2023-2024 ANDROLOGISCHE
ASPECTEN VAN
SEKSUALITEIT EN
VOORTPLANTING
MET INBEGRIP VAN
GEVALSBESPREKING
PROF ANTONIO
Laurence Claessens
, INHOUDSTAFEL
INHOUDSTAFEL ...............................................................................................................................................................1
CONCEPTMAP..................................................................................................................................................................4
GENITALE ONTWIKKELING – DSD...................................................................................................................................5
Genitale ontwikkeling .................................................................................................................................................5
Geslacht ...................................................................................................................................................................5
Normale genitale ontwikkeling ..................................................................................................................................5
Bipotentiele gonaden .............................................................................................................................................5
Interne genitalia..................................................................................................................................................5
externe genitalia .................................................................................................................................................6
It all starts with Y.....................................................................................................................................................6
Ontwikkeling van de mannelijke foetus ................................................................................................................7
hormoonaanmaak in de foetale teelbal............................................................................................................7
Indalen van de testis ...............................................................................................................................................9
Niet-ingedaalde teelbal: cryptorchidie..............................................................................................................9
Hypospadias ........................................................................................................................................................9
Testicular dysgenesis syndrome ..................................................................................................................... 10
Stoornissen in genitale ontwikkeling ...................................................................................................................... 11
Virilisatie en ambigue genitalia........................................................................................................................... 11
Disorders in seks development ........................................................................................................................... 12
sex chromosomal DSD ..................................................................................................................................... 13
Klinefleter syndroom ................................................................................................................................... 13
47, XYY .......................................................................................................................................................... 17
Tunrner syndroom ....................................................................................................................................... 17
46, XY DSD ........................................................................................................................................................ 18
androgeen insensitivteitssyndroom (AIS).................................................................................................. 19
Problemen in androgeen aanmaak ............................................................................................................ 22
Problemen in gonadale ontwikkeling......................................................................................................... 24
Persistent Mullerian duct............................................................................................................................ 25
46, XX DSD ........................................................................................................................................................ 26
Stoornis in androgeenaanmaak (te veel)................................................................................................... 26
MANNELIJKE INFERTILITEIT.......................................................................................................................................... 28
Vruchtbaarheid ........................................................................................................................................................ 28
Spermatogenese ...................................................................................................................................................... 29
Spermakwaliteit ................................................................................................................................................... 30
1
, Normale variatie in zaadcelaanmaak ............................................................................................................. 30
Verminderde en optimale spermakwaliteit................................................................................................... 31
Subfertiliteit.............................................................................................................................................................. 32
Oorzaken verminderde sperma-aanmaak.............................................................................................................. 32
Pretesticulair probleem: secundair hypogonadisme .................................................................................... 34
Testiculair probleem: primair hypogonadisme.............................................................................................. 35
Testiculair probleem: gestoorde spermatogenese ....................................................................................... 35
Post-testiculair probleem: obstructie............................................................................................................. 37
Work-up mannelijke vruchtbaarheid...................................................................................................................... 38
Spermastalen........................................................................................................................................................ 38
Aanvullende tests ............................................................................................................................................ 40
SPerm preparation techniques ....................................................................................................................... 41
Capacitatietest ................................................................................................................................................. 41
Spermiogram .................................................................................................................................................... 41
Anamnese ............................................................................................................................................................. 41
Klinisch onderzoek ............................................................................................................................................... 42
Echo scrotum ........................................................................................................................................................ 42
Hormonaal bilan................................................................................................................................................... 43
Genetisch onderzoek ........................................................................................................................................... 43
Azoöspermie............................................................................................................................................................. 43
Testiculair sperm extraction (TESE) ................................................................................................................ 44
‘Behandeling’ mannelijke infertiliteit ................................................................................................................. 46
HYPOGONADISME ........................................................................................................................................................ 47
hypothalamo-hypofysaire-testiculaire as............................................................................................................... 47
Variatie testosteron ............................................................................................................................................. 47
Totaal versus vrij hormoon.................................................................................................................................. 48
SHGB: Impact van leeftijd en geslacht ........................................................................................................... 48
Testosteron: effecten in het lichaam...................................................................................................................... 49
Metabolisatie........................................................................................................................................................ 49
Effecten van androgenen in het lichaam............................................................................................................ 50
Hypogonadisme ....................................................................................................................................................... 50
Indeling ................................................................................................................................................................. 50
Primair versus secundair ................................................................................................................................. 50
Organisch versus functioneel .......................................................................................................................... 51
Oorzaken............................................................................................................................................................... 52
primair hypogonadisme .................................................................................................................................. 52
Secundair hypogonadisme .............................................................................................................................. 52
