Laboratory Examination in Reproductive System Disorders

DR.dr. TINNY RASJAD INDRA SpPK (K)

NORMAL PHYSIOLOGY

Hormonal regulation
Hormones synthesized by : Testis testosterone Ovary progesterone and estradiol Pituitary follicle stimulating hormone (FSH) luteinizing hormone (LH) Hypothalamus gonadottropin releasing hormone (GnRH) Placenta human chorionic gonadotropin (hCG) estrogens progesterone

Regulation of reproduction in male

LH Luteinizing hormone FSH Follicle-stimulating hormone GnRH Gonadotropin releasing hormone

Regulation of reproduction in male

Hypothalamus secretes GnRH binds to specific cell membrane receptor on gonadotroph in the anterior pituitary synthetize and secrete LH and FSH FSH induces Sertoli cells to synthetize and secrete androgen-binding protein maintains high testosterone concentration. LH induces Leydig cells to synthesize and secrete testosterone Testosterone is required for normal spermatogenesis and normal male growth, some transported to hypothalamus and anterior pituitary where it has a negative feedback effect.

Regulation of reproduction in female

Regulation of reproduction in female

Hypothalamus secretes GnRH binds to specific cell membrane receptor on gonadotroph in the anterior pituitary synthesize and secrete LH and FSH Regulatory process in female is cyclic menstrual cycle pituitary, ovarian and uterine changes occur during 28 days FSH regulating follicular phase of the ovarian cycle Growing follicle produces estradiol restores endometrium proliferative phase

Regulation of .. (cont)
Estradiol has a negative-feed back on hypothalamus and anterior pituitary Near the end of the follicular phase, feed back effect of estradiol switches to positive surge in GnRH, FSH and LH secretion ovulation Estradiol production drops Disrupted follicle differentiate into corpus luteum (luteal phase of the ovarian cycle) synthesize and secrete estradiol and progesterone cause development of endometrium (secretory phase of endometrium)

Regulation of .. (cont)
Infertile cycle : Corpus luteum regress estradiol and progesterone synthesis and secretion decrease endometrium shed during menstruation Hypothalamic and anterior pituitary negative feed back decrease FSH and LH are synthesized and secreted again to begin another cycle

Pregnancy
9 days after fertilization implantation trophoblasts synthesize hCG (human chorio gonadotropin, a LH like hormone) are found in maternal blood hCG prevents corpus luteum from regression estradiol and progesterone synthesis continues maintain uterine endometrium throughout pregnancy

Reproductive disorders

Overview
Male Infertility Benign Prostatic Hypertrophy Prostate Cancer Female Infertility Endometriosis Pelvic Inflammatory Disease Ovarian Cysts Cancer
Breast Cervical Uterine

BENIGN PROSTAT HYPERTROPHY (BPH)

Benign Prostatic Hypertrophy (BPH) Pathophysiology

Common in older men; varies from mild to severe Change is actually hyperplasia of prostate
Nodules form around urethra Result of imbalance between estrogen and testosterone

No connection w/ prostate cancer Rectal exams reveals enlarged gland Incomplete emptying of bladder leads to infections Continued obstruction leads to distended bladder, dilated ureters, renal damage
If significant, surgery required

Lab test : PSA (Prostat Specific antigen) normal/ increase 4 10 ng/ml (in 20% patients)

Prostate Cancer

Prostate CancerEtiology
Cause not determined
Genetic, environmental, hormonal factors

Common in North American and northern Europe Incidence higher in black population than white
Genetic factor?

