Safety of Drugs in Male IBD Patients Wishing to Conceive
Safety of Drugs in Male IBD Patients Wishing to Conceive
The general evaluation of male infertility begins with a history and physical exam. In a patient with IBD, one should pay close attention to the disease history (years since diagnosis, number of flares, severity), including medical and surgical therapy. A detailed male reproductive history should be taken including coital frequency/timing, duration of infertility, incidence of prior fertility, childhood illness/developmental history, systemic medical illnesses, surgical history, sexual history, sexually transmitted disease (STD) history and gonadal toxin exposure including heat. A testicular exam should be performed to rule out anatomical causes of infertility (varicocele, absent vasa, absent testicle, pain, masses or deformities). Patients should undergo two semen analyses. In the case of an abnormal semen analysis, an endocrine evaluation should be undertaken, assessing serum FSH, LH, testosterone and prolactin. This also can be done earlier in the work-up if other signs of hypogonadism are identified. If the patient has an abnormal scrotal exam, a scrotal ultrasound should be obtained.
If the patient has a low ejaculatory volume (<1 mL) or no ejaculate, a post-ejaculatory urinalysis should be performed to look for the presence of sperm, indicating retrograde ejaculation. If the patient has a normal post-ejaculatory urinalysis, a transrectal ultrasound (TRUS) should be obtained to assess for ejaculatory duct patency.
Further testing may include semen white blood cell count (WBC), anti-sperm antibodies (Ab), post-coital cervical mucus, sperm penetration assay, genetic screening for cystic fibrosis transmembrane conductance regulator (CFTR) mutations, karyotype for chromosomal abnormalities, or Y-chromosome microdeletions. A diagnostic algorithm as listed below can serve as a guideline for practitioners in evaluating infertility in this patient population (Figure 1).
(Enlarge Image)
Figure 1.
Urological approach to evaluating and treating male patients with IBD experiencing infertility. Abnormal testicular exam includes palpable varicocele, absent vasa, absent testicle, pain, masses or deformities. Abnormal testicular ultrasound can include heterogenous testicular texture or tumour, atrophic testicle, varicocele, impaired blood flow, signs of infection, or torsion. Normal testicular ultrasound reveals appropriately sized, homogenous testicular texture and contour with normal Doppler flow without hydrocele or hernia. The World Health Organization (WHO) considers normal sperm parameters to include semen volume >1.5 mL, total sperm count >39 million per ejaculate, sperm concentration of >15 million per mL, total motility >40%, progressive motility >32%, vitality (% of live spermatozoa) >58% and >4% normal sperm morphology. Post-ejaculatory urinalysis is used as an aid in evaluating for retrograde ejaculation. If a significant proportion of the total sperm count is discovered in the post-ejaculatory urinalysis, further evaluation and treatment should be undertaken. IBD, inflammatory bowel disease; STD, sexually transmitted disease; FSH, follicle stimulating hormone; LH, luteinising hormone; WBC, white blood cells; Ab, antibodies.
The World Health Organization (WHO) considers normal sperm parameters to include semen volume >1.5 mL, total sperm count >39 million per ejaculate, sperm concentration of >15 million per mL, total motility >40%, progressive motility >32%, vitality (% of live spermatozoa) >58% and >4% normal sperm morphology.
Diagnosis of Infertility in Male IBD Patients
The general evaluation of male infertility begins with a history and physical exam. In a patient with IBD, one should pay close attention to the disease history (years since diagnosis, number of flares, severity), including medical and surgical therapy. A detailed male reproductive history should be taken including coital frequency/timing, duration of infertility, incidence of prior fertility, childhood illness/developmental history, systemic medical illnesses, surgical history, sexual history, sexually transmitted disease (STD) history and gonadal toxin exposure including heat. A testicular exam should be performed to rule out anatomical causes of infertility (varicocele, absent vasa, absent testicle, pain, masses or deformities). Patients should undergo two semen analyses. In the case of an abnormal semen analysis, an endocrine evaluation should be undertaken, assessing serum FSH, LH, testosterone and prolactin. This also can be done earlier in the work-up if other signs of hypogonadism are identified. If the patient has an abnormal scrotal exam, a scrotal ultrasound should be obtained.
If the patient has a low ejaculatory volume (<1 mL) or no ejaculate, a post-ejaculatory urinalysis should be performed to look for the presence of sperm, indicating retrograde ejaculation. If the patient has a normal post-ejaculatory urinalysis, a transrectal ultrasound (TRUS) should be obtained to assess for ejaculatory duct patency.
Further testing may include semen white blood cell count (WBC), anti-sperm antibodies (Ab), post-coital cervical mucus, sperm penetration assay, genetic screening for cystic fibrosis transmembrane conductance regulator (CFTR) mutations, karyotype for chromosomal abnormalities, or Y-chromosome microdeletions. A diagnostic algorithm as listed below can serve as a guideline for practitioners in evaluating infertility in this patient population (Figure 1).
(Enlarge Image)
Figure 1.
Urological approach to evaluating and treating male patients with IBD experiencing infertility. Abnormal testicular exam includes palpable varicocele, absent vasa, absent testicle, pain, masses or deformities. Abnormal testicular ultrasound can include heterogenous testicular texture or tumour, atrophic testicle, varicocele, impaired blood flow, signs of infection, or torsion. Normal testicular ultrasound reveals appropriately sized, homogenous testicular texture and contour with normal Doppler flow without hydrocele or hernia. The World Health Organization (WHO) considers normal sperm parameters to include semen volume >1.5 mL, total sperm count >39 million per ejaculate, sperm concentration of >15 million per mL, total motility >40%, progressive motility >32%, vitality (% of live spermatozoa) >58% and >4% normal sperm morphology. Post-ejaculatory urinalysis is used as an aid in evaluating for retrograde ejaculation. If a significant proportion of the total sperm count is discovered in the post-ejaculatory urinalysis, further evaluation and treatment should be undertaken. IBD, inflammatory bowel disease; STD, sexually transmitted disease; FSH, follicle stimulating hormone; LH, luteinising hormone; WBC, white blood cells; Ab, antibodies.
The World Health Organization (WHO) considers normal sperm parameters to include semen volume >1.5 mL, total sperm count >39 million per ejaculate, sperm concentration of >15 million per mL, total motility >40%, progressive motility >32%, vitality (% of live spermatozoa) >58% and >4% normal sperm morphology.
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