Male Infertility: Problems and Solutions (Current Clinical Urology)

Current Clinical Urology Eric A. Klein, MD, Series Editor

For other titles published in the series, go to www.springer.com/series/7635

Male Infertility Problems and Solutions

Edited by

Edmund S. Sabanegh, Jr., M.D.

Editor Edmund S. Sabanegh, Jr., MD. Chairman, Department of Urology Glickman Urological and Kidney Institute Cleveland Clinic Cleveland, Ohio USA [email protected]

Series Editor Eric A. Klein, Md Professor of surgery Cleveland Clinic Lerner College of Medicine Head, Section of Urologic Oncology Glickman Urological and Kidney Institute Cleveland, OH

ISBN 978-1-60761-192-9 e-ISBN 978-1-60761-193-6 DOI 10.1007/978-1-60761-193-6 Springer New York Dordrecht Heidelberg London Library of Congress Control Number: 2010938366 © Springer Science+Business Media, LLC 2011 All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Humana Press, c/o Springer Science+Business Media, LLC, 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. Printed on acid-free paper Humana Press is part of Springer Science+Business Media (www.springer.com)

Preface

With almost 50% of infertility attributed either wholly or in part to male issues, it has become increasingly important to look at infertility from a couple’s perspective. Advances in assisted reproductive technologies allow more conceptions than ever before, but such treatments may come with significant financial and safety cost. These costs are certainly justifiable with the targeted use of these innovative advances, but they should not be applied in a blanket fashion to all causes of infertility. Thorough evaluation of the male with the correction of underlying issues can maximize the potential for natural reproduction. In this text, we have assembled world-renowned experts in the field to provide a clear and concise overview of state-of-the-art developments in male infertility for both the novice and experienced

p­ ractitioners in the field. We have placed special emphasis on diagnostic and treatment algorithms to allow the reader to obtain rapid answers to this challenging medical issue. The text is intended for general urologists, gynecologists, primary care providers, and allied health providers who manage infertility in both men as well as women. It is our sincere hope that this book allows rapid acquisition of pertinent background and development of management plans in this ever changing field. It is an exciting time to be involved in the treatment of infertility. We hope this book further stimulates your interest as together we manage couples in a compassionate, safe, and efficient fashion. Cleveland, OH, USA

Edmund S. Sabanegh, Jr.

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Acknowledgments

Special thanks to my clinical fellows, Kashif Siddiqi, MD and John Kefer, MD for their diligent assistance throughout the preparation of this book and

to my children, Emily and Ned and my wife, Amy. Without their support, none of this would have been possible.

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Contents

Preface ..........................................................................................................................................................

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Contributors ..................................................................................................................................................

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The Initial Consultation for Male Infertility ............................................................................................ Wayne Kuang

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Interpretation of Basic Semen Analysis and Advanced Semen Testing ................................................. Ashok Agarwal and Tamer M. Said

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Azoospermia: Diagnosis and Management .............................................................................................. John C. Kefer and Dan B. French

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Ejaculatory Dysfunction............................................................................................................................. Dana A. Ohl, Susanne A. Quallich, Jens Sønksen, Nancy L. Brackett, and Charles M. Lynne

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Genetic Issues with Male Fertility ............................................................................................................. Robert D. Oates

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Endocrinopathies in Male Infertility......................................................................................................... Stephanie E. Harris, Hussein M.S. Kandil, and Craig S. Niederberger

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Female Fertility: Implications to Management of Male Factor.............................................................. Jeffrey M. Goldberg and Michelle Catenacci

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Varicocele: To Fix or Not to Fix ................................................................................................................. Fábio Firmbach Pasqualotto, Edson Borges, Felipe Roth, Luana Venturin Lara, and Eleonora Bedin Pasqualotto

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Medical Management of Male Infertility .................................................................................................. Eric E. Laborde, Vishal Bhalani, Neal Patel, and Robert E. Brannigan

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Surgical Reconstructions for Obstruction ................................................................................................ Edmund S. Sabanegh, Jr. and Kashif Siddiqi

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Techniques for Sperm Harvest................................................................................................................... Wayland Hsiao and Peter N. Schlegel

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Sperm Banking: When, Why, and How? .................................................................................................. Sajal Gupta, Lucky H. Sekhon, and Ashok Agarwal

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Assisted Reproduction and Male Factor Fertility: Which Type Is Right? ............................................ James Goldfarb and Nina Desai

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Ethical Dilemmas in Male Infertility......................................................................................................... Barbara Chubak and Anthony J. Thomas

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Index .............................................................................................................................................................

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Contributors

Ashok Agarwal, Ph.D., H.C.L.D. Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA

James Goldfarb, M.D., M.B.A. In-Vitro Fertilization Center, Cleveland Clinic, Cleveland, OH 44195, USA

Vishal Bhalani, M.D. Department of Urology, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA

Sajal Gupta, M.D. Center for Reproductive Medicine and Andrology Laboratory and Reproductive Tissue Bank, Glickman Urological & Kidney Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk A19.1, Cleveland, OH 44195, USA

Edson Borges, Jr, M.D., Ph.D. Fertility - Center for Assisted Fertilization, São Paulo, SP, Brazil; Institute Sapientiae - Center of Post-Graduation in Human Assisted Reproduction Brazil Nancy L. Brackett, Ph.D. The Miami Project to Cure Paralysis, University of Miami School of Medicine, Miami, FL 33101, USA Robert E. Brannigan, M.D. Department of Urology, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA Michelle Catenacci, M.D. Obstetrics/Gynecology and Women’s Health Institute, Cleveland Clinic, Cleveland, OH, USA Barbara Chubak, M.D. Department of Bioethics, Cleveland Clinic, Cleveland, OH, USA Nina Desai, Ph.D., H.C.L.D. In-Vitro Fertilization Center, Cleveland Clinic, Cleveland, OH 44195, USA Dan B. French, M.D. Dallas Center for Pelvic Medicine, Suite 200, 10501 N Central Expressway, 75231 Dallas, TX, USA Jeffrey M. Goldberg, M.D. Obstetrics/Gynecology and Women’s Health Institute, Cleveland Clinic, Cleveland, OH, USA

Stephanie E. Harris, M.D. University of Illinois at Chicago, Chicago, IL, USA Wayland Hsiao, M.D. James Buchanan Brady Foundation, Starr 900, Department of Urology, Weill Cornell Medical College, The New York Presbyterian Hospital, 525 East 68th Street, New York, NY 10021, USA Hussein M.S. Kandil, M.D. University of Illinois at Chicago, Chicago, IL, USA John C. Kefer, M.D., Ph.D. Center for Male Fertility/Andrology, Glickman Urological and Kidney Institute, Mailcode Q10, 9500 Euclid Ave, 44113 Cleveland, OH, USA Wayne Kuang, M.D. Division of Urology, University of New Mexico, Albuquerque, NM, USA Eric E. Laborde, M.D. Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA Luana V. Lara, B.Sc. CONCEPTION - Center for Human Reproduction, Caxias do Sul, RS, Brazil

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Contributors

Charles M. Lynne, M.D. Department of Urology, University of Miami School of Medicine, Miami, FL, USA

Susanne A. Quallich, N.P.-C. Department of Sexual and Reproductive Medicine, University of Michigan, Ann Arbor, MI 48108, USA

Craig S. Niederberger, M.D. University of Illinois at Chicago, Chicago, IL, USA

Felipe Roth, M.D. CONCEPTION - Center for Human Reproduction, Caxias do Sul, RS, Brazil

Robert D. Oates, M.D. Boston University School of Medicine, Boston, MA 02118, USA Dana A. Ohl, M.D. Department of Sexual and Reproductive Medicine, University of Michigan, Ann Arbor, MI 48108, USA Eleonora B. Pasqualotto, M.D., Ph.D. CONCEPTION - Center for Advanced Research in Human Reproduction, Infertility & Sexual Function, Center for Biological and Health Sciences, University of Caxias do Sul, Caxias do Sul, RS, Brazil; Department of Obstetrics–Gynecology, General Hospital, University of Caxias do Sul, Caxias do Sul, RS, Brazil Fábio F. Pasqualotto, M.D., Ph.D. University of Caxias do Sul, RS, Brazil; Institute of Biotechnology, University of Caxias do Sul, RS, Brazil; Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Brazil; CONCEPTION - Center for Human Reproduction, Caxias do Sul, RS, Brazil; Rua Pinheiro Machado, 2569, sl 23/24, Bairro São Pelegrino, Caxias do Sul, RS, Brazil Neal Patel, B.S. Chicago Medical School at Rosalind Franklin University of Medicine and Science, North Chicago, IL 60061, USA

Edmund S. Sabanegh, Jr., M.D. Center for Male Fertility, Glickman Urological and Kidney Institute, Cleveland, OH, USA Tamer M. Said, M.D., Ph.D. The Toronto Institute for Reproductive Medicine – ReproMed, Toronto, ON, Canada Peter N. Schlegel, M.D. James Buchanan Brady Foundation, Starr 900, Department of Urology, Weill Cornell Medical College, The New York Presbyterian Hospital, 525 East 68th Street, New York, NY 10021, USA Lucky H. Sekhon, B.Sc. Center for Reproductive Medicine and Andrology Laboratory and Reproductive Tissue Bank, Glickman Urological & Kidney Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk A19.1, Cleveland, OH 44195, USA Kashif Siddiqi, M.D. Center for Male Fertility, Glickman Urological and Kidney Institute, Cleveland, OH, USA Jens Sønksen, M.D., Ph.D. Department of Urology, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark Anthony J. Thomas Jr., M.D. Department of Bioethics, Cleveland Clinic, Cleveland, OH, USA

The Initial Consultation for Male Infertility Wayne Kuang MD

Contents Introduction....................................................................................................................................................................... Male Infertility.................................................................................................................................................................. Sexual History................................................................................................................................................................... Developmental and Childhood History............................................................................................................................. Infection History............................................................................................................................................................... Medical History................................................................................................................................................................ Surgical History................................................................................................................................................................ Social History.................................................................................................................................................................... Medications....................................................................................................................................................................... Physical Exam................................................................................................................................................................... Summary........................................................................................................................................................................... References.........................................................................................................................................................................

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Abbreviations

Introduction

AAS Anabolic androgenic steroids CAH Congential adrenal hyperplasia CF Cystic fibrosis Gy Gray HPG Hypothalamic – gonadal – axis IHH Isolated hypogonadotropic hypogonadism IVF In vitro fertilization LH Luteinizing hormone

A thorough history and physical exam is a critical stepping stone towards the diagnosis and treatment of male infertility. This review focuses on obtaining a sexual, developmental, infection, medical, surgical and social history, providing an overview of medications that may impair a man’s fertility potential and performing a careful physical exam (see Table 1). The interpretation of hormonal, seminal and genetic testing is discussed in later chapters in association with specific disease entities.

Male Infertility W. Kuang () Division of Urology, University of New Mexico, Southwest Fertility Center for Men, Albuquerque, NM, USA

Infertility is defined as failure to conceive after 12 or more months of regular unprotected intercourse (Practice Committee of the American Society for

From: Current Clinical Urology: Male Infertility: Problems and Solutions, Edited by: E.S. Sabanegh, DOI: 10.1007/978-1-60761-193-6_1,  Springer Science+Business Media, LLC 2011

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Table 1. Male infertility history. Infertility history   Duration   Previous partner   Previous pregnancies   Previous infertility therapy   Partner’s fertility status Sexual history   Timing and frequency of sex   Libido and erectile function   Lubricants   Ejaculatory status and volume Developmental and childhood history   Undescended testicles   Pre-pubertal hypogonadism   Congenital syndromes Infection history   Viral febrile infection   Sexually transmitted    HIV    Gonorrhea    Chlamydia   Bacterial    Atypical (mycoplasma)    Prostatitis    Epididymitis    Tuberculosis   Post-pubertal mumps orchitis Medical history   Systemic illnesses    Diabetes    Chronic liver disease    Renal failure    Thyroid disease    Malnutrition    Metabolic syndrome    Blood dyscrasias   Neurologic disease    Multiple sclerosis    Transverse myelitis    Spinal cord injury   Cancer   Cystic fibrosis   Post-pubertal hypogonadism    Klinefelter’s syndrome

   IHH    Pituitary diseases/tumour Surgical history   Trauma   Penis    Chordee    Hypospadias    Urethroplasty   Scrotum    Orchiopexy    Orchiectomy    Torsion    Vasectomy   Inguinal    Orchidopexy    Hernia   Pelvis    Bladder neck surgery    TURP   Retroperitoneum    Fibrosis    RPLND Social history   Environmental exposures    Chemicals    Radiation   Recreational drugs   Tobacco use   Heat exposure   Stress   Anabolic-androgenic steroids Family history   Cystic fibrosis   Male infertility   Hypogonadism Medications Review of systems   Headache   Visual field changes   Galactorrhea   Gynecomastia   Anosmia

Reproductive Medicine 2008). A comprehensive male infertility evaluation should be pursued sooner than at 1 year if there is a previous history of infertility, a known risk factor, advanced female age or a specific request by the couple. In the USA, 7.5% of sexually experienced men reported that they had sought assistance in having a child (Anderson et al. 2009). Conception rates for fertile couples can be as high as 30% per month and approximately 85% within 1 year (Spira 1986; Ford et al. 2000; Thonneau et al. 1991). When left untreated, 20–35% of couples can conceive naturally even after a 2-year period of infertility (Collins

et al. 1983; Aafjes et al. 1978). While fecundity begins to decline for both men and women at the age of 31, the rate of decline is faster for women starting at the age of 37 (Ford et al. 2000; van Noord-Zaadstra et al. 1991; Schwartz and Mayaux 1982). A growing body of evidence suggests an association between advanced paternal age and miscarriage, genetic abnormalities (Down’s), autism spectrum disorder (ASD) as well as schizophrenia (Durkin et al. 2008; Fisch 2009; Belloc et al. 2008; Weiser et al. 2008). A contributory male infertility factor is identified in almost 50% of infertile couples while it is the sole

TURP transurethral resection of the prostate; RPLND retroperitoneal lymph node dissection; IHH isolated hypogonadotropic hypogonadism

The Initial Consultation for Male Infertility

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Table 2. Distribution of diagnoses for male infertility (World Health Organization; n = 7,057) Adapted from EAU guidelines on male infertility 2005; with permission Diagnosis Percentage (%) Idiopathic Idiopathic abnormal semen analysis Varicocele Infection Immunologic factor Other abnormalities Acquired factor Congenital anomaly Coital factor Endocrine abnormality

48.5 26.4 12.3 6.6 3.1 3.0 2.6 2.1 1.7 0.6

cause in 20–30% of infertile couples (Thonneau et al. 1991; Hull et  al. 1985). These factors range from being correctable to irreversible. Significant medical pathologies that threaten a man’s overall health or life (endocrinopathies, testicular and prostate cancer, brain and spinal cord tumours) can be identified in up to 6% of infertile men (Honig et  al. 1994; Kolettis and Sabanegh 2001; Walsh et al. 2009; Peng et al. 2009). The distribution of diagnoses seen in a male infertility clinic reveals that 75% of men will have idiopathic infertility with or without an abnormal semen analysis (see Table 2) Dohle et al. 2005. The goal of a comprehensive male infertility evaluation is to optimize a man’s reproductive potential while maximizing his overall health. In close colla­ boration with the female fertility specialists, a male fertility specialist should help a couple identify the treatment option that best resonates with their reproductive philosophy, needs and timetable. For the infertile man, the best reproductive option may involve rectifying correctable causes with surgical or medical therapy. Alternatively, sperm retrieval in conjunction with assisted reproductive techniques can overcome irreversible factors. Options of having non-biological children (donor insemination or adoption) or staying as they are should also be presented. It is important to be aware that the reproductive journey towards building a family can be emotionally taxing and lead to issues of depression, sexual dysfunction and relationship problems (Shindel et al. 2008).

Sexual History The best chance for conception is within the 7-day window that ends on the day of ovulation and is highest within 2 days of ovulation (Wilcox et al. 1995). Given

that abstinence intervals of 2 days are associated with normal sperm densities and that moving sperm can live in the cervical mucus for more than 2 days, the following frequency of intercourse is suggested for couples seeking to optimize coitus: every other day starting 7 days before ovulation, including the day of and the day after (Wilcox et al. 2001; Perloff and Steinberger 1964). Strict timing of intercourse can escalate the stress of infertility (Lenzi et al. 2003). Couples should be advised to find a coital frequency that maximizes fecundity but minimizes emotional distress. Specific coital positions are not associated with increased fertility. Regardless of position, sperm can be found within the oviduct within 5 min after deposition of sperm in the proximal vagina (Settlage et  al. 1973). There are no data to support an association of orgasm with increased fertility or specific coital practices with gender selection. An assessment of libido as well as erectile and ejaculatory function is critical since it may be the only symptoms of hypogonadism or ejaculatory dysfunction. Commercially available water-based lubricants which include KY Jelly, Surgilube, Astroglide, Replens and Touch have been found to be spermicidal (Kutteh et  al. 1996). After a 30-min incubation with KY Jelly or Surgilube, no moving or viable sperm are found in in vitro studies (Tagatz et al. 1972). Natural products such as vegetable oils (canola, vegetable, olive, safflower and peanut) as well as glycerin and petroleum jelly only cause a mild decrease in sperm motility (Kutteh et  al. 1996; Goldenberg and White 1975). While saliva is often thought of as a “more natural” lubricant, mild impairment of sperm motility has been seen (Tulandi et al. 1982). In 2008, in vitro studies suggest that a newer commercially available hydroxyethylcellulose-based lubricant, such as PreSeed, has minimal deleterious effects on mobility and sperm chromatin integrity (Agarwal et al. 2008). Obviously, the optimal artificial lubricant for vaginal dryness has yet to be identified based on more than just in vitro studies. While lubricants are not recommended by male fertility specialists, it may be a necessity for successful intercourse. In these situations, couples are advised to use the minimal amount necessary, to avoid water-based lubricants and to consider using vegetable oils, saliva, glycerin, petroleum jelly as well as hydroxyethylcellulose-based lubricants. Men with low or absent ejaculate volumes may have an anatomic (partial or complete) or functional obstruction of the ejaculatory ducts, and often present with infertility, hematospermia or painful ejaculation. The etiology may be congenital or acquired. After retrograde

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ejaculation, hypogonadism, absent vas deferens, and suspect medications are ruled out, seminal vesicle aspiration, chromotubation or seminovesiculography will help further characterize the obstruction (Smith et  al. 2008). The finding of three sperm per high-powered field with seminal vesicle aspiration is consistent with obstruction. The injection of the seminal vesicles with contrast (seminovesiculography) or indigo carmine/ methylene blue (chromotubation) can confirm patency with radiographic imaging or cystoscopy, respectively. All three of these diagnostic studies are performed under transrectal ultrasound guidance. Other acquired causes of ejaculatory include systemic illnesses (diabetes), neurologic disorders (multiple sclerosis, transverse myelitis, spinal cord injury), retroperitoneal surgeries or fibrosis, as well as bladder neck surgeries (transurethral resection of the prostate or bladder neck incision) (Smith et  al. 2008; Arafa and El Tabie 2008; Chally et  al. 1998; Fisch et  al. 2002; Jewett and Groll 2007; Ralph and Wylie 2005; Witt and Grantmyre 1993). Medications, including anti-hypertensives (prazosin, phentolamine, thiazides), anti-depressants (imipramine, amitriptyline), anti-psychotics (thioridazine, haloperidol), 5a-reductase inhibitors and a-blockers, may be contributory factors to ejaculatory dysfunction (Smith et  al. 2008; Hellstrom and Sikka 2006; Narayan and Lepor 2001; Carbone and Hodges 2003). Selective a-adrenergic blockers, such as tamsulosin, may result in decreased ejaculatory volume in almost 90% of men, and ejaculatory dysfunction can be seen in almost 8% of men on a 5a-reductase inhibitors such as finasteride (Hellstrom and Sikka 2006; Narayan and Lepor 2001; Carbone and Hodges 2003).

Developmental and Childhood History Unilateral cryptorchidism has been associated with a mildly decreased paternity rate of 90%, whereas bilateral cryptorchidism significantly decreases paternity rates to 65% with an associated decreased sperm concentration (Lee 2005). Preliminary data suggest that earlier orchiopexy is associated with lower folliclestimulating hormone (FSH) levels with potential benefits to spermatogenesis (Coughlin et  al. 1999). Vanishing testes syndrome (anorchia) in a newborn is a rare condition where undescended testicles must be ruled out. Another rare cause of impaired testicular function is seen in autoimmune testicular failure (Tsatsoulis and Shalet 1991).

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Men with pre-pubertal onset of hypogonadism may present to a male infertility clinic with a known endocrinopathy, including various clinical syndromes (Prader-Willi, Lawrence-Moon-Biedl, Familial Cerebral Ataxia) or the classic form of Isolated Hypogonadotropic Hypogonadism (IHH) which is called Kallman’s syndrome when anosmia is evident (Fechner et  al. 2008). Pre-pubertal onset of hypogonadism may require hormonal stimulation to initiate or complete puberty and spermatogenesis (Kulin 1997; Pozo and Argente 2003). Eunuchoid features (arm span exceeds height by more than 5  cm) with small “infantile” testes and penis may be seen. Other rare diseases that present in early childhood and impair a man’s reproductive capacity are 5a-reductase deficiency, androgen resistance, congenital adrenal hyperplasia (CAH) and isolated gonadotropin deficiencies of the pituitary. 5a-reductase deficiency results in ambiguous genitalia with abnormal prostate development due to the relative absence of dihydrotestosterone while virilization at puberty is maintained due to elevated testosterone (Chan et  al. 2009; Wilson et al. 1993). Androgen resistance is due to a defect in the androgen receptor that prevents negative-feedback inhibition of luteinizing hormone secretion by the pituitary, and androgenization is abnormal. Consequently, complete androgen insensitivity presents as a phenotypic female (testicular feminization), whereas partial androgen insensitivity presents with ambiguous genitalia (Reifenstein syndrome) (Cheikhelard et al. 2008; Griffin 1992; Boehmer et  al. 2001). The two major types of CAH are 21-hydroxylase and 11b-hydroxylase deficiencies. An inability to produce cortisol results in an overproduction of androgens that suppress gonadotropin secretion. The resulting hypogonadotropic hypogonadism with elevated adrenal androgens leads to precocious puberty and small testicles with suppressed spermatogenesis (Antal and Zhou 2009; Speiser and White 2003; Stikkelbroeck et  al. 2001). Finally, isolated LH deficiency leads to abnormal androgenization with spermatogenesis whereas isolated FSH deficiency causes infertility with normal androgenization (Giltay et al. 2004; Trarbach et al. 2007).

Infection History A history of sexually transmitted diseases (STDs), urinary tract infections (UTIs) or other genitourinary inflammatory processes may impair the production and quality of sperm and may cause obstruction of the reproductive tract (Keck et al. 1998). Viral orchitis can

The Initial Consultation for Male Infertility

be seen in up to 40% of men with post-pubertal mumps (Philip et al. 2006). Systemic therapy with interferonalpha 2B can prevent infertility and testicular atrophy associated with bilateral orchitis (Erpenbach 1991). STDs, such as Chlamydia and Mycoplasma, are associated with decreased sperm counts and higher sperm DNA fragmentation that improves with antibiotics (Gallegos et  al. 2008; Joki-Korpela et  al. 2009). Infertility may be identified in 1–2% of men with a history of Chlamydia (Trei et  al. 2008). Gonorrhea can result in obstructive urethral strictures that impair proper vaginal deposition of semen or epididymorchitis affecting sperm quality (Ochsendorf 2008). Tuberculosis can lead to the obstruction of the epididymides and vas deferens by granuloma formation and its associated fibrosis (Kumar 2008). Chronic prostatitis or epididymorchitis due to either atypical or typical bacterial infections can lead to leukocytospermia. The presence of these white blood cells in the semen can result in increased sperm DNA fragmentation thought to be the result of increased reactive oxygen species (Gdoura et al. 2008). While the DNA of herpes viruses can be found in semen of infertile men, no association has been found with abnormal semen parameters (Neofytou et al. 2009). Recent data show that HIV-1 infected men can ejaculate sperm that contain HIV-1 DNA, and this infection may be associated with increased sperm DNA fragmentation (Cardona-Maya et al. 2009; Muciaccia et al. 2007).

Medical History Systemic illnesses may adversely affect a man’s reproductive capacity. Various degrees of hypogonadism can be seen in chronic liver disease, renal failure, thyroid disease, malnutrition, metabolic syndrome and blood dyscrasias (sickle cell anemia, hemachromatosis and thalassemia) (Sokol 2009; Kasturi et al. 2008). Febrile illnesses have been known to decrease sperm concentration that may take 3–4  months from which to recover (Buch and Havlovec 1991). Primary ciliary dyskinesia (disorder of ciliary motility) that includes Kartagener’s (infertility and situs inversus) and Young’s syndrome (azoospermia with epididymal obstruction) present with chronic sinopulmonary infections (Cowan et  al. 2001; Ichioka et  al. 2006; Wilton et  al. 1991). Historically, patients with cystic fibrosis (CF) rarely survived beyond adolescence. With medical advancements, CF men are now surviving into their reproductive years, and fertility is an important survivorship issue. While the vas deferens are absent

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(congenital bilateral absence of the vas deferens or CBAVD) in 99% of CF men, spermatogenesis is normal within the testicles which allows in  vitro fertilization (IVF) to be a viable reproductive option (Taussig et al. 1972; Sokol 2001; Jarzabek et al. 2004; Kaplan et al. 1968). Endocrinopathies may be found in up to 10% of men who undergo a comprehensive male infertility evaluation (Sigman and Jarow 1997). Infertile men with post-pubertal onset of hypogonadism (sexual dysfunction, decreased libido, impaired spermatogenesis, decreased bone and muscle mass, fatigue, decreased facial and body hair, thinning facial skin) may be suffering from a late-onset form of IHH or various pituitary diseases. With normal pubertal development, men with late-onset IHH may report recent-onset impotence or decreased libido (Nachtigall et al. 1997; Ascoli and Cavagnini 2006). The hypogonadism for these men may have gone undiagnosed and untreated for years. Pituitary diseases that may result in hypogonadotropic hypogonadism include craniopharyngioma, prolactinproducing micro- and macroadenomas, infiltrative diseases such as sarcoidosis, amyloidosis, granulomatous diseases of histiocytosis X as well as iron-depositing conditions such as hemochromatosis and transfusionrequiring sickle cell anemia or thalassemia (Sokol 2009). Headaches, galactorrhea and impaired visual fields may be the presenting signs and symptoms of a prolactin-producing pituitary tumour (Mascarell and Sarne 2007; Verhelst and Abs 2003). Of note, infertile men who have the mildest form of androgen resistance will have normal male development and present with only an abnormal semen analysis. Klinefelter’s syndrome is the most common genetic cause of azoospermia. The prevalence is 40 in 100,000 and is found in up to 3% of infertile men. Unfortunately, less than 10% are diagnosed before puberty (Bojesen et al. 2003; Bojesen and Gravholt 2007). The diagnosis is often significantly delayed since few physical abnormalities are seen before puberty and since the presentation of hypogonadism can be insidious with various degrees of virilization that can be quite mild. Unfortunately, the small testes that are firm due to hyalinization of tubules are often overlooked during routine medical exams and only detected during a male infertility examination (Sokol 2009). Presenting with hypergonadotropic hypogonadism and non-obstructive azoospermia, these men may be able to use testicular sperm found by microdissection for IVF with intracytoplasmic sperm injection (ICSI) (Ramasamy et  al. 2009; Paduch et al. 2009).

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Table 3. Medications and male infertility. Medication class Direct effects on sperm or testicle Chemotherapy

Radiation Anti-hypertensives Anti-inflammatories

Antibiotics

Anti-depressants

Examples

References

Cyclophosphamide Chlorambucil Melphalan Busulfan Cisplatin Procarbazine >0.2 Gy Nifedipine Spirinolactone Colchicine

Meistrich (2009), Amory (2007) Meistrich (2009), Amory (2007) Meistrich (2009), Amory (2007) Meistrich (2009), Amory (2007) Meistrich (2009), Amory (2007) Meistrich (2009), Amory (2007) Howell and Shalet (2005), Rowley et al. (1974) Enders (1997), Hershlag et al. (1995) Caminos-Torres et al. (1977) Haimov-Kochman and Ben-Chetrit (1998), Mijatovic et al. (2003) Moody et al. (1997), Heetun et al. (2007) Albert et al. (1975), Reproductive toxicology (1997) Hargreaves et al. (1998) Hargreaves et al. (1998) Hargreaves et al. (1998) Hargreaves et al. (1998) Schlegel et al. (1991) Kumar et al. (2006), Tanrikut et al. (2009) Kumar et al. (2006)

Sulfasalazine Nitrofurantion Erythromycin Tetracycline Co-Trimazole Chloraquine Minocycline Paroxetine Fluoxetine

Indirect effect by altering the HPG axis 5a-Reductase inhibitor Finasteride Dutasteride Anti-androgens Ketoconazole H2 blocker Cimetidine GnRH analogues Leuprolide Goserelin Opiates Methadone Morpheine Anti-psychotics Lithium Chlorpromazine Anti-depressants Imipramine Androgens Testosterone

Selective a-blockers

Anabolic Steroids Tamsulosin

Amory et al. (2007), Liu et al. (2008) Amory et al. (2007) Pont et al. (1984) Van Thiel et al. (1979), Wang et al. (1982) Pace et al. (1991), Wilson et al. (2007) Pace et al. (1991) Daniell (2002), Ragni et al. (1985) Roberts et al. (2002), Singer et al. (1986), Abs et al. (2000) Gibbons and Gibbons (1984), Shen et al. (1992) Levin et al. (1981) Levin et al. (1981) Contraceptive efficacy of testosterone-induced azoospermia in normal men (1990) Holma (1977), Torres-Calleja et al. (2000) Hellstrom and Sikka (2009)

HPG hypothalamic-pituitary-gonadal; GnRH gonadotropin releasing hormone; H2 histamine H2 receptor

Cancer treatments using chemotherapy or radiotherapy may impair spermatogenesis resulting in permanent oligospermia or azoospermia. Prior to cancer therapy, men with testicular cancer have increased sperm DNA fragmentation, and almost 50% of these men with testicular cancer will have subfertile sperm concentrations (<13.5  M/mL) (Williams et  al. 2009). Chemotherapy acts directly on rapidly dividing and genetically active germ cells. Cisplatin and alkylating agents, such as cyclophosphamide, melphalan, busulfan, procarbazine and chlorambucil, as well as radiation, are the most damaging agents (see Table 3). Whether spermatogenesis can fully recover is dependent on the dose and duration of therapy, the number of spermatogonial stem cells that survive and whether they have retained the ability to differentiate (Meistrich 2009). Recovery from

azoospermia after cisplatin-based chemotherapy has been seen in 50% of men at 2 years while 80% recover by 5 years (Howell and Shalet 2005). While the chance of recovery is inversely proportional to the duration of azoospermia, sperm have been shown to return to the ejaculate even after 19 years of azoospermia (Costabile 1993; Marmor et al. 1992; Palmieri et al. 1996; Pryzant et al. 1993). More studies are required to determine the best clinical recommendations concerning the fertility capacity and mutational risk of sperm after cancer therapy since conventional sperm parameters such as concentration and motility will not accurately reflect the genomic integrity (Spermon et al. 2006). Radiotherapy studies show that damage to spermatogonia can be seen at doses as low as 0.2 Gray (Gy) and can be irreversible at doses greater than 1.2  Gy (Howell and Shalet

The Initial Consultation for Male Infertility

2005). Routine radiodiagnostic exams for a man are not associated with impaired fecundity (Sinno-Tellier et al. 2006).

Surgical History A complete history may unveil factors that have caused or are contributing to a diminished reproductive potential for a man. Previous surgeries may suggest possible causes of obstruction or decreased sperm production. Surgery for testicular torsion is associated with decreased sperm counts (Arap et  al. 2007). Scrotal ­surgeries such as hydrocelectomy or spermatocelectomy may result in the injury of adjacent structures such as the epididymis or the vas deferens. These injuries may require microsurgical reconstruction to restore excurrent ductal patency (Zahalsky et al. 2004; Hopps and Goldstein 2006). Inguinal herniorrhapy can result in testicular atrophy (<5%) and vasal injury (<2%). This vasal injury can be successfully microsurgically reconstructed in 57% of cases (Shin et al. 2005; Wantz 1984; Ridgway et al. 2002). Scrotal blunt trauma can lead to direct testicular injury. 80% of ruptured testicles can be preserved, and the risk of developing anti-sperm antibodies exists, but is small (van der Horst et  al. 2004; Lin et al. 1998). Bladder neck surgery, including transurethral resection of the prostate and bladder neck incisions may result in retrograde ejaculation (Ralph and Wylie 2005). With nerve-sparing templates, the incidence of ejaculatory dysfunction has dramatically improved for retroperitoneal lymph node dissections (Jewett and Groll 2007).

Social History In the USA, 35% of men of reproductive age smoke cigarettes. Cigarette smoking is associated with an 18% decrease in total sperm count (Kunzle et  al. 2003). While moderate alcohol intake is unlikely to adversely affect a man’s reproductive potential, excessive or chronic consumption can lead to hypergonadotropic hypogonadism with impaired semen parameters (Marinelli et al. 2004; Muthusami and Chinnaswamy 2005). Marijuana use has been shown to inhibit motility and the acrosome reaction as well as deregulate the hypothalamic-pituitary-gonadal (HPG) axis (Rossato et  al. 2005, 2008; Whan et  al. 2006). Preliminary in vitro sperm studies suggest cocaine impairs sperm motility, while animal studies have shown increased testicular sperm apoptosis (Hurd et  al. 1992; Yang

7

et  al. 2006). Mild to severe emotional stress can depress testosterone by altering LH secretion with secondary impairment of spermatogenesis (McGrady 1984; Nindl et al. 2006; Schneid-Kofman and Sheiner 2005). Recognizing that well-designed studies are needed to understand the risk associated with xenobiotics and other environmental exposures, recent investigations suggest that agricultural pesticides, lead, cadmium, microwave, air pollution, phthalate may impair semen parameters (Swan 2006; Juhler et al. 1999; Jonsson et al. 2005; Ong et al. 2002; Rubes et al. 2005; Schrader et al. 1998; Telisman et al. 2000; Weyandt et al. 1996). Normal testicular temperature is estimated to be 1–2°F less than core body temperature. Excessive use of hot tubs for a month can impair sperm motility (Procope 1965; Shefi et al. 2007). Size and type of underwear do not contribute to abnormally increased scrotal temperatures (Muthusami and Chinnaswamy 2005; Hjollund et  al. 2002). While laptop computers do increase scrotal temperatures, more studies are needed to demonstrate an adverse relationship between the duration of exposure and reproductive potential (Niederberger 2005; Sheynkin et  al. 2005). Saunas have no significant effects on total sperm count or motility (Saikhun et al. 1998). Misuse of anabolic-androgenic steroids (AAS) continues within the arena of amateur and professional sports (Kicman and Gower 2003; Hartgens and Kuipers 2004). Athletes seek to optimize the anabolic effects while minimizing the androgenic effects, and they may not fully appreciate the secondary effect of male infertility (Kuhn 2002). Up to 10% of high school students use AAS (Buckley et al. 1988; Windsor and Dumitru 1989). While athletes have attracted much attention, the majority of users in the USA are actually young men (average age of 30) who are not seeking to maximize their athletic performance. These men aim to optimize strength, increase muscle mass and improve appearances (Cohen et al. 2007). Recognized for their contraceptive properties that induce a hypogonadotropic hypogonadal state associated with testicular atrophy, AAS suppress spermatogenesis and can lead to azoospermia within 120  days. Cessation of AAS can allow for recovery within 3–4  months in 84% of men with only 46% of them returning to their baseline sperm concentration (Holma 1977; Torres-Calleja et  al. 2000; Contraceptive efficacy of testosterone-induced azoospermia in normal men 1990). For those men who remain azoospermic, gonadotropin replacement therapy is a viable option (Turek et al. 1995).

8

Kuang

Medications Medications may impair the sperm quality and quantity or lead to ejaculatory dysfunction. Many drugs can adversely affect spermatogenesis by directly harming sperm or impairing testicular function. Medications can also indirectly negatively impact the HPG axis (Amory 2007). Antibiotics are also a potential contributory cause of impaired fertility (Schlegel et  al. 1991). It is critical to identify any suspect medications during a male infertility evaluation since stopping or changing prescription medications may improve semen parameters in 90% of men and improve pregnancy rates (Hayashi et  al. 2008). A detailed review of all medications is beyond the scope of this article, but an overview is presented with references in Table 3.

Physical Exam Androgen deficiency can result in signs of insufficient virilization. Depending on the onset and duration of hypogonadism, androgen deficiency can result in variable degrees of virilization. Pre-pubertal onset is associated with small penis and testes with possible cryptorchidism, eunuchoid features (arm span exceeds height by more than 5 cm) and the absence of a male pattern of hair distribution. Post-pubertal onset may have more subtle signs of decreased bone and muscle mass, fatigue, decreased facial and body hair, thinning facial skin (see Table 4) (Nachtigall et al. 1997; Ascoli and Cavagnini 2006). Rarely, gynecomastia or galactorrhea may suggest a pituitary abnormality or testosterone/estrogen imbalance. Elevated body mass index (BMI) is associated with a sex hormone imbalance that can increase the risk of infertility by 36% in obese men (Nguyen et al. 2007; Jensen et  al. 2004). Inspection of the abdominal, Table 4. Physical exam of hypogonadal men (Sokol 2009). Feature Voice Pubic, chest and facial hair Male-pattern baldness Eunuchoid Genitalia Size of testes Consistency of testes

Pre-pubertal onset

Post-pubertal onset

High-pitched ↓↓

Normal ↓

No Yes “Infantile” Very small (“infantile”) Firm

Yes No Normal Small Soft

inguinal and scrotal skin may reveal or confirm past surgical scars. The penis is examined for size, hypospadias and chordee. An abnormal urethral meatal location or degree of penile curvature can lead to improper deposition of semen in the posterior fornix of the vagina. The presence of bilateral vas should be confirmed, and any induration may be due to obstruction or inflammation. The absence of one or both vas may be found in 2% of male infertility patients, and they should be screened for cystic fibrosis (CF) genetic mutations (Sokol 2001; Jarzabek et al. 2004). Epididymal cysts, induration or fullness can also suggest an obstructive or inflammatory process. The spermatic cord should be examined for a varicocele: a collection of abnormally dilated veins within the spermatic cord. It is the most common abnormality found on physical exam and is a condition that when corrected can improve a man’s fertility potential (WHO manual for the standardised investigation and diagnosis of the infertile couple 2000; Costabile and Spevak 2001; Marmar et al. 2007). A varicocele can be identified in a standing position by scrotal palpation with and without a Valsalva maneuver (bearing down after a deep breath) (Naughton et al. 2001). Testicular size and consistency should be noted. Normal testicular size is approximately 20 mL, and 85% of the volume is attributed to sperm production by the seminiferous tubules (Spyropoulos et al. 2002; Wikramanayake 1995). Hand-held calipers or testicular ultrasound improves the accuracy of measurements and can be used to calculate the ­volume based on a simple formula (length × width ×  height × 0.71) (Sakamoto et  al. 2007). While small testes are associated with impaired spermatogenesis, it does not accurately predict the presence of testicular sperm even for men with non-obstructive azoospermia (Tunc et  al. 2006). The consistency of the small, firm testicles noted in Klinefelter’s patients is due to hyalinization of tubules, and this is also seen in conditions leading to pre-pubertal onset of hypogonadism. Digital rectal examination may identify benign prostatic enlargement, nodules, and midline abnormalities; confirm the presence of the seminal vesicles; and rule out prostatitis. Transrectal ultrasound can verify any suspected abnormalities. Interestingly, conception rates are the same for infertile men regardless of whether the physical exam was abnormal, supporting the multifactorial nature of fertility and the importance of a concomitant female fertility evaluation (Abramsson et al. 1989).

The Initial Consultation for Male Infertility

Summary A comprehensive male infertility evaluation is a critical part of optimizing a couple’s reproductive potential, and it starts with a thorough history and physical exam. While it is important to identify factors that are impairing a man’s fertile capacity, it is as important to identify disease conditions that may be threatening to a man’s health or life.

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Kuang Sinno-Tellier S, Bouyer J, Ducot B, Geoffroy-Perez B, Spira A, Slama R. Male gonadal dose of ionizing radiation delivered during X-ray examinations and monthly probability of pregnancy: a population-based retrospective study. BMC Public Health. 2006;6:55. Smith JF, Walsh TJ, Turek PJ. Ejaculatory duct obstruction. Urol Clin North Am. 2008;35(2):221–7, viii. Sokol RZ. Infertility in men with cystic fibrosis. Curr Opin Pulm Med. 2001;7(6):421–426. Sokol RZ. Endocrinology of male infertility: evaluation and treatment. Semin Reprod Med. 2009;27(2):149–158. Speiser PW, White PC. Congenital adrenal hyperplasia. N Engl J Med. 2003;349(8):776–788. Spermon JR, Ramos L, Wetzels AM, et  al. Sperm integrity pre- and post-chemotherapy in men with testicular germ cell ­cancer. Hum Reprod. 2006;21(7):1781–1786. Spira A. Epidemiology of human reproduction. Hum Reprod. 1986;1(2):111–115. Spyropoulos E, Borousas D, Mavrikos S, Dellis A, Bourounis M, Athanasiadis S. Size of external genital organs and somatometric parameters among physically normal men younger than 40 years old. Urology. 2002;60(3):485–9; discussion 490–1. Stikkelbroeck NM, Otten BJ, Pasic A, et al. High prevalence of testicular adrenal rest tumors, impaired spermatogenesis, and Leydig cell failure in adolescent and adult males with congenital adrenal hyperplasia. J Clin Endocrinol Metab. 2001;86(12):5721–5728. Swan SH. Semen quality in fertile US men in relation to geographical area and pesticide exposure. Int J Androl. 2006;29(1):62–8; discussion 105–8. Tagatz GE, Okagaki T, Sciarra JJ. The effect of vaginal lubricants on sperm motility and viability in vitro. Am J Obstet Gynecol. 1972;113(1):88–90. Tanrikut C, Feldman AS, Altemus M, Paduch DA, Schlegel PN. Adverse effect of paroxetine on sperm. Fertil Steril. 2009. Taussig LM, Lobeck CC, di Sant’Agnese PA, Ackerman DR, Kattwinkel J. Fertility in males with cystic fibrosis. N Engl J Med. 1972;287(12):586–589. Telisman S, Cvitkovic P, Jurasovic J, Pizent A, Gavella M, Rocic B. Semen quality and reproductive endocrine function in relation to biomarkers of lead, cadmium, zinc, and copper in men. Environ Health Perspect. 2000;108(1):45–53. Thonneau P, Marchand S, Tallec A, et  al. Incidence and main causes of infertility in a resident population (1,850,000) of  three French regions (1988–1989). Hum Reprod. 1991; 6(6):811–816. Torres-Calleja J, De Celis R, Gonzalez-Unzaga M, PedronNuevo N. Effect of androgenic anabolic steroids on semen parameters and hormone levels in bodybuilders. Fertil Steril. 2000;74(5):1055–1056. Trarbach EB, Silveira LG, Latronico AC. Genetic insights into human isolated gonadotropin deficiency. Pituitary. 2007; 10(4):381–391. Trei JS, Canas LC, Gould PL. Reproductive tract complications associated with Chlamydia trachomatis infection in US Air Force males within 4 years of testing. Sex Transm Dis. 2008;35(9):827–833. Tsatsoulis A, Shalet SM. Antisperm antibodies in the polyglandular autoimmune (PGA) syndrome type I: response to cyclical steroid therapy. Clin Endocrinol (Oxf). 1991;35(4): 299–303. Tulandi T, Plouffe L, Jr., McInnes RA. Effect of saliva on sperm motility and activity. Fertil Steril. 1982;38(6):721–723.

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13 Whan LB, West MC, McClure N, Lewis SE. Effects of delta9-tetrahydrocannabinol, the primary psychoactive cannabinoid in marijuana, on human sperm function in vitro. Fertil Steril. 2006;85(3):653–660. Wikramanayake E. Testicular size in young adult Sinhalese. Int J Androl. 1995;18(Suppl 1):29–31. Wilcox AJ, Weinberg CR, Baird DD. Timing of sexual intercourse in relation to ovulation. Effects on the probability of conception, survival of the pregnancy, and sex of the baby. N Engl J Med. 1995;333(23):1517–1521. Wilcox AJ, Dunson DB, Weinberg CR, Trussell J, Baird DD. Likelihood of conception with a single act of intercourse: providing benchmark rates for assessment of post-coital ­contraceptives. Contraception. 2001;63(4):211–215. Williams DH,4th, Karpman E, Sander JC, Spiess PE, Pisters LL, Lipshultz LI. Pretreatment semen parameters in men with cancer. J Urol. 2009;181(2):736–740. Wilson JD, Griffin JE, Russell DW. Steroid 5 alpha-reductase 2 deficiency. Endocr Rev. 1993;14(5):577–593. Wilson AC, Meethal SV, Bowen RL, Atwood CS. Leuprolide acetate: a drug of diverse clinical applications. Expert Opin Investig Drugs. 2007;16(11):1851–1863. Wilton LJ, Teichtahl H, Temple-Smith PD, et al. Young’s syndrome (obstructive azoospermia and chronic sinobronchial infection): a quantitative study of axonemal ultrastructure and function. Fertil Steril. 1991;55(1):144–151. Windsor R, Dumitru D. Prevalence of anabolic steroid use by male and female adolescents. Med Sci Sports Exerc. 1989;21(5):494–497. Witt MA, Grantmyre JE. Ejaculatory failure. World J Urol. 1993;11(2):89–95. Yang GS, Wang W, Wang YM, Chen ZD, Wang S, Fang JJ. Effect of cocaine on germ cell apoptosis in rats at different ages. Asian J Androl. 2006;8(5):569–575. Zahalsky MP, Berman AJ, Nagler HM. Evaluating the risk of epididymal injury during hydrocelectomy and spermatocelectomy. J Urol. 2004;171(6 Pt 1):2291–2292.

Interpretation of Basic Semen Analysis and Advanced Semen Testing Ashok Agarwal and Tamer M. Said

Contents Introduction....................................................................................................................................................................... Basic Semen Analysis....................................................................................................................................................... Macroscopic Parameters.............................................................................................................................................. Microscopic Parameters............................................................................................................................................... Sperm Motion Kinetics..................................................................................................................................................... Investigations for Antisperm Antibodies.......................................................................................................................... Sperm Function Tests........................................................................................................................................................ Evaluation of Oxidative Stress.......................................................................................................................................... Assessment of DNA Integrity........................................................................................................................................... Summary........................................................................................................................................................................... References.........................................................................................................................................................................

Introduction A consensus exists that the basic semen analysis is the most important tool in male fertility investigation. In the last two decades, researchers and clinicians alike have relied on the World Health Organization (WHO) criteria for the interpretation of basic semen analysis. Nevertheless, the criteria for what constitutes a normal semen analysis remain controversial. Although a single test such as the routine semen analysis can deliver several sperm attributes, male fertility cannot be determined based solely on its results. In this

A. Agarwal (*) Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA e-mail: [email protected] T.M. Said The Toronto Institute for Reproductive Medicine – ReproMed, Toronto, ON, Canada

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chapter, we present an overview of the interpretation of results derived from the most standardized tests used for the evaluation of the fertility potential of a seminal ejaculate.

Basic Semen Analysis Routine semen analysis continues to be the main pillar in male fertility investigation. In order to establish consistency in laboratory procedures, the WHO first published a manual for the examination of human semen and semen-cervical mucus interaction in 1980. The manual also identified standards to exclude ­influences such as the health of patient over the previous spermatogenic cycle, length of sexual abstinence, time, and temperature. The manual has been regularly updated (1980, 1987, 1992, 1999) (Lewis 2007). The addition of normal reference values in the WHO manuals has been of significant help in establishing some consistency of what constitutes a normal value

From: Current Clinical Urology: Male Infertility: Problems and Solutions, Edited by: E.S. Sabanegh, DOI: 10.1007/978-1-60761-193-6_2,  Springer Science+Business Media, LLC 2011

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(Table  1). Nevertheless, it is critical to note that the WHO manuals report reference values identified in fertile population rather than the minimum requirements for male fertility. Most recently, the data have been modified based on the assessment of 4,500 men in 14 different countries. In men, whose partners were able to conceive within 12 months (n = 428 – 1,941), the lower reference limits were: semen volume = 1.5/mL; total sperm number = 39 million per ejaculate; sperm concentration = 15 million/mL; vitality = 58% live; progressive motility = 32%; total (progressive + nonprogressive) motility = 40%; morphologically normal forms = 4.0% (Cooper et al. 2010). The heterogeneity of human semen further diminishes the clinical significance of the WHO reference values. Data indicate that there are subtle variations in semen parameters between men in different geographic areas and even between samples from the same individual (Alvarez et al. 2003; Jorgensen et al. 2001). The limited power of semen analysis in predicting fertility has been reported from the 1980s to the present (Glazener et al. 1987; Swan 2006). Analysis of the seminal fluid must include the evaluation of both macroscopic and microscopic parameters. Analysis should be performed on multiple ejaculates before characterizing a man as normal or infertile due to the large within-subject variation in sperm parameters (Keel 2006).

Macroscopic Parameters The macroscopic properties of a semen sample include volume, appearance, color, coagulation/liquefaction, Table 1. Normal values for semen parameters according to the WHO (1999). Parameter Volume pH Concentration Total spermatozoa per ejaculate Motility Morphology

Viability Leukocytes Antisperm antibodies Zinc Citric acid Fructose

Reference value ³2.0 mL 7.2–8.0 ³20 × 106/mL ³40 × 106 ³50% motile (grade a + b), or ³25% grade a Data suggest that <15% is associated with decreased fertilization following assisted reproductive techniques ³75% live spermatozoa <1.0 × 106/mL <50% bound sperm using immunobead or MAR tests ³2.4 mM per ejaculate ³52 mM per ejaculate ³13 mM per ejaculate

and viscosity. The volume (normal >2  mL) of the ejaculate is an accurate indicator of various abnormalities. Absence of any semen volume after orgasm, termed aspermia, occurs in patients with diabetic neuropathy, following the intake of sympatholytic drugs and following surgical procedures that damage the sympathetic nervous plexus or resection of the prostate. In some of these cases, there may be retrograde flow of the semen into the bladder, and the examination of the postejaculatory urine should be conducted. Hypospermia (semen volume <0.5 mL), could be due to the loss of a portion of the ejaculate during collection, short abstinence period or incomplete orgasm. Hypospermia with pH less than 7.4 may indicate partial/complete ejaculatory duct obstruction or absent seminal vesicles. If hypospermia is associated with pH more than 7.8, it could indicate accessory gland impairment as in the case of hypogonadism, inflammation, or narcotics intake. Regarding the appearance, it was thought that a translucent sample denotes the absence of sperm cells; however, other nonsperm cellular components may render the sample opaque. Therefore, the appearance of an ejaculate, whether translucent or opaque, does not seem to have any clinical value. Semen color is also considered insignificant in assessing sperm fertilization potential. However, it may be a good sign of associated clinical conditions, such as excessive erythrocytes, i.e., hematospermia (red color) or jaundice (yellow color). A normal semen sample coagulates immediately after ejaculation and then liquefies within 15–30 min. Failure of coagulation denotes the lack of secretions from the seminal vesicles, which may be due to either obstruction or the absence of seminal vesicles. Prolonged liquefaction indicates poor prostatic secretion as in the case of inflammation. Viscosity is another parameter that is considered abnormal if the length of a thread exceeds 60 mm. If these cases are associated with low sperm motility, the sperm transportation will be compromised.

Microscopic Parameters Microscopic attributes of the seminal fluid include sperm concentration, motility, viability, morphology as well as nonsperm cellular components in the form of leukocyte concentration and immature germ cells. Among the parameters reported in a routine semen analysis, it is not yet known which one would be the most associated with fertility. While multiple reports

Interpretation of Basic Semen Analysis and Advanced Semen Testing

point to sperm morphology as the parameter with the most discriminatory power, others indicate that sperm concentration and/or motility are the most valuable (Lewis 2007).

