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Male Infertility Review 2011 Paul J. Turek MD FACS, FRSM Director, The Turek Clinic, San Francisco, CA Former Professor and Endowed Chair, UCSF

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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Page 1: 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)

Male Infertility Review 2011

Paul J. Turek MD FACS, FRSM Director, The Turek Clinic, San Francisco, CA Former Professor and Endowed Chair, UCSF

Page 2: 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)
Page 3: 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)
Page 4: 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)

Y chromosome (SRY gene)

4-6 wks

6 wks

7-15 wks

Bipotential gonad

Ovary

Testis

Page 5: 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)

Embryology-Testis

Gonocytes •  Inactive until puberty •  Meiosis inhibited by MIS •  Pubertal testosterone meiosis

Testosterone •  1st surge in utero •  2nd surge in neonatal period •  3rd rise at puberty; peaks in

2nd to 3rd decade

Adult Senescence

Test

oste

rone

(ng/

dL)

0

100 200

400 600

Page 6: 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)

7-15 wks

Page 7: 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)

Embryology-Bipotential Gonad

Upper gubernaculum Mesonephros Gonad

Urogenital cord Dorsal mesentery Mullerian duct Metanephros Mesonephric (Wolffian) duct Lower gubernaculum Intestine

Midline

Page 8: 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)

Mullerian and Wolffian Duct Relationships

Page 9: 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)

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.

Page 10: 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)

Embryology-Questions

When does meiosis begin in the human male?

What hormone is responsible for regression of female internal genitalia?

What gene is responsible for male sexual differentiation?

What gene mutation should be examined in men with idiopathic ejaculatory duct obstruction?

How many testosterone peaks have occurred by the time a man reaches age 30?

Puberty

MIS

SRY, (SOX-9)

CFTR=cystic fibrosis trans- membrane regulatory gene

3-First trimester, neonatal and adult

Page 11: 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)

4 x 3 cm (20mL)

64 days

10 days

80%germ

cells 600 million sperm

10-15 lobules

Need 3 months to make and ejaculate sperm. Soft, small testes imply a sperm production problem

Rete testis

(cauda)

(corpus)

(caput)

Page 12: 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)
Page 13: 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)
Page 14: 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)
Page 15: 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)

Cremasteric artery!

Page 16: 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)

SERTOLI CELL

Page 17: 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)

Cycles- Production varies with time, same location

Waves-production varies in different locations

Page 18: 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)

Premature ejaculation Retrograde ejaculation Anejaculation

10% Prostate

10% Vas

deferens 80%

Seminal vesicle

Page 19: 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)
Page 20: 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)

The H-P-G Axis

Page 21: 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)
Page 22: 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)
Page 23: 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)
Page 24: 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)

PRL

Page 25: 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)

H-P-G Axis: Testosterone

Albumin bound 60%

SHBG bound 40%

Free/unbound 1-2%

• Testosterone comes in several forms. • Only free and albumin (weakly bound) are “active.” • SHBG-bound is inactive.

SHBG-T

Free T

Albumin-T

Total Testosterone Bioavailable

Testosterone

Page 26: 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)

Testosterone

Testosterone

Dihydrotestosterone

5- a -Reductase Vesicle Seminal

Penis Prostate Scrotum

Vas Deferens

Epididymis

Ejaculatory ducts

H-P-G Axis: Testis & Testosterone

External Internal

Page 27: 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)
Page 28: 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)
Page 29: 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)
Page 30: 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)

Likely Kallmann Syndrome: Anosmia, delayed puberty, azoospermia, small testes, micropenis.

DDx: Sickle cell disease, Hemochromatosis, Bardet-Biedl syndrome, Cerebellar ataxia, Prader-Willi syndrome

Page 31: 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)

Likely Klinefelter Syndrome: Delayed puberty, azoospermia, small testes, micropenis.

47, XXY

Page 32: 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)

Likely Prolactinoma (MRI pituitary to r/o macroadenoma)

Page 33: 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)
Page 34: 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)
Page 35: 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)

History Physical Exam

Semen Analysis x 2

Eliminate Gonadotoxins

Improved

Hormone Evaluation

Blood Semen

Imaging

Page 36: 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)
Page 37: 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)

400% Better!

Page 38: 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)

Clinical Male Infertility: Chemotherapy

Turek PJ. Fertility Preservat Males with Cancer, 2002

Agent!

Cisplatin!Cytoxan!

Adriamycin!Vinblastine!

Page 39: 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)
Page 40: 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)
Page 41: 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)

Vas deferens

Testis

Epididymis

Varicocele

Penis

Inguinal ring Physical

Examination

prostate

Body habitus

20 sex characteristics

Breast exam

Page 42: 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)
Page 43: 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)
Page 44: 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)

X

X

X

How to Approach

Varicocele Repair?

Page 45: 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)
Page 46: 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)

History Physical Exam

Semen Analysis x 2

Hormone Evaluation

Blood Semen

Imaging

Page 47: 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)
Page 48: 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)
Page 49: 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)

% Normal Kruger Morphology!

Page 50: 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)

Peroxidase stain

Page 51: 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)

+

-

-

FSH

T

G R H

Page 52: 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)
Page 53: 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)
Page 54: 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)
Page 55: 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)
Page 56: 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)
Page 57: 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)

History

Genetic Infertility is Subtle

Physical

Semen Analysis

Hormones

Other Tests

Clean!!

Small testes

Low or no sperm

Normal

Page 58: 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)
Page 59: 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)
Page 60: 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)

The CFTR Gene

Page 61: 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)
Page 62: 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)
Page 63: 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)
Page 64: 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)
Page 65: 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)
Page 66: 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)
Page 67: 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)
Page 68: 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)
Page 69: 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)
Page 70: 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)
Page 71: 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)
Page 72: 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)
Page 73: 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)

Rebuild ICSI

ICSI

1% all men; 5% infertile men

Bx

Page 74: 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)
Page 75: 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)
Page 76: 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)
Page 77: 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)
Page 78: 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)
Page 79: 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)
Page 80: 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)

Hemivasotomy

Page 81: 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)
Page 82: 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)
Page 83: 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)
Page 84: 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)

Outer!

Inner!

Page 85: 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)
Page 86: 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)
Page 87: 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)
Page 88: 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)
Page 89: 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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Page 91: 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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Page 93: 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)

Nonobstructive Azoospermia: How to Best Find Sperm?

Page 94: 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)
Page 95: 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)
Page 96: 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)

Good Luck!!


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wtmif;ausmif;om;ESifhvli,frsm;tpnf;t&rS xkwfa0onf? Augus 2012.pdf1 wtmif;ausmif;om;ESifhvli,frsm;tpnf;t&kH;rS xkwfa0onf? တခါမွမႀကံဳဖူးသည့္ေခ်ာင္းေရႀကီးမွဳ

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