Fertility Testing- FINALS L8

MALE FERTILITY TESTING

1. Semenalysis

2. Ultrasound

3. Testicular Biopsy

4. Vasography

5. Panleukocyte Immunocytochemical staining

MACROSCOPIC EXAMINATION

Performed after liquefaction (30-60 minutes)

• VISCOCITY- consistency of the fluid

• VOLUME- 2-5 mL

• SEMEN PH- measured within 1 hour (7.2-8.0)

SPERM CONCENTRATION

Normal: 20-160 mil./mL

SPERM MOTILITY

>50% shows moderate to strong forward motion

SPERM MORPHOLOGY

>50% normal forms

TERATOAZOOSPERMIC INDEX (TZI)

Average number of defects per sperm

SPERM AGGLUTINATION

• DIRECT OR INDIRECT MIXED AGGLUTINATION REACTION (MAR)- for IgG or IgA

• IMMUNOBEAD ASSAY- detect all three Ig classes when beads are coated with monospecific antisera to each class

ULTRASOUND

• Cost-effective & non-invasive

• Assess testicular anatomy & vascularity

SCROTAL ULTRASOUND

• Epididymis

• Cysts

• Infections

• Masses

• Obstructions

• Testicles Infections

• Truma

EPIDIDYMIS (SU)

Normal caput diameter 7-8 mm

CYSTS (SU)

• Hypo-/anechoic, well circumscribed, commonly located at head

• Simple cysts (no sperm) & spermatoceles (sperm present) not associated with infertility

INFECTIONS (SU)

• Enlarged, thickened, decreased echogenicity

• MAGI associated with decreased motility, increased sperm DNA fragmentation, abnormal sperm morphology

MASSES (SU)

• Presence of vascularity, varied echotexture

• Most commonly adenomatoid tumors; others include cystadenomas, mesotheliomas, sarcomas

OBSTRUCTION (SU)

• Epididymal enlargement, prominence of rete testis, hypoechoic appearance

• Normal volume ejaculate with oligo-/azoospermia

TESTICLES INFECTIONS (SU)

• EARLY: Decreased echogenicity, increased heterogeneity, enlargement

• LATE: Atrophy, increased echogenicity

• Associated with subsequent infertility, particularly with post pubertal mumps

TRAUMA (SU)

• May visualize seminiferous tubules, hematomas

• May lead to secondary infertility, antisperm antibodies

TRANSRECTAL ULTRASOUND

PROSTATE- Cysts

SEMINAL VESICLES- EDOa

CYSTS (PROSTATE)

• May be located peripherally, midline, paramedian, hypo-/anechoic, thin wall

• May result in obstruction, rare malignant processes

EDOA (SEMINAL VESICLES)

• Dilated ejaculatory duct & SVs, may have calcification

• Low volume ejaculate, oligo-/azoospermia, decreased fructose & semen pH, requires confirmatory aspiration demonstrating sperm

TESTICULAR BIOPSY- PURPOSE

• Check the location & condition of a lump in the testes

• Diagnose causes of male infertility

• Obtain sperm for in vitro fertilization (IVF)

OPEN BIOPSY

• Surgical biopsy

• Small tissue sample is taken from both testicles

PERCUTAENOUS BIOPSY

• Fine needle biopsy

• Tissue sample is aspirated

• Also performed on both testicles

VASOGRAPHY

• Used to evaluate the condition of vas deferens & ejaculatory ducts

• Uses radiologic dye

• X-ray is taken as dye flows through the ejaculatory ducts

• Only performed when there’s abnormal findings in biopsy & when the ultrasound is uncertain

PANLEUKOCYTE (CD45) IMMUNOCYTOCHEMICAL STAINING

• Detects peroxidase negative polymorphonuclear leukocytes which can only be detected thru immunocytochemical

• Helps in differentiating leukocytes & germ cells

1.0 x 10^6 cells/mL

Consensus threshold value for peroxidase positive cells

LEUKOCYTE IN SEMEN; CD45- BEARING CELLS ARE STAINED RED

• If there are fewer CD45-positive cells than spermatozoa in the sample (i.e., <400), the sampling error will exceed 5%, in this case, the sampling error for the number of cells counted

• If fewer than 25 C45-positive cells are counted, report the number of CD45-positive cells observed with the comment “too few for accurate determination of concentration”