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collection (World Health Organization 1999). The presence of low sperm motility, asthenozoospermia, could occur as a result of prolonged time to processing of collected samples. Sample containers may be toxic to the sperm, and sample exposure to extreme Sperm Concentration temperature or sunlight may result in decreased sperm motility. Long periods of abstinence also proved to The cutoff point of 20 million spermatozoa/mL has be a cause of poor sperm motility. Other causes of been repeatedly suggested as the lower normal value asthenozoospermia include sperm axonemal deformifor sperm concentration in an ejaculate (World Health ties, excessive leukocytes, and unknown idiopathic Organization 1999). In a study that evaluated two factors. Asthenozoospermia is also most commonly semen specimens from each of the male partners in seen with antisperm antibodies. The observation of 765 infertile couples and 696 fertile couples, subfersperm clumping combined with low sperm motility tile men had sperm concentrations of less than 13.5 ×  is a further indication of the presence of antisperm 106/mL (Guzick et  al. 2001). On the other hand, antibodies. another study that evaluated 166 male factor inferAsthenozoospermia warrants the investigation of tility patients and 56 proven fertile donors has sperm viability to identify the presence of necrosuggested the concentration of 31.2 × 106/mL as a zoospermia (nonviable spermatozoa). Immotile sperm prognostic factor for fertility status (Nallella et  al. may still be viable and could be used in assisted 2006). Therefore, the literature describes significant reproductive techniques (ART). Sperm viability could overlap in threshold sperm concentration between be assessed using supravital stains such as Eosin-Y. fertile and infertile men. The percentage of sperm with intact membranes that The observation of a low sperm concentration, exclude the stain should be equal to or exceed 75% oligozoospermia, is indicated when sperm concen(World Health Organization 1999). tration falls below 5–10 × 106/mL depending on the cutoff point used. It may be due to the loss of a portion of the ejaculate, partial obstruction of the Sperm Morphology genital tract, drugs or genetic abnormalities. Other Different methods for staining and the evaluation of factors include medications such as nitrofurantoin sperm morphology have been described (Ombelet and excessive heat exposure. On the other hand, et  al. 1995). One method for assessing morphology azoospermia, complete absence of spermatozoa, is based on the sperm meeting strict criteria (Kruger may be due to the obstruction of the sperm transport, et al. 1987). Both the WHO suggested criteria and the hypogonadism, and iatrogenic causes, such as chemstrict method constitute the two most commonly used otherapy or idiopathic factors, that are most probably criteria for the evaluation of normal sperm morpholgenetic in origin. If azoospermia is detected, the ogy. Data highlight a reasonable predictive power of semen analysis must be repeated to confirm that no sperm morphology in centers using the same or differiatrogenic cause, such as loss of the sample, was the ent criteria, however, the cutoff values for normality reason of the finding. Documented azoospermia is are different (Ombelet et al. 1997). one of the conditions, where chemical analysis of the Debate is still ongoing regarding the evaluation seminal plasma may be of importance. Fructose, norcriteria that should be used and the one that offers the mally present in seminal plasma, originates mainly most predictive power for in  vivo and in  vitro fertilfrom the seminal vesicles. Absence of fructose in ity. Previously, the WHO manuals recommended 30% azoospermic patient may be indicative of ductal normal forms as the cutoff point for normality (World obstruction (Jarow et al. 1989). Health Organization 1992). On the other hand, authors advocating the use of the strict criteria suggest >4% Sperm Motility as a cutoff point for correlation with positive IVF The presence of progressively motile sperm in the outcomes. A systematic review has evaluated the data ejaculate is critical to ensure adequate sperm trans- produced around the 5% normal sperm morphology port and fertilization. Sperm motility is considered as threshold using the strict criteria. Results showed compromised if the percentage of forward ­progressive that the overall fertilization rates were 59.3% for the sperm falls below 50% within 60  min of sample £4% group, 77.6% for the >4% group, and the overall

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pregnancy rates were 15.2% and 26.0%, respectively (Coetzee et al. 1998). It is important to note that other studies have found the strict criteria to be of less value in predicting IVF outcomes. A study conducted on 132 couples undergoing IVF found that the comparison of traditional morphology and strict criteria with regard to IVF outcome favored traditional morphology in several areas. In particular, low scores were more predictive of poor IVF outcome (Morgentaler et  al. 1995).

Nonsperm Cellular Components Immature germ cells in the ejaculate are usually associated with below normal sperm counts. Special attention should be given to the concentration of leukocytes in the seminal ejaculate. Leukocytes are normally present in the seminal fluid; however, a concentration of >1 × 106/mL is considered abnormal (World Health Organization 1999). A positive correlation was observed between leukocyte count and the total count of microorganisms in semen sample. An optimal sensitivity/specificity ratio appears at 0.2 × 106 WBC/mL semen (Punab et al. 2003). The excessive presence of leukocytes may be detrimental to spermatozoa due to their excessive production of reactive oxygen species (ROS) and cytotoxic cytokines. The presence of erythrocytes is indicative of reproductive tract pathology, while the presence of microorganisms is an indication of genital tract infection.

Sperm Motion Kinetics Several systems referred to as computer-aided semen analyzers (CASA) have been developed using digital image analysis for the automated analysis of seminal ejaculate (Mortimer 2000). Although this technology was initially welcomed as a major contribution to the semen diagnostics, its application has been challenged by a wide margin of error in setup procedures and object detection (Davis and Katz 1993). Thus, to date, manual semen analysis performed by a welltrained technician remains the most reliable method for the assessment of sperm concentration, percentage motility and morphology (Consensus Workshop on Advanced Diagnostic Andrology Techniques 1996). Relying on serial digital images, the CASA system can plot the movement of a sperm head creating a trajectory and reconstructing the movement track. This function appears to be the only area, where CASA can be of benefit since the resulting sperm motion

Agarwal and Said

kinetics are impossible to assess using routine microscopy. Sperm kinetics include measuring the distance between each head point for a given sperm during the acquisition period (curvilinear velocity, VCL, mm/s), the distance between first and last head points divided by the acquisition time (straight line velocity, VSL, mm/s), and the measure of sperm head oscillation (amplitude of lateral head displacement, ALH, mm). Linearity (LIN, %) measures the departure from linear progression and is calculated as VSL/VCLX100, while the average path velocity (VAP, mm/s) is a smoothed path constructed by averaging several positions on the sperm track (Kay and Robertson 1998). Several studies have shown that the quantitative assessment of sperm kinetics is of clinical value in identifying men with unexplained infertility and predicting in  vivo and in  vitro fertility (Consensus Workshop on Advanced Diagnostic Andrology Techniques 1996; Peedicayil et  al. 1997; Shibahara et  al. 2004). Despite the documented clinical value of assessment of sperm kinetics, there is an agreement that individual motion characteristics are of little value (Consensus Workshop on Advanced Diagnostic Andrology Techniques 1996). Moreover, it was agreed that studies that have only reported differences in sperm kinetics between populations do not provide any useful information (Guidelines on the Application of CASA Technology in the Analysis of Spermatozoa 1998). A relevant analysis of the sperm motion should focus on the identification of normal values for a movement pattern. As an example, spermatozoa capable of penetrating preovulatory cervical mucus had VAP ± 25.0  mm and ALH ± 4.5  mm (Mortimer et  al. 1986; Aitken et al. 1985). Another specific movement pattern is hyperactivation, which is acquired during the capacitation process and enables spermatozoa of mechanical thrust to penetrate the zona pellucida (Ho and Suarez 2001). Several values have been suggested to define hyperactivated sperm (VSL: 0.1 to >91.5  mm/s, LIN: <60 to 345%, ALH: 0.5 to >9.9 mm) (Kay and Robertson 1998). Clearly, the difference in CASA instruments used, their setup as well as the counting chambers between studies have made it impossible to reach an agreement. To date, there is no consensus regarding the proportion of hyperactivated sperm that should be present in the ejaculates of fertile men. Although a correlation was established between hyperactivation and successful fertilization in vitro (Sukcharoen et al. 1995), this parameter cannot be considered of clinical significance since there are no universal criteria to define hyperactivation.

Interpretation of Basic Semen Analysis and Advanced Semen Testing

Investigations for Antisperm Antibodies The presence of antisperm antibodies (ASA) has been documented to impede human fertility via several mechanisms (Naz and Menge 1994). Nevertheless, the testing for ASA is controversial due to variations between different testing methodologies and the interpretation of the results in the context of male infertility. Most of the methods previously described for the detection of ASA are now obsolete due to the relatively high interassay variability and their limited clinical benefits. Only two methods are now accepted to test for the presence of ASA, the mixed antiglobulin reaction (MAR) test and the immunobead test (IBT) (World Health Organization 1999). The currently recognized cutoff point for a positive ASA test stands at 50% of spermatozoa showing the binding in the MAR test or the IBT (World Health Organization 1999). In general, there is a limited role for ASA testing in the diagnosis of male infertility and any subsequent treatments that might be contemplated accordingly. Elevated ASA levels were seen in 18% of men presenting with unexplained infertility in one study (Fichorova and Boulanov 1996). Therefore, a valid indication for ASA testing appears to be cases with unexplained infertility, where a reason for delay in fertility could be attributed to the presence of ASA. Other indications could include severe asthenozoospermia.

Sperm Function Tests The diagnosis of male infertility is mostly based on the descriptive evaluation of human semen, including the number of spermatozoa that are present in the ejaculate, their motility, and their morphology. However, it is not so much the absolute number of spermatozoa that determines fertility, but their functional competence (Aitken 2006). Sperm function testing is used to determine if the sperm have the biologic capacity to perform the tasks necessary to reach and fertilize ova and ultimately result in live births. These tasks include penetrating the cervical mucus, reaching the ova, undergoing capacitation and the acrosome reaction, zona pellucida penetration, and ooplasm incorporation. Defects in any of these steps may result in infertility (Sigman and Zini 2009). In the era of IVF and ICSI, sperm function testing appears to have lost some of its significance. However,

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many couples are looking for less invasive and inexpensive solutions, therefore establishing an exact diagnosis in these cases would be extremely important to identify success rates for spontaneous pregnancy or intrauterine insemination (Muller 2000). Several sperm function tests have been developed, including tests for cervical mucus penetration, capacitation, zona recognition, the acrosome reaction, and sperm–oocyte fusion. However, few were adopted in routine clinical practice and no single sperm function has been proven to be a reliable predictor of male fertility. Three functions have been widely investigated as diagnostics for male fertility: sperm–mucus penetration, acrosome reaction, and zona penetration capabilities (Agarwal et al. 2008a). Sperm–cervical mucus penetration tests (SMTP) measure the ability of spermatozoa in the semen to swim through cervical mucus or substitute. Each test, whether in vitro or in vivo SMTP, has a different reference range which adds to the dilemma of interpreting the results. According to the WHO criteria, the presence of >50 motile spermatozoa/high power field in cervical mucus collected during the postcoital test indicates a normal clinical condition. Another important clinical use of the sperm–mucus penetration test is in the diagnosis of sperm autoimmunity (Kremer and Jager 1992). Acrosome reaction (AR), the release of proteolytic enzymes allowing egg penetration, should occur at the time of sperm–zona binding. Two types of anomalies could be seen in AR tests. AR insufficiency occurs when the difference in AR between calcium ionophore treated and untreated sperm is <15%, while AR prematurity is described when >20% of spermatozoa show spontaneous AR (Tesarik and Mendoza 1995). Both deficiencies could be bypassed by performing ICSI. The zona-free hamster oocyte sperm penetration assay (SPA) examines the ability of human spermatozoa to capacitate, undergo the acrosome reaction, fuse with the vitelline membrane of the oocyte and initiate nuclear decondensation (Johnson et  al. 1995). Normal cutoff values have been reported to be 4–20% (Muller 2000). Applications of the SPA include the prediction of the likelihood of spontaneous pregnancy in vivo and the likelihood of successful fertilization during IVF. While correlation with IVF results has been documented, results of SPA may not be considered meaningful as the test was reported to have 20–30% false positive rates and 0–100% false negative rates (Consensus Workshop on Advanced Diagnostic Andrology Techniques 1996).

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Evaluation of Oxidative Stress Oxidative stress has been widely implicated in the pathogenesis of male infertility (Sharma and Agarwal 1996; Agarwal et  al. 2008b). Normally, equilibrium exists between ROS production and antioxidant scavenging activities in the male reproductive tract. However, the production of excessive amounts of ROS produced by leukocytes and immature spermatozoa may overwhelm the antioxidant defense mechanisms and cause oxidative stress. Although the number of leukocytes in the ejaculate correlates with higher levels of ROS, the leukocyte number alone cannot be used to assess the level of ROS because leukocyte levels below the accepted WHO reference values were also shown to be associated with ROS (Sharma et al. 2001). The OS status of an individual can be identified by measuring the ROS levels and total antioxidant capacity (TAC). ROS levels are usually measured by chemiluminescence method (Kobayashi et  al. 2001), while total antioxidant capacity is measured by enhanced chemiluminescence assay or colorimetric assay (Said et  al. 2003). Recently, normal reference values for seminal ROS in fertile population have been developed. In semen samples without leukocytes, the normal cutoff for ROS was 0.55 × 104 counted photons per minute with 76.4% area under the curve (AUC) in the neat samples and 10.0 × 104 counted photons per minute with 77% AUC in the washed samples. In semen samples with leukocytes (<1 × 106), the cutoff for ROS in neat samples was 1.25 with 72.7% AUC and 51.5 with 81% AUC in the washed samples (Athayde et  al. 2007). The reference values for TAC is 1,420 mM trolox equivalent/mL. Infertile men with seminal plasma TAC below the above value may have depleted TAC and are therefore more vulnerable to OS-induced damage. A ROS-TAC score has been proposed as a parameter derived both from levels of ROS produced and the antioxidant levels. The composite score is calculated using the principal component analysis, which provides linear combinations or weighted sums that account for the most variability among correlated variables (Sharma et  al. 1999). Therefore, the ROSTAC score minimizes the variability present in the individual parameters of oxidative stress. ROS-TAC score was used to identify patients with idiopathic infertility as patients who had lower scores compared to controls (32.8 ± 14.2 vs. 50.0 ± 10.0, p < 0.001) (Pasqualotto et  al. 2008a). A similar approach was used to characterize infertile patients with ­varicocele

Agarwal and Said

providing a mechanism for infertility in these cases (Pasqualotto et  al. 2008b). Most importantly, ROSTAC scores were correlated with pregnancy outcomes. The expected pregnancy rates for a patient with ROS-TAC score of 30 would be 13.9, 21.0, and 31.6% for 12, 24, and 36 months, respectively; whereas a score of 50 would have expected pregnancy rates of 35.1, 48.9, and 54.3% over the same intervals (Sharma et al. 1999).

Assessment of DNA Integrity Assessment of the sperm DNA integrity is one of the most investigated sperm parameters during the last decade. Yet, there is little consensus regarding testing methodologies for sperm DNA integrity and cutoff points that are clinically relevant with in  vivo and in vitro fecundity. Different methods may be used to evaluate the status of the sperm DNA for the presence of abnormalities or simply immaturity. Most of these assays have many advantages as well as limitations. The choice of which assay to perform depends on many factors, such as the expense, the available laboratory facilities, and the presence of experienced technicians. Among the different methods that could be used, only the flow cytometric-based sperm chromatin structure assay (SCSA) and terminal deoxynucleotidyl transferase-mediated fluorescein-deoxyuridine triphosphate-nick end labeling assay (TUNEL) assay have been well standardized and have made their way in routine clinical practice. Testing for sperm DNA integrity is to be considered for the screening of infertile men as well as for the cases of unexplained infertility (Host et  al. 1999; Saleh et  al. 2002). Testing has also been recommended as a prognostic factor of ART outcomes (Evenson and Wixon 2006; Evenson and Wixon 2008). The cutoff values for abnormal samples vary between 27 and 40% of sperm showing fragmented DNA using the SCSA and between 20 and 36% using the TUNEL assay (Sergerie et  al. 2005; Committee 2008). However, a recent systematic review and metaanalysis reported that the commonly used tests, such as SCSA and TUNEL, may not be predictive of pregnancy outcome after IVF/ICSI (Collins et  al. 2008). The study suggests testing of DNA integrity may be appropriate in the subgroups of infertile patients, such as couples with history of repeated pregnancy loss and those with idiopathic infertility (Carrell et  al. 2003; Saleh et al. 2003).

Interpretation of Basic Semen Analysis and Advanced Semen Testing

Summary Routine semen analysis is almost always performed as a part of the investigation of the infertile couple and its interpretation plays a major role in charting the treatment plan(s). Human semen is very different from other body fluids, mainly because of its heterogeneity, which has negative effects on the quality of the semen analysis. Thus, there is a legitimate concern about the value of semen analysis in any clinical situation, although it remains an essential tool for the identification of infertility and the diagnosis of its severity. Technical variations in semen testing methodologies add to the challenges that face clinicians while attempting to deduct clinically significant information from these various assays. The results of routine semen analysis and other investigations currently available should not be overinterpreted and should be considered in conjunction with the history and clinical examination of the infertile couple.

References Agarwal A, Bragais FM, Sabanegh E. Assessing sperm function. Urol Clin North Am. 2008a;35:157–171, vii Agarwal A, Makker K, Sharma R. Clinical relevance of oxidative stress in male factor infertility: an update. Am J Reprod Immunol. 2008b;59:2–11 Aitken RJ. Sperm function tests and fertility. Int J Androl. 2006;29:69–75; discussion 105–108 Aitken RJ, Sutton M, Warner P, Richardson DW. Relationship between the movement characteristics of human spermatozoa and their ability to penetrate cervical mucus and zonafree hamster oocytes. J Reprod Fertil. 1985;73:441–449 Alvarez C, Castilla JA, Martinez L, Ramirez JP, Vergara F, Gaforio JJ. Biological variation of seminal parameters in healthy subjects. Hum Reprod. 2003;18:2082–2088 Athayde KS, Cocuzza M, Agarwal A, et al. Development of normal reference values for seminal reactive oxygen species and their correlation with leukocytes and semen parameters in a fertile population. J Androl. 2007;28:613–620 Carrell DT, Liu L, Peterson CM, et al. Sperm DNA fragmentation is increased in couples with unexplained recurrent pregnancy loss. Arch Androl. 2003;49:49–55 Coetzee K, Kruge TF, Lombard CJ. Predictive value of normal sperm morphology: a structured literature review. Hum Reprod Update. 1998;4:73–82 Collins JA, Barnhart KT, Schlegel PN. Do sperm DNA integrity tests predict pregnancy with in  vitro fertilization? Fertil Steril. 2008;89:823–831 Committee AP. The clinical utility of sperm DNA integrity testing. Fertil Steril. 2008;90:S178–S180 Consensus Workshop on Advanced Diagnostic Andrology Tech­ niques. ESHRE (European Society of Human Reproduction and Embryology) Andrology Special Interest Group. Hum Reprod. 1996;11:1463–1479 Cooper TG, Noonan E, von Eckardstein S, et al. World Health Organization reference values for human semen characteristics. Hum Reprod Update. 2010;16(3):231–245

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Davis RO, Katz DF. Operational standards for CASA instruments. J Androl. 1993;14:385–394 Evenson D, Wixon R. Meta-analysis of sperm DNA fragmentation using the sperm chromatin structure assay. Reprod Biomed Online. 2006;12:466–472 Evenson DP, Wixon R. Data analysis of two in  vivo fertility studies using Sperm Chromatin Structure Assay-derived DNA fragmentation index vs. pregnancy outcome. Fertil Steril. 2008;90:1229–1231 Fichorova RN, Boulanov ID. Anti-seminal plasma antibodies associated with infertility: I. Serum antibodies against normozoospermic seminal plasma in patients with unexplained infertility. Am J Reprod Immunol. 1996;36:198–203 Glazener CM, Coulson C, Lambert PA, et al. The value of artificial insemination with husband’s semen in infertility due to failure of postcoital sperm-mucus penetration--controlled trial of treatment. Br J Obstet Gynaecol. 1987;94: 774–778 Guidelines on the Application of CASA Technology in the Analysis of Spermatozoa. ESHRE Andrology Special Interest Group. European Society for Human Reproduction and Embryology. Hum Reprod. 1998;13:142–145 Guzick DS, Overstreet JW, Factor-Litvak P, et al. Sperm morphology, motility, and concentration in fertile and infertile men. N Engl J Med. 2001;345:1388–1393 Ho HC, Suarez SS. Hyperactivation of mammalian spermatozoa: function and regulation. Reproduction. 2001;122:519–526 Host E, Lindenberg S, Kahn J, Christensen F. DNA strand beaks in human sperm cells: a comparison between men with normal and oligozoospermic sperm samples. Acta Obstet Gynecol Scand. 1999;78:336–339 Jarow JP, Espeland MA, Lipshultz LI. Evaluation of the azoospermic patient. J Urol. 1989;142:62–65 Johnson A, Bassham B, Lipshultz LI, Lamb DJ. A quality control system for the optimized sperm penetration assay. Fertil Steril. 1995;64:832–837 Jorgensen N, Andersen AG, Eustache F, et al. Regional differences in semen quality in Europe. Hum Reprod. 2001;16: 1012–1019 Kay VJ, Robertson L. Hyperactivated motility of human spermatozoa: a review of physiological function and application in assisted reproduction. Hum Reprod Update. 1998;4: 776–786 Keel BA. Within- and between-subject variation in semen parameters in infertile men and normal semen donors. Fertil Steril. 2006;85:128–134 Kobayashi H, Gil-Guzman E, Mahran AM, et al. Quality control of reactive oxygen species measurement by luminol-dependent chemiluminescence assay. J Androl. 2001;22:568–574 Kremer J, Jager S. The significance of antisperm antibodies for sperm-cervical mucus interaction. Hum Reprod. 1992;7: 781–784 Kruger TF, Acosta AA, Simmons KF, et  al. New method of evaluating sperm morphology with predictive value for human in vitro fertilization. Urology. 1987;30:248–251 Lewis SE. Is sperm evaluation useful in predicting human fertility? Reproduction. 2007;134:31–40 Morgentaler A, Fung MY, Harris DH, Powers RD, Alper MM. Sperm morphology and in  vitro fertilization outcome: a direct comparison of World Health Organization and strict criteria methodologies. Fertil Steril. 1995;64:1177–1182 Mortimer ST. CASA-practical aspects. J Androl. 2000;21: 515–524

22 Mortimer D, Pandya IJ, Sawers RS. Relationship between human sperm motility characteristics and sperm penetration into human cervical mucus in  vitro. J Reprod Fertil. 1986;78:93–102 Muller CH. Rationale, interpretation, validation, and uses of sperm function tests. J Androl. 2000;21:10–30 Nallella KP, Sharma RK, Aziz N, Agarwal A. Significance of sperm characteristics in the evaluation of male infertility. Fertil Steril. 2006;85:629–634 Naz RK, Menge AC. Antisperm antibodies: origin, regulation, and sperm reactivity in human infertility. Fertil Steril. 1994;61:1001–1013 Ombelet W, Menkveld R, Kruger TF, Steeno O. Sperm morphology assessment: historical review in relation to fertility. Hum Reprod Update. 1995;1:543–557 Ombelet W, Wouters E, Boels L, et  al. Sperm morphology assessment: diagnostic potential and comparative analysis of strict or WHO criteria in a fertile and a subfertile population. Int J Androl. 1997;20:367–372 Pasqualotto FF, Sharma RK, Pasqualotto EB, Agarwal A. Poor semen quality and ROS-TAC scores in patients with idiopathic infertility. Urol Int. 2008a;81:263–270 Pasqualotto FF, Sundaram A, Sharma RK, Borges E, Jr., Pasqualotto EB, Agarwal A. Semen quality and oxidative stress scores in fertile and infertile patients with varicocele. Fertil Steril. 2008b;89:602–607 Peedicayil J, Deendayal M, Sadasivan G, Shivaji S. Assessment of hyperactivation, acrosome reaction and motility characteristics of spermatozoa from semen of men of proven fertility and unexplained infertility. Andrologia. 1997;29:209–218 Punab M, Loivukene K, Kermes K, Mandar R. The limit of leucocytospermia from the microbiological viewpoint. Andrologia. 2003;35:271–278 Said TM, Kattal N, Sharma RK, et al. Enhanced chemiluminescence assay vs colorimetric assay for measurement of the total antioxidant capacity of human seminal plasma. J Androl. 2003;24:676–680 Saleh R, Agarwal A, Nelson D, et al. Increased sperm nuclear DNA damage in normozoospermic infertile men: a prospective study. Fertil Steril. 2002;78:313–318

Agarwal and Said Saleh RA, Agarwal A, Nada EA, et  al. Negative effects of increased sperm DNA damage in relation to seminal oxidative stress in men with idiopathic and male factor infertility. Fertil Steril. 2003;79(Suppl 3):1597–1605 Sergerie M, Laforest G, Bujan L, Bissonnette F, Bleau G. Sperm DNA fragmentation: threshold value in male fertility. Hum Reprod. 2005;20:3446–3451 Sharma RK, Agarwal A. Role of reactive oxygen species in male infertility. Urology. 1996;48:835–850 Sharma RK, Pasqualotto FF, Nelson DR, Thomas AJ, Jr., Agarwal A. The reactive oxygen species-total antioxidant capacity score is a new measure of oxidative stress to predict male infertility. Hum Reprod. 1999;14:2801–2807 Sharma RK, Pasqualotto AE, Nelson DR, Thomas AJ, Jr., Agarwal A. Relationship between seminal white blood cell counts and oxidative stress in men treated at an infertility clinic. J Androl. 2001;22:575–583 Shibahara H, Obara H, Ayustawati, et al. Prediction of pregnancy by intrauterine insemination using CASA estimates and strict criteria in patients with male factor infertility. Int J Androl. 2004;27:63–68 Sigman M, Zini A. Semen analysis and sperm function assays: what do they mean? Semin Reprod Med. 2009;27: 115–123 Sukcharoen N, Keith J, Irvine DS, Aitken RJ. Definition of the optimal criteria for identifying hyperactivated human spermatozoa at 25 Hz using in-vitro fertilization as a functional end-point. Hum Reprod. 1995;10:2928–2937 Swan SH. Semen quality in fertile US men in relation to geographical area and pesticide exposure. Int J Androl. 2006;29:62–68; discussion 105–108 Tesarik J, Mendoza C. Alleviation of acrosome reaction prematurity by sperm treatment with egg yolk. Fertil Steril. 1995; 63:153–157 World Health Organization: WHO laboratory Manual for the Examination of Human Semen and Sperm-Cervical Mucus Interaction. Cambridge University Press. 1992;4. World Health Organization: WHO laboratory Manual for the Examination of Human Semen and Sperm-Cervical Mucus Interaction. Cambridge University Press. 1999;4

Azoospermia: Diagnosis and Management John C. Kefer and Dan B. French

Contents Introduction....................................................................................................................................................................... Initial Evaluation............................................................................................................................................................... History and Physical Exam.......................................................................................................................................... Semen Analysis............................................................................................................................................................ Serum Hormonal Evaluation........................................................................................................................................ Genetic Testing................................................................................................................................................................. Y Chromosome Microdeletions................................................................................................................................... Karyotype..................................................................................................................................................................... CFTR Gene Mutation Screening.................................................................................................................................. Diagnosis........................................................................................................................................................................... Common Causes of Azoospermia..................................................................................................................................... Obstructive Causes....................................................................................................................................................... Nonobstructive Causes................................................................................................................................................. Ejaculatory Dysfunction................................................................................................................................................... Summary........................................................................................................................................................................... References.........................................................................................................................................................................

Introduction Azoospermia, or the complete absence of sperm in the ejaculate, accounts for 10–20% of males presenting with infertility (Jarow et  al. 1989). Azoospermia is diagnosed when two semen samples, given at least 2 weeks apart, show no sperm before or after centrifugation (Sharlip et al. 2006). The presence of any J.C. Kefer Center for Male Fertility/Andrology, Glickman Urological and Kidney Institute, Mailcode Q10, 9500 Euclid Ave, 44113 Cleveland, OH, USA D.B. French () Dallas Center for Pelvic Medicine, Suite 200, 10501 N Central Expressway, 75231 Dallas, TX, USA e-mail: [email protected]

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sperm in the centrifuged pellet is considered severe oligospermia, also called cryptospermia, ruling out obstruction. The initial evaluation of the azoospermic patient should be to classify the condition as obstructive or nonobstructive.

Initial Evaluation History and Physical Exam The etiology of azoospermia is first determined through careful patient history. Pertinent information regarding the initial history is covered in detail in the chapter “The Initial Consultation for Male Infertility.” Table  1 summarizes some of the salient aspects of a patient history. A careful physical exam provides

From: Current Clinical Urology: Male Infertility: Problems and Solutions, Edited by: E.S. Sabanegh, DOI: 10.1007/978-1-60761-193-6_3,  Springer Science+Business Media, LLC 2011

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Kefer and French

Table 1. Pertinent history. Suggestive of testis failure Cryptorchidism Testicular torsion Malignancy, chemotherapy or radiation Mumps Toxic exposures Pubertal onset Suggestive of endocrinopathy Anosmia Severe headaches Visual field disturbances Substance/steroid abuse Gynecomastia

Suggestive of obstruction or ejaculatory dysfunction Genital tract infection Family history of cystic fibrosis Inguinal hernia repair Scrotal surgery Retroperitoneal surgery

further insight into the etiology of azoospermia. Body habitus, the degree of virilization, pubic hair pattern, and the presence of gynecomastia suggests an endocrine disturbance, such as an imbalance in the ratio of testosterone to estradiol or prolactin excess, or chromosomal abnormalities like Klinefelters syndrome. Testicular size may be assessed using an orchidometer, calipers, or scrotal ultrasound to differentiate obstructive from nonobstructive azoospermia (NOA). Orchidometers have been shown to underestimate size in smaller testes, but the clinical relevance is likely minimal (Kim and Schlegel 2008). Atrophic testes suggest impaired spermatogenesis as seminiferous tubules comprise the bulk of testicular tissue, however, normal size does not rule out azoospermia. Epididymal dilation or induration suggests obstruction, and should not be confused with a nonobstructing spermatocele. Atretic, poorly developed vas deferens or the absent vas deferens suggests congenital bilateral the absence of the vas deferens (CBAVD) and obstructive azoospermia. Presence of a varicocele, inguinal, or scrotal scars should also be noted. Rarely, rectal exam will reveal a cystic mass or seminal vesicle dilation suggestive of ejaculatory duct obstruction (EDO) (Kim and Schlegel 2008).

Semen Analysis Semen analysis documents the absence of sperm as well as the volume of ejaculate. Normal ejaculate volume precludes obstruction distal to the ejaculatory duct and indicates either NOA or bilateral obstruction of the vas deferens or epididymis. Though the WHO defines a normal ejaculate volume as 2–5  ml,

(World Health Organization 1999) a volume over 1 ml is rarely pathologic. When the ejaculate volume is less than 1 ml, ejaculatory dysfunction, obstructive azoospermia from EDO or CBAVD, or endocrine dysfunction can be considered. The absence of sperm in the ejaculate and first void after ejaculation (postejaculation urinalysis) rules out retrograde ejaculation. Since a majority of the ejaculate volume is supplied from the seminal vesicles and prostate, any obstruction more proximal to these organs minimally impacts ejaculatory volume. The exception to this situation is CBAVD, as the vas deferens and seminal vesicles are both wolffian structures and absent vasa are accompanied by atretic or atrophied seminal vesicles. Fructose from the seminal vesicles can be assessed on routine semen analysis, and the absence of fructose in a low volume ejaculate can indicate EDO or CBAVD.

Serum Hormonal Evaluation The goal of the serum hormonal evaluation is to assess the hypothalamic-pituitary-gonadal (HPG) axis, help differentiate obstructive from NOA, and provide prognostic information regarding treatment success. Though follicle-stimulating hormone (FSH) provides the most critical information needed, it is reasonable to also assess leutinizing hormone (LH), testosterone, and prolactin levels. FSH is secreted by the anterior pituitary gland in response to gonadotropin releasing hormone (GnRH) from the hypothalamus. FSH acts on the testes as the primary signal for spermatogenesis. Inhibin is produced by Sertoli cells of the testis and provides negative feedback for the regulation of FSH secretion. A markedly elevated FSH, particularly a level over twofold normal, is diagnostic of a defect in spermatogenesis and consistent with NOA (Jarow et  al. 1989). However, a normal FSH does not exclude NOA. Nonetheless, the etiology of azoospermia is best ruled out with testis biopsy, as there is no definitive FSH threshold that predicts lack of sperm on microscopic TESE (Ballesca et  al. 2000). Some authors have advocated the use of inhibin-B as a marker for spermatogenesis to predict presence of sperm at TESE (Mahmoud et  al. 1998). Inhibin-B is a hormone secreted by Sertoli cells that correlates inversely with serum FSH levels. Several studies have described serum inhibin-B as a better predictor of successful TESE than FSH, though the levels of inhibinB noted to predict the successful sperm retrieval with TESE remain undefined (Ballesca et  al. 2000;

Azoospermia: Diagnosis and Management

Brugo-Olmedo et al. 2001). Levels of inhibin-B in the seminal plasma have also been studied, but the clinical utility of this requires further investigation (SadeghiNejad and Farrokhi 2007; Hopps et  al. 2003). One study suggested inhibin-B predicted successful sperm retrieval (Nagata et al. 2005), whereas another noted that the contribution from accessory sex glands limits the utility of seminal fluid inhibin-B as a marker for spermatogenesis (El Garem et al. 2002).

Genetic Testing Several genetic conditions have been identified as contributing to azoospermia. A male determined to have NOA should undergo karyotyping and Y chromosome microdeletion testing. When physical exam notes unilateral or bilateral absence of the vas, testing for mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) should be performed.

Y Chromosome Microdeletions About 15% of patients with NOA will have a detectable Y chromosome microdeletion (Sadeghi-Nejad and Farrokhi 2007). A region on the long arm of the Y chromosome has been identified as the “Azoospermia Factor” and is further subdivided into three smaller regions, AZFa, AZFb, and AZFc. Deletions in these regions are frequently noted in azoospermic men, and the identification of a particular AZF deletion can provide valuable prognostic information. Complete deletions of the AZFa or AZFb regions indicate that sperm will not be found at the time of testicular sperm extraction (TESE), whereas deletions in AZFc indicate a 50% likelihood of finding sperm on microTESE (Hopps et  al. 2003). Though Y chromosome microdeletions are usually de novo mutations, these can nonetheless be transmitted to any male offspring, and it is critical to counsel patients regarding this potential (Mau Kai et al. 2008).

Karyotype Patients with NOA should be evaluated with a karyotype to identify any numerical or structural chromosomal abnormalities. Klinefelter’s syndrome (47 XXY) is the most common abnormality identified by karyotype, accounting for up to 14% of patients with NOA (Rao and Rao 1977). Less common conditions such as 46 XX male or chromosomal translocations can also be identified as well as mixed gonadal dysgenesis in the mosaic form of 45 X/46 XY.

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CFTR Gene Mutation Screening CBAVD and Cystic Fibrosis (CF) are considered two ends of a phenotypic spectrum of mutations in the CFTR gene. CF is an autosomal recessive disorder where those affected are homozygous recessive, whereas CBAVD is more often related to heterozygous individuals (Sheynkin et al. 1998). Over 70% of men with CBAVD will have at least one mutation in the CFTR gene and 19% will have two mutations (Chillón et  al. 1995). Therefore, because CFTR gene mutations are so common in men with CBAVD and the risk to their potential offspring so severe, the authors recommend screening both the patient and his partner for CF mutations. If any of the above mentioned tests reveal a genetic abnormality, genetic counseling prior to IVF/ICSI should be offered to the infertile couple. See also the chapter “Genetic Issues with Male Fertility” for a more detailed discussion of the genetic basis of azoospermia.

Diagnosis The diagnosis of azoospermia must differentiate obstructive from NOA. A markedly elevated FSH level (greater than two times normal) and normal semen volume is diagnostic of NOA. Figure 1 provides an algorithm to aid in the diagnosis of azoospermia. In the case of mild or moderate FSH elevation, physical exam findings can often provide enough information to differentiate NOA for obstructive azoospermia. Bilateral testis atrophy, lack of epididymal dilation, and the presence of vas deferens all increase suspicion for NOA. In the unusual case, where doubt still persists, testis biopsy should be performed for both diagnostic and possibly therapeutic purposes. Preoperatively, the patient should be counseled regarding possible cryopreservation of testicular sperm, if found, for future use with in vitro fertilization and intracytoplasmic sperm injection (IVF/ICSI). If sperm are found at the time of biopsy, vasogram to assess the site of obstruction may be performed but should be undertaken in conjunction with the reconstruction of obstruction. It is reasonable to perform vasogram and attempted reconstruction at a later date as this allows the surgeon to counsel the couple in regards to their options of IVF/ICSI versus attempted repair. Chapters “Surgical Reconstructions for Obstruction” and “Sperm Retrieval Techniques” offer more details concerning the methods of genital tract reconstruction and sperm retrieval, respectively.

No Sperm

Vasogram

Fig. 1. Diagnosis of azoospermia

Many Sperm

TESE or MicroTESE

Normal

on

CBAVD

+

l

TRUS with SV Aspiration to Eval EJDO

hic

+ AZFc only or no Y deletions detected

Consider TESE or MicroTESE

Genetic Testing

Testis Failure

+ AZFa or + AZFb

p Atro

Marked elevation (> 2 x normal)

No Biopsy consider adoption or donor sperm

Testis Size

FSH

Retrograde Ejaculation

Norma

Present

Absent

Vas deferens

−

Post Ejaculate Urinalysis

< 1 cc

Semen Volume

Epididymal obstruction Attempt Vaso Epididymostomy

No ucti str Ob

Repair dependent on site of obstruction

If traditional TESE done, consider repeat with MicroTESE

No Biopsy consider adoption or donor sperm

+ AZFa or + AZFb

+ AZFc only or no Y deletions detected

Ob

Genetic Testing

on cti str u

Normal

26 Kefer and French

Azoospermia: Diagnosis and Management

Common Causes of Azoospermia Obstructive Causes Obstructive azoospermia can result from blockage at any location along the genital outflow tract. The major causes of obstructive azoospermia are discussed below.

Iatrogenic Causes Vasectomy is certainly the most common cause of obstructive azoospermia with over 500,000 being performed annually in the USA (Monoski et  al. 2006) and 1–3% of these men eventually desires reversal. Interestingly, about 7% of patients with obstructive azoospermia are found to have vasal injury due to hernia repair, scrotal surgery or other lower abdominal procedures (Sheynkin et al. 1998). In the case of vasectomy, the diagnosis of azoospermia is obvious and the patients’ options for biologic fatherhood are either vasectomy reversal or surgical sperm retrieval combined with IVF/ICSI. Other causes of obstructive azoospermia should be considered when a patient has a history of inguinal hernia repair, or other inguinal surgeries. Other possible causes include scrotal, abdominal, or pelvic surgeries. In cases of longstanding obstruction, secondary obstruction of the epididymis can develop, significantly decreasing the likelihood of successful reconstruction using primary vasal anastomosis. These patients may require a vaso-epididymal anastomosis to treat their obstruction. Testis size is usually normal and laboratory evaluation reveals a normal semen volume and normal hormonal profile. Testis biopsy revealing normal spermatogenesis confirms the diagnosis of obstruction. Sperm cryopreservation should also be offered at the time of biopsy for possible use with IVF/ ICSI should reconstruction fail. Vasography is used to determine the location of obstruction, but the procedure can itself cause vasal obstruction, so it should only be performed at the time of planned reconstruction. If vasography does not reveal vasal obstruction, then epididymal obstruction is diagnosed and vasoepididymostomy should be performed. In cases of unilateral obstruction with contralateral testis atrophy, a cross-over repair is often successful (Meacham et al. 1993). Overall, a 65% patency rate has been reported after reconstruction in iatrogenic vasal injury (Shlegel et al. 1996). See chapter “Surgical Reconstructions for Obstruction” for more details.

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Ejaculatory Duct Obstruction Complete EDO can account for 1–5% of cases of azoospermia (Turek et  al. 1996). Semen analysis reveals a low volume azoospermic ejaculate and negative seminal fructose with normal serum FSH. These patients are distinguished from those with CBAVD because a normal vas deferens is palpable on exam. Transrectal ultrasound (TRUS) and seminal vesicle aspiration may confirm diagnosis if sperm are noted in the seminal vesicle aspirate (Silber et  al. 1997; Devroey et  al. 1995). A seminal vesicle 15  mm or wider suggests possible obstruction (Meacham et  al. 1993). Other findings might include midline cysts, a dilated ejaculatory duct or calcifications near the verumontanum.

Congenital Bilateral Absence of the Vas Deferens The cardinal finding in these patients is the absence of vasa on exam, and these patients also present with low ejaculate volume, and normal testis size and hormonal profile. The head of the epididymis also tends to be dilated. As discussed previously, CFTR gene testing should be performed appropriate genetic counseling performed if positive. If there is no detectable mutation, renal ultrasonography is recommended due to the association with renal anomalies such as unilateral renal agenesis. Interestingly, according to Schlegel et al. (1997) 11% of patients with CBAVD had renal agenesis and no renal anomalies were detected in patients with CFTR mutations (Tsujimura et al. 2002). In patients with unilateral absence of the vas deferens, 26% had ipsilateral renal agenesis, and 25% of patients with unilateral vasal agenesis also tested positive for a CFTR gene mutation. In patients with unilateral absence of the vas deferens, 80% were found to have a renal anomaly affecting the ipsilateral kidney (Shlegel et  al. 1996). One suggested alternative algorithm for the evaluation of the patient with CBAVD described obtaining a renal ultrasound and forgoing genetic testing unless the female partner was found to have a CFTR mutation (Sharlip et  al. 2006). For patients with CBAVD to biologically father a child, surgical sperm retrieval with the use of IVF/ICSI is required. The best method of sperm retrieval may vary with the experience of the surgeon and the preferences of the IVF laboratory but various techniques include PESA, MESA, TESE, or TESA and are discussed in the chapter “Sperm Retrieval Techniques.”

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Nonobstructive Causes NOA is synonymous with testis failure and implies spermatogenic dysfunction. Until the advent of IVF/ ICSI, men with this condition were not able to biologically father children. Despite azoospermia, however, low levels of spermatogenesis can exist in the testis (Silber et  al. 1997) and these sperm can be used for IVF/ICSI (Devroey et al. 1995). Though sperm retrieval rates with traditional TESE range from 35 to 62%, most report a sperm retrieval rate slightly less than 50% (Friedler et al. 1997; Tsujimura et  al. 2002; Tsujimura et  al. 2006; Kahraman et  al. 1996; Schlegel et al. 1997). The use of microsurgical dissection technique to identify isolated seminiferous tubules with active spermatogenesis was first described by Schlegel who demonstrated an improvement in sperm retrieval rate from 45 to 63% in a consecutive series comparing conventional to microdissection TESE (Schlegel 1999). This advantage has since been confirmed by other authors (Okada et al. 2002) and the microdissection TESE has proven successful in cases, where conventional TESE has failed (Okada et  al. 2002). Clinical pregnancy rates with IVF/ICSI using testicular sperm from patients with NOA vary greatly from 20 to 50%, likely due to the many other factors that influence IVF outcome (Ghazzawi et  al. 1998; Palermo et al. 1999; Friedler et al. 2002). See chapter “Sperm Retrieval Techniques” for more details regarding surgical sperm retrieval in patients with NOA.

Klinefelter’s Syndrome Klinefelter’s Syndrome is present in about 13% of cases of testis failure (Matsimuya et  al. 1994). This diagnosis should be suspected when gynecomastia and small firm testes are noted in addition to elevated gonadotropins, hypogonadism, and azoospermia. A Karyotype revealing 47XXY with or without mosaicism is the hallmark of diagnosis. TESE in these patients can be as successful as that for other men with NOA approaching a 50% retrieval rate, even in nonmosaic patients (Vernaeve et al. 2004). See chapter “Genetic Issues with Male Fertility” for more information regarding Klinefelter’s syndrome.

Azoospermia Secondary to Cancer Therapy Hodgkin’s disease and testis cancer are two of the most common malignancies among men of reproductive age. NOA resulting from cytotoxic chemotherapy or radiation exposure to the testes is a unique situation in that it may be reversible with time-dependent return of spermatogenesis. Howell and Shalet reviewed the

Kefer and French

effects of cancer treatment on spermatogenesis and noted that chemotherapy regimens for Hodgkin’s disease containing procarbazine resulted in azoospermia in over 90% of patients with little hope of recovery. Newer therapies using doxorubicin without procarbazine seem to be associated with transient azoospermia, with near complete recovery of spermatogenesis within 18 months (Howell and Shalet 2005). In patients with testis cancer, unilateral orchiectomy alone can result in azoospermia in about 9% of cases (Ishikawa et  al. 2007). In normospermic patients receiving platinum-based chemotherapy for testis cancer, 20% became azoospermic but 48% had return of spermatogenesis 2 years after treatment and by 5 years, 80% of patients had return of spermatogenesis (Lampe et al. 1997). For those patients in whom azoospermia persists, TESE has been successful at retrieving sperm in 45% of attempts (Chan et al. 2001). The effects of radiation on spermatogenesis are dose dependent and also vary by the frequency of exposure. When treatment consists of a single fraction, recovery can be expected within 18 months for doses 1 Gy or less and within 30 months for doses 2–3 Gy. Doses above 4  Gy may require 5 years or more for the recovery of spermatogenesis and doses over 6 Gy may result in permanent azoospermia. When doses are fractionated, the impact on spermatogenesis is more severe with no patient having recovered spermatogenesis in intermediate term follow-up at doses 1.4 Gy or higher (Danish et al. 1980).

Hypogonadotropic Hypogonadism Hypogonadotropic hypogonadism (HH) is a special circumstance in that it represents a potentially reversible form of NOA, although it accounts for only about 2% of cases of NOA (Jarow et al. 1989). The etiology of HH may include a prolactin secreting pituitary adenoma (marked by hyperprolactinemia), Kallmann syndrome (marked by anosmia), or of an idiopathic nature. HH may also result after pituitary surgery, pituitary radiation, or in the setting of other pituitary tumors, and these tend to present with visual field deficits and/or severe headaches. Serum LH and testosterone levels are usually markedly decreased. When HH is diagnosed, MRI of the pituitary can be used to evaluate pituitary anatomic pathology. In cases of hyperprolactinemia, medical therapy has almost obviated the need for pituitary surgery or radiotherapy. Cabergoline is preferred over bromocriptine due to a more favorable side effect profile (De Rosa et al. 1998). Kallmann syndrome is marked by delayed pubertal development and anosmia. Cryptorchidism, micropenis,

Azoospermia: Diagnosis and Management

craniofacial anomalies, and renal anomalies may also be present to varying degrees (Danish et al. 1980). Both Kallmann syndrome and other forms of HH can be treated with gonadotropin therapy. HCG therapy alone, 2,000–3,000 IU subcutaneously three times weekly, can induce spermatogenesis in acquired forms of HH. If this is unsuccessful, then FSH can be added after 6 months of hCG therapy. FSH can be given in the form of human menopausal gonadotropin (hMG) 150  IU intramuscularly three times weekly or recombinant human FSH 75 IU three times weekly. Combination HCG and FSH therapy has been shown to induce spermatogenesis in 60–90% of patients and baseline testis size is the best predictor of success (Ishikawa et al. 2007; Warne et al. 2009). When sperm still do not appear in the ejaculate after gonadotropin therapy, TESE with IVF/ICSI has been used successfully to achieve pregnancy (Fahmy et  al. 2004). More detail concerning endocrinopathies can be found in the chapter “Endocrinopathies in Male Infertility.”

Ejaculatory Dysfunction Anejaculation or retrograde ejaculation can result from medications such as alpha blockers that decrease internal sphincter tone, diseases such as diabetes mellitus or multiple sclerosis, sympathetic nerve damage from retroperitoneal surgery, or anatomic changes from bladder neck or prostate surgery. Retrograde ejaculation is a rare cause of azoospermia (Jarow et al. 1989), more often resulting in low volume oligospermia but is easily diagnosed with postejaculate urinalysis looking for the presence of sperm. Treatment with sympathomimetics such as pseudoephedrine prior to planned ejaculation is often successful unless there is anatomic alteration of the bladder neck. In these cases, recovery of sperm from alkalinized urine and concentration by centrifugation combined with IUI can be successful (Meacham 2005). Spinal cord injury (SCI) is a common cause of anejaculation and unfortunately these patients rarely respond to sympathomimetic therapy. Penile vibratory stimulation using specialized or general use vibrators is the first line therapy to induce ejaculation and is successful in up to 70% of SCI patients (Ohl et  al. 1996; Brackett et al. 1998). Patients with cervical or thoracic level injuries are more successful with vibratory stimulation than those with lower level spinal cord or peripheral nerve injuries (Bird et al. 2001). Electroejaculation may also be used to induce emission in spinal cord injured patients but it requires special equipment. Depending on the level and type of

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lesion, premedication to avoid autonomic dysreflexia and/or general anesthesia may be required. More details are provided in the chapter “Ejaculatory Dysfunction.”

Summary Confirmation of azoospermia is not an endpoint in the evaluation of male infertility. A thorough history and physical exam augmented by laboratory studies often categorizes azoospermia as either obstructive or nonobstructive, though on occasion a testis biopsy is needed for diagnosis. IVF/ICSI has radically changed the outlook for men with NOA, as prior to this technology, these men could not biologically father children. Diagnosis of obstructive azoospermia and further delineation of the cause or site of obstruction is required so that the patient can be offered the appropriate treatment options, mainly either reconstruction/relief of obstruction if possible or sperm retrieval with IVF/ICSI.

References Ballesca JL, Balasch J, Calafell JM, et  al. Serum inhibin B determination is predictive of successful testicular sperm extraction in men with non-obstructive azoospermia. Hum Reprod. 2000;18:1734–1738 Bird VG, Brackett NL, Lynne CM, et al. Reflexes and somatic responses as predictors of ejaculation by penile vibratory stimulation in men with spinal cord injury. Spinal Cord. 2001;39:514–519 Brackett NL, Ferrell SM, Aballa TC, et al. An analysis of 653 trials of penile vibratory stimulation in men with spinal cord injury. J Urol. 1998;159:1931–1934 Brugo-Olmedo S, De Vincentiis S, Calamera JC, et al. Serum inhibin B may be a reliable marker of the presence of testicular spermatozoa in patients with nonobstructive azoospermia. Fertil Steril. 2001;76:1124–1129 Chan PTK, Palermo GD, Veeck LL, et  al. Testicular sperm extraction combined with intracytoplasmic sperm injection in the treatment of men with persistent azoospermia postchemotherapy. Cancer. 2001;92:1632–1637 Chillón M, Casals T, Mercier B, et al. Mutations in the cystic fibrosis gene in patients with congential absence of the vas deferens. NEJM. 1995;332:1475–1480 Danish RK, Lee PA, Mazur T, et  al. Micropenis. II. Hypogonadotropic hypogonadism. Johns Hopkins Med J. 1980;146:177–184 De Rosa M, Colao A, Di Sarno A, et al. Cabergoline treatment rapidly improves gonadal function in hyperprolactinemic males: a comparison with bromocriptine. Eur J Endocrinol. 1998;138:286–293 Devroey P, Liu J, Nagy Z, et al. Pregnancies after testicular sperm extraction and intracytoplasmic sperm injection in nonobstructive azoospermia. Hum Reprod. 1995;10:1457–1460 El Garem YF, El Arinin AF, El Beheiry AH, et al. Possible relationship between seminal plasma inhibin B and spermatogenesis in patients with azoospermia. J Androl. 2002;23:825–829

30 Fahmy I, Kamal A, Shamloul R, et al. ICSI using testicular sperm in male hypogonadotropic hypogonadism unresponsive to gonadotropin therapy. Hum Reprod. 2004;19:1558–1561 Friedler S, Raziel A, Strassburger D, et al. Testicular sperm retrieval by percutaneous fine needle aspiration compared with testicular sperm extraction by open biopsy in men with non-obstructive azoospermia. Hum reprod. 1997;12:1488–1493 Friedler S, Raziel A, Strassburger D, et al. Factors influencing the outcome of ICSI in patients with obstructive and nonobstructive azoospermia: a comparative study. Hum Reprod. 2002;17:3114–3121 Ghazzawi IM, Sarraf MG, Taher MR, et al. Comparison of the fertilizing capability of spermatozoa from ejaculates, epididymal aspirates, and testicular biopsies using intracytoplasmic sperm injection. Hum Reprod. 1998;13:348–352 Hopps CV, Mielnik A, Goldstein M, et al. Detection of sperm in men with Y chromosome microdeletions of the AZFa, AZFb, and AZFc regions. Hum Reprod. 2003;18:1660–1665 Howell SJ, Shalet SM. Spermatogenesis after cancer treatment: damage and recovery. J Natl Cacner Inst Monogr. 2005;34: 12–17 Ishikawa T, Ooba T, Kondo Y, et al. Assessment of gonadotropin therapy in male hypogonadotropic hypogonadism. Fertil Steril. 2007;88:1697–1698 Jarow JP, Espeland MA, Lipshultz LI. Evaluation of the azoospermic patient. J Urol. 1989;142:62–65 Kahraman S, Özgür S, Alatas C, et al. Fertility with testicular sperm extraction and intracytoplasmic sperm injection in non-obstructive azoospermic men. Hum Reprod. 1996;11: 756–760 Kim HH, Schlegel PN. A guidelines based approach to obstructive azoospermia. AUA Update Ser. 2008;27:49–56 Lampe H, Horwich A, Norman A, et  al. Fertility after chemotherapy for testicular germ cell cancers. J Clin Oncol. 1997;15: 239–245 Mahmoud AM, Comhaire FH, Depuydt CE. The clinical and biological significance of serum inhibins in infertile men. Reprod Toxicol. 1998;12:591–599 Matsimuya K, Namiki M, Takahara S, et  al. Clinical study of azoospermia. Int J Androl. 1994;17:140–142 Mau Kai C, Juul A, McElreavey K, et  al. Sons conceived by assisted reproduction techniques inherit deletions in the azoospermia factor (AZF) region of the Y chromosome and the DAZ gene copy number. Hum Reprod. 2008;23:1669–1678 Meacham RB. Strategies for enhancing sperm survival in specimens obtained from patients with retrograde ejaculation. J Androl. 2005;26:174–175 Meacham RB, Hellerstein DK, Lipshultz LI. Evaluation and treatment of ejaculatory duct obstruction in the infertile male. Fertil Steril. 1993;59:393–397 Monoski MA, Li PS, Baum N, et  al. No-scalpel, no-needle vasectomy. Urology. 2006;68:9–14 Nagata Y, Fujita K, Banzai J, et al. Seminal plasma inhibin-B level is a useful predictor of the success of conventional testicular sperm extraction in patients with non-obstructive azoospermia. J Obstet Gynaecol Res. 2005;31:384–388 Ohl DA, Menge AC, Sønksen J. Penile vibratory stimulation in spinal cord injured men: optimized vibration parameters and prognostic factors. Arch Phys Med Rehabil. 1996;77:903–905

Kefer and French Okada H, Dobashi M, Yamazaki T, et al. Conventional versus microdissection testicular sperm extraction for nonobstructive azoospermia. J Urol. 2002;168:1063–1067 Palermo GD, Schlegel PN, Hariprashad JJ, et  al. Fertilization and pregnancy outcome with intracytoplasmic sperm injection for azoospermic men. Hum Reprod. 1999;14:741–748 Rao MM, Rao DM. Cytogenetic studies in primary infertility. Fertil Steril. 1977;28:209–210 Sabanegh ES, Thomas AJ. Effectiveness of crossover transseptal vasoepididymostomy in treating complex obstructive azoospermia. Fertil Steril. 1995;63(2):392–395 Sadeghi-Nejad H, Farrokhi F. Genetics of azoospermia: Current knowledge, clinical implications, and future directions. Part II Y chromosome microdeletions. Urol J. 2007;4:192–206 Schlegel PN. Testicular sperm extraction: microdissection improves sperm yield with minimal tissue escision. Hum Reprod. 1999;14:131–135 Schlegel PN, Palermo GD, Goldstein M, et al. Testicular sperm extraction with intracytoplasmic sperm injection for nonobstructive azoospermia. Urology. 1997;49:435–440 Sharlip ID, Jarow J, Belker AM, et al. The Male Infertility Best Practice Policy Committee of the American Urological Association and the Practice Committee of the American Society for Reproductive Medicine. Report on evaluation of the azoospermic male. Fertil Steril. 2006;86:S210–S215 Sheynkin YR, Hendin BH, Schlegel PN, et  al. Microsurgical repair of iatrogenic injury to the vas deferens. J Urol. 1998;159:139–141 Shlegel PN, Shin D, Goldstein M. Urogenital anomalies in men with congenital absence of the vas deferens. J Urol. 1996; 155:1644–1648 Silber SJ, Nagy Z, Devroey P, et al. Distribution of spermatogenesis in the testicles of azoospermic men: the presence or absence of spermatids in the testes of men with germinal failure. Hum Reprod. 1997;12:2422–2428 Tsujimura A, Matsumiya K, Miyagawa Y, et  al. Conventional multiple or microdissection testicular sperm extaction: a comparative study. Hum Reprod. 2002;17:2924–2929 Tsujimura A, Miyagawa Y, Takao T, et al. Salvage microdissection testicular sperm extraction after failed conventional testicular sperm extraction in patients with nonobstructive azoospermia. J Urol. 2006;175:1446–1449 Turek PJ, Magana JO, Lipshultz LI. Semen parameters before and after transurethral surgery for ejaculatory duct obstruction. J Urol. 1996;155:1291–1293 Vernaeve V, Staessen C, Verheyen G, et  al. Can biological or clinical parameters predict testicular sperm recovery in 47,XXY Klinefelter’s syndrome patients? Hum Reprod. 2004;19:1135–1139 Warne DW, Decosterd G, Okada H, et al. A combined analysis of data to identify predictive factors for spermatogenesis in men with hyopgonadotropic hypogonadism treated with recombinant human follicle-stimulating hormone and human chorionic gonadotropin. Fertil Steril. 2009;92:594–603 World Health Organization, WHO Laboratory Manual for the Examination of Human Semen and Sperm Cervical Mucus Interactions. 4th ed. Cambridge United Kingdom: Cambridge University Press;1999

Ejaculatory Dysfunction Dana A. Ohl, Susanne A. Quallich, Jens Sønksen*, Nancy L. Brackett, and Charles M. Lynne

Contents Introduction.......................................................................................................................................................................... Normal Ejaculation.............................................................................................................................................................. Types of Ejaculatory Dysfunction....................................................................................................................................... Premature Ejaculation..................................................................................................................................................... Idiopathic Anejaculation/Anorgasmia............................................................................................................................ Neurogenic Anejaculation............................................................................................................................................... Retrograde Ejaculation.................................................................................................................................................... Evaluation of Ejaculatory Dysfunction................................................................................................................................ Interventions for Ejaculatory Dysfunction........................................................................................................................... Medications..................................................................................................................................................................... Artificial Insemination for Retrograde Ejaculation......................................................................................................... Penile Vibratory Stimulation........................................................................................................................................... Electroejaculation............................................................................................................................................................ Surgical Sperm Retrieval................................................................................................................................................ Choice of Sperm Retrieval Technique................................................................................................................................. Diagnostic and Treatment Algorithms................................................................................................................................. Summary.............................................................................................................................................................................. References............................................................................................................................................................................

