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Azoospermia case
- 1. Presented by – Dr Anuradha M Sawant AZOOSPERMIA – A CHALLENGE FOR THE INFERTILITY SPECIALIST 1
- 2. Married since 7 years Cohabitating since 3 years No history of use of any contraception Couple presented with inability to conceive 2
- 3. CASE HISTORY 26 years old Nulligravida Wife of Serving Soldier Hindu Graduate Homemaker 3
- 4. MENSTRUAL HISTORY Menarche- 14 years of age Previous Menstrual Cycles- Irregular 3-5 days bleeding/ 60-90 days cycles No dysmenorrhea No passage of clots PV 4
- 5. OBSTETRIC HISTORY - Nulligravida FAMILY HISTORY – Not significant PAST HISTORY- Not significant 5
- 6. PERSONAL HISTORY No Alcohol No Smoking No Tobacco use No Drug abuse 6
- 7. GENERAL PHYSICAL EXAMINATION Overweight Height- 160 cm / Weight- 70 kg / BMI-27.3 kg/m2 No Pallor/ Icterus/ Edema/ Cyanosis/ Clubbing/ Lymphadenopathy/Galactorrhea/ Thyromegaly Pulse:88 bpm Blood Pressure:126/88mm Hg Respiratory Rate- 18 bpm SPO2- 99% RA 7
- 8. HIRSUTISM – Present Sum total score of 10 (Ferriman - Gallwey Score) 8
- 9. ACANTHOSIS NIGRICANS - seen 9
- 10. BREAST EXAMINATION TI TANNER Stage IV 10
- 11. SYSTEMIC EXAMINATION Respiratory System: Bilaterally equal breath sounds, No adventitious sounds Cardiovascular System: S1 & S2 Normal, No diastolic murmurs heard Central Nervous System: HMF – Normal Per Abdomen: Soft ,non tender , no organomegaly 11
- 12. LOCAL GENITAL EXAMINATION External Genitalia- Vulva normal, No clitoromegaly seen Per Speculum– Vagina and Cervix Healthy Per Vaginum – Cervix is Firm, Posterior, Mobile Uterus Normal Size & Anteverted Bilateral Adnexa Free 12
- 13. INVESTIGATIONS Parameter Value Hemoglobin 12gm% Blood Sugar F/PP 98/115 mg/dl Blood Group B Positive HIV/ HBsAg/ AntiHCV/ VDRL Negative Mantoux test 3mm 13
- 14. HORMONE PROFILE Parameter Values Normal Values Follicular Stimulating Hormone (D2) 5.58 IU/L 3 – 10 IU/L Luteinizing Hormone(D2) 4.2 IU/L 1.9 – 12.5 IU/L Serum Prolactin 15 μg/L <25μg/L Serum Thyroid Stimulating Hormone 2.8 mIU/L 0.4 to 4.0 m IU/L Anti–Mullerian Hormone 8.4 ng/ml 1.5 – 4.0 ng/ml Sr Testosterone 98 ng/dl 15- 70 ng/dl 14
- 16. HYSTEROSALPINGOGRAPHY Uterine Cavity Normal Bilateral Fallopian Tubes Visualized Bilateral Spill Seen 16
- 17. HYSTEROSCOPY Cervical Canal – Normal Endometrial Cavity – Normal Bilateral Ostia Visualised OSTIA 17
- 19. CASE HISTORY 30 year old Hindu Graduate Serving Soldier(GD) 19
- 20. CASE HISTORY No History Of- Coital Difficulty Premature Ejaculation Erectile Dysfunction Penile Discharge/Ulcerations STD/ Infections of Genital Tract 20
- 21. PERSONAL HISTORY No Alcohol No Smoking No Tobacco Use No Drug Abuse 21
- 22. PAST HISTORY- Viral Orchitis Genital Trauma Prior Pelvic or Inguinal Surgery Prior Chemotherapy Radiation No History of- 22
- 23. FAMILY HISTORY Birth defects Cystic fibrosis Reproductive failures No History of- 23
- 24. GENERAL PHYSICAL EXAMINATION Average built & nourished Height- 172 cm Wt- 70 kg BMI-23.8kg/m2 Male pattern hair distribution No gynaecomastia/ No Thyromegaly No pallor/ icterus/ edema/ cyanosis/ clubbing/ lymphadenopathy PR: 80bpm BP: 126/80 mm Hg RR- 20 bpm 24
- 25. SYSTEMIC EXAMINATION Respiratory System: Bilaterally equal breath sounds, No adventitious sounds Cardiovascular System: S1 & S2 Normal, No diastolic murmurs heard Central Nervous System: HMF – Normal Per Abdomen: Soft ,non tender , no organomegaly , Bilateral hernia sites normal 25
- 26. LOCAL GENITAL EXAMINATION Penis and bilateral scrotal sacs normal Testis palpable in both scrotum ,Normal volume No varicocele/Hydrocele 26
- 27. SEMEN ANALYSIS No motile/immotile spermatozoa seen 27
- 28. INVESTIGATIONS Semen Analysis- Azoospermia Semen culture : Sterile USG Scrotum- Normal Scan 28
- 29. INVESTIGATION PARAMETER VALUES HIV Non Reactive HBsAg Negative Anti HCV Negative VDRL Negative Blood Group A Positive 29
- 30. INVESTIGATIONS Parameter Values Normal values Testosterone 800 ng/dL 270- 1070 ng/dL Follicle Stimulating Hormone 4.8 IU/L 2- 12 IU/L Luteinizing Hormone 3.2 IU/L 2-9 IU/L Thyroid Stimulating Hormone 2.8 m IU/L 0.5 – 4.15 m IU/L 30
- 31. DIAGNOSIS PRIMARY INFERTILITY Male factor: Obstructive Azoospermia( OA ) Female factor: Polycystic Ovarian Syndrome 31
- 32. DISCUSSION 32
Editor's Notes
- Transvagical ultrasound is considered the gold standard in the diagnosis of polycystic ovaries. Features can affect either one (unilateral polycystic ovary) or both ovaries. Features include presence of 10-12 or more follicles 3,5 individual follicles are generally similar in size and measure 2-9 mm in diameter 7 peripheral distribution of follicles - this can give a "string of pearls" appearance background ovarian enlargement (volume greater than 10 cc 7) central stromal brightness +/- prominance General imaging differential considerations include multi-follicular ovaries (MFO) 2 - fewer cysts ( ~ 6 or more per ovary), which tend to be larger (up to 10 mm in diameter) and distributed throughout the ovary with no stromal hypertrophy
- AMH is expressed by granulosa cells of the ovary . it is a measure of certain aspects of ovarian function,[19] useful in assessing conditions such as polycystic ovary syndrome and premature ovarian failure
- patient is truly azoospermic is confirmed by centrifugation of the semen sample with meticulous microscopic examination of the pellet on two different occasions. - The presence of any sperm in the pellet rules out bilateral ductal obstruction, and the patient should be evaluated for oligospermia and not azoospermia.