0% found this document useful (0 votes)
84 views40 pages

Infertility Cases Fairmont

This document presents 11 clinical cases related to male infertility. Case 1 involves an azoospermic patient with low ejaculate volume, suggesting obstruction. Rectal ultrasound is recommended to confirm the diagnosis. Case 2 involves a patient with small testes, elevated gonadotropins and poor semen quality, indicating primary testicular failure. Case 3 involves a patient who should be treated presumptively for chlamydia with tetracycline due to possible infection affecting motility. Case 4 involves evaluating the patient for antisperm antibodies due to low motility. Case 5 recommends hormone testing for an patient with abnormal semen parameters. Case 6 recommends assisted reproductive technology for a patient with idiopathic oligosperm

Uploaded by

Smart Urosurgeon
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPT, PDF, TXT or read online on Scribd
0% found this document useful (0 votes)
84 views40 pages

Infertility Cases Fairmont

This document presents 11 clinical cases related to male infertility. Case 1 involves an azoospermic patient with low ejaculate volume, suggesting obstruction. Rectal ultrasound is recommended to confirm the diagnosis. Case 2 involves a patient with small testes, elevated gonadotropins and poor semen quality, indicating primary testicular failure. Case 3 involves a patient who should be treated presumptively for chlamydia with tetracycline due to possible infection affecting motility. Case 4 involves evaluating the patient for antisperm antibodies due to low motility. Case 5 recommends hormone testing for an patient with abnormal semen parameters. Case 6 recommends assisted reproductive technology for a patient with idiopathic oligosperm

Uploaded by

Smart Urosurgeon
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPT, PDF, TXT or read online on Scribd
You are on page 1/ 40

Management of Infertility

Prof. Dr.
AbdelFattah Agour
Urology Department
Ain Shams University

Male Infertility
Clinical Cases

Case 1
Infertile couple for 5 years
Female evaluation is normal. The male is 28

years
Physical examination: Normal, virilized male,
24 ml testes bilaterally. No varicocele
Semen analysis: volume 0.6 cc. azoospermia
Laboratory data:
LH 5 (normal 3-11 IU) - FSH 7 (normal 3-11 IU)
Testosterone 500 (normal 250-900 ng/dl)

Case 1
What should be done next for this

patient?
a)
b)
c)
d)

Post-ejaculate urine
Rectal ultrasound
Full endocrine studies
Testis biopsy

Correct answer .. b)
Azoospermia with low ejaculate volume
denoting obstruction at the level of ejaculatory
ducts or hypoplasia of the vas deference and
seminal vesicles.
TRUS, does confirm the diagnosis
Post ejaculate urine is needed in cases of low
ejaculate volume but in the presence of
sperms (in non azoospermic patients).
A semen fructose can also be done

Case 2
33 years old man, married for 2 years, presents with

a history of infertility. His wife has been pregnant


before.
Physical exam.: reveals 10 ml testes bilaterally. No
varicocele
Laboratory data:
Semen Analysis occasional non-motile sperms

LH 17 (normal 3-11 IU)


FSH 33 (normal 3-11 IU)
Testosterone 290 (normal 250-900 ng/dl)

Case 2
What is the most likely diagnosis?
a)
b)
c)
d)
e)

Primary testicular failure


Hypogonadotropic hypogonadism
Young's syndrome
Idiopathic oligospermia
Pituitary tumor

Correct answer a)
The combination of poor semen quality,

small testes size, and elevated


gondotrophins is diagnostic of primary
testicular failure
Hypogonadotropic hypogonadism would result in low

gondotrophins
Idiopathic oligospermia = normal hormone studies
Youngs syndrome is not associated with small testes.
pituitary tumors are rarely associated with elevation
of both gondotrophins

Case 3
21 years old man presents with a 3 year history of

infertility. His wife evaluation is unremarkable.


Physical examination: well developed, well nourished
male, testes 28 mL bilaterally. No varicocele
Semen analysis: 20 million sperm/ml, 3 cc, many
round cells present.
Laboratory data

LH 7 (normal 3-11 IU)


FSH 10 (normal 3-11 IU)
Testosterone 680 (normal 250-900 ng/dl)

Case 3
What is the appropriate treatment for

this patient if special semen stains are


not available?
a)
b)
c)
d)
e)

Clomid
HCG
Trimethoprim-sulpha
Tetracycline
Nitrofurantoin

Correct answer .. d
Treatment of choice is tetracycline
Even

if the routine cultures are negative


This is because the patient may be
infected with Chlamydia and even
possibly ureaplasma.
The other medications listed either will
not treat infection or are not as effective
against Chlamydia.

