Laboratory Examination in Reproductive System Disorder

Dr Ati Rastini R.I., SpPK(K)

Disorders of Male Reproductive System

TESTES TESTOSTERON SPERM

ANDROGEN DEFICIENCY ISOLATED

ANDROGEN DEFICIENCY
Etiology : Primary hypogonadism testicular failure Secondary hypogonadism hypothalamicpituitary defects

Primary hypogonadism
Diagnose : Testosterone levels Gonadotropin levels (LH and FSH) are Etiology : Klinefelters syndrome most common Acquired primary testicular failure results from viral orchitis, trauma, cryptorchidism, radiation damage, systemic diseases (amyloidosis, Hodgkins disease, sickle cell disease). Toxins marijuana, alcohol, heroin, lead, antineoplastic, and chemotheurapeutic agents. Ketoconazole blocked testosterone synthetis. Competitive inhibition by spironolactone and cimetidine.

Secondary hypogonadism
Diagnose : Testosterone levels low Gonadotropin levels low (hypogonadotropic hypogonadism)

Etiology : Kallmanns syndrome : impairment of synthesis/release GnRH (gonadotropin releasing hormone) LH, FSH with/without anosmia Cushings syndrome, adrenal hypolpasia congenita, hemochromatosis, hyperprolactinemia

Clinical Feature
History focus on developmental stages such as puberty and growth spurts Physical examination should focus on secondary sex characteristics : hair growth in the face, axilla, chest, pubic region, gynaecomastia, testicular volume, prostate, height and body proportion. The presence of varicocele Morning total testosterone levels <6.93 nmol/L (<200 ng/dL), in association with symptoms, suggests testosterone deficiency. Levels >12.13 nmol/L (>350 ng/dL) makes the diagnosis of androgen deficiency unlikely.

Clinical Feature (cont)

Levels between 6.93 nmol/L and 12.13 nmol/L must be repeated and a free testosterone levels should be measured. Levels of LH and FSH can be used to differentiate between primary and secondary hypogonadism. Measurement of prolactin level and MRI scan of the hypothalamic-pituitary region should be considered in secondary hypogonadism

MALE INFERTILITY
Plays a role in 1/3 of infertile couples. Causes of male infertility : Primary hypogonadism (30 40%) Disorders of sperm transport (10 20%) Secondary hypogonadism (2%) Unknown etiology (50%) Impaired spermatogenesis occurs with testosterone deficiency but may also be present without testosterone deficiency.

Male Infertility (cont)

Isolated impaired spermatogenesis : Y chromosome microdeletions and substitutions Viral orchitis,Tuberculosis,STDs Radiation,Chemotherapeutic agent Environmental toxins Prolonged elevation of testicular temperature

Male Infertility (cont)

Ejaculatory obstruction : Congenital (cystic fibrosis, idiopathic) Acquired (vasectomy, accidental ligation, obstruction of the epididymis) Androgen abuse testicular atrophy and low sperm count

Male infertility (cont)

Clinical features : Evidence of hypogonadism may be present Testicular size and consistency may be abnormal, varicocele may be apparent on palpation Key diagnostic test : semen analysis sperm counts <13 million/mL, motility : <32%, and <9% normal morphology subfertility. If the sperm count is low on repeated exam , or if there is clinical evidence of hypogonadism, testosterone level should be measured.

Semen Collection
Sexual abstinence 3 4 days before specimen collection When performing fertility testing, 2 3 test performed with 2 weeks intervals Provide warm sterile glass or plastic container Inform the patient not to void into the container Avoid collecting semen in condom spermaticide Semen collected at home should be send immediately in room temperature within 1 hr Record the time specimen collected and receipt

Semen analysis
Examination : Appearance greyish white, translucent, with specific odor Liquefaction a fresh specimen liquify within 30 60 min after collection. Failure to liquify indicates deficient in prostatic enzyme Volume : 2 5 mL decreased volume associated with infertility Viscosity : refers to the consintency of the fluid increased viscosity and incomplete liquefaction will impede sperm motility

Semen analysis (cont)

pH : alkaline, 7.2 8.0. Increased pH indicative of infection. Decreased pH increased production of prostatic fluid Sperm count Normal count >20 million/mL or >40 million/ ejaculate (only developed sperm should be counted) !0 20 million/mL considered borderline Round cells : undeveloped sperm / WBC > 1 million/mL leukocytes indicates infection of reproductive organ that leads to infertility perform aerobic and anaerobic culture

Semen analysis (cont)

Spermatides >1 million/mL indicates spermatogenesis disruption usually caused by viral infection, exposure to toxic chemicals, and genetic disorders Sperm motility Capability of sperm cells to move forward is criticial for fertility. Motility is evaluated by both speed and direction. A minimum motility of 50% with 20% rating after 1hour is considered normal

SPERM MOTILITY GRADING GRADE WHO CRITERIA

4.0
3.0 2.0 1.0 0

a
b c d e

Rapid, straight motility

Slower speed, some lateral movements Slow forward progression, noticeable lateral movement No forward progression No movement

Semen analysis (cont)

