Male Factor Infertility - PCRM Vancouver Fertility Clinic · subfertile male group vs that of the...
Transcript of Male Factor Infertility - PCRM Vancouver Fertility Clinic · subfertile male group vs that of the...
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Male Factor InfertilitySimplified Evalua�on and Treatment*†^
* In 20 minutes or less † In 20 slides ^ 5 minute office visit
ALWAYS EVALUATE THE MALE &&&& THE FEMALE
Why1. To help the couple achieve a
pregnancy
2. Infertility may be the presenting symptom of serious disease:• Tumors (testis, pituitary)
• Hypogonadism
• Genetic abnormalities e.g. Klinefelter’s syndrome and cystic fibrosis
When
Always
• No pregnancy within 1 year• Earlier if at increased risk for
infertility
• Do NOT:• Delay until after the partner has
been evaluated
• Delay/stop if there is a partner issue
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History & Exam
History• Pregnancies
• Duration of infertility
• Intercourse
• Surgery/trauma/infections in the inguinal, pelvic or gonadal areas
• Gonadotoxins
• Other
ExamBest done with patient standing*
• Virilization
• Penis
• Testicular volume/consistency
• Vas deferens
• Varicocele
* Vasovagal reactions
Lab Testing
Semen• Single semen analysis
• ≥4 days of abstinence
• Repeat semen analysis if abnormal value
Barratt et al. Hum Rep Update 2017 23(6):660
Zhu et al. Hum Reprod 2016 31:511
Blood• Prolactin
• Testosterone
• FSH (Follicle Stimulating Hormone)
• LH (Luteinizing Hormone)
• Estradiol
• TSH
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Flags Results Reference Range Units
Semen Analysis
Semen Analysis
Place of collection Home Collection
Collection Date 20180601
Collection Time 06:57
Received Time 07:30
Analysis Time 08:17
Time Since Collection A 80 <=60 MINUTES
Complete Sample? YES YES
Sexual Abstinence Duration 4 27 DAYS
Semen Appearance OPAQUE OPAQUE
Semen Viscosity A MODERATE NORMAL
Semen Liquefaction A >60 <=60 MINUTES
Semen pH 8.1 >=7.2
Semen Volume 3.3 >=1.5 ml
Sperm Concentration 102 >=15 Mil/ml
Total Motility/Ejaculate A 36.8 >=40 %
Motility Progressive 32.4 >=32 %
Normal Forms 4 >=4 %
Viscosity treatment used. High round cell count at 2.2 Mil/mL. Sample
was received 73 minutes after collection.
Reference Ranges as per World Health Organization Laboratory
Manual for the Examination and Processing of Human Serum, 5th ed.,
2010.
SubFertility Index
SFI Concentration 1
SFI Total Motility 1
SFI Morphology 2.88
SFI Total Composite A 2.9 (1.0 = Most Fertile, 15.8 = Least Fertile)
SubFertility Index is an Odds Ratio of probability of belonging to the
subfertile male group vs that of the fertile male group.
As per publication by David Guzick et al, on New Engl J Med Vol
345:138893.
Please note that none of these measures are diagnostic of infertility
and that this is an analysis of the male factor for invivo conception
only.
Semen Analysis
• Volume
• Concentration
• Motility
• Morphology
Semen
Analysis is
Rarely
Diagnostic
‘The reference limits should not be over-interpreted to distinguish fertile from infertile men accurately, but they do represent semen characteristics associated with a couple’s [chances of] achieving pregnancy within 12 months of unprotected sexual intercourse’
• Cooper et al WHO reference values for human semen characteristics Hum Rep Update 2009
‘…comparing a patient’s semen parameters to the distribution of results for fertile men is not in itself sufficient to determine whether or not the patient is fertile or infertile’
• Bjorndahl What is normal semen quality? Hum Fertil 2011
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Semen Analysis Looses Diagnostic Specificity
in Real Life because of Disease PrevalencePublication
• Fertile : Infertile 1 : 1
• True +ve : False +ve 6 : 2
Real Life
• Fertile : Infertile 6 : 1
• True +ve : False +ve 6 : 12
Semen Analysis is Predictive
CITES: Fertility vs. Infertility vs. Sterility
Success Year 2
Success Year 3
Success Year 4
Success Year 5 and After
Never Successful
Semen Analysis
Azoospermia
Non-Azoospermia
CITES – Canadian Infertility Therapy Evaluation Study; Collins, Burrow, Willams.
