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Male subfertility (Aetiology (Trauma
Testicular torsion
Neurological…
Male subfertility
Aetiology
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Infection
STI e.g. CT, NG
Orchitis e.g. mumps
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Drugs
Sperm production .e.g. anabolic steroids, chemotherapy, alcohol, nicotine
Penile function e.g. B-blockers, SSRIs
Congenital/genetic
Systemic: Kleinfelter's syndrome
Pit/hypo: Kallman syndrome
Testicular: cryptorchidism, Congenital bilateral absence of vas deferens (CBAVD), AIS
Penile deformities e.g. hypospadia, phimosis
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Functional
Ed due to anxiety, depression
Idiopathic
Idiopathic oligoasthenoteratozoospermia* (OAT; oligozoospermia, asthenozoospermia, and teratozoospermia)
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Pathophysiology
Spermatogenesis
Spermatogonia (diploid germ cells) multiply by mitosis
in the seminiferous tubules then undergo meiosis (haploid)
LH stimulates Leydig cells - testosterone
Testosterone + FSH - stimulate Sertoli cells to make metabolic support for the germ cells
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Abnormalities
Too few (oligo/azoospermia)
Poor motility (asthenozoospermia)
Abnormal morphology (teratozoospermia)
Management
Medical
Gonadotrophins
Indication: hypogonadic hypogonadism
MOA: replaces low level GnRH, allowing testes
to be stimulated to spermatogenesis
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Surgical
Sperm retrieval
Indication: retrograde ejaculation, other
MOA: retrieval from urine or testes itself
Assisted reproduction
Indication: poor sperm count/motility/forms
MOA: IUI, ICSI
Repair
Indication: obstruction, vasectomy
MOA: surgical repair of affected structure
Conservative
Medication review
Antispermatogenics: alcohol, anabolic steroids, sulfasalazine
Anti-androgenic: cimetidine, spironolactone
ED: a/B-blockers, antidepressants, diuretics, metaclopramide
Information and advice
Lifestyle (smoking, alcohol, BMI)
Regular UPSI 2-3d/wk throughout cycle
Investigations once 1-2y no conception
Semen analysis (2-7d of sexual abstinence, deliver asap at room temp)
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Diagnosis
Examination
General
Signs of gynaecomastia,
secondary sexual characteristics
Genital
Orchidometer (testicular vol), testicular swellings
Urethral meatus position, structural abnormalities
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Investigations
Semen analysis
Vol > 1.5 mL
Concentration >15x10^6 /mL
Motility (progressive >32%, total >40%)
Normal forms >4%
Bloods
Hormones - FSH (high in testicular failure),
testosterone/LH (low in androgen deficiency)
CF screen (CBAVD)
Karyotyping (47 XXY)
Bedside
Obs (BP, HR, RR, sats, temp)
Weight, height (BMI)
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History
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PMH
Any congenital penile malformations or cryptorchidism
Previous STIs
Medical conditions e.g. CF, Kleinfelter's,
neurological disease e.g. MS, spinal injury
SH
Occupation (drilling, toxin exposure etc),
smoking, alcohol, drugs, diet, support
PC/HPC
How long trying for, how regularly
Previous children (self and partner)
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