Male Infertility Review 2011Paul J. Turek MD FACS, FRSM Director, The Turek Clinic, San Francisco, CA Former Professor and...
4-6 wks 6 wks           Y chromosome (SRY gene)7-15 wks                                              Testis               ...
Embryology-TestisGonocytes                                     Testosterone•  Inactive until puberty                     •...
7-15 wks
Embryology-Bipotential Gonad                          Upper gubernaculum                          Mesonephros             ...
Mullerian andWolffian DuctRelationships
Embryology-Mesonephric Duct AbnormalitiesCongenital Absence of the Vas Deferens (CAVD)  • Unilateral: most azoospermic  • ...
Embryology-QuestionsWhen does meiosis begin in the human male?       PubertyWhat hormone is responsible for regression of ...
(caput)                 10 days4 x 3 cm                      Rete testis (20mL)                                  (corpus) ...
Cremasteric artery!
SERTOLI CELL
Cycles-         Production         varies with         time, same         locationWaves-productionvaries in differentlocat...
10%                  Prostate                  10%                    Vas       80%                  deferens   Seminal   ...
TheH-P-G Axis
PRL
H-P-G Axis: Testosterone• Testosterone comes in several forms.• Only free and albumin (weakly bound) are “active.”• SHBG-b...
H-P-G Axis: Testis & TestosteroneTestosterone           Testosterone                                                Semina...
Likely Kallmann Syndrome: Anosmia, delayed puberty, azoospermia,small testes, micropenis.DDx: Sickle cell disease, Hemochr...
Likely Klinefelter Syndrome: Delayed puberty, azoospermia, small                 testes, micropenis.                      ...
Likely Prolactinoma (MRI pituitary to r/o macroadenoma)
History  Physical ExamSemen Analysis x 2            Eliminate Gonadotoxins                                  Improved      ...
400%Better!
Clinical Male Infertility: Chemotherapy  Agent!Cisplatin!Cytoxan!Adriamycin!Vinblastine!    Turek PJ. Fertility Preservat ...
Physical                            Inguinal ringExaminationBody habitus20 sex characteristics   VaricoceleBreast exam    ...
How to ApproachVaricocele Repair?                         X                         X                     X
History  Physical ExamSemen Analysis x 2            Hormone           Evaluation                          Blood           ...
% Normal Kruger Morphology!
Peroxidase stain
G              R              H                      -                  -FSH          +      T
Genetic Infertility is Subtle                                               Low or                                        ...
The CFTR Gene
1% all men; 5% infertile men                               Rebuild                               ICSI                     ...
Hemivasotomy
Inner!Outer!
Nonobstructive Azoospermia: How to Best Find Sperm?
Good Luck!!
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed...
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Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed Chair, University of California San Francisco (UCSF)

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Lecture written and presented by Paul J. Turek MD FACS, FRSM. Dr. Turek is the Director of the The Turek Clinic in San Francisco and Former Professor and Endowed Chair at the University of California San Francisco (UCSF).

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Male Infertility Review 2011 By Paul J. Turek MD FACS, FRSM, Director of The Turek Clinic and Former Professor and Endowed Chair, University of California San Francisco (UCSF)

