1. Questions

2. 1) Which hormones play a central role in regulation of Sertoli cell function?    a    LH, FSH    b    FSH, estradiol    c    Prolactin, LH    d    FSH, testosterone    e    ABP, testosterone

3. 1) Which hormones play a central role in regulation of Sertoli cell function?    a    LH, FSH    b    FSH, estradiol    c    Prolactin, LH    d    FSH, testosterone    e    ABP, testosterone

4. FSH and testosterone play the most important role in the regulation of Sertoli cell function, including androgen binding protein (ABP) production

5. 2) How do elevated levels of prolactin influence testosterone production?    a    Inhibit gonadotrophin-releasing hormone (GnRH) and LH    b    Indirectly inhibit Sertoli cells    c    Directly inhibit Leydig cells    d    Upregulate inhibin    e    Downregulate activin

6. 2) How do elevated levels of prolactin influence testosterone production?    a    Inhibit gonadotrophin-releasing hormone (GnRH) and LH    b    Indirectly inhibit Sertoli cells    c    Directly inhibit Leydig cells    d    Upregulate inhibin    e    Downregulate activin

7.     3) All the following are true statements regarding semen analysis EXCEPT:    a    Abstinence of 2 to 7 days before a semen analysis is optimal    b    Two separate samples at least 7 days apart should be analyzed    c    Coitus interruptus is an accurate and reliable method of obtaining semen    d    Only 50% of men will have a recognizable cause of infertility on the basis of the standard semen analysis    e    The most common cause of low-volume ejaculate is incomplete collection

8. 3)  All the following are true statements regarding semen analysis EXCEPT:    a    Abstinence of 2 to 7 days before a semen analysis is optimal    b    Two separate samples at least 7 days apart should be analyzed    c    Coitus interruptus is an accurate and reliable method of obtaining semen    d    Only 50% of men will have a recognizable cause of infertility on the basis of the standard semen analysis    e    The most common cause of low-volume ejaculate is incomplete collection

9. Coitus interruptus is an accurate and reliable method of obtaining semen Often the initial drops of ejaculate that are lost contain the largest concentration of spermatozoa

10. 4) Initial hormone evaluation in an infertile man with severe oligospermia includes:    a    testosterone and FSH    b    FSH and LH    c    FSH, LH, and prolactin    d    FSH and inhibin B    e    LH, prolactin, and free testosterone

11. 4) Initial hormone evaluation in an infertile man with severe oligospermia includes:    a    testosterone and FSH    b    FSH and LH    c    FSH, LH, and prolactin    d    FSH and inhibin B    e    LH, prolactin, and free testosterone

12. Although not universally agreed on, a reasonable progression of hormone analysis would be a morning testosterone and FSH, and if these were abnormal, one should repeat morning testosterone, LH, and prolactin (especially in low testosterone).

13. 5) Which of the following is TRUE regarding genetic testing in male infertility patients?    a    25% of all infertile males will have structural and numerical chromosomal abnormalities    b    Genetic testing with karyotype and Y-chromosome microdeletion is indicated for all patients with azoospermia or severe oligospermia    c    Y-chromosome microdeletion exists in 50% of patients with azoospermia    d    CFTR mutations are identified in only 10% of patients with congenital bilateral absence of vas deferens (CBAVD)    e    None are true

14. 5) Which of the following is TRUE regarding genetic testing in male infertility patients?    a    25% of all infertile males will have structural and numerical chromosomal abnormalities    b    Genetic testing with karyotype and Y-chromosome microdeletion is indicated for all patients with azoospermia or severe oligospermia    c    Y-chromosome microdeletion exists in 50% of patients with azoospermia    d    CFTR mutations are identified in only 10% of patients with congenital bilateral absence of vas deferens (CBAVD)    e    None are true

15. Genetic testing with karyotype and Y-chromosome microdeletion is indicated for all patients with azoospermia or severe oligospermia Genetic abnormalities are rare in men with infertility; however, 10% to 15% of azoospermic men will have a karyotype abnormality In addition, 10% to 15% of men with azoospermia or severe oligospermia may have microdeletions of the Y-chromosome in addition CFTR mutations are found in 80% of men with CBAVD.

16. 6) Which of the following is TRUE regarding ejaculatory duct obstruction (EJDO)?    a    Normal volume azoospermia is a common presentation for EJDO    b    EJDO will often present with low-volume azoospermia    c    Seminal vesicle width greater than 12 to 15 mm is suggestive of obstruction    d    In a patient with suspected EJDO, seminal pH will usually be around 8    e    If any sperm is found in seminal vesicle aspiration at the time of transrectal ultrasonography (TRUS), the diagnosis of EJDO is confirmed

