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Five-minute Practitioner: January 2007

Only got five minutes? Then just read these key points on: male infertility, prostate disease and myeloproliferative disorders

Only got five minutes? Then just read these key points on: male infertility, prostate disease and myeloproliferative disorders

Male infertility

Sperm dysfunction is the most common cause of infertility and affects one in fifteen men. Up to one in five 18-year-olds are classed as sub-fertile. There are no drug treatments to enhance sperm function that have been shown to be effective in controlled trials, and IVF and ICSI are the only treatments.

Information should be obtained from the man regarding previous conceptions, surgery likely to affect fertility, such as vasectomy, drug use, including illicit use, for example steroids for bodybuilding, and age. If the couple have been trying to conceive for more than 12 months a semen analysis should be performed.

In some cases the semen analysis result is very helpful, for example in patients with azoospermia or when many motile sperm are present in the ejaculate. However, the majority of men fall between these extremes, and for these patients semen analysis is only moderately predictive of future fertility. Generally, the chance of conception is decreased with lower semen parameters (for example a sperm concentration below 10 million per ml), but this is not always the case.

Prostate disease

The recent prostate cancer prevention trial (PCPT) demonstrated that 17 per cent of men who were identified with prostate cancer in fact had a PSA value below 4.0 ng/ml, and some patients had a value below 2.5 ng/ml.

Early results suggest that the sensitivity and specificity of the recently developed PCA3 test are better than those for PSA. The PCA3 test may reduce the number of patients requiring TRUS biopsies.

The test is based on the molecular analysis of prostate epithelial cells, obtained from the first 50 ml of urine passed after a relatively vigorous prostatic massage.

Hormone relapsed prostate cancer survival may be prolonged by the judicious use of chemotherapy with docetaxel. Zolendronic acid has also been shown to delay development of skeletal-related events by up to six months, but not to improve survival.

The advent of Greenlight laser vaporisation and Holmium laser enucleation of the prostate has altered surgical options for BPH, so patients can be admitted for day surgery or a 24-hour hospital stay.

Myeloproliferative disorders

The term mpd generally refers to polycythaemia vera (PV), essential thrombocythaemia (ET) and idiopathic myelofibrosis?(IM). Other, more rare conditions classed as MPDs include hypereosinophilic syndrome and systemic mastocytosis.

There is considerable overlap between disease groups; ET may transform to PV, and both conditions may transform to IM in up to five per cent of cases. Transformation to acute leukaemia occurs in around 0.3 per cent of patients per year. Leukaemic transformation does not occur in patients under 60.

Up to 97 per cent of patients with PV and around 50 per cent of those with ET or IM?will express V617F JAK2. Screening for the V617F JAK2 mutation involves fairly simple, but quite time-consuming, PCR-based techniques on DNA derived from affected cells in fresh anticoagulated peripheral blood.

One of the greatest difficulties for clinicians is differentiating true MPDs from other problems that present with an abnormal FBC. It is always worth checking an isolated abnormal finding in a basically well person (where HCT <0.58, PLT <1,000) with a repeat count six to eight weeks later.

Low-dose aspirin significantly reduces cardiovascular morbidity and mortality in patients with PV.

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