1 Male Infertility

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MALE INFERTILITY

Yefim R. Sheynkin, M.D.

I. Brief anatomy and physiology of male reproductie system

In order to properly understand the causes and treatment of male

infertility it is essential to appreciate thenormal anatomy and physiology

of male reproduction. Human male reproductive systemincludes hypothalamic-pituitary-testis ais,

the epididymis, vas deferens, seminal

vesicles, prostate and urethra. !roduction ofspermato"oa re#uires approimately $

months from the initial mitotic division. %he

testis is composed primarily of seminiferoustu&ules packed closely together '()* of

testicular volume+, and interstitial cells.

ach tu&ule is $- cm long and /-$

microns in diameter. %here areapproimately ) tu&ules per testis %he

cells 0ithin the seminiferous tu&ules are

germ cells that mature into spermato"oa,and Sertoli cells that serve as supporting

cells for developing germ cells. Sertoli cells

create a &lood-testis &arrier, and separate thegerminal epithelium into &asal and

adluminal compartments. %he ma1or cell in

the interstitial space outside the

seminiferous tu&ule is the

2eydig cell, 0hich producestestosterone, a necessary

component for germ cellmaturation. Spermatogenic

development involves &oth

mitotic and meiotic divisions ofgerm cells. %he mature

spermato"oon is released into

the tu&ule lumen.It is approimately 3 microns

in length. %he head consists of

1

!ead

Midpiece

Tail

Mitochondria

A"oneme

#entral sheath

Microtu$ule

dou$lets % &'()

#entral pair of

microtu$ules

Acrosome*lasma mem$rane

Nucleus


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the condensed nucleus, the acrosome, mem&rane-&ound organelle that contains the en"ymes

re#uired for penetration of the egg prior to fertili"ation.

%he tail consists of a middle piece containing mitochondria, the principal piece, and an endpiece. Sperm form the seminiferous tu&ule enter the efferent ducts connecting the testis to the

caput epididymis. %he epididymis is a single duct / meters in length, and is divided

anatomically into caput 'head+, corpus '&ody+, and cauda 'tail+. pididymis serves as spermconduit and sperm reservoir 0here sperm ac#uire motility and fertili"ing capacity. %he vas

deferens then transports sperm into the pelvis, 0here it 1oins the seminal vesicles to form thee1aculatory ducts, 0hich enter the prostatic urethra.

4ust prior to e1aculation, the testes are &rought close to the a&domen and fluid is rapidlytransported through the vas deferens to the e1aculatory duct and su&se#uently into the prostatic

urethra.

II.EN+,#RIN,L,-Y ,F MALE RE*R,+#TI,N.

!ulsatile hypothalamic release of 56RH stimulates the secretion of 7SH and 2H &y anterior

pituitary. %hese hormones then act at the level of the testis. 2H stimulating testosterone

production &y the 2eydig cells, and 7SH acting on the Sertoli cell to support spermatogenesis.

Serum testosterone and inhi&in ' Sertoli-cell product+ do0nregulate 2H and 7SH secretion vianegative feed&ack loop.

III. Male Factor Infertility

Infertility is defined as a couple8s ina&ility to achieve pregnancy follo0ing one year ofunprotected intercourse. It has &een estimated that 9)-/* of couples attempting to achieve

pregnancy are una&le to do so. : male factor is contri&utory in more than )* of couples

presenting for fertility evaluation. Sperm form the seminiferous tu&ule enter the efferent ductsconnecting the testis to the caput epididymis.

2

%herefore, a thorough evaluation of mal

partner should &e pursued as strongly as female evaluation at the same time. It ha

&een sho0n that the longer couple

remains infertile, the 0orse their chancefor an effective treatment. Initial

screening of the male partner should &e

considered 0henever patient presents 0itchief complaint of infertility regardless of

length of infertility valuation of the

infertile man should include completehistory/ detailed physical e"amination

-erm cells 0ertoli cells Leydig cells

F0!L!*rolactin

0permatogenesis

0e" accessory glandsInhi$in

T

E1

%2) %')

%')

%2)3

%2)

%2)

#orte"Neurotransmitters

-nR! !ypothalamus

*ituitary


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and pertinent la$oratory tests. ;se of detailed 4uestionnairefacilitates the accumulation of

necessary information. %he male reproductive history often helps to eplain a&normal semen

analysis and direct further treatment.

