Male Infertility

MALE INFERTILITY

Q. 1

Male infertility occurs if the sperm count is less than :

 A

100 mill / ml

 B

75 mill / ml

 C

50 mill / ml

 D

20 mill / ml

Q. 1

Male infertility occurs if the sperm count is less than :

 A

100 mill / ml

 B

75 mill / ml

 C

50 mill / ml

 D

20 mill / ml

Ans. D

Explanation:

20 mill / ml


Q. 2 Infertility is a common feature in Sertoli cell only syndrome, because:
 A Too many Sertoli cells inhibit spermatogenesis via, inhibin
 B Proper blood testis barrier is not established
 C There is no germ cells in this condition
 D Sufficient numbers of spermatozoa are not produced
Q. 2 Infertility is a common feature in Sertoli cell only syndrome, because:
 A Too many Sertoli cells inhibit spermatogenesis via, inhibin
 B Proper blood testis barrier is not established
 C There is no germ cells in this condition
 D Sufficient numbers of spermatozoa are not produced
Ans. C

Explanation:

The absence of germ cell (Sertoli Cell-only syndrome) causes infertility. The main characteristic of Sertoli Cell, syndrome consists of testicular tubes that show a moderate decrease in diameter and are void of germ cells. Also the testes decrease in size and are azoospermia.


Q. 3

Semen analysis of a young man who presented with primary infertility revealed low volume, fructose negative ejaculate with azoospermia. Which of the following is the most useful imaging modality to evaluate the cause of his infertility?

 A

Spermatic venography

 B

Retrograde urethrography

 C

Transrectal ultrasonography

 D

Colour duplex ultrasonography of the scrotum

Q. 3

Semen analysis of a young man who presented with primary infertility revealed low volume, fructose negative ejaculate with azoospermia. Which of the following is the most useful imaging modality to evaluate the cause of his infertility?

 A

Spermatic venography

 B

Retrograde urethrography

 C

Transrectal ultrasonography

 D

Colour duplex ultrasonography of the scrotum

Ans. C

Explanation:

Clinical diagnosis of ejaculatory duct obstruction is based on a triad of small ejaculate volume, azoospermia and absence of seminal fructose.

This condition is distinguished from congenital bilateral absence of the vas deferens by the presence of a palpable vas deferens on examination.

Transrectal ultrasound and seminal vesicle aspiration are investigations which help in confirmation of the  diagnosis. Transrectal ultrasound helps in the evaluation of seminal vesicles, ejaculatory ducts and prostate gland abnormalities.

Ref: Manual of Assisted Reproductive Technologies and Clinical Embryology By Pankaj Talwar, Page 825; Male Infertility: Problems and Solutions By Edmund S. Sabanegh, Pages 27-29; Male Reproductive Dysfunction By S. C. Basu, 2nd Edition, Page 310.


Q. 4

A 30-year-old man consults a gynecologist for the cause of his infertility. On questioning, he informs the doctor that he never suffered from any major illness in the past and also got married 5 years back. However, his physical examination reveals failure of testes to descend down in the scrotum. The semen analysis shows absence of spermatozoa. The blood lab report shows plasma gonadotrophins, 12 Ru/24 hrs; Plasma testosterone, 7 ug/l and semen 2 ml. The factor responsible for the absence of spermatozoa in this patient is?

 A

Degeneration of the epithelium of seminiferous tubules

 B

Decreased secretion of gonadotrophins

 C

Decreased concentration of testosterone

 D

Hypofunctioning of the pituitary gland

Q. 4

A 30-year-old man consults a gynecologist for the cause of his infertility. On questioning, he informs the doctor that he never suffered from any major illness in the past and also got married 5 years back. However, his physical examination reveals failure of testes to descend down in the scrotum. The semen analysis shows absence of spermatozoa. The blood lab report shows plasma gonadotrophins, 12 Ru/24 hrs; Plasma testosterone, 7 ug/l and semen 2 ml. The factor responsible for the absence of spermatozoa in this patient is?

