Diagnostic and Therapeutic Andrology

Module details

Title

Diagnostic and Therapeutic Andrology

Type

Specialist

Module code

SLS323

Credits

10

Requirement

Compulsory

Aim of this module

This module will provide the trainees with knowledge and understanding of diagnostic andrology and the process of fertilisation. They will understand and gain experience of insemination methodologies and reporting outcomes from insemination/fertilisation. They will also consider the impact of male infertility on individuals, relationships and society gaining insight into support services available and the importance of providing compassionate, patient-centred care. The impact of culture, equality and diversity on practice will be explored.

Competencies

#	Learning outcome	Competency	Action
# 1	Learning outcome 1,4, 5, 6	Competency Identify macroscopically the different types of potential disease using a range of semen samples: ejaculatory dysfunction accessory gland dysfunction infection/inflammation	Action View
# 2	Learning outcome 1,4	Competency Using freshly ejaculated samples perform manual assessment of human semen according to or exceeding the requirements.	Action View
# 3	Learning outcome 1,2,4	Competency Using fresh ejaculates and pre- recorded video data, perform assessment of human sperm motility that accords to local IQA/EQA data.	Action View
# 4	Learning outcome 1,3,4	Competency Identify markers of normal sperm morphology and Live/Dead cells using representative prepared specimens from a range of ejaculates.	Action View
# 5	Learning outcome 1,4	Competency Perform scoring of sperm morphology according to the Teratozoospermia Index (TZI) system.	Action View
# 6	Learning outcome 1,4,6	Competency Identify the presence and where possible mechanisms of transmission and clinical manifestations of both acute and chronic infections.	Action View
# 7	Learning outcome 3,5,6	Competency Interpret analytical findings in the correct clinical context and considering the current literature and discuss your interpretation with a senior colleague(s).	Action View
# 8	Learning outcome 6	Competency Work, where appropriate, in partnership with service users.	Action View
# 9	Learning outcome 6	Competency Work, where appropriate, in partnership with colleagues.	Action View

Assessments

You must complete:

• 2 case-based discussion(s)
• 2 of the following DOPS/ OCEs:

Discuss provision of a diagnostic semen sample with a patient including requirements before and receipt of the sample. Reflect upon the patient experience and helpful strategies to improve this.	OCE
Perform all aspects of a basic semen analysis according to ESHRE / WHO guidelines including morphology by TZI.	DOPS
Perform a laboratory diagnostic for antisperm antibodies	DOPS
Correctly identify the support services available to a male patient / couple for infertility, both locally and Nationally.	DOPS
Perform and prepare a preliminary report on a post vasectomy semen analysis, recognizing the accuracy of the result and potential for adverse outcome.	DOPS
Perform IQC / EQA / Inter-Operator assessment of samples and benchmark your results within the scheme. Discuss potential actions.	DOPS
Perform an audit on a process within the laboratory Quality Management Scheme	DOPS
Prepare a testicular biopsy specimen through all steps to and including pathological (histological) examination	DOPS
Discuss the impact of male infertility on the individual and the couple	OCE
Present a case in partnership with someone from another clinical specialism as part of the diagnosis and review process	OCE
Observe a medical / surgical intervention on a male patient aimed at affecting male fertility, evaluate how this links to this diagnostic pathway.	OCE

Learning outcomes

1. Recognise and interpret the macroscopic and microscopic appearance of semen, and relate to any pathological process determining the potential implications for conception or child-health.
2. Advise on and appropriately request additional tests to aid in diagnosis, or implications of observed disease exercising their own professional judgement.
3. Recognise and diagnose the success or failure of male contraceptive interventions in microscopic specimens, including but not necessarily  limited to post-vasectomy semen analysis.
4. Recognise and interpret the effects of medical intervention upon semen properties (including but not limited to clearance of pathological organisms; success of vasectomy reversal; recovery from chemo- or radiotherapeutic intervention)
5. Prepare preliminary reports based on using interpretive and diagnostic skills under supervision.
6. Work in partnership with other clinical specialisms as part of the systematic diagnosis and review of individual cases.

Learning outcomes

1. Explain spermatogenesis, spermiogenesis, maturation and ejaculation and discuss the importance of assessed macroscopic and microscopic parameters.
2. Explain how anti-sperm antibodies form, their relevance and methods of diagnosis.
3. Explain where white blood cells in semen may originate from, potential causes and effects.
4. Explain the natural journey of the sperm from ejaculation to oocyte contact.
5. Explain oogenesis and oocyte maturation and discuss the cellular and molecular basis of fertilisation.
6. Evaluate techniques for gamete preparation and handling.
7. Describe methods of insemination and the identification of normal and abnormally fertilised oocytes.
8. Discuss the impact of male infertility on individuals and relationships and the support services available.
9. Discuss the impact of male fertility on the individual and society.
10. Critically evaluate the role of the multi-disciplinary team with respect to infertility and the importance of effective communication.