!I0T,RY

(. Fertility history. !roper evaluation &egins 0ith a comprehensive

fertility #uestionnaire. %he age of the partners, detailed history of couple8s

length of infertility, prior pregnancies, miscarriages and a&ortions must &e

ascertained. :ny previous evaluation or treatment should &e noted.

1. 0e"ual history. %oo fre#uent intercourse or compulsive mastur&ation depletes

sperm reserve. Most effective fre#uency of intercourse is every ryptorchidism' (* of men attending an infertility clinic+?progressive and irreversi&le

loss of germ cells. )* of men 0ith a history of unilateral and (* of men 0ith &ilateralcryptorchidism are su&fertile. Ho0ever, paternity 0as documented in =* of men 0ith a

history of unilateral and $)* 0ith a history of &ilateral cryptorchidism. %he effect ofearly' &efore 9 year of life+ corrective surgery is not clear and may not preserve spermatogenicepithelium.

!repu&ertal mumps does not affect testes 0hile postpu&ertal mumps orchitis may cause

severe spermatogenic disorders and testicular atrophy.

Hernia@hydrocele repair? ./* of men 0ith o&structive a"oospermia attending aninfertility clinic 0as found to have iatrogenic in1uries to the vas deferens.

:dolescence

3

89:59:

19:

INFERTILITY

(9: of other;ise healthy men are infertile

,ne in eery < couples in the .nited 0tates is infertile


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%esticular torsion@trauma? !atients 0ith unilateral torsion may &e at risk for contralateral

testicular damage. %he etiology of the contralateral damage is thought to &e immunologically

mediated.

:dult

Many systemic diseases directly or indirectly affect fertility. 1aculatory disorders are

common in patients 0ith dia&etes mellitus, multiple sclerosis, transverse myelitis and spinalcord in1uries. !atients 0ith testicular cancer have impaired pretreatment testicular function and

also are at risk of infertility secondary to various surgical, chemotherapeutic and AR%treatment strategies due to destruction of spermatogonia. Men 0ho under0ent retroperitoneal

lymph nodes dissection are at risk of e1aculatory failure due to damage of sympathetic chain

overlying aortic &ifurcation. :ny recent fe&rile illness may cause significant, &ut usually transient, damage to

spermato"oa. %herefore semen analysis should &e repeated in at least $ months.

%he history should include detailed revie0 of medications and eposure to environmentalgonadotoins. Medications that affect spermatogenesis include cimetidine, ketocona"ole,

spironolactone,dilantin, caffeine, sulfasala"ine, colchicine, allopurinol, calcium channel

&lockers. Mari1uana, heroin, cocaine, alcohol, nicotine sho0ed Spermatotoic effect.%he use of ana&olic steroids &y athletes suppresses gonadal function &y depressing pituitaryoutput of 2H and 7SH through feed&ack inhi&ition. %he usual results are severe oligospermia

or a"oospermia, 0hich is usually, &ut not al0ays, reversi&le after discontinuation of steroids.

*!Y0I#AL E=AM

!hysical eamination is performed in a ;arm room $y an e"aminer ;ith ;arm2

gloed handssince contraction of dartos muscle induced &y lo0 temperature makes

eamination of scrotal contents difficult. !hysical eamination &egins 0ith thorough

o&servation of the general status and &ody ha&itus of the patient as 0ell as secondary secharacteristics. Incomplete masculini"ation 0ith disproportional long etremities due to

deficient androgen stimulation re#uired for epiphyseal closure at time of pu&erty often

indicates Bleinfelter8s syndrome.%he thyroid is palpated and heart and lungs auscultated. %he &reasts are o&served and

palpated for gynecomastia ' may &e associated 0ith estrogen secreting testicular tumors,

adrenal tumor and liver disease+. 5alactorrhea may &e associated 0ith prolactin-secretingpituitary adenoma. !alpation and percussion of a&domen then performed.

!enis and urethral meatus are eamined for condylomata, discharge, position of the

meatus' hypospadia+ Scrotal eamination is first performed 0ith patient supine. %his allo0s varicocele, if

present to collapse. : large varicocele that does not collapse 0arrants a search fora&dominal mass.