2
, Symptomen .......................................................................................................................................................... 53
Tekort aan androgenen ................................................................................................................................... 54
Diagnose ............................................................................................................................................................... 55
Wanneer testen? ............................................................................................................................................. 55
Meten van testosteron in het bloed............................................................................................................... 56
Oorzaak Hypogonadisme opsporen ............................................................................................................... 56
Behandeling.......................................................................................................................................................... 57
Primair hypogonadisme .................................................................................................................................. 57
Secundair hypogonadisme .............................................................................................................................. 57
Voordelen en nadelen van TRT....................................................................................................................... 57
Organisch vs functionele ................................................................................................................................. 57
TRT = testosteron replacement therapie ....................................................................................................... 58
Gonadotropinen............................................................................................................................................... 59
Behandeling van functioneel hypogonadisme .............................................................................................. 60
Nieuwe studie .............................................................................................................................................. 61
Casussen ................................................................................................................................................................... 62
Casus 1 .................................................................................................................................................................. 62
casus 2................................................................................................................................................................... 63
Casus 3 .................................................................................................................................................................. 63
HYPERSEKSUALITEIT EN GENDERDYSFORIE................................................................................................................ 65
Chemische castratie................................................................................................................................................. 65
ADT ........................................................................................................................................................................ 65
Medicatie:......................................................................................................................................................... 65
Opstart therapie............................................................................................................................................... 67
Opvolging therapie .......................................................................................................................................... 67
Genderdysforie......................................................................................................................................................... 68
Geslacht en gender .............................................................................................................................................. 68
Genderdysforie..................................................................................................................................................... 68
Prevalentie ....................................................................................................................................................... 68
Wet op naam en geslachtswijziging ............................................................................................................... 69
Genderzorg....................................................................................................................................................... 70
Hormonale behandeling.............................................................................................................................. 70
Chirurgische behandeling ........................................................................................................................... 77
Besluit ................................................................................................................................................................... 79
EXAMEN ........................................................................................................................................................................ 80
3
ASPECTEN VAN
SEKSUALITEIT EN
VOORTPLANTING
MET INBEGRIP VAN
GEVALSBESPREKING
PROF ANTONIO
Laurence Claessens
, INHOUDSTAFEL
INHOUDSTAFEL ...............................................................................................................................................................1
CONCEPTMAP..................................................................................................................................................................4
GENITALE ONTWIKKELING – DSD...................................................................................................................................5
Genitale ontwikkeling .................................................................................................................................................5
Geslacht ...................................................................................................................................................................5
Normale genitale ontwikkeling ..................................................................................................................................5
Bipotentiele gonaden .............................................................................................................................................5
Interne genitalia..................................................................................................................................................5
externe genitalia .................................................................................................................................................6
It all starts with Y.....................................................................................................................................................6
Ontwikkeling van de mannelijke foetus ................................................................................................................7
hormoonaanmaak in de foetale teelbal............................................................................................................7
Indalen van de testis ...............................................................................................................................................9
Niet-ingedaalde teelbal: cryptorchidie..............................................................................................................9
Hypospadias ........................................................................................................................................................9
Testicular dysgenesis syndrome ..................................................................................................................... 10
Stoornissen in genitale ontwikkeling ...................................................................................................................... 11
Virilisatie en ambigue genitalia........................................................................................................................... 11
Disorders in seks development ........................................................................................................................... 12
sex chromosomal DSD ..................................................................................................................................... 13
Klinefleter syndroom ................................................................................................................................... 13
47, XYY .......................................................................................................................................................... 17
Tunrner syndroom ....................................................................................................................................... 17
46, XY DSD ........................................................................................................................................................ 18
androgeen insensitivteitssyndroom (AIS).................................................................................................. 19
Problemen in androgeen aanmaak ............................................................................................................ 22
Problemen in gonadale ontwikkeling......................................................................................................... 24
Persistent Mullerian duct............................................................................................................................ 25
46, XX DSD ........................................................................................................................................................ 26
Stoornis in androgeenaanmaak (te veel)................................................................................................... 26
MANNELIJKE INFERTILITEIT.......................................................................................................................................... 28
Vruchtbaarheid ........................................................................................................................................................ 28
Spermatogenese ...................................................................................................................................................... 29
Spermakwaliteit ................................................................................................................................................... 30
1
, Normale variatie in zaadcelaanmaak ............................................................................................................. 30
