AMC Clinical exam-recalls

Your next patient in general practice is a 28 old married man, Mr. Brown, who has been seen by another GP about one week ago because he and his wife have unsuccessfully tried to achieve a pregnancy for approximately 12 months. Your colleague organized a semen analysis and told the patient that all the details and possibilities would be discussed at the next consultation.
Mr. Brown returned today to get the result and appropriate advice.


Semen analysis:           volume:                    5mls (normal 2-6 mls)
                                     Concentration:         2 million sperm / ml (normal >20 million)
                                     Motility:                   20% (normal >50%)
                                     Normal forms:          5% (>20%)


Your task is to:
1. Take an appropriate history
2. Perform a physical examination
3. Explain your findings, possible diagnosis and advice to the patient
4. Answer any questions


History:
Mr. Brown and his wife have tried unsuccessfully for about 12 months to achieve a pregnancy. His wife’s physical examination and tests organized by her gynaecologist were all normal.
• Sexual function is normal
• He never had a problem with his testicles regarding infection (mumps orchitis / STD), trauma or congenital issues (cryptorchidism), no operations like hernia repair, no past or recent medical problems
• No contact with chemicals, pesticides etc.
• No alcohol, non smoker
• You are not on any medication and haven’t been for the last 6 months
• No use of ‘recreational’ drugs

EXAMINATION: (LOOK, LISTEN, FEEL !!!!):
Mr. Brown looks generally well, normal vital signs, no abnormal findings on P/E.
No gynaecomastia
TESTICLES:
About 3x4 cm or about 20 mls in volume, the consistency is firm, normal epididymis and spermatic cord, no other pathology.

DIAGNOSIS:
“ABNORMAL SEMEN SPECIMEN” — avoid the term ‘infertility’ at this stage!

ADVICE:
1. One specimen is not sufficient to make a definite diagnosis; one should have at least two separate samples about 3 to 6 weeks apart before one can consider the diagnosis of infertility.
2. Some specific blood tests can be helpful to make a diagnosis like serum follicle stimulating hormone (FSH), testosterone level, antisperm antibodies and sperm function tests
3. Currently there is no treatment available but options like in vitro fertilization (IVF), specifically intracytoplasmic sperm injection into the oocyte (ICSI) or donor sperm are available.

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Causes of male infertility:

Reduced sperm production
• Congenital cryptorchidism (maldescent)
• Inflammation, e.g. mumps orchitis

 Antispermatogenic agents
— Chemotherapy
— drugs
— Irradiation
— heat

• Idiopathic
• Klinefelter’s syndrome (46 XXY)

Hypothalamic pituitary disease
• Hypogonadotropic disorder

Disorders of coitus
• Erectile dysfunction
• Psychosexual ejaculatory failure

Retrograde ejaculatio
— Genitourinary surgery
— Autonomic disorders, e.g. diabetes
— Congenital abnormalities

Ductal obstruction

amc clinical exam