Normal testesare firm, a&out ongenital &ilateral a&sence of the vas deferens 0as o&served in 9.$*

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of men presenting for infertility evaluation. %his condition is associated 0ith renal agenesis

and a&normalities in /* of patients, therefore renal sonogram should &e o&tained. Men

0ith this condition may test positive for cystic fi&rosis gene mutation.

>aricocelemay &e graded in severity as follo0s?

5rade I? present only 0ith Calsalva 5rade II? present 0ithout Calsalva

5rade III? visi&le through the skin ' &ag of 0orms +

Digital rectal eamination is al0ays performed for evaluation of the prostate for masses,cysts, irregularities. Stool should &e tested for occult &lood.

N+ER0TAN+IN- 0EMEN ANALY0I0

0ource >olume #haracteristics

rethral and$ul$ourethral glands

9.(29.1cc >iscous/ clear

Testes/ epididymides/asa

deferentia

9.(29.1cc 0perm present

*rostate 9.82(.9cc Acidic/;atery

0eminal esicles (.925.9cc Al?aline/gelatinous/

fructose positie

#omplete e6aculate 1.928.9cc Li4uefies in 19218min

0emen analysis is not a test for fertility. 7ertility determination is a couple-related

phenomenon that re#uires the initiation of a pregnancy. !atient cannot &e declare fertile&ased only on normal semen analysis. It 0as sho0n that $* of all patients 0ith normal

semen analysis have a&normal sperm function .Semen specimen are o&tained &y mastur&ation into a sterile 0ide-mouth container after

/-) days of a&stinence and analy"ed 0ithin 9 hour of collection. %ypically t0oe semen

analyses are o&tained over 9 months period prior to making any final conclusion regarding

&aseline sperm #uality or #uantity.

0emen analysis@ #ommonly used normal parameters

>,LME 1.9 MLp! .12.C

#,N#ENTRATI,N 19"(9IABILITY 89:

M,R*!,L,-Y 59: IT! N,RMAL M,R*!,L,-Y

B# ("(9


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+efinitions?

Azoospermia: no sperm

Oligospermia: low sperm concentration Aspermia no ejaculate

Asthenospermia: low motility

Teratospermia: poor morphology

Normal e6aculate olumeis &et0een / and 3 ml. 3)*of the volume is from seminalvesicles, $-$)* is from the prostate and only )* from the vasa. 6ormal semen pH is ./-=..

!rostatic secretion is acidic 0hile seminal vesicle fluid is alkaline' seminal fructose derivedfrom seminal vesicles+. :"oospermia 0ith lo0 e1aculate volume , fructose negative and acidic

may imply o&struction of the e1aculatory ducts. pH over =. may indicate infection

#oncentration? a"oospermic specimen contains no sperm, oligoseprmic specimen reveals

concentration of less than /93@ml and normospermic specimen contains more than

/93@ml.

Motility and for;ard progression? normally E)* of sperm in the specimen are motile.

7or0ard progression descri&es ho0 fast the motile sperm are moving' normal /F in the scalefrom to ompared to somatic cells, sperm

contain an unusually high percentage of polyunsaturated fatty acids in their mem&ranes. %his,

ho0ever, is an essential prere#uisite for normal sperm mem&rane function, &ut makes sperm inparticular suscepti&le for oidation &y reactive oygen species 'RS+, 0hich cause lipid

peroidation. In etreme cases this might result in a dramatic loss of normal sperm function orimpaired mem&rane integrity , thus indicating decreased fertili"ing capa&ility of spermato"oa.

idative damage to spermato"oa is closely correlated 0ith inflammatory processes in thegenital tract and occurrence of leukocytes that generate at least 9 times more RS than

spermato"oa themselves. Several authors revealed that $-


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antioidants may &e a&le to tolerate greater concentrations of seminal leukocytes. Despite an

apparently a&normal threshold level for leukocytes 0ithin the semen, a 0ide range of

conflicting evidence still eists as to the significance of seminal leukocytes, normal num&er ofJ> and infertility

+NA integrity

D6: fragmentation is closely related to fertili"ation D6: fragmentation can &e measured&y different methods including %;62 assay, S>SI ' Sperm >hromatin Structure :ssay+ or

7ISH assays. D6: fragmentation inde ' D7I+ assessed as * sperm 0ith fragmentedD6:' &y S>SI+ indicates ?

KcellentL fertility potential if 9)* K5oodL fertility potential if 9)-/(.(*

K!