17. 6) Which of the following is TRUE regarding ejaculatory duct obstruction (EJDO)?    a    Normal volume azoospermia is a common presentation for EJDO    b    EJDO will often present with low-volume azoospermia    c    Seminal vesicle width greater than 12 to 15 mm is suggestive of obstruction    d    In a patient with suspected EJDO, seminal pH will usually be around 8    e    If any sperm is found in seminal vesicle aspiration at the time of transrectal ultrasonography (TRUS), the diagnosis of EJDO is confirmed

18. EJDO will often present with low-volume azoospermia, with an acidic pH usually reflecting only prostatic secretions Occasional sperm may be present in seminal vesicles on men without EJDO, but findings of 3 or more sperm/HPF in the seminal vesicle usually indicate EJDO

19. 7) In the evaluation for vasectomy reversal, which clinical finding is suggestive of epididymal obstruction?    a    Varicocele    b    Hydrocele    c    Sperm granuloma    d    Normal serum follicle-stimulating hormone (FSH) level    e    Vasal gap larger than 2 cm

20. 7) In the evaluation for vasectomy reversal, which clinical finding is suggestive of epididymal obstruction?    a    Varicocele    b    Hydrocele    c    Sperm granuloma    d    Normal serum follicle-stimulating hormone (FSH) level    e    Vasal gap larger than 2 cm

21. The presence of a hydrocele in the presence of excurrent ductal system obstruction is often associated with secondary epididymal obstruction Surgeons attempting reconstruction should be aware of the possibility of the need for a vasoepididymostomy

22. 8) In which of the following scenarios is a testis biopsy least helpful?    a    Failure to retrieve motile sperm from the epididymis    b    Sperm retrieval for nonobstructive azoospermia    c    Diagnostic evaluation of men with congenital absence of vas and normal FSH levels    d    Diagnostic evaluation in azoospermic men with normal findings on scrotal examination and normal serum testosterone and FSH levels    e    Sperm retrieval for men diagnosed with Sertoli cell–only pattern in the testes

23. 8) In which of the following scenarios is a testis biopsy least helpful?    a    Failure to retrieve motile sperm from the epididymis    b    Sperm retrieval for nonobstructive azoospermia    c    Diagnostic evaluation of men with congenital absence of vas and normal FSH levels    d    Diagnostic evaluation in azoospermic men with normal findings on scrotal examination and normal serum testosterone and FSH levels    e    Sperm retrieval for men diagnosed with Sertoli cell–only pattern in the testes

24.  Diagnostic evaluation of men with congenital absence of vas and normal FSH levels
Testis biopsy is indicated in azoospermic men with testes of normal size and consistency, palpable vasa deferentia, and normal serum FSH levels
Under these circumstances, biopsy will distinguish obstructive azoospermia from primary seminiferous tubular failure
In the testes of men with congenital absence of vasa, biopsy always reveals normal or at least some spermatogenesis and biopsy is not necessary before definitive sperm aspiration and in-vitro fertilization (IVF) with ICSI

25. 9) All of the following situations are appropriate for assisted reproduction with ICSI as a first line of treatment EXCEPT:    a    obstruction with multiple failures of reconstruction    b    mild oligoasthenospermia with varicoceles and a female partner of 29 years of age    c    Klinefelter syndrome    d    only a few viable sperm found in the ejaculate    e    postchemotherapy azoospermia

26. 9) All of the following situations are appropriate for assisted reproduction with ICSI as a first line of treatment EXCEPT:    a    obstruction with multiple failures of reconstruction    b    mild oligoasthenospermia with varicoceles and a female partner of 29 years of age    c    Klinefelter syndrome    d    only a few viable sperm found in the ejaculate    e    postchemotherapy azoospermia

27. Mild oligoasthenospermia with varicoceles and a female partner of 29 years of age
Assisted reproduction can be offered to men with surgically unreconstructable obstruction such as congenital absence of the vas deferens; men with few viable sperm in the ejaculate; azoospermic men with varicoceles (half of these men will respond to varicocelectomy with return of enough sperm to ejaculate to achieve pregnancy using IVF with ICSI); and men with nonobstructive azoospermia.

28. 10) In which of the following scenarios would a diagnostic testicular biopsy provide valuable clinical information?    a    Men with azoospermia, atrophic testes, and an FSH level of 25 IU/L    b    Men with a 47 XXY karyotype    c    Men with a fecundity history who seek vasectomy reversal    d    Men with primary infertility, azoospermia, normal physical examination findings, and a normal serum FSH level    e    Men with anejaculation caused by high spinal cord injury

29. 10) In which of the following scenarios would a diagnostic testicular biopsy provide valuable clinical information?    a    Men with azoospermia, atrophic testes, and an FSH level of 25 IU/L    b    Men with a 47 XXY karyotype    c    Men with a fecundity history who seek vasectomy reversal    d    Men with primary infertility, azoospermia, normal physical examination findings, and a normal serum FSH level    e    Men with anejaculation caused by high spinal cord injury

30. Testis biopsy is indicated in azoospermic men with testis of normal size and consistency, palpable vasa deferentia, and normal serum FSH levels