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. Male Infertility Review 2011 Paul J. Turek MD FACS, FRSM Director, The Turek Clinic, San Francisco, CA Former Professor and Endowed Chair, UCSF
- 4. 4-6 wks 6 wks Y chromosome (SRY gene) 7-15 wks Testis Bipotential gonad Ovary
- 5. Embryology-Testis Gonocytes 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
- 6. 7-15 wks
- 7. Embryology-Bipotential Gonad Upper gubernaculum Mesonephros Gonad Urogenital cord Dorsal mesentery Mullerian duct Metanephros Mesonephric (Wolffian) duct Lower gubernaculum Intestine Midline
- 9. Embryology-Mesonephric Duct Abnormalities Congenital 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.
- 10. Embryology-Questions When does meiosis begin in the human male? Puberty What 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 gene How many testosterone peaks have occurred by 3-First trimester, the time a man reaches age 30? neonatal and adult
- 11. (caput) 10 days 4 x 3 cm Rete testis (20mL) (corpus) 80 64 days %ge rm 600 10-15 cells (cauda) million lobules sperm Need 3 months to make and ejaculate sperm. Soft, small testes imply a sperm production problem
- 16. SERTOLI CELL
- 17. Cycles- Production varies with time, same location Waves-production varies in different locations
- 18. 10% Prostate 10% Vas 80% deferens Seminal vesicle Premature ejaculation Retrograde ejaculation Anejaculation
- 20. The H-P-G Axis
- 24. PRL
- 25. H-P-G Axis: Testosterone • Testosterone comes in several forms. • Only free and albumin (weakly bound) are “active.” • SHBG-bound is inactive. Free/unbound Albumin bound 1-2% SHBG bound 60% 40% SHBG-T Total Free T Testosterone Bioavailable Testosterone Albumin-T
- 26. H-P-G Axis: Testis & Testosterone Testosterone Testosterone Seminal Vesicle 5-a -Reductase Epididymis Dihydrotestosterone Vas Deferens Ejaculatory ducts Prostate Scrotum Penis External Internal
- 30. Likely Kallmann Syndrome: Anosmia, delayed puberty, azoospermia, small testes, micropenis. DDx: Sickle cell disease, Hemochromatosis, Bardet-Biedl syndrome, Cerebellar ataxia, Prader-Willi syndrome
- 31. Likely Klinefelter Syndrome: Delayed puberty, azoospermia, small testes, micropenis. 47, XXY
- 32. Likely Prolactinoma (MRI pituitary to r/o macroadenoma)
- 35. History Physical Exam Semen Analysis x 2 Eliminate Gonadotoxins Improved Hormone Evaluation Blood Semen Imaging
- 37. 400% Better!
- 38. Clinical Male Infertility: Chemotherapy Agent! Cisplatin! Cytoxan! Adriamycin! Vinblastine! Turek PJ. Fertility Preservat Males with Cancer, 2002
- 41. Physical Inguinal ring Examination Body habitus 20 sex characteristics Varicocele Breast exam Vas deferens Penis Epididymis Testis prostate
- 44. How to Approach Varicocele Repair? X X X
- 46. History Physical Exam Semen Analysis x 2 Hormone Evaluation Blood Semen Imaging
- 49. % Normal Kruger Morphology!
- 50. Peroxidase stain
- 51. G R H - - FSH + T
- 57. Genetic Infertility is Subtle Low or no sperm Clean!! Semen Analysis History Hormones Physical Other Tests Small testes Normal
- 60. The CFTR Gene
- 73. 1% all men; 5% infertile men Rebuild ICSI Bx ICSI
- 80. Hemivasotomy
- 84. Inner! Outer!
- 93. Nonobstructive Azoospermia: How to Best Find Sperm?
- 96. Good Luck!!