 A

Degeneration of the epithelium of seminiferous tubules

 B

Decreased secretion of gonadotrophins

 C

Decreased concentration of testosterone

 D

Hypofunctioning of the pituitary gland

Ans. A

Explanation:

Primary infertility affects 15-20% of married couples.
Apart from case history and physical examination, endocrine profile and semen analysis are essential to disclose the underlying cause.
The testes have two distinct but related functions, both of which are under adenohypophyseal and hypothalamic control.
The first one is the production and storage of viable spermatozoa, and the second one is the synthesis and secretion of androgenic hormones.
Various factors that can induce sterility in men are: trauma, infections like mumps, environmental factors like excessive heat, medications, and drugs.

Because of the failure of testes to descend into the scrotum, seminiferous tubules remain infantile in structure and due to greater temperature of the inguinal canal, they degenerate. However, the secondary sexual characteristics are not affected. 

 
Ref: Hoffman B.L., Schorge J.O., Schaffer J.I., Halvorson L.M., Bradshaw K.D., Cunningham F.G., Calver L.E. (2012). Chapter 20. Treatment of the Infertile Couple. In B.L. Hoffman, J.O. Schorge, J.I. Schaffer, L.M. Halvorson, K.D. Bradshaw, F.G. Cunningham, L.E. Calver (Eds), Williams Gynecology, 2e. 

Q. 5

A couple presents to a clinic for work-up of infertility after 5 years of unprotected intercourse. The wife denies any medical problems and notes regular menstrual cycles. The husband states that he has had chronic sinusitis and lower respiratory tract infections. Physical examination of the woman is unremarkable. Examination of the man is remarkable for dextrocardia. Further work-up of the husband will most likely reveal?

 A

Azoospermia

 B

Germinal cell aplasia

 C

Immotile sperm

 D

Isolated gonadotropin deficiency

Q. 5

A couple presents to a clinic for work-up of infertility after 5 years of unprotected intercourse. The wife denies any medical problems and notes regular menstrual cycles. The husband states that he has had chronic sinusitis and lower respiratory tract infections. Physical examination of the woman is unremarkable. Examination of the man is remarkable for dextrocardia. Further work-up of the husband will most likely reveal?

 A

Azoospermia

 B

Germinal cell aplasia

 C

Immotile sperm

 D

Isolated gonadotropin deficiency

Ans. C

Explanation:

The husband is suffering from Kartagener’s syndrome, an autosomal recessive disorder characterized by infertility, situs inversus, chronic sinusitis, and bronchiectasis.

The underlying cause of these varied manifestations are defects in the dynein arms, spokes of microtubule doublets of cilia in the airways and the reproductive tract.

Since sperm motility is dependent on the functioning of cilia, infertility frequently accompanies this disorder.

Situs inversus occurs because ciliary function is necessary for cell migration during embryonic development.

Azoospermia is not a feature of Kartagener’s syndrome, as sperm production or survival is not affected in this disorder.

Germinal cell aplasia, also known as Sertoli only syndrome, is characterized by oligospermia or azoospermia.

Isolated gonadotropin deficiency is characterized by delayed or incomplete pubertal maturation.

Ref: Federico M.J., Stillwell P., Deterding R.R., Baker C.D., Balasubramaniam V., Zemanick E.T., Sagel S.D., Halbower A., Burg C.J., Kerby G.S. (2012). Chapter 19. Respiratory Tract & Mediastinum. In W.W. Hay, Jr., M.J. Levin, R.R. Deterding, J.J. Ross, J.M. Sondheimer (Eds), CURRENT Diagnosis & Treatment: Pediatrics, 21e.


Q. 6

A 46-year-old chronic alcohilic complains of infertility. What is the cause of testicular atropy ?

 A

Liver dysfunction

 B

Thrombosis of testicular vessels

 C

Vitamin B12 deficiency

 D

Peripheral neuropathy

Q. 6

A 46-year-old chronic alcohilic complains of infertility. What is the cause of testicular atropy ?

 A

Liver dysfunction

 B

Thrombosis of testicular vessels

 C

Vitamin B12 deficiency

 D

Peripheral neuropathy

Ans. A

Explanation:

Liver dysfunction causes increased estrogen and decreased testosterone leading to testicular atropy.