Case 4
24 year old man presents with a 3 year

history of infertility. His wife evaluation is


normal.
Physical Exam: Well developed, well
nourished, male. Testes 23 ml bilaterally, no
varicocele.
Semen analysis: 30 million/ml, 4 ml. Motility
10%, Morphology normal.

Case 4
What is the next best step in the

management of this patient?


a)
b)
c)
d)
e)

LH, FSH, testosterone


Artificial insemination
Antisperm antibody testing
Clomid therapy
Doppler study for varicocele

Correct answer..c
Patients with unexplained low motility should

be evaluated for

Antisperm Antibodies

The antisperm antibodies in the semen rather

than the blood are those which interfere with


motility and fertility.
If difficult to obtain such testing, the blood
level of antisperm antibodies is appropriate.

Case 5
28 years old man presents with a 3 year

history of 1ry infertility. His wife is normal. His


history is unremarkable.
Physical Exam: Reveals a 26 ml testis on the
right, a 22 ml testis on the left and a grade IIIII varicocele.
Semen analysis: 3 cc,17 million sperm/cc.
35% motility, 50% abnormal Morphology.

Case 5
If a second semen analysis is similar to the

first, the next step in management should


be?
a)
b)
c)
d)
e)

Clomid therapy
HCG
LH, FSH, and testosterone
Varicocele repair
Intrauterine insemination

Correct answer.c
Some authorities would recommend

Varicocele Repair.

Clomiphene therapy would be reasonable,

but should be preceded by LH, FSH, and


testosterone levels estimation.
There is no strong indication for intrauterine
insemination, since the results will almost
certainly be in the normal range.
Thus, there is really no absolutely incorrect
answer to this case.

Case 6
35 years old man presents with a 4 years history

of infertility. His wife 34 years old and she is


normal.
Physical Exam.: Reveals normal male, well
virilized, testis size 24 ml bilaterally, no
varicocele.
Semen analysis: volume 3 ml, count 8 million/ml,
motility 40%.
Laboratory data:

LH 8 (normal 3-11 IU)


FSH 7 (normal 3-11 IU)
Testosterone 480 (normal 250-900 ng/dl)

Case 6
The most practical initial treatment for

this patient is?


a)
b)
c)

ART
Low dose androgen therapy
Clomid therapy.

Correct answer.a
This patient has idiopathic oligospermia. There is no

documented effective treatment for this problem.

FEMALE AGE IS VERY CRITICAL IN

CHOSSING THE METHOD OF


TREATMENT.
IVF/ICSI are relatively costly interventions however, it has

reasonable sucsess rate (pregnancy rate ~30%)/.


Low dose androgen therapy is totally irrational and will suppress
endogenous androgen.

Clomiphene therapy

has CONTROVERSIAL

EFFICACY
Another option not listed might be intrauterine insemination.

Case 7
28 years old married man who suffered a spinal
cord injury 3 years ago presents with failure of
ejaculation.
Physical Exam: Reveals a paraplegic male who
has 20 ml testes bilaterally, no varicocele.
Semen analysis: Unobtainable
Laboratory data:

LH 8 (normal 3-11 IU)


FSH 6 (normal 3-11 IU)
Testosterone 400 (normal 250-900 ng/dl)

Case 7
The best initial treatment for this

patient is?
a)
b)
c)
d)

Electro-ejaculation
Epididymal aspiration
Alloplastic spermatocele
Ephedrine

Correct answer.a
Electro-ejaculation has proved

reasonably successful in patients with


spinal cord injuries.
Eighty to 90% of the patients are able to
ejaculate some motile sperm.
Epididymal aspiration and ART is used if
failed the ElectroEjaculation.
Alloplastic spermatocele is not a
practical option.

