andrology dr hab. rafał kurzawa clinic of reproduction and gynecology pomeranian academy of...
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ANDROLOGYANDROLOGY
Dr hab. Rafał KurzawaCLINIC of REPRODUCTION and
GYNECOLOGY
POMERANIAN ACADEMY of MEDICINE
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Epidemiologia niepłodnościEpidemiologia niepłodności
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Symptomatology of male infertility Symptomatology of male infertility
TYPE I TYPE I – erection problems – erection problems (0,3-7%)(0,3-7%) TYPE II TYPE II – azoospermia – azoospermia (0,9%-16%)(0,9%-16%) TYPE III – immunological infertility TYPE III – immunological infertility (3,4%-25%)(3,4%-25%) TYPE IV – abnormal seminal quality TYPE IV – abnormal seminal quality (23%-48%)(23%-48%) TYPE V TYPE V – idiopathic sperm dysfunction – idiopathic sperm dysfunction (0-25%)(0-25%)
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Diagnosis Diagnosis
General examination General examination Semen analysis Semen analysis Other diagnostic tests: Other diagnostic tests:
– USGUSG– Hormonal diagnostic Hormonal diagnostic – Diagnostic tests for Assisted Reproductive Diagnostic tests for Assisted Reproductive
Technology Technology
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TYPE I – erection problems TYPE I – erection problems (0,3-7%)(0,3-7%)
Normal ejaculation Normal ejaculation – Hypospermia (semen volume < 2,0 ml) – chronic prostatitis Hypospermia (semen volume < 2,0 ml) – chronic prostatitis – Impotence Impotence
Retrograde ejaculation Retrograde ejaculation – Neurogenic– DM, SM Neurogenic– DM, SM – Anatomical Anatomical – Jatrogenic – drugs, operations Jatrogenic – drugs, operations
disejaculation disejaculation – Functional – anorgazmiaFunctional – anorgazmia– Neurogenic – spinal injury Neurogenic – spinal injury – Jatrogenic – drugs, chemiotherapy, radiotherapy, operations Jatrogenic – drugs, chemiotherapy, radiotherapy, operations
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TYPE II – azoospermia TYPE II – azoospermia (0,9%-16%)(0,9%-16%)
Pre-testicular causes Pre-testicular causes – Hypothalamic or pituitary disorder – LH, FSH deficiency, Hypothalamic or pituitary disorder – LH, FSH deficiency,
Kallman syndrome, trauma, tumors, inflammation, Kallman syndrome, trauma, tumors, inflammation, meningitismeningitis
Testicular causes Testicular causes – Primary testicular failure Primary testicular failure – Congenital – 47XXY, del Y, AZFCongenital – 47XXY, del Y, AZF– Acquired- mumps, testicular torsion, castrationAcquired- mumps, testicular torsion, castration– Jatrogenic – radiotherapy, chemiotherapy Jatrogenic – radiotherapy, chemiotherapy
Post-testicular causes Post-testicular causes – Congenital – CBAVD, CFCongenital – CBAVD, CF– Acquired – inflammations (gonorrhea) Acquired – inflammations (gonorrhea) – Jatrogenic – vasectomy, hernia operation Jatrogenic – vasectomy, hernia operation
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Diagnostic tests for Assisted Diagnostic tests for Assisted Reproductive Technology- ICSI Reproductive Technology- ICSI
FSHFSH– If < 12IU – sperm biopsy If < 12IU – sperm biopsy
is effective in 80-90% is effective in 80-90% Blocked ejaculatory Blocked ejaculatory
duct duct (Micro-Epidydymal (Micro-Epidydymal Sperm Aspiration –Sperm Aspiration –MESE) MESE)
Other Other (Testicular Sperm (Testicular Sperm Extirpation- TESE, Extirpation- TESE, Testicular Sperm Testicular Sperm Aspiration- TESA) Aspiration- TESA)
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TYPE III – immunological infertility TYPE III – immunological infertility (3,4%-25%)(3,4%-25%)
antisperm antibodies – antisperm antibodies – the immune system may the immune system may produce antibodies that produce antibodies that attack and weaken or attack and weaken or disable spermdisable sperm – Auto-immunological Auto-immunological
diseases diseases – Concequences of Concequences of
testicular trauma testicular trauma
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Congenital Congenital – Undescended testicles Undescended testicles
Sexually transmitted Sexually transmitted disease (gonorrhoea) or disease (gonorrhoea) or testicular infection testicular infection (mumps) (mumps)
Vascular Vascular – Testicular torsion Testicular torsion – Varicocoeles Varicocoeles
Diseases: Diseases: – Thyroid faiure; Addison Thyroid faiure; Addison
disease, hepar diseases; disease, hepar diseases; DM, auto-immunological DM, auto-immunological diseases; diseases;
Environmental factorsEnvironmental factors– Drugs (sulfasalazine, T, Drugs (sulfasalazine, T,
chemiotherapy)chemiotherapy)– Temperature Temperature – Other factors (X-rays, lead, Other factors (X-rays, lead,
cigarette smoke, alcohol; cigarette smoke, alcohol; marijuana, frequently marijuana, frequently wearing tight-fitting pants wearing tight-fitting pants and underwear)and underwear)
Immunological Immunological – Testitis Testitis
Genetic Genetic – del Y, aberrations (count del Y, aberrations (count
and structure of and structure of chromosomes) chromosomes)
Idiopathic [46%] Idiopathic [46%]
