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Nick Raine-Fenning · Posted: Wed Apr 02, 2008 8:30 pm Post subject: March 2008_Gyn 1: Azoospermia

Gynaecology 1: March 2008

Discuss the salient points in the history and examination of a man with azoospermia (7/8 marks)

Discuss the investigations (6/7 marks)

Discuss the management (7/8 marks)

stephyaileen · Joined: 31 Mar 2008 Posts: 3 Location: blackburn

Azoospermia is the complete absence of spem in the ejaculate .It is found in 1% of males.
Two samples should be analysed with proper instructions given on the method of collection. Centrifugation of samples may yield sperm in 20% of cases.

History should include:
Medical(illness requiring radiotheraphy or chemotheraphy)
Surgical(Childhood hernia, undescended testes)
Sexually transmitted infections
Trauma
Exposure to drugs or toxins
Family history

Examination
General examintaion(height,weight,BP)
Secondary sexual characteristics
Genital examination
Testes(volume and consisitency)
Epididymides(volume and consistency)
Vas deferentia(presence or absence)
Assess for any abnormalities(lumps/varicolceles)

Investigations
Endocrine profile:FSH,LH,testosterone,prolactin
Inhibin B (correlates with spermatogenesis)
Genetic tests- peripheral karyotyping, Y micro-deletion,Cystic fibrosis mutations
Ultrasound scan (if abnormal examination)
Post-ejaculate urine(if retrograde ejaculation suspected)

Management
Pre-testicular azoospermia is due to lack of gonadotrophic stimulation of the testes, which could be congenital or acquired.Clinically there is hypogonadism,investigation includes pituatory imaging and treatment is with gonadotrophins.
Testicular azoospermia is due to testicular dysfunction/failure.It could be associated with karyotypic abnormalities or Y deletion.Treatment is with attempted testicular sperm extraction(50% success) or ICSI
Post-testicular azoospermia is due to obstruction or retrograde ejaculation.Treatment is either surgical correction of obstruction or sperm retrieval and ICSI Smile

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 915

hi stephyaileen,

welcome to the forum and a good try. the college looks for justification i.e what and why sometimes how of any h/o, exam, Ix we suggest. do you what to give each stem a try again with reasonings?

regards
raj
_________________
Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
SpR O&G Wessex Region

Nick Raine-Fenning · Posted: Sun Jun 08, 2008 8:08 am Post subject:

May I extend Raj's welcome - welcome!! Very Happy

Great answer. Have a go at putting some of your answers into sentences with the following links 'because', 'suggests', 'indicates', 'raises the possibility of ' etc and you will see an essay develop before your eyes.

I like the definition to begin with - this is important. Prevalence, aetiology, and differential are alos important stressing the common and sinister causes for the latter.
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"Teale Fenning Medical Education" delivering evidence-based, exam-orientated learning since 1997

stephyaileen · Joined: 31 Mar 2008 Posts: 3 Location: blackburn

Thanks for the suggestions guys!here goes

Discuss the salient points in the history and examination of a man with azoospermia
Azoospermia is the complete absence of spem in the ejaculate .It is found in 1% of males. Two samples should be analysed with proper instructions given on the method of collection. Centrifugation of samples may yield sperm in 20% of cases
Causes of azoospermia may be classified into obstructive azoospermia(OA) and non-obstructive azoospermia(NOA).
OA causes include infection(chlamydia, gonococcus, TB.filiriasis),surgery(hernia, hydrocele, vasectomy), trauma,congenital and developmental abnormalities.NOA causes are genetic,testicular trauma, tumor and torsion,varicocele and toxins

Medical history may include illness like diabetes miellitus, multiple sclerosis, orchitis or a history of undescended testes as a child.A surgical history needs to rule out surgical obstruction at childhood surgery( hernia repair,hydrocele repair or orchidopexy) or intentionally at vasectomy.Sexually transmitted infections such as chlamydia or gonococcal epididymidis and rarely tuberculosis and filiriasis can cause obstructive azoospermia.Testicular trauma or torsion can also result in azoospermia.Family history should exclude syndromes like cystic fibrosis as 95% of males with CF are infertile secondary to OA.
Examination
General examintaion should include height,weight,BP and secondary sexual characteristics
Genital examination
The volume and consistency of the testes may be normal in OA as it is characterised by normal spermatogenesis. In NOA which is charcterised by impaired spermatogenesis, the testes is soft in consistency and of decreased volume (<15ml) as a consequence of testicular dysfunction
Large cystic epididymides with inspissated epididymal secretions are due to OA.(Young's syndrome)) Congenital bilateral absence of the vas deferens (CBAVD) occur in 2% of OA.
Assessment for lumps or varicolceles should also be done.

Discuss the investigations (6/7 marks)
An endocrine profile may reveal raised serum FSH which is probable in NOA. Serum FSH levels are usually normal in OA (<10IU/L).Associated LH,testosterone,prolactin should be done to exclude hypogonadotrophic hypogonadism(HH).
Inhibin B which is produced by Sertoli cells is shown to correlate with spermatogenesis and is a predictor for sperm retrieval success
Genetic tests like peripheral karyotyping, Y micro-deletion,Cystic fibrosis mutations can reveal causes for azoospermia
If the genital examination is abnormal, an ultrasound scan should be done to rule out testicular tumours and cysts.
A post-ejaculate urine can diagnose retrograde ejaculation which is a certain cause of aspermia

Discuss the management (7/8 marks)
Pre-testicular azoospermia is due to lack of gonadotrophic stimulation of the testes, which could be congenital or acquired.Clinically there is hypogonadism,investigation includes pituatory imaging and treatment is with gonadotrophins.
Testicular azoospermia is due to testicular dysfunction/failure.It could be associated with karyotypic abnormalities or Y deletion.Treatment is with attempted testicular sperm extraction(50% success) or ICSI
Post-testicular azoospermia is due to obstruction or retrograde ejaculation.Treatment is either surgical correction of obstruction or sperm retrieval and ICSI

premgunny · Joined: 09 Apr 2008 Posts: 16

Hi,

I am prem.

Great answer , just to add to it - history of anosmia will give clue for hypogonadotrophic hypogonadism (Kallmann's syndrome)

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 915

hi stephyaileen,

good attempt, i'll add.....

causes --
drug induced -- antipsychotics, haloperidol, alpha methyl dopa, reserpine,

examination --
where you mention sec sexual characters -- add a few findings that you may get and what disease they will associate with.

investigations --

testicular biopsy / epididymal aspirate -- is for investigation + treatment (ICSI)
Trans rectal USS -- for blocks in vas for level of block and seminal vesicles -- see if dilated. can help with aspiration under USS guidance and help plan surgical treatment of block reversal.
also mention orchidometry and it's importance and fallacies
with hormonal profile -- do not forget thyroid.

treatment --

involve andrologist, counseling, leaflets , support groups and access to HFEA site for info
donor IUI, donor IVF, donor ICSI as needed.
adoption is also an option, as is do nothing -- need to give pros and cons of this
surgery for varicocele,as it does not improve fertility.
androgens, kinin enhancers -- of limited value
antibiotics if symptomatic
risk to male offsprings of Y deletion and hence infertility when they grow up.

r
_________________
Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
SpR O&G Wessex Region