CAUSES OF MALE INFERTILITY

• Sperm abnormalities

• Low sperm count or lack of sperm

• Ejaculation problems

• Other causes

SPERM ABNORMALITIES MAY BE CAUSED BY

• Inflammation of the testicles

• Swollen veins in the scrotum

• Abnormally developed testicles

LOW SPERM COUNT OR LACK OF SPERM

• A pre-existing genetic condition

• Use of alcohol, tobacco, or other drugs

• Severe mumps infection after puberty

• Hernia repairs

• Hormone disorder

• Exposure to poisonous chemicals

• Exposure to radiation

• Blockage caused by a previous infection

• Wearing restrictive or tight underwear

• Injury to the groin area

EJACULATION PROBLEMS

• Premature ejaculation

• Retrograde ejaculation

• Erection dysfunctions

• Complications from radiation therapy or surgery

OTHER CAUSES OF MALE INFERTILITY

• History of STDs

• Urinary tract infection (UTI)

• Use of certain types of medications (steroids)

MANAGEMENT OF MALE INFERTILITY

• Lifestyle Change

• Artificial Insemination

• Hormone Treatment

• IVF

LIFESTYLE CHANGE

Avoid heat sources, radiation, chemicals, alcohol, drugs, tobacco

ARTIFICIAL INSEMINATION

Sperm is collected through multiple ejaculations; manually placed in female’s uterus or fallopian tubes

HORMONE TREATMENT

Clomid or testosterone may increase sperm count

IVF

Fertilization of mature ovum in lab & reimplantation of zygotes into uterus via laparoscopy

FEMALE FERTILITY TESTING

1. Hormone Testing

2. Other infertility tests

AMENORRHEA

Absence of menstrual flow which could be genetic and/or anatomic abnormality or endocrine abnormality

STEPWISE APPROACH TO EVALUATING AMENORRHEA

• Step 1: HCG is measured to exclude pregnancy. Although a result > 5 mIU/mL is typically indicative of pregnancy, or other conditions.

• Step 2: PRL, TSH, and FT4 are measured to exclude a prolactinoma and thyroid disease.

• Step 3: If HCG, PRL, TSH, and FT4 are all normal, then endogenous estrogen status is evaluated with the progestin withdrawal test

• Step 4: Serum FSH and LH levels determined

• Step 5: Serum androgens measured

INFERTILITY TESTS FOR WOMEN

• Pelvic ultrasound

• Hysterosalpingogram (HSG)

• Sonohysterogram

• Laparoscopy

• Pap Smear

• Colposcopy

PELVIC ULTRASOUND

Helps to see the size & position of vagina, cervix, uterus & ovary

HYSTEROSALPINGOGRAM (HSG)

Looks inside of uterus & fallopian tubes & area around them

SONOHYSTEROGRAM

Utilizes saline & ultrasound to look at female reproductive organs

LAPAROSCOPY

Used to asses woman’s pelvic organs (uterus, fallopian tubes, & ovaries) using a thin, lighted scope that’s put through a small cut (incision) in the belly

PAP SMEAR

Routine physical exam for women, collects a small sample of cells from the cervix

COLPOSCOPY

Test to look at vagina & cervix through lighted magnifying tool (colposcope)

CAUSES OF FEMALE INFERTILITY

• Ovulation Disorders

• Tubal Infertility

• Endometriosis

• Uterine or Cervical Causes

OVULATION DISORDER

• Polycystic ovary syndrome (PCOS)

• Hypothalamic dysfunction

• Premature ovarian failure

• Too much PRL

TUBAL INFERTILITY

• Pelvic inflammatory disease

• Previous surgery in the abdomen or pelvis

• Pelvic tuberculosis

ENDOMETRIOSIS

• Extra tissue growth outside the uterus

• Affects the lining of the uterus

UTERINE OR CERVICAL CAUSES

• Benign polyps or tumors

• Endometriosis scarring

• Uterine abnormalities present from birth

• Cervical stenosis

MANAGEMENT OF FEMALE INFERTILITY

• Infection

• Endometriosis

• Cervical Problems

• Endocrine Problems

• Fallopian Tube Problems

INFECTION

• Terazol- for yeast infection

• Metronidazole- for bacterial vaginosis/trichomoniasis

ENDOMETRIOSIS

• Danazole (Danocrine)

• Oral Contraceptives- continuously to suppress ovulation & treatment for endometriosis

• Surgical Removal- for moderate to severe disease [laparoscopy]

CERVICAL PROBLEMS

• Estrogen Therapy

• Cryosurgery- freezes the surface of the cervix if there’s recurrent cervicitis

ENDOCRINE PROBLEMS

• Hypothyroid- replacement therapy (Synthroid)

• Hyperthyroid / Hyperthyroidism- surgery, radioiodine, medicines

FALLOPIAN TUBE PROBLEMS

• Treatment for Infections- terazol, metronidazole

• Lysis & Excision of Adhesions- with microsurgery