TYPE IV – abnormal sperm quality TYPE IV – abnormal sperm quality (23%-48%) (23%-48%)
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Obraz morfologicznyObraz morfologiczny
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Treatment Treatment
Risk factor elimination Risk factor elimination Give up smoking Give up smoking Testicular temperatue decreaseTesticular temperatue decrease Regular sexual intercourses (2-3 per Regular sexual intercourses (2-3 per
week) week) Antioxydants Antioxydants
– Vitamin E, C, Zinc Vitamin E, C, Zinc Tetracicline Tetracicline
– Chlamydia Trachomatis infection Chlamydia Trachomatis infection
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Treatment (pharmacotherapy)Treatment (pharmacotherapy)
Risk factor elimination Risk factor elimination Hormonal treatment Hormonal treatment
– Testosterone Testosterone – hCGhCG – FSH FSH – C.C, tamoxyphen C.C, tamoxyphen
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Varicose veins in the spermatic Varicose veins in the spermatic cord cord
Physical examination Physical examination – I I Valsalva test examination ( or during Valsalva test examination ( or during
cough) cough) – II II large veins during palpation large veins during palpation – IIIIII visible varicouse veins visible varicouse veins
Other diagnostic test Other diagnostic test – Semen analysis (SA) Semen analysis (SA) – USG USG
Treatment Treatment – Operation Operation – ART.: IUI, IVF, ICSI ART.: IUI, IVF, ICSI
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Diagnostic and therapeutic algorithm Diagnostic and therapeutic algorithm (female)(female)
Sperm analysis
O, A, T, OA, OT, TA, OAT
grave O, A, T, OA, OT, TA, OAT
azoospermia Testicular cells?
TESE, MESA
Treatment: operation, CC, hMG (FSH)
ICSI
IUI
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Sperm analysis- Sperm analysis- recommendation by WHOrecommendation by WHO
– General female infertility diagnostic test- SAGeneral female infertility diagnostic test- SA– sterility sterility – sample should be delivered to laboratory in 60 sample should be delivered to laboratory in 60
min. after ejaculation min. after ejaculation – abstinence min. 48 hours max. 7 days abstinence min. 48 hours max. 7 days – the next semen analysis between 7 days and the next semen analysis between 7 days and
3 months 3 months
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Seminal quality, cytology and Seminal quality, cytology and sperm quantitation sperm quantitation
– liquefactionliquefaction
– viscosity viscosity
– volumevolume
– colorcolor
– pHpH
– smellsmell
– Sperm count Sperm count – Sperm motion analysis Sperm motion analysis – WBC count (pyospermia) WBC count (pyospermia) – Spermatozoa count Spermatozoa count – Antisperm antibodies Antisperm antibodies – Sperm morphology Sperm morphology – Microbiology Microbiology
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Semen analysis Semen analysis
– Microscope Microscope – Makler counting chamber Makler counting chamber – Immunobead test (IgG, IgA or IgM)Immunobead test (IgG, IgA or IgM)
– CASA CASA (computer-assisted sperm analysis)(computer-assisted sperm analysis)
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Sperm motion analysis Sperm motion analysis 0- 0- immotile immotile 1- weak movement with no forward progression 1- weak movement with no forward progression 2- weak to moderate forward progression 2- weak to moderate forward progression 3- good forward progression; active tail movement 3- good forward progression; active tail movement 4- rapid forward progression; vigorous tail movement 4- rapid forward progression; vigorous tail movement
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Seminal quality- ranges Seminal quality- ranges
–Liquefaction < 60 minutes Liquefaction < 60 minutes
–Volume > 2 ml Volume > 2 ml
–Color- gray to white opalescent fluid Color- gray to white opalescent fluid
–pH 7,2 – 8,0 pH 7,2 – 8,0
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IMMUNOBEAD TEST IMMUNOBEAD TEST
Microscopic polyacrylamide spheres, ranging in Microscopic polyacrylamide spheres, ranging in size from 2 to 10 um, coated with anti-human size from 2 to 10 um, coated with anti-human immunoglobins against human IgG, IgA or IgMimmunoglobins against human IgG, IgA or IgM
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Normal sperm rangeNormal sperm range
Motility Motility >50% 4 or 3 ; or >25% 4>50% 4 or 3 ; or >25% 4 Sperm count Sperm count >20>20··101066/ml/ml WBC count WBC count <10<1066/ml/ml Spermatozoa Spermatozoa <5<5··101066/ml/ml Autoagglutinating Autoagglutinating <10%<10% Immunebead testImmunebead test <10%<10% Sperm morphology Sperm morphology >30% normal forms >30% normal forms
(WHO); 5-14% strict criteria (Kruger)(WHO); 5-14% strict criteria (Kruger)
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Definitions of „abnormal” counts Definitions of „abnormal” counts
NormozoospermiaNormozoospermia Oligozoospermia Oligozoospermia << 2020··101066/ml/ml AstenozoospermiaAstenozoospermia <50% 4 or 3 ; or <25% <50% 4 or 3 ; or <25%
44 TeratozoospermiaTeratozoospermia <30% <30% Azoospermia Azoospermia no sperm no sperm