Management of Infertility

Prof. Dr.

AbdelFattah AgourAbdelFattah 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) Post-ejaculate urine

b) Rectal ultrasound

c) Full endocrine studies

d) 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) Primary testicular failure

b) Hypogonadotropic hypogonadism

c) Young's syndrome

d) Idiopathic oligospermia

e) 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 Young’s 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) Clomid

b) HCG

c) Trimethoprim-sulpha

d) Tetracycline

e) 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) LH, FSH, testosterone

b) Artificial insemination

c) Antisperm antibody testing

d) Clomid therapy

e) 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 II-III 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) Clomid therapy

b) HCG

c) LH, FSH, and testosterone

d) Varicocele repair

e) 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) ART

b) Low dose androgen therapy

c) 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) Electro-ejaculation

b) Epididymal aspiration

c) Alloplastic spermatocele

d) 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) Husband insemination

b) In vitro fertilization

c) Clomid

d) 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) Husband insemination

b) In vitro fertilization and Gamete manipulation

c) Clomid

d) HCG

Correct answer……b

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) Microscopic vasovasostomy

b) Non microscopic vasovasostomy

c) Epididymal aspiration

d) Artificial insemination

e) 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) Serum antisperm antibodies

b) Semen antisperm antibodies

c) 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 shoulda) Stop

b) Do a vasovasostomy

c) Do a vasoepididymostomy

d) Do a retrograde dye study

e) 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 b

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.

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