Verminderde en optimale spermakwaliteit................................................................................................... 31
Subfertiliteit.............................................................................................................................................................. 32
Oorzaken verminderde sperma-aanmaak.............................................................................................................. 32
Pretesticulair probleem: secundair hypogonadisme .................................................................................... 34
Testiculair probleem: primair hypogonadisme.............................................................................................. 35
Testiculair probleem: gestoorde spermatogenese ....................................................................................... 35
Post-testiculair probleem: obstructie............................................................................................................. 37
Work-up mannelijke vruchtbaarheid...................................................................................................................... 38
Spermastalen........................................................................................................................................................ 38
Aanvullende tests ............................................................................................................................................ 40
SPerm preparation techniques ....................................................................................................................... 41
Capacitatietest ................................................................................................................................................. 41
Spermiogram .................................................................................................................................................... 41
Anamnese ............................................................................................................................................................. 41
Klinisch onderzoek ............................................................................................................................................... 42
Echo scrotum ........................................................................................................................................................ 42
Hormonaal bilan................................................................................................................................................... 43
Genetisch onderzoek ........................................................................................................................................... 43
Azoöspermie............................................................................................................................................................. 43
Testiculair sperm extraction (TESE) ................................................................................................................ 44
‘Behandeling’ mannelijke infertiliteit ................................................................................................................. 46
HYPOGONADISME ........................................................................................................................................................ 47
hypothalamo-hypofysaire-testiculaire as............................................................................................................... 47
Variatie testosteron ............................................................................................................................................. 47
Totaal versus vrij hormoon.................................................................................................................................. 48
SHGB: Impact van leeftijd en geslacht ........................................................................................................... 48
Testosteron: effecten in het lichaam...................................................................................................................... 49
Metabolisatie........................................................................................................................................................ 49
Effecten van androgenen in het lichaam............................................................................................................ 50
Hypogonadisme ....................................................................................................................................................... 50
Indeling ................................................................................................................................................................. 50
Primair versus secundair ................................................................................................................................. 50
Organisch versus functioneel .......................................................................................................................... 51
Oorzaken............................................................................................................................................................... 52
primair hypogonadisme .................................................................................................................................. 52
Secundair hypogonadisme .............................................................................................................................. 52
2
, Symptomen .......................................................................................................................................................... 53
Tekort aan androgenen ................................................................................................................................... 54
Diagnose ............................................................................................................................................................... 55
Wanneer testen? ............................................................................................................................................. 55
Meten van testosteron in het bloed............................................................................................................... 56
Oorzaak Hypogonadisme opsporen ............................................................................................................... 56
Behandeling.......................................................................................................................................................... 57
Primair hypogonadisme .................................................................................................................................. 57
Secundair hypogonadisme .............................................................................................................................. 57
Voordelen en nadelen van TRT....................................................................................................................... 57
Organisch vs functionele ................................................................................................................................. 57
TRT = testosteron replacement therapie ....................................................................................................... 58
Gonadotropinen............................................................................................................................................... 59
Behandeling van functioneel hypogonadisme .............................................................................................. 60
Nieuwe studie .............................................................................................................................................. 61
Casussen ................................................................................................................................................................... 62
Casus 1 .................................................................................................................................................................. 62
casus 2................................................................................................................................................................... 63
Casus 3 .................................................................................................................................................................. 63
HYPERSEKSUALITEIT EN GENDERDYSFORIE................................................................................................................ 65
Chemische castratie................................................................................................................................................. 65
ADT ........................................................................................................................................................................ 65
Medicatie:......................................................................................................................................................... 65
Opstart therapie............................................................................................................................................... 67
Opvolging therapie .......................................................................................................................................... 67
Genderdysforie......................................................................................................................................................... 68
Geslacht en gender .............................................................................................................................................. 68
Genderdysforie..................................................................................................................................................... 68
Prevalentie ....................................................................................................................................................... 68
Wet op naam en geslachtswijziging ............................................................................................................... 69
Genderzorg....................................................................................................................................................... 70
Hormonale behandeling.............................................................................................................................. 70
Chirurgische behandeling ........................................................................................................................... 77
Besluit ................................................................................................................................................................... 79
EXAMEN ........................................................................................................................................................................ 80
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