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*Dr. Sonksen is a shareholder of Multicept Corporation, Copenhagen, Denmark.

Introduction

D.A. Ohl () and S.A. Quallich Department of Sexual and Reproductive Medicine, University of Michigan, Ann Arbor, MI 48108, USA e-mail: [email protected]

Successful male reproductive function requires the integration of a great many functions: hormonal input to support the development of ductal structures and initiation and maintenance of spermatogenesis; erectile function from hormonal, neural, and vascular systems required for sexual intercourse; and ejaculatory function from a variety of neural sources to allow the delivery of the semen. Ejaculatory dysfunction is a relatively uncommon etiology of infertility, but there are certain medical conditions where it is very prevalent. This chapter reviews the types of ejaculatory dysfunction and their evaluation and management.

J. Sønksen Department of Urology, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark N.L. Brackett The Miami Project to Cure Paralysis, University of Miami School of Medicine, Miami, FL 33101, USA C.M. Lynne Department of Urology, University of Miami School of Medicine, Miami, FL 33101, USA

From: Current Clinical Urology: Male Infertility: Problems and Solutions, Edited by: E.S. Sabanegh, DOI: 10.1007/978-1-60761-193-6_4,  Springer Science+Business Media, LLC 2011

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Normal Ejaculation Important anatomic structures in the ejaculation reflex contribute varying amounts of volume to the ejaculation. They are, in decreasing order of volume: seminal vesicles (60–70%), prostate (20–30%), testis/vas deferens (1–2%), and the bulbourethral glands (scant). The seminal vesicles contribute fructose and the coagulating protein seminogellin, whereas the prostate contributes the protein that supports liquefaction, which is prostate-specific antigen (Robert and Gagnon 1999). The bulbourethral glands mainly secrete a “pre-ejaculate” during sexual stimulation (Chughtai et al. 2005). The seminal vesicle ducts and ampullae of the vasa deferentia coalesce into paired ejaculatory ducts that empty into the urethra, distal to the bladder neck/internal sphincter. The ejaculatory reflex has different neural controls for its various components. Sensory input arises from the dorsal nerves of the penis and enters the cord at levels S2-4. Seminal emission and bladder neck closure are under control from sympathetic fibers arising from levels T10-L2, via the sympathetic chains and hypogastric plexus. The projectile phase of ejaculation is directed involuntarily by somatic fibers from S2-4. These neural controls work together in a coordinated fashion to cause simultaneous emission of semen into the urethra and bladder neck closure (emission phase), followed by rhythmic contraction of the periurethral muscles, which forcefully expels the semen (projectile phase). Ongoing bladder neck contraction during the projectile phase prevents retrograde ejaculation into the bladder (Thomas 1983). Erection is stimulated by parasympathetic fibers coursing to the penis, resulting in vascular changes in the corporal tissue. Erection is not a requirement to ejaculate, due to a different neurological control mechanism. Most cases of erectile dysfunction are multifactorial, and vascular dysfunction is very common. Consequently, there can be a “disconnect” where erectile function is impaired and ejaculation is preserved. If fertility is desired in this situation, artificial insemination can be utilized.

Ohl et al.

It may be life-long or acquired, and can be a source of considerable distress in the sex lives of affected couples. Behavioral therapy and/or medications may be helpful in extending the ejaculatory latency time (Shull and Sprenkle 1980; Pryor et al. 2006). Ejaculation may occur prior to intromission, resulting in the lack of semen delivery and infertility on that basis. This can be treated at home by the couple with semen collection and home-based insemination, to circumvent the fertility issue. Most of the time, however, even if ejaculation is rapid, the semen in still delivered intravaginally. PE remains primarily a sexual dysfunction and not a cause of infertility.

Idiopathic Anejaculation/Anorgasmia Men with idiopathic anejaculation have no demonstrable neurological reason for their dysfunction, and are thought by most to have a functional or psychogenic condition. These men typically have suffered the inability to climax and ejaculate during sexual stimulation for their entire sexual lives. Some men might report the ability to ejaculate with masturbation or with a different partner, but the inability during sexual intercourse with the usual partner. The presence of nocturnal emission which occurs regularly gives credence to the psychogenic theory (Geboes et  al. 1975; Hovav et  al. 1999). Perelman has suggested that acquired idiopathic anejaculation may be due to idiosyncratic masturbation patterns (Perelman 2006). It is reasonable to treat men with idiopathic anorgasmia with behavioral therapy techniques, but success rates remain low. Because these men are unable to produce a semen specimen, infertility results from idiopathic anejaculation. They can be treated with ejaculation induction procedures (Wheeler et al. 1988; Stewart and Ohl 1989; Denil et  al. 1996), but surgical sperm retrieval and IVF, discussed later in this chapter, are more cost-effective.

Neurogenic Anejaculation

Types of Ejaculatory Dysfunction There are several broad categories of ejaculatory dysfunction.

Premature Ejaculation Premature ejaculation (PE) is very common, affecting up to 31% of men aged 18–59 (Laumann et al. 1999).

In this group of patients, there is a demonstrable neurological reason for the ejaculatory dysfunction. This leads to two different presentations: the inability to reach the ejaculatory reflex threshold (the most common situation); or the ability to experience a climax, but with the absence of seminal emission due to the neurologic condition. In men with spinal cord injury (SCI), there may be preserved reflex erectile function, especially with

Ejaculatory Dysfunction

the higher level lesions, but it is uncommon for an SCI man to be able to ejaculate during sexual activity (Sønksen and Biering-Sørensen 1992). SCI is the most common cause of neurogenic anejaculation seen in the clinical setting. Other spinal cord conditions, such as transverse myelitis and multiple sclerosis, show similarities to the SCI group, but because of the wide-ranging presentations of these conditions, there is also a wide range of ejaculatory dysfunctions seen. Patients with spina bifida can have life-long problems with the inability to ejaculate. Occult lower cord myelodysplasia may present later in life with other neurological symptoms associated with tethered cord syndrome. Men who have been subjected to retroperitoneal surgery may have interruption of the postganglionic sympathetic fibers arising from the sympathetic chain. These include testis cancer patients who have undergone a retroperitoneal lymph node dissection (RPLND) (Kedia et  al. 1977), and some who have had aortic replacement surgery (Weinstein and Machleder 1975). Patients with post-RPLND ejaculatory dysfunction present with a normal feeling of orgasm and ejaculation. This presentation leads many to refer to post-RPLND ejaculatory dysfunction as “retrograde ejaculation”; however, this is not the case. A study by Kedia suggested that if a dry orgasm is noted following RPLND, there is a high likelihood that this symptom represents the total absence of ejaculation and not simply retrograde ejaculation (Kedia et al. 1975). Diabetes mellitus usually affects sexual function via erectile dysfunction, but ejaculatory dysfunction may also occur (Sexton and Jarow 1997). Men with ejaculation changes due to diabetes exhibit a slowly progressive decline in ejaculatory function (Dunsmuir and Holmes 1996). Typically, the initial symptom will be a decrease in the amount of ejaculate that then progresses to a definite retrograde situation, with postclimax urine cloudiness, to the loss of the cloudiness consistent with the eventual loss of the retrograde component. The ability to climax is usually preserved despite the emission change. Medications can prevent climax, and therefore prevent ejaculation. The selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants are the most common. Administration to a normal individual can result in delayed ejaculation or complete inability to climax. The rate of male sexual dysfunction with antidepressants, when all types of antidepressants are considered, is as high as 62.4% (Montejo et al. 2001).

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Retrograde Ejaculation In retrograde ejaculation, there is a specific impairment of bladder neck closure. After seminal emission, the semen that is deposited into the urethra flows backward into the bladder, as there is nothing preventing it from doing so. The patient might notice a cloudiness of the urine after orgasm, indicating that the semen is mixed with the urine. Many of the etiologies of neurogenic anejaculation listed above, particularly the non-SCI etiologies, may result in retrograde ejaculation because of the common alpha adrenergic control of emission and bladder neck closure. There are other specific causes of retrograde ejaculation. Certain medications will usually not limit the ability to achieve climax and seminal emission, but can specifically impair bladder neck contraction. The most common class is the alphaadrenergic antagonists, such as tamsulosin, given for prostatic obstruction. Usually, there will be some diminution in seminal emission, but retrograde ejaculation is more common due to opening of the bladder neck, which is, of course, the goal of therapy for the prostatic issue (Hellstrom and Sikka 2006). Surgical bladder neck dysfunction, such as from transurethral prostate ablation, can create an anatomically open bladder neck. These are rarely seen in practice today (Dunsmuir and Emberton 1996; Thorpe et al. 1994).

Evaluation of Ejaculatory Dysfunction The medical history is used to characterize the type of ejaculatory change. In the instance of spinal cord injury, the situation may be obvious. Other cases are more challenging, as many men confuse erectile and ejaculatory dysfunction. Some might not have an idea about what constitutes normal ejaculation if the problem has been life-long. Detailed questions regarding the exact events that occur during sexual activity may be necessary. For instance, some men might believe that Cowper’s gland secretions represent a normal ejaculate, and only on detailed history will the truth be evident. Past medical and surgical history and a list of medications should be examined. Physical examination should verify normal size and consistency of the testicles and the presence of the vas deferens. Hormone blood testing can be helpful in determining if sperm production is likely to be present (Fig.  3).

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Semen analysis should be performed on any antegrade specimen, and the examination of the postorgasm urine for the presence of sperm is useful in defining retrograde ejaculation.

Interventions for Ejaculatory Dysfunction Medications Medications that cause ejaculatory dysfunction, such as alpha blockers and antidepressants should be discontinued. Administration of sympathomimetic agents may aid in the treatment of men with ejaculatory dysfunction (Kamischke and Nieschlag 1999; Kamischke and Nieschlag 2002). These agents may be effective in converting retrograde ejaculators into antegrade ejaculators, or help those with no seminal emission to produce semen in either the retrograde or antegrade direction. These agents might be most helpful in those with a gradually progressive problem, such as diabetic neuropaths, although the time course during which the drugs are helpful may be limited (Gilja et al. 1994). If sympathomimetics are successful in restoring antegrade ejaculation, they may be given for a finite period of time leading up to the partner’s ovulation, raising the possibility that normal intercourse might result in pregnancy. The authors prefer sustained-release pseudoephedrine 240  mg/24  h, for 1 week leading up to, and including the day of ovulation.

Ohl et al.

Artificial Insemination for Retrograde Ejaculation In men who have persistent retrograde ejaculation, despite medical therapy, sperm retrieval from the bladder and intrauterine insemination (IUI) is possible. The authors recommend alkalization of the urine with 500  mg of sodium bicarbonate 12 and 2  h prior to ­collection. The bladder should be emptied prior to masturbation and immediately after climax to limit urine contact. Alternatively, catheterization with instillation of media into the bladder and catheterization immediately after climax may increase motile sperm yield (Suominen et al. 1991).

Penile Vibratory Stimulation In many men with anejaculation due to SCI, a vibrator placed on the penis can create enough stimulus to produce an ejaculatory reflex. This procedure requires that all components of the reflex pathway be intact. The best candidates for this procedure are men with SCI with complete upper motor neuron lesions above T10 (Ohl et al. 1996; Bird et al. 2001; Sønksen et al. 1996). Men with incomplete spinal injuries and men with other neurogenic anejaculation etiologies respond poorly to penile vibratory stimulation (PVS). In men with a tendency for autonomic dysreflexia (AD), pretreatment with 10–20 mg of sublingual nifedipine can increase the safety of the procedure by abrogating blood pressure rises associated with the application of the vibrator. In addition, blood pressure should be monitored during procedures. The vibrator is placed on the frenulum until ejaculation occurs (Fig.  1). A  vibration

Fig. 1. Positioning of the device during penile vibratory stimulation

Ejaculatory Dysfunction

35

amplitude of 2.5 mm or greater will maximize ejaculation rates (Sønksen and Biering-Sørensen 1994). There are characteristic tonic muscle contractions of the legs and abdomen prior to ejaculation, followed by what appears to be a fairly normal ejaculatory response. Stimulation is given in period of 3 min with 1 min rest between cycles. If no ejaculation is seen within 3–6 cycles of stimulation, the PVS is considered a failure. Adverse events include AD and penile skin changes. If safety is determined in the clinic, the patient and/or partner can be trained to carry out PVS at home, and to perform vaginal insemination with the specimen, leading to great cost savings. The patient and partner simply collect the specimen in a container aspirate into a 10-ml syringe, place the syringe high into the vagina, and expel the contents. This procedure, of course, is carried out on the day of ovulation.

Electroejaculation Rectal probe electroejaculation (EEJ) can be offered to men with SCI who have failed PVS. This procedure nearly always results in a successful collection of semen. The procedures require no anesthesia in men with SCI, due to the lack of sensation. If the lesion is incomplete and sensation limits the ability to perform EEJ without an anesthetic, other alternative procedures are more appropriate (see discussion in next section). Similarly to PVS, SCI men prone to autonomic dysreflexia are pretreated with nifedipine (Steinberger et al. 1990). After emptying the bladder with a catheter, instilling medium into the bladder and performing preprocedure rectoscopy, a rectal probe is inserted and electrical activity is given in waves to stimulate ejaculation. During EEJ, both antegrade and retrograde expulsion of semen might occur, so following the procedure, repeat catheterization is needed to collect the retrograde ejaculate (Fig. 2). Rectal probe EEJ may induce AD in susceptible individuals, and is quite common in men with complete spinal lesions above T6. There is also a risk of rectal injury, but this more serious complication is extremely rare, on the order of one in several thousand procedures. It is essential that this procedure only be performed by health care professional with adequate training in the technique. A more detailed description of the EEJ procedure can be found in the literature (Ohl 1993).

Fig. 2. (a) Seager Model 14 EEJ machine (Dalzell Medical Systems, The Plains, VA). (b) Seager EEJ probes. (c) EEJ probe insertion

with ejaculatory dysfunction and men with obstructive or nonobstructive azoospermia.

Surgical Sperm Retrieval

Choice of Sperm Retrieval Technique

Anejaculatory men can have sperm retrieved by percutaneous or surgical methods, from either the testis or the epididymis. These methods are no different in men

PVS should be attempted first in men with SCI because of greater patient acceptance (Ohl et al. 1997), better semen

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quality than EEJ (Ohl et al. 1997; Brackett et al. 1997), and limited invasiveness. EEJ should be considered second line therapy for SCI men. It is the authors’ opinion that surgical sperm retrieval should be reserved for patients not responding to PVS or EEJ, since it commits the couple to in  vitro fertilization with intracytoplasmic sperm injection, thereby increasing the cost of treatment. Although EEJ has been described in non-SCI men, we believe that it is not the best treatment for men who have other etiologies of anejaculation. A cost-benefit analysis published in 2001 suggested that EEJ should only be used in SCI who can undergo the procedure without an anesthetic, allowing EEJ, coupled with IUI to give a low-cost treatment combination (Ohl et  al. 2001). The increased cost associate with the anesthetic, coupled with a low cycle fecundity from IUI, suggested that IVF is more cost-effective when an anesthetic is required. If IVF is planned, surgical sperm retrieval becomes more appealing.

Diagnostic and Treatment Algorithms Figures 3–5 represent the authors’ suggested diagnostic and treatment algorithms for men presenting with infertility due to ejaculatory dysfunction. Figure 3 shows the initial approach to a neurologic patient presenting with infertility and a low volume

Ohl et al.

or absent ejaculate. The first challenge is characterizing the problem with a careful history, physical examination, evaluation of the postorgasm urine and hormonal assays. Depending on the results of testing, the various interventions listed in the algorithm can be introduced. If retrograde ejaculation is proven, the processes in Fig. 4 can be undertaken. Procedures are modified based on two main factors: the patient’s response to sympathomimetic medication, and the number of total motile sperm. The algorithm in Fig. 5 should be followed for men presenting with neurogenic anejaculation. This flow chart summarizes the approaches detailed earlier in the text.

Summary Ejaculatory dysfunction is a relatively uncommon cause on infertility, but one that has a number of treatments that may be effective in allowing procreation to take place. By carefully evaluating men suspected of problems with ejaculation, and stepwise application of the techniques described in this chapter, it is highly likely that a successful outcome is realized.

Fig. 3. Evaluation of ejaculatory dysfunction. FSH follicle-stimulating hormone; IUI intrauterine insemination; IVF in vitro fertilization; TUR transurethral resection

Fig.  4. Treatment of men with retrograde ejaculation. TMS total motile sperm; IUI intrauterine insemination; IVF ± ICSI in vitro fertilization ± intracytoplasmic sperm injection

Fig. 5. Treatment of men with neurogenic anejaculation. TMS total motile sperm; IUI intrauterine insemination; IVF in vitro fertilization; ICSI intracytoplasmic sperm injection

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References Bird VG, Brackett NL, Lynne CM, et al. Reflexes and somatic responses as predictors of ejaculation by penile vibratory stimulation in men with spinal cord injury. Spinal Cord. 2001;39(10):514–9. Brackett NL, Padron OF, Lynne CM. Semen quality of spinal cord injured men is better when obtained by vibratory stimulation versus electroejaculation. J Urol. 1997;157(1):151–7. Chughtai B, Sawas A, O’Malley RL, et al. A neglected gland: a review of Cowper’s gland. Int J Androl. 2005;28(2):74–7. Denil J, Kupker W, Al-Hasani S, et al. Successful combination of transrectal electroejaculation and intracytoplasmic sperm injection in the treatment of anejaculation. Hum Reprod. 1996;11(6):1247–9. Dunsmuir WD, Emberton M. There is significant sexual dysfunction following TURP. Br J Urol. 1996;77(Suppl 1):39–40. Dunsmuir WD, Holmes SA. The aetiology and management of erectile, ejaculatory, and fertility problems in men with diabetes mellitus. Diabet Med. 1996;13(8):700–8. Geboes K, Steeno O, De Moor P. Primary anejaculation: diagnosis and therapy. Fertil Steril. 1975;26(10):1018–20. Gilja I, Parazajder J, Radej M, Cvitkovi P, Kovaci M. Retrograde ejaculation and loss of emission: possibilities of conservative treatment. Eur Urol. 1994;25(3):226–8. Hellstrom WJ, Sikka SC. Effects of acute treatment with tamsulosin versus alfuzosin on ejaculatory function in normal volunteers. J Urol. 2006;176(4):1529–33. Hovav Y, Dan-Goor M, Yaffe H, et al. Nocturnal sperm emission in men with psychogenic anejaculation. Fertil Steril. 1999; 72(2):364–5. Kamischke A, Nieschlag E. Treatment of retrograde ejaculation and anejaculation. Hum Reprod Update. 1999;5(5):448–74. Kamischke A, Nieschlag E. Update on medical treatment of ejaculatory disorders. Int J Androl. 2002;25(6):333–44. Kedia KR, Markland C, Fraley EE. Sexual function following high retroperitoneal lymphadenectomy. J Urol. 1975;114(2):237–9. Kedia KR, Markland C, Fraley EE. Sexual function after high retroperitoneal lymphadenectomy. Urol Clin North Am. 1977;4(3):523–8. Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. JAMA. 1999; 281(6):537–44. Montejo AL, Llorca G, Izquierdo JA, et al. Incidence of sexual dysfunction associated with antidepressant agents: a prospective multicenter study of 1022 outpatients. J Clin Psychiatry. 2001;62(Suppl 3):10–21. Ohl DA. Electroejaculation. Urol Clin North Am. 1993;20(1): 181–8. Ohl DA, Menge AC, Sønksen J. Penile vibratory stimulation in spinal cord injured men: optimized vibration parameters and

Ohl et al. prognostic factors. Arch Phys Med Rehabil. 1996;77(9): 903–5. Ohl DA, Sønksen J, Menge AC, et al. Electroejaculation versus vibratory stimulation in spinal cord injured men: sperm quality and patient preference. J Urol. 1997;157(6):2147–9. Ohl DA, Wolf LJ, Menge AC, et  al. Electroejaculation and assisted reproductive technologies in the treatment of anejaculatory infertility. Fertil Steril. 2001;76(6):1249–55. Perelman MA. Unveiling retarded ejaculation. J Urol. 2006;175 (Suppl 4):430. Pryor JL, Althof SE, Steidle C, et al. Efficacy and tolerability of dapoxetine in treatment of premature ejaculation: an integrated analysis of two double-blind, randomised controlled trials. Lancet. 2006;368(9539):929–37. Robert M, Gagnon C. Semenogelin I: a coagulum forming, multifunctional seminal vesicle protein. Cell Mol Life Sci. 1999;55(6–7):944–60. Sexton WJ, Jarow JP. Effect of diabetes mellitus upon male reproductive function. Urology. 1997;49(4):508–13. Shull GR, Sprenkle DH. Retarded ejaculation reconceptualization and implications for treatment. J Sex Marital Ther. 1980;6(4): 234–6. Sønksen J, Biering-Sørensen F. Fertility in men with spinal cord or cauda equina lesions. Semin Neurol. 1992;12(2):106–14. Sønksen J, Biering-Sørensen F, Kristensen JK. Ejaculation induced by penile vibratory stimulation in men with spinal cord lesion. The importance of the vibratory amplitude. Paraplegia. 1994;32(10):651–60. Sønksen J, Ohl DA, Giwercman A, et  al. Quality of semen obtained by penile vibratory stimulation in men with spinal cord injuries: observations and predictors. Urology. 1996;48(3):453–7. Steinberger RE, Ohl DA, Bennett CJ, et al. Nifedipine pretreatment for autonomic dysreflexia during electroejaculation. Urology. 1990;36(3):228–31. Stewart DE, Ohl DA. Idiopathic anejaculation treated by electroejaculation. Int J Psychiatry Med. 1989;19(3):263–8. Suominen JJ, Kilkku PP, Taina EJ, et al. Successful treatment of infertility due to retrograde ejaculation by instillation of serum-containing medium into the bladder. A case report. Int J Androl. 1991;14(2):87–90. Thomas AJ, Jr. Ejaculatory dysfunction. Fertil Steril. 1983;39(4): 445–54. Thorpe AC, Cleary R, Coles J, et al. Written consent about sexual function in men undergoing transurethral prostatectomy. Br J Urol. 1994;74(4):479–84. Weinstein MH, Machleder HI. Sexual function after aorto-lliac surgery. Ann Surg. 1975;181(6):787–90. Wheeler JS, Jr., Walter JS, Culkin DJ, et al. Idiopathic anejaculation treated by vibratory stimulation. Fertil Steril. 1988;50(2):377–9.

Genetic Issues with Male Fertility Robert D. Oates

Contents Introduction....................................................................................................................................................................... In Whom Do We Look?.................................................................................................................................................... What Are the Tests that Can Be Done?............................................................................................................................ What Does a Positive Result Mean?................................................................................................................................. What Can We Do About It?.............................................................................................................................................. Conclusion........................................................................................................................................................................ References.........................................................................................................................................................................

39 39 40 41 43 44 44

Introduction

In Whom Do We Look?

Male factor reproductive deficiency is wholly or ­partially contributory to the inability of many couples to achieve their goal of natural conception. As such, the evaluation of the male with history, physical examination, semen analyses, and other appropriate tests is mandatory when a couple presents with infertility. The failure to conceive should never be presumed to result from an isolated or obvious factor in one partner. Both the man and the woman should be looked at as individuals and undergo the assessment when initially presenting. In this chapter, we focus on several genetic mishaps and aberrations known to be causal in precipitating severe male factor infertility. In whom do we look, what are the tests that can be done, what does a positive result mean, and what we might be able to do about it are the questions we focus on from a clinical standpoint.

Those men who have severe oligospermia (< 5 ­million sperm/cc) without another known cause (such as prior spermatotoxic chemotherapy or bilateral mumps orchitis) should be offered a karyotype and Y chromosome microdeletion (YCMD) assay as described below (Oates et  al. 2009). These are done not only to elucidate a possible genetic etiology, but also to provide information that is often crucial for the couple to know prior to deciding upon or acting on the next step. In the severely oligospermic man with no remedial cause, there will be ejaculate sperm to be used for intracytoplasmic sperm injection (ICSI). However, even in the nonobstructive azoospermic patient, spermatozoa can be found in approximately 50% of men when testis sperm extraction (TESE) is employed and is also successfully used in conjunction with ICSI (Ramasamy et  al. 2009). Both these groups of men will have normal semen volumes and pH, elevated FSH levels above those seen in men with adequate spermatogenesis (which are generally in the lower aspects of the “reference range”), and no evidence of an obstructive process afflicting the ductal system with testes that range in size from just smaller than

R.D. Oates () Boston University School of Medicine, Boston, MA 02118, USA e-mail: [email protected]

From: Current Clinical Urology: Male Infertility: Problems and Solutions, Edited by: E.S. Sabanegh, DOI: 10.1007/978-1-60761-193-6_5,  Springer Science+Business Media, LLC 2011

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average to atrophic. LH may be normal or elevated (as for FSH) depending on whether the androgenic function of the testes is also compromised. In azoospermic men with low semen volume (<1.0 cc) and pH (£7.0), Congenital bilateral absence of the vas deferens (CBAVD) is a likely possibility and is easily confirmed by palpation – no vasa are able to be felt on physical examination, there is always an epididymal remnant that is full and firm, and the testis size is typically normal as spermatogenesis is not affected (Southern 2007). These men and their partners need a cystic fibrosis mutation assay performed prior to any surgical intervention to harvest sperm for ICSI, as detailed below.

What Are the Tests that Can Be Done? For the severely oligospermic or nonobstructive azoospermic man, both a karyotype and a YCMD assay should be offered (Stahl et  al. 2009). Both are blood tests performed on routine venipuncture samples. A karyotype looks at the number and structure of the chromosomal set found in the patient’s leukocytes, which are representative and reflective of all somatic and early germ cells (spermatogonia). The natural chromosomal complement of the male is 46, XY and the female 46, XX. There may be abnormalities in number (45, 47, etc.) or structure (translocations between two chromosomes, loss of a piece of one of the chromosomes, etc.) that may be discovered and be the root cause of the spermatogenic insufficiency. A YCMD assay molecularly defines whether there are missing regions of the Y chromosome which may not be detected cytologically on karyotype (Reijo et al. 1995; Tilford et al. 2001; Skaletsky et al. 2003). Within these regions reside numerous genes that appear to be involved only in the quantitative aspects of the spermatogenic process. When lost due to a microdeletion of that region of the Y chromosome, spermatogenesis will be either completely or partially disrupted (Sadeghi-Nejad and Oates 2008). Clinical terminology describes three areas of interest that may be “microdeleted” in a man with sperm

Oates

p­ roduction deficiency/absence: the AZFa, AZFb, and AZFc regions (Fig.  1) (Repping et  al. 2002; Hopps et al. 2003). It was previously thought AZFb and AZFc were separate and distinct, but it is now recognized that they encompass one lengthy stretch on the long arm of the Y chromosome and that there are several subsegments of that stretch that can be microdeleted. Microdeletion is an aberrant, occasional consequence of the evolved molecular geography of the Y chromosome (Simoni et al. 2008). In the male with CBAVD, cystic fibrosis mutation analysis is required (Claustres 2005; Samli et al. 2006; Bareil and Guittard 2007). Clinical cystic fibrosis is an inherited autosomal recessive disease, occurring in Northern Europeans with a frequency of 1:1,600 (the carrier frequency is 1:20) (Strausbaugh and Davis 2007). The predominant pathophysiologic features are obstructive/infectious pulmonary disease and exocrine pancreatic failure. Males also exhibit the absence of the vas deferens bilaterally and resultant obstructive azoospermia. The cystic fibrosis gene is located on the long arm of chromosome 7 (7q31.2) and encodes for a protein termed the cystic fibrosis transmembrane conductance regulator (CFTR). CFTR functions as a chloride channel which spans the epithelial cell membrane and helps regulate osmosis, and thereby the fluidity of mucus and other secretions. When the function of the total CFTR pool (a combination of CFTR from the maternally inherited CF allele coupled with CFTR from the paternally inherited CF allele) is compromised, mucus and secretions in the respiratory tree and pancreatic ducts are thickened and viscous, eventually leading to the pulmonary and digestive hallmarks of Clinical CF. It is the combination of mutations that determines the severity of clinical disease (Table  1). When the two mutations inherited are both “severe” in nature, Clinical CF will be manifest in the individual. However, if the two mutations, in combination (e.g., a “severe” mutation and a “mild” mutation), affect the amount or function of the CFTR pool to a lesser extent, a less pronounced phenotype will occur. CBAVD, as a clinical entity, is the mildest expression of CFTR dysfunction with no clinical features of CF other than vasal agenesis in the male. The spectrum is wide, though, and an individual may fall anywhere along it

Fig. 1. The Y chromosome: sites of clinically important microdeletion

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Table 1. Expected clinical expression dependent upon cystic fibrosis mutation status. Maternal CF gene mutation status No mutation Mild mutation Severe mutation

Paternal CF gene mutation status

Nature of epithelial secretions

Male clinical expression

No mutation Mild mutation Mild mutation

Thin and watery Less thin, less watery Slightly thick, more viscous

No disease present CBAVD only CBAVD ± mild respiratory or pancreatic disease

(e.g., lifelong, mild sinusitis but no pancreatic issues) depending on the mutations present in each of his CF genes along with other, putative modifying factors – both genetic and environmental. CF mutation assays are blood tests and panels have been constructed that look at different numbers of mutations, depending on the clinical circumstance (Ratbi et  al. 2007). There have been over 1,000 mutations and abnormalities described to date but most are quite rare. A common strategy has been to test for the most common 30–40 mutations and then expand the set by another 60 or so if two mutations are not identified on initial screen. If both mutations are still not found, a full gene screen is becoming more commonplace as the next step. A new technique is also being employed to screen for large duplications and deletions (Saillour et al. 2008; Hantash et  al. 2006). In men with CBAVD, testing must include a search for the 5T allele (IVS8-5T), one of the most common aberrations detected in the CBAVD population (Chiang et  al. 2009; Tamburino et  al. 2008). In intron 8 of the CF gene, there is a polymorphic polythymidine tract where there is a run of five, seven, or nine thymidine bases in a row. If only five thymidines exist, the transcribed pre-mRNA is subject to aberrant and inefficient splicing and the final mRNA molecule (from which the protein will be translated) may be missing exon 9 derived bases. Consequently, the resultant CFTR protein molecules will be missing the amino acids derived from the exon 9 base pairs and will be handicapped in their action and functional ability.

What Does a Positive Result Mean? If an AZFa, AZFb, or an AZFb/c microdeletion is found on YCMD assay in the NOA male, this result means that sperm will not be found on TESE as these microdeletions have been associated with a complete absence of spermatogenesis (Hopps et al. 2003; Yang et al. 2008). Therefore, these microdeletions are prognostic for the couple in a negative, but still helpful way. A positive result, as above, obviates the need for an invasive and futile surgical procedure, it spares the

female from the rigors of an ICSI stimulation when a combined approach is taken (testis tissue harvesting simultaneous with oocyte retrieval), and it saves the couple thousands of dollars when they do not have insurance coverage. One of these microdeletions will be found in approximately 2% of NOA men (Stahl et al. 2009). There are no other phenotypic or health consequences of an AZFa, AZFb, or AZFb/c microdeletion. The microdeletion is nearly always de  novo, meaning it is not “inherited” from the father of the patient as the father’s Y chromosomes are all normal and intact – it is just the Y chromosome that was in the sperm that fertilized the egg that became the patient that carried the microdeleted Y chromosome. If an AZFc microdeletion is detected in the NOA male, it is encouraging in that the chance for sperm presence on TESE is approximately 70% (Oates et al. 2002). In addition, it has been shown that those sperm are completely functional and can lead to fertilization, embryo development, and term pregnancy (Mulhall et al. 1997). The sperm produced by an AZFc microdeleted but severely oligospermic male work equally as well. An AZFc microdeletion affects the quantitative aspects of spermatogenesis but not the qualitative characteristics of the spermatozoa themselves. An AZFc microdeletion occurs in 1:4,000 men overall, 10% of NOA men and 5% of severely oligospermic men (Stahl et al. 2009). There are no other phenotypic or health consequences of an AZFc microdeletion. However, all male offspring of an AZFc microdeleted man will inherit the AZFc microdeletion (Oates et al. 2002). As is easily deduced from the information above, all men with an AZFc microdeletion have a severe reduction in sperm density, ranging from very low counts (infertility, potentially treatable with ICSI) to azoospermia with no sperm discovered on TESE (sterility, not presently treatable). It is expected that the sons will find themselves as adult males somewhere along this same spectrum – and not necessarily where their father might have been. Sterility may be in their future (Fig. 2). If a chromosomal constitution of 47, XXY is demonstrated on karyotype, the patient is diagnosed with Klinefelter Syndrome (Bojesen and Gravholt 2007;

42

Oates

Fig. 2. Vertical transmission of AZFc microdeletion: predicted outcomes in male offspring

Paduch et al. 2008). As with all genetically ­determined disease, there is a wide phenotypic spectrum and Klinefelter Syndrome demonstrates this perfectly. Both the spermatogenic and androgenic abilities of the testes are exceedingly dysfunctional. If the Leydig cells are so poorly productive of testosterone in the late adolescent and early teenage years, virilization and  pubertal development will not occur on sched­ ule  or as robustly as they should. These boys will present to their pediatrician or pediatric endocrinologist and the diagnosis will be made. Most likely, testosterone therapy will be prescribed to initiate puberty and then maintain masculinization. If, however, the amount of testosterone released was biologically adequate enough to stimulate virilization and pubertal changes, the boy may easily escape detection and move seamlessly into adulthood and marriage, presenting for diagnosis only when infertility occurs (Wikstrom et al. 2006). Typically, libido and erection are adequate in these men. Therefore, there is no single phenotypic presentation of Klinefelter syndrome – 47, XXY individuals may not be distinguished by physical appearance alone. What is common to all 47, XXY boys or men, however, are very small (8–10 cc) testes. In addition, it is very rare to have sperm in the ejaculate and all will show marked elevation of FSH, significant compensatory elevation of LH and variable testosterone levels. Approximately 50% of 47, XXY men who are diagnosed at the time of infertility evaluation and have not been on prior testosterone supplementation/ replacement will have sperm found during microsurgical TESE that can be used to generate chromosomally

normal pregnancies in conjunction with ICSI (Yarali et al. 2009). If a chromosomal constitution of 46, XX is demonstrated on karyotype, the patient is diagnosed with 46, XX male syndrome or “46, XX testicular disorder of sex development” (Vorona et al. 2007). The phenotype is male as SRY, normally located on the distal end of the short arm of the Y chromosome, has been translocated to another chromosome, most often an X. As an important and necessary member of the cascade that determines bipotential gonadal fate, driving the primitive tissues to become testes and not ovaries, SRY is usually present, although cases of SRY negative males have been described. However, the critical regions essential for spermatogenesis on the long arm of the Y chromosome are all completely absent (AZFa, AZFb, and AZFc). No sperm will be found on TESE and this information prior to any surgical procedure allows the couple to forego a costly and wasted operation. If an isodicentric Y chromosome (two short arms, two centromeres, and a single long arm of quite variable length) is found, the patient may or may not have any spermatogenic potential (Lange et al. 2009). This depends on whether the residual long arm has the three regions discussed previously still present and functional. Correlation with a YCMD assay is helpful to gain an appreciation of what remains on the aberrant Y. If a translocation is found, it may or may not be causal as regards spermatogenic compromise. Which two chromosomes are involved, are the sex chromosomes a part of the anomaly, is it a Robertsonian translocation are all important questions that help the

Genetic Issues with Male Fertility

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Fig. 3. Expected clinical presentation of offspring if female partner is a CF mutation carrier

Geneticist inform the couple of the chances of passing along chromosomal abnormalities in the sperm which may create an unhealthy chromosomal situation in any conceived embryo/fetus/child. If CFTR mutations are found in the man with clinical CF or CBAVD, his female partner should have CF mutation analysis as well (Tamburino et  al. 2008). They need to know whether she is a carrier of a CF mutation herself to allow prediction of disease phenotype in their offspring. Each child will necessarily inherit one of the two paternal mutations, but if the child also inherits a maternal mutation, then that child may/may not express clinical disease, ranging from CBAVD (if a male) all the way to clinical cystic fibrosis (Fig. 3).

What Can We Do About It? We cannot change a person’s genetic makeup, we cannot replace a piece of a missing Y chromosome, we cannot remove an extra X chromosome, nor can we fix a mutated cystic fibrosis gene. At this point, what we can do is to use the information to inform and educate not only the individual male, but also the couple, to allow them to make the best decisions for themselves possible. As above, there is no need to perform TESE for a male with an AZFa, AZFb, or AZFb/c microdeletion, the 46, XX male syndrome, or a combined karyotype/ YCMD that demonstrates an isodicentric Y chromosome or ring Y chromosome (Layman et al. 2009) that is missing most of the long arm where the AZF regions are located. There will be no sperm on TESE. For a male with an AZFc microdeletion, he may choose not to use his sperm or accept the consequence that a male

child will be infertile or sterile, or employ preimplantation diagnosis and only transfer female embryos (Stouffs et al. 2005). The choice is theirs to make only if educated prior to intervention. For a male with 47, XXY Klinefelter syndrome, a combined microsurgical TESE/ICSI cycle is appropriate as sperm may be found (Sciurano et al. 2009). 47, XXY males need to be followed, as well, for androgenic deficiency with all of its resultant consequences. There is an increased incidence of mediastinal germ cell tumors, breast cancer, varicose veins, learning difficulties, and Leydig cell tumors in this population (Swerdlow et al. 2005; Aguirre et al. 2006). Whether or not preimplantation diagnosis should be carried out on any embryos prior to implantation is still debatable, but certainly worthy of discussion. If a chromosomal translocation exists, discussion with a Geneticist prior to an ICSI cycle will help in the decision of whether preimplantation diagnosis will be helpful to maximize pregnancy with a chromosomally healthy fetus. In the male with CBAVD and identified CF ­mutations, it is important to offer family screening as his brothers and sisters will be at risk of having inherited either their mother’s, their father’s, or both mutations. They are at risk of disease as well. The male himself may have a past history of sinusitis, occasional pneumonias, episodes of bronchitis, etc. that are now recognized to be part of the CF mutation spectrum and may be, in the future, treated differently than in the past (Samli et al. 2006). For the couple, if the female partner is a carrier, preimplantation genetic diagnosis can be employed at the time of ICSI to identify for transfer only those embryos that did not inherit the maternal mutation and will, therefore, not be expected to exhibit CF mutation spectrum disease (Phillipson et al. 2000).

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Conclusion Severe reproductive failure most likely has a genetic basis of which we only have a limited amount of knowledge at the present time. Before embarking on strategies to overcome the consequent infertility, it is imperative to consider the possible reasons, then to carry out a rational and comprehensive diagnostic plan to identify those etiologies, and empower the individual and couple to make the best decisions they can for themselves. As our knowledge accumulates and expands, we will understand more and more and be able to provide an answer to those most important questions that we have outlined.

References Aguirre D, Nieto K, Lazos M, et al. Extragonadal germ cell tumors are often associated with Klinefelter syndrome. Hum Pathol. 2006;37(4):477–480. Bareil C, Guittard C, Altieri JP, Templin C, Claustres M, des Georges M. Comprehensive and rapid genotyping of mutations and haplotypes in congenital bilateral absence of the vas deferens and other cystic fibrosis transmembrane conductance regulator-related disorders. J Mol Diagn. 2007;9(5): 582–588. Bojesen A, Gravholt CH. Klinefelter syndrome in clinical practice. Nat Clin Pract Urol. 2007;4(4):192–204. Chiang HS, Lu JF, Liu CH, Wu YN, Wu CC. CFTR (TG)m(T)n polymorphism in patients with CBAVD in a population expressing low incidence of cystic fibrosis. Clin Genet. 2009;76(3):282–286. Claustres M. Molecular pathology of the CFTR locus in male infertility. Reprod Biomed Online. 2005;10(1):14–41. Hantash FM, Milunsky A, Wang Z, et al. A large deletion in the CFTR gene in CBAVD. Genet Med. 2006;8(2):93–95. Hopps CV, Mielnik A, Goldstein M, Palermo GD, Rosenwaks Z, Schlegel PN. Detection of sperm in men with Y chromosome microdeletions of the AZFa, AZFb and AZFc regions. Hum Reprod. 2003;18(8):1660–1665. Lange J, Skaletsky H, van Daalen SK, et al. Isodicentric Y chromosomes and sex disorders as byproducts of homologous recombination that maintains palindromes. Cell. 2009;138(5): 855–869. Layman LC, Tho SP, Clark AD, Kulharya A, McDonough PG. Phenotypic spectrum of 45, X/46, XY males with a ring Y chromosome and bilaterally descended testes. Fertil Steril. 2009;91(3):791–797. Mulhall JP, Reijo R, Alagappan R, et al. Azoospermic men with deletion of the DAZ gene cluster are capable of completing spermatogenesis: fertilization, normal embryonic development and pregnancy occur when retrieved testicular spermatozoa are used for intracytoplasmic sperm injection. Hum Reprod. 1997;12(3):503–508. Oates RD, Silber S, Brown LG, Page DC. Clinical characterization of 42 oligospermic or azoospermic men with microdeletion of the AZFc region of the Y chromosome, and of 18 children conceived via ICSI. Hum Reprod. 2002;17(11):2813–2824.

Oates Oates RD, Lamb D. Genetic Aspects of Male Infertility. In: LI Lipshultz, S Howards, C Niederberger, eds. Infertility in the Male, 4th ed. Cambridge: Cambridge University Press; 2009. Paduch DA, Fine RG, Bolyakov A, Kiper J. New concepts in Klinefelter syndrome. Curr Opin Urol. 2008;18(6):621–627. Phillipson GT, Petrucco OM, Matthews CD. Congenital bilateral absence of the vas deferens, cystic fibrosis mutation analysis and intracytoplasmic sperm injection. Hum Reprod. 2000;15(2):431–435. Ramasamy R, Lin K, Gosden LV, Rosenwaks Z, Palermo GD, Schlegel PN. High serum FSH levels in men with nonobstructive azoospermia does not affect success of microdissection testicular sperm extraction. Fertil Steril. 2009;92(2):590–593. Ratbi I, Legendre M, Niel F, et al. Detection of cystic fibrosis transmembrane conductance regulator (CFTR) gene rearrangements enriches the mutation spectrum in congenital bilateral absence of the vas deferens and impacts on genetic counselling. Hum Reprod. 2007;22(5):1285–1291. Reijo R, Lee TY, Salo P, et al. Diverse spermatogenic defects in humans caused by Y chromosome deletions encompassing a novel RNA-binding protein gene. Nat Genet. 1995;10(4): 383–393. Repping S, Skaletsky H, Lange J, et al. Recombination between palindromes P5 and P1 on the human Y chromosome causes massive deletions and spermatogenic failure. Am J Hum Genet. 2002;71(4):906–922. Sadeghi-Nejad H, Oates RD. The Y chromosome and male infertility. Curr Opin Urol. 2008;18(6):628–632. Saillour Y, Cossee M, Leturcq F, et al. Detection of exonic copynumber changes using a highly efficient oligonucleotidebased comparative genomic hybridization-array method. Hum Mutat. 2008;29(9):1083–1090. Samli H, Samli MM, Yilmaz E, Imirzalioglu N. Clinical, andrological and genetic characteristics of patients with congenital bilateral absence of vas deferens (CBAVD). Arch Androl. 2006;52(6):471–477. Sciurano RB, Luna Hisano CV, Rahn MI, et al. Focal spermatogenesis originates in euploid germ cells in classical Klinefelter patients. Hum Reprod. 2009;24(9):2353–2360. Simoni M, Tuttelmann F, Gromoll J, Nieschlag E. Clinical consequences of microdeletions of the Y chromosome: the extended Munster experience. Reprod Biomed Online. 2008; 16(2):289–303. Skaletsky H, Kuroda-Kawaguchi T, Minx PJ, et  al. The malespecific region of the human Y chromosome is a mosaic of discrete sequence classes. Nature. 2003;423(6942):825–837. Southern KW. Cystic fibrosis and formes frustes of CFTRrelated disease. Respiration. 2007;74(3):241–251. Stahl PJ, Masson P, Mielnik A, Marean MB, Schlegel PN, Paduch DA. A decade of experience emphasizes that testing for Y microdeletions is essential in American men with azoospermia and severe oligozoospermia. Fertil Steril. 2008; 90(1):319. Stouffs K, Lissens W, Tournaye H, Van Steirteghem A, Liebaers I. The choice and outcome of the fertility treatment of 38 couples in whom the male partner has a Yq microdeletion. Hum Reprod. 2005;20(7):1887–1896. Strausbaugh SD, Davis PB. Cystic fibrosis: a review of epidemiology and pathobiology. Clin Chest Med. 2007;28(2):279–288. Swerdlow AJ, Schoemaker MJ, Higgins CD, Wright AF, Jacobs PA. Cancer incidence and mortality in men with Klinefelter ­syndrome: a cohort study. J Natl Cancer Inst. 2005;97(16):1204–1210.

Genetic Issues with Male Fertility Tamburino L, Guglielmino A, Venti E, Chamayou S. Molecular analysis of mutations and polymorphisms in the CFTR gene in male infertility. Reprod Biomed Online. 2008;17(1): 27–35. Tilford CA, Kuroda-Kawaguchi T, Skaletsky H, et al. A physical map of the human Y chromosome. Nature. 2001;409(6822): 943–945. Vorona E, Zitzmann M, Gromoll J, Schuring AN, Nieschlag E. Clinical, endocrinological, and epigenetic features of the 46, XX male syndrome, compared with 47, XXY Klinefelter patients. J Clin Endocrinol Metab. 2007;92(9):3458–3465.

45 Wikstrom AM, Dunkel L, Wickman S, Norjavaara E, AnkarbergLindgren C, Raivio T. Are adolescent boys with Klinefelter syndrome androgen deficient? A longitudinal study of Finnish 47, XXY boys. Pediatr Res. 2006;59(6):854–859. Yang Y, Ma MY, Xiao CY, Li L, Li SW, Zhang SZ. Massive deletion in AZFb/b + c and azoospermia with Sertoli cell only and/or maturation arrest. Int J Androl. 2008;31(6): 573–578. Yarali H, Polat M, Bozdag G, et al. TESE-ICSI in patients with non-mosaic Klinefelter syndrome: a comparative study. Reprod Biomed Online. 2009;18(6):756–760.

Endocrinopathies in Male Infertility Stephanie E. Harris, Hussein M.S. Kandil, and Craig S. Niederberger

Contents Introduction....................................................................................................................................................................... Physiologic Regulation of the Hypothalamic–Pituitary–Testicular Axis......................................................................... Evaluation and Testing...................................................................................................................................................... Hyperprolactinemia........................................................................................................................................................... Hypogonadotropic Hypogonadism................................................................................................................................... Failure of Hypothalamus.............................................................................................................................................. Pituitary Insufficiency.................................................................................................................................................. Other Syndromes Leading to Hypogonadotropic Hypogonadism............................................................................... Isolated Luteinizing Hormone or Follicle-Stimulating Hormone Deficiency.............................................................. Hypergonadotropic Hypogonadism.................................................................................................................................. Klinefelter Syndrome................................................................................................................................................... Gonadal Toxicity.......................................................................................................................................................... Inactivating Luteinizing Hormone–Follicle-Stimulating Hormone Receptor Mutations............................................ Hypogonadism with Normal or Elevated Testosterone.................................................................................................... Infertility Associated with Exogenous Testosterone Therapy..................................................................................... Androgen Receptor Defects and Androgen Insensitivity Syndromes.......................................................................... Congenital Adrenal Hyperplasia.................................................................................................................................. Leydig Cell Tumors..................................................................................................................................................... Treatment Options............................................................................................................................................................. Treatment of Hyperprolactinemia................................................................................................................................ Treatment of Hypogonadotropic Hypogonadism......................................................................................................... Treatment of the Endocrinopathy Associated with Klinefelter Syndrome.................................................................. Conclusions....................................................................................................................................................................... References.........................................................................................................................................................................

Introduction Endocrine disorders are a potentially reversible cause of some cases of male-factor infertility. Therefore, a meticulous infertility workup must include endoS.E. Harris, H.M.S. Kandil, and C.S. Niederberger () University of Illinois at Chicago, Chicago, IL, USA e-mail: [email protected]

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crinologic evaluation and seminal studies. This is especially true where assisted reproductive techniques are becoming more advanced and more widely used. If an endocrine cause is found, reproductive specialists, either urologists or reproductive endocrinologists, should work together to develop the best treatment plan for the couple that addresses any endocrinopathy in the male partner (Sussman et al. 2008).

From: Current Clinical Urology: Male Infertility: Problems and Solutions, Edited by: E.S. Sabanegh, DOI: 10.1007/978-1-60761-193-6_6,  Springer Science+Business Media, LLC 2011

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Physiologic Regulation of the Hypothalamic–Pituitary–Testicular Axis The hypothalamic–pituitary–testicular (HPT) axis is the descriptive term for an integrated mechanism by which the brain signals the male reproductive system to carry out its two main functions – androgen secretion and spermatogenesis. Recent discoveries have postulated that puberty is a result of kisspeptin stimulation of G-protein-coupledreceptor-54 (GPR54) leading to subsequent reactivation of the secretion of gonadotropin-releasing hormone (GnRH) following the pre-pubertal quiescent phase (Jayasena et  al. 2009). The GPR54/kisspeptin system also plays a role in maintaining pulsatility of GnRH secretion throughout adulthood (Roa et al. 2008). Once stimulated by the GPR54/kisspeptin system, the hypothalamus secretes GnRH in a pulsatile fashion. GnRH is released into the hypothalamic-hypophyseal portal circulation and reaches the anterior pituitary, where it stimulates the release of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) into the systemic circulation (Vien et al. 2008). Physiologic control of FSH and LH secretion by the pituitary gland is influenced by either the stimulatory action of GnRH or an inhibitory effect produced as a result of feedback by sex hormones (Hayes et al. 2001). FSH, a pituitary hormone, stimulates spermatogenesis via testicular Sertoli cells, which also secrete a hormone down-regulating the release of FSH called inhibin B that acts at the level of the pituitary gland. Defective spermatogenesis is commonly associated with reduced levels of inhibin B, correlating with an associated rise in FSH secretion (Anawalt et  al. 1996; McLachlan 2000). LH stimulates testicular Leydig cells to release testosterone which is necessary for spermatogenesis (McLachlan 2000). Testosterone modulates the secretion of LH through a dual feedback mechanism at the level of the hypothalamus and the pituitary gland. Direct feedback occurs via interaction with the androgen receptor. Indirect negative feedback is a result of testosterone’s aromatization to estradiol. Estradiol inhibits the secretion of FSH at the level of the pituitary gland (Hayes et al. 2001). Prolactin is secreted by the anterior pituitary in a pulsatile manner under the effect of hypothalamic secretion of prolactin-releasing factors (PRFs) and is negatively and tonically controlled by prolactininhibiting factors (PIFs), the most important of which is dopamine. Prolactin inhibits the release of LH and FSH, and directly impairs testicular androgen production (Mancini et al. 2008).