Sperm morphology Evaluation of head, neck piece, mid piece and tail and their size, acrosomal cap and vacuolization The head represents the sperm cell itself with its enzyme-containing acrosomal cap Find abnormal heads : double head, giant head, pin head, tapered head and constricted head Abnormal tail : coiled, bend, doubled Long neck piece backward bending head

ADDITIONAL TEST FOR ABNORMAL SPERM ANALYSIS Abnormal Result Decreased motility with normal count Decreased count Decreased motility with clumping Possible Abnormality Viability Lack of seminal vesicle support medium Male antisperm antibodies Test Eosin-nigrosin stain Fructose level Mixed agglutination reaction Immunobead tests (Sperm agglutination with male serum) Sperm agglutination with female serum/cervical mucosa

Normal analysis with continued infertility

Female antisperm antibodies

NORMAL VALUE IN SEMEN ANALYSIS

VOLUME 2 5 mL

VISCOSITY
pH SEMEN CONCENTRATION SPERM COUNT MOTILITY

Pours in droplets
7.2 8.0 > 20 million/mL > 40 million/ejaculate > 50% in 1 hour

QUALITY
MORPHOLOGY ROUND CELLS

> 2 or a, b, c, according to sperm motility grading

14% normal forms (strict criteria) >30% normal forms (routine criteria) < 1 million/mL

HORMONAL REGULATION IN FEMALE REPRODUCTIVE SYSTEM

FSH LH

GRAAFIAN FOLLICLES

OESTROGENES

OESTRIOL PROGESTERON OESTROGENES

OVULATION

CORPUS LUTEUM

PITUITARY

Gn-RH

UTERUS hCG

HYPOTHALAMUS

Reverence Values of Pituitary Gonadotrophins and Female Sex Hormons in plasma

LH (u/L) Children Menstruating adults Follicular phase Mid-cycle peak 1 - 10 8 60 16 4 15 40 600 500 1600 <6 4 10 13 FSH (u/L) 13 Oestradiol-17 (pmol/L) 40 120 Progesteron (nmol/L) <6

Luteal phase Post menopause

2 14 > 15

15 > 20

280 1000 < 150

> 20 <6

DISORDERS OF THE FEMALE REPRODUCTIVE SYSTEM

The pituitary hormone : luteinizing hormone (LH), follicle stimulating hormone (FSH), stimulate ovarian follicular development and result in ovulation at about day 14 of the 28day menstrual cycle.

INFERTILITY
Definition : inability to conceive after 12 months of unprotected sexual intercourse.

Clinical features
Initial evaluation : Discussion of the appropriate timing of intercourse Documentation of tubal patency in the female Confirmation of ovulatory cycles : history of regularity of menses, urinary ovulation predictor kits, basal body t graphs, plasma progesterone measurements during the luteal phase. FSH level <10 IU/mL on day 3 of the cycle predicts adequate ovarian oocyte reserve.

Amenorrhoe
Due to primary (gonadal) secondary (pituitary)

Amenorrhoe (cont)
Basal tests Preliminary investigation : Plasma / urine [oestriol] Total urinary oestrogens Low value confirm gonadal failure but do not diferentiate the ovarial / pituitary site To confirm the site, need to measure plasma [FSH], [LH], urinary excretion of [FSH] and [LH], plasma prolactin, [oestradiol-17] and [progesterone]

Amenorrhoe (cont)
Gonadal failure due to gonads disease The ovaries fail to respond to endogenous gonadotrophin no progesteron nor oestrogens produced lack of feed back inhibition to pituitary and hypothalamus plasma [LH] and [FSH]

Amenorrhoe (cont)
Gonadal failure due to non gonadal causes Primary causes : hypothalamic or pituitary or both Plasma [LH] and [FSH] are low or normal-low while plasma oestradiol-17 and progesterone are low In Stein-Leventhal syndrome (polycystic ovary) primary pathological abnormality lies in the hypothalamus / pituitary. Plasma [LH] and [tertosterone] , plasma [oestrogens]

Amenorrhoe (cont)
Hyperprolactinemia happens in 20% of women with secondary amenorrhoe and ovulatory failure. Some have galactorrhoea

Suggested scheme for the use of endocrine tests in investigation of female subfertility
1. Plasma [progesterone] or 24 hr urinary pregnandiol excretion about the 21st day of menstrual cycle + basal temperature charts. 2. Plasma or urinary [oestrogens] low value confirms gonadal failure primary/secondary 3. Plasma [FSH]. = probably has primary ovarian failure. If normal / low proceed to 4) 4. Plasma [prolactin]. , confirm that she does not under stress / consuming oral conraceptives to perform thyroid function. If normal / low proceed to 5) 5. Dynamic tests. Using GnRH test, if subnormal due to pituitary failure secondary to hypothalamus disease.

Human Chorionic Gonadotropin (hCG)

Synthetized by placental syncytiotrophoblast Secreted into maternal circulation and excreted in maternal urine in very early stage of pregnancy Urinary hCG output peaks about 7th 10th weeks With LH like effect against corpus luteum to maintain steroids production hCG produced in other conditions, by trophoblastic tumors in male / female Male : testicular teratoma Female : hydatidiform mole and choriocarcinoma