DEFINITION HX & PH/EX

Transcription

1 DEFINITION HX & PH/EX

2 Because of the success of the assisted reproductive techniques (ART), the evaluation of the man is often ignored. The physician should not forget the fact that many causes of male infertility such as varicocele, ductal obstruction, and infections are easily and effectively treated

3 At least 20% of cases of infertility are due entirely to a male factor, with an additional 30% to 40% of cases involving both male and female factors. Therefore, a male factor is present in one half of infertile couples

4 Studies of couples of unknown fertility status that are attempting to conceive have demonstrated that although most couples achieve conception within 1 year, approximately 15% of couples are unable to do so

5 Although infertility is often not considered to exist until after 12 months of attempted conception, with the advancing age of infertile couples, we do not recommend deferring an initial evaluation. A basic, simple, cost-effective evaluation of both the male and female partners should be initiated at the time of presentation

6 Of infertile couples without treatment, 25% to 35% will conceive at some time by intercourse alone. Within the first 2 years 23% will conceive, whereas an additional 10% will do so within 2 more years. This baseline pregnancy rate of 1% to 3% per month (in non-azoospermic couples) must be kept in mind while managing infertile couples and evaluating the results of therapy.

7 The duration of infertility, details of prior pregnancies initiated, methods of birth control utilized in the past, the couple's frequency of sexual intercourse, as well as the timing of coitus should be recorded. It should be determined whether the couple realizes that ovulation occurs during the middle of the menstrual cycle and that the female is only fertile during this time.

8 Unilateral cryptorchidism slightly decreases fertility, and bilateral cryptorchidism results in a significant reduction in fertility A history of delayed or absent puberty may be associated with an endocrinopathy or androgen receptor abnormality A history of gynecomastia may be associated with either testis cancer, hyperprolactinemia, or estrogen abnormalities Congenital abnormalities of urinary tract or central nervous system

9 Pelvic or retroperitoneal surgery may affect erectile and ejaculatory function. Bladder neck surgery may result in retrograde ejaculation. Retroperitoneal lymph node dissection for testis cancer may injure the sympathetic nerves, resulting in failure of emission or retrograde ejaculation. The vas deferens may be inadvertently injured or stripped of its blood supply during a herniorrhaphy Testicular trauma or torsion may result in testicular atrophy; such patients may also be predisposed to the development of antisperm antibodies, although the evidence for this is not strong

10 The patient should be questioned for a history of urinary tract infections or sexually transmitted diseases Mumps does not appear to affect the testis when it occurs in a prepubertal child; however, mumps orchitis and other forms of viral orchitis may develop if the patient has passed puberty. Infertility is common in patients with end-stage renal disease Spermatogenesis may take up to 4 to 5 years to return after radiation therapy or chemotherapy After a febrile illness, spermatogenesis may be impaired for up to 3 months

11 There are three male infertility conditions associated with chronic upper respiratory infections: 1.Immotile cilia syndrome, or Kartagener's syndrome, should be suspected in patients with immotile sperm, a history of frequent respiratory tract infections, and situs inversus 2..Almost all male patients with clinical cystic fibrosis have bilateral congenital absence of the vas deferens 3 Azoospermia associated with a history of frequent respiratory infections also suggests the possibility of Young's syndrome

12 Many medications and drugs, including nitrofurantoin, cimetidine, sulfasalazine, cocaine, nicotine, and marijuana have been implicated as impairing spermatogenesis Anabolic steroid abuse by athletes has been increasing. Hypogonadotropic hypogonadism may result from the androgenic component of the steroids. Normal hormonal function usually returns after these agents are discontinued, but this is not always the case Exposure to chemicals and heat, hot baths, steam baths, radiation, cigarettes Exposure to lead, mercury, arsenic, hydrocarbons, cadmium,pesticide

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14 Radiation dose (rads) Time until recovery of Spermatogenesis months 30 months 5 years Permanent sterility

15 Good Adriamycin Methotrexate Prednisone Estrogens Androgens Cisplatin Thioguanin Doxorubicin 6-Mercaptopurine Moderate Vincristine PEB ABVD Poor Cyclophosphamide Chlorambucil Mechlorethamine Procarbazine MOPP

16 The physical examination should be directed toward identifying abnormalities that may be associated with infertility : patient's habitus pattern of virilization secondary sex characteristics Lack of temporal pattern balding and fine wrinkles Gynecomastia Situs inversus

17 The penis should be examined for evidence of hypospadias and severe chordee. Both of these may interfere with proper deposition of semen in the deep vagina near the cervix. The possibility of epididymal obstruction is suggested by the presence of induration or cystic dilation of the epididymis.( Spermato-celes and epididymal cysts are common findings and do not indicate the presence of obstruction). Palpation of the vas deferens is performed to ensure its presence as well as to rule out areas of atrophy.

18 The scrotal contents should be examined with the patient standing in a warm room to allow for relaxation of the cremaster muscle Testicular volume = numbers of germm cells The normal adult testis is greater than 4 3 cm in its greates dimensions or greater than 20 ml in volume (Asian men normally have smaller testes)

19 Examination of the spermatic cords should be performed to identify the presence of a varicocele. Small varicoceles (grade I) are palpable only during the Valsalva maneuver. Moderate-sized varicoceles (grade II) are palpable with the patient in the standing position, whereas large varicoceles (grade III) are visible through the scrotal skin and are palpable when the patient is in the standing position