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

ANDROLOGY Case Presentation Dr Rosalina M.Ali 20 Sept 2013 Hospital Ampang. 16% couples fail to conceive after 1 year of trying. Male factor : 30% Combination male and female factors : 40%. Mdm N 33yo/ Malay Clerk/NKMI Married for 4 years Presented with history of primary infertility.

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

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  1. ANDROLOGYCase PresentationDr Rosalina M.Ali20 Sept 2013Hospital Ampang

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

  3. Mdm N 33yo/ Malay Clerk/NKMI Married for 4 years Presented with history of primary infertility • 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 • Family History : Nil in significance

  4. Examination : unremarkable Height 145, Weight 74 , BMI 35 • 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: TSH 0.799 T4 18.2 LH 4.5 IU/L FSH 6.3 IU/L Progesterone 30 nmol/L Estradiol 97 pmol/L Prolactin 11 Mu/L

  6. 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 younger brother was married for 4 years before wife conceived. • Smokes 12 cigarettes ,now 3-4 cigarettes /day • Never had hx of long exposure to toxic material/ pesticide • No hx of Mumps

  8. 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

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

  10. SFA : July 2011 -> azoospermia

  11. Scrotal U/S: No significant abnormality • Biopsy (15/8/13) Right testes: -> PESA : once aspiration (0.3cm3) 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 no mature sperm / spermatids were seen

  13. AGE • ENVIRONMENTAL • OCCUPATIONAL • LIFESTYLE

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

  15. TESTICULAR Congenital • genetic, chromosomal, Noonan syndrome, cryptorchidism Acquired - injury, varicocele, chemo/radiotherapy,testicular tumours

  16. POST TESTICULAR Congenital - cystic fibrosis, CAVD Acquired • vasectomy, infection Disorders of sperm fx & motility Sexual dysfunction

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

  18. Basal hormone levels in various clinical status

  19. WHO reference limits and 95% CI for semen parameters

  20. 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 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 d: These are immotile and fail to move at all. Sometimes also denoted motility I.

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

  22. THANK YOU

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