Q. 7

Kartagener’s syndrome includes –

 A

Situs inversus

 B

Bronchiectasis Sinusitis

 C

Male infertility

 D

All

Q. 7

Kartagener’s syndrome includes –

 A

Situs inversus

 B

Bronchiectasis Sinusitis

 C

Male infertility

 D

All

Ans. D

Explanation:

Ans. is ‘a’ i.e., Situs inversus; ‘b’ Bronchiectasis, Sinusitis’ `c’ Male infertility

o Kartagener’s syndrome is a subgroup of primary ciliary dyskinesia. [Ref Bobbin’s r/e p. 692 & 71h/e p. 727] Primary ciliary dyskinesia ‑

o It is an antosomal recessive syndrome.

o It is characterized by poorly functioning cilia. There is absence or shortening of Dynein arms that are responsible for the coordinated bending of cilia.

o Approximately half of the patients with primary ciliary dyskinesia have kartagener’s syndrome.

Kartagener’s syndrome

Poor functioning of cilia contribute to retention of secretions and recurrent infections

Sinusitis              –>

Lack of ciliary activity interferes with bacterial clearance, predisposing sinuses to infection

 Situs inversus       —>       Due to ineffective cell motility during embryogenesis

Infertility                           Due to ineffective mobility of sperm


Q. 8

A 25 year old married male presents with infertility. He had undergone retroperitoneal lymphnode disection at age of 15 years for embryonal carcinoma of right testis. Semen analysis shows-quantity-0.5 ml, no. sperm, no fructose. Biopsy of testis shows normal spermato genesis. Best treatment here would be ‑

 A

Artificial insemination of donor

 B

Penile-prosthesis

 C

Microtesticular aspiration and intracyto plasmic injection

 D

None of the above

Q. 8

A 25 year old married male presents with infertility. He had undergone retroperitoneal lymphnode disection at age of 15 years for embryonal carcinoma of right testis. Semen analysis shows-quantity-0.5 ml, no. sperm, no fructose. Biopsy of testis shows normal spermato genesis. Best treatment here would be ‑

 A

Artificial insemination of donor

 B

Penile-prosthesis

 C

Microtesticular aspiration and intracyto plasmic injection

 D

None of the above

Ans. C

Explanation:

Ans. is ‘c’ i.e., Microtesticular Aspiration and intra-cytoplasmic injection

  • Absence of sperms in presence of normal spermatogenesis along with absence of fructose is suggestive of an obstruction in the ejaculatory duct (as described in previous chapter – Prostate & seminal vesicles)
  • “Sperm aspiration techniques are indicated in men in whom the transport of sperm is not possible because the ductal system is absent or surgically unreconstructable. Aspiration procedures can involve microsurgery to collect sperm from the sperm reservoirs within the genital tract (vas deferens, epididymis or testicle)” – Smith’s Urology 17/e, p 710
  • Microtesticular aspiration of sperm with In Vitro Fertilization can help this couple to achieve pregnancy. (Intracytoplasmic injection is a form of IVF)

Q. 9

Most common cause of surgically treatable male infertility is –

 A

Varicocele

 B

Cryptorchidism

 C

Stricture urethra

 D

Epidydimitis

Q. 9

Most common cause of surgically treatable male infertility is –

 A

Varicocele

 B

Cryptorchidism

 C

Stricture urethra

 D

Epidydimitis

Ans. A

Explanation:

Ans. is ‘a’ i.e., Varicocele 


Q. 10

A couple presents with infertility. On investigation, the husband is found to have azoospermia on semen analysis. Vas was not palpable on per rectal examination. Semen had low volume, high viscosity and fructose was present. What will you do next?

 A

Karyotype

 B

PSA

 C

Trans-rectal ultrasound

 D

CFTR gene mutation analysis

Q. 10

A couple presents with infertility. On investigation, the husband is found to have azoospermia on semen analysis. Vas was not palpable on per rectal examination. Semen had low volume, high viscosity and fructose was present. What will you do next?

 A

Karyotype

 B

PSA

 C

Trans-rectal ultrasound

 D

CFTR gene mutation analysis

Ans. D

Explanation:

Ans. d. CFTR gene mutation analysis


Q. 11

If the life style factor that is causing infertility in a young male is identified. Which of the following life style modification will have no effect?

 A

Weight gain

 B

Less exercise

 C

Vegetarian diet

 D

Weight loss

Q. 11

If the life style factor that is causing infertility in a young male is identified. Which of the following life style modification will have no effect?

