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Disclosure
Male Fertility Issues:
Common Presentations in I have no current affiliation or financial
arrangement with any grantor or
Primary Care commercial interests that might have
direct interest in the subject matter of
Susanne Quallich, ANP-BC, NP-C, CUNP this CE Program.
Division of Sexual and Reproductive Medicine
Department of Urology
University of Michigan Health System
June 2011
Objectives Male Infertility
15% of couples with
At the end of this presentation, the infertility
participant should be able to: ◦ 30% due to male factors
◦ Recognize a male patient who may have risk ◦ 20% due to combined
factors or diagnoses that place him at risk for factors
subfertility or infertility
◦ Understand the preliminary evaluation and In 50% of cases of
need for specialist referral infertility, the male is
◦ Describe potential methods for preserving contributing to the
male fertility problem (Sharlip, et al, 2002)
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When to Evaluate Male Infertility But…
American Society for Reproductive Medicine In Michigan
states that couples should seek evaluation after ◦ Most insurance doesn’t cover treatment
12 months’ of unprotected intercourse, but if ◦ Some partial coverage
the female of the couple is 35 or older, couples
should seek evaluation after 6 months
14 states require insurance coverage to offer
When the couple is worried some sort of diagnosis and treatment
◦ Arkansas, California, Connecticut, Hawaii, Illinois,
If previously there was not an issue establishing Maryland, Massachusetts, Montana, New Jersey, New
a pregnancy York, Ohio, Rhode Island, Texas, West Virginia
◦ Scope of coverage varies greatly
After surgical or medical treatments that may
affect fertility
Which conditions place men at risk? General History
Gonadotoxin exposure: General information and
Obesity/hypogonadism reproductive history
◦ Smoking
Varicocele ◦ Radiation exposure ◦ Previous children?
• Sexual or ejaculatory ◦ Alcohol Childhood and
◦ Chemotherapy developmental history
dysfunction ◦ Drugs Past medical history:
• Medications ◦ Temperature Extremes surgical, medical,
• Klinefelter’s medications
◦ ?testicular torsion
• Infections ◦ ?mumps orchitis
• Dietary influences
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Male History: Past Surgery History (continued)
Herniorrhaphy--(vas) Review of symptoms: Sexual history
Pelvic surgery--(vas) ◦ fevers, colds Family history
Bladder neck surgery--(ejaculation) ◦ sinus infections Female evaluation?
Surgeries which impair retroperitoneal ◦ anosmia
sympathetic nerve function ◦ peripheral field visual
◦ Aortic dissection problems
◦ Rectal surgery ◦ breast pain or
◦ RPLND for testis cancer secretion
◦ Some patients will have retrograde ejaculation; most
will have anemission ◦ scrotal pain
Physical Examination of the Physical Examination of the Subfertile
Subfertile Male Male
General Genitourinary- skill with this exam is key
◦ Secondary sexual ◦ Penis
characteristics
◦ Scrotum
◦ Body habitus
Presence of vas deferens and consistency
◦ Any system Presence of varicocele and grading
suggested by the Epididymis: presence and texture
history Testis: size (4 cm in length or 20 ml in vol.) and consistency
◦ Tanner stage ◦ Prostate
gynecomastia
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Examination Specifics Examination Specifics
Testes Mass associated with testicle- tumor, hydrocele,
spermatocele Cremasteric Brushing or touching skin of the scrotum in downward
Solitary testes- maldescent of testicle or previous reflex direction will result in prompt elevation of testicle on
surgical removal the same side. Can be aggravated by cool room-
reflex may be engaged prior to any contact with
Small, soft testicle(s)- Klinefleter’s disease, history of
infection, late orchidopexy examiner
Epididymis Cystic or nodular- spermatocele, previous or current Valsalva Performed with patient standing, and in warm room;
infection, history of vasectomy maneuver to having patient perform Valsalva reverses flow into
Large and fluctuant- spermatocele evaluate for pampiniform plexus and results in palpable distention
Localized pain- epididymitis, post-vasectomy pain varicocele of vessels to aid in identification of dostended
syndrome vessels. Graded as I, II, III
Vas Absence of vas bilaterally or unilaterally- cystic fibrosis Adapted from Quallich, S.A. (2011). Male Reproductive System. In Advanced Assessment:
deferens, Sperm granuloma- s/p vasectomy Interpreting Findings and Formulating Differential Diagnoses, Goolsby, M.J. & Grubbs, L., (Eds.).
Philadelphia: F.A. Davis.
spermatic Congested veins unilaterally or bilaterally- varicocele
cord Beading/nodularity of cord- obstruction of epididymis,
tubercular infection of epididymis
Adapted from Quallich, S.A. (2011). Male Reproductive System. In Advanced Assessment: Interpreting Findings and
Formulating Differential Diagnoses, Goolsby, M.J. & Grubbs, L., (Eds.). Philadelphia: F.A. Davis.
