Instructions
You are a medical student on placement in general practice. Sanjay Menon, 33, a truck driver, and his partner Meera, 31, have been trying for a baby for two years. The GP has asked you to review his results before the couple come back in.
Interpret the results provided
Outline to the examiner:
- Your findings
- Your most likely diagnosis and differentials
- You do not need to take a history or examine the patient
- Mr Menon is in the waiting room; you will speak to the examiner
- The examiner will ask you questions at the end
GP notes, three months ago
Trying to conceive for 2 years; intercourse 2 to 3 times a week. Normal erections and ejaculation; libido a bit low and often tired. Shaves about once a week. Needed learning support for reading at school. No previous pregnancy with any partner.
GP notes: past and social history
No undescended testes, mumps, testicular injury or surgery, hernia repair or sexually transmitted infection. No chemotherapy or radiotherapy. Never used testosterone, anabolic steroids or supplements. Non-smoker; about 6 standard drinks a week; no recreational drugs.
GP examination, three months ago
Height 189 cm, arm span 196 cm, weight 84 kg, BMI 23.5. Sparse facial, chest and pubic hair. Mild gynaecomastia on both sides. Testes about 4 mL each on the orchidometer, firm and non-tender; no masses. Vas deferens palpable on both sides; epididymes normal; no varicocele.
Partner's tests (Meera, 31)
Regular 28-day cycles. Day 21 progesterone 42 nmol/L (ovulation confirmed). AMH 22 pmol/L (normal for age). Both tubes open on a tubal patency ultrasound. Rubella immune; cervical screening up to date.
Semen analysis (two samples, 8 weeks apart)
Abstinence 3 and 4 days (2-7). Both collections complete; at the laboratory within 1 hour. Volume 2.9 and 3.2 mL (1.4 or more). pH 7.6 and 7.7 (7.2 or more). Peroxidase-positive leucocytes 0.2 million/mL (under 1.0).
Semen analysis: sperm (both samples)
Sperm concentration 0 million/mL in both samples (16 or more). Centrifuged pellet: no sperm seen in either sample. Motility, morphology and vitality: not assessable.
Hormones (8.30 am, fasting)
FSH 38 IU/L (1.5-12.4); LH 21 IU/L (1.7-8.6); total testosterone 7.8 nmol/L (8.6-29.0); prolactin 190 mIU/L (86-324)
Semen analysis (two samples, 8 weeks apart)
| Item | Value | Reference range |
|---|---|---|
| Abstinence before collection | 3 days and 4 days | 2-7 days |
| Collection | Complete; reached the laboratory within 1 hour (both samples) | - |
| Volume | 2.9 mL and 3.2 mL | >=1.4 mL |
| pH | 7.6 and 7.7 | >=7.2 |
| Sperm concentration | 0 million/mL (both samples) | >=16 million/mL |
| Centrifuged pellet | No sperm seen (both samples) | - |
| Motility, morphology and vitality | Not assessable | - |
| Peroxidase-positive leucocytes | 0.2 million/mL | <1.0 million/mL |
Hormones (8.30 am, fasting)
| Item | Value | Reference range |
|---|---|---|
| FSH | 38 IU/L | 1.5-12.4 IU/L |
| LH | 21 IU/L | 1.7-8.6 IU/L |
| Total testosterone | 7.8 nmol/L | 8.6-29.0 nmol/L |
| Prolactin | 190 mIU/L | 86-324 mIU/L |