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Evaluation and Testing Investigation into potential endocrine causes of male infertility starts with a detailed history exploring pubertal timing or symptoms of hypogonadism (low libido, erectile dysfunction, fatigue, and decreased energy), in addition to a physical examination assessing the degree of virilization (Seftel 2006a). Classic endocrine evaluation would include a morning testosterone and FSH. A Sigman and Jarow (1997) study from 1997 detected a low overall (9.6%) incidence of endocrinopathies in their population of 1,026 infertile men. The most commonly detected abnormality was an isolated FSH elevation (7.9%). However, recent data from our institution reported much higher incidences of hypogonadism, nearing 50%, especially in men with non-obstructive azoospermia (NOA) (Sussman et  al. 2008). This was similarly seen by authors at Baylor who reported a 47.1% incidence of hypogonadism in their NOA population (Weedin et al. 2009). At our institution, the initial endocrine evaluation involves a morning blood draw for total testosterone, LH, FSH, albumin, sex-hormone binding globulin (SHBG), and estradiol. We find that in most instances pooled samples are not needed, which is in concert with the findings of others (Bain et al. 1988). There are instances where the total testosterone can be an unreliable indicator of overall gonadal function, including obesity, diabetes mellitus, hyperthyroidism, alcohol abuse, liver disease, and certain medications. In many instances, this is related to elevations in SHBG (Seftel 2006b), which also occur with aging (Wu et al. 2008). In vivo, testosterone exists in three forms: in its free state (2–3%), bound loosely to albumin (~60%), and bound tightly to SHBG (Sussman et  al. 2008). Measuring free testosterone has proven unreliable with most commonly available commercial assays, and an accurate determination would require equilibrium dialysis, which is expensive and not easily automated. As a result, many laboratories, including ours, have elected to use a calculated bioavailable testosterone using the albumin, SHBG, and total testosterone values with an online calculator that can be found at http://issam.ch/ freetesto.htm (Vermeulen et al. 1999). Prolactin is included in the initial evaluation if the patient complains of symptoms of headache or decreasing visual fields, takes medications known to elevate prolactin levels, or is drawn if significant hypogonadism is noted by total testosterone. Thyroid function tests may also be useful since elevated thyrotropin-releasing hormone levels (TRH) can cause hyperprolactinemia (Jarow 2003, 2007). The American Association of Clinical Endocrinologists

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recommend pituitary MRI in cases of unexplained hypogonadotropic hypogonadism (HH) where the testosterone levels are <150 ng/dL even in the absence of other signs or symptoms (American Association of Clinical Endocrinologists 2002). Although they note that this recommendation is not generated from the scientific literature and represents a “reasonable level at which to pursue pituitary imaging” (American Association of Clinical Endocrinologists 2002), it may allow for the earlier detection of ­non-functional pituitary adenoma, which represents 30% of all pituitary tumors, are more common in men, and are a known cause of hypogonadism (Cury et al. 2009).

Hyperprolactinemia Hyperprolactinemia is purported to exist in 11% of oligozoospermic men and 16% of men with impaired erectile function, and is considered to be the most common endocrinologic cause of hypothalamic– pituitary axis diseases (Luciano 1999; De Rosa et  al. 2003). It is characterized by the presence of abnormally high levels of prolactin, which results in depression of LH and FSH secretion via negative feedback on the hypothalamus. This leads to reduced levels of serum testosterone and impairment of spermatogenesis causing oligozoospermia and infertility (Jarow 2007). Hyperprolactinemia can be a product of excess production from a prolactin-secreting pituitary tumor; however, other causes of elevated prolactin levels include hypothyroidism, systemic diseases, stress, and medication. Medications known to cause hyperprolactinemia include neuroleptics, tricyclic antidepressants, SSRIs, verapamil, methyldopa, reserpine, metoclopramide, domperidone, H2 blockers, opiates, cocaine, estrogens, and protease inhibitors (Mancini et  al. 2008). Decreased libido, erectile dysfunction, gynecomastia, and infertility are the most common presentations of hyperprolactinemia, in addition to headache or visual field defects caused by an enlarging adenoma (Mancini et al. 2008; Jarow 2007).

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Failure of Hypothalamus Congenital idiopathic hypogonadotropic hypogonadism (IHH) can be divided into two types: patients with ansomia, the classic Kallmann’s syndrome patients, and the normosmic (nIHH) patients. Kallmann’s syndrome has an estimated incidence of 1 in 8,000 boys (Hardelin and Dode 2008). Typically, this disorder is diagnosed due to lack of pubertal development, with prepubertal-sized testes and absent virilization, in concert with low gonadotropins and steroids, as well as a compromised sense of smell. These patients may also have cleft lip or palate, bimanual synkinesis (mirror movements of the upper limbs), renal agenesis, eye movement abnormalities, congenital ptosis, or hearing impairment. Known mutations in KAL1, FGFR1, PROK2, PROKR2, and FGF8 account for approximately 30% of cases (Hardelin and Dode 2008). There is a subset of late onset or acquired IHH that presents with hypogonadism associated with inappropriately low gonadotropins and is accompanied with erectile dysfunction and new onset infertility (Sokol 2009).

Pituitary Insufficiency Hypopituitarism, or partial or complete failure of the anterior pituitary, has a reported incidence of 11.9–42.1 cases per million inhabitants per year and a prevalence of 300–455 per million inhabitants (Ascoli 2006). Clinical symptoms may be subtle; however, if the portion of the anterior pituitary that secretes LH or FSH is involved, HH may result. The causes of hypopituitarism are varied, can be of prepubertal or adult onset, and include perinatal damage, craniopharyngioma or other parasellar tumors, traumatic brain injury, cerebral irradiation, pituitary infarction following severe illness, lymphocytic hypophysitis, subarachnoid hemorrhage, infections, granulomatous diseases (i.e., neurosarcoid), infiltrative disease such as amyloidosis or histiocytosis X, and diseases that cause iron overload which can be deposited in the pituitary resulting in decreased gonadotropin secretion (i.e., hemochromatosis or any bleeding disorder that results in multiple blood transfusions) (Sokol 2009; Ascoli 2006; Buretic-Tomljanovic and Vlastelic 2009).

Hypogonadotropic Hypogonadism Hypogonadotropic hypogonadism (HH) is a state of low androgen secretion as a result of absent or low gonadotropic stimulation, which may be either congenital or acquired. This results in disrupted spermatogenesis, which, in many cases, may result in restoration of spermatogenesis with treatment.

Other Syndromes Leading to Hypogonadotropic Hypogonadism Syndromic genetic disorders including Prader–Willi, Alstrom’s, familial cerebral ataxia, and Laurence– Moon–Biedl syndrome have also been associated with HH (Sokol 2009; Farooqi 2005).

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Isolated Luteinizing Hormone or FollicleStimulating Hormone Deficiency Isolated LH deficiency is a rare but reported cause of infertility or subfertility. Men affected with the syndrome have normally masculinized genitalia at birth secondary to placental hCG activity; however, they typically fail to go through puberty and therefore exhibit a eunuchoid body habitus with small testes as adults (Themmen and Huhtaniemi 2000). These patients demonstrate low testosterones, but may have either elevated LH activity (Weiss et al. 1992) or undetectable LH levels (LofranoPorto 2007) depending on whether or not the mutant LH protein is immunoreactive. A milder phenotype, reported by Shiraishi and Naito, describes the case of a boy presenting with hypoandrogenism, delayed puberty, and oligoasthenozoospermia but demonstrating normal gonadotropin levels and relatively preserved testis size (18  mL). In this case, a mutation in the LHB subunit produced a variant LH with lower receptor-binding activity. When treated with hCG, the patient virilized normally with correction in his semen parameters; however, upon cessation of hCG, his hypogonadism returned (Shiraishi and Naito 2003). In a collected series of men with isolated FSH deficiency, most, but not all, men displayed oligozoospermia or azoospermia. Eight of the nine had normal testosterone and normal pubertal development with testis biopsies varying from normal to maturation arrest (Themmen and Huhtaniemi 2000).

Hypergonadotropic Hypogonadism Klinefelter Syndrome Klinefelter syndrome (KS), the most frequent karyotypic abnormality detected in infertile men with a prevalence of 1 in 660, causes hypergonadotropic hypogonadism in the adult male (Bojesen and Gravholt 2007). A disorder of aneuplody (most commonly 47, XXY; however, mosaicism does occur), KS is a condition in which males have an extra X sex chromosome and is the most common male sex chromosomal disorder resulting in testicular maldevelopment (Bojesen et  al. 2004). The classic phenotype represented by a tall male with eunuchoid proportions, sparse body hair, gynecomastia, small testes, azoospermia, low testosterone, and decreased verbal intelligence, is often not present (Bojesen and Gravholt 2007). It is often undiagnosed, as during infancy to early puberty, the gonadotropin and androgen levels are relatively normal; however, at the onset of puberty, the serum testosterone

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concentration plateaus in the low normal range, an elevation in the estradiol level is seen, and the FSH and LH levels rise and coincide with decreased inhibin B levels (Wikstrom and Dunkel 2008). By the time these men reach adulthood, 65–85% have low serum testosterone concentrations (Wikstrom and Dunkel 2008). In addition, hyalinization of the seminiferous tubules and Leydig cell hyperplasia are present in adult KS testes (Wikstrom and Dunkel 2008; Wikström et  al. 2006; Abramsky and Chapple 1997). As a result, many are placed on testosterone supplementation, if not required to complete puberty, to prevent hypoandrogenism-related complications. These complications may not be insignificant, as men with KS have an increased risk of osteoporotic fractures of the forearm, hip, or spine (Bojesen et al. 2006) as well as an increased risk of death from hip fractures (Swerdlow et al. 2005). In addition, whole brain MRI studies of treated versus untreated KS patients demonstrated diminished gray matter volumes in the left temporal lobes of the untreated patients (Patwardhan et  al. 2000). Managing the endocrinopathy requires balancing the need to preserve potential spermatogenesis, while ensuring adequate androgen levels.

Gonadal Toxicity Following treatment with cytotoxic chemotherapy and radiotherapy, there is a high risk of developing Leydig cell dysfunction, identified as elevated LH levels in conjunction with low to normal testosterone (Howell et al. 2000). Due to the increased sensitivity of germ cells to radiation and chemotherapy compared with that of Leydig cells, reduced fertility is considered to be a more common complication than hypogonadism following such treatments. Therefore, all patients should be advised to undergo sperm cryopreservation prior to any cytotoxic or radiation treatment (Brydøy et al. 2007).

Inactivating Luteinizing Hormone– Follicle-Stimulating Hormone Receptor Mutations LH and FSH act through the LH receptor (LHR) and FSH receptor (FSHR), respectively, both of which belong to the G-protein-coupled receptor family. Androgen synthesis is encouraged following the stimulation of the LHR, whereas FSHR activation promotes the Sertoli cells function and maintains spermatogenesis (Bruysters et  al. 2008; Huhtaniem 2000). Gonadotropin receptor mutations have been described in some patients with hypogonadal states

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and pubertal abnormalities (Simoni 1998). They can vary in their severity, causing either complete or partial LH resistance (Salameh et al. 2005). Inactivating LHR mutations present as hypergonadotropic hypogonadism with pseudohermaphroditism and histologic evidence of hypoplastic Leydig cells (Simoni 1998). In these cases, Sertoli cell histology and numbers are not affected (Bruysters et al. 2008). A mutation in the FSHR results in variable degrees of spermatogenetic dysfunction causing infertility (Simoni 1998). These patients present with a moderately elevated FSH, normal or slightly elevated LH, normal testosterone, and variable reduction in testicular size. The semen analysis may demonstrate oligozoospermia; however, normal spermatogenesis may still be maintained (Huhtaniem 2000).

Hypogonadism with Normal or Elevated Testosterone The most common clinical scenario presenting with an elevated testosterone would be secondary to exogenous androgen administration. A urinary screen for the testosterone to epitestosterone ratio may be needed; however, there are uncommon clinical scenarios when endogenous androgen excess may be the culprit. These include androgen resistance syndromes due to androgen receptor defects (Sokol 2009), congenital adrenal hyperplasia, Leydig cell tumors, adrenal tumors, hCG secreting tumors (testis, hepatoblastoma, lung, or brain), and activating LH receptor mutations (McLachlan and de Krester 2006). In cases of low gonadotropins with a normal or elevated testosterone unrelated to exogenous androgens, estradiol, hCG, and adrenal androgens with a testicular ultrasound can help to diagnose these potentially treatable conditions (McLachlan and de Krester 2006).

Infertility Associated with Exogenous Testosterone Therapy Exogenous testosterone administration acts as a contraceptive agent as it inhibits LH and FSH secretion, causing infertility secondary to reduced spermatogenesis (Amory et  al. 2006). Normally, intratesticular testosterone (ITT) is 100-fold higher than serum testosterone. Completion of spermatogenesis requires a normal testosterone level in the intratesticular environment (Coviello et  al. 2004). Treatment with testosterone can deplete intratesticular testosterone and arrest spermatogenesis (Coviello et  al. 2005). Some

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investigators have demonstrated that ITT concentrations can be preserved during periods of testosteronemediated gonadotropin suppression using low-dose (125–500 IU) hCG therapy every other day (Coviello et  al. 2005); however, cessation of exogenous testosterone with initiation of clomiphene citrate (CC) is the method we employ to treat these patients.

Androgen Receptor Defects and Androgen Insensitivity Syndromes The androgen receptor gene (AR) is located on the X-chromosome; therefore, any mutation affecting the gene will affect males. Females are carriers (Kerkhofs et al. 2009). Over 600 mutations in the AR have been identified and may lead to defective spermatogenesis and idiopathic male infertility (Yong et al. 2003; Lan et  al. 2008). The AR-HAP4 haplotype identified through genetic testing is associated with a fourfold increase in the incidence of male infertility (Saare et al. 2008). Androgen insensitivity syndrome (AIS) has an estimated prevalence of 1 in 20,000 live male births (Lan et  al. 2008). When the AR structure or function is extensively affected, complete AIS or testicular feminization results. Partial AIS refers to a mutation that does not completely alter AR function, yielding variable degrees of hypovirilized phenotypic changes including partial labial fusion, ambiguous genitalia, hypospadias, bifid scrotum, and gynecomastia. AR mutations resulting in minimal decreases in AR activity can result in subtle AIS presenting with depressed spermatogenesis alone (Yong et al. 2003; Lan et al. 2008). In the subtle cases, the hormonal profile of an elevated testosterone, elevated LH, and normal FSH in conjunction with abnormal spermatogenesis suggests this diagnosis (Sokol 2009).

Congenital Adrenal Hyperplasia Patients with congenital adrenal hyperplasia often have suppressed gonadotropins secondary to high levels of adrenal androgens that are produced as a result of defects in the cortisol production and while they are normally virilized, spermatogenesis is not stimulated because FSH levels are low. Males with mild forms that are non-salt wasting may not be diagnosed, alternatively they may have been previously diagnosed but have inadequate glucocorticoid suppression and either group may present with infertility. Patients with 11-b (beta) hydroxylase deficiency would be expected to

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have hypertension as well. They may also have adrenal rest tumors identified within their testes (Sokol 2009).

Leydig Cell Tumors Leydig cell tumors are also a rare but well-described cause of hypogonadism with normal serum androgens and an elevated estradiol. In addition to spermatogenic disruption with resultant infertility, feminization with gynecomastia resulting from increased peripheral conversion of testosterone to estradiol can be seen. Although typically sporadic, they have been associated with activating mutations of the LHR gene and mutation of the fumurate hydratase gene. Treatment either with orchiectomy or potentially testis sparing surgery, if benign (only 10% are malignant), has been shown to lead to restoration of fertility (McLachlan and de Krester 2006).

Treatment Options Treatment of Hyperprolactinemia Treatment of hyperprolactinemia is generally aimed to control either symptoms resulting from excess prolactin, such as sexual dysfunction and infertility, or mass effects related to the pituitary lesion if present (De Rosa et  al. 2003). Treatment options include observation, medical, surgical or radiation therapy. Observation is utilized for asymptomatic patients not experiencing absolute indications for active treatment. Close follow-up should be carried out to determine whether tumor is enlarging (Gillam et al. 2006). Medical therapy may be employed with a choice of either bromocriptine (BRC)or cabergoline (CAB). BRC is a dopamine (D2) receptor agonist with D1 antagonist properties (Gillam et al. 2006). BRC causes reduction in the size of the prolactinoma in up to >80% of patients, in addition to reduction in the prolactin level (De Rosa et al. 2003). It is given in doses ranging from 2.5 to 15 mg two or three times daily. Increased bone density and improved seminal parameters can be observed after establishment of a normal prolactin level (Gillam et  al. 2006). CAB is a D2 selective agonist used for the treatment of hyperprolactinemia by suppressing the synthesis of prolactin and reducing the weight of the pituitary more effectively than with BRC. Typical dosing is 0.5–1  mg twice weekly (Gillam et al. 2006; Eguchi et al. 1995). In women with hyperprolactinemia, CAB has demonstrated better efficacy with fewer side effects (Mancini et al. 2008). BRC, although cheaper, has a discontinuation rate of 12% as a result of side effects, whereas this rate in cabergoline

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is 3% (Mancini et  al. 2008). In studies in men, BRC and cabergoline demonstrated a similar ability to normalize prolactin levels; however, patients receiving CAB were noted to have improvements in semen parameters after 3 months of treatment compared with a longer period for BRC (De Rosa et al. 2003). With both agents, nausea and/or vomiting is the most commonly observed side effect in approximately one-third of patients (Mancini et al. 2008). Postural hypotension can develop with either therapy and can lead to dizziness or syncope. This can be alleviated by taking the medications at bedtime (Gillam et  al. 2006). Other rare side effects reported with BRC include new onset psychosis or aggravation of preexisting psychosis and cerebrospinal fluid rhinorrhea due to shrinkage of a large adenoma. Dyskinesias, reversible pleuropulmonary changes (pulmonary infiltrates, fibrosis, pleural effusions, or pleural thickening) and retroperitoneal fibrosis are also seen rarely at high doses typically only seen with treatment of Parkinson’s disease (Gillam et  al. 2006). Psychosis has not been reported with CAB, but the reversible pleuropulmonary changes have been reported. In addition, some patients treated with high doses of CAB (~4 mg daily) have developed valvular heart disease, in some cases requiring cardiac valve replacement (Gillam et al. 2006). Surgical treatment of a prolactinoma is indicated when even the maximum doses of medical therapy is not effective in reducing the prolactin level, or when tumor enlargement continues despite an adequately lowered prolactin level (Gillam et al. 2006). Radiotherapy is an uncommonly used treatment modality due to the results achieved with medical and surgical therapies for the majority of prolactinomas but can generally be used as a last resort (Gillam et al. 2006).

Treatment of Hypogonadotropic Hypogonadism There are multiple approaches for the treatment of Kallmann’s syndrome or nIHH. Pulsatile gonadotropin therapy has been used either with a GnRH pump of subcutaneous injections of GnRH every 2 h or intranasal GnRH. This method is costly and cumbersome, but effective (Hoffman and Crowley 1982). Gonadotropin therapy is another option with hCG and recombinant FSH (rFSH), which has for the most part supplanted human menopausal gonadotropin (hMG) in this regimen. hCG stimulates the synthesis and secretion of testosterone by the Leydig cell. It is generally used at a dose of 1,500–2,000 IU two to three times per week

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and titrated to normal serum testosterone levels. Once testosterone levels are corrected, 75  IU rFSH three times weekly is added to the regimen to stimulate spermatogenesis. In lieu of the rFSH, 75 IU hMG can be used two to three times weekly (Sokol 2009). Finally, some have had success treating these men with oral CC. CC is a selective estrogen receptor modulator that is used to disrupt estrogen-mediated negative feedback. As a result, the pituitary responds by secreting more LH, which leads to increased testicular production of testosterone (Hill et  al. 2009). In a small series of patients with adult onset HH using 50  mg of CC three times per week, three of the four demonstrated improvement in testosterone and seminal parameters at 3 months (Whitten et al. 2006). In addition, in one study of 50 patients with both Kallmann’s syndrome and nIHH, 10% of patients experienced reversal of their endocrine defect following treatment (Raivio et al. 2007). This suggests that all men be evaluated periodically for the continued need for hormonal treatment. In our clinic, men with hypogonadism desiring fertility preservation are started on a regimen of CC, provided they have no history of pituitary surgery. All patients are informed that CC is used off label when initiating drug therapy of CC 50  mg every other day. Testosterone, albumin, and SHBG are repeated after 2 weeks of therapy to verify adequate response. We are looking for a testosterone level in the 600–800 ng/dL range, with a calculated bioavailable testosterone greater than 200 ng/ dL (Hussein et al. 2005). If the patient has not achieved this and is compliant with medication, the dose can be increased to 50 or 100 mg daily. When a patient fails to respond hormonally on maximal CC therapy, the patient is switched to hCG/rFSH therapy; however, in our experience, most men respond to low-dose oral CC therapy. Occasionally, men present with a markedly elevated estradiol in addition to secondary hypogonadism, creating a testosterone to estradiol ratio that is less than ten. In this situation, we consider initiating anastrozole 1 mg daily in lieu of or in addition to CC therapy.

Treatment of the Endocrinopathy Associated with Klinefelter Syndrome Previously thought to be uniformly infertile, IVF/ ICSI in concert with a microTESE has allowed these men a potential chance for fertility. Success rates at sperm retrieval in these men vary from 40 to 72% (Levron et al. 2000; Schiff et al. 2005), resulting in a 46% pregnancy rate in the Schiff series (Schiff et  al. 2005). With the success of these techniques, one must consider how best to manage the endocrinopathy seen

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in these patients. Frequently, Klinefelter patients have hyperestrogenemia along with a borderline or low testosterone, in conjunction with an elevated testosterone to estradiol ratio (Paduch et  al. 2009). Pavlovich and colleagues (2001) noted that the mean testosterone to estradiol ratio in fertile control reference subjects was 14.5 compared with a mean TE ratio of 6.9 in men with severe infertility. A study of 68 men with KS noted that in men with successful sperm retrieval, the preoperative and posttreatment TE ratio was significantly different (13.6 vs. 10.0) than in KS men with unsuccessful procedures (Ramasamy et  al. 2009). In these cases, aromatase inhibitors have been used to decrease estradiol levels (Pavlovich et  al. 2001; Ramasamy et al. 2009; Raman and Schlegel 2002). Aromatase is a cytochrome P450 enzyme located primarily in the skin and also in the skin, liver, and testis, and converts testosterone into estradiol. Paduch and colleagues (2009) have demonstrated that in testis of KS men, there is a fourfold greater expression of this enzyme. Both steroidal (testolactone) and nonsteroidal (anastrozole) aromatase inhibitors have been studied for their ability to correct the hormonal imbalance in infertile men with abnormal testosterone-to-estradiol ratios. The results demonstrated that either was effective at raising testosterone levels; however, anastrozole was slightly more effective at lowering estradiol levels and correcting the testosterone-to-estradiol ratio (Raman and Schlegel 2002). In Schlegel’s study assessing mTESE/ICSI success in KS patients, patients with testosterones levels less than 15.6 nmol/L or a testosterone-to-estradiol ratio of less than 100 were started on an aromatase inhibitor. If their testosterone levels did not respond, hCG was added in concert to the aromatase inhibitor. Exogenous testosterone had been stopped 6 months prior to treatment. Under these conditions, a sperm retrieval rate of 72% was noted (Schiff et al. 2005). With treatment doses of aromatase inhibitors (anastrozole 1  mg daily and testolactone 100–200  mg daily), the most commonly seen complication (7–17%) was elevation of liver enzymes; therefore, serial monitoring of liver function tests is recommended (Schiff et al. 2007).

Conclusions Endocrinopathies treated in the context of preserving male fertility is the milieu of the andrologist. When recognized and appropriately treated, these cases can offer an opportunity for a patient to see marked improvement in semen parameters, as is the case in some of the secondary hypogonadism patients. In other patients, particularly the Klinefelter patients, practitioners must

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balance the challenge of preventing complications secondary to hypogonadism while preserving the chance of fertility. Lastly, it is this common thread, in most endocrinopathies discussed above – the hypoandrogenism – that will follow many of these men throughout their lives; therefore, they deserve to be educated about its potential risks, while being treated with careful regard to their reproductive needs.

References Abramsky L, Chapple J. 47, XXY (Klinefelter syndrome) and 47, XYY: Estimated rates of and indication for postnatal diagnosis with implications for prenatal counseling. Prenat Diagn. 1997;17:363–368. American Association of Clinical Endocrinologists. Medical guidelines for clinical practice for the evaluation and treatment of hypogonadism in adult male patients: 2002 update. Endocr Pract. 2002;8:440–456. Amory JK, Page ST, Bremner WJ. Drug Insight: Recent advances in male hormonal contraception. Nat Clin Pract Endocrinol Metab. 2006;2:32–41. Anawalt BD, Bebb RA, Matsumoto AM, et al. Serum inhibin B levels reflect sertoli cell function in normal men and men with testicular dysfunction. J Clin Endocrinol Metab. 1996; 81:3341–3345. Ascoli P, Cavagnini F. Hypopituitarism. Pituitary. 2006;9:335–342. Bain J, Langevin R, D’Costa M, et al. Serum pituitary and ­steroid hormone levels in the adult male: One value is as good as the mean of three. Fertil Steril. 1988;49:123–126. Bojesen A, Gravholt C. Klinefelter syndrome in clinical practice. Nat Clin Pract Urol. 2007;4:192–204. Bojesen A, Juul S, Birkebaek N, et  al. Increased Mortality in Klinefelter Syndrome. J Clin Endocrinol Metab. 2004;89: 3830–3834. Bojesen A, Juul S, Birkebaek NH, et al. Morbidity in Klinefelter syndrome: A Danish register study based on hospital discharge diagnoses. J Clin Endocrinol Metab. 2006;91:1254–1260. Bruysters M, Christin-Maitre S, Verhoef-Post M, et al. A new LH receptor splice mutation responsible for male hypogonadism with subnormal sperm production in the propositus, and infertility with regular cycles in an affected sister. Hum Reprod. 2008;23:1917–1923. Brydøy M, Fosså SD, Dahl O, et  al. Gonadal dysfunction and fertility problems in cancer survivors. Acta Oncol. 2007;46: 480–489. Buretic-Tomljanovic A, Vlastelic I, Radojcic Badovinac A, et al. The impact of hemochromatosis mutation and transferrin genotype on gonadotropin serum levels in infertile men. Fertil Steril. 2009;91:1793–1800. Coviello AD, Bremner WJ, Matsumoto AM, et al. Intratesticular testosterone concentrations comparable with serum levels are not sufficient to maintain normal sperm production in men receiving a hormonal contraceptive regimen. J Androl. 2004;25:931–938. Coviello AD, Matsumoto AM, Bremner WJ, et  al. Low-dose human chorionic gonadotropin maintains intratesticular testosterone in normal men with testosterone-induced gonadotropin suppression. J Clin Endocrinol Metab. 2005;90: 2595–2602.

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Endocrinopathies in Male Infertility McLachlan RI. The endocrine control of spermatogenesis. Baillieres Best Pract Res Clin Endocrinol Metab. 2000;14:345–362. McLachlan RI, de Krester DM. Hypogonadotropism with elevated serum testosterone: Reversible causes of secondary infertility. Nat Clin Pract Urol. 2006;3:560–565. Paduch DA, Bolyakov A, Cohen P, et al. Reproduction in men with Klinefelter syndrome: The past, the present and the future. Semin Reprod Med. 2009;27:137–148. Patwardhan AJ, Eliez S, Bender B, et al. Brain morphology in Klinefelter syndrome: Extra X chromosome and testosterone supplementation. Neurology. 2000;54:2218–2223. Pavlovich CP, King P, Goldstein M, et al. Evidence of a treatable endocrinopathy in infertile men. J Urol. 2001;165:837–841. Raivio T, Falardeau J, Dwyer A, et  al. Reversal of idiopathic hypogonadotropic hypogonadism. N Engl J Med. 2007;357: 863–873. Raman JD, Schlegel PN. Aromatase inhibitors for male infertility. J Urol. 2002;167:624–629. Ramasamy R, Ricci JA, Palermo GD, et al. Successful fertility treatment for Klinefelter’s syndrome. J Urol 2009;182:1108–1113. Roa J, Aguilar E, Dieguez C, et al. New frontiers in kisspeptin/ GPR54 physiology as fundamental gatekeepers of reproductive function. Front Neuroendocrinol. 2008;29:48–69. Saare M, Belousova A, Punab M, et al. Androgen receptor gene haplotype is associated with male infertility. Int J Androl. 2008;31:395–402. Salameh W, Choucair M, Guo TB, et al. Leydig cell hypoplasia due to inactivation of luteinizing hormone receptor by a  novel homozygous nonsense truncation mutation in the ­seventh transmembrane domain. Mol Cell Endocrinol. 2005; 229:57–64. Schiff JD, Palermo GD, Veeck LL, et  al. Success of testicular sperm injection and intracytoplasmic sperm injection in men with Klinefelter Syndrome. J Clin Endocrinol Metab. 2005;90:6263–6267. Schiff JD, Ramirez ML, Bar-Chama N. Medical and surgical management: Male infertility. Endocrinol Metab Clin N Am. 2007;36:313–331. Seftel A. Male hypogonadism. Part I: Epidemiology of hypogonadism. Int J Imp Res. 2006a;18:115–120. Seftel A. Male hypogonadism. Part II: Etiology, pathophysiology, and diagnosis. Int J Imp Res. 2006b;18:223–228. Shiraishi K, Naito K. Fertile eunuch syndrome with the mutations (Trp8Arg and Ile15Thr) in the B subunit of luteinizing hormone. Endocr J. 2003;50:733–737.

55 Sigman M, Jarow JP. Endocrine evaluation of infertile men. Urology. 1997;50:659–664. Simoni M. Mutations of the G protein-coupled receptors of the hypothalamo–pituitary–gonadal axis. Where do we stand? Eur J Endocrinol. 1998;139:145–147. Sokol RZ. Endocrinology of male infertility: Evaluation and treatment. Semin Reprod Med. 2009;27:149–158. Sussman EM, Chudnovsky A, Niederberger CS. Hormonal evaluation of the infertile male: Has it evolved? Urol Clin North Am. 2008;35:147–155. Swerdlow AJ, Higgins CD, Schoemaker MJ, et al. Mortality in patients with Klinefelter syndrome in Britain: A cohort study. J Clin Endocrinol Metab. 2005;90:6516–6522. Themmen APN, Huhtaniemi IT. Mutations of gonadotropins and gonadotropin receptors: Elucidating the physiology and pathophysiology of pituitary-gonadal function. Endocr Rev. 2000;21:551–583. Vermeulen A, Verdonck L, Kaufman JM. A critical evaluation of simple methods for the estimation of free testosterone in serum. J Clin Endocrinol Metab. 1999;84:3666–3672. Vien L, Leo L, Billy C. Gonadotropin-releasing hormone: Regulation of the GnRH gene. FEBS J. 2008;275:5458–5478. Weedin JW, Rumohr JA, Bennett RC, et al. Leydig cell failure frequently associated with spermatogenic failure. J Urol. 2009;181:788–789. Weiss J, Axelrod L, Whitcomb RW, et al. Hypogonadism caused by a single amino acid substitution in the B subunit of luteinizing hormone. N Engl J Med. 1992;326:179–183. Whitten SJ, Nangia AK, Kolettis PN. Select patients with hypogonadotropic hypogonadism may respond to treatment with clomiphene citrate. Fertil Steril. 2006;86: 1664–1668. Wikstrom AM, Dunkel L. Testicular function in Klinefelter Syndrome. Horm Res. 2008;69:317–326. Wikström AM, Dunkel L, Wickman S, et al. Are adolescent boys with Klinefelter syndrome androgen deficient? A longitudinal study of Finnish 47, XXY Boys. Pediatr Res. 2006;59: 854–859. Wu FC, Tajar A, Pye SR, et al. Hypothalamic-pituitary-testicular axis disruptions in older men are differentially linked to age and modifiable risk factors: The European male aging study. J Clin Endocrinol Metab. 2008;93:2737–2745. Yong E, Loy C, Sim K. Androgen receptor gene and male infertility. Hum Reprod Update. 2003;9:1–7.

Female Fertility: Implications to Management of Male Factor Jeffrey M. Goldberg and Michelle Catenacci

Contents Evaluation......................................................................................................................................................................... Ovulatory Dysfunction...................................................................................................................................................... Tubal Disease.................................................................................................................................................................... Uterine Factors.................................................................................................................................................................. Endometriosis................................................................................................................................................................... Unexplained Infertility...................................................................................................................................................... References.........................................................................................................................................................................

Evaluation The evaluation has undergone an evolution with several time-honored standard tests becoming extinct and new ones being utilized in their place. The postcoital (Sims-Huner) test to assess pre-ovulatory cervical mucus quality and the presence of motile sperm within it has been abandoned as it lacks clinical validity (Practice Committee of the American Society of Reproductive Medicine 2006; Helmerhorst et  al. 2009). The test had poor reproducibility and even poorer predictive value. Treating patients with abnormal test results with intrauterine insemination (IUI) did not improve cumulative pregnancy rates. While the concept of luteal phase deficiency may have merit, there is no clinical test to diagnose it (Practice Committee of the American Society of Reproductive Medicine 2006). Luteal phase progesterone is secreted in pulsatile fashion, so individual values are useless for anything other than to confirm J.M. Goldberg () and M. Catenacci Obstetrics/Gynecology and Women’s Health Institute, Cleveland Clinic, Cleveland, OH, USA e-mail: [email protected]

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that ovulation has occurred. The gold standard test, endometrial biopsy for dating the endometrium using established histologic criteria, is expensive and painful, and suffers from high inter- and intra-assay variability. It also failed to distinguish between fertile and infertile women (Murray et al. 2004). Finally, routine diagnostic laparoscopy is no longer advised for the evaluation of unexplained infertility. In patients with no red flags for pelvic disease (i.e., pelvic pain, dysmenorrhea, or dyspareunia; prior abdomino-pelvic surgery; or history of sexually transmitted infections) as well as normal pelvic examination, ultrasonogram and hysterosalpingogram, the most likely abnormal finding would be minimal to mild stage endometriosis. As will be explained further in the endometriosis section, the number of laparoscopies to diagnose and treat this condition in order to obtain one extra successful pregnancy is 40. Thus, routine diagnostic laparoscopy is not considered to be cost-effective in women with unexplained infertility without symptoms and/or medical history, which would raise the incidence of finding pelvic disease. The current basic infertility evaluation consists of a semen analysis, documentation of ovulation, and assessment of the uterine cavity and fallopian tubes.

From: Current Clinical Urology: Male Infertility: Problems and Solutions, Edited by: E.S. Sabanegh, DOI: 10.1007/978-1-60761-193-6_7,  Springer Science+Business Media, LLC 2011

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A menstrual history with cycle intervals of 21–35 days, not varying by more than a week, is good evidence of ovulation. Confirmatory tests may include a biphasic basal body temperature chart, luteal phase progesterone level over 3  ng/ml, detection of an LH surge with a urinary ovulation predictor kit, or serial pelvic ultrasonograms demonstrating the growth and disappearance of a dominant follicle. If the cycles fall outside the normal parameters, the minimal evaluation is a TSH and prolactin level. Additional studies may be obtained based on history and physical findings. The hysterosalpingogram (HSG) is the first-line test to diagnose uterine or tubal disease. The procedure is performed in a fluoroscopy suite using transcervically injected water- or oil-soluble iodine-based contrast while observing on the monitor. The test can reveal intrauterine filling defects due to endometrial polyps, submucosal myomas, adhesions, and mullerian anomalies such as uni- and bicornuate, septate, and didelphic uteri. Tubal conditions include proximal occlusion, hydrosalpinges, salpingitis isthmica nodosa, and postspill loculation due to peritubal adhesions. Pregnancy rates are also increased for several months following the procedure. This may be due to mechanically flushing mucus plugs out of the proximal fallopian tubes, stimulating ciliary activity of the endosalpinx, or altering the tubo-peritoneal environment. Sonohysterography (SHG) is used to better delineate uterine defects seen on HSG. By injecting saline into the uterus through a small flexible catheter while performing transvaginal sonography, one can distinguish between polyps and myomas as well as determine their size and location to aid in treatment planning. SHG has been shown to be as accurate as hysteroscopy (Goldberg et al. 1997). Unlike hysteroscopy, it also allows for the visualization of extracavitary myomas as well as the ovaries. Several new modalities are being evaluated to assess ovarian reserve. Ovarian reserve is an indirect reflection of the quality and quantity of eggs remaining from the ongoing depletion of the finite pool and is a predictor of fertility potential. Women with diminished ovarian reserve tend to respond poorly to fertility drugs and have a poorer prognosis for conception than age-matched peers with normal ovarian reserve testing. Candidates for ovarian reserve testing include women 35  years of age; those with prior ovarian surgery, family history of early menopause, or poor response to exogenous gonadotropins; smokers; and patients prior to IVF treatment. There are several basal tests that are performed around cycle day 3, including serum FSH, estradiol,

Goldberg and Catenacci

and inhibin B; and transvaginal ultrasonography to measure ovarian volume and antral follicle counts. A Clomid challenge test measures serum FSH and estradiol on cycle day 3 followed by 100 mg of clomiphene citrate on cycle days 5–9, and then repeating an FSH on day 10. The Clomid challenge test increases the sensitivity for diagnosing diminished ovarian reserve compared to the unstimulated day 3 FSH and estradiol levels. Finally, serum antimullerian hormone levels may be assayed at any time of the cycle. The blood tests suffer from interassay variability and/or lack of standardization, and ultrasonography is dependent upon the skill of the sonographer. Of the above tests, the Clomid challenge test and antral follicle count are currently the most widely applied.

Ovulatory Dysfunction Ovulation disorders have been classified into three groups by the World Health Organization. Group 1 is hypogonadotropic hypoestrogenism with amenorrhea and low serum levels of FSH and estrogen. In some cases, it may be due to emotional or physical stress (such as very vigorous exercise) or extremes of body weight. The diagnosis is hypothalamic amenorrhea when no obvious causes are evident. In such cases, ovulation may be induced with exogenous parenteral gonadotropins. The second group demonstrates hypothalamic–pituitary dysfunction with oligomenorrhea or amenorrhea. Lastly, group 3 is hypergonadotropic hypoestrogenism due to ovarian failure and is manifested by amenorrhea with elevated FSH and low estradiol levels. There is no effective ­fertility ­treatment for group 3 except oocyte donation. Group 2 is by far the most common and has oligomenorrhea or amenorrhea with normal FSH and estrogen levels. Many women in group 2 have polycystic ovarian syndrome (PCOS). The diagnosis of PCOS requires the presence of at least two of the following three criteria: menstrual irregularities/anovulation, clinical or laboratory evidence of hyperandrogenemia, or polycysticappearing ovaries on pelvic sonography. Women with PCOS may also have insulin resistance and many are overweight or obese. The first step in treatment is dietary modification and regular exercise with the goal of weight reduction. Several trials have demonstrated that a 5–10% weight loss is rewarded with high rates of ovulation and spontaneous pregnancies (Giallauria et al. 2009; Huber-Buchholz et al. 1999). First-line medications for ovulation induction are clomiphene citrate (CC) and letrozole. CC is a

Female Fertility: Implications to Management of Male Factor

­ onsteroidal compound with both estrogenic and n ­anti-estrogenic properties depending on the target ­tissue. It works as an anti-estrogen in the hypothalamus, leading to an increase in FSH secretion. Its central action may cause headaches, visual changes, mood changes, and hot flushes. It may also have an anti-estrogenic effect on the endometrium, which may impair receptivity (Sovino et  al. 2002). Letrozole is an aromatase inhibitor. It decreases systemic estrogen levels, which releases the negative feedback inhibition on the hypothalamus and results in increased FSH secretion. Studies have shown letrozole to be as effective as CC in inducing ovulation while avoiding the above side effects of CC (Requena et  al. 2008; Mitwally and Casper 2001). Both medications are taken orally for 5  days in the early follicular phase. Approximately 75–80% of patients will ovulate, and half of these will conceive with either medication (Mitwally and Casper 2001; Imani et al. 1998). There is a 5–10% risk of multiple pregnancy but nearly all of these are twins. Treatment is generally continued for a total of six cycles. When single-agent therapy with CC or letrozole fails to induce ovulation, the addition of metformin, an oral insulin-sensitizing agent, may restore ovulatory function in some PCOS patients. However, as a first-line agent, metformin was shown to be inferior to CC and there was no added benefit to combining the two in a large blinded randomized trial (Legro et  al. 2007). Some argue that metformin should be continued once pregnancy is established to reduce the risk of gestational diabetes and pregnancy loss (Glueck et al. 2002). Others recommend discontinuing it as it cannot be assumed to be safe in pregnancy (Gilbert et al. 2006). When oral agents fail to induce ovulation, or achieve a pregnancy within six ovulatory cycles, superovulation (SO) with parenteral gonadotropins is usually the next step. Recombinant or urine-derived FSH is administered as a daily subcutaneous (SQ) injection for approximately 1  week, starting around day 3 of a spontaneous or progestin-induced menses. The patients are monitored with ultrasonograms of the ovary and serum estradiol levels, and the FSH dose is titrated according to the ovarian response. Ovulation is triggered with an SQ injection of hCG, which acts as an LH surge, when monitoring demonstrates that the follicle(s) is (are) mature, i.e., 18–20 mm in mean diameter. IUI is usually performed 36 h later, just prior to ovulation. The monthly fecundity rate with SO/IUI is similar to that in age-matched fertile controls, which is around 20% per cycle (Hughes 1997). Downsides to

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this treatment are the inconvenience of daily injections and frequent monitoring, high cost of the medication, a multiple pregnancy rate of approximately 20%, including a 1% risk of triplets or more, and finally, the risk ovarian hyperstimulation syndrome which, in rare instances, may be life threatening. Laparoscopic ovarian drilling is another option for CC-resistant PCOS patients. This procedure is performed by inserting a monopolar needle electrode into the ovarian stroma and applying current for a few seconds. The technique has not been standardized regarding the number of punctures per ovary, dose and duration of current, or whether one or both ovaries are to be treated. Ovarian drilling decreases androgen production from the ovary and LH levels are reduced as well. Approximately 70–80% ovulate spontaneously or in response to oral agents that were ineffective preoperatively (Seow et al. 2008). Pregnancy rates are comparable to those of SO but without the risk for multiple pregnancy (Farquhar et al. 2005).

Tubal Disease Tubal pathology is responsible for approximately 30% of female infertility. Risk factors for tubal disease include a history of pelvic inflammatory disease, appendicitis with rupture, previous pelvic surgery, prior ectopic pregnancy, and endometriosis (Luttjeboer et al. 2009). The diagnosis can be made by HSG or during laparoscopy with chromopertubation. Proximal tubal blockage can be caused by spasm of the utero-tubal ostia, luminal plugs of mucus and debris, or occlusion from fibrosis or salpingitis isthmica nodosa, a condition with diverticuli of the endosalpinx into the muscularis and fibrosis of the cornual-isthmic segment (Sulak et al. 1987). Treatment for proximal tubal blockage is by tubal cannulation using a small catheter with a guide wire. Once the blockage is passed, contrast is then injected to confirm patency. Tubal cannulation can be performed under fluoroscopic guidance or hysteroscopically while an assistant observes through a laparoscope. Tubal patency can be achieved in 75–85% of the cases. However, the reocclusion rate is approximately 30% (Das et  al. 2007). The average ongoing pregnancy rate is about 50% after hysteroscopic cannulation, but only 15% following fluoroscopic cannulation (Honoré et al. 1999). Distal tubal occlusion is most commonly caused by a previous episode of pelvic inflammatory disease and often results in hydrosalpinges. Mildly dilated

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hydrosalpinges with thin walls, relatively free of ­adhesions and a normal endosalpinx, may be opened by ­laparoscopic neosalpingostomy, resulting in intrauterine pregnancy rates of 58–77% with an ectopic rate of 2–10%. Corresponding rates after neosalpingostomy for large hydrosalpinges with fibrotic walls, encapsulated in dense adhesions, or with little normal endosalpinx are 0–22% and 4–16%, respectively (Nackley and Muasher 1998). These poor prognosis patients are better served with laparoscopic salpingectomy as they will need IVF, and the presence of hydrosalpinges reduces the IVF success rate by ~50% (Zeyneloglu et  al. 1998). Removal of the hydrosalpinges restores these rates back to normal (Strandell et al. 1999). Microsurgical tubal anastomosis for reversal of previous surgical sterilization is associated with pregnancy rates over 90% in women aged less than 40 years (Kim et  al. 1997). Even women 40  years of age and older have good success rates of up to 51% (Dubuisson et al. 1995). Pregnancy rates after laparoscopic tubal anastomosis have been shown to be comparable to those after microsurgical tubal anastomosis by laparotomy (Cha et al. 2001). The implementation of robotic assistance to try to overcome the technical difficulties of laparoscopic microsurgery was not found to improve success rates and was associated with increased operative time and cost compared with conventional laparoscopy and minilaparotomy (Goldberg and Falcone 2003; Rodgers et al. 2007).

Uterine Factors Myomas (fibroids) are common benign tumors arising from the myometrium. They may be single or multiple and can affect any part of the uterus. They may be completely within the cavity, suspended from the serosal surface by a pedicle, or intramural within the uterine wall. They range in size from 1 mm to the size of a term pregnancy. Finally, they may cause pelvic pain and pressure, urinary frequency, menorrhagia, and dysmenorrhea as well as increased abdominal girth. While 20–50% of reproductive age women have myomas, less than 10% contribute to infertility (Practice Committee of the American Society of Reproductive Medicine 2008). It is generally accepted that myomas that distort the uterine cavity are responsible for infertility and recurrent pregnancy loss, and that their removal restores reproductive function. It remains questionable whether intramural myomas that do not impinge on the cavity impair fertility (Practice

Goldberg and Catenacci

Committee of the American Society of Reproductive Medicine 2008; Taylor and Gomel 2008). Nonsurgical treatment of myomas such as uterine artery embolization, MR-guided focused ultrasound, or Dopplerguided transvaginal occlusion of the uterine arteries may be successful at relieving pain and/or bleeding symptoms, but they are not currently advised for women who are considering future fertility (Practice Committee of the American Society of Reproductive Medicine 2008; Taylor and Gomel 2008). Surgical removal of myomas can be performed by laparotomy, laparoscopy (with or without robotic assistance), or hysteroscopy depending on the size, location, and number of myomas present. Pregnancy rates have been reported to be 40–60% after abdominal or laparoscopic myomectomy (Somigliana et  al. 2008). Hysteroscopic removal of submucosal myomas shows similar results (Varasteh et  al. 1999). Patients may develop abdominal and/or intrauterine adhesions following myomectomy and rare cases of uterine rupture during pregnancy after myomectomy have also been described (Yang et al. 2008; Kelly et al. 2008). Other cavitary lesions that impact fertility include intrauterine polyps and adhesions. It remains unclear which polyps have a negative impact on fertility based on size and location. While hysteroscopic polypectomy is a simple procedure, data on the benefits of treatment are limited and conflicting (Taylor and Gomel 2008). Most would consider removing large polyps, >1  cm, especially if IVF is planned. Intrauterine adhesions, or Asherman’s syndrome, can also be associated with infertility. Adhesions can form after intrauterine infection or surgical procedures such as D&C or myomectomy for submucosal myomas. Hysteroscopic adhesiolysis may be facilitated by transabdominal ultrasonographic guidance. Live birth rates of 32–76% after treatment have been reported. The severity of the disease is inversely proportional to the success rate (Berman 2008). Congenital uterine anomalies tend to cause recurrent pregnancy loss and preterm delivery, but fertility is usually not significantly compromised. Septate uterus is the most common anomaly and is often associated with recurrent first trimester miscarriage. It is easily treated by dividing the septum hysteroscopically. A meta-analysis of 16 nonrandomized studies reported that the miscarriage rate decreased from 88% before hysteroscopic septoplasty to 14% after, while the term delivery rate increased from 3 to 80% (Hormer et  al. 2000). Furthermore, hysteroscopic septoplasty in women with otherwise unexplained

Female Fertility: Implications to Management of Male Factor

infertility resulted in higher pregnancy and live birth rates than those in women with unexplained infertility managed expectantly (Mollo et al. 2009). Bicornuate uterus may increase mid-trimester pregnancy loss and preterm delivery. However, treatment is only indicated in the rare cases of repetitive previable deliveries. Treatment with abdominal metroplasty (Strassman unification) can improve outcomes in these select patients (Papp et  al. 2006). There is no surgical ­correction for ­unicornuate or didelphic uteri.

Endometriosis Endometriosis is a disease defined by ectopic endometrial glands and stroma. Currently, definitive diagnosis requires direct vision at surgery. While medical therapy is useful for relieving the pain associated with endometriosis, there is no effective medical treatment for improving fertility (Adamson and Past 1994). Moderate and severe endometriosis (stages III and IV) may adversely affect fertility rates through marked anatomic distortion due to large endometriomas and/ or pelvic adhesions. Laparoscopic excision of disease can improve spontaneous pregnancy rates and possibly subsequent assisted reproductive pregnancy rates. Therapeutic effects are most significant in the immediate postoperative period, with decreasing pregnancy rates seen with increased time from surgery (Porpora et al. 2002). While there are many theories on how endometriosis may impair fertility, it remains largely unknown how, or even if, minimal to mild disease (stages I and II) reduces fertility (Gupta et  al. 2008). Two randomized multicenter trials examined the fertility rates with treated and untreated minimal to mild endometriosis. In the Canadian study, laparoscopic treatment resulted in a statistically significant improvement of cumulative pregnancy rates (Marcoux et  al. 1997). Conversely, an Italian group failed to show any benefit of laparoscopic treatment over diagnostic laparoscopy only (Parazzini 1999). A meta-analysis combining these two studies showed a statistically significant absolute difference of 8.6%, which translates to a number needed to treat of 12 to obtain 1 additional successful pregnancy (Al-Inany 2000). If we consider that the prevalence of endometriosis in infertile women is about 30%, the number of laparoscopies needed to be performed to diagnose and treat stage 1 and 2 endometriosis is actually 40 to obtain one subsequent pregnancy.

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If surgical correction of endometriosis fails to result in a pregnancy within a year, subsequent treatment depends on the stage of disease. Stage 1–2 disease is treated as unexplained infertility with CC or SO with IUI. In fact, the pregnancy rates are similar to those in patients with unexplained infertility (Werbrouck et al. 2006). Those with stage 3–4 disease are best managed by proceeding directly to IVF. There is no consensus regarding whether endometriosis affects IVF outcomes. There is also an ongoing debate on the advisability of removing ovarian endometriomas prior to SO for IVF. Proponents site improved technical ease of follicle monitoring and aspiration, and perhaps higher IVF success rates, while opponents claim that ovarian cystectomy may damage the ovary resulting in diminished ovarian reserve. A recent meta-analysis comparing treated versus nontreated endometriomas found no significant differences in response to gonadotropins or pregnancy rates (Tsoumpou et  al. 2009).

Unexplained Infertility The monthly fecundity rate (MFR) in couples with unexplained infertility without treatment is 2–4%. The MFR with timed IUI during spontaneous menstrual cycles was not significantly different from that of untreated patients with unexplained infertility, and is therefore not an effective treatment (Kirby et  al. 1991). Likewise, the MFR with CC and timed intercourse was no better than untreated controls (Guzick et al. 1998). However, the combination of CC and IUI resulted in an MFR of 8% and SO with IUI increased it further to 17%, close to the normal 20% in the fertile population (Guzick et  al. 1998). Finally, IVF for unexplained infertility yields a 31.7% live birth rate per cycle, similar to that in patients with tubal, ovulatory, and male factor infertility (Assisted Reproductive Technology Report 2006). The typical course of treatment is 3–6 cycles of CC/IUI followed by up to three cycles of SO/IUI, then IVF. This management scheme has been challenged by a recent randomized trial comparing three cycles of CC/IUI, then three cycles of SO/IUI before IVF with eliminating SO/IUI and going directly to IVF after the three cycles of CC/IUI. The time to pregnancy and cost were improved in the accelerated group without SO/IUI (Reindollar et  al. 2009). Ultimately, the decision is influenced by the woman’s age, duration of infertility, and the couple’s desires.