  1. 1. Male Infertility Review 2011Paul J. Turek MD FACS, FRSM Director, The Turek Clinic, San Francisco, CA Former Professor and Endowed Chair, UCSF
  2. 2. 4-6 wks 6 wks Y chromosome (SRY gene)7-15 wks Testis Bipotential gonad Ovary
  3. 3. Embryology-TestisGonocytes Testosterone•  Inactive until puberty •  1st surge in utero•  Meiosis inhibited by MIS •  2nd surge in neonatal period•  Pubertal testosterone meiosis •  3rd rise at puberty; peaks in 2nd to 3rd decade Testosterone (ng/dL) 600 400 200 100 0 Adult Senescence
  4. 4. 7-15 wks
  5. 5. Embryology-Bipotential Gonad Upper gubernaculum Mesonephros Gonad Urogenital cord Dorsal mesentery Mullerian duct Metanephros Mesonephric (Wolffian) duct Lower gubernaculum IntestineMidline
  6. 6. Mullerian andWolffian DuctRelationships
  7. 7. Embryology-Mesonephric Duct AbnormalitiesCongenital Absence of the Vas Deferens (CAVD) • Unilateral: most azoospermic • Bilateral: all azoospermic • Any segment of Wolffian duct • If ipsilateral kidney also absent: No CFTR mutations • If ipsilateral kidney is present: 80% have CFTR mutations CF results in: Pneumonia, pancreatic insufficiency, bowel obstruction, sinusitis, nasal polyps, and death by 35 years of age.
  8. 8. Embryology-QuestionsWhen does meiosis begin in the human male? PubertyWhat hormone is responsible for regression of MIS female internal genitalia?What gene is responsible for male sexual SRY, (SOX-9) differentiation?What gene mutation should be examined CFTR=cystic in men with idiopathic ejaculatory fibrosis trans- duct obstruction? membrane regulatory geneHow many testosterone peaks have occurred by 3-First trimester, the time a man reaches age 30? neonatal and adult
  9. 9. (caput) 10 days4 x 3 cm Rete testis (20mL) (corpus) 80 64 days %ge rm 600 10-15 cells (cauda) millionlobules sperm Need 3 months to make and ejaculate sperm. Soft, small testes imply a sperm production problem
  10. 10. Cremasteric artery!
  11. 11. SERTOLI CELL
  12. 12. Cycles- Production varies with time, same locationWaves-productionvaries in differentlocations
  13. 13. 10% Prostate 10% Vas 80% deferens Seminal vesiclePremature ejaculationRetrograde ejaculationAnejaculation
  14. 14. TheH-P-G Axis
  15. 15. PRL
  16. 16. H-P-G Axis: Testosterone• Testosterone comes in several forms.• Only free and albumin (weakly bound) are “active.”• SHBG-bound is inactive. Free/unboundAlbumin bound 1-2% SHBG bound 60% 40% SHBG-T Total Free T Testosterone Bioavailable Testosterone Albumin-T
  17. 17. H-P-G Axis: Testis & TestosteroneTestosterone Testosterone Seminal Vesicle 5-a -Reductase Epididymis Dihydrotestosterone Vas Deferens Ejaculatory ducts Prostate Scrotum Penis External Internal
  18. 18. Likely Kallmann Syndrome: Anosmia, delayed puberty, azoospermia,small testes, micropenis.DDx: Sickle cell disease, Hemochromatosis, Bardet-Biedl syndrome,Cerebellar ataxia, Prader-Willi syndrome
  19. 19. Likely Klinefelter Syndrome: Delayed puberty, azoospermia, small testes, micropenis. 47, XXY
  20. 20. Likely Prolactinoma (MRI pituitary to r/o macroadenoma)
  21. 21. History Physical ExamSemen Analysis x 2 Eliminate Gonadotoxins Improved Hormone Evaluation Blood Semen Imaging
  22. 22. 400%Better!
  23. 23. Clinical Male Infertility: Chemotherapy Agent!Cisplatin!Cytoxan!Adriamycin!Vinblastine! Turek PJ. Fertility Preservat Males with Cancer, 2002
  24. 24. Physical Inguinal ringExaminationBody habitus20 sex characteristics VaricoceleBreast exam Vas deferens Penis Epididymis Testis prostate
  25. 25. How to ApproachVaricocele Repair? X X X
  26. 26. History Physical ExamSemen Analysis x 2 Hormone Evaluation Blood Semen Imaging
  27. 27. % Normal Kruger Morphology!
  28. 28. Peroxidase stain
  29. 29. G R H - -FSH + T
  30. 30. Genetic Infertility is Subtle Low or no sperm Clean!! Semen Analysis History Hormones Physical Other Tests Small testes Normal
  31. 31. The CFTR Gene
  32. 32. 1% all men; 5% infertile men Rebuild ICSI Bx ICSI
  33. 33. Hemivasotomy
  34. 34. Inner!Outer!
  35. 35. Nonobstructive Azoospermia: How to Best Find Sperm?
  36. 36. Good Luck!!

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