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

2. 16% couples fail to conceive after 1 year of trying. 16% couples fail to conceive after 1 year of trying. Male factor : 30% Male factor : 30% Combination male and female factors : 40% Combination male and female factors : 40%

3. Mdm N 33yo/ Malay Clerk/NKMI Mdm N 33yo/ Malay Clerk/NKMI Married for 4 years Presented with history of primary infertility Menses Hx: Menarche 12yo Menses Hx: Menarche 12yo Cycle 30-32days with 5 days flow No dysmenorrhea, no menorrhagia Latest pap smear on March 2013 normal Social history :Non smoker, does not consume alcohol Social history :Non smoker, does not consume alcohol Family History : Nil in significance Family History : Nil in significance

4. Examination : unremarkable Examination : unremarkable Height 145, Weight 74, BMI 35 Height 145, Weight 74, BMI 35 Investigation: Investigation: - MGTT 18/23 started on insulin - HSG :Irregular filling defect in right uterine cornua. Possible uterine polyp or blood clots. Bilateral tubes patent. - Infectious screening : Non reactive

5. Hormonal profile: Hormonal profile: TSH 0.799 T418.2 LH 4.5 IU/L FSH 6.3 IU/L Progesterone 30 nmol/L Estradiol97 pmol/L Prolactin11 Mu/L

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

7. Family hx: no known medical illness Family hx: no known medical illness younger brother was married for 4 years before wife conceived. Smokes 12 cigarettes,now 3-4 Smokes 12 cigarettes,now 3-4 cigarettes /day Never had hx of long exposure to toxic material/ pesticide Never had hx of long exposure to toxic material/ pesticide No hx of Mumps No hx of Mumps

8. Examination: Examination: Normotensive, normal hair distribution general examination unremarkable Testes – 2 masses felt over the right testes, separated from each other 2 x 2cm, 2 x 3cm. Non tender R L R L

9. Infectious screening : NR Infectious screening : NR Hormonal profile (12/6/13) Hormonal profile (12/6/13) FSH 15.8, LH 8.6 Testosterone 9.1 Prolactin 143 Investigation

10. SFA : July 2011 SFA : July 2011 -> azoospermia -> azoospermia 08/04/201327/6/2013 Ph7.57.5 Vol 2mls 2mls1.5mls Others NIL Others NIL ImpAzoospermia

11. Scrotal U/S: No significant abnormality Scrotal U/S: No significant abnormality Biopsy (15/8/13) Biopsy (15/8/13) Right testes: -> PESA : once aspiration (0.3cm 3) no mature sample seen -> TESA : 3 biopsy samples 0.2cm First and second biopsy showed no mature sperm seen Third biopsy only 1 mature sperm (grade c) Seen

12. Left Testes : 2 biopsy taken showed Left Testes : 2 biopsy taken showed no mature sperm / spermatids were seen

13. CAUSES OF MALE INFERTILITY ENVIRONMENT OCCUPATION LIFESTYLE PRE TESTICULAR POST TESTICULAR AGE

14. AGE AGE ENVIRONMENTAL ENVIRONMENTAL OCCUPATIONAL OCCUPATIONAL LIFESTYLE LIFESTYLE

15. PRE TESTICULAR PRE TESTICULAR Hypothalamic disease Pituitary disease - tumour, radiation, surgery, hyperprolactinaemia, exogenous hormone

16. TESTICULAR TESTICULARCongenital - genetic, chromosomal, Noonan syndrome, cryptorchidism Acquired - injury, varicocele, chemo/radiotherapy, testicular tumours

17. POST TESTICULAR POST TESTICULARCongenital - cystic fibrosis, CAVD Acquired - vasectomy, infection Disorders of sperm fx & motility Sexual dysfunction

18. INVESTIGATION Semen Analysis Semen Analysis Endocrine test Endocrine test Genetic evaluation Genetic evaluation Imaging Imaging Testicular biopsy Testicular biopsy Other sperm function tests Other sperm function tests

19. ClinicalConditionFSHLH Testos- terone Prolactin NormalSpermatogenesisNormalNormalNormalNormal HypogonadotrophicHypogonadismLowLowLowNormal AbnormalSpermatogenesisHigh/NNormalNormalNormal HypergonadotrophicHypogonadismHighHighNormal/LowNormal Prolactin secreting tumour Normal/ Low LowHigh Basal hormone levels in various clinical status

21. WHO reference limits and 95% CI for semen parameters PARAMETERREFERENCE LIMIT 95% CI Semen volume (ml)1.51.4 -1.7 Sperm concentration (10 6/ ML) 15.012 -16 Total Number 10 6/ ejeculate) 39.033 - 46 Total motility40.038 - 42 Progressive motility32.031 - 34 Normal forms (%)4.03 - 4 Vitality (%)58.055 - 63

22. A more specified measure is motility grade, where the motility of sperm are divided into four different grades: Grade a: Sperm with progressive motility. These are the strongest and swim fast in a straight line. Sometimes it is also denoted motility IV. Grade a: Sperm with progressive motility. These are the strongest and swim fast in a straight line. Sometimes it is also denoted motility IV. Grade b: (non-linear motility): These also move forward but tend to travel in a curved or crooked motion. Sometimes also denoted motility III. Grade b: (non-linear motility): These also move forward but tend to travel in a curved or crooked motion. Sometimes also denoted motility III. Grade c: These have non-progressive motility because they do not move forward despite the fact that they move their tails. Sometimes also denoted motility II. Grade c: These have non-progressive motility because they do not move forward despite the fact that they move their tails. Sometimes also denoted motility II. Grade d: These are immotile and fail to move at all. Sometimes also denoted motility I. Grade d: These are immotile and fail to move at all. Sometimes also denoted motility I.

23. References TOG 2013 volume 15:1-9 TOG 2013 volume 15:1-9 NICE clinical guideline 156 NICE clinical guideline 156 Assessment and treatment for people with fertility problems Fertility & Sterility 2012 Vol 98, No 2 August ASRM Fertility & Sterility 2012 Vol 98, No 2 August ASRM

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