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References Adamson GC, Past DJ. Surgical treatment of endometriosis associated infertility: meta-analysis compared with survival analysis. Am J Obstet Gynecol. 1994;171:1488–1505. Al-Inany HG. Evidence my change with more trials: concepts to be kept in mind. Hum Reprod. 2000;15:2447–9 Berman JM. Intrauterine adhesions. Semin Reprod Med. 2008;26:349–55. Cha SH, Lee MH, Kim JH, et al. Fertility outcome after tubal anastomosis by laparoscopy and laparotomy. J Am Assoc Gynecol Laparosc. 2001;8:348–52. Das, S, Luciano NG, and Mourad SW. Proximal tubal disease: the place for tubal cannulation. Reprod Biomed Online. 2007;15:383–388 Dubuisson JB, Chapron C, Nos C, et al. Sterilization reversal: fertility results. Hum Reprod. 1995:10:1145–51. Farquhar C, Vanderkerchkove P, Lilford R. Laparoscopic “drilling” by diathermy or laser for ovulation induction in anovulatory polycystic ovary syndrome. Cochrane Database Syst Rev. 2005;3. Giallauria F, Palomba S, Vigorito C, et al. Androgens in polycystic ovary syndrome: the role of exercise and diet. Semin Reprod Med. 2009;27:306–15. Gilbert C, Valois M, Koren G. Pregnancy outcome after firsttrimester exposure to metformin: a meta-analysis. Fertil Steril. 2006;86:658–63. Glueck CJ, Wang P, Goldenberg N, et al. Pregnancy outcomes among women with polycystic ovary syndrome treated with metformin. Hum Reprod. 2002;17:2858–64. Goldberg JM and Falcone T. Laparoscopic microsurgical tubal anastomosis with and without robotic assistance. Hum Reprod. 2003;18:145–7. Goldberg JM, Falcone T, Attaran M. Sonohysterographic evaluation of uterine abnormalities noted on hysterosalpingography. Hum Reprod. 1997;12:2151–3. Gupta S, Goldberg JM, Aziz N, Goldberg E, Krajcir N, Agarwal A. Pathogenic mechanisms in endometriosis-associated infertility. Fertil Steril. 2008;90:247–57. Guzick DS, Sullivan MW, Adamson GD, Cedars MI, Falk RJ, Peterson EP, Steinkampf MP. Efficacy of treatment for unexplained infertility. Fertil Steril. 1998;70:207–13. Helmerhorst FM, Van Vliet HAAM, Gornas T, Finken MJ, Grimes DA. Intra-uterine insemination versus timed intercourse or expectant management for cervical hostility in subfertile couples. Cochrane Database Syst Rev. 2009;3 Honoré GM, Holden AE, and Schenken RS. Pathophysiology and management of proximal tubal blockage. Fertil Steril. 1999;71:785–95. Hormer HA, Li TC, Cooke ID. The septate uterus: a review of management and reproductive outcome. Fertil Steril. 2000;73:1–14. Huber-Buchholz MM, Carey DG and Norman RJ. Restoration of reproductive potential by lifestyle modification in obese polycystic ovary syndrome: rose of insulin sensitivity and luteinizing hormone. J Clin Endocrinol Metab. 1999;84:1470–4. Hughes EG. The effectiveness of ovulation induction and intrauterine insemination in the treatment of persistent infertility: a meta-analysis. Hum Reprod. 1997;12:1865–72. Imani B, Eijkemans MJ, te Velde ER, et al. Predictors of patients remaining anovulatory during clomiphene citrate induction of ovulation in normogonadotropic oligoamenorrheic infertility. J Clin Endocrinol Metab. 1998;83:2361–5.

Goldberg and Catenacci Kelly BA, Bright P, and Mackenzie IZ. Does the surgical approach used for myomectomy influence the morbidity in subsequent pregnancy? J Obstet Gynaecol. 2008;28:77–81. Kim SH, Shin CJ, Kim JC, et al. Microsurgical reversal of tubal sterilization: a report on 1118 cases. Fertil Steril. 1997;68: 865–870. Kirby CA, Flaherty SP, Godfrey BM, Warnes GM, Matthews CD. A prospective trial of intrauterine insemination of motile spermatozoa versus timed intercourse. Fertil Steril. 1991;56:102–7. Legro RS, Barnhart HX, Schlaff WD, et  al. Clomiphene, ­metformin, or both for infertility in the polycystic ovary ­syndrome. N Engl J Med. 2007;356:551–66. Luttjeboer FY, Verhoeve HR, van Dessel HJ, et al. The value of medical history taking as risk indicators for tuboperitoneal pathology: a systematic review. BJOG. 2009;116:612–25. Marcoux S, Maheux R, Bérubé S. Laparoscopic surgery in infertile women with minimal or mild endometriosis. Canadian Collaborative Group on Endometriosis. N Engl J Med. 1997; 337:217–22. Mitwally MF and Casper RF. Use of an aromatase inhibitor for induction of ovulation in patients with an inadequate response to clomiphene citrate. Fertil Steril. 2001;75:305–9. Mollo A, De Franciscis P, Colacurci N, Cobellis L, Perino A, Venezia R, Alviggi C, De Placido G. Hysteroscopic resection of the septum inmproves the pregnancy rate of women with unexplained infertility: a prospective controlled trial. Fertil Steril. 2009;91:2628–31. Murray MJ, Meyer WR, Zaino RJ, Lessey BA, Novotny DB, Ireland K, Zeng D, Fritz MA. A critical analysis of the accuracy, reproducibility, clinical utility of histologic endometrial dating in fertile women. Fertil Steril. 2004;81:1333–43. Nackley AC, Muasher SJ. The significance of hydrosalpinx in in vitro fertilization. Fertil Steril. 1998;69:373. Papp Z, Mezei G, Gávai M, et  al. Reproductive performance after transabdominal metroplasty: a review of 157 consecutive cases. J Reprod Med. 2006;51:544–52. Parazzini F. Ablation of lesions or no treatment in minimal-mild endometriosis in infertile women: a randomized trial. Gruppo Italiano per lo Studio dell’Endometriosi. Hum Reprod. 1999; 14:1332–1334. Porpora MG, Pultrone DC, Bellavia M, et al. Reproductive outcome after laparoscopic treatment of endometriosis. Clin Exp Obstet Gynecol. 2002;29:271–3 Practice Committee of the American Society of Reproductive Medicine. (2006) Optimal evaluation of the infertile female. Fertil Steril. (in press). Practice Committee of the American Society of Reproductive Medicine. Myomas and reproductive function. Fertil Steril. 2008;90:S125–30 Reindollar RH, Regan MM, Neumann PJ, Levine BS, Thornton KL, Alper MM, Goldman MB. A randomized clinical trial to evaluate optimal treatment for unexplained infertility: the fast track and standard treatment (FASTT) trial. Fertil Steril. 2009 (in press). Assisted Reproductive Technology (ART) Report, (2006) http:// www.cdc.gov/art/ART2006/section2b.htm#f20 Requena A, Herrero J, Landeras J, et  al. Use of letrozole in assisted reproduction: a systematic review and meta-analysis. Hum Reprod Update. 2008;14:571–82 Rodgers AK, Goldberg JM, Hammel JP, et al. Tubal anastomosis by robotic compared with outpatient minilaparotomy. Obstet Gynecol. 2007;109:1375–80.

Female Fertility: Implications to Management of Male Factor Seow KM, Juan CC, Hwang JL, et al. Laparoscopic surgery in polycystic ovary syndrome: reproductive and metabolic effects. Semin Reprod Med. 2008;26:101–10. Somigliana E, Vercellini P, Benaglia L et al. The role of myomectomy in fertility enhancement. Curr Opin Obstet Gynecol. 2008;20:379–85. Sovino H, Sir-Petermann T and Devoto L. Clomiphene citrate and ovulation induction. Reprod Biomed Online. 2002;4:303–10. Strandell A, Lindhard A, Waldenstrom U, et  al. Hydrosalpinx and IVF outcome: a prospective, randomized multicenter trial in Scandinavia on salpingectomy prior to IVF. Hum Reprod. 1999;14:2762–9. Sulak PJ, Letterie GS, Coddington CC, et al. Histology of proximal tubal occlusion. Fertil Steril. 1987;48:437–40. Taylor E and Gomel V. The uterus and fertility. Fertil Steril. 2008;89:1–16. Tsoumpou I, Kyrgiou M, Gelbaya TA, Nardo LG. The effect of surgical treatment for endometrioma on in viro fertilization

63 outcomes: a systematic review and meta-analysis. Fertil Steril. 2009;92:75–87. Varasteh NN, Neuwirth RS, Levine B, et  al. Pregnancy rates after hysteroscopic polypectomy and myomectomy in infertile women. Obstet Gynecol. 1999;94:168–71. Werbrouck E, Spiessens C, Meuleman C, D’Hooghe T. No difference in cycle pregnancy rate and in cumulative live-birth rate between women with surgically treated minimal to mild endometriosis and women with unexplained infertility after controlled ovarian hyperstimulation and intrauterine insemination. Fertil Steril. 2006;86:566–71. Yang JH, Chen MJ, Wu MY, et  al. Office hysteroscopic early lysis of intrauterine adhesion after transcervical resection of multiple apposing submucous myomas. Fertil Steril. 2008; 89:1254–9. Zeyneloglu HB, Arici A, Olive DL. Adverse effects of hydrosalpinx on pregnancy rates after in  vitro fertilization-embyro transfer. Fertil Sterl. 1998;70:492–9.

Varicocele: To Fix or Not to Fix Fábio Firmbach Pasqualotto, Edson Borges, Felipe Roth, Luana Venturin Lara, and Eleonora Bedin Pasqualotto

Contents Introduction....................................................................................................................................................................... Incidence........................................................................................................................................................................... Etiology of Varicocele....................................................................................................................................................... Pathophysiology and Typical Testicular Histological Abnormalities in Men with Varicocele........................................ Seminal Reactive Oxygen Species/Antioxidants Imbalance (Oxidative Stress).......................................................... Varicocele – Is it a Reason for Infertility?........................................................................................................................ Diagnosis of Varicocele.................................................................................................................................................... Clinical Treatment for Varicocele – When and Which Drug?.......................................................................................... Subclinical Varicocele: A Different Entity....................................................................................................................... Surgical Versus Embolization Approach.......................................................................................................................... Azoospermia and Varicocele............................................................................................................................................. Improvement in Semen Parameters After Varicocelectomy: Is There an Improvement with Assisted Fertilization?...... Varicocele in the Adolescent............................................................................................................................................. There Is a Benefit of Surgery for Couples with a Clear Indication of Assisted Fertilization........................................... Best Patient to Benefit from Surgery................................................................................................................................ Conclusions....................................................................................................................................................................... References.........................................................................................................................................................................

F.F. Pasqualotto (*) University of Caxias do Sul, RS, Brazil; Institute of Biotechnology, University of Caxias do Sul, RS, Brazil; Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Brazil; CONCEPTION – Center for Human Reproduction, Caxias do Sul, RS, Brazil; Rua Pinheiro Machado, 2569, sl 23/24, Bairro São Pelegrino, Caxias do Sul, RS, Brazil e-mail: [email protected] E. Borges Fertility – Center for Assisted Fertilization, São Paulo, SP, Brazil; Institute Sapientiae – Center of Post-Graduation in Human Assisted Reproduction, Brazil

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F. Roth and L.V. Lara CONCEPTION – Center for Human Reproduction, Caxias do Sul, RS, Brazil E.B. Pasqualotto CONCEPTION – Center for Advanced Research in Human Reproduction, Infertility & Sexual Function, Center for Biological and Health Sciences, University of Caxias do Sul, Caxias do Sul, RS, Brazil; Department of Obstetrics–Gynecology, General Hospital, University of Caxias do Sul, Caxias do Sul, RS, Brazil

From: Current Clinical Urology: Male Infertility: Problems and Solutions, Edited by: E.S. Sabanegh, DOI: 10.1007/978-1-60761-193-6_8,  Springer Science+Business Media, LLC 2011

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Introduction Tulloch (1955) reported that ligation of the spermatic vessels cured a 27-year-old azoospermic male with bilateral varicoceles. Within 3  months of the surgery, spermatozoa had returned to the seminal fluid, and within 9  months the patient’s wife became pregnant. Tulloch’s account sparked a renewed interest in the surgical correction of varicoceles, but this interest would not be long-lasting. Uncertain of the value of treating varicoceles for infertility, Baker et al. (1985) reviewed a series of 651 subfertile couples in which the man had a varicocele. They detected no improvement in pregnancy rates in couples where the man had undergone varicocele ligation and concluded that testicular vein ligation is not effective in improving fertility. They declared that the “onus is now on proponents of the treatment of varicoceles in infertile men by operation or other techniques to prove their case.” The debate has since raged, and countless studies and reviews have been published on this topic, few of which have succeeded in bringing clarity to the controversy. In the past decade, several controlled studies involving modern techniques of diagnosis and treatment have been published on this subject. In this review, we discuss the evidence and the role of varicocele repair for the treatment of male infertility.

Incidence Varicocele remains an enigma in the treatment of male infertility (Noske and Weidner 1999; Galarneau and

Fig. 1. Example of a clinical grade III varicocele

Pasqualotto et al.

Nagler 1999; World Health Organization 1992; Steeno et al. 1976; Kursh 1987). Despite over 30 years of evidence that the repair of varicoceles results in improved fertility, the retrospective nature of most of these reports has led to controversy regarding the utility of treatment (Pryor and Howards 1987; Nagler et al. 1997; Zini et al. 1997a). The enigma of the varicocele, although a source of frustration for clinicians, has been a siren call for researchers as attested to by the substantial, if flawed body of literature on the topic. Evaluation of a patient with a varicocele should include a careful medical and reproductive history, a physical examination, and at least two semen analyses (Jarow et al. 2002; Weidner et al. 2002). The physical examination should be performed with the patient in both the recumbent and upright positions. It is considered a subclinical varicocele when detected only with the ultrasound, grade I, palpable with Valsalva, grade II, palpable without Valsalva, and grade III, easily observed (Fig. 1). Imaging studies are not indicated for the standard evaluation unless the physical exam is inconclusive (Jarow et  al. 2002). Therefore, when a suspected varicocele is not clearly palpable, the scrotum should be examined while the patient performs a Valsalva maneuver in a standing position. The incidence of varicocele varies according to age with the following distribution: 2–6  years, 0.79%; 7–10  years, 0.96%; 11–14  years, 7.8%, and 15–19 years, 14.1% (Akbay et al. 2000). After the 20s, its incidence varies from 10 to 25% (Callam 1994). In the elderly (median of 60  years), varicocele is

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present in up to 42.9% of the population (Canales et  al. 2005). Up to now, there are no prospective, randomized controlled studies to demonstrate a relationship between varicocele and hormonal abnormalities. The incidence of varicocele is about 20% in the general population rising to almost 40% in infertile men (Magdar et  al. 1995). In men with secondary infertility, the prevalence of varicocele may be as high as 80% (Gorelick and Goldstein 1993; Witt and Lipshultz 1993), although in one study the prevalence of varicocele in men with primary and secondary infertility was no different (45 and 44%, respectively) (Jarow et  al. 1996). These observations suggest not only that the presence of a varicocele can cause a progressive decline in fertility, but also that a significant proportion of men with a varicocele (75%) are fertile. However, it is important to realize that there is some variability in the reported prevalence of varicoceles in populations of fertile and infertile men (World Health Organization 1992). Much of this may have to do with the interphysician variability in establishing the clinical diagnosis of the varicocele and in the notable increase in prevalence of varicocele with age (World Health Organization 1992; Levinger et al. 2007). Also, an inverse correlation seems to exist between body mass index (BMI) and the incidence of varicocele [GR-B] (Handel et al. 2006). But the main question remains: Are all adult varicoceles alike? Are varicoceles in a 25-year-old man the same as those in a 55-year-old man? A recent article addressed this very important question. The authors reviewed 581 consecutive nonazoospermic men presenting with a clinical varicocele and infertility, dividing them into two groups: 115 men aged 40  years and over and 466 men younger than 40 years of age (Zini et al. 2008). The authors compared preoperative clinical parameters and outcome measures including semen analysis, pregnancy rate, and assisted reproductive technology (ART) utilization rate. The proportion of men with secondary infertility was significantly higher in the group of men aged 40  years and older as was partner age. More importantly, they found no significant differences in mean improvement in sperm parameters, ART utilization, or pregnancy rates after varicocelectomy in the older group compared with the younger group. They also compared the spontaneous pregnancy rate in couples with advanced paternal age (40  years or older) who underwent varicocelectomy to an age-matched control group who did not undergo surgery. The authors concluded that paternal age may not adversely affect pregnancy outcome after varicocelectomy, supporting the practice of surgical

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management in older men with clinical varicocele and infertility. The reason for this discrepancy remains unknown, although it is postulated that the cause of infertility is related to both temperature and time (Jarow et al. 2002; Weidner et al. 2002; Pasqualotto et al. 2003a). The blood supply to the testes, as well as the resulting countercurrent heat exchange, results in cooler intratesticular temperatures than body temperatures (Nagler et al. 1997; Zini et al. 1997a). Disruption of this system can result in hyperthermia of the testes. As the left side drains into a system with higher resistance, small venules may persist or open during embryogenesis. Testicular blood flow remains low before puberty, and therefore these veins do not become clinically apparent until adolescence when testicular blood flow increases, which explains the appearance of most varicoceles around puberty. Men with varicocele who have intense physical activity regularly 4–5 times a week, lasting from 2 to 4 h/day over a period of 4 years, have a decrease in semen parameters (Luigi et  al. 2001). Also, the presence of varicocele in first degree relatives is more frequent than in the general population (Buschi et al. 1980).

Etiology of Varicocele The etiology of varicocele is thought to be multifactorial. The anatomic differences in venous drainage between the left and right internal spermatic vein (accounting for the predominance of left-sided varicocele) and the incompetence of venous valves resulting in reflux of venous blood and increased hydrostatic pressure are the most popular theories for varicocele development (Buschi et al. 1980; Braedel et al. 1994). Increased intra-abdominal pressure (associated with an active lifestyle) during childhood and early adolescence may be a predisposing factor in the development of a varicocele (Scaramuzza et al. 1996). On the other hand, obesity may be associated with a lower risk of developing a varicocele (Handel et al. 2006). Although varicoceles are almost always larger and more common on the left side (Dubin and Amelar 1977), the incidence of bilateral varicoceles is in the range of 15–50% (Nagler et  al. 1997; Zini et  al. 1997a; Pasqualotto et  al. 2003a). The rare, isolated right-sided varicocele generally suggests that the right internal spermatic vein enters the right renal vein, but it should prompt further investigation as this finding may be associated with situs inversus or retroperitoneal lesions (Comhaire et al. 1981).

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Pathophysiology and Typical Testicular Histological Abnormalities in Men with Varicocele Varicocele is caused by reflux in the internal spermatic vein, due either to anatomical or functional inadequacy of its valvular system, or to the presence of collateral circulation between the renal vein or perirenal plexus and the internal spermatic vein (reno-gonadal bypass). Reflux may be enhanced as a result of renal venous compression between the aorta and the cranial mesenteric artery (so-called nut cracker phenomenon) (Sayfan et al. 1984). The direction of blood circulation is inverted (centrifugal) in the caudal section of the internal spermatic vein and cranial segment of the pampiniform plexus, at least when the person stands erect or performs Valsalva maneuver. Refluxing blood has been shown to contain a high concentration of certain catecholamines, particularly norepinephrine (Comhaire and Vermeulen 1974; Cohen et al. 1975). The increased hydrostatic pressure in the intrascrotal veins enhances the physiological countercurrent exchange from these veins to the testicular artery that is coiled and surrounded within the venous plexus. The increased norepinephrine concentration causes constriction of the intratesticular arterioles (Chakraborty et  al. 1985), decreasing arterial perfusion as evidenced by isotope studies (Comhaire et al. 1983). Long-lasting exposure to a high concentration of catecholamines and vasoconstriction results in endothelial hyperplasia of the intratesticular arterioles, rendering the perfusion deficit irreversible in spite of treatment interrupting reflux. The Sertoli cells are very sensitive to impaired arterial blood supply and hypoxemia. They display microscopic alterations and vacuoles, and become incapable of “sustaining” the spermatogenic cells (Terquem and Dadoune 1981). Spermatids, spermatocytes, and, finally, spermatogonia are “sloughed” from the spermatogenic epithelium, appearing in increased number in the ejaculate as (peroxidase negative) round cells (MacLeod 1965). Also, the secretory capacity of the Sertoli cells is decreased with subnormal concentration of inhibins (A and B) in serum (Mahmoud et  al. 1998). This results in increased serum concentration of FSH, which stimulates the Sertoli cells. The latter produce excess amounts of, among other substances, Interleukin-6 (IL-6) (Comhaire et  al. 1998), which, in turn, inhibits the production and secretion of Sertoli cell transferrin. Transferrin is of pivotal importance in the transportation of iron through the blood–testis barrier to the

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dividing spermatocytes and the spermatids (Sylvester and Griswold 1994). These display transferrin receptors on their membrane. Decreased iron supply, as a consequence of the transferrin deficit, results in decreased cell division and oligozoospermia. The ejaculates of subfertile men with varicocele were shown to contain increased concentrations of IL-6 and decreased transferrin, and the latter was found to increase after treatment (Comhaire et  al. 1998; Nallella et  al. 2004). Leydig cell function is also impaired in men with varicocele, causing premature “ADAM” (androgen deficiency of the aging male) (Pirke et  al. 1983; Comhaire and Vermeulen 1975). However, varicocele patients at reproductive age usually have normal serum testosterone, although the secretory reserve of Leydig cells may be decreased (Castro-Magana et al. 1991). Scrotal hyperthermia likely represents the primary mechanism by which a varicocele affects endocrine function and spermatogenesis. Indeed, scrotal and intratesticular temperatures are elevated in humans and in experimental animal models with varicocele (Zorgniotti and Macleod 1973; Goldstein and Eid 1989). In addition, varicocelectomy has been shown to reduce testicular temperature (Wright et al. 1997). The detrimental effect of hyperthermia on testicular function may be a result of the reduced thermal stability of testicular proteins compared with that of proteins from other organs (Mieusset et  al. 1989). Also, the deleterious effect of hyperthermia may also be exerted on the epididymis. Experimental elevations in epididymal temperature may reduce the storage capacity of this epididymis, resulting in a decrease in both sperm count and quality in the ejaculate (Bedford and Yanagimachi 1991). The theory of adrenal and renal metabolite reflux stems from early anatomic radiographic studies, documenting reflux of blood from the renal vein into the internal spermatic vein. Despite the reports demonstrating correlations between increased concentrations of these metabolites in the internal spermatic vein and the presence of a varicocele, few of these metabolites have clearly been shown to be gonadotoxic (Comhaire and Vermeulen 1974; Cohen et al. 1975). Moreover, increased hydrostatic pressure in the internal spermatic vein from renal vein reflux may also be responsible for varicocele-induced pathology (Shafik and Bedeir 1980). Our current understanding of the pathophysiology of varicocele is nebulous (Raman et  al. 2005). The possible causes of varicocele are (a) absence or congenital incompetence of the left spermatic veins valves and

Varicocele: To Fix or Not to Fix

(b) difficulties in the venous return due to obstruction or compression of the vein system (Nistal et al. 2004). There are several theories to explain the impact of varicocele over testicular function, although none solely is able to elucidate the variable effects of the varicocele in the spermatogenesis and male infertility (Nistal et al. 2004). These theories include hyperthermia (Nistal et al. 2004), hypoxia (Nistal et al. 2004; Agarwal et al. 2006), decrease in intratesticular and epididymal blood flow, intratesticular hormonal abnormalities (Nistal et al. 2004), oxidative stress (Agarwal et al. 2006), and renal and adrenal metabolite reflux (Nistal et al. 2004).

Seminal Reactive Oxygen Species/ Antioxidants Imbalance (Oxidative Stress) A free radical is defined as any molecule that has one or more unpaired electrons. Reactive oxygen species (ROS) are a highly active form of free radicals and consist of hypochlorite radical (−OHCl), superoxide anion (O2−), and the hydroxyl radical (OH−). ROS are a normal part of the cellular milieu and are essential for all aerobic life. Their principal function is as secondary messengers for signal transduction within cells (Steeno et  al. 1976). ROS are particularly important in normal fertilization since they are required during the acrosome and capacitation reactions by inducing hyperactivation of the sperm. Normally, ROS are rapidly cleared through the action of a host of antioxidants. An imbalance in the generation of ROS or their clearance through such scavenging mechanisms results in a state of relative excess of ROS that is called oxidative stress (Kolettis et al. 1999; Sharma et al. 1999; Pasqualotto et al. 2000, 2001, 2008; Hendin et al. 1999; Pasqualotto 2001, 2002). Varicoceles may be associated with an increase in the ROS generation and oxidative stress. Oxidative stress results not only from an overproduction of ROS but also from a decline in the antioxidants. Sharma et  al. (1999) recommended the use of combined ROS–TAC score in the evaluation of oxidative stress. They noted that among 56 patients with varicoceles, the ROS–TAC score was significantly lower than in the controls. While evaluating both these parameters in 53 men – 21 infertile men with varicoceles, 15 men with incidental varicoceles, and 17 fertile men without varicoceles – Hendin et al. (1999) found the levels of ROS to be significantly higher in men with varicoceles than in controls but no difference between fertile and infertile men with varicoceles. They also noted the antioxidant capacity to be lower in both the fertile and infertile varicocele patients. Several studies have focused on the detrimental effect of ROS on sperm function. Sperm are considered particularly

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susceptible to ROS-induced damage because of their high membrane polyunsaturated fat content and low amount of cytoplasm that can generate antioxidants. The effects of oxidative stress have thus been in the form of abnormal morphology, motility, function, and DNA damage. A number of these changes may not be apparent on a routine semen analysis but may manifest as unexplained infertility or repeated fertilization failure in an assisted reproductive cycle. Apoptosis is the mechanism of spontaneous, regulated cell death that ensures the maintenance of a normal cell life. Increased apoptosis may be responsible for depletion of germ cells and consequently poor semen parameters. It may also induce spontaneous death of mature sperm. Experimental rat model studies of varicocele found an increased rate of apoptosis in the varicocele group when compared to the sham surgery group (Cam et al. 2004; Barqawi et al. 2004). This apoptosis may be ROS-mediated and could be reversed through the use of antioxidants such as melatonin (Onur et  al. 2004). Levels of ROS have been found to correlate with the degree of apoptosis and also with poor fertilization rates following ICSI (Host et al. 2002). Nitric oxide may also induce free radicalmediated cellular damage. These may be elevated in isolation in the spermatic vein with normal peripheral levels. In a study comparing adolescents with and without varicoceles, spermatic vein levels of nitric oxide were significantly higher in the adolescents with varicoceles (Turkyilmaz et al. 2004). A varicocele is associated with bilateral spermatogenic abnormalities and Leydig cell dysfunction (Comhaire and Vermeulen 1975; Dubin and Hotchkiss 1969; Johnsen and Agger 1978). The testicular histology in infertile men with varicocele is variable, but most studies report reduced spermatogenesis (hypospermatogenesis) (Agger and Johnsen 1978; Ibrahim et al. 1977). In addition, abnormalities in the ultrastructure of testicular tissue of men with varicocele have also been described (Santoro and Romeo 2001). They noted that histologic changes were less pronounced in adolescents than in adults, implying that uncorrected adolescent varicoceles will be associated with greater testicular injury later in life. The observed increase in germ cell apoptosis associated with varicocele is thought to occur as a result of hyperthermia and low testosterone levels in the testis (Lue et al. 2002). Testosterone concentration is lower in older (>30 years) compared with younger men with varicocele, a trend not seen in men without varicocele, suggesting a progressive, adverse effect of varicocele on Leydig cell function (World Health Organization 1992). Therefore, there is

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no pathognomonic testicular histological abnormality in patients with varicocele (Wang et al. 1991). Leydig cell hyperplasia, maturation arrest, decrease in the number of Sertoli cells per seminiferous tubule, and germinal epithelium displacement have all been seen (Wang et  al. 1991; Paduch and Skoog 2001). Tissue abnormalities are similar to the ones found in patients with spermatogenesis abnormalities without varicocele (Wang et al. 1991; Paduch and Skoog 2001).

Varicocele – Is it a Reason for Infertility? The true effect of varicocele on male fertility potential is not known. Numerous studies have demonstrated an association between varicocele and reduced male fertility potential (e.g., poor semen parameters, infertility). However, most varicocele studies involve highly selected populations (e.g., infertile men) and rarely examine unselected men, representing an important reason for the difficulty in relating varicoceles with male fertility. Moreover, the lack of reliable endpoints for measuring fertility represents another challenge in relating varicoceles with male infertility. Conventional semen parameters (sperm concentration, motility, and morphology) are generally monitored in varicocele studies, but these parameters exhibit a high degree of biological variability and are of modest value in predicting male fertility potential (Guzick et al. 2001). Pregnancy is also of limited value in assessing the influence of varicocele on male fertility potential because this outcome is heavily influenced by female factors (Pasqualotto 2002). Varicocele remain the most common cause of male infertility, although the literature shows conflicting data as well as the conclusions obtained throughout studies with low level of evidence or inadequate trials. The World Health Organization (WHO) observational study involving 9,034 men verified that 25.6% of patients with abnormal semen analysis have varicocele, and in these men there is a significant decrease in the ipsilateral testicle volume compared to the contralateral testicle. This decrease in testicular volume does not happen in men with infertility without varicocele (World Health Organization 1992). It has been demonstrated that testicular atrophy may be associated with an adverse effect of varicocele on

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male fertility (Lipshultz and Corriere 1977; Pinto et al. 1994; Sigman and Jarow 1997; Zini et al. 1997b). In men with a left varicocele, mean left testicular volume is less than right testicular volume (Pinto et  al. 1994; Sigman and Jarow 1997; Zini et  al. 1997b). However, the relationship between varicocele grade and the degree of testicular atrophy is less clear. The impact of testicular atrophy on male fertility remains to be established, although most studies indicate that atrophy is associated with reduced sperm parameters. Studies have reported that in men with left varicocele, those with testicular atrophy have poorer sperm parameters than do men without atrophy. Similarly, in adolescents, a volume differential greater than 10% between the normal and affected testis correlates with a significantly decreased sperm concentration and total motile sperm count. However, loss of testicular volume is not clearly associated with loss of fertility (Pinto et al. 1994). The influence of varicocele on sperm parameters has not been established conclusively. In studies of infertile men, varicoceles have been associated with abnormal sperm parameters. It has been observed that the majority of semen samples from infertile men with varicocele have poorer sperm parameters (lower sperm counts, increased numbers of spermatozoa with abnormal forms, and decreased sperm motility) than those of fertile men. However, the “stress pattern” described by MacLeod (i.e., increased proportions of sperm with tapered heads and immature forms) is not a specific marker for varicocele and, therefore, is not diagnostic of this condition (MacLeod 1965; Ayodeji and Baker 1986). Although studies on the prevalence of varicocele in men with primary and secondary infertility suggest that the presence of a varicocele may cause a progressive decline in fertility, this has not been confirmed by prospective studies. Pasqualotto et al. (2005a) demonstrated a clear correlation between semen quality and clinical varicocele in men with infertility. Semen quality from men without infertility but with the presence of clinical varicocele did not differ from men without clinical varicocele.

Diagnosis of Varicocele Up to now, there are no gold standard criteria for the diagnosis of varicocele (Liguori et al. 2004). The physical examination with the patient in the standing position in a 25°C room temperature has been the

Varicocele: To Fix or Not to Fix

method most commonly used (Dubin and Amelar 1970), but its sensitivity and specificity are only 70% (Nagler et al. 1977). Varicoceles diagnosed by physical examination are considered “clinical” and they are classified according to their size. The largest (grade III) are seen prior to palpation or Valsalva; the moderate (grade II) are detected through palpation without the Valsalva maneuver; and the smallest (grade I) are detected via palpation and Valsalva maneuver only (Trum et  al. 1996; Geatti et  al. 1991). The most sensitive test for the diagnosis of pampiniform plexus vein reflux (clinical vs. subclinical varicocele) is the spermatic vein venography (Gat et  al. 2004; Kattan 1998). In comparison to venography, color Doppler ultrasound has more than 90% sensitivity and specificity (Trum et  al. 1996), while the scrotal thermography and scintigraphy have variable results (Geatti et  al. 1991; Gat et al. 2004).

Clinical Treatment for Varicocele – When and Which Drug? There are few well-designed studies about medical treatment for varicocele. The use of carnitine combined with nonsteroidal anti-inflammatory drugs for 6 months in patients with clinical varicocele and infertility was not able to solve improve semen parameters or achieve a higher pregnancy rate (Cavallini et  al. 2003, 2004). Clomiphene citrate has been shown to have no effect on sperm concentration and motility in patients with subclinical varicocele when compared with surgery (Unal et  al. 2001), and minimal data exist validating the use of clomiphene citrate in patients with clinical varicocele. Kallikrein was noted to improve semen parameters in 38 men, showing a statistical improvement in sperm motility as well as morphology compared to the control group (Micic et al. 1990). A recent study comparing the association between menotropin therapy and varicocelectomy indicated that the sooner the medical treatment was initiated, the better the clinical outcomes (De Rose et al. 2003). Even though the use of antioxidants to treat male infertility in patients with varicocele is considered highly controversial, recent articles have demonstrated a benefit of antioxidants in patients with varicocele (Kefer and Sabanegh 2009).

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Subclinical Varicocele: A Different Entity By definition, subclinical varicocele is defined as being identified only with the help of ultrasound (Zini et  al. 1997a). The subclinical varicocele nowadays is not associated with male infertility. The scrotal Doppler ultrasound may be indicated to evaluate infertile men when the physical examination is inconclusive or difficult (Practice Committee of the American Society for Reproductive Medicine 2006; Donkol and Salem 2007). As there is no evidence in the medical literature to define the ideal treatment for men with subclinical varicocele (Gat et  al. 2003; Pasqualotto et  al. 2005b), subclinical varicocele treatment for infertility is not recommended.

Surgical Versus Embolization Approach The aim of varicocele repair is to occlude the spermatic veins to prevent venous reflux. This may be accomplished with open surgery, microsurgical or laparoscopic ligation of the internal spermatic veins, or by introducing sclerosing agents or embolization devices into the spermatic veins. The treating physician’s experience and expertise, together with the option available, should determine the choice of varicocele treatment. There are two approaches to varicocele repair: surgery and percutaneous embolization (Jarow et al. 2002; Weidner et al. 2002). Surgical repair of a varicocele may be accomplished by various open surgical methods, including retroperitoneal, inguinal, and subinguinal approaches, or by laparoscopy (Raman et  al. 2005; Nistal et  al. 2004). Even though none of these methods have been proven to be superior to the others in its ability to improve fertility, several studies have shown that microsurgical inguinal or subinguinal techniques have significantly better results in terms of sperm motility improvement, pregnancy rate, recurrence, and complications than those of the traditional surgical approaches of high ligation or of laparoscopy (Goldstein et al. 1992). Marmar and Kim (1994) introduced the subinguinal microsurgical varicocelectomy with ligation and Goldstein et al. (1992) modified the microsurgical technique with delivery of the testis in search of scrotal collaterals including the gubernacular veins. The percutaneous embolization is done through the occlusion of the internal spermatic vein (Gat et al. 2005).

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There are no studies proving one method is superior to another regarding fertility improvement; however, differences in the complication and recurrence rates have been described (Al-Kandari et al. 2007). Subinguinal varicocelectomy with optical magnification increases the probability of arterial and lymphatic preservation, significantly decreasing the risks of recurrence and postoperative complication in relation to laparoscopy and surgeries without magnification (Al-Kandari et  al. 2007; Yavetz et  al. 1992; Nieschlag et  al. 1993). In fact, there are two approaches to increase the magnification: loupe and operative microscope. While the use of loupe increases few time the magnification, experienced surgeons use the microscope in order to recognize and avoid unnecessary injuries to the vas deferens, lymphatics, and arteries. On the other hand, there have been no prospective, randomized studies of microsurgical varicocelectomy versus no treatment. Percutaneous embolization is associated with higher recurrence rates, even higher than the conventional surgical approaches, without taken into account the complications related to the percutaneous embolization method itself (Shlansky-Goldberg et  al. 1997). Patients with bilateral clinical varicoceles should be considered for bilateral varicocelectomy (Libman et al. 2006).

Azoospermia and Varicocele A varicocele repair may be considered for men with azoospermia who have a palpable varicocele. Therefore, azoospermic patients with germ cell aplasia in a single large testis biopsy may have an improvement in semen quality following varicocelectomy. Due to the possibility of their relapsing into azoospermia after an initial improvement in semen quality following varicocelectomy, patients should be informed of the possibility of sperm cryopreservation. In azoos­ permic patients, the surgical treatment of varicocele may promote spermatogenesis, avoiding the need to obtain sperm from the testicle for assisted reproduction (Matthews et  al. 1998; Kim et  al. 1999; Pasqualotto et  al. 2003b, 2006; Schlegel and Kaufmann 2004). It is of utmost importance to consider the genetics before repairing a clinical varicocele in cases of azoospermia. Patients with varicocele and azoospermia and with abnormal karyotype or Y-microdeletion most probably do not benefit from the surgical procedure.

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Improvement in Semen Parameters After Varicocelectomy: Is There an Improvement with Assisted Fertilization? Varicocele repair, intrauterine insemination (IUI), and in  vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) are options for the management of couples with male factor infertility associated with a varicocele (Fisher and Sandlow 2001; Daitch et  al. 2001; Palermo et al. 1992; Cayan et al. 2002; Schlegel 1997; Penson et al. 2002). The decision as to which method of management to use is influenced by many factors. Most importantly, varicocele repair has the potential to reverse a pathological condition and effect a permanent cure for infertility, as opposed to IUI or the ART required for each attempt at pregnancy (Cayan et  al. 2002). Other factors to be considered are age of the female partner, the unknown long-term health effects of IVF and ICSI on the offspring resulting from these techniques, and the possibly greater cost effectiveness of varicocele treatment than of IVF with or without ICSI (Schlegel 1997; Penson et  al. 2002). Finally, failure to treat a varicocele may result in a progressive decline in semen parameters, further reducing a man’s chances for future fertility. There are few studies with prospective evidence evaluating outcomes following varicocelectomy. Further, there are no standard patterns in the selection methods, diagnosis, forms of treatment, and variables evaluated. One randomized study demonstrated that there is an improvement in semen quality in 50% of the cases (Cayan et al. 2000). A meta-analysis of clinical randomized studies demonstrated that surgery or embolization treatment for varicocele in men with infertility does not increase the chance of natural pregnancy (Evers and Collins 2007); however, there are several criticisms regarding the selection of the studies included in this chapter (Ficarra et  al. 2006). Another recent metaanalysis demonstrated that after varicocelectomy, the chances of natural pregnancy increased 2.8 times comparing to patients without any type of treatment or with clinical treatment (Marmar et al. 2007). Testicular size, grade of varicocele, seminal para­ meters, and hormonal levels may be considered as prognostic parameters for men with varicocele (Fretz and Sandlow 2002). However, it is not possible to draw conclusions as to which parameters are predictive as treatment outcomes (Callam 1994; Krause et al. 2002; Grasso et al. 2000). Although a large body of literature suggests improved semen parameters and fertility

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following varicocelectomy, some investigators have challenged the benefit of these procedures because these are case-controlled studies rather than prospective randomized trials (Benoff and Gilbert 2001; Schatte et  al. 1998; Vazquez-Levin et  al. 1997; Kibar et  al. 2002; Zini et  al. 1999). In fact, even though the preponderance of adult studies supports a favorable effect of varicocelectomy on male fertility potential, most of these studies are uncontrolled (Madgar et al. 1995). The statistical evaluation of these data is the subject of an ongoing debate and the fertility outcomes of varicocele repair have been described in numerous published studies (Benoff and Gilbert 2001; Schatte et al. 1998; Vazquez-Levin et al. 1997; Kibar et al. 2002; Zini et al. 1999). Most of these studies lack adequate numbers of patients, randomization, and/or controls, and it is not possible therefore to reach a clear conclusion on the fertility outcome (Evers and Collins 2007). Several recent reviews have critically examined the results of randomized controlled trials of varicocelectomy. Recently, Evers and Collins (2007) reported a meta-analysis including seven prospective randomized trials that evaluated varicocelectomy and pregnancy outcomes. They claimed that there was insufficient evidence to conclude that treatment of clinical varicocele improved the likelihood of conception for couples with male infertility. They stated that the routine treatment of the male partner of subfertile couples was unadvisable. This conclusion is regrettable because the data in the meta-analysis were questionable. Specifically, several patients in the study groups had normal semen analysis. Of the seven studies, four included men with subclinical varicoceles. Two of the studies had questionable data for the outcome of controls, including one with an accumulative pregnancy rate for controls of 47%, whereas the other had a 24.5% pregnancy rate with counseling of controls that actually included optimization of female reproductive functions (Evers and Collins 2007). The pregnancy rates for controls among the remaining studies in the meta-analysis ranged between 4.5 and 10%. Finally, the varicocele treatment did not include microsurgical procedures as suggested by the Best Practice Study Groups, and there was limited follow-up information concerning recurrences with either high ligation or embolization (Jarow et al. 2002). A Cochrane review identified five randomized controlled trials that examined the outcomes in couples with male factor infertility and varicoceles, and concluded that they did not show sufficient evidence regarding the treatment of varicoceles to warrant their repair (Evers et al. 2001). However, these studies were

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chosen for this review only because of their status as randomized clinical trials; no evaluation of the methods was performed. A review of these trials shows that one examined only subclinical varicoceles, and three others exhibited methodological problems including the use of embolization, high pregnancy rates in untreated couples (25% in a 1-year period), and inherent selection bias in the study (many couples opted to pursue assisted reproductive technology rather than enter the study). Although few randomized controlled trials show the benefit of treating varicocele-related infertility, many nonrandomized studies support this concept (Evers et  al. 2001). Numerous studies, most of them retrospective, were reviewed and the following conclusions drawn. Most participants showed improvement in postoperative sperm density and motility. The natural pregnancy rates varied, but the overall average was 37%, a clearly higher figure than any reported for nontreatment. Although many of these studies suffer from the flaws of nonrandomized trials, these results would be difficult to explain on the basis of chance alone.

Varicocele in the Adolescent An important consideration for varicocele management is patient age. Pediatric or adolescent varicocele is a different disease entity from adult varicocele, with its own diagnostic and therapeutic considerations. The main challenge in the management of a varicocele in adolescents is to establish criteria for the indications of treatment, in other words, to identify which of the patients will be benefit from surgery. Adolescent males who have unilateral or bilateral varicoceles and objective evidence of reduced testicular size ipsilateral to the varicocele should be considered candidates for varicocele repair (Kursh 1987; Jarow et  al. 2002; Madgar et  al. 1995; Laven et al. 1992). If objective evidence of reduced testis size is not present, adolescents with varicoceles should be followed up with annual objective measurements of testis size and/or semen analysis in order to detect the earliest sign of varicocele-related testicular injury (Jarow et  al. 2002; Weidner et  al. 2002). Varicocele repair should be offered at the first detection of testicular or semen abnormality. In the adolescent population, the hypotrophy rate caused by varicocele is 9%, and should be always related to the child/adolescent development according to the Tanner Kass classification (Kass et al. 2001). Most studies of adolescents with varicocele indicate that varicocelectomy has a beneficial effect on testicular

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function and/or male fertility potential. In general, surgery is indicated in boys with testicular atrophy and/or abnormal semen parameters. Controlled studies indicate that at follow-up evaluation (1–15 years), varicocelectomy is associated with higher sperm parameters and higher testicular volumes than that of observation. Moreover, microsurgical repair has been associated with better outcomes (testicular growth, complication rate) than that of nonmicrosurgical varicocelectomy in adolescents (Laven et  al. 1992; Palermo et  al. 1992; Cayan et  al. 2002; Schlegel 1997; Penson et  al. 2002; Alukal and Lipshultz 2009). As such, the data indicate that varicocelectomy is recommended in adolescents with varicocele and abnormal sperm parameters and/or testicular atrophy. In adults, the grade of varicocele is related to the testicular volume: the presence of varicocele grade I has low impact in testicular volume, grade II is related to unilateral atrophy, and grade III is related with bilateral abnormalities (Kass et al. 2001). Despite that, the grade of varicocele is not related to the presence or gravity of testicular disproportion in adolescents (Alukal et al. 2005). The criteria for definition of testicular hypotrophy include: 1. Difference in both testicular sizes between 10 and 25% (Sayfan et al. 1997; Podesta et al. 1994) 2. The absolute difference between both testicles between 2 and 3 ml (Podesta et al. 1994) Scrotal pain appears to be uncommon in adolescents with varicocele, with an incidence of 2–4% (Diamond 2007). There are no studies evaluating the indications for varicocelectomy in these cases. The same techniques for varicocele repair in adults are routinely used in the adolescents (Yaman et  al. 2006; Cayan et al. 2005; Schiff et al. 2005; Barqawi et al. 2002). The improvement in sperm motility following varicocelectomy is higher in adolescents compared to adults (Ku et  al. 2005) and the increase in testicular size of the affected testis occurs in between 50 and 90% of the cases. In the presence of bilateral normal testicular develop­ ment and absence of symptoms, there is no evidence to support the benefits of varicocele repair. These adolescents must be followed annually with physical exam, ultrasound, and semen analysis, whenever possible (Diamond 2007). In cases of testicular hypotrophy and/or abnormalities in the semen, surgical repair of the varicocele should be considered.

Pasqualotto et al.

There Is a Benefit of Surgery for Couples with a Clear Indication of Assisted Fertilization Some studies indicate that IVF/ICSI seems to be no more effective than varicocelectomy, but more expensive than the surgical procedure (Schlegel 1997; Penson et  al. 2002; Yoshida et  al. 2000). In their meta-analysis, Penson et  al. (2002) reported that the probability of a live birth after varicocelectomy was 29.7% (with 1% having twins) as compared to 25.4% after IVF/ICSI (with a multiple gestation rate of 39%). In a separate study, Schlegel (1997) reported that the cost per baby delivered with IVF/ICSI was $89,091 as compared to $26,268 after varicocelectomy. Thus, varicocele surgery seems desirable for selected varicocele cases. The surgical approach of the varicocele may be capable to avoid the need of assisted reproduction, even reducing the treatment complexity grade when indicated (Daitch et  al. 2001; Cayan et  al. 2002). In azoospermic patients, the surgical treatment of varicocele may promote spermatogenesis, avoiding the need to obtain sperm from the testicle for assisted reproduction (Pasqualotto et al. 2003b, 2006; Schlegel and Kaufmann 2004). Patients should be evaluated after varicocele treatment for persistence or recurrence of the varicocele. If the varicocele persists or recurs, internal spermatic venography may be performed to identify the site of persistent venous reflux. Either surgical ligation or percutaneous embolization of the refluxing veins may be used. Semen analysis should be performed after varicocele treatment at about 3-month intervals for at least 1 year or until pregnancy is achieved. IUI or ART should be considered for couples in which infertility persists after anatomically successful varicocele repair (Jarow et al. 2002; Weidner et al. 2002).

Best Patient to Benefit from Surgery Agarwal et  al. (2007) analyzed 17 studies reporting outcomes of microsurgical varicocelectomy a high ligation series for varicocele treatment in infertile men, and they demonstrated that surgical varicocelectomy significantly improves semen parameters in infertile men with palpable varicocele and abnormal semen analysis. There has always been a problem defining the exact subgroup that would indeed benefit from varicocele surgery. Attempts have been made

Varicocele: To Fix or Not to Fix

using the patient age, semen report, varicocele grade, hormone profile GnRH stimulation test, testicular histology, etc., but most have failed to provide clear results (Yoshida et al. 2000; Marks et al. 1986). Faced with this dilemma, the guidelines proposed by the American Urology Association and the American Society of Reproductive Medicine seem to be the most prudent evidence-based medicine that should be followed (Jarow et  al. 2002). These guidelines suggest that varicocelectomy should be offered only to men who are infertile, have a normal or correctable disease in the partner, have a clinically palpable varicocele, and have a consistent abnormality in their semen analysis or sperm functions. In addition, it is advisable to obtain several semen tests over a period of time to confirm the abnormality before proceeding with surgery. The AUA guidelines are applicable to the majority of patients that present with a varicocele. However, the patient with azoospermia and a clinically palpable varicocele continues to be a problem in clinical decision making.

Conclusions Despite the absence of definitive studies on the fertility outcome of varicocele repair, varicocele treatment should be considered as a choice for appropriate infertile couples because varicocele repair has been proven to improve semen parameters in most men. Varicocele treatment may improve fertility and the risks of varicocele treatment are small. Epidemiological data and observations on the pathogenic mechanisms leave no reasonable doubt on the association between varicocele and male reproductive failure. Varicoceles continue to stimulate controversy among reproductive experts. Despite conflicting evidence from both randomized and nonrandomized trials, clinical experience still favors the surgical treatment of clinical varicoceles in men with infertility. Considering economical, ethical, and evidence-based arguments, varicocele treatment should be offered to selected subfertile patients. However, it is incumbent on fertility specialists to design and recruit participants (or patients) in randomized, properly controlled trials to reach a definitive conclusion. In addition, several recent publications indicate that treatment of adolescents may prevent sperm deterioration from occurring later in life. These publications may encourage early diagnosis and (nonsurgical) treatment of varicocele at school age.

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Pasqualotto et al. Scaramuzza A, Tavana R, Marchi A. Varicoceles in young soccer players. Lancet 1996; 348: 1180–1181 Schatte EC, Hirshberg SJ, Fallick ML, Lipshultz LI, Kim ED. Varicocelectomy improves sperm strict morphology and motility. J Urol 1998; 160: 1338–1340 Schiff J, Kelly C, Goldstein M, et al. Managing varicoceles in children: results with microsurgical varicocelectomy. BJU Int 2005; 95(3): 399–402 Schlegel PN. Is assisted reproduction the optimal treatment for varicocele-associated male infertility? A cost-effectiveness analysis. Urology 1997; 49: 83–90 Schlegel PN, Kaufmann J. Role of varicocelectomy in men with nonobstructive azoospermia. Fertil Steril 2004; 81: 1585–1588 Shafik A, Bedeir GA. Venous tension patterns in cord veins. I. In normal and varicocele individuals. J Urol 1980; 123: 383–385 Sharma RK, Pasqualotto FF, Nelson DR, Thomas AJ, Agarwal A. The reactive oxygen species – total antioxidant capacity score is a new measure of oxidative stress to predict male infertility. Hum Reprod 1999; 14(11): 2801–2807 Shlansky-Goldberg RD, Van Arsdalen KN, Rutter CM, Soulen MC, Haskal ZJ, Baum RA, Redd DC, Cope C, Pentecost MJ. Percutaneous varicocele embolization versus surgical ligation for the treatment of infertility: changes in seminal parameters and pregnancy outcomes. J Vasc Interv Radiol 1997; 8: 759–767 Sigman M, Jarow JP. Ipsilateral testicular hypotrophy is associated with decreased sperm counts in infertile men with varicoceles. J Urol 1997; 158: 605–607 Steeno O, Knops J, Declerck L, Adimoelja A, Van de Voorde H. Prevention of fertility disorders by detection and treatment of varicocele at school and college age. Andrologia 1976; 8: 47–53 Sylvester SR, Griswold MD. The testicular iron shuttle: a “nurse” function of the Sertoli cells. J Androl 1994; 15: 381–385 Terquem A, Dadoune JP. Morphological findings in varicocele: an ultrastructural study of 30 bilateral testicular biopsies. Int J Androl 1981; 4: 515–531 Trum JW, Gubler FM, Laan R, van der Veen F. The value of palpation, varicoscreen contact thermography and colour Doppler ultrasound in the diagnosis of varicocele. Hum Reprod 1996; 11(6): 1232–1235 Tulloch WS. Varicocele in subfertility; results of treatment. Br Med J 1955; 2: 356–358 Turkyilmaz Z, Gulen S, Sonmez K, et al. Increased nitric oxide is accompanied by lipid oxidation in adolescent varicocele. Int J Androl 2004; 27: 183–187 Unal D, Yeni E, Verit A, Karatas OF. Clomiphene citrate versus varicocelectomy in treatment of subclinical varicocele: a prospective randomized study. Int J Urol 2001; 8(5): 227–230 Vazquez-Levin MH, Friedmann P, Goldberg SI, Medley NE, Nagler HM. Response of routine semen analysis and critical assessment of sperm morphology by Kruger classification to therapeutic varicocelectomy. J Urol 1997; 158: 1804–1807 Wang YX, Lei C, Dong SG, et al. Study of bilateral histology and meiotic analysis in men undergoing varicocele ligation. Fertil Steril 1991; 55: 152–155

Varicocele: To Fix or Not to Fix Weidner W, Colpi GM, Hargreave TB, Papp GK, Pomerol JM. EAU guidelines on male infertility. Eur Urol 2002; 42: 313–322 Witt MA, Lipshultz LI. Varicocele: a progressive or static lesion? Urology 1993; 42: 541–543 World Health Organization. The influence of varicocele on parameters of fertility in a large group of men presenting to infertility clinics. Fertil Steril 1992; 57(6): 1289–1293 Wright EJ, Young GP, Goldstein M. Reduction in testicular temperature after varicocelectomy in infertile men. Urology 1997; 50: 257–259 Yaman O, Soygur T, Zumrutbas AE, Resorlu B. Results of microsurgical subinguinal varicocelectomy in children and adolescents. Urology 2006; 68: 410–412 Yavetz H, Levy R, Papo J, Yogev L, Paz G, Jaffa AJ, Homonnai ZT. Efficacy of varicocele embolization versus ligation of the left internal spermatic vein for improvement of sperm quality. Int J Androl 1992; 15: 338–344

79 Yoshida K, Kitahara S, Chiba K, et al. Predictive indicators of successful varicocele repair in men with infertility. Int J Fertil Womens Med 2000; 45: 279–284 Zini A, Girardi SK, Goldstein M. Varicocele. In: Hellstrom WJG (ed.) Male infertility and sexual dysfunction. Springer, New York, 1997a, pp. 201–218 Zini A, Buckspan M, Berardinucci D, Jarvi K. The influence of clinical and subclinical varicocele on testicular volume. Fertil Steril 1997b; 68: 671–674 Zini A, Buckspan M, Jamal M, Jarvi K. Effect of varicocelectomy on the abnormal retention of residual cytoplasm by human spermatozoa. Hum Reprod 1999; 14: 1791–1793 Zini A, Boman J, Jarvi K, et  al. Varicocelectomy for infertile couples with advanced paternal age. Urology 2008; 72: 109–113 Zorgniotti AW, Macleod J. Studies in temperature, human semen quality, and varicocele. Fertil Steril 1973; 24: 854–863

Medical Management of Male Infertility Eric E. Laborde, Vishal Bhalani, Neal Patel, and Robert E. Brannigan

Contents Introduction....................................................................................................................................................................... Endocrinopathies............................................................................................................................................................... Hormonal Deficiency................................................................................................................................................... Hormonal Excess......................................................................................................................................................... Infection and Inflammation............................................................................................................................................... Ejaculatory Dysfunction................................................................................................................................................... Erectile Dysfunction......................................................................................................................................................... Medications and Substances That Impair Male Fertility.................................................................................................. Conclusion........................................................................................................................................................................ References.........................................................................................................................................................................

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Introduction

Endocrinopathies

Men presenting with impaired reproductive potential often benefit from directed medical therapy. These treatments target an array of abnormalities, including endocrine anomalies, infection/inflammation, ejaculatory dysfunction, and erectile dysfunction. In this chapter, we provide a framework for evaluating and treating men with infertility amenable to medical therapy.