Hypothalamic-Pituitary-Gonadal
(HPG) Axis Endocrinopathies: Obesity
Hypothalamus Aromatization of testosterone in fatty tissue to
estradiol
- GnRH + ◦ less testosterone available for maintenance and
Activin virilization
+ decline in sperm production
Pituitary testes no longer receive an adequate hormonal signal to
produce sperm
_
FSH + + LH _ Results of lowered testosterone
Testis Testosterone ◦ evidence of feminization (such as gynecomastia)
-
Inhibin FSH
LH ◦ regression of secondary male sexual characteristics
Leydig Cells ◦ low count or azoospermia
Sertoli Cells Support germ cells
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Endocrinopathies: Obesity Other Endocrinopathies
Testosterone/free testosterone levels, Testosterone replacement in reproductive-age
with estradiol, LH and FSH levels men for low testosterone
determine degree to which obesity has Testosterone replacement for congential
upset hormonal balance hypogonadotropic hypogonadism
Others:
◦ Primary panhypogonadism
Most definitive treatment is weight loss ◦ Partial androgen resistance
◦ some patients may respond well clomiphine Reversible endocrinopathies that directly
citrate, a synthetic nonsteroidal antiestrogen contribute to male infertility are unusual
(Kolettis, 2003)
Varicocele
Varicocele Pathophysiology
Most asymptomatic
Current estimates place the prevalence in males at
15%-20% Possible symptoms: dull ache, fullness, pain
Increases to 40% or higher in men presenting for an that does not radiate, pulling on affected
infertility evaluation, in the context of secondary side
infertility Possible semen analysis derangements
No specific risk factors
Lack of adequate venous valves in internal spermatic Subclinical: present on ultrasound only,
system not detected on physical exam
◦ Dilation of the vessels of pampiniform plexus
◦ ?significance to male infertility
Results in
◦ Heating the scrotum Grade I: present only with Valsalva
◦ Changes in testicular blood flow Grade II: present without Valsalva
◦ Reflux of hormones Grade III: visible through the skin ("bag of
◦ Atrophy of the cremasteric muscle worms")
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Erectile Dysfunction Sexual Dysfunction Issues
Need adequate delivery of sperm in Premature ejaculation
order to fertilize… ◦ Emerging recognition as ?clinically significant
problem
PDE5 inhibitors
◦ ? Cialis use: possible effect on PDE11 Inability to climax
receptors of sperm ◦ Psychosocial/psychological issue
? effect of MUSE on sperm
◦ Residual in urethra Delayed ejaculation
◦ Common with aging (~50% in men over 60)
◦ Common in ED patients +/- BPH/LUTS
Medication effects
Medications That Impair
Ejaculatory Dysfunction
Male Fertility
Anatomic, functional, medical, neurologic, surgical, Mechanisms
or secondary to medications ◦ Direct gonadotoxic
effect
Retrograde ejaculation: failure of bladder neck ◦ Alteration of HPA axis
closure ◦ Effects on erectile
◦ cloudy urine after ejaculation function
◦ possible hematospermia
◦ Effects on ejaculatory
◦ possible recent onset anejaculation
function
◦ Lowering libido
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Medications That Impair
Medication Influences**
Male Fertility
Spironolactone ↓ spermatogenesis
Psychotheraputic Testosterone Ca+2 channel ↓ fertilization capacity
agents Anabolic steroids blockers
◦ TCA, SSRIs Antihypertensives Nitrofuratoin (high ↓ spermatogenesis
Antiandrogens Diuretics doses)
α-5 reductase ◦ spironalactone Cimetidine ↓ spermatogenesis
inhibitors Alpha antagonists Cyclosporine ↓ spermatogenesis
Cimetidine Ketoconazole
Sulfasalazine Colchicine ↓ fertilization capacity
Chemotherapy
agents Erythromycin ↓ sperm density/motility
Adapted from Brugh, Matschke, & Lipshultz, Endo & Meta Clin, 2003
** does not include medications that can impair erectile function
Klinefelter’s Disease Klinefelter’s Disease
Most common abnormality of sexual differentiation- Lack of development of
1:500 live births secondary sexual
characteristics
One of most common causes of primary ◦ small [ 101F will alter sperm production
XXY
Dietary Influences on Male Fertility Dietary Influences on Male Fertility
• Zinc- severe deficiency: hypogonadism • Vitamin C- severe deficiency: ? Role in sperm
production
• Selenium- severe deficiency: mood • Deficiency prevalence 5-20% in US (Am J Pub Health,
alterations 2004)
• Vitamin A- severe deficiency: reproductive • Vitamin D- possible minor role in male
issues (needed for spermatogenesis, fertility
differention of spermaogonia)
• Vitamin E- possible role in viability of
• Vitamin B12- severe deficiency: unknown, spermatid population, epithelial cell
but is found in high concentrations in maturation
seminal vesicle fluid
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Dietary Influences on Male Fertility Prevention of Male Infertility
• L-Carnitine- possible role in epididymal and
sperm function Lifestyle issues
Obesity
• Folate- deficiency uncommon, possible role Smoking
in male infertility but not characterized
Drug use
◦ Anabolic steroids
• Lycopene- ? Role, highly concentrated in
testes Medication use
• Glutathione- ?protects sperm from oxidative
stress
Conclusions Conclusions
• Many men are concerned about preserving • Nurse practitioners have a unique opportunity
their fertility to identify men who are potentially at risk for
alterations to their fertility, and a role in
• Best advice is that if they are trying to dispelling misconceptions regarding a diagnosis
conceive with their partner, they should stop of a fertility problem
exposure to anything that may potentially alter
the number, function or shape of their sperm
• Practitioners should feel comfortable
• Recommend low-dose multivitamin safely to addressing basic male reproductive health
promote overall health, with possible questions, and referring men to a male
secondary benefits to reproductive status infertility specialist or an andrologist for
(empiric therapy) additional evaluation
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