Testosterone receptors found on cancer cells

Prostate CancerSigns and Symptoms

Hard nodule in periphery of gland
Detected by rectal exam

No early urethral obstruction

b/c of location As tumor develops, some obstruction occurs
Hesitancy, decreased stream, urinary frequency, bladder infection

Prostate CancerDiagnostic Tests

2 helpful serum markers
Prostate-specfic Antigen (PSA) > 10-40 ng/ml
Useful screening tool for early detection

Prostatic acid phosphatase (PAP)

elevated when metastatic cancer present

Ultrasound and biopsy confirms

Prostate CancerTreatment
Surgery and radiation Risk of impotence or incontinence When tumor androgen sensitive:
orchiectomy (removal of testes) or Antitestosterone drug therapy

5 yr survival rate is 85-90%

INFERTILITY

Infertility
The main reproduction problem a couple visits their physician is INFERTILITY
Definition : inability to conceive after 12 months of unprotected sexual intercourse.

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

Male Infertility
Can be solely male, solely female, or both Considered infertile after one year of unprotected intercourse fails to produce a pregnancy Male problems include
Changes is sperm or semen Hormonal abnormalities
Pituitary disorders or testicular problems

Physical obstruction of sperm passageways

Congenital or scar tissue from injury

Semen analysis
Assess specific characteristics
Number, motility, normality

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, hormone level should be measured.

Sperma analysis

NORMAL VALUE IN SEMEN ANALYSIS

VOLUME
VISCOSITY pH SEMEN CONCENTRATION SPERM COUNT MOTILITY QUALITY MORPHOLOGY ROUND CELLS

2 5 mL
Pours in droplets 7.2 8.0 > 20 million/mL > 40 million/ejaculate > 50% in 1 hour > 2 or a, b, c, according to sperm motility grading 14% normal forms (strict criteria) >30% normal forms (routine criteria) < 1 million/mL

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 (meneybabkan gangguan) 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 4.0 3.0 2.0 1.0 a b c d WHO CRITERIA 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 Possible Abnormality Viability Test Eosin-nigrosin stain

Decreased count
Decreased motility with clumping

Lack of seminal vesicle support medium

Male antisperm antibodies

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

ANDROGEN DEFICIENCY

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

Primary hypogonadism
Diagnose : Testosterone level 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 hypoplasiacongenita, hemochromatosis, hyperprolactinemia

Clinical Feature
History focus on developmental stages such as puberty and growth 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.

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

FEMALE REPRODUCTIVE SYSTEM DISORDER

HORMONAL REGULATION IN FEMALE REPRODUCTIVE SYSTEM

FSH LH GRAAFIAN FOLLICLES

OESTROGENES OVULATION CORPUS LUTEUM

OESTRIOL PROGESTERON OESTROGENES

PITUITARY

Gn-RH

UTERUS

HYPOTHALAMUS

hCG

Reverence Values of Pituitary Gonadotropins and Female Sex Hormones in plasma

LH (u/L) FSH (u/L) Oestradiol-17 (pmol/L) Progesteron (nmol/L)

Children Menstruating adults Follicular phase Mid-cycle peak Luteal phase Post menopause

13 1 - 10 8 60 2 14 > 15

13 16 4 15 15 > 20

40 120 40 600 500 1600 280 1000 < 150

<6 <6 4 10 > 20 <6

 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.

Female Infertility
Associated w/ hormonal imbalances
Result from altered function of hypothalamus, anterior pituitary, or ovaries Typically after long use of birth control pill

Structural abnormalities
Small or bicornuate uterus

Obstruction of fallopian tubes

Scar tissue or endometriosis

Access of viable sperm

Change in vaginal pH
Due to infection or douches

Excessively thick cervical mucus Development of antibodies in female to particular sperm

Smoking by male or female

Female Infertility
Broad range of tests avail
General health status checked 1st Pelvic examinations, ultrasound, CT scans check for structural abnormalities Tubal insufflation (gas/pressure measurement) or hysterosalpingogram (X-ray w/ contrast material) used to check tubes Blood tests throughout cycle to check hormone levels

Amenorrhoe
Due to primary (gonadal) secondary (pituitary)

Amenorrhoe (cont)
Basal tests Preliminary investigation : Plasma / urine [estriol] Total urinary estrogens 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

SELAMAT BELAJAR