Prognosis for live birth among untreated infertile couples. Fertil Steril 1995
WALCHEREN Primary Care Study Hum Reprod
1998 12(7):1582
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CONCENTRATION and Pregnancy with SEX
Slama et al. Time to pregnancy and semen parameters… Human Reproduction 2002 17(2):503-515
MORPHOLOGY and Pregnancy via SEX
Slama et al. Time to pregnancy and semen parameters… Human
Reproduction 2002 17(2):503-515
Lipshultz et al. Men with a complete absence of normal sperm morphology exhibit
high rates of success without assisted reproduction. Asian J of Andrology 2017
19:39-42
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MORPHOLOGY and Pregnancy via IUI
Kohn et al. Effect of Sperm Morphology on Pregnancy Success via Intrauterine Insemination: A Systematic Review and Meta-Analysis. J Urology 2017 199:812-822
MORPHOLOGY and Pregnancy via IVF
Shabtaie et al. Role of Abnormal Sperm Morphology in Predicting Pregnancy Outcomes. Curr Urol Rep 2016 17:67
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Semen AnalysisCollection Date 20180601
Collection Time 06:57
Received Time 07:30
Analysis Time 08:17
Time Since Collection A 80
Complete Sample? YES
Sexual Abstinence Duration 4
Semen Appearance OPAQUE
Semen Viscosity A MODERATE
Semen Liquefaction A >60
Semen pH 8.1
Semen Volume 3.3
Sperm Concentration 102
Total Motility/Ejaculate A 36.8
Motility Progressive 32.4
Normal Forms 4
Viscosity treatm
was received 73
Reference Range
Manual for the E
2010.
SubFertility Index
SFI Concentration 1
SFI Total Motility 1
SFI Morphology 2.88
SFI Total Composite A 2.9
SubFertility Inde
Collection Date 16/04/06
Complete Sample? Yes
Time Since Collection 175
Semen Liquefaction Complete
Semen Viscosity Normal
Semen Colour Normal
Semen Volume 2.7
Sperm Concentration L 0.0
Total Sperm Count/Ejaculate L 0.0
Pathologist Comments Azoospermia.
Reference ran
Manual forComplete Sample? YES
Sexual Abstinence Duration 3.5
Semen Appearance OPAQUE
Semen Viscosity NORMAL
Semen Liquefaction <30
Semen pH 8.1
Semen Volume 1.9
Sperm Concentration 210
Total Motility/Ejaculate 75.0
Motility Progressive 72.6
Normal Forms A 1
High round ce
Reference Ran
Manual for the
CONCENTRATION
VOLUME
MOTILITY
MORPHOLOGY
Endocrine Evaluation
TESTS
• LH and FSH should be <6
• Testosterone
• Prolactin
DIAGNOSES
• Hypogonadism
• Testosterone use
• Pituitary tumors
Corradi et al. Urologic Clin North Amer 2016 43(2):151
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Assess
Predict/Improve
Select From Options
Intercourse
Insemination
IVF
Pregnancy rate
Risks
Costs
Family planning
Preferences/Beliefs
General
Advice
• Antioxidants
• Folic acid (folate)
• L-carnitine
• Zinc
• Vitamin E/C
• Coenzyme Q10
• Weight loss
• Smoking cessation
• Avoid excessive ‘wet’ heat
Showell et al. Cochrane Systematic Review 2014 Issue 12, Barrat et al. Global WHO Guidance Male Infertility Human Reprod Update 2017 23(6):660
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Medications
SOMETIMES (Off Label)
• SERMs: Clomiphene, Tamoxifen
• Aromatase Inhibitors: Anastrazole, Letrozole
• GNRH agonists
• Gonadotropins: FSH, LH
NEVER
• Exogenous Testosterone is CONTRACEPTIVE in males
Subspecialty
Infertility
SUBSPECIALTY ASSESSMENT
• Very low/no sperm
• Endocrine abnormalities
• Prolonged duration of infertility
• Genetic testing
TREATMENT
• Varicocelectomy
• Surgical reconstruction
• Surgical sperm retrieval
Comprehensive and Integrated Care with the
Reproductive Endocrinologist
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Azospermia ≠ Absence of Spermatogenesis
Microdissection Testicular Sperm Extraction
• MicroTeSE: 30-50% of men who have no sperm in the ejaculate Concurrent IVF with fresh sperm generally recommended
Schlagel Hum Reprod 1999 Jan;14(1):131-5
SUMMARY
Always evaluate the male (and the female)
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Refer if you’re unsure or for specialized care
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Semen analysis is a crude test and is rarely diagnostic. Concentration can help predict success.
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FSH, LH, prolactin, testosterone +/-estradiol, TSH
Don’t give testosterone
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