 A

Weight gain

 B

Less exercise

 C

Vegetarian diet

 D

Weight loss

Ans. C

Explanation:

Ans. c. Vegetarian diet

Vegetarian diet will have minimal or no effect on fertility.                                                                                      1

‘Weight definitely matters when it comes to fertility. Women who are overweight – or underweight – tend to have a more difficult time conceiving. The same goes for men, but more about that later.’- http //www early-pregnancy-tests com/ weight-fertility html

‘Exercise can affect fertility in several ways. Over-exercising is one of the bigger causes of infertility for women. If a woman exercises too much, she is at a risk of losing too much of her body fat. Body fat plays an essential role in the production of estrogen; without enough estrogen, a woman who over-exercises might not ovulate. The technical term for not ovulating is oligomenorrhea, and is a major cause of fertility problems. Women who don’t get enough exercise can impact their fertility negatively as well. By not getting enough exercise, a woman runs the risk of becoming overweight or obese. An overweight or obese woman, because she has more fat cells, can actually have too much estrogen. This overproduction of estrogen can negatively impact ovulation and conception. In addition, being overweight puts you at risk for insulin resistance, which can ultimately keep you from ovulating. http://wwwbabyhopes.com/articles/exercise-fertility.html


Q. 12

Identify this testicular pathology causing male infertility :(Left image is normal ,shown for comparison).

 

 A

Cryptorchidism

 B

Agonadism

 C

Mumps orchitis

 D

Maturation arrest

Q. 12

Identify this testicular pathology causing male infertility :(Left image is normal ,shown for comparison).

 

 A

Cryptorchidism

 B

Agonadism

 C

Mumps orchitis

 D

Maturation arrest

Ans. A

Explanation:

Ans:A.)Cryptorchidism.

Image shows: Microscopic appearance of normal testis (A) contrasted with that of cryptorchid testis (B).

Cryptorchidism

  • Cryptorchidism or undescended testis is a condition in which the testicle is arrested at some point along its descent.
  • Its incidence is about 0.2% in adult male population.
  • In 70% of cases, the undescended testis lies in the inguinal ring, in 25% in the abdomen and, in the remaining 5%, it may be present at other sites along its descent from intra-abdominal location
  • to the scrotal sac.

MORPHOLOGIC FEATURES.

  • Cryptorchidism is unilateral in 80% cases and bilateral in the rest.
  • Grossly, the cryptorchid testis is small in size, firm and fibrotic.
  • Histologically, contrary to previous beliefs, the changes of atrophy begin to appear by about 2 years of age. These changes are as under :
  • 1. Seminiferous tubules: There is progressive loss of germ cell elements so that the tubules may be lined by only spermatogonia and spermatids but foci of spermatogenesis are discernible in 10% of cases.
    • The tubular basement membrane is thickened.
    • Advanced cases show hyalinised tubules with a few Sertoli cells only, surrounded by prominent basement membrane.
  • 2. Interstitial stroma: There is usually increase in the interstitial fibrovascular stroma and conspicuous presence of Leydig cells, seen singly or in small clusters.

Q. 13

A 35 year old male seeks an evaluation for infertility after failed attempts at conception. He also reports scrotal heaviness. On examination,following is seen.What are the indications of surgery in this condition?

 A

Pain

 B

Small testis

 C

Oligospermia

 D

All of the above

Q. 13

A 35 year old male seeks an evaluation for infertility after failed attempts at conception. He also reports scrotal heaviness. On examination,following is seen.What are the indications of surgery in this condition?

 A

Pain

 B

Small testis

 C

Oligospermia

 D

All of the above

Ans. D

Explanation:

Ans:D.)All of the above.

VARICOCELE

  • A varicocele is a dilatation of the pampiniform venous plexus and the internal spermatic vein.
  • Varicoceles are much more common (approximately 80-90%) in the left testicle than in the right because of several anatomic factors, including the following:
  • The angle at which the left testicular vein enters the left renal vein
  • The lack of effective antireflux valves at the juncture of the testicular vein and renal vein
  • The increased renal vein pressure due to its compression between the superior mesenteric artery and the aorta.
  • A patient with a varicocele is usually asymptomatic and often seeks an evaluation for infertility after failed attempts at conception. He may also report scrotal pain or heaviness. Careful physical examination remains the primary method of varicocele detection. An obvious varicocele is often described as feeling like a bag of worms.
  • Reasons for surgical correction of a diagnosed variocele include relieving significant testicular discomfort or pain not responsive to routine symptomatic treatment, reducing testicular atrophy (volume


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