Case 8
30 year old man with a 2 year history of infertility is

married to a 31 year old woman. His history is


unremarkable. She is felt to be normal by her
gynecologist.
Physical Exam: Normal male, well virilized, testes 27
ml bilaterally, no varicocele.
Semen analysis: 1.3 cc, 50 million/cc, motility 65%,
morphology normal.
Laboratory data:

LH 8 (normal 3-11 IU)


FSH 6 (normal 3-11 IU)
Testosterone 400 (normal 250-900 ng/dl)

Case 8
The best initial treatment for this

patient is?
a)
b)
c)
d)

Husband insemination
In vitro fertilization
Clomid
HCG

Correct answer.a
This is one of the few unequivocal indications

for Husband Insemination. That is, a


low volume ejaculate with good quality sperm.
Clomiphene and HCG will not raise the
volume of the ejaculate.
In vitro fertilization is very expensive to be a
first choice.

Case 9
28 years old male with a 5 year history of infertility.

His wife is felt to be normal.


Physical Exam: Well developed, well nourished,
male. Testes 23 ml on left, 22 ml on right, no
varicocele.
Semen analysis: volume 3 cc, count 1 million/cc,
motility 45%, morphology normal
Laboratory data:

LH 8 (normal 3-11 IU)


FSH 6 (normal 3-11 IU)
Testosterone 400 (normal 250-900 ng/dl)

Case 9
The best therapy for this patient is?
a)
b)
c)
d)

Husband insemination
In vitro fertilization and Gamete
manipulation
Clomid
HCG

Correct answerb
Long duration of infertility(>3 years) combined

with severe oligospermia is not likely to


respond to any line of treatment in a
reasonable period.
There is clearly no therapy that is
documented to be effective for such a patient.
However, Gamete

Manipulation has the

promise of being useful in men with very few


good swimming sperms.

Case 10
A 38 year old man presents 6 years

after having a difficult inguinal hernia


repair. He is now complaining of 2ry
infertility. The wife is thought to be
normal by her gynecologist.
Semen analysis: volume 3 cc,
Azoospermia.

Case 10 A
The best treatment for this patient is?
a)
b)
c)
d)
e)

Microscopic vasovasostomy
Non microscopic vasovasostomy
Epididymal aspiration
Artificial insemination
Alloplastic spermatocele

Answer a vs c
Inguinal exploration and microscopic

vasovasostomy , although difficult , it carries


the best results for long term management.
Sperm retrieval and IVF/ICSI is also a good
thought after considering the female age.

Case 10
Which of the following most

significantly reduces the pregnancy


rate after technically successful
vasovasostomy?
a)
b)
c)

Serum antisperm antibodies


Semen antisperm antibodies
Time since vasectomy

Correct answer..b
Although all the factors cited might

reduce the pregnancy rate after


technically successful vasovasostomy,
the most critical factor is Antisperm
Antibodies In The Semen.
If these are present, a pregnancy rate
falls dramatically.

Case 10 B
If there is no fluid from the testicular

end of the vas at the time of a


vasovasostomy, the surgeon should
a)
b)
c)
d)
e)

Stop
Do a vasovasostomy
Do a vasoepididymostomy
Do a retrograde dye study
Do a testis biopsy.

Correct answer..b, c
Most surgeons will proceed for

vasoepididymostomy,
however some believe that
vasovasostomy still has a higher
success rate.!!

Case 11
14 y.o boy. Presented with mild scrotal

discomfort.
O/E GIII left varicocele.
Left testicular size 16cc, the Rt 18cc.
Scrotal US confirmed the diagnosis

The next step


1-ask for semen analysis
2-suggest varicolcelectomy
3-suggest annual evaluation

Correct answer

Adolescent clinical varicocele with early

testicular changes should be managed by


varicocele ligation (preferably inguinal
approach), without need for Semen analysis.
Annual evaluation of testicular size might be
required in cases of good sized testes on
initial evaluation.

Thank You

You might also like

pFad - Phonifier reborn

Pfad - The Proxy pFad of © 2024 Garber Painting. All rights reserved.

Note: This service is not intended for secure transactions such as banking, social media, email, or purchasing. Use at your own risk. We assume no liability whatsoever for broken pages.


Alternative Proxies:

Alternative Proxy

pFad Proxy

pFad v3 Proxy

pFad v4 Proxy