Indicative content

Macroscopic and Microscopic Parameters of Semen

The diagnostic/prognostic value of semen analysis including the validity reproducibility, reliability and limitations of testing procedures.

 Macroscopic

• Appearance
• Volume
• Liquefaction
• Viscosity
• pH
• Biochemical measurements (including Zinc and Fructose)

 Microscopic parameters

• Motility
• Concentration
• Morphology (including different staining and scoring methods)

 White blood cells or anti-sperm antibodies

• Methods of assessment
• Relevance
• Observed infections in semen

 From ejaculation to oocyte contact

• Capacitation
• Hyper-motility

 Advanced Markers of Sperm Function

• When and why non-standard semen analysis tests are performed and the clinical relevance (if any).
• Methods available to assess sperm DNA damage; what is actually measured and the clinical data supporting these tests and how cross- comparable data may or may not
• Oxidative
• Acrosome
• Nuclear matrix assessment and
• Hyaluronate
• Ejaculate component mix (prostatic:seminal vesicles).
• Electron
• Mouse-Oocyte Activation Assays (with reference to UK legal regulation).
• Other advanced assays of motility, cell surface or biological properties as relevant.
• Limitations and uncertainty associated with non-standard semen analysis.

 Oogenesis and oocyte maturation/cellular and molecular basis of fertilisation

• Endocrine control over male fertility
• Developmental and genetic control of spermatogenesis and spermiogenesis, including cytology of meiosis
• Physiology of mature sperm
• Acrosome reaction
• Sperm capacitation and zona pellucida binding, including structure and properties of the zona
• Follicle growth in the human ovary
• Oocyte growth and maturation, including genetic and cellular regulation of meiosis
• Cellular and molecular basis of fertilisation including the role for sperm structures (e.g. aster formation).
• Pronuclear formation, including completion of meiosis II
• Normal, failed and abnormal fertilisation (polyspermy, ploidy errors and parthenogenesis), theories of origin and implications for patient treatment
• Syngamy and first cell division

 Gamete procurement, preparation and handling

• Sperm procurement: antegrade and retrograde, patient compliance, identity checks,
• Non-surgical options for sample procurement with particular reference to spinal-cord injury (including but not limited to vibratory stimulation and electroejaculation).
• Surgical sperm retrieval
• Laboratory skills, culture media options and aseptic technique for semen preparation and oocyte collection and handling
• Emerging advanced sperm-preparation methods including Electrophoretic, hyaluronate binding and Magnetic Cell Sorting technologies and the evidence for their

 Methods of Insemination

• Insemination methods
• Risks of loss of viability associated with the handling of gametes and relevant control measures
• Reporting outcomes from insemination/fertilisation

 Impact of male infertility

• Financial impacts of male fertility on the individual / couple and society
• Psychological impacts of male infertility on the individual
• Coping strategies and how differing individuals may react and potential roles for counselling in this
• Breaking and managing bad news
• Impact of culture, equality and diversity on practice

 Multi-Disciplinary Team (MDT)/Communication

• Working with Medical and AHP colleagues for the patient
• Working with Medical & AHP colleagues to support each other
• Troubleshooting as a team
• Management of records and all other information in accordance with applicable legislation, protocols and guidelines.

Activities

• Review prepared microscope slides with your supervisor and draft a diagnosis, taking into account all relevant clinical details, and the macroscopical and microscopical appearances of the semen.
• Double-headed microscopical slide / on screen video review – Working directly with an Andrologist to perform light microscopy studies on specimens from a range of clinical referrals. Use of a two binocular heads or ‘on-screen’ review might help. In each case identify key features and agree how these may be incorporated into a report prepared in the correct clinical context.
• Assess multiple archive IQC / EQA samples (videos and stained slides) and compare to pre-established results. Using fresh samples, perform assessments and compare against an experienced staff member in the laboratory.
• Attend multidisciplinary team meetings and participate in multidisciplinary review meetings at which results are presented as part of the clinical record. Prepare a portfolio of cases to illustrate how key findings influenced diagnosis and patient management and discuss these with your supervisor
• Prepare an evidence-based report listing the strengths and limitations of the investigative techniques used in named clinical conditions and present this to colleagues.
• Attend clinics and ward rounds where patients with named clinical conditions are investigated (this will require co-operation with a Urology department and the permission of patients) to broaden understanding of the importance of pathology to the patient journey and write a reflective account of what you have learned if possible including discussion with some patients.
• Observe pathological investigation of a testicular biopsy and relate this to their understanding of condition.
• Prepare a portfolio of cases from named clinical conditions where you have played a role in the systematic investigation All of these experiences should be recorded in your e-portfolio.

 

 

• Become familiar with detail of laboratory quality management systems and satisfying the requirements of ISO15189 and UKAS standards of accredited diagnostic testing. Perform examination and other audits as part of the laboratory accreditation process (including understanding how different EQA schemes operate worldwide and how targets are set and regulated).