness as diabetes.
The patient should be counselled to decrease alcohol consumption and to decrease or stop smoking.
Examination should be to detect presence of absence of secondary sexual characters, signs of prolactinoma, testicular size, and presence of varicocele.

The patient is asked for a semen analysis and this should be assessed according to the WHO criteria. If there is evidence of poor semen quality or abnormal criteria, then the analysis is repeated after three months.
A persistenly abnormal semen analysis means the patient needs referral to a specialist andrologist or urologist.
In a specialist center, microbiology of the semen may be performed. Cases suggestive of hypogonadism will have biochemical measurements of FSH, LH and those with signs suggestive of prolactinoma, serum prolactin.
There have been no proved benefits to the measurement of antisperm antibodies.

If the infertility factor is mild, a six month course of intrauterine insemination may be successful, so long as there is no female factor of infertility.
Hypogonadotrophic hypogonadism should be treated using gonadotrophic hormones to stimulate spermatogenesis.
Bromocriptine will treat cases with hyperprolactinemia.
If the patient presents with azoospermia, then a testicular biopsy should be taken only in a specialised center where sperm recovery and cryopreservation may be carried out.
If surgical intervention is necessary this also should only be done in a specialised clinic, cases of surgical correction of epididymal block, and sperm recovery. Varicoceles present in men who have normal semen measurements gain no benefit from surgery, and surgery should only be attempted in cases where sperm quality is affected.
Sperm recovery is useful in cases of obstructive azoospermia and ejaculatory failure.
If the above treatment options fail then three consecutive courses of invitro fertilisation may be attempted, pregnancy rates are high in the first three courses though the benefit grows doubtful after that and an attempt at intracytoplasmic sperm injection should be offered especially in patients who?s semen quality is poor or azoospermia or failed IVF. They should also be offered karyotyping to identify cases of Kleinfilters disease for example.
A cheaper option, if there is no ethical objection, is to offer donor insemination, this may prove useful in cases with severe infectious, or genetic disabilities, or those with severe sperm deficit.
Throughout the whole period of treatment the psychological impact of results and failed treatments must not be underestimated, the patient should be given early on helpline and fertility support group numbers. Psychological, or social help if necessary should be readily available including a counsellor who is not a member of the treating team.