Tips from an old
man of Kolkata – Tips to remember in male subfertility :- What mistakes we
commonly do?
1: What is % of men who
faces collection problems in IUI
-
10 % of men are
unable to give a semen sample
-
Some have never masturbated
-
Some are inhibited in the clinic
-
Some fail on demand
Failure to give a sample can be very embarrassing and
disheartening for a man and can produce long delays in treatment . To
avoid this problem always ask
whether a man can collect a sample when
advising a semen test . If the reports
difficulty in collecting semen instruct him to try collecting at
home using coitus interruptus . Special non
spermicidal condoms are also
available. Those who are still unable to
collect a sample will usually be able to
ejaculate when stimulated with a
vibrator .
Tips to
remember in male subfertility :2: Interpretation Problems-2 :-
Many
pathology laboratories still quote the old
norms misleading the doctor and making the couple
unnecessarily nervous.
It
is important to remember that semen analysis is only a rough predictor of fertility. Many men with
poor semen parameters will
father children while others with seemingly normal parameters will be infertile. So far as male
fertility is concerned the
duration of infertility should be considered in addition to the semen analyses. If the duration is
short then even with a low
count the chances of pregnancy are good
while if the duration of
infertility is long then even k with a
normal analysis the chances of
pregnancy are poor.
Time acts as a filter sorting
out the fertile from the sub fertile regardless of the semen
parameters Hence young couples
who have been trying only
for a short time should not rush into
advanced reproductive techniques.
Tips to remember in
male subfertility :-3:-Reassurance is very
important when the semen is sub normal because
the male ego is very threatened
by a poor semen report.
Tips
to remember in male subfertility :-4 Further
Evaluation when & how ?
Investigations
are needed only in some cases.
Hormone
assay: Not required in every case
-
If count > 5 mill/ ml FSH will be almost always
normal
-
If count < 5 mill/ ml
then FSH alone should be done
-
LH testosterone assay only if there is hypo androgenisation or ED
-
Prolactin assay only if there is ED.
Routine
USG when ? : Is not needed for
every case since a good clinical examination can detect the relevant findings . Since surgery
of subclinical varicoceles does not improve
the semen quality routine ultrasound to screen for a subclinical
varicocele is of no value.
USG
when ?? USG is mainly done to confirm the diagnosis of a clinical
varicocele when surgery is being
planned. USG of the scrotal contents is
also useful is very obese
men in whom clinical examination
is difficult.
Tips to
remember in male subfertility :-6 Sometimes simple advice can help a lot.
_ Advise correct timing of intercourse
-
Prescribe Sildenafil if man has situational Ed
-
Correct personal habits
-
Avoid sauna/steam
-
Regulars meals more salads fruits
-
Loose underwear
-
Therapy for stress relief
-
Reduce smoking alcohol
stop drugs
Tips to remember in
male subfertility :-7 :-What is not to be done ? Don’t offer necessary or harmful treatments which will
not yield any fruitful result, Such Tr should be avoided , Examples are Mistake : a) testosterone injections-à they may cause
suppression of spermatogenesis
through pituitary feedback
: Mistake : b) No medl
tr for azoo/ isolated sperm defects . Do not
waste time and money treating
azoospermia or isolated sperm
defects medically , better
counsel for surgery or ICSI as suggested by andrologist or ART
exoert..
-
Mistake : c) Do not give antibiotics for pus cells without confirming pyospermia by stained
smear examination. Mistake : d) There are confusions with pus cells with three
kinds of round cells some of which may be immature sperm cells : These 3 types
of round cells in the semen are 1) leucocytes
2) macrophages and 3) spermatocytes . We know that only leucocytes indicate
infection Mistake : e : by the
pathologist ) Most labs do not distinguish between these cell
types and erroneously label all round cells as
pus cells leading to a false diagnosis
of infection and unnecessary
antibiotic therapy .
Tips
to remember in male subfertility :-8 :-Hormone injections for hypogonadotropic hypogonadism-how useful-Rational ?
HMG and HCG injections mimic the action of natural
FSH and LH. In men with genuine hypogonadotropic hypogonadism i,e
documented that in a man with low density where hormone levels are well
below normal treatment with HCG followed
by HCG + HMG can induce spermatogenesis in an azoospermic main . However these injections are expensive and men with pituitary failure need therapy
for 1-2 years . Hence the cost
of complete therapy is very high
Before starting therapy ensure that the patient can spend
on the full course since stopping midway will be a waste
of all that he has spent In
our country the majority
of hypogonadotropic patients
cannot afford gonadotropin therapy. The value of empirical
gonadotropin therapy in men with normal hormone levels is unproven.
-
Varicocele :Few points which Gynae don’t exactly remember: but Old man of Kolkata does remember 1):-Varicocele affects 15% of all men
-
2) Many men with varicoceles
are fertile
-
3) A varicocele in an
infertile man may be coincidental
-
4) After varicocele
surgery only some men will
have improved semen
-
5) Some infertile men
with varicoceles may improve on medical
therapy alone
-
6)Hence not every
infertile man with a
varicocele needs surgery .
7) Microsurgical ligation is the preferred technique
-
Because artery and lymphatics can be preserved & moreover all
veins can be identified lower recurrence rate
Laparoscopic ligation of varicocele –how
useful?
-
No longer recommended
-
Higher recurrence rate
-
More invasive than the
open microsurgical approach
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