Normal spermatogenesis requires both luteinizing hormone (LH) and follicle-stimulating hormone (FSH). Each hormone targets the testis, with LH exerting its effects on Leydig cells and FSH acting on Sertoli cells. While FSH is required along with LH for initiating spermatogenesis, the ongoing role of FSH after initiation is somewhat controversial (Moudgal and Sairam 1998; Plant and Marshall 2001). Interestingly, germ cells do not possess androgen receptors, so the androgens secreted by Leydig cells exert their effects on spermatogenesis through androgen receptors on Sertoli cells (Lyon et al. 1975). Endocrinopathies account for a minority of the cases of male infertility, but these conditions offer an important opportunity to provide effective therapy to infertile couples. Our discussion on the use of hormonal agents focuses on directed therapy in specific patient populations. Empiric endocrine therapy for

E.E. Laborde, V. Bhalani, and R.E. Brannigan () Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA e-mail: [email protected] N. Patel Chicago Medical School at Rosalind Franklin University of Medicine and Science, North Chicago, IL 60061, USA

From: Current Clinical Urology: Male Infertility: Problems and Solutions, Edited by: E.S. Sabanegh, DOI: 10.1007/978-1-60761-193-6_9,  Springer Science+Business Media, LLC 2011

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men with idiopathic infertility is not advocated in this chapter, as these treatment options have typically yielded disappointing clinical outcomes. Endocrine abnormalities can be broadly grouped into two disorders: hormonal deficiency and hormonal excess.

Hormonal Deficiency Hypogonadotropic Hypogonadism Hypogonadotropic hypogonadism hormonal ­deficiency can arise from a number of congenital or acquired conditions. Congenital causes of hypogonadotropic hypogonadism include Kallmann syndrome, which is most commonly due to a mutation in the KAL1 gene and is characterized by anosmia, cleft palate, cryptorchidism, and congenital failure of hypothalamic gonadotropinreleasing hormone (GnRH) secretion. Failure of GnRH secretion leads to FSH and LH deficiencies. Acquired forms of hypogonadotropic hypogonadism may arise from causes such as pituitary tumors or pituitary trauma. For both congenital and acquired forms of hypogonadotropic hypogonadism, the underlying problem is low levels of gonadotropin secretion. The treatment of hypogonadotropic hypogonadism consists of gonadotropin therapy. Pharmacologic agents used include human chorionic gonadotropin (hCG), human menopausal gonadotropin (hMG), and recombinant follicle-stimulating hormone (r-FSH). hMG is a combined preparation of human FSH and LH which is extracted and purified from the urine of postmenopausal women. The FSH activity of hMG is markedly greater than the LH activity of the preparation, thus necessitating the concurrent use of hCG as well. A typical gonadotropin regimen for men with hypogonadotropic hypogonadism consists of an initial 3–6  months of hCG monotherapy with dosages ranging from 1,000 to 1,500 USP units IM/SC three times per week. The goal of this therapy is sustained normal testosterone levels. After the 3–6  months of hCG monotherapy, hMG at dosages of 75–150 IU IM/SC three times per week administered at a separate injection site are initiated. As an alternative to hMG, r-FSH can be utilized at dosages of 150 IU SC three times per week. A majority of men will have sperm present in the ejaculate after 6 months of combined therapy, but treatment response may be noted at up to 12 months. After gonadotropin treatment of hypogonadotropic hypogonadism, men often have resultant low sperm concentrations (<20 million sperm per ml) on semen analysis testing. Interestingly, despite

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an abnormally low sperm concentration, these men characteristically have good ability to conceive (Burris et al. 1988). A recent, 30-year retrospective study from Japan by Miyagawa et al. (2005) showed that the combination regimen of biweekly intramuscular injections of hCG (3,000 IU) and hMG (75 IU) over 1–20 years resulted in sperm production in 71% of men with testicular volumes greater than 4 ml (Lyon et al. 1975). Interestingly, only 36% of the men with testicular volumes <4 ml had resultant sperm production after this therapy. Antiestrogen agents have also been used in the setting of hypogonadotropic hypogonadism. Clomiphene citrate, a synthetic antiestrogen, is perhaps the most widely used agent in this class. Clomiphene citrate binds to the hypothalamic and pituitary estrogen receptor sites, thus blocking estrogen’s central feedback inhibition of gonadotropin secretion. This in turn leads to elevated gonadotropin levels and an increase in testosterone production. A number of clinical studies have revealed varying results in the setting of “idiopathic infertility,” but Kolettis and coworkers specifically evaluated clomiphene citrate among men with hypogonadotropic hypogonadism (Whitten et  al. 2006). Although their series was relatively small, they found that patients who presented postpuberty with idiopathic hypogonadotropic hypogonadism and with an otherwise normal evaluation responded favorably to 50 mg of clomiphene citrate, three times per week. Three of four men in this study had improvement in serum testosterone levels and semen parameters after only 3–4  months of therapy, and two of these three men achieved pregnancies. It is important for the reader to know that while clomiphene citrate is widely used in the treatment of men with hypogonadotropic hypogonadism, its use in this setting is currently considered to be an ‘off-label’ usage.

Hypothyroidism Thyroid hormones are essential in organ development and routine metabolism. From a reproductive perspective, hypothyroidism has long been associated with diminished libido and erectile dysfunction (Griboff 1962). A recent study by Meeker et al. (2007) revealed a correlation between thyroxine (T4) level and sperm concentration. Jaya Kumar et  al. (1990) previously reported that hypothyroid men had improved sperm count and motility after treatment with T4 to achieve euthyroid status. While there is an overall relative paucity of data regarding hypothyroidism and semen parameters, these studies do suggest a link between thyroid function and spermatogenesis.

Medical Management of Male Infertility

Hormonal Excess Androgen Excess Although testosterone excess is not a classic “medical condition,” clinicians must be familiar with this condition in order to help optimize male reproductive potential. Androgen excess typically occurs in the setting of men taking exogenous testosterone or illicit anabolic steroid supplements. Serum hormone testing commonly reveals very low (suppressed) FSH and LH levels, and normal to high serum testosterone levels. These agents often lead to markedly decreased intratesticular testosterone production with resultant partial or complete suppression of sperm production. Given these effects, depot forms of androgens are the major component of the medical male hormonal contraceptive agents now undergoing development. Exogenous testosterone should thus generally be avoided in men actively pursuing pregnancy. Treatment for men with androgen excess entails ceasing the exogenous testosterone or anabolic steroid. If the patient has hypogonadism and persistent oligo- or azoospermia after ceasing the exogenous androgen therapy, efforts to stimulate intratesticular testosterone production with hCG with or without hMG treatment may be beneficial (Menon 2003; Turek et al. 1995).

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in increased semen volume, sperm concentration, and motility in oligospermic patients.

Thyroid Excess (Hyperthyroidism) As mentioned above, the role of thyroid hormones in maintaining ongoing spermatogenesis is not entirely clear. A 1999 study assessing the impact of hyperthyroidism (Graves’ disease) on reproduction found that patients with hyperthyroidism had lower bioavailable testosterone, higher sex hormone-binding globulin, and higher LH levels compared to controls (Abalovich et al. 1999). Also, hyperthyroid patients were reported to have markedly impaired semen parameters, including low motility (85.7%), low ejaculate volume (61.9%), low sperm concentration (42.9%), and abnormally low percentage of normally shaped sperm (19%). The authors noted that 85% of the seminal abnormalities observed in the baseline samples had normalized on repeat semen testing conducted 7–19  months after achievement of euthyroid status. The authors stressed that using bioavailable testosterone was particularly effective in detecting hypogonadism in this population. Additionally, they attributed the pretreatment seminal defects to the hyperthyroidism, because the majority of these deficits had normalized once a euthyroid state was achieved.

Estrogen Excess Testosterone is converted to estradiol in adipose tissue by the enzyme aromatase, and the optimal ratio of testosterone to estradiol is >10:1. With the rising prevalence of obesity, an increasing number of men are presenting with perturbed testosterone-to-estradiol ratios. In addition to obesity, liver failure is also a fairly common cause of estrogen excess. Estrogen excess results in inhibition of gonadotropin secretion, and thus diminished intratesticular testosterone production. Some studies suggest that estrogen excess, in combination with androgen deficiency, results in impaired spermatogenesis (Jones et al. 1978). Aromatase inhibitors are effective in reducing levels of estradiol while increasing levels of testosterone. These agents are available in steroidal (testolactone) and nonsteroidal (anastrozole) formulations. Pavlovich et al. (2001) treated men with severe infertility with testolactone and found a statistically significant increase in the testosterone-to-estradiol ratio, as well as improvement in semen parameters. Raman and Schlegel (2002) reported that a daily 1 mg dose of the nonsteroidal aromatase inhibitor anastrozole resulted

Prolactin Excess (Hyperprolactinemia) Hyperprolactinemia is detected on routine serum testing and can arise in the setting of hypothyroidism, liver disease, stress, use of certain medications (phenothiazines and tricyclic antidepressants) and prolactinsecreting pituitary adenomas (prolactinomas). While patients with prolactinomas are often asymptomatic, they may present with galactorrhea or symptoms of low testosterone, such as diminished libido and erectile dysfunction. Given that the location of the pituitary gland is near the optic chiasm, patients may also present with visual field disturbances due to compression of the optic nerve by the prolactinoma. This compression can result in bilateral temporal hemianopia, characterized by bilateral temporal visual field defects. Hyperprolactinemia results in inhibition of hypothalamic secretion of GnRH, which in turn leads to decreased secretion of FSH and LH, diminished testosterone, and impaired spermatogenesis. Collectively, the male patient often presents with diminished libido, erectile dysfunction, and decreased semen parameters. Hence, his overall reproductive potential may be

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markedly diminished due to the cumulative effects of the prolactinoma. When elevated serum prolactin levels are detected, pituitary gland MRI imaging should be obtained. Prolactinomas are characterized based on their radiographic size and appearance. Lesions <10  mm are classified as microadenomas, while lesions >10  mm are macroadenomas. The dopamine agonists bromocriptine, cabergoline, pergolide, and quinagolide are used in the treatment of prolactinomas. Of these, bromocriptine and cabergoline are the most widely used and studied. Both agents inhibit prolactin secretion and lead to regression of the tumors, which commonly takes months. Patients should be counseled that possible side effects of these agents include nausea, vomiting, and postural hypotension. Few studies have documented the impact of dopamine agonists on semen parameters. Thorner et  al. (1974) assessed the effects of bromocriptine therapy alone and reported no significant improvement in sperm motility. However, De Rosa et al. (1998) published a more recent study comparing bromocriptine and cabergoline in patients with prolactinomas, and they reported improvements in sperm number, total motility, rapid progression and normal morphology for both agents after 6 months of therapy. Regarding overall efficacy in treating prolactinomas, cabergoline is more effective than bromocriptine in restoring prolactin levels to normal and in decreasing tumor size (Gillam et  al. 2006). Patients are less likely to be resistant to the therapeutic effects of cabergoline than bromocriptine, and most patients resistant to bromocriptine respond to cabergoline (Gillam et al. 2006). Cabergoline offers higher odds of permanent remission and discontinuation than bromocriptine and has less adverse effects (Gillam et al. 2006). For these collective reasons, cabergoline is typically the frontline agent for the medical treatment of prolactinomas. As an alternative to medical therapy, radiation therapy and transsphenoidal surgical resection of the prolactinoma are also therapeutic options. With treatment of the prolactinoma, reversal of the GnRH inhibition may follow. The patient’s gonadotropic levels should be assessed, though, as gonadotropin therapy may still be needed despite resolution of hyperprolactinemia.

Infection and Inflammation Infection and inflammation of the male reproductive tract can occur in concert with one another or independently. Numerous in  vitro studies have

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demonstrated that some bacteria can have a direct detrimental effect on sperm function and viability. Additionally, leukocytes in the genital tract can promote both cellular and humoral immune response mechanisms that lead to germinal epithelial damage with resultant fertility impairment. Care should be used in diagnosing genital tract infections and inflammation. Inspection of semen for leukocytes should be done with the understanding that “round cells” on semen analysis may represent either leukocytes or immature germ cells. Semen cultures should be collected only after careful cleaning of the penis and urethral meatus with antimicrobial soap. The results of semen cultures should be interpreted with caution as pathogens such as Ureaplasma urealyticum, Escherichia coli, Enterococcus, Proteus mirabilis, and Mycoplasma hominis have been found in the same frequency in men who have leukocystospermia as men who do not (Chan and Schlegel 2002a, b). Organisms such as Chlamydia trachomatis, Neisseria gonorrhoeae, Treponema pallidum, Mycobacterium tuberculosis, Haemophilus ducreyi, herpes simplex virus, HPV, and Trichomonas vaginalis have been associated with impaired sperm function in vitro (Hosseinzadeh et al. 2000; Kohn et al. 1998; Rose et  al. 1994), or found to bind human sperm (Greendale et al. 1993; Nunez-Calonge et al. 1998). Therefore, treating the above pathogens may prove beneficial. In addition to the adverse effect of certain pathogens on sperm function, leukocytospermia itself can be detrimental in the absence of bacteria. Several studies have found poor semen parameters in men with leukocytospermia (Arata de Bellabarba et  al. 2000; Aziz et al. 2003). However, this is controversial as not all studies support the association between leukocytospermia and infertility (el-Demiry et al. 1986). One proposed mechanism by which leukocytospermia can negatively influence semen parameters is through reactive oxygen species (ROS). Leukocytes produce ROS, and ROS are known to cause oxidative stressinduced cellular damage (Sharma and Agarwal 1996). Several treatment options exist to protect spermatozoa from the deleterious effects of leukocytes, and therefore optimize semen quality. The four major pharmacologic approaches are antimicrobial therapy to treat clinical or subclinical infection, anti-inflammatory medications (such as COX-2 inhibitors), antioxidant therapy to minimize associated oxidative stress, and antihistamines to stabilize mast cells. Figure  1 is an algorithm summarizing diagnostic and therapeutic approaches for pyospermia.

Medical Management of Male Infertility

85 Semen Analysis

Round cells Present

Yes

No

Special Staining • Immunohistochemistry (CD 45+) • Peroxidase staining

Positive

Negative

Round cells are white blood cells

Suspect round cells are immature sperm

Consider testing for Chlamydia and Gonorrhea (urine PCR or urethral swab culture)

Perform semen culture

Negative Consider NSAIDs/antioxidants

Consider performing prostate localization (VB1, VB2, EPF, VB3) cultures*

Positive Treat with culture-specific antibiotics

*Prostate localization cultures: VB1 culture = culture of first 10 mL voided urine VB2 culture = culture of midstream voided urine EPF = culture of expressed prostate fluid (fluid expressed per urethra after prostate massage) VB3 culture = culture of voided urine after prostate massage

Fig. 1. Diagnosis and treatment of pyospermia (white blood cells present in the ejaculate)

Ejaculatory Dysfunction During normal ejaculation, stimulation of the sympathetic nerves, T10–L2, causes emission of semen into the posterior urethra. Antegrade ejaculation is then accomplished by sympathetically induced closure of the bladder neck and rhythmic contractions of the pelvic floor muscles.

Retrograde ejaculation should be suspected in any patient with low semen volume or aspermia (no antegrade ejaculate upon climax). Patients with retrograde ejaculation may also have oligospermia or azospermia. For individuals suspected of having retrograde ejaculation, a postejaculate urinalysis should be ­examined. While absolute criteria for diagnosing retrograde ejaculation have not been defined, greater

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Table 1. Medical therapy for retrograde ejaculation (from Ohl et al. 2008). Agent Ephedrine sulfate Imipramine hydrochloride Pseudoephedrine hydrochloride

Drug class

Dosage (mg)

Frequency (per day)

  25   25 120

2× 3× 2×

Alpha- and beta-adrenergic agonist Tricyclic antidepressant Alpha- and beta-adrenergic agonist

than 10–15 sperm/hpf in a postejaculate urinalysis is consistent with the diagnosis. Once the diagnosis is made, medical treatment with agents such as ephedrine, imipramine, and pseudoephedrine can often result in bladder neck closure during climax and achievement of antegrade ejaculation (Ohl et al. 2008). These treatments are typically initiated approximately 7  days prior to anticipated ovulation or donation. Suggested dosage and frequency of administration as suggested by Ohl et al. (2008) are summarized in Table  1. Kamischke and Nieschlag (2002) demonstrated that these medications are effective in up to 50% of patients. Medical therapy is most successful for nonanatomic causes of retrograde ejaculation, and tachyphylaxis can be observed if these drugs are used over multiple ovulatory cycles. If medications are not successful in converting retrograde to antegrade ejaculation, sperm can often be retrieved from postejaculate urine (PEU) samples and used for intrauterine insemination (IUI) or in vitro fertilization (IVF). Prior to collection of the PEU specimen, steps can be taken to ameliorate the bladder environment that is otherwise toxic to sperm due to urine acidity and possibly urine osmolality. Ohl et al. (2008) recommend administration of 500 mg sodium bicarbonate 12 h and 2 h prior to ejaculation to help diminish urine acidity. Additionally, they suggest fluid loading prior to the procedure may help abate the potential negative effect of increased urine osmolality on sperm viability (Ohl et al. 2008). For a patient who cannot ejaculate and whose postorgasmic urinalysis does not reveal sperm, anejaculation should be suspected. An attempt can be made to treat such patients with sympathomimetics, but there have been only sparse reports in the literature of success with medical therapy (Goldwasser et  al. 1983; Schill 1990). Anejaculatory patients not responsive to the above medical therapies are usually next treated with penile vibratory stimulation or electroejaculation.

only clinical sign of underlying significant problems impacting the patient’s reproductive health, such as diabetes mellitus and endocrinopathies (hypogo­ nadism, hyperprolactinemia). The evaluation and treatment of men with ED focuses on “goal-directed” therapy. In addition to a complete medical history and physical exam, these patients should also undergo an initial hormonal evaluation, including testosterone and prolactin serum levels. Patients presenting with ED should be queried regarding the circumstances of their ED to help differentiate organic versus functional causes. A thorough review of the patient’s medications should be conducted, as some drugs may interfere with normal erectile function. Beta blockers and thiazide diuretics agents commonly impair erectile function. Discontinuation or substitution of these agents for others should be considered in concert with the prescribing physician. While we will not detail the comprehensive evaluation and treatment of men with ED in this section, oral PDE-5 inhibitors, intraurethral prostaglandin E1, and intracavernosal injection of vasoactive agents (papaverine, phentolamine, and prostaglandin E1) are all commonly used to restore erectile function in men with ED.

Medications and Substances That Impair Male Fertility In this chapter, we have overviewed numerous agents capable of improving overall male reproductive potential. In contrast, a large number of medications and substances can also detrimentally affect male reproduction. Knowledge of these agents and their effects is very important, as cessation or substitution may help optimize male reproductive potential. Table 2 provides a listing of these deleterious medications and substances.

Erectile Dysfunction

Conclusion

Erectile dysfunction (ED) can impact fertility by impairing a couple’s ability to successfully engage in intercourse. Erectile dysfunction may also be the

Men with impaired reproductive potential often suffer from conditions that can benefit from directed medical therapy. Available medical treatments address an array

Medical Management of Male Infertility Table 2. Medications and substances capable of impairing male fertility. Alcohol Allopurinol Alpha-adrenergic blockers Anabolic steroids Antipsychotics Beta-blockers Erythromycin Calcium channel blockers Chemotherapy Cimetidine Cocaine Colchicine Cyclosporine Dilantin

Gentamicin Heroin Lithium Marijuana Methadone Monoamine oxidase inhibitors Nitrofurantoin Phenothiazines Spironolactone Sulfasalazine Tetracycline Thiazide diuretics Tobacco Tricyclic antidepressants

of abnormalities, including endocrine anomalies, infection/inflammation, ejaculatory dysfunction, and erectile dysfunction. In this chapter, we have provided an overview of the evaluation and treatment of men with infertility amenable to medical therapy. While surgical therapies are a mainstay in the ­urologist’s therapeutic armamentarium, it is essential that less invasive medical therapies not be overlooked as the clinician attempts to optimize the male’s reproductive potential.

References Abalovich M, Levalle O, Hermes R, et  al. Hypothalamic– pituitary–testicular axis and seminal parameters in hyper­ thyroid males. Thyroid 1999;9:857–863 Arata de Bellabarba G, Tortolero I, Villarroel V, Molina CZ, Bellabarba C, Velazquez E. Nonsperm cells in human semen and their relationship with semen parameters. Arch Androl 2000;45:131–136 Aziz N, Fahey JL, Detels R, Butch AW. Analytical performance of a highly sensitive C-reactive protein-based immunoassay and the effects of laboratory variables on levels of protein in blood. Clin Diagn Lab Immunol 2003;10:652–657 Burris AS, Clark RV, Vantman DJ, Sherins RJ. A low sperm concentration does not preclude fertility in men with isolated hypogonadotropic hypogonadism after gonadotropin therapy. Fertil Steril 1988;50:343–347 Chan PT, Schlegel PN. Inflammatory conditions of the male excurrent ductal system. Part I. J Androl 2002a;23:453–460 Chan PT, Schlegel PN. Inflammatory conditions of the male excurrent ductal system. Part II. J Androl 2002b;23:461–469 De Rosa M, Colao A, Di Sarno A, et al. Cabergoline treatment rapidly improves gonadal function in hyperprolactinemic males: a comparison with bromocriptine. Eur J Endocrinol 1998;138:286–293 el-Demiry MI, Young H, Elton RA, Hargreave TB, James K, Chisholm GD. Leucocytes in the ejaculate from fertile and infertile men. Br J Urol 1986;58:715–720

87 Gillam MP, Molitch ME, Lombardi G, Colao A. Advances in the treatment of prolactinomas. Endocr Rev 2006;27: 485–534 Goldwasser B, Madgar I, Jonas P, Lunenfeld B, Many M. Imipramine for the treatment of sterility in patients following retroperitoneal lymph node dissection. Andrologia 1983;(15 Spec No):588-91 Greendale GA, Haas ST, Holbrook K, Walsh B, Schachter J, Phillips RS. The relationship of Chlamydia trachomatis infection and male infertility. Am J Public Health 1993;83: 996–1001 Griboff SI. Semen analysis in myxedema. Fertil Steril 1962;13: 436–443 Hosseinzadeh S, Brewis IA, Pacey AA, Moore HD, Eley A. Coincubation of human spermatozoa with Chlamydia ­trachomatis in  vitro causes increased tyrosine phos­phory­ lation of sperm proteins. Infect Immun 2000;68:4872–4876 Jaya Kumar B, Khurana ML, Ammini AC, Karmarkar MG, Ahuja MM. Reproductive endocrine functions in men with primary hypothyroidism: effect of thyroxine replacement. Horm Res 1990;34:215–218 Jones TM, Fang VS, Landau RL, Rosenfield R. Direct inhibition of Leydig cell function by estradiol. J Clin Endocrinol Metab 1978;47:1368–1373 Kamischke A, Nieschlag E. Update on medical treatment of ejaculatory disorders. Int J Androl 2002;25:333–344 Kohn FM, Erdmann I, Oeda T, el Mulla KF, Schiefer HG, Schill WB. Influence of urogenital infections on sperm functions. Andrologia 1998;30(Suppl 1):73–80 Lyon MF, Glenister PH, Lamoreux ML. Normal spermatozoa from androgen-resistant germ cells of chimaeric mice and the role of androgen in spermatogenesis. Nature 1975;258:620–622 Meeker JD, Godfrey-Bailey L, Hauser R. Relationships between serum hormone levels and semen quality among men from an infertility clinic. J Androl 2007;28:397–406 Menon DK. Successful treatment of anabolic steroid-induced azoospermia with human chorionic gonadotropin and human menopausal gonadotropin. Fertil Steril 2003;79(Suppl 3):1659–1661 Miyagawa Y, Tsujimura A, Matsumiya K, et  al. Outcome of gonadotropin therapy for male hypogonadotropic hypogonadism at university affiliated male infertility centers: a 30-year retrospective study. J Urol 2005;173:2072–2075 Moudgal NR, Sairam MR. Is there a true requirement for follicle stimulating hormone in promoting spermatogenesis and fertility in primates? Hum Reprod 1998;13:916–919 Nunez-Calonge R, Caballero P, Redondo C, Baquero F, Martinez-Ferrer M, Meseguer MA. Ureaplasma urealyticum reduces motility and induces membrane alterations in human spermatozoa. Hum Reprod 1998;13:2756–2761 Ohl DA, Quallich SA, Sonksen J, Brackett NL, Lynne CM. Anejaculation and retrograde ejaculation. Urol Clin North Am 2008;35:211–220 Pavlovich CP, King P, Goldstein M, Schlegel PN. Evidence of a treatable endocrinopathy in infertile men. J Urol 2001;165: 837–841 Plant TM, Marshall GR. The functional significance of FSH in spermatogenesis and the control of its secretion in male primates. Endocr Rev 2001;22:764–786 Raman JD, Schlegel PN. Aromatase inhibitors for male infertility. J Urol 2002;167:624–629

88 Rose BR, Thompson CH, Jiang XM, et al. Detection of human papillomavirus type 16 E6/E7 transcripts in histologically cancer-free pelvic lymph nodes of patients with cervical carcinoma. Gynecol Oncol 1994;52:212–217 Schill WB. Pregnancy after brompheniramine treatment of a diabetic with incomplete emission failure. Arch Androl 1990;25:101–104 Sharma RK, Agarwal A. Role of reactive oxygen species in male infertility. Urology 1996;48:835–850

Laborde et al. Thorner MO, McNeilly AS, Hagan C, Besser GM. Long-term treatment of galactorrhoea and hypogonadism with bromocriptine. Br Med J 1974;2:419–422 Turek PJ, Williams RH, Gilbaugh JH III, Lipshultz LI. The reversibility of anabolic steroid-induced azoospermia. J Urol 1995;153:1628–1630 Whitten SJ, Nangia AK, Kolettis PN. Select patients with hypogonadotropic hypogonadism may respond to treatment with clomiphene citrate. Fertil Steril 2006;86:1664–1668

Surgical Reconstructions for Obstruction Edmund S. Sabanegh, Jr. and Kashif Siddiqi

Contents Introduction....................................................................................................................................................................... Anatomy, Physiology, and Pathology of the Excurrent Ductal System............................................................................ Etiology of Ductal Obstruction......................................................................................................................................... Reconstructive Procedures................................................................................................................................................ Types of Reconstruction: Vasovasostomy (VV) Vs. Vasoepididymostomy (VE)....................................................... Operative Planning....................................................................................................................................................... Modified One-Layer Vasovasostomy........................................................................................................................... Multi-Layer Vasovasostomy........................................................................................................................................ Microscopic Vasoepididymostomy.............................................................................................................................. Microsurgical Reconstruction Outcomes..................................................................................................................... Summary........................................................................................................................................................................... References.........................................................................................................................................................................

Introduction Microsurgical reconstruction of the male genital tract is the mainstay for the treatment of ductal obstruction. Up to 6% of patients presenting with primary infertility will have ductal obstruction, which may be curable with surgical reconstruction (Potts and Pasqualotta 1999). Furthermore, vasectomy is the most common urologic procedure performed and studies have shown that 6% of men will request a reversal due to changing life circumstances. Vasal injuries secondary to trauma or iatrogenic causes may also be corrected with microsurgical reconstruction.

E.S. Sabanegh Jr. () and K. Siddiqi Center for Male Fertility, Glickman Urological and Kidney Institute, Cleveland, OH, USA e-mail: [email protected]

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Surgical reconstruction of the genital tract developed through a long history of incremental improvements in surgical technique and technology. In 1902, Martin first described a technique to treat epididymal obstruction by performing a side-to-side anastomosis between the vas and the epididymis using fine silver wire in a patient with gonococcal epididymitis (Martin et  al. 1902). Thirty years later, Hagner reported his surgical outcomes using this technique, with patency confirmed in over 60% of patients (Hagner 1936). With improvements in magnification, Silber developed a technique for directly anastomosing the musoca of the vas deferens to a single epididymal tubule (Silber 1978). The development of the microsurgical vasovasostomy progressed in a similar fashion, with Quinby initially describing the procedure in 1919 using a strand of silkworm as a stent. Microsurgical vasovasostomy was described in 1977, and the technique has undergone technical modification since then.

From: Current Clinical Urology: Male Infertility: Problems and Solutions, Edited by: E.S. Sabanegh, DOI: 10.1007/978-1-60761-193-6_10,  Springer Science+Business Media, LLC 2011

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This chapter will focus on the salient features of ductal obstruction of the male genital tract to allow the identification of the appropriate candidate for microsurgical treatment. Surgical preparation and techniques will be briefly described, along with an outcomes and cost analysis. Finally, we will examine the role of microsurgical reconstruction in the era of assisted reproduction technology.

Anatomy, Physiology, and Pathology of the Excurrent Ductal System Sound knowledge of the anatomy and physiology of the male reproductive system is essential to understand surgical reconstruction of the ductal system. Spermatozoa are produced within the seminiferous tubules and released into the lumen. The terminal ends of the tubules drain into the rete testis. Six to eight efferent ducts coalesce from the rete testis and become the caput of the epididymis. The confluence of the efferent ducts marks the beginning of the epididymal tubule, a single, highly convoluted thin-walled tubule measuring 3 m in length tightly coiled to a 4- to 5-cm-

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long structure. The epididymis is divided into the head (caput), midbody (corpus), and the tail (cauda). At the termination of the cauda epididymis, the tubule is invested with a thick muscular wall marking the beginning of the vas deferens. The vas deferens leaves the scrotum and traverses the inguinal canal into the retroperitoneum, where it crosses anterior to the ureter and behind the medial umbilical ligament. In the retrovesical space, the vas becomes more dilated to form the ampulla before tapering in its terminal end as the ejaculatory duct entering the prostatic urethra at the level of the verumontanum. The epididymis provides several vital functions in spermatogenesis: maturation, transport, concentration, and storage. Testicular sperm do not display progressive motility and are incapable of fertilizing. However, epididymal sperm are motile and able to fertilize (Hinrichsen and Blaquier 1980). Although the exact mechanism is unknown, spermatozoa appear to develop maturity based upon contact with and transit through the proximal epididymis (Lacham and Trounson 1991). Both animal and human studies support the notion that sperm fertility maturation is achieved at the distal corpus or proximal cauda

Fig. 1. Schematic of the male reproductive tract with the most common etiology of obstruction based upon the anatomic location of the injury

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epididymis (Silber 1989; Schlegel 1993). The cauda epididymis serves mostly in a storage capacity prior to ejaculation.

Etiology of Ductal Obstruction Genital duct obstruction may occur anywhere along the course of the excurrent ductal system and is often classified by its etiology into congenital, inflammatory, traumatic/iatrogenic, and idiopathic (Fig.  1). Congenital bilateral absence of the vas deferens is the most common congenital cause of obstructive azoospermia. Patients with this condition present with low volume azoospermia, and are not amenable to surgical reconstruction although surgical sperm retrieval and in  vitro fertilization are effective reproductive options. On the other hand, contrary, obstruction secondary to prior infection may be surgically correctable. Many pathogenic organisms from Mycobacterium tuberculosis to Chlamydia may cause epididymal scarring as a result of infectious epididymitis, which may be unilateral or bilateral. Traumatic disruption of the male genital ducts is an uncommon cause of epididymal obstruction. Iatrogenic injuries more commonly occur after routine scrotal surgery or inguinal herniorraphy (Hopps and Goldstein 2006). By far, the most common cause of obstructive azoospermia is elective vasectomy. While usually a focal obstructive site, high intraluminal pressures after vasectomy can result in rupture of the delicate epididymal tubule with secondary obstruction in the epididymis. This phenomenon is more common in patients with an obstructive interval of more than 10  years. Similarly, prolonged obstructive interval in patients with traumatic/iatrogenic injuries may also result in secondary epididymal obstruction.

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vasectomized men depends upon a number of factors, including the obstructive interval, quality of fluid from the proximal vas segment, and partner factors such as age, fertility status, and parity. Secondary epididymal obstruction rarely occurs within 4 years of a ­vasectomy, but is present in more than 60% of patients after 15 years of vasal obstruction (Fuchs and Burt 2002). A linear regression algorithm based upon time since vasectomy and patient age has been developed to predict if a VE would be required during vasectomy reversal (Parekattil et al. 2005). The score was set at a sensitivity of 100% to allow urologists to identify patients with an increased likelihood of requiring a vasoepididymostomy due to an occult epididymal obstruction. This model was subsequently validated in a multi-institutional study of 345 patients (Parekattil et al. 2006). Many intra-operative factors also influence the type of reconstruction chosen for patients seeking vasectomy reversal. Patients with copious clear fluid with motile sperm in the proximal vas segment had a 94% chance of a return of sperm to the ejaculate after vasovasostomy compared with 60% for those with no sperm in the vasal fluid (Belker et al. 1991). Recent studies also indicate that vasovasostomy is indicated in patients with sperm parts from the proximal vas segment in lieu of whole sperm with excellent patency and pregnancy rates (Sigman 2004). VE is indicated if the intravasal fluid is absent, or if the fluid is thick or inspissated and does not contain sperm. Proximal vasal length of more than 2.7 cm and whole sperm in the vasal fluid also favor VV over VE (Witt et al. 1994). The presence of a sperm granuloma is associated with better quality intravasal fluid and improved patency rates compared with those without a sperm granuloma. The beneficial effects of a sperm granuloma are thought to be due to a “pop off valve” pressure releasing effect of the granuloma on the proximal ductal system, minimizing the likelihood of proximal epididymal obstruction.

Reconstructive Procedures Types of Reconstruction: Vasovasostomy (VV) Vs. Vasoepididymostomy (VE) Most men with primary obstructive azoospermia will be obstructed at the level of the epididymis and will need a vasoepididymostomy to reconstruct the genital tract appropriately. However, patients who have had a vasectomy may be obstructed at the vasectomy site, or more proximally in the case of a secondary epididymal obstruction. The choice of reconstruction in

Operative Planning Microsurgical reconstructions are generally performed as ambulatory outpatient procedures. For vasectomy reversal when the obstructive interval is shorter (less than 10  years), it is reasonable to perform the surgery under local anesthesia with sedation since it is unlikely to require the more complicated vasoepididymal anastomosis. If a VE is anticipated, or in patents too anxious for a local anesthetic, a general anesthetic or continuous epidural anesthesia is preferred.

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After the patient is anesthetized, careful positioning is critical because these are prolonged procedures that can incur significant morbidity from undue pressure or overextension of the arms. All pressure points should be carefully padded and the patient’s arms should be abducted comfortably at a 45° angle from the body. Sequential compression devices are placed on both calves for deep venous thrombosis prophylaxis. Post-operative infections from scrotal surgery are uncommon, although prophylaxis with broad-spectrum antibiotics is routinely administered prior to incision. At the start of the procedure, the vas is isolated through the scrotal skin using a towel clamp in the region of the vasectomy defect. A vertical surgical incision is centered over each hemiscrotum to allow for extension into the groin if more extensive mobilization of the vas is required. In the case where a vasovasostomy is anticipated, these incisions are 1–2 cm in length to allow only the vas ends to be delivered through the skin incision. If a vasoepididymostomy will be required or if a long vasal defect is appreciated, a longer skin incision is made to allow delivery of the testis. After completing a vertical scrotal incision as described above, blunt and sharp dissection is used in the region of the prior vasectomy to dissect the vas with its vascular pedicle from the surrounding tissue. Microsurgical bipolar or battery-operated disposable thermal cautery units can be used to obtain meticulous hemostasis, while minimizing collateral cautery injury. After the vas deferens has been sufficiently mobilized but before the vas is cut, the vasal vascular pedicle is ligated about 1 mm from the site of planned transection. The vas is cut across in a perpendicular fashion proximal to the vasectomy site. The vas ends must be resected back to normal healthy tissue to minimize the chance of early post-operative stenosis. Fluid from the proximal vas is expressed and examined under high-power light microscopy. While the presence of complete spermatozoa is associated with the best prognosis for future fertility, copious clear fluid without spermatozoa also portends a good outcome. Vasovasostomy may be performed using optical loupes or a microscope. Two of the most widely accepted techniques, the modified one-layer and the multilayer vasal anastomosis will be briefly described below. Both of these methods have proved to be equally effective with regard to patency and pregnancy when performed by an experienced surgeon (Parekattil et  al. 2006). The one-layer anastomosis is useful when the vasovasostomy is to be performed in the straight portion of the vas deferens and there

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is minimal discrepancy in luminal size between the proximal and distal ends. The multi-layer technique offers great precision in approximating the lumen of each end of the vas, particularly when there are widely discrepant luminal diameters.

Modified One-Layer Vasovasostomy (Fig. 2) This technique is ideal for anastomosis in the straight portion of the vas deferens using either loupe or microscope magnification. Some surgeons prefer this approach because it is simpler and requires less microsurgical skill. The healthy vasal ends are prepared as described above and approximated in preparation for anastomosis. The distal lumen can be gently dilated with the tip of the jeweler’s forceps to allow more symmetric luminal diameter. Starting posteriorly, a 9-0 nylon suture is passed through the entire thickness of the vas deferens, taking great care to ensure passage through the mucosa on the proximal and distal segments. Two additional full-thickness nylon sutures are placed circumferentially on each side of the 9-0 nylon suture. Three full-thickness 9-0 sutures are then placed in the anterior aspect and tied subsequently. The anastomosis is completed by bolstering the anastomosis with 9-0 nylon seromuscular sutures between the previously placed full-thickness sutures.

Multi-Layer Vasovasostomy (Fig. 3) The multilayer vasovasostomy provides precise alignment of the layers of the vas deferens, and therefore necessitates the use of a microscope and should be performed by surgeons with the appropriate skill set. The vasal ends are prepared in a similar fashion as described for the modified one-layer anastomosis. With two 9-0 nylon sutures, the posterior vasal ends are brought together at the 5 and 7 o’clock positions, incorporating only adventitia and muscularis. These sutures serve to stabilize the anastomosis in advance of placing the delicate luminal stitches. A doublearmed 10-0 nylon suture is then passed inside-out through the mucosa edges of each vas end at the 6 o’clock position. This suture is tied and six or seven additional 10-0 nylon luminal stitches are placed circumferentially. Because of the difference in luminal diameter between the dilated proximal vas lumen and the smaller distal vas lumen, sutures should be spaced to allow careful alignment of the lumen, avoiding bunching of the luminal edges. Once the luminal layer

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Fig. 2. Modified one-layer vasovasostomy. (a) 9-0 nylon suture is placed full-thickness through the serosa, muscularis, and the mucosa of the vas end in both the proximal and distal segments. These posterior sutures are placed initially and tied. Double-armed suture is preferable for ease in suture placement. (b) Three anterior sutures of 9-0 nylon are pre-placed and then tied in succession. (c) The anastomosis is supported by 9-0 nylon sutures placed in the seromuscular layer in between the previously placed sutures

is completed, a reinforcing layer of 9-0 nylon is passed through the seromuscular tissue re-approximating the seromuscular layer. A third layer of 9-0 nylon suture is used to approximate the loose periadventitial layer adjacent to the vas ends.

Microscopic Vasoepididymostomy (Fig. 4) In patients with primary azoospermia with confirmed spermatogenesis or a prolonged obstructive interval after vasectomy, a vasoepididymostomy is the appropriate reconstructive option. Although many techniques have been described, the most commonly performed is

the end-to-side vasoepididymostomy which approximates the vasal end to the side of the epididymal tubule. After delivery of the testis and epididymis through a vertical scrotal incision, the epididymis is explored to find the site of obstruction. Beginning in the tail of the epididymis, exploration is carried out systematically moving proximal until normalappearing motile or non-motile sperm are found. With the tubule opened and sperm presence confirmed, a single 10-0 nylon suture is placed inside-out at the lateral border of the cut mucosal edge. This acts as an identification suture for use later with the anastomosis. The vas is secured to the epididymal tunic with

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Fig. 3. Multilayer vasovasostomy. (a) Two sutures of 9-0 nylon are initially placed in posteriorly in the seromuscular layer of the proximal and distal ends of the vas to bring the ends of the vasa together. Following this, 10-0 nylon sutures are placed in the musoca of the vas posteriorly and tied down after each suture is placed. (b) The mucosal anastomosis then progresses anteriorly using 10-0 nylon suture, which is then pre-placed and tied down once all of the anterior sutures are placed. (c) The anastomosis is then bolstered with a second layer of 9-0 nylon suture placed in the seromuscular layer at regular intervals

two 9-0 nylon sutures at the 5 and 7 o’clock positions. Next, three or four double-armed 10-0 nylon sutures are placed in a quadrant fashion through the edge of the epididymal tubule. The sutures are placed in the corresponding quadrant of the vasal mucosa and tied. The anastomosis is completed with additional 9-0 nylon sutures between the epididymal tunic and the seromuscular layer of the vas deferens. Finally, several 9-0 nylon sutures are used to anchor the vas deferens to the parietal layer of the tunica vaginalis.

These final sutures serve to prevent direct tension on the anastomosis and are placed well away from the vasoepididymostomy site. A novel intussusception technique has recently been described (Berger 1998a; Marmar 2000) and has been gaining popularity with reports demonstrating improved outcomes compared with the standard endto-side anastomosis (Fig.  5) (Shiff et  al. 2005). The intent of this technique is to allow the precision of the standard end-to-side anastomosis while simplifying

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Fig. 4. End-to-side vasoepididymostomy. (a) The vas is brought in proximity to the lateral aspect of the epididymis. The epididymis is explored until sperm are found starting in the distal epididymis and moving proximally. Two 9-0 nylon sutures are used to secure the seromuscular layer of the vas approximately 0.5 cm distal to the lumen to the tunica albuginea of the epididymis near the region of the epididymotomy. (b) Three to four sutures of 10-0 nylon are pre-placed in the lumen of the epididymis and into the mucosa of the vas and tied down. (c) The anastomosis is supported with a second layer of 9-0 nylon, approximating the tunica albuginea of the epididymis to the seromuscular layer of the vas

and minimizing the microsuture placement. It differs from the end-to-side technique in that the lumen is opened after the sutures are positioned in the epididymal tubule and once opened, the epididymal loop is drawn into the vasal lumen with the sutures rather than approximated to it. Three double-armed 10-0 nylon sutures are placed in a triangular configuration in the desired epididymal loop. The epididymal tubule is carefully opened between the positioned sutures. Once the presence of sperm is confirmed in the epididymal fluid, the needles are passed through the corresponding areas of the lumen of the vas in an inside-out fashion. The sutures are then tied, creating an invagination of the epididymal loop into the vasal lumen. A similar two-suture technique has also been described for intussusception vasoepididymostomy (Berger 1998a).

Microsurgical Reconstruction Outcomes The largest series of patients analyzing vasovasostomy outcomes was described in 1991 by members of the vasovasostomy study group. The primary endpoints were patency and pregnancy rates, and the results were

grouped based upon obstructive interval. The overall average patency rate was 86%, with an average pregnancy rate of 52% (Parekattil et al. 2006). Many other groups have published data regarding outcomes for vasectomy reversal considering different variables (Table  1) (Lee et  al. 2008a). Vasoepididymostomy results are largely dependent on microsurgical skill and technique. Reported patency rates vary widely from 39 to 92%, with pregnancy rates between 13 and 56% (Table 2). As microsurgical techniques become more sophisticated, even patients with complicated conditions have excellent reconstruction outcomes. Reports of microsurgical reconstruction after failed reversal demonstrate patency and pregnancy rates of 79 and 31%, respectively (Hernandez and Sabanegh 1999). Successful vasoepididymostomy has also been described after percutaneous epididymal sperm aspiration (PESA) (Marmar et  al. 2008). Another important consideration is that although vasal patency may be demonstrated a few weeks after a vasovasostomy, vasoepididymostomy patients may demonstrate sperm in the ejaculate only months after surgery, and are not judged to be failures until at least 12 months have passed (Jarow et al. 1995).

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Fig.  5. Intussusception vasoepididymostomy. (a) Three sutures of 10-0 nylon are pre-placed into the epididymal lumen prior to making an epididymostomy. The epididymotomy is then performed, and if sperm are found, the anastomosis is completed. (b) One previously placed 10-0 nylon suture is then anastomosed to the mucosa of the vas by taking both needles, and placed in close proximity in the vas musoca and tied down. (c) The remaining sutures are preplaced in a similar fashion in the corresponding locations on the vas mucosa and then tied down

In any discussion of microsurgical outcomes, many factors are taken into consideration other than obstructive interval. The partner’s age is an additional factor that impacts on the eventual success of vasectomy reversal. Fuchs and Burt reported that the pregnancy rate was 64% in partners who were less than 30 years of age and dropped progressively to 28% in women aged 40 years or older (Hopps and Goldstein 2006). The overall pregnancy rates seemed to favor vasectomy reversal over intracytoplasmic sperm injection until spouses were over age 35 years, where both techniques

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noted dropping success rates. Kolettis reported similar pregnancy rates for vasectomy reversal in a study of couples with spouses aged 35 years or older (Kolettis et al. 2003a). Others have found good pregnancy rates until spousal age reaches 40  years (Gerrard et  al. 2007). Microsurgical vasectomy reversal also has higher pregnancy rates in couples with proven fertility together prior to the vasectomy, with reported patency rates of 93% and pregnancy rates of 60% (Kolettis et al. 2003b). In an age of increasing cost consciousness, the efficacy of vasectomy reversal compared with that of sperm retrieval and in vitro fertilization (SR/IVF) is an important consideration for couples. Studies analyzing cost effectiveness of vasectomy reversal suffer from lack of standardization of cost (direct vs. indirect costs) and outcomes (institutional vs. national outcome measures), sometimes making direct comparison difficult. Other important considerations include preexisting female factor infertility and the number of children the couple desire. Nevertheless, several studies report the cost effectiveness of vasectomy reversal over SR/IVF in certain circumstances. Lee reported increased cost effectiveness of vasectomy reversal over SR/IVF factoring in costs of procedures, complications, multiple gestations, and lost productivity (Lee et  al. 2008b). Meng reported outcomes based upon a decision analysis model to determine effectiveness of surgery vs. ART (Meng et al. 2005). They concluded that vasectomy reversal is superior to SR/IVF if patency rates are above a threshold level of 79%. Deck reported that even with older female partners (>37 years old), vasectomy reversal was more cost effective than IVF, although they reported only an 8% live birth rate of IVF in older women (Deck and Berger 2000). Although these studies shed some light on the cost conundrum, clearly, randomized controlled trials with standardization of costs (both direct and indirect) are necessary to truly answer this question.

Summary Surgical reconstruction of the male reproductive tract has been revolutionized by the advent of micro­surgery. A variety of techniques and procedures has been developed and may be tailored to the requirements of each individual patient. Ultimately, outcomes remain dependent upon the surgeon’s experience and skill with the techniques presented in this chapter.

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Table 1. Vasectomy reversal outcomes (including both vasovasostomy and vasoepididymostomy). Study authors

Year

Patency rate (%)

Live delivery rate (%)

Belker et al. (1991) Boorjian et al. (2004) Chan and Goldstein (2004) Fuchs and Burt (2002) Heidenreich et al. (2000) Kolettis et al. (2002) Jarow et al. (1995) Jr Kolettis (1997) Gerrard et al. (2007) Matthews et al. (1995) Nalesnik and Sabanegh (2003) Schlegal and Goldstein (1993) Silber and Grotjan (2004) Thomas (1987) Total

1991 2004 2004 2002 2000 2002 1995 1997 2007 1995 2003 1993 2004 1987

1,231/1,469 (84) 196/213 (92) 22/27 (82) 147/173 (85) 120/156 (77) 57/74 (77) 37/46 (81) 49/58 (85) 30/32 (93) 164/200 (82) 44/73 (60) 77/110 (70) 3,040/3,378 (90) 172/228 (75) 5,386/6,237 (86)

664/1,469 (45) 168/213 (79) 22/27 (82) 66/173 (38) 81/156 (52) 26/74 (35) 15/46 (33) 21/58 (36) 18/32(56) 65/200 (32) 21/73 (28) 43/110 (39) 1,460/1,738 (84) 59/228 (26) 2,729/4,597 (59)

Table 2. Vasoepididymostomy outcomes. Author

Year

Dubin and Amelar (1984) Silber and Grotjan (2004) Dewire et al. (1995) Berger (1998b) Marmar (2000) Chan et al. (2005)

1984 2004 1995 1998 2000 2005

# Patients    46 1,139   137    12    9    68

References Belker AM, Thomas AJ Jr., Fuchs EF et  al; Results of 1,469 microsurgical vasectomy reversals by the Vasovasostomy Study Group. J Urol. 1991; 145:505. Berger RE; Triangulation end-to-side vasoepididymostomy. J Urol. 1998; 159:1951. Boorjian SA, Lipkin M, Goldstein M; The impact of obstructive interval and sperm granuloma on outcome of vasectomy reversal. J Urol. 2004; 171(1):304–6. Chan PT, Goldstein M; Superior outcomes of microsurgical vasectomy reversal in men with the same female partners. Fertil Steril. 2004; 81(5):1371–4. Chan PT, Brandell RA, Goldstein M; Prospective analysis of outcomes after microsurgical intussusceptions vasoepididymostomy. BJU Int. 2005; 96:598. Deck AJ, Berger RE; Should vasectomy reversal be performed in men with older female partners? J Urol. 2000; 163:105–6. Dewire D, Thomas AJ. Microsurgical end-to-side vasoepididymostomy. In: Surgery of Male Fertility. Edited by M. Goldstein. Philadelphia:WB Saunders Company, pp. 128–34, 1995. Dubin L, Amelar RD; Magnified surgery for epididymovasostomy. Urology. 1984; 23:525. Fuchs EF, Burt RA; Vasectomy reversal performed 15 years or more after vasectomy: correlation of pregnancy outcome with partner age and with pregnancy results of in vitro fertilization with intracytoplasmic sperm injection. Fertil Steril. 2002; 77:516.

Anastomosis

Patency (%)

Pregnancy (%)

End-to-end End-to-end End-to-side Intussusception Intussusception Intussusception

39 78 79 92 78 84

13 56 50 Not reported 22 40

Gerrard ER, Sandlow JI Jr., Oster RA et al; Effect of female age on pregnancy rates after vasectomy reversal. Fertil Steril. 2007; 87:1340–4. Hagner F; The operative treatment of sterility in the male. JAMA. 1936; 107:1851 Heidenreich A, Altmann P, Engelmann UH; Microsurgical vasovasostomy versus microsurgical epididymal sperm aspiration/testicular sperm extraction of sperm combined with intracytoplasmic sperm injection. Eur Urol. 2000; 37:609–14. Hernandez J, Sabanegh ES; Repeat vasectomy reversal after initial failure: overall results and predictors for success. J Urol. 1999; 161:1153–6. Hinrichsen MJ, Blaquier JA; Evidence supporting the existence of sperm maturation in the human epididymis. J Reprod Fertil. 1980; 60:291. Hopps CV, Goldstein M; Microsurgical reconstruction of iatrogenic injuries to the epididymis from hydrocelectomy. J Urol. 2006; 176:2077. Jarow JP, Sigman M, Buch JP et  al; Delayed appearance of sperm after end-to-side vasoepididymostomy. J Urol. 1995; 153:1156. Kolettis PN, Thomas AJ Jr.; Vasoepididymostomy for vasectomy reversal: a critical assessment in the era of intracytoplasmic sperm injection. J Urol. 1997; 158:467–70. Kolettis PN, Sabanegh ES, D’amico AM et  al; Outcomes for vasectomy reversal performed after obstructive interval of at least 10 years. Urology. 2002; 60(5):855–8.

98 Kolettis PN, Sabanegh ES, Nalesnik JG et  al; Pregnancy outcomes after vasectomy reversal for female partners 35 years old or older. J Urol. 2003; 169:2250. Kolettis PN, Woo L, Sandlow JI; Outcomes of vasectomy reversal performed for men with the same female partners. Urology. 2003; 61:1221–3. Lacham O, Trounson A; Fertilizing capacity of epididymal and testicular spermatozoa microinjected under the zona pellucida of the mouse oocyte. Mol Reprod Dev. 1991; 29:85. Lee R, Li PS, Schlegel PN, Goldstein M; Reassessing reconstruction in the management of obstructive azoospermia: reconstruction or sperm acquisition? Urol Clin N Am. 2008; 35:289–301. Lee R, Li PS, Goldstein M, et al; A decision analysis of treatments for obstructive azoospermia. Hum Reprod. 2008; 23:2043–9. Marmar JL; Modified vasoepididymostomy with simultaneous double needle placement tubulotomy and tubular invagination. J Urol. 2000; 163:483. Marmar JL, Sharlip I, Goldstein M; Results of vasovasostomy or vasoepididymostomy after failed percutaneous sperm aspirations. J Urol. 2008; 179:1506–9. Martin E, Carnett JB, Levi JV, Pennington ME; The surgical treatment of sterility due to obstruction at the epididymis together with a study of the morphology of human sperm. University of Pennsylvania Medical Bulletin. 1902; 15:2–15. Matthews GJ, Shlegel PN, Goldstein M; Patency following microsurgical vaso-epididymostomy and vasovasostomy: temporal considerations. J Urol. 1995; 154:2070–3. Meng MV, Greene KL, Turek PJ; Surgery or assisted reproduction? A decision analysis of treatment costs in male infertility. J Urol. 2005; 174:1926–31.

Sabanegh, Jr. and Siddiqi Nalesnik JG, Sabanegh ES Jr; Vasovasostomy: multiple children and long-term pregnancy rates. Curr Surg. 2003; 60:348. Parekattil SJ, Kuang W, Agarwal A et al; Model to predict if a vasoepididymostomy will be required for vasectomy reversal. J Urol. 2005; 173:1681. Parekattil SJ, Kuang W, Kolettis PN et  al; Multi-institutional validation of vasectomy reversal predictor. J Urol. 2006; 175:247. Potts JM, Pasqualotta FF, Nelson D et al; Patient characteristics associated with vasectomy reversal. J Urol. 1999; 161(6): 1835–9. Schlegal PN, Goldstein M; Microsurgical vasoepididymostomy: refinements and results. J Urol. 1993; 150:1165–8. Shiff J, Chan P, Li PS et al; Outcome and late failures compared in 4 techniques of microsurgical vasoepididymostomy in 153 consecutive men. J Urol. 2005; 174(2):651–5. Sigman M; The relationship between intravasal sperm quality and patency rates after vasovasostomy. J Urol. 2004; 171:307–9. Silber SJ; Microscopic vasoepididymostomy: specific microanastomosis to the epididymal tubule. Fertil Steril. 1978; 30(5):565–7. Silber SJ; Apparent fertility of human spermatozoa from the caput epididymidis. J Androl. 1989; 10:263. Silber SJ, Grotjan HE; Microscopic vasectomy reversal 30 years later: a summary of 4010 cases by the same surgeon. J Androl. 2004; 25:845–9. Thomas AJ; Vasoepididymostomy. Urol Clin North Am. 1987; 14:527–38. Witt MA, Heron S, Lipshultz LI; The postvasectomy length of the testicular remnant: a predictor of surgical outcome in microscopic vasectomy reversal. J Urol. 1994; 151:892–4.

Techniques for Sperm Harvest Wayland Hsiao and Peter N. Schlegel

Contents Introduction . ....................................................................................................................................................................... Ejaculatory Dysfunction...................................................................................................................................................... Technique of Rectal Probe Electrostimulation ................................................................................................................... Obstructive Azoospermia . .................................................................................................................................................. Percutaneous Sperm Retrieval Techniques.......................................................................................................................... Microsurgical Epididymal Sperm Aspiration...................................................................................................................... Nonobstructive Azoospermia . ............................................................................................................................................ Fine Needle Aspiration with Mapping ............................................................................................................................... Open Testicular Sperm Extraction....................................................................................................................................... Processing of Testicular Tissue Samples............................................................................................................................. Summary.............................................................................................................................................................................. References . .........................................................................................................................................................................

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Introduction

Ejaculatory Dysfunction

Advances in assisted reproductive techniques have allowed spermatozoa retrieved from any portion of the reproductive tract to be used for pregnancy. This chapter focuses on the techniques of sperm harvesting in men with ejaculatory failure, obstructive azoospermia, and nonobstructive azoospermia.

The goal of treatment of patients with retrograde ejaculation (RE) involves enabling the successful antegrade flow of semen during ejaculation. The treatment of this condition is largely medical with the use of sympathomimetics drugs initiated the night before and the morning of sperm harvest. Ephedrine sulfate (25  mg PO BID), Imipramine hydrochloride (50  mg PO QD and titrate to 50  mg PO TID), Midodrine (7.5  mg orally, dosing to max of 20  mg), or Pseudoephedrine hydrochloride (90  mg PO QID) have been used successfully in the treatment of RE. Imipramine seems to have a high success rate in patients with retroperitoneal sympathetic denervation (Nijman et  al. 1982). If attempts at medical conversion to antegrade ejaculation are unsuccessful, then sperm may be harvested

W. Hsiao and P.N. Schlegel () James Buchanan Brady Foundation, Starr 900, Department of Urology, Weill Cornell Medical College, The New York Presbyterian Hospital, 525 East 68th Street, New York, NY 10021, USA e-mail: [email protected]

From: Current Clinical Urology: Male Infertility: Problems and Solutions, Edited by: E.S. Sabanegh, DOI: 10.1007/978-1-60761-193-6_11,  Springer Science+Business Media, LLC 2011

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from the ­postejaculate urine. Alkalinization of urine with 5–10 cc of ­polycitra is used with each dose of sympathomimetics. It should also be remembered that retrograde ejaculation may be an early sign of diabetes mellitus, and screening of men with unexplained acquired failure of ejaculation should include urinalysis and blood sugar levels. For patients with spinal cord injury (SCI) above the level of T12 or patients with psychogenic anejaculation, penile vibratory stimulation (PVS) is a very effective harvesting technique. Vibratory stimulation must be individualized for each patient, but are best applied to the frenular surface of the penis with a narrow head device. These devices are widely available at commercial outlets and can be used at home. In those who fail PVS, up to 20% will be salvaged with two vibrators (Brackett et al. 2007). In those SCI patients who fail vibratory stimulation alone, the addition of midodrine is thought by some to significantly increase the rate of antegrade ejaculation as well as orgasm (Soler et  al. 2007, 2008).

Technique of Rectal Probe Electrostimulation For anejaculatory patients, rectal probe electrostimulation (i.e., electroejaculation) remains a viable method of sperm harvesting. The procedure is performed under general anesthesia for men who are sensate below the waist. There seems to be little difference in sperm quality for specimens obtained by electroejaculation versus PVS, though both have higher DNA fragmentation rates than normal controls (Restelli et al. 2009). The high osmolarity and acidic pH of urine may adversely affect sperm quality. Because of this, the patient should be well hydrated and start with an empty bladder. It is important to alkalinize the urine with either IV bicarbonate or an oral preparation of sodium or potassium citrate. As sperm quality may be adversely affected by contact with blood, it is important to avoid any urethral trauma. Many water-based lubricants are toxic to spermatozoa (Anderson et  al. 1998; Agarwal et al. 2008), therefore we prefer to use 5 cc of mineral oil for catheter lubrication. We do not routinely catheterize the patient prior to electroejaculation. The patient is placed in the lateral decubitus position. Anoscopy is performed to confirm that the rectum is empty, and no rectal mucosal abnormalities are present. The rectal probe  is inserted completely into the rectum with

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the electrodes ­oriented anteriorly over the prostate and seminal vesicles. Stimulation is carried out with a standard electrical stimulation system starting at maximum energy of 5  V. The stimulation pattern is a “peaked sine wave,” with gradual increase of the voltage, followed by rapid decrease once the peak is reached. The voltage maximum is then increased in a stepwise manner up to 30 V. Between each stimulation, a 5–7 s pause in provided, where the observation of the urethral meatus is done to allow the detection of antegrade semen flow. The procedure is also monitored by the observation of penile tumescence, and rectal temperature. Typically, penile tumescence is noted first, followed by seminal emission. When seminal emission ceases, rectal temperature of 38°C is observed, or a maximum of 30 V is attained, electrostimulation is stopped. Anoscopy is performed again to insure that there is no rectal mucosal injury, which is a potential complication of this procedure. The patient is turned supine and urethral catheterization is carried out. An initial retrograde specimen is diluted in human tubal fluid (HTF) buffered with HEPES and plasmanate, pH 7.4, and sent for immediate processing, as is the antegrade ejaculate. The bladder is then irrigated with HTF, and this second retrograde specimen is sent for immediate processing as well. The initial choice of intrauterine insemination (IUI) or intracytoplasmic sperm injection (ICSI) for use of these specimens is dependent on electroejaculated sperm quality. If normal sperm quality is present and assisted reproduction is not required for the female partner, then a trial of intrauterine inseminations can be attempted. Initial electroejaculates are processed with gradient density centrifugation and cryopreserved. Ohl et al. (2001) found a 8.7% per cycle fecundity over 653 completed cycles of electroejaculation with IUI and the median number of IUI cycles to achieve pregnancy was three. With ICSI coupled to electroejaculation, we reported a fertilization rate of 75% per injected oocyte and a clinical pregnancy rate of 55% per fresh semen retrieval attempt (Chung et al. 1998). It should be noted that men with spinal cord injuries above T6 are at the risk of autonomic dysreflexia. Any intervention that involves hollow visceral dilation or neurologic stimulation of the lower reproductive tract, including bladder filling, enemas, or rectal probe electrostimulation, should involve blood pressure monitoring. Patients with a history of autonomic dysreflexia should have prophylactic treatment with nifedipine prior to electrical stimulatory procedure (Nijman et al. 1982). Alternatively, those patients could get spinal anesthesia and blood pressure monitoring.

Techniques for Sperm Harvest

Obstructive Azoospermia Men with obstructive azoospermia include men after vasectomy or other acquired obstruction, those with congenital bilateral absence of the vas deferens, and ejaculatory duct obstruction. The location of viable sperm and the presence of optimal sperm qualities change in chronic obstruction. For men with obstruction, the distal areas of the reproductive tract (typically the distal epididymis) contain large numbers of macrophages and degenerating spermatozoa. These spermatozoa are being removed from the reproductive tract by macrophages, and these nonviable sperm are generally not suitable for use with assisted reproduction. In obstruction, better quality sperm can be found proximally, in the rete testis, vasa efferentia, or caput epididymis, and the more distal (cauda) epididymis is the site of sperm degeneration. This finding is often referred to as “inverted motility” (Mooney et al. 1972). In fact, motile spermatozoa are found at concentrations up to one million sperm/ml in the obstructed epididymis. These factors should be taken into account during any attempt at sperm retrieval. Options for harvesting include percutaneous as well as open techniques.

Percutaneous Sperm Retrieval Techniques Percutaneous techniques for sperm retrieval include testicular fine needle aspiration (TFNA), percutaneous epididymal aspiration of sperm (PESA), and

Fig. 1. Technique of fine needle aspiration of testis

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percutaneous biopsy of the testis (PercBiopsy). The primary indication for open testicular sperm retrieval today should be for sperm acquisition in nonobstructive azoospermia. TFNA is the least involved of these procedures to perform, but yields the lowest number of sperm (Friedler et  al. 1997). After the induction of local anesthesia to the scrotal skin as well as a spermatic cord block, the testis is stabilized between the surgeon's thumb and forefinger, and a needle is inserted along the long axis of the testis. The needle is withdrawn slightly and redirected in order to disrupt the testicular architecture. The procedure is repeated until adequate testicular material has been aspirated. A Franzen needle holder can be used to provide negative pressure for needle aspiration (Fig. 1). PESA can also be performed under local anesthesia with low cost and without microsurgical skills. In this procedure, a 21 gauge butterfly needle is attached to a 20  ml syringe and is inserted into the caput epididymis and then slowly withdrawn until fluid can be seen in the tubing. The tubing is then clamped and the fluid flushed out with medium. This procedure can be repeated several times. Percutaneous biopsy involves the use of a 15-gauge biopsy gun with a short (1  cm) excursion to retrieve testicular tissue (Fig. 2). Anesthesia is achieved with a spermatic cord block as well as topical application of local anesthetic, such as EMLA cream (Astra-Zeneca Pharmaceuticals, Worcester, MA.) Multiple biopsies can be obtained through a single entry site. This procedure provides higher sperm yield than needle

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Fig. 2. Technique of percutaneous testicular biopsy (Percbiopsy)

aspiration, but microsurgical epididymal sperm aspiration (MESA) by far has a higher sperm yield with sperm of better quality (Sheynkin et  al. 1998), thus decreasing the chance of needing a subsequent sperm retrieval procedure.

Microsurgical Epididymal Sperm Aspiration MESA is our preferred approach for patients with obstructive azoospermia who would consider more than one IVF cycle for treatment. It is preferred over a percutaneous approach because of its ability to retrieve greater numbers of sperm, the direct visualization of the epididymal puncture, and the minimal contamination of the sample with blood. MESA is performed as an open operation under an operating microscope. Individual tubules of the epididymis are isolated, and micropuncture aspiration is performed. Initial aspiration is performed starting one-half way up the obstructed reproductive segment, and subsequent punctures are carried out proximally (Fig. 3). Sperm quality (motility) is analyzed for each specimen until optimal sperm quality in the obstructed epididymis is empirically identified. In some cases, access to the efferent ducts is needed to provide sperm of optimal quality. Efferent duct exploration

is effected by opening the tunica vaginalis and viewing the junction of the testis and epididymis. Micropuncture aspiration can then be performed. MESA typically results in sperm retrieval of more than 100 × 106 sperm with adequate motility for effective cryopreservation of multiple samples. However, multiple studies have repeatedly demonstrated that vasectomy reversal, when possible, is far more cost effective than MESA with ICSI (Pavlovich and Schlegel 1997; Lee et  al. 2008; Heidenreich et al. 2000).

Nonobstructive Azoospermia For men with nonobstructive azoospermia (NOA), testicular sperm extraction is required, and there is a higher risk of failure to retrieve spermatozoa. Couples must be apprised of this risk prior to attempted sperm retrieval with assisted reproduction. However, testicular sperm extraction is the only option for biological fatherhood for these men at this time. If a simultaneous sperm retrieval-ICSI is planned for NOA and the couple is willing to consider donor insemination, then donor spermatozoa should be available at the time of procedure. On testis biopsy, men with NOA will demonstrate the patterns of Sertoli cell-only, maturation arrest or severe hypospermatogenesis. One of the most ­significant recent

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Fig. 3. Technique for microsurgical epididymal sperm aspiration

advances in male infertility was the recognition that the testis is not uniform, and therefore men with NOA may harbor small pockets of sperm production retrievable with multiple biopsies. Sperm retrieved in such a manner­ may be used for ICSI, even though quantitative levels of sperm production are so impaired that no sperm make it into the ejaculate (Agarwal et al. 2008).

Fine Needle Aspiration with mapping Fine needle aspiration of the testis, as performed for obstructive azoospermia, has been performed as a technique to "map" sites of sperm production to guide subsequent biopsies (Turek et  al. 1997). However, TFNA has been shown in multiple controlled series

to be less effective than open testicular biopsies for extracting spermatozoa from men with NOA (Amer et al. 2000; Schlegel 1999). Therefore, we do not recommend TFNA as a primary or solitary technique of sperm retrieval for NOA.

Open Testicular Sperm Extraction Open testicular biopsies, either single or multiple, have been performed in a number of different ways for testicular sperm extraction. However, since the testicular blood supply is distributed over the surface of the testis before it penetrates into the testicular parenchyma, multiple blind biopsies can interrupt the testicular blood supply and devascularize the testis if all

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branches of the testicular artery are divided. Therefore, it is important to avoid subtunical testicular vessels during testicular biopsy procedures, especially if large or multiple biopsies are performed. In addition, the identification of regions of the testis that have sperm production cannot be reliably evaluated prior to invasive biopsies at this time. Multiple random biopsies may lead to the removal of large volumes of testicular tissue with uncertain results of sperm retrieval. The risk of testicular injury along with low spermatozoa yields led to the development of microsurgical TESE (mTESE). This technique involves

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placing a wide incision in the tunica albuginea in an avascular region and eversion of the testicular parenchyma for microdissection (Fig. 4). With high power (12–16×) magnification, subtunical vessels as well as intratesticular vessels can be identified and preserved. Microscopic dissection and direct examination of seminiferous tubules allow the identification of the rare regions that contain sperm in men with NOA. The tubules with spermatozoa are wider and more opaque than the fibrotic Sertoli cell-only tubules (Fig.  5). Overall, mTESE has been shown to result in a higher number of sperm harvested,

Fig. 4. Exposure during microdissection TESE

Fig. 5. Intraoperative picture during microdissection TESE. White arrow points toward tubules more likely to have spermatogenesis

Techniques for Sperm Harvest

increased chance of retrieving sperm and decreased testicular tissue removed (Schlegel 1999; Tsujimura et  al. 2002). The only predictor of successful treatment is the most advanced stage seen on biopsy and not the predominant stage (Su et al. 1999). Testicular volume, serum FSH levels and etiology of NOA appear to have little or no effect on the chance of sperm retreival (Su et  al. 1999; Ramasamy et  al. 2009; Ramasamy and Schlegel 2007). Postoperative ultrasound has demonstrated fewer acute and chronic changes after microdissection as compared to conventional TESE (Ramasamy et al. 2005). Of course, an increased number of biopsies is always counterbalanced by greater risk of damage to the vascularity of the testis, so the surgeon must be constantly aware of this. For the selection of the initial side, we prefer to start on the side with larger testicular volume or the side with the more advanced spermatogenic pattern seen on histology if a prior biopsy was done (with the most advanced being normal spermatogenesis followed by late maturation arrest, early maturation arrest, and sertoli-cell only pattern in that order).

Processing of Testicular Tissue Samples For testicular tissue samples, isolation of individual tubules from the mass of coiled testicular tissue is achieved by the initial dispersal of the testis biopsy specimen, typically in a 300–500  ml volume of supportive medium. Mechanical disruption of the tubules is accomplished by mincing the extended tubules with sterile scissors in HTF/Plasmanate medium. Additional dispersion of tubules and higher sperm yield is achieved by passing the suspension of testicular tissue through a 24-gauge angiocatheter (Ostad et al. 1998). For minimal tissue specimens, little dissection is performed in the operating room. Individual seminiferous tubules may be opened individually in the embryology laboratory, immediately prior to ICSI. Intraoperatively, a “wet preparation” of the suspension is examined under phase contrast microscopy at 200× power looking for sperm. If no spermatozoa are seen, then (1) additional biopsies of tissue are obtained through the same tunical incision, (2) biopsies are performed using additional incisions, and (3) contralateral biopsies are obtained, if needed. Even a single spermatozoon, seen on the entire slide from a limited aliquot of the retrieved tissue, may reflect enough sperm within that testicular tissue specimen

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to proceed with ICSI. Multiple biopsies can be critical for the successful treatment of men with nonobstructive azoospermia, as only 23% of men have sperm found on the first standard biopsy for nonobstructive azoospermia, and sperm may be first seen in up to the 14th biopsy (Ostad et  al. 1998). After dispersal, immediate intraoperative evaluation of the specimens is performed by a member of the IVF laboratory in the operating room. Subsequent processing of the testicular tissue suspension, including microdissection of the specimens is performed in the IVF laboratory. Aliquots of tissue are also processed for cryopreservation. Instead of performing random, blind biopsies of testicular tissue, we prefer to use microdissection to guide the removal of testicular tissue, optimizing the chance of sperm retrieval and limiting the need to remove excess testicular tissue. Postoperative scar can affect functioning testicular tissue (both hormone production and sperm production). Scar is most likely to form if bleeding occurs after the testis is closed, so meticulous hemostasis with bipolar cautery is a critical component of a safe microdissection TESE procedure. Overall, the chance of sperm retrieval with microTESE for men with NOA is 58%, with subsequent pregnancy rates (clinical pregnancy; fetal heartbeat seen on ultrasound) of 45%. These men typically undergo simultaneous sperm retrieval on the day before oocyte retrieval in a programmed IVF cycle at Weill Cornell. Results have remained consistent in over 1,000 attempts at TESE at our institution. The risk of hematoma is 2–3% after this procedure, and the risk of impaired testosterone production is 3–5%, postoperatively. On repeat mTESE, if the first time was successful, then there is 96% sperm retrieval rate; with the diagnosis of hypospermatogenesis, there was sperm retrieval rate of 76%, but a 33% sperm retrieval rate when no sperm were found on previous mTESE (Haimov-Kochman et al. 2009).

Summary Sperm retrieval for use with assisted reproduction is commonly indicated and a highly effective approach to allow azoospermic men to become fathers. The type of azoospermia (obstructive or nonobstructive) determines the approach to sperm retrieval, as well as pretreatment evaluation and chances of success. The use of the techniques outlined in this section helps optimize sperm retrieval, while minimizing the potential risks of the procedure.

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References Agarwal A, Deepinder F, Cocuzza M, Short RA, Evenson DP. Effect of vaginal lubricants on sperm motility and chromatin integrity: a prospective comparative study. Fertility and Sterility. 2008;89(2):375–379. Amer M, Ateyah A, Hany R, Zohdy W. Prospective comparative study between microsurgical and conventional testicular sperm extraction in non-obstructive azoospermia: follow-up by serial ultrasound examinations. Human Reproduction (Oxford, England). 2000;15(3):653–656. Anderson L, Lewis SE, McClure N. The effects of coital lubricants on sperm motility in  vitro. Human Reproduction (Oxford, England). 1998;13(12):3351–3356. Brackett NL, Kafetsoulis A, Ibrahim E, Aballa TC, Lynne CM. Application of 2 vibrators salvages ejaculatory failures to 1 vibrator during penile vibratory stimulation in men with spinal cord injuries. The Journal of Urology. 2007;177(2): 660–663. Chung PH, Palermo G, Schlegel PN, Veeck LL, Eid JF, Rosenwaks Z. The use of intracytoplasmic sperm injection with electroejaculates from anejaculatory men. Human reproduction (Oxford, England). 1998;13(7):1854–1858. Friedler S, Raziel A, Strassburger D, Soffer Y, Komarovsky D, Ron-El R. Testicular sperm retrieval by percutaneous fine needle sperm aspiration compared with testicular sperm extraction by open biopsy in men with non-obstructive azoospermia. Human Reproduction (Oxford, England). 1997; 12(7):1488–1493. Haimov-Kochman R, Lossos F, Nefesh I, et  al. The value of repeat testicular sperm retrieval in azoospermic men. Fertility and Sterility. 2009;91(4 Suppl):1401–1403. Heidenreich A, Altmann P, Engelmann UH. Microsurgical vasovasostomy versus microsurgical epididymal sperm aspiration/testicular extraction of sperm combined with intracytoplasmic sperm injection. A cost-benefit analysis. European Urology. 2000;37(5):609–614. Lee R, Li PS, Goldstein M, Tanrikut C, Schattman G, Schlegel PN. A decision analysis of treatments for obstructive ­azoospermia. Human Reproduction (Oxford, England). 2008;23(9):2043–2049. Mooney JK, Jr., Horan AH, Lattimer JK. Motility of spermatozoa in the human epididymis. The Journal of Urology. 1972;108(3):443–445. Nijman JM, Jager S, Boer PW, Kremer J, Oldhoff J, Koops HS. The treatment of ejaculation disorders after retroperitoneal lymph node dissection. Cancer. 1982;50(12):2967–2971. Ohl DA, Wolf LJ, Menge AC, et  al. Electroejaculation and assisted reproductive technologies in the treatment of anejaculatory infertility. Fertility and Sterility. 2001;76(6): 1249–1255.

Hsiao and Schlegel Ostad M, Liotta D, Ye Z, Schlegel PN. Testicular sperm ­extraction for nonobstructive azoospermia: results of a multibiopsy approach with optimized tissue dispersion. Urology. 1998;52(4):692–696. Pavlovich CP, Schlegel PN. Fertility options after vasectomy: a cost-effectiveness analysis. Fertility and Sterility. 1997; 67(1):133–141. Ramasamy R, Schlegel PN. Microdissection testicular sperm extraction: effect of prior biopsy on success of sperm retrieval. The Journal of Urology. 2007;177(4):1447–1449. Ramasamy R, Yagan N, Schlegel PN. Structural and functional changes to the testis after conventional versus microdissection testicular sperm extraction. Urology. 2005;65(6): 1190–1194. Ramasamy R, Lin K, Gosden LV, Rosenwaks Z, Palermo GD, Schlegel PN. High serum FSH levels in men with nonobstructive azoospermia does not affect success of microdissection testicular sperm extraction. Fertility and Sterility. 2009;92(2):590–593. Restelli AE, Bertolla RP, Spaine DM, Miotto A, Jr., Borrelli M, Jr., Cedenho AP. Quality and functional aspects of sperm retrieved through assisted ejaculation in men with spinal cord injury. Fertility and Sterility. 2009;91(3): 819–825. Schlegel PN. Testicular sperm extraction: microdissection improves sperm yield with minimal tissue excision. Human Reproduction. 1999;14(1):131–135. Sheynkin YR, Ye Z, Menendez S, Liotta D, Veeck LL, Schlegel P. Controlled comparison of percutaneous and microsurgical sperm retrieval in men with obstructive azoospermia. Human Reproduction (Oxford, England). 1998;13(11): 3086–3089. Soler JM, Previnaire JG, Plante P, Denys P, Chartier-Kastler E. Midodrine improves ejaculation in spinal cord injured men. The Journal of Urology. 2007;178(5):2082–2086. Soler JM, Previnaire JG, Plante P, Denys P, Chartier-Kastler E. Midodrine improves orgasm in spinal cord-injured men: the effects of autonomic stimulation. The Journal of Sexual Medicine. 2008;5(12):2935–2941. Su LM, Palermo GD, Goldstein M, Veeck LL, Rosenwaks Z, Schlegel PN. Testicular sperm extraction with intracytoplasmic sperm injection for nonobstructive azoospermia: testicular histology can predict success of sperm retrieval. The Journal of Urology. 1999;161(1):112–116. Tsujimura A, Matsumiya K, Miyagawa Y, et al. Conventional multiple or microdissection testicular sperm extraction: a comparative study. Human Reproduction. 2002;17(11): 2924–2929. Turek PJ, Cha I, Ljung BM. Systematic fine-needle aspiration of the testis: correlation to biopsy and results of organ “mapping” for mature sperm in azoospermic men. Urology. 1997;49(5):743–748.

Sperm Banking: When, Why, and How? Sajal Gupta, Lucky H. Sekhon, and Ashok Agarwal

Contents Why and When Do Men Need to Bank Their Sperm?........................................................................................................ Couples........................................................................................................................................................................... Patients with Cancer........................................................................................................................................................ Factors That Prevent Patients from Sperm Banking............................................................................................................ How Does Sperm Banking Work: Techniques of Semen Cryopreservation........................................................................ Preparation and Preselection........................................................................................................................................... Rapid Freezing................................................................................................................................................................ Slow Freezing................................................................................................................................................................. Advantages and Disadvantages of Cryoprotectants............................................................................................................. Glycerol........................................................................................................................................................................... TEST-Yolk Buffer........................................................................................................................................................... The Effect of Cryopreservation on Sperm Characteristics.................................................................................................. ART Outcomes with Banked Semen Specimens................................................................................................................. Advantages of ICSI and Use of Cryopreserved Spermatozoa........................................................................................ Challenges and Risks Associated with Cryopreservation............................................................................................... Conclusion........................................................................................................................................................................... References............................................................................................................................................................................

Cryopreservation is the collection, freezing, and longterm storage of sperm, and is a highly effective method of protecting male fertility potential. Cryopreservation of semen is a vital procedure which can be employed for a variety of purposes, including donor insemination and the preservation of gametes in patients undergoing gonadotoxic treatment. It also may be helpful S. Gupta, L.H. Sekhon, and A. Agarwal () Center for Reproductive Medicine and Andrology Laboratory and Reproductive Tissue Bank, Glickman Urological & Kidney Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk A19.1, Cleveland, OH 44195, USA e-mail: [email protected]

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to fertile couples who experience difficulty conceiving (Thomson et al. 2009). The increasing success of cancer treatment and concerted efforts to ensure quality of life after successful treatment have placed great emphasis on the need to preserve the reproductive capability of young men. Many health care professionals agree that the option to bank one’s sperm should be offered systematically to all patients who may benefit, including those at risk for future infertility such as patients about to undergo cytotoxic chemotherapy (Achille et al. 2006; Kliesch et al. 1997a). However, this recommendation has yet to become standard practice. In a 2002 survey, only 10% of American physicians reported offering sperm

From: Current Clinical Urology: Male Infertility: Problems and Solutions, Edited by: E.S. Sabanegh, DOI: 10.1007/978-1-60761-193-6_12,  Springer Science+Business Media, LLC 2011

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banking routinely (Schover et  al. 2002a). Semen cryopreservation may be overlooked due to lack of physician awareness regarding the need for fertility preservation and the effectiveness of this option (Joint Council for Clinical Oncology 1998). Furthermore, physicians may overestimate the limitations of poor baseline sperm quality in their patients, leading them to view cryopreservation as futile (Lee et  al. 2006). However, with recent developments in reproductive technology, even men with severely impaired sperm parameters can benefit from cryopreservation as procedures such as intracytoplasmic sperm injection (ICSI) require only a few sperm to achieve fertilization and pregnancy (Hourvitz et  al. 2008; Agarwal and Allamaneni 2005; Abdel-Hafez et  al. 2009). Zapzalka et al. conducted a survey, revealing that 74% of oncologists were not aware of recent advances in assisted reproductive technology (ART) (Bonetti et al. 2009). Currently, the use of cryopreservation by urologists and gynecologists in in  vitro fertilization (IVF) programs remains limited (Abdel-Hafez et  al. 2009). Failure to offer this ignores the only possible reproductive option available to certain patients. All males of reproductive age facing a disease or gonadotoxic therapy should consider sperm banking before spermatogenesis is affected (Bonetti et al. 2009). Physicians are responsible for providing patients with the education necessary to decide for or against cryopreservation. Oncologists and patients agree that better educational materials would help to facilitate this process (Edge et  al. 2006). Information leaflets have been identified as a valuable resource to aid health care professionals in discussing cryopreservation although even this avenue remains underutilized (Achille et  al. 2006; Schover et al. 2002a; Bazeos et al. 1999). Huyghe et  al. conducted randomized trials that explored the effectiveness of multimedia educational tools (Huyghe et al. 2009). These programs were shown to be successful in increasing physician knowledge and alleviating decisional conflict in patients (Huyghe et  al. 2009). Presenting cryopreservation as the standard of care and sufficiently educating patients facilitates sperm banking.

Why and When Do Men Need to Bank Their Sperm? Couples Sperm cryopreservation may serve as a convenient solution for fertile couples who have difficulties coinciding intercourse with ovulation, due to reasons such

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as travel or geographical separation. Approximately 12% of couples are unable to conceive after 1  year of unprotected intercourse (Eisenberg et  al. 2010). Male factor causes account for 30–40% of these cases (Abdel-Hafez et  al. 2009). In the most severe cases of male infertility, couples may opt to undergo intrauterine insemination (IUI) using donor sperm (Abdel-Hafez et  al. 2009; Crha et  al. 2009). Donor insemination programs require cryopreservation of semen samples as the use of frozen semen allows screening of donors for infectious disease, such as HIV and hepatitis B, prior to insemination (Sherman et al. 1986). Azoospermia is implicated in 10% of male infertility (Abdel-Hafez et al. 2009). Cryopreservation allows for the long-term storage of sperm retrieved from azoospermic patients via testicular sperm extraction (TESE) or percutaneous epididymal sperm aspiration (PESA), negating the need for repeat procedures (Donnelly et al. 2001). While some studies have not demonstrated an association of repeated testicular aspiration with any major testicular complications (Westlander et  al. 2001), others report that multiple biopsies may pose the risk of inflammation and hematoma at the biopsy site, which can lead to testicular devascularization and fibrosis (Schlegel and Su 1997). Men may cryopreserve semen samples before undergoing prostate or testicular surgery as serum testosterone levels have been shown to remain low postoperatively, for at least 1  year (Manning et al. 1998). Cryopreservation of sperm before having a vasectomy allows a patient to store his gametes for future use in the event that circumstances or personal preferences change. For some patients who seek to regain their fertility after vasectomy-induced obstructive azoospermia, the use of ICSI with cryopreserved sperm, originally retrieved by minimally invasive techniques such as TESE and PESA, is a viable and more practical treatment alternative to microsurgical reconstruction of the male genital tract (Schoysman et  al. 1993; Devroey et  al. 1995; Craft et  al. 1993). In cases where the obstructive interval is long term, the success rates of ICSI have been shown to surpass those of vasectomy reversal (Kolettis et al. 2002). In cases of ejaculatory dysfunction, IUI using cryopreserved semen samples can allow couples to conceive (Craft et al. 1993). Individuals who work in occupations that involve toxic chemicals, ionization radiation, or biological hazards also should consider banking sperm as these exposures may jeopardize their reproductive potential.

Sperm Banking: When, Why, and How?

Patients with Cancer In the United States, approximately 1.3 million patients are diagnosed with cancer annually, with an average 5-year survival rate of 60%, resulting in about 9.8 million cancer survivors (American Cancer Society 2005). Most of the common malignancies seen in the reproductive-age male, including testicular cancer and Hodgkin’s disease (Hourvitz et  al. 2008), have total survival rates exceeding 95% for early-stage disease (Sant et  al. 2007). Williams et  al. demonstrated that the average age among 2,680 subjects with testicular cancer was 29.9 (Williams et  al. 2009). As full recovery can be achieved in a majority of these young patients, recent efforts have concentrated on minimizing treatment-associated morbidity by preserving patient fertility via the cryopreservation of gametes (Hallak et al. 1999). The quality of spermatozoa in men diagnosed with cancer is often suboptimal, even prior to the initiation of chemotherapy or radiotherapy (Lass et  al. 1998). Pre-existing germ cell defects that lead to cancer also cause defective spermatogenesis (Agarwal and Allamaneni 2005). At diagnosis of testicular cancer or Hodgkin’s disease, 50–70% of patients present with oligozoospermia (Howell and Shalet 2002). Many studies suggest that semen quality is significantly correlated with type of malignancy (Lass et al. 1998; Ragni 2003; Bahadur et  al. 2005), whereas others failed to demonstrate this association (Padron et  al. 1997; Meseguer et  al. 2006; Chung et  al. 2004). Testicular tumors may exert damaging local effects that can impair sperm quality. Numerous studies have demonstrated reduced sperm counts and motility in patients with testicular cancer (Hourvitz et  al. 2008; Crha et  al. 2009; Williams et  al. 2009). Hodgkin’s disease may activate cytokine secretion, which contributes to oxidative stress and impaired fertility (Colpi et al. 2004; Rueffer et al. 2001). Patients with Hodgkin’s disease have been shown to have semen samples with significantly lower sperm concentration and motility than patients with non-Hodgkin’s lymphoma (Botchan et  al. 1997). However, other studies failed to confirm this finding (Crha et al. 2009; Agarwal et al. 1996). The fact that this patient population may face reproductive challenges even before the onset of cancer treatment further highlights the importance of timely cryopreservation. The degree to which different modalities of cancer therapy are gonadotoxic depends on the agents used, duration of treatment, cumulative dosages, and the age of the patient (Achille et  al. 2006). In general, sper-

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matogenesis and semen parameters are expected to return to normal levels in 50% of patients 2 years posttreatment and in 85% of patients 5 years after cessation of treatment (Howell and Shalet 2005). However, between 15 and 30% of patients are permanently affected by gonadotoxic treatment and do not recover their reproductive ability (Palermo et  al. 1992). It is impossible to predict which patients will be affected permanently (Schrader et al. 2001). The gonadotoxic effect of chemotherapy is well established (Achille et  al. 2006; Bonetti et  al. 2009; Schrader et  al. 2001; Kobayashi et  al. 2001a). Most patients develop azoospermia 12  weeks after commencing chemotherapeutic regimens (Schrader et  al. 2001). Chemotherapy targets cells outside the G0 phase of the cell cycle, leading to the destruction of proliferating spermatogonia (Bonetti et al. 2009). The degree to which testicular function is impaired is dose and agent dependent (Kobayashi et al. 2001a). More than 50% of patients receive high doses of chemotherapy (Bonetti et al. 2009). Alkylating agents such as cyclophosphamide and ifosfamide or combination therapies such as MOPP (mechlorethamine, oncovin, procarbazine, and prednisone) confer the greatest risk of infertility when taken as a higher cumulative dose for longer periods of time (Bahadur et al. 2000). Ionizing radiation frequently induces azoospermia (Kobayashi et al. 2001a) in a dose-dependent manner, with higher exposures leading to more severe gonadal dysfunction in men (Bahadur et al. 2000). Combination chemoradiotherapy has a synergistic negative effect on infertility (Colpi et al. 2004). Surgical cancer treatments such as retroperitoneal lymph node dissection can also contribute to infertility by causing retrograde ejaculation or anejaculation (Puscheck et al. 2004). It is of crucial importance that newly diagnosed male cancer patient’s bank semen samples at the earliest possible stage and before commencing cancer therapy. Studies have shown that only 5–10% of patients that bank their semen prior to treatment return for IVF treatment using their cryopreserved specimens (Agarwal et  al. 2004). Several possible reasons for this include the recovery of spermatogenesis after cessation of chemotherapy, death of the patient, anxiety regarding IVF treatment, financial constraints, no plans for more children, and patient uncertainty regarding a long-term prognosis (Bonetti et  al. 2009; Crha et  al. 2009). This “underutilization” has brought into question the promotion of routine pretreatment cryopreservation (Audrins et al. 1999). However, despite the fact that relatively few patients may return for treatment, cryopreservation should continue to be offered by

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health care professionals as standard care to all patients at risk for iatrogenic infertility (Hourvitz et al. 2008).

Factors That Prevent Patients from Sperm Banking Despite the well-established link between antineoplastic therapy and infertility, only 18–24% of young men with cancer were reported, by survey, to have banked their semen prior to treatment (Schover et al. 2002a). Surveys show that failure of physicians to provide patients with sufficient information in a timely manner is one of the main reasons patients fail to utilize cryopreservation to preserve their fertility (de Vries et  al. 2009). This could include situations in which the option was not presented entirely (Schover et  al. 2002a), the actual risk of infertility was downplayed by the physician (Achille et al. 2006), or patients who were interested failed to receive counseling and referral to a sperm bank (Schover et  al. 2002a). Schover et al. (2002a) reported that although more than 90% of oncologists felt that male patients at risk for infertility should be offered sperm banking, only 52% discussed the option with their patients (de Vries et al. 2009). Even when properly informed regarding infertility risk and cryopreservation, 42–54% of patients did not use sperm banking (Kliesch et  al. 1997a). This may be accounted for by patients’ personal preferences, financial constraints, time interval from diagnosis to treatment, and anxiety regarding the consequences of sperm banking. Of those who chose not to bank semen samples, 15% cited lack of interest in parenthood as their primary reason. For newly diagnosed cancer patients, immediate preoccupation with treatment and concerns about survival often take priority over family planning, resulting in sperm banking becoming a secondary consideration (Achille et al. 2006). Patients are more likely to be reluctant to sperm bank when the process would delay the initiation of treatment (Achille et  al. 2006). Some cancer patients require emergency treatment and do not have sufficient time to bank their semen. Patients with leukemia have a relatively reduced time interval between initial diagnosis and the initiation of gonadotoxic therapy (Williams et al. 2009). As cancer, itself, may already have a profound financial impact, many patients have concerns regarding the cost of sperm banking and continued long-term storage of specimens (Achille et al. 2006). A survey of patients revealed financial constraints to be a major obstacle for 7% of cancer survivors who chose not to bank sperm (Schover et  al. 2002a). Cost may play an even larger

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role in younger patients with limited or no income (Achille et al. 2006). Schover et al. demonstrated that physicians may overestimate the number of patients for whom sperm banking is not affordable (Schover et al. 2002). Therefore, health care professionals may fail to counsel patients appropriately based on their perception of patient factors. Patient anxiety may arise from misguided beliefs about the efficacy of cryopreservation and risk of transmitting genetic defects to progeny (Achille et al. 2006). However, many detailed studies have shown no increased risk of congenital defects and malignant tumors in the offspring of oncologic patients (Meirow and Schiff 2005). Providing the patient with accurate information may help restore the patient’s perception of the benefits of sperm banking. Rates of cryopreservation might be further improved by presenting sperm banking as a standard practice to patients and their families.

How Does Sperm Banking Work: Techniques of Semen Cryopreservation Sperm cryopreservation is routinely performed in ART centers and andrology laboratories. The process involves freezing cells to −196°C, the boiling point of liquid nitrogen – a common agent employed in the freezing and storage of spermatozoa. Before banking, semen samples are prepared to select the highest quality sperm for cryopreservation. Vitrification involves the use of cryopreservation agents that minimize cryodamage by decreasing intracellular water content and preventing intracellular ice crystal formation during the freezing process (Hiemstra et al. 2005). Freezing of specimens is accomplished by either rapid or slow freezing techniques. A significant post-thaw decrease in sperm quality has been observed, irrespective of the method used (Nallella et al. 2004; Paras et al. 2008) (Fig. 1). In general, rapid freezing may cause cell lysis by its dehydrating effects and slow freezing may lead to increased ice crystal formation (Kliesch et  al. 1997b). Some studies have suggested that the success of freeze–thaw technique may depend on differential thawing temperatures, as thawing at 37°C after rapid freezing and at 22°C after slow freezing was shown to yield the best results (Verheyen et  al. 1993). Optimal cooling rates prevent intracellular ice formation. Sources of sperm include semen, retrograde urine, or testicular tissue obtained surgically via conventional testicular biopsy or microsurgical testicular sperm retrieval (micro-TESE).

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Fig. 1. Computer-assisted semen analyzer for prefreeze analysis and post-thaw analysis of count and motility parameters

Preparation and Preselection The swim-up method involves centrifugation of a semen sample into pellets, which are then covered with culture medium. The spermatozoa with better motion characteristics, percentage motility, and viability are separated out as they swim up into the culture medium and can be selected for cryopreservation (Esteves et  al. 2002). It has been used by many laboratories as the main sperm washing technique to separate ejaculated spermatozoa from the seminal environment, eliminating dead spermatozoa along with exfoliated epithelial cells, cellular debris, leukocytes, and amorphous material (Berger et al. 1985). In comparison to untreated specimens, swim-up-selected cryopreserved sperm have been shown to exhibit faster velocity and progression, higher percentages of intact acrosomes, increased ability to undergo acrosome reaction (Esteves et al. 2002), and better performance in the sperm penetration assay after thawing (Russell and Rogers 1987). Magnetic-activated cell sorting (MACS) is another preparation technique that has been shown to select motile, viable, morphologically normal spermatozoa displaying higher cryosurvival rates and subsequent fertilization potential (Said et al. 2005; Grunewald et al. 2001, 2006). MACS uses annexin microbeads to immunolabel and remove apoptotic spermatozoa (Said et al. 2008). Annexin is a phospholipid-binding protein with a high affinity for phosphatidylserine (PS) – an early

marker of apoptosis when it is externalized to the outer aspect of the cell membrane. Externalized PS indicates impaired membrane integrity (Glander and Schaller 1999). Studies have shown that nonapoptotic sperm selected by MACS before cryopreservation exhibit significantly higher motility (Said et  al. 2005), higher levels of intact mitochondria, and decreased pan-caspase activation which leads to decreased rates of sperm apoptosis after thawing compared with sperm that were not selected by MACS (Grunewald et al. 2006).

Rapid Freezing The Irvine Scientific (IS) method is a fast and convenient cryopreservation method, allowing for rapid freezing and long-term storage of sperm. The protocol requires the entire volume of freezing medium to be added at one time followed by immersion of specimens in liquid nitrogen (Nallella et al. 2004; Kobayashi et al. 2001b). Contrary to the idea that gradual acclimatization to very low temperatures protects sperm functional integrity to a greater extent, several studies have shown the IS method to be superior to slow freezing in terms of better post-thaw sperm motility and cryosurvival (Nallella et al. 2004; Hallak et al. 2000).

Slow Freezing The Cleveland Clinic Foundation (CCF) method of controlled, slow freezing involves the gradual and

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successive addition of freezing media (Fig.  2), followed by storing specimens first at −20°C for 8 min, then in nitrogen vapors at −96°C for 2  h, followed by ­immersion in liquid nitrogen at −196°C (Nallella

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et  al. 2004; Kobayashi 2001b) (Figs.  3 and 4). An analysis by Nallella et  al. demonstrated the CCF method to result in thawed sperm with significantly better ­kinematics – with superior curvilinear ­velocity,

Fig. 2. Cryopreservation protocol: shaker for the mixing of the cryoprotectants

Fig. 3. Short-term storage of semen sample in liquid nitrogen tanks

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the high concentrations (30–50%) of cryoprotectants used in vitrification compared with slow freezing can result in drastically reduced spermatozoal motility. Several special carrier systems for the vitrification solution such as cryoloop, open pulled straws, open straws, and flexipet-denuding pipettes are widely marketed. Cooling can be achieved using either liquid nitrogen or liquid nitrogen vapor phase (Figs.  3 and 4). There is ongoing investigation on optimizing the protocols and determining the precise balance of cryoprotectants and more precisely adjusting their concentration and ratios for the best outcomes with sperm vitrification.

Advantages and Disadvantages of Cryoprotectants The freezing and thawing process of cryopreservation has detrimental effects on spermatozoa such as impaired sperm motility and vitality and reduced acrosome integrity (Esteves et al. 1998). Various cryoprotectants and cryopreservation methods are used to protect sperm viability post-thawing (Joint Council for Clinical Oncology 1998). The use of a cryoprotective agent to protect sperm cells during the freezing process is imperative; however, these substances can cause irreparable damage to the ultrastructural morphology of the sperm. Fig. 4. Long-term storage of semen sample in liquid nitrogen tank. The figure shows a metal canister containing boxes filled with cryovials

straight-line velocity, and average path velocity compared with sperm cryopreserved by the IS method (Nallella et  al. 2004) (Fig.  1). Slow, staged freezing using automated, computerized methods is thought to be more exact and has been reported to limit cryodamage of low-quality sperm (Ragni et al. 1990). However, automated freezers are time-consuming and expensive, requiring up to five times more liquid ­nitrogen (Paras et al. 2008).

Vitrification Nawroth et  al. described semen cryopreservation achieved by directly plunging spermatozoa into liquid nitrogen (cooling rate ~50,000  K/min or more) (Nawroth et  al. 2002). The vitrification technique is advantageous, in that it requires no equipment and is straightforward, quick, and inexpensive. However,

Glycerol Sperm cells are highly permeable to glycerol, which is a commonly used cryoprotectant (Hallak et  al. 2000). Glycerol is often supplemented with citrate or egg yolk, which act as cryobuffers because they contain macromolecules that do not permeate the cell membranes of the sperm. Glycerol serves as an energy source for spermatozoa and also maintains osmotic pressure by forming hydrogen bonds with membrane phospholipids and sugars (Yildiz et  al. 2007). This increases membrane stability and reduces the overall damage to the membrane (Yildiz et al. 2007). Egg yolk/glycerol mixture has been found to ­support superior post-thaw outcomes compared with using glycerol alone (Reed et al. 2009). Recent studies have shown that it is possible to replace hen’s egg yolk with soy lecithin when cryopreserving human sperm without adverse effects on post-thaw motility, morphology, or sperm chromatin decondensation.

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TEST-Yolk Buffer A combination of TES [N-Tris(hydroxymethyl) methyl-2-aminoethanesulfonic acid, pK 7.5] and Tris[(hydroxymethyl)aminomethane] is combined with fresh egg yolk, dextrose, and penicillin–streptomycin to form the cryobuffer known as TEST(TES and Tris)-yolk buffer (TYB) (Nallella et  al. 2004). TYB is the preferred cryoprotectant for normal as well as subnormal semen samples, as opposed to using only the glycerol cryoprotectant. In a study that compared TYB to proprietary media which are commonly used cryobuffer solutions such as Sperm Freezing Medium (Cooper Surgical, Trumbull, CT) and Enhance Sperm Freeze (Conception Technologies, San Diego, CA), the sperm that was cryopreserved in TYB was shown to have the longest longevity (Hallak et  al. 2000). Sperm membranes may be stabilized by an altered phospholipid: cholesterol ratio imposed by the TYB, which may in turn reduce damage by free radicals. Sperm cryopreserved with TYB containing 15% glycerol has higher post-thaw motility and viability than those sperm that are cryopreserved with glycerol alone ( p = 0.004) and it also promotes a higher recovery of motile sperm, and preserves the normal forms of a larger percentage of sperm ( p = 0.04), leading to improved capacitation and sperm penetration.

The Effect of Cryopreservation on Sperm Characteristics DNA stability, acrosomal integrity, motility, and viability are features required by a sperm cell that allow it to independently fertilize an egg (Ozkavukcu et al. 2008). These sperm functions must be present in prefreeze specimen and conserved throughout cryopreservation and the post-thaw period for fertilization to be possible with IUI and IVF. Both viability and motility tend to decrease by the same percentage after cryopreservation in both healthy individuals and testicular cancer patients. Bonetti et  al. found a mean post-thaw recovery rate just under 30% in both cancer patients and healthy patients (Bonetti et  al. 2009). However, cancer patients usually have a lower prefreeze quality sperm than do healthy patients (Williams et al. 2009), so their semen tends to have the lowest post-thaw qualities. Pre-existing defects in germ cells or spermatogenesis, including a possible history of cryptorchidism, or contralateral or intraepithelial germ

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cell neoplasia are common in patients with cancer and could cause low sperm quality (Williams et al. 2009). Also, local endocrine effects of the tumor, systemic endocrine disturbances, autoimmune effects resulting in antisperm antibodies, and the stressors resulting from illness could also lower sperm quality (Hallak et  al. 1999). Sperm cryopreservation protocols need to be optimized to compensate for the decrease in cryopreservation-thawing tolerance of spermatozoa in cancer patients. The literature reports no correlation between postthaw semen parameters and the duration of semen storage (Edelstein et al. 2008); nor was there a correlation between the male partner’s age and the post-thaw semen profile (Hourvitz et al. 2008). The longest duration of freezing with successful IUI outcome of live births have been reported with utilizing sperm stored for 28 years. The freezing and thawing process rather than the duration of storage appears to negatively impact and causes deterioration in sperm quality. Viability of spermatozoa decreases significantly after freezing and thawing. Many studies have shown that the number of viable sperm in a prefreeze sample is reduced by about 50% by cryopreservation. Crystal ice formation outside the cell affects cell morphology by concentrating the surrounding matrix rapidly, leading to high solute content outside the cells and osmotic damage. Cryoprotectant enters the cell through the plasma membrane before freezing and is removed during thawing, a process that can cause osmotic injury and damage to the cell membrane (Hallak et al. 2000). This damage inevitably results in lower sperm motility. Cryopreservatives like glycerol enter and exit the cell and can lead to swelling and shrinkage that may damage the majority of organelles and deform membrane structures. Post-thaw motility is reduced in cryopreserved semen samples and depends on the prefreeze motility of the semen sample (Ozkavukcu et  al. 2008). Most studies indicate that viability and motility – the most important sperm parameters that determine independent fertilization capacity – are reduced by 50% between the prefreeze and post-thaw semen samples. Much (but not all) of the reduced motility is likely a direct result of reduced viability caused by damage to cell membranes of the sperm when they are frozen. Some studies have shown that mitochondria contain defects after cryopreservation, but usually this only occurs when the plasma membrane is also damaged. In addition, reactive oxygen species (ROS) can be formed during both freezing and thawing processes, leading to decreased motility through peroxidation of the plasma lipid membrane. However, seminal plasma

Sperm Banking: When, Why, and How?

contains innate antioxidants, which is one benefit of using unaltered semen during freezing. Treatment of semen samples with pentoxifylline before freezing has been shown to significantly enhance sperm motility, the amplitude of the lateral displacement of the spermatozoal head, and the ability of spermatozoa to undergo the acrosome reaction (Esteves et  al. 1998; Schmidt et  al. 2004). The positive effects of pentoxifylline may be attributed to its removal of ROS and increase of intracellular cAMP (Esteves et  al. 1998). Pentoxifylline has beneficial effects on spermatozoa prior to cryopreservation and is proposed to improve the fertilizing ability of cryopreserved spermatozoa.

ART Outcomes with Banked Semen Specimens Cryopreservation of spermatozoa provides a readily available gamete reserve for ART and allows coordination with oocyte retrieval. While post-thaw semen quality is often not good enough for IUI, ICSI allows even the poorest quality sperm to fertilize oocytes. Amazingly, the only male factor that determines successful fertilization by ICSI is the production of a single motile sperm – the outcome is independent of other basic semen parameters, not including DNA integrity (Hallak et al. 1999). If a patient cannot produce a sample, minimally invasive procedures are available to recover samples of sperm from the testis and epididymis. Success rates of IVF and ICSI treatments using cryopreserved semen currently are almost as high as those using fresh semen (van Casteren et  al. 2008). The average success rate of achieving pregnancy using cryopreserved semen is 54% and can range between 33 and 73% (van Casteren et al. 2008) To date, there are limited data regarding the outcome of ART treatment using cryopreserved sperm from male cancer survivors (Tournaye et  al. 2004). Another study described 258 patients who cryopreserved their semen before chemotherapy; only 18 of these returned for treatment, with six pregnancies achieved (Audrins et al. 1999).

Advantages of ICSI and Use of Cryopreserved Spermatozoa The developments in IVF and ICSI have revolutionized the treatment of male-factor infertility and have made sperm cryopreservation both cost-effective and

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the most successful treatment option for men who have viable sperm (Palermo et al. 1992). ICSI reduces the need for storage of many samples and increases the chances for future reproductive success. This is especially helpful in cases where patients only have the opportunity to preserve one or two specimens before initiating cancer treatment (Hourvitz et al. 2008). In a recent report, the ART outcomes in 118 male cancer survivors undergoing 169 IVF–ICSI cycles were studied in a large series of couples treated with IVF–ICSI using cryopreserved sperm stored before cancer therapy. The clinical pregnancy rate was 56.8%, comparable to the average pregnancy rate achieved with other male-factor patients. The pregnancy outcome in such cases after conventional IVF, before the use of ICSI, was significantly lower. Fertilization failures with IVF were seen in 11% of the patients, as compared with 0.6% after the introduction of ICSI. Lass et  al. reported on 231 men referred for cryopreservation for malignant diseases (Lass et  al. 1998). Of the six couples who returned for infertility treatment after chemotherapy, two couples achieved pregnancy after IUI, one couple after IVF, and two couples with ICSI. Given the superior success rates of ICSI over IUI, ICSI should be performed with cryopreserved sperm to avoid the risk of failed fertilization and avoid the exhaustion of a limited sperm supply. Other investigators report significantly higher pregnancy rates and better results using ICSI compared with IVF or IUI (Agarwal et  al. 2004; Schmidt et  al. 2004; Revel et  al. 2005; Kelleher et  al. 2001). Certainly, patients with good post-thaw semen quality and sufficient samples can be treated initially by IUI before attempting ICSI–IVF cycles; however, success rates may be low (Agarwal et al. 2004). Agarwal et al. conducted a study in which the success rate with ICSI with cryopreserved sperm was 37% (Agarwal et  al. 2004). A recent study from Copenhagen reported a total of 151 ART cycles (55 IUI cycles, 82 ICSI, and 14 ICSI-frozen embryo replacement), in which the clinical pregnancy rate per cycle was 14.8% after IUI and 38.6% after ICSI. In the past, semen with poor prefreeze or postthaw quality produced by testicular cancer patients was not conducive to achieving pregnancy by IUI and resulted in low rates of successful pregnancies (Bonetti et al. 2009). However, with the advent of new ARTs such as ICSI, semen samples with the poorest semen parameters can be used to achieve pregnancy because the male patient is required to produce only a single motile sperm. Even though cancer patients have lower quality sperm and quality is further lowered by

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cryopreservation, ICSI circumvents this issue, making it worthwhile to cryopreserve semen samples with even the worst classical sperm parameters (de Vries et  al. 2009). ICSI is an option for utilizing the cryopreserved sperm retrieved with TESE and micro-TESE in patients with obstructive as well as nonobstructive azoospermia (Ishikawa et al. 2009). Even though the overall number of embryos transferred and the pregnancy rate per cycle have been reported to be lower in the nonobstructive group, the pregnancy rate per cycle was not different.

Challenges and Risks Associated with Cryopreservation There are reported risks of cross-contamination from leakage of cryopreserved samples in liquid nitrogen (Clarke et al. 1999). Regulatory bodies have issued current good tissue practice (CGTP) guidelines to prevent any adverse events resulting from these risks. All facilities offering sperm banking are regulated by the FDA and American Association of Tissue Banks (AATB) guidelines and need to be registered with these bodies. FDA has issued guidelines for human cells, tissues, and cellular- and tissue-based products (HCT/P) establishments, and they should follow the requirements in the CGTP regulations.

Conclusion Cryopreservation is a state-of-the-art technique for storing sperm for a range of indications in the infertility practice. Cryopreserved sperm can be utilized for IVF or ICSI and for multiple, timed artificial ­inseminations of partner or donor semen. Sperm also can be surgically harvested and cryopreserved before ­infertility treatment, such as at varicocele ligation, or ­vasectomy. Cryopreservation has become increasingly recognized as a therapy to alleviate the reproductive morbidity associated with cancer treatment. Chemotherapy, radiation, or surgical therapy or a combination of these have gonadotoxic effects, ­leading to impairment of sperm quality resulting in infertility. Fertility preservation options should be discussed at an early stage during treatment planning for cancer. Continuing research on developing fast, simple, and cost-effective protocols for semen ­cryopreservation is needed. The potential of ­cryopreservation techniques continues to be explored with exciting research, ­focusing on areas such as ­cryoprotectant-free sperm vitrification and refining the cooling and warming protocols to obtain optimal outcomes with ­vitrification.

Gupta et al.

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117 Joint Council for Clinical Oncology. Management of gonadal toxicity resulting from the treatment of adult cancer. London, UK: Royal College of Physicians, 1998 Kelleher S, Wishart SM, Liu PY, et al. Long-term outcomes of elective human sperm cryostorage. Hum Reprod 2001; 16(12): 2632–2639 Kliesch S, Bergmann M, Hertle L, Nieschlag E, Behre HM. Semen parameters and testicular pathology in men with testicular cancer and contralateral carcinoma in situ or bilateral testicular malignancies. Hum Reprod 1997a; 12(12): 2830–2835 Kliesch S, Kamischke A, Cooper TG, Nieschlag E. Andrology. Cryopreservation of human spermatozoa. Berlin: Springer, 1997b, pp. 505–520 Kobayashi H, Larson K, Sharma RK, et  al. DNA damage in patients with untreated cancer as measured by the sperm chromatin structure assay. Fertil Steril 2001a; 75(3): 469–475 Kobayashi H, Ranganathan P, Mahran AM, Sharma RK, Thomas AJ, Agarwal A. Comparison of two cryopreservation protocols for freezing human spermatozoa. Fertil Steril 2001b; 76(3 Suppl 1): S229–S230 Kolettis PN, Sabanegh ES, D’amico AM, Box L, Sebesta M, Burns JR. Outcomes for vasectomy reversal performed after obstructive intervals of at least 10  years. Urology 2002; 60(5): 885–888 Lass A, Akagbosu F, Abusheikha N, et  al. A programme of semen cryopreservation for patients with malignant disease in a tertiary infertility centre: lessons from 8 years’ experience. Hum Reprod 1998; 13(11): 3256–3261 Lee SJ, Schover LR, Partridge AH, et al. American Society of Clinical Oncology recommendations on fertility preservation in cancer patients. J Clin Oncol 2006; 24(18): 2917–2931 Manning M, Junemann KP, Alken P. Decrease in testosterone blood concentrations after testicular sperm extraction for intracytoplasmic sperm injection in azoospermic men. Lancet 1998; 352(9121): 37 Meirow D, Schiff E. Appraisal of chemotherapy effects on reproductive outcome according to animal studies and clinical data. J Natl Cancer Inst Monogr 2005; 34: 21–25 Meseguer M, Molina N, Garcia-Velasco JA, Remohi J, Pellicer A, Garrido N. Sperm cryopreservation in oncological patients: a 14-year follow-up study. Fertil Steril 2006; 85(3): 640–645 Nallella KP, Sharma RK, Allamaneni SS, Aziz N, Agarwal A. Cryopreservation of human spermatozoa: comparison of two cryopreservation methods and three cryoprotectants. Fertil Steril 2004; 82(4): 913–918 Nawroth F, Isachenko V, Dessole S, et al. Vitrification of human spermatozoa without cryoprotectants. CryoLetters 2002; 23(2): 93–102 Ozkavukcu S, Erdemli E, Isik A, Oztuna D, Karahuseyinoglu S. Effects of cryopreservation on sperm parameters and ultrastructural morphology of human spermatozoa. J Assist Reprod Genet 2008; 25(8): 403–411 Padron OF, Sharma RK, Thomas AJ Jr., Agarwal A. Effects of cancer on spermatozoa quality after cryopreservation: a 12-year experience. Fertil Steril 1997; 67(2): 326–331 Palermo G, Joris H, Devroey P, Van Steirteghem AC. Pregnancies after intracytoplasmic injection of single spermatozoon into an oocyte. Lancet 1992; 340(8810): 17–18 Paras L, Freisinger J, Esterbauer B, Schmeller N, Szlauer R, Jungwirth A. Cryopreservation technique: comparison of Test yolk buffer versus SpermCryo and vapour versus computerised freezing. Andrologia 2008; 40(1): 18–22

118 Puscheck E, Philipp PA, Jeyendran RS. Male fertility preservation and cancer treatment. Cancer Treat Rev 2004; 30(2): 173–180 Ragni G, Caccamo AM, Dalla Serra AD, Guercilena S. Computerized slow-staged freezing of semen from men with testicular tumors or Hodgkin’s disease preserves sperm better than standard vapor freezing. Fertil Steril 1990; 53(6): 1072–1075 Ragni G, Somigliana E, Restelli L, Salvi R, Arnoldi M, Paffoni A. Sperm banking and rate of assisted reproduction treatment: insights from a 15-year cryopreservation program for male cancer patients. Cancer 2003; 97(7): 1624–1629 Reed ML, Ezeh PC, Hamic A, Thompson DJ, Caperton CL. Soy lecithin replaces egg yolk for cryopreservation of human sperm without adversely affecting postthaw motility, morphology, sperm DNA integrity, or sperm binding to hyaluronate. Fertil Steril 2009; 92(5): 1787–1790 Revel A, Haimov-Kochman R, Porat A, et al. In vitro fertilization–intracytoplasmic sperm injection success rates with cryopreserved sperm from patients with malignant disease. Fertil Steril 2005; 84(1): 118–122 Rueffer U, Breuer K, Josting A, et al. Male gonadal dysfunction in patients with Hodgkin’s disease prior to treatment. Ann Oncol 2001; 12(9): 1307–1311 Russell LD, Rogers BJ. Improvement in the quality and fertilization potential of a human sperm population using the rise technique. J Androl 1987; 8(1): 25–33 Said TM, Grunewald S, Paasch U, Rasch M, Agarwal A, Glander HJ. Effects of magnetic-activated cell sorting on sperm motility and cryosurvival rates. Fertil Steril 2005; 83(5): 1442–1446 Said T, Agarwal A, Zborowski M, Grunewald S, Glander H, Paasch U. Utility of magnetic cell separation as a molecular sperm preparation technique. J Androl 2008; 29(2): 134–142 Sant M, Aareleid T, Artioli ME, Berrino F, et al. Ten-year survival and risk of relapse for testicular cancer: a EUROCARE high resolution study. Eur J Cancer 2007; 43(3): 585–592 Schlegel PN, Su LM. Physiological consequences of testicular sperm extraction. Hum Reprod 1997; 12(8): 1688–1692 Schmidt KL, Larsen E, Bangsboll S, Meinertz H, Carlsen E, Andersen AN. Assisted reproduction in male cancer survivors: fertility treatment and outcome in 67 couples. Hum Reprod 2004; 19(12): 2806–2810 Schover LR, Brey K, Lichtin A, Lipshultz LI, Jeha S. Knowledge and experience regarding cancer, infertility, and sperm banking in younger male survivors. J Clin Oncol 2002a; 20(7): 1880–1889

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Assisted Reproduction and Male Factor Fertility: Which Type Is Right? James Goldfarb and Nina Desai

Contents Intrauterine Insemination..................................................................................................................................................... IUI Outcomes....................................................................................................................................................................... In Vitro Fertilization/Intracytoplasmic Sperm Injection...................................................................................................... Summary.............................................................................................................................................................................. References............................................................................................................................................................................

Over the past 25 years, the reproductive endocrinologist and the in  vitro fertilization (IVF)/andrology laboratory have had an increasing role in the treatment of male infertility. In general, the male with compromised fertility is first evaluated by the reproductive urologist. Based upon this evaluation and a thorough discussion with the couple, the reproductive endocrinology team has several options in maximizing the couple’s chance to conceive. The two interventions currently employed are intrauterine insemination (IUI) and intracytoplasmic sperm injection (ICSI).

Intrauterine Insemination IUI became popular as a treatment for male infertility in the 1980s. Prior to this, fertility clinics did not have the ability to place sperm directly into the uterus; the high concentration of prostaglandins in the semen causes significant cramping and even potentially anaphylactic reactions. With the advent of IVF, sperm J. Goldfarb () and N. Desai In-Vitro Fertilization Center, Cleveland Clinic, Cleveland, OH 44195, USA e-mail: [email protected]

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“washing” techniques were developed, allowing the separation of sperm from other seminal contents. This “sperm washing procedure” made it possible for clinics to begin to safely provide IUI. IUI has become a first-line treatment for mild and moderate male factor infertility (Dadkhah et  al. 2004). Other indications for IUI include disorders of seminal delivery due to anatomic penile defects such as penile curvature and hypospadias, retrograde ejaculation, female factors such as cervical stenosis and cervicitis as well as idiopathic infertility. There are several methods the andrology lab uses to wash sperm for IUI depending on lab preference and semen parameters. The simplest technique involves the mixing of semen with culture medium and centrifuging for 10–20  min to pellet the sperm. Another approach has been to isolate motile sperm from the semen using the “swim-up” technique. Culture medium is gently layered over the sperm pellet after a short incubation, and the motile sperm fraction swimming up in to the culture medium layer is collected. Density gradient separation of sperm is by far the most widely used methodology. The semen is placed on a colloidal suspension of silica particles and centrifuged. Dead sperm, blood cells, and cellular debris remain at the top of the gradient column, while

From: Current Clinical Urology: Male Infertility: Problems and Solutions, Edited by: E.S. Sabanegh, DOI: 10.1007/978-1-60761-193-6_13,  Springer Science+Business Media, LLC 2011

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the pellet is enriched for highly motile morphologically normal sperm. There are also several commercially available kits for preparation of IUI samples that do not require the availability of an andrology lab. Commercially available kits allow a physician to prepare IUI samples without any special equipment or training. There have been no studies comparing the efficacy of commercially available kits and laboratory preparation of IUI samples. IUI may be performed without ovarian stimulation in patients with regular menses, however, usually oral medications (clomiphene or letrozole) or injectable gonadotropins are given in preparation for IUI. It is imperative that timing of ovulation is accurately determined to accurately perform the insemination. When IUI is done in conjunction with natural cycles or oral medications, home urinary luteinizing hormone (LH) predictors can be used to time ovulation. Alternatively, ultrasound monitoring and administration of human chorionic gonadotropin (HCG) can be used to determine timing of IUI. For women who have difficulty using LH predictors or those who are not comfortable with this responsibility, monitoring with ultrasound is indicated. Regardless, many studies have demonstrated that pregnancy rates with home urinary LH monitoring are comparable to those utilizing ultrasound monitoring (Zreik et al. 1999; Lewis et al. 2006; Vlahos et  al. 2005). Generally, the IUI procedure is performed about 24 h after a urinary LH rise or 36 h after the administration of HCG. The insemination process involves passing a very tiny catheter through the cervix to the top of the endometrial cavity. The process is generally no more uncomfortable than a Papanicolaou test and does not require any anesthesia. The procedure is generally quite safe, with only occasional cramping (which may be severe) and infection as uncommon complications. A review of infectious complications in 38 reported series on IUIs showed five infections in 3,129 patients and it is felt that the infection rate, if anything, may be overstated (Sacks and Simon 1991).

IUI Outcomes Many articles have been published describing outcomes of IUI based upon a number of factors and variables. While these studies are quite heterogeneous, a careful review helps to shed some light on the key elements for success in IUI. In 1999 Stone (Stone et al. 1999) reported on almost 10,000 IUI cycles done over 6 years for a variety of indications. Moreover, the stimulation protocols as

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well as the sperm preparation techniques were not standardized. Despite these confounding factors, several conclusions may be drawn that are consistent with previously published data: pregnancy rates rose as the number of motile sperm inseminated increased from four to six million, but plateaued after that. Success rates for male factor infertility were 8.4% per insemination cycle. Cycles in which the woman underwent ovarian stimulation had higher pregnancy rates than nonstimulated cycles, and pregnancy rates declined with increasing maternal age. Dickey et  al. (2002) reported on over 3,000 IUI cycles in which all patients were given clomiphene in preparation for IUI. Many clinicians, like Dickey, utilize medications with all insemination cycles, while others will initially use no ovarian stimulation if the patient ovulates well on her own. The authors found cumulative pregnancy rates to be 43% after four cycles if the husband had an abnormal semen analysis, but met “IUI threshold levels” of more than five million total sperm and more than 30% progressive motility. In contrast, when the semen analysis did not reach these threshold values, the cumulative pregnancy rate plateaued at 10% after three cycles. Van Wert et al. (2004) reported a meta-analysis looking at the postwash total motility as a predictor of pregnancy with IUI. They found that programs had “cutoff levels” between 0.8 and 5 million total motile sperm. These cutoff levels allowed prediction of failure to become pregnant to be as high as 100%. The sensitivity of the test (ability to predict pregnancy) was, however, limited, indicating that couples with a very low IUI sample were very unlikely to conceive, but those with a higher levels of total motile sperm were not assured of conceiving. Dovey et  al. (2008) reported on 4,100 clomiphenestimulated IUI cycles and showed pregnancy rates per cycle declined from 11.5% in women under 35 to 4.3% in women 41–42 years of age and to 1% in women over 42 years old. They concluded the low success rate with clomid and IUI when the woman is above age 42 suggests IUI has no place in treatment for this age group. As described above, Stone et al. (1999) reported a higher pregnancy rate in stimulated when compared with nonstimulated cycles. There have been many other studies comparing different ovarian stimulation protocols and IUI success. Matorras et al. (2002) evaluated IUI outcomes in women undergoing IUI with donor sperm, thus controlling for the insemination samples. They found the clomiphene group had a per cycle pregnancy rate of 6.1 versus 14.4% for the group of women who were stimulated with gonadotropins. Similarly, Mahani and Afnan (2004) showed trends toward higher IUI pregnancy rates as more aggressive

Assisted Reproduction and Male Factor Fertility: Which Type Is Right?

ovarian stimulations were employed. Gregoriou et al. (2008) and Dickey et al. (2004) both report reasonable pregnancy rates (14% and 20% respectively) using gonadotropin stimulation for women who have failed 3 clomiphene/IUI cycles, however, the incidence of high-order multiple pregnancies was increased by gonadotropin treatment in these patients. Interestingly, Dickey’s patients who had had five or more Clomid/ IUI cycles had pregnancy rate of only 3.6% when they underwent gonadotropin/IUI. Thus, in Dickey’s, experience patients who had had five or more cycles of Clomid/IUI did not have good success rates if they proceeded to gonadotropins/IUI. Letrozole, an aromatase inhibitor, has been used as an alternative to clomiphene in IUI cycles. Letrozole’s efficacy seems to be comparable to clomiphene (Badawy et al. 2009) and may be associated with fewer side effects and multigestation pregnancies. To summarize, factors that promote improved IUI outcomes in couples with male factor infertility include:

infertility including male factor infertility (Van Eum et  al. 1985). IVF of eggs could be accomplished with between 50,000 and 200,000 motile sperm, thus IVF could be utilized for oligospermia. However, men with severe oligospermia or azoospermia do not have enough sperm to be able to fertilize eggs by conventional IVF. In the late 1980s, several modifications to conventional IVF were devised to promote fertilization in couples with severe male factor. These methods included: •  Microdrop fertilization – the egg and sperm are put in close approximation by putting them together in a small drop of mineral oil. •  Subzonal injection (SUZI) – several sperm are injected under the zona pellucida (Fig. 1). •  Partial zona dissection (PZD) – a small hole is made in the zona pellucida and then several sperm are placed outside of the egg near the hole in the zona pellucida. •  Intracytoplasmic sperm injection (ICSI) – a single sperm is injected directly into the cytoplasm of the egg (Fig. 2).

•  Maternal age less than 35. •  Stimulation with gonadotropins compared with oral medications. •  IUI specimens with at least 5 million total motile sperm. It is known that pregnancies are occasionally achieved with very poor IUI specimens. In our institution, we have observed pregnancies with counts as low as 60,000 motile sperm. It is also very clear that the overall success rates with IUI are not particularly good even with gonadotropin therapy (which has the added complication of a high rate of multiple pregnancies). If cost was not an issue one could make a very good case for trying three cycles of the relatively simple clomiphene or letrozole combined with IUI and then proceeding directly to IVF. As will be seen in the next section, IVF has more than twice the success rate as IUI and significantly lower risks of high-order multiple pregnancies. In fact, many programs in states with mandated insurance coverage of IVF forego gonadotropin/IUI and proceed directly to IVF in the setting of IUI failure with oral medications (personal communication).

Fig. 1. Picture of subzonal injection zonal

In Vitro Fertilization/ Intracytoplasmic Sperm Injection In vitro fertilization (IVF) was first successful in England in 1978. Initially IVF was utilized almost exclusively for couples in whom the female had tubal disease. By the mid-1980s, IVF was being utilized for other causes of

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Fig. 2. Intracytoplasmic sperm injection

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Initial experience in the USA with the above methods was not overly encouraging. ICSI was not at all efficacious; inconsistent fertilization occurred with the other three methods with none being clearly superior. However, in 1992, researchers in Belgium devised modifications to the ICSI procedure, resulting in excellent fertilization rates, approaching those of routine IVF with normal sperm parameters (Van Rumste et al. 2000). The ICSI technique developed in Belgium was reasonably easy to adopt by others. Within a few years ICSI was widely used (Tarin 1995), and remains the most significant development in assisted reproduction since the initiation of IVF. As long as one motile sperm can be found for each mature egg, very severe male factor infertility results in fertilization rates and most importantly pregnancy rates comparable to other causes of infertility. Success rates (measured by the take-home baby rate) of 50% or more for couples in whom the woman is under 35 years old are now achieved in many IVF programs. Further, ICSI has now evolved to the point where even azoospermic men can have surgical sperm retrieval and can now father a pregnancy with ICSI. Men with obstructive azoospermia secondary to entities such as previous vasectomy and congenital absence of vas deferens (CAVD) can undergo percutaneous epididymal sperm aspiration (PESA), a very minor surgical procedure. Men with nonobstructive azoospermia from primary testis failure can undergo several different types of testicular samplings to look for viable immature sperm which can be used for ICSI. Sperm harvest procedures are described in Chap. 11. In general, PESA yields an excellent concentration of motile sperm resulting in fertilization and pregnancy rates comparable to ICSI or conventional IVF with ejaculated sperm. Sperm recovered from the testes tends to be much more challenging. Often there are so few sperm that even one motile sperm for each egg cannot be found or takes several hours to find. In addition, fertilization rates and implantation rates (chance of a transferred embryo to result in a pregnancy) are lower with testicular sperm versus ejaculated sperm (Pasqualotto et al. 2002). Because of ICSI, men who 20 years ago would have had no chance to father a child now have a chance to do so. Even men with genetic abnormalities such as Klinefelter Syndrome or AZF microdeletion have been reported to father children with ICSI (Denschlag et al. 2004). The pregnancy rates after ICSI are generally based on the female’s age and her ovarian function. Reports on the risk of congenital abnormalities with the use

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of ICSI compared to conventional IVF are conflicting. A multicenter study of 5-year-old ICSI offspring indicated there was an increase in major congenital anomalies, but the increase was small (Bonduelle et  al. 2005). Other complications of IVF are not significantly different when comparing ICSI to routine IVF. The major complication of multiple pregnancies can be controlled by limiting the number of embryos transferred. American Society of Reproductive Guidelines suggests transferring no more than two embryos in patients under 35 and in good prognsis patients recommends transferring only one (The Practice Committee of the American Society for Reproductive Medicine and the Practice Committee of the Society for Assisted Reproductive Technology 2009). Hyperstimulation is the main physical risk to women undergoing ovarian hyperstimulation. The risk of hyperstimulation is no higher in ICSI cases than in IVF cases.

Summary In summary, men who have abnormal sperm para­ meters that cannot be corrected by the reproductive urologist can, in almost every case, have a chance to conceive with interventions available through the reproductive endocrinologist. With the advent of IVF and ICSI, even men with severe male ­factor infertility are able to father children, advancing the discipline of infertility and providing hope to couples who previously had no chance at attaining fertility.

References Badawy A, Elnashar A, Totongy M. Clomiphene citrate or aromatase inhibitors for superovulation in women with unexplained infertility undergoing intrauterine insemination: a prospective randomized trial. Fertil Steril 2009;92: 1355–1359. Bonduelle M, Wennerholm U-B, Loft A, Tarlatzis BC, Peters C, Henriet S, Man C, Victorin-Cederquist A, Van Steirteghem A, Balaska A, Emberson JR, Sutcliffe AG. A mulit-centre cohort study of the physical health of 5-year-old children conceived after intracytoplasmic sperm injection, in  vitro fertilization and natural conception. Hum Reprod 2005;20:413–419. Dadkhah F, Nahabidian A, Ahmadi GH. The correlation between semen parameters in processed and unprocessed semen with pregnancy rate in intrauterine insemination in the treatment of male factor infertility. Urol J 2004;1(4): 273–275. Denschlag D, Clemens T, Kunze M, Wolff G, Keck C. Assisted reproductive techniques in patients with Klinefelter syndrome: a critical review. Fertil Steril 2004;82:775–779.

Assisted Reproduction and Male Factor Fertility: Which Type Is Right? Dickey RP, Taylor SN, Lu PY, Sartor BM, Rye PH, Pyrzak R. Effect of diagnosis, age, sperm quality, and number of preovulatory follicles on the outcome of multiple cycles of Clomiphene citrate-intrauterine insemination. Fertil Steril 2002;78: 1088–1095. Dickey RP, Taylor SN, Lu PY, Sartor BM, Pyrzak R. Clomiphene citrate intrauterine insemination (IUI) before Gonadotropin IUI affects the pregnancy rate and the rate of high-order multiple pregnancies. Fertil Steril 2004;82(3):764–765. Dovey S, Sneeringer RM, Penzias AS. Clomiphene citrate and intrauterine insemination: analysis of more than 4100 cycles. Fertil Steril 2008;90:2281–2286. Gregoriou O, Vlahos NF, Konidaris S, Papadias K, Botsis D, Creatsas GK. Randomized controlled trial comparing superovulation with Letrozole versus recombinant follicle-stimluating hormone combined with intrauterine insemination for couples with unexplained infertility who had failed clomiphene citrate stimulation and intrauterine insemination. Fertil Steril 2008;90(3):678–683. Lewis V, Queenan J Jr., Hoeger K, Stevens J, Guzick DS. Clomiphene citrate monitoring for intrauterine insemination timing: a randomized trial. Fertil Steril 2006;85:401–406. Mahani IM, Afnan M. The pregnancy rates with intrauterine insemination (IUI) in superovulated cycles employing different protocols (clomiphen citrate (CC), human menopausal Gonadotropin (HMG) and HMG+CC) and in natural ovulatory cycle. J Pak Med Assoc 2004;54(10):503–505. Matorras R, Diaz T, Corcostegui B, Ramon O, Pijoan JI, Rodriguez-Escudero FJ. Ovarian stimulation in intrauterine insemination with donor sperm: a randomized study comparing clomiphene citrate in fixed protocol versus highly purified urinary FSH. Hum Reprod 2002;8: 2107–2111. Pasqualotto FF, Ross-Ferragut LM, Rocha CC, Iaconelli A Jr., Borges E Jr. Outcome of in vitro fertilization and intracytoplasmic injection of epididymal and testicular sperm obtained from patients with obstructive and nonobstructive azoospermia. J Urol 2002;167(4):1753–1756. Sacks PC, Simon JA. Infectious complications of intrauterine insemination: a case report and literature review. Int J Fertil 1991;36(6):331–339.

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Stone BA, Vargyasm JM, Ringler GE, Stein AL, Marrs RP. Determinants of the outcome of intrauterine insemination: analysis of outcomes of 9963 consecutive cycles. Am J Obstet Gynecol 1999;180:1522–1534. Tarin JJ. Subzonal insemination, partial zona dissection or intracytoplasmic sperm injection? An easy decision? Hum Reprod 1995;10(1):165–170. The Practice Committee of the American Society for Reproductive Medicine and the Practice Committee of the Society for Assisted Reproductive Technology. Guidelines on number of embryos transferred. Fertil Steril 2009;92(5): 1518–1519, Van Eum JF, Acosta AA, Swanson RJ, Mayer J, Ackerman S, Burkman LJ, Veech L, McDowell JS, Bernardus RE, Jones HW Jr. Male Factor evaluation in in  vitro fertilization: Norfolk experience. Fertil Steril 1985;44(3):375–383. Van Rumste MM, Evers JL, Farquhar CM, Blake DA. Intracytoplasmic sperm injection versus partial zona dissection, subzonal insemination and conventional techniques for oocyte insemination during in  vitro fertilization. Cochrane Database Syst Rev 2000;(2):CD001301. Review. Update in: Cochrane Database Syst Rev. 2003; (2):CD001301. Van Wert J-M, Repping S, Van Voorhis BJ, van der Veen F, Bossuyt PMM, Mol BWJ. Performance of the postwash total motile sperm count as a predictor of pregnancy at the time of intrauterine insemination: a meta-analysis. Fertil Steril 2004;82(3):612–620. Vlahos NF, Coker L, Lawler CF, Zhao Y, Bankowski B, Wallach EE. Women in ovulatory dysfunction undergoing ovarian stimulation with clomiphene citrate for intrauterine insemination may benefit from administration of human chorionic Gonadotropin. Fertil Steril 2005;83: 1510–1516. Zreik TH, Garcia-Velasco JA, Habboosh MS, Olive DL, Arici A. Prospectiverandomized, cross-over study to evaluate the benefit of human chorionic gonadotriphin-timed versus ­urinary luteinizing hormone-timed intrauterine inseminations in Clomiphene citrate-stimulated treatment cycles. Fertil Steril 1999;71:1070–1074.

Ethical Dilemmas in Male Infertility Barbara Chubak and Anthony J. Thomas

Contents In Vitro Fertilization and Intracytoplasmic Sperm Injection............................................................................................... Posthumous Sperm Retrieval............................................................................................................................................... Donor Insemination............................................................................................................................................................. Conclusion........................................................................................................................................................................... References............................................................................................................................................................................

Recent decades have witnessed a significant rise in the numbers of couples seeking infertility care worldwide (Balen 2008). This phenomenon has been driven, in part, by the availability of assisted reproductive therapies (ART) and the social circumstances that motivate couples to defer having children until they are older. If both these phenomena persist into the future, we can anticipate that more patients will seek treatment for infertility and more healthcare providers will choose to specialize in reproductive health to meet these needs. Therefore, it is increasingly important that physicians evaluate and treat these patients in ways that are both ethically and medically sound. Ethical standards have developed over the course of human history and are a complex product of biological imperatives, religious doctrines, intellectual erudition, and cultural praxis. As such, conditions like male infertility, in which all of these factors may be relevant, are loci of profound ethical tension, with

B. Chubak () and A.J. Thomas Department of Bioethics, Cleveland Clinic, Cleveland, OH, USA e-mail: [email protected]

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dilemmas arising whenever there is conflict between what can and what should be done. The limited space of this chapter does not permit the analysis of all the ethical issues that arise from male ­infertility (Table  1). However, by delving into some of the issues that commonly trouble doctors and patients, it is hoped that this chapter offers a guide to an ethical thought process.

In Vitro Fertilization and Intracytoplasmic Sperm Injection Despite the many causes and treatments for male infertility listed in this and other books, when faced with an infertile couple, some physicians may recommend skipping the steps of thorough examination and individual diagnosis for the male partner. Instead, they opt for rapid recourse to ART, using it as the standard therapy for both sexes, in the form of in vitro fertilization (IVF) alone for the female factor, and in combination with intracytoplasmic sperm injection (ICSI) to address both male and female factors. Some peer-reviewed medical literature has argued in support of this practice, maintaining that the efficiency,

From: Current Clinical Urology: Male Infertility: Problems and Solutions, Edited by: E.S. Sabanegh, DOI: 10.1007/978-1-60761-193-6_14,  Springer Science+Business Media, LLC 2011

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Chubak and Thomas Table 1. Some ethical issues in male infertility. Adequate evaluation of the infertile male Donor insemination Economic inequities in care Excessive use of IVF-ICSI Pediatric oncofertility Posthumous reproduction Postmortem sperm retrieval Property interest in banked sperm Reproduction by patient without capacity Responsibility for banked sperm Sex selection of child Truth telling and respecting confidentiality

safety, and success of IVF-ICSI are reason enough to limit the evaluation of the male member of an infertile couple and encourage the use of this advanced form of ART (Nicopoullos et al. 2004; Tournaye 2006). Patients may accept ART for the treatment of their infertility out of desperation, particularly if their reproductive potential is time-limited by advancing female age, and IVF-ICSI may provide the most rapid relief of their anxieties. As the most advanced reproductive technology currently available, its use reinforces for patients that their concerns are taken seriously and that “everything is being done.” It offers the possibility of pregnancy in the presence of male factor infertility that may or may not be amenable to other interventions. In addition, as IVF is the foundation of a multibillion-dollar industry, some may have additional incentive to recommend this technology. While there is nothing fundamentally wrong with a doctor providing his patients with the most expeditious means to establish the pregnancies they long for, any consideration of the benefits of treatment must be balanced with the measure of associated harms. Specific harm to the male partner may follow from the recommendation of IVF/ICSI without first evaluating him adequately, with a careful history, physical examination, and appropriate laboratory evaluation. In the absence of these studies, one might readily overlook a potentially correctable cause for the infertility, or perhaps, of greater consequence, identify a serious medical condition (e.g., testis tumor, genetic abnormality, etc.) which if unrecognized, may result in greater harm to the male or to their offspring. Failure to seek out relevant male factors limits a patient’s ability to make an informed, autonomous choice of intervention, and requires him to act, perhaps unjustly, transferring the burdens of treatment for his own medical problem onto his female partner and child, both of whom bear the brunt of the risks associated with IVF-ICSI.

Posthumous Sperm Retrieval Anecdotal evidence suggests that since the first reported case of posthumous insemination in 1980, most have been associated with patients who chose to bank sperm in order to have children in the aftermath of gonadotoxic chemotherapy (Bahadur 2002). More ethically controversial are the cases in which a man suddenly dies and his female partner/spouse or other medical decision maker requests the removal of sperm from his body, to be used for the purpose of conception at some future date. Controversy arises from the ways in which posthumous sperm retrieval (PSR) and posthumous reproduction cast doubt upon the meaning of such fundamental concepts as life and death, parenthood, and bodily integrity. Equally contested is the degree to which PSR may be compared to the widely accepted practice of posthumous organ donation, given the difference between solid organs, which can prolong life, and gametes, which can create it. Because PSR necessarily involves a number of individuals, it is helpful to identify all of the stakeholders. These include the man who died; his relatives who may or may not include a spouse, parent or sibling; a female partner; the doctors who are asked to do the sperm retrieval, and later, an insemination or IVF/ICSI; and finally, society as a whole, which has an interest in the maintenance of established roles and relationships. Ethics requires enumerating the benefits and burdens of the action to be taken, which may not always be clear-cut (Bahadur 2002; Strong et  al. 2000). For example, the extraction of sperm from a man without his prior consent may be considered a violation of his autonomy and a desecration of his corpse; but it may also be that once dead, a man has no meaningful autonomy or interest in what happens to his body. Even if one were to accept PSR as an ethically appropriate act, it does not necessarily follow that sperm, thus obtained, should be used to conceive a child which the deceased had never intended. The posthumous extraction of sperm and the potential for use in reproduction is particularly problematic from an ethical viewpoint when the subject of PSR is a minor who has never thought of becoming a father, and therefore has no lifetime interest in paternity. Adding to the complexity of PSR is the question of the underlying motivation of the requester and the degree to which this motive influences the ethics of the case. The request for extraction of sperm from a

Ethical Dilemmas in Male Infertility

minor usually comes from his parents, who ­wishing to preserve some vestige of their son through the birth of his child may have expectations that are unrealistic and even harmful to any resulting newborn. Similarly, a female partner may request PSR in a desperate attempt to retain some physical connection with the deceased. This desire for connection and continuity is a natural part of the grieving process, which may be accommodated by requiring a “grieving period” of at least 6 months before the saved sperm may be used (Batzer et  al. 2003). Given this time, many women choose not to use the sperm obtained via PSR for reproductive purposes (Bahadur 1996). Legal systems in many countries have grappled with whether to allow PSR. In the USA, PSR and ART may be performed without a man’s prior consent, but states that have passed the Uniform Parentage Act (UPA) will only recognize a dead man as father of the resulting child if he gave recorded consent to that reproductive process while still living (National Conference of Commissioners on Uniform State Laws 2009). In contrast, in the UK, postmortem retrieval, storage, and the use of sperm for conception are only permitted with the man’s prior written consent. Germany, Sweden, and Canada all prohibit PSR outright, while France and Western Australia permit sperm retrieval but forbid the use of that sperm for posthumous insemination. A recent court case in Israel, which ruled that PSR was permissible even when a man did not agree to it during his life (Oren and Bewley 2009), generated so much controversy that the military has begun to encourage young men to document advance directives regarding PSR before beginning their mandatory service (Personal communication from Efrat Hakak). These differences in opinion between states suggest that while it is important to consider legal issues when faced with a request for PSR, its legal status is inadequate as a guide to appropriate ethical decision making. Guidelines published by the American Society for Reproductive Medicine (ASRM) are also of limited utility, advising that requests for PSR “need not be honored” but “should be answered within the context of individual circumstances and applicable state laws” (Ethics Commitee of the ASRM 2004). Ultimately, with PSR as with other ethical dilemmas in medicine, answers to the questions of what to do and how to act are best found not in the law or in social norms, but in one’s conscience, guided by the basic bioethical principles of autonomy, beneficience, nonmaleficence, and justice.

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Donor Insemination For most infertility treatments, a fundamental basis of fatherhood is assumed to be the use of a man’s sperm to conceive his genetically related progeny. This privileging of biological fatherhood was part of the inspiration for the development of ICSI, which makes it possible for men with very poor quality sperm to become biological fathers. ICSI is not a panacea for otherwise treatment-resistant male infertility, and sometimes, recourse to the use of donor sperm is offered as an option, using either vaginal, intrauterine insemination (IUI), or IVF. Donor insemination (DI) has been part of medical practice since the 1940s, but time has done little to resolve the ethical dilemmas associated with DI, dilemmas that can also arise with the use of IVF-ICSI and PSR. For the earliest DI, doctors encouraged men to seek out the related donors and mixed donor and patient sperm, so as to still offer the possibility, however illusory, of biologic fatherhood. Today, the example of adoption practices and concerns about the maintenance of family relationships have led to a preference for unrelated donors and an increased enthusiasm for openness about DI (Daniels et  al. 1995). Recent studies advise parents and practitioners that children born from DI should be told about the method of their conception when they are able to understand it, but despite such recommendations, parents tend to avoid telling their children about being conceived via DI (Maron et  al. 2009). Studies of the secrecy that shrouds the use of donor sperm show that it is motivated primarily by the recipients’ interest in protecting the male partner, whose virility and status as a father, might be compromised if their children, friends, or family learned that they used DI to conceive (Czyba and Chevret 1979; Jadva et al. 2009). A further concern is the protection of the child, who might be upset to learn that his father is genetically unrelated to him (Daniels et al. 1995; Jadva et al. 2009). In the context of infertility care that includes IVF-ICSI and PSR, with their genetic definitions of fatherhood, these are concerns that should be taken seriously. Truth-telling is fundamental to the ethical practice of medicine. Doctors may be ethically conflicted about respecting the choice of the infertile couple to keep their use of DI from their child, knowing that in the future, the child may experience psychological or somatic harm as a consequence of this decision. The real possibility of such harm was recently made clear by the case of an apparently healthy sperm donor who

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transmitted a novel b-myosin heavy-chain mutation causative of hypertrophic cardiomyopathy to his many offspring (Maron et  al. 2009). Children who never learn about the DI may potentially suffer medical problems which might have been avoided, had they known of their paternal biological families’ medical histories. Children who learn of their conception by DI later in life are more likely to suffer anger and damage to their relationships with their nurturing parents (Cook et al. 1995). Discussion regarding the pros and cons of telling a child of his biologic beginnings should take place, but ultimately, the decision whether to tell the truth about DI must be made by both nurturing parents. When discussing all aspects of DI with patients, frank and open discussion with both members of the couple is absolutely imperative. Physicians and other members of the healthcare team need to be cognizant of the potential for coercion of one partner by the other, or of both members of the couple by outside influences. Threats or even marital dissolution, if one member of the couple does not agree to the use of donor sperm to conceive, are inconsistent with the maintenance of a healthy relationship for the couple and the resultant child.

Conclusion Ethics relates to those moral ideas and ideals that we most value as individuals, members of communities, and as a society. The ethical dilemmas that can occur in the practice of reproductive medicine are emotionally and intellectually challenging, as well as wideranging in their impact. Donor insemination, PSR, IVF-ICSI, and other interventions related to the diagnosis and treatment of infertility all share the potential to alter patients’ family roles and gendered sense of self, both of which are foundational to personal identity and values. Underlying all interventions to treat infertility is a judgment: that it is worth risking the compromise of these important identities and values in order for a couple to bear a desired child. Therefore, when providing patients with infertility care, doctors exercise extraordinary power to reinforce or to change social norms about fatherhood, for their individual patients and for the groups that their patients are a part of. More than any new technologies or rise in disease prevalence, it is out of deference to this power

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that doctors must be both conscious and conscientious about the ethical practice of male infertility care.

References G Bahadur, “Posthumous Assisted Reproduction: Cancer Patients, Potential Cases, Counselling and Consent,” Human Reproduction 1996;11(12):2573–2575. G Bahadur, “Death and Conception,” Human Reproduction 2002;17(10):2769–2778. A Balen, Infertility in Practice, 3rd ed. London: Informa Healthcare, 2008. FR Batzer, JM Hurwitz, and A Caplan, “Postmortem Parenthood and the Need for a Protocol With Posthumous Sperm Procurement,” Fertility and Sterility 2003;79(6): 1263–1269. TL Beauchamp and JF Childress, Principles of Biomedical Ethics, 5th ed. Oxford: Oxford University Press, 2001. R Cook, et  al., “Disclosure of Donor Insemination: Parental Attitudes,” American Journal of Orthopsychiatry 1995; 65(4): 549–559. JC Czyba and M Chevret, “Psychological Reactions of Couples to Artificial Insemination with Donor Sperm,” International Journal of Fertility 1979;24(4):240–245. KR Daniels, GM Lewis, and W Gillett, “Telling Donor Insemination Offspring About Their Conception: The Nature of Couples’ Decision-Making,” Social Science and Medicine 1995;40(9):1213–1220. Ethics Commitee of the ASRM (American Society for Repro­ ductive Medicine), “Posthumous reproduction,” Fertility and Sterility 2004;82(suppl 1):S260–S262 V Jadva, et  al., “The Experiences of Adolescents and Adults Conceived by Sperm Donation: Comparisons by Age of Disclosure and Family Type,” Human Reproduction 2009; 24(8):1909–1919. B Maron, et al., “Implications of Hypertrophic Cardiomyopathy Transmitted by Sperm Donation,” Journal of the American Medical Association 2009;302(15):1681–1684. National Conference of Commissioners on Uniform State Laws, “Uniform Parentage Act (2000)” Available at http://aals.org. cnchost.com/profdev/family/sampson.pdf (Last accessed August 11, 2009). JD Nicopoullos, et al., “Male-Factor Infertility: Do We Really Need Urologists? A Gynaecological View,” British Journal of Urology International 2004;93(9):1188–1190. O Oren and S Bewley, “Conception After Death: The Ethics of A Mother’s Use of Her Dead Son’s Sperm,” Student British Medical Journal 2009;17:1040. Personal communication from Efrat Hakak, JD, Jerusalem, Israel. C Strong, JR Gingrich, and WH Kutteh, “Ethics of Postmortem Sperm Retrieval: Ethics of Sperm Retrieval After Death or Persistent Vegetative State,” Human Reproduction 2000; 15(4):739–745. H Tournaye, “Evidence-Based Management of Male Subfer­ tility,” Current Opinion in Obstetrics & Gynecology 2006;18: 253–259.

Index

A 5α (alpha)-reductase deficiency, 4 Anabolic-androgenic steroids (AAS), 7 Androgen excess, 83 Antisperm antibodies (ASA), 19 Assisted reproductive technology (ART) challenges and risks, 116 ICSI and cryopreserved spermatozoa, 115–116 success rates, 115 AZF microdeletion, 41, 43 Azoospermia diagnosis, 25–26 ejaculatory dysfunction, 29 evaluation history and physical exam, 23–24 semen analysis, 24 serum hormonal evaluation, 24–25 genetic testing CFTR gene mutation screening, 25 karyotype, 25 Y chromosome microdeletions, 25 non-obstructive causes cancer therapy, 28 HH, 28–29 Klinefelter syndrome (KS), 28 obstructive causes congenital bilateral absence, of vas deferens, 27 ejaculatory duct obstruction (EDO), 27 iatrogenic, 27 semen cryopreservation, 108 sperm harvesting techniques non-obstructive, 102–105 obstructive, 101–102 varicocele, 72 C Clomid challenge test, 58 Clomiphene citrate (CC), 58–59, 71, 82 Computer-aided semen analyzers (CASA), 18 Congenital adrenal hyperplasia (CAH), 4 Congenital bilateral absence of the vas deferens (CBAVD), 27 Cystic fibrosis mutation analysis, 40–41 Cystic fibrosis transmembrane conductance regulator (CFTR), 40

D DI. See Donor insemination Distal tubal occlusion, 59–60 Donor insemination (DI) fatherhood, 127 medicine, ethical practice, 127–128 pros and cons, 128 secrecy, 127 Ductal obstruction, surgical reconstructions anatomy, physiology and pathology, 90 etiology of, 91 reconstructive procedure microscopic vasoepididymostomy, 93–95 modified one-layer vasovasostomy, 92, 93 multi-layer vasovasostomy, 92–94 operative planning, 91–92 outcomes, 95–96 vasovasostomy vs. vasoepididymostomy, 91 E Ejaculatory duct obstruction (EDO), 27 Ejaculatory dysfunction azoospermia, 29 diagnostic and treatment algorithms, 36 evaluation, 33–34 interventions artificial insemination, retrograde ejaculation, 34 electroejaculation (EEJ), 35 medications, 34 penile vibratory stimulation (PVS), 34–35 surgical sperm retrieval, 35 medical management, male infertility, 85–86 neurogenic anejaculation treatment, 37 normal ejaculation, 32 retrograde ejaculation treatment, 37 sperm harvesting, 99–100 sperm retrieval technique, 35–36 types idiopathic anejaculation/anorgasmia, 32 neurogenic anejaculation, 32–33 premature ejaculation (PE), 32 retrograde ejaculation, 33 Electroejaculation (EEJ), 35, 100 Endocrinopathies, male infertility evaluation and testing, 48–49 hypergonadotropic hypogonadism

129

130

Index

Endocrinopathies, male infertility (cont.) gonadal toxicity, 50 Klinefelter syndrome (KS), 50 LH–FSH receptor mutations, 50–51 hyperprolactinemia, 49, 52 Endocrinopathies, male infertility (cont) hypogonadism androgen receptor defects and insensitivity syndromes, 51 congenital adrenal hyperplasia, 51–52 exogenous testosterone therapy, 51 Leydig cell tumors, 52 hypogonadotropic hypogonadism hypothalamus failure, 49 isolated LH/FSH deficiency, 50 pituitary insufficiency, 49 syndromic genetic disorders, 49 treatment of, 52–53 hypothalamic-pituitary-testicular (HPT) axis, 48 Klinefelter syndrome (KS) and, 53 medical management hormonal deficiency, 82 hormonal excess, 83–84 spermatogenesis requirement, 81 Endometriosis, 61 End-to-side vasoepididymostomy, 95 Erectile dysfunction, 86 Estrogen excess, 83 Ethical dilemmas donor insemination fatherhood, 127 medicine, ethical practice, 127–128 secrecy, 127 in vitro fertilization and intracytoplasmic sperm injection (IVF-ICSI), 125–126 PSR complexity of, 126–127 definition, 126 legal issues, 127 F Female fertility endometriosis, 61 evaluation Clomid challenge test, 58 hysterosalpingogram (HSG), 58 infertility evaluation, 57–58 laparoscopy, 57 luteal phase deficiency, 57 ovarian reserve, 58 sonohysterography (SHG), 58 monthly fecundity rate (MFR), 61 ovulatory dysfunction classification, 58 clomiphene citrate (CC) and letrozole, 58–59 laparoscopic ovarian drilling, 59 metformin, 59 superovulation (SO), 59 tubal disease, 59–60 uterine factors

congenital uterine anomalies, 60–61 myomas (fibroids), 60 polyps and adhesions, 60 Follicle-stimulating hormone (FSH), 24, 48 G Genetic issues, male fertility azoospermia CFTR gene mutation screening, 25 karyotype, 25 Y chromosome microdeletions, 25 CF mutations, 43 non-obstructive azoospermic patient, 39–40 results AZF microdeletion, 41, 43 Klinefelter syndrome (KS), 41–42 XX male syndrome, 42–43 severe oligospermia, 39 test cystic fibrosis mutation analysis, 40–41 YCMD assay, 40 XXY Klinefelter syndrome (KS), 43 Gonadotoxic therapy, 109 G-protein-coupled-receptor-54 (GPR54), 8 H HH. See Hypogonadotropic hypogonadism Hodgkins disease, 109 Hypergonadotropic hypogonadism gonadal toxicity, 50 Klinefelter syndrome (KS), 50 LH–FSH receptor mutations, 50–51 Hyperprolactinemia bromocriptine and carbergoline, 84 hypothalamic secretion inhibition, 83–84 serum testing, 83 Hyperthyroidism, 83 Hypogonadism androgen receptor defects and insensitivity syndromes, 51 congenital adrenal hyperplasia, 51–52 exogenous testosterone therapy, 51 Leydig cell tumors, 52 Hypogonadotropic hypogonadism (HH) antiestrogen agent, 82 azoospermia, 28–29 gonadotropin therapy, 82 hormonal deficiency, 82 hypothalamus failure, 49 isolated LH/FSH deficiency, 50 pituitary insufficiency, 49 syndromic genetic disorders, 49 treatment of, 52–53 Hypothalamic-pituitary-testicular (HPT) axis, 48 Hypothyroidism, 82 Hysterosalpingogram (HSG), 58 I Idiopathic anejaculation/anorgasmia, 32 IHH. See Isolated hypogonadotropic hypogonadism

Index 131 Intracytoplasmic sperm injection (ICSI), 115–116. See also In vitro fertilization (IVF) Intrauterine insemination (IUI) density gradient separation, 119–120 outcomes, 120–121 procedure, 120 sperm washing procedure, 119 swim-up technique, 119 Intussusception vasoepididymostomy, 94–96 In vitro fertilization (IVF) azoospermia, 122 ethical dilemmas, 125–126 fertilization rates, 122 methods, 121 overview, 121 Isolated hypogonadotropic hypogonadism (IHH), 4 IUI. See Intrauterine insemination IVF. See In vitro fertilization K Klinefelter syndrome (KS) azoospermia, 28 endocrinopathies, male infertility hypergonadotropic hypogonadism, 50 treatment, 53 genetic issues, 41–43 L Leydig cell tumors, 52 Luteinizing hormone (LH), 48 M Magnetic-activated cell sorting (MACS), 111 Male infertility androgen resistance, 4 cryptorchidism, 4 definition, 1–3 diagnoses, 3 endocrinopathies evaluation and testing, 48–49 hypergonadotropic hypogonadism, 50–51 hyperprolactinemia, 49, 52 hypogonadism, with normal/elevated testosterone, 51–52 hypogonadotropic hypogonadism, 49–50, 52–53 hypothalamic-pituitary-testicular (HPT) axis, 48 Klinefelter syndrome (KS) and, 53 ethical dilemmas donor insemination, 127–128 in vitro fertilization and intracytoplasmic sperm injection (IVF-ICSI), 125–126 PSR, 126–127 history, 2 IHH, 4 infection history, 4–5 medical history cancer treatment, 6–7 cystic fibrosis (CF), 5 hypogonadism, 5 Klinefelter syndrome (KS), 5

medical management ejaculatory dysfunction, 85–86 endocrinopathies, 81–84 erectile dysfunction, 86 infection and inflammation, 84 medications, 6, 8, 86 physical examination hormone imbalance, 8 rectal examination, 8 testicular size, 8 sexual history conception chance, 3 ejaculatory obstruction, 3–4 lubricants, 3 social cause alcohol intake, 7 anabolic-androgenic steroids (AAS), 7 surgical history, 7 varicocele, 70 Metformin, 59 Microsurgical epididymal sperm aspiration (MESA), 102, 103 Micro-surgical TESE (mTESE), 104–105 N Neurogenic anejaculation diabetes mellitus, 33 retroperitoneal lymph node dissection (RPLND), 33 spinal cord injury (SCI), 32–33 O Ovulatory dysfunction classification, 58 clomiphene citrate (CC) and letrozole, 58–59 laparoscopic ovarian drilling, 59 metformin, 59 superovulation (SO), 59 P Penile vibratory stimulation (PVS), 34–35 Percutaneous embolization, 72 Percutaneous epididymal sperm aspiration (PESA), 101, 102, 108 Polycystic ovarian syndrome (PCOS), 59 Posthumous sperm retrieval (PSR) complexity of, 126–127 definition, 126 legal issues, 127 Premature ejaculation (PE), 32 Prolactin, 48 PSR. See Posthumous sperm retrieval R Reactive oxygen species (ROS), 18, 20 Rectal probe electrostimulation technique, 100 Retrograde ejaculation (RE), 33, 37, 99–100 Retroperitoneal lymph node dissection (RPLND), 33

132

Index

S Semen analysis antisperm antibodies (ASA), 19 azoospermia evaluation, 24 DNA integrity assessment, 20 Semen analysis (cont.) function tests, 19 macroscopic parameters, 16 microscopic parameters, 16–17 oxidative stress evaluation, 20 sperm concentration, 17 morphology, 17–18 motility, 17 motion kinetics, 18 non-sperm cellular components, 18 WHO manuals procedures, 15–16 Semen cryopreservation advantages and disadvantages glycerol, 113 TEST-yolk buffer, 114 assisted reproductive technology (ART) challenges and risks, 116 ICSI and cryopreserved spermatozoa, 115–116 success rates, 115 definition, 107 need for cancer patients, 109–110 couples, 108 patients preventing factors financial impact, 110 personal preferences, 110 physicians failure, 110 physician awareness and responsibility, 107–108 on sperm characteristics mean post-thaw recovery rate, 114 pentoxifylline, 115 post-thaw motility, 114–115 semen storage duration, 114 techniques overview, 110 preparation and preselection, 111 rapid freezing, 111 slow freezing, 111–113 uses, 108 Semen parameters, varicocelectomy controlled trials, 73 factors, 72 pregnancy rate, 73 quality improvement, 72 studies, 72 Sertoli cells, 68 Sonohysterography (SHG), 58 Spermatozoa, 66 Sperm harvesting techniques ejaculatory dysfunction, 99–100 non-obstructive azoospermia fine needle aspiration with mapping, 103 open testicular sperm extraction, 103–105 testicular sperm extraction, 102–103 testicular tissue samples processing, 105

obstructive azoospermia microsurgical epididymal sperm aspiration, 102, 103 percutaneous sperm retrieval techniques, 101–102 rectal probe electrostimulation, 100 Sperm, semen analysis concentration, 17 DNA integrity assessment, 20 function tests, 19 morphology, 17–18 motility, 17 motion kinetics, 18 non-sperm cellular components, 18 Spinal cord injury (SCI), neurogenic anejaculation, 32–33 Subinguinal varicocelectomy, 72 Superovulation (SO), 59 Surgical reconstructive procedure microscopic vasoepididymostomy, 93–95 modified one-layer vasovasostomy, 92, 93 multi-layer vasovasostomy, 92–94 operative planning, 91–92 outcomes, 95–96 vasovasostomy vs. vasoepididymostomy, 91 T Testicular fine needle aspiration (TFNA), 101 Testicular sperm extraction (TESE), 108 V Varicocele adolescent males testicular hypotrophy, 74 varicocelectomy, 73 azoospermia, 72 blood flow, 67 clinical treatment, 71 diagnosis, 70–71 etiology, 67 incidence, 66–67 male infertility conventional semen parameters, 70 influence, 70 testicular atrophy, 70 pathophysiology causes, 68 scrotal hyperthermia, 68 seminal reactive oxygen species, 69–70 Sertoli cells, 68 spermatic vein reflux, 68 semen parameters, varicocelectomy controlled trials, 73 factors, 72 pregnancy rate, 73 quality improvement, 72 studies, 72 subclinical varicocele, 71 surgery benefit

Index 133 fertilization, 74 guidelines, 75 surgical vs. embolization, 71–72 Vasoepididymostomy (VE), ductal obstruction, 91 Vasovasostomy (VV) modified one-layer, 92, 93 multi-layer, 92–94

operative planning, 91–92 vs. vasoepididymostomy (VE), 91 Vitrification, 113 Y Y chromosome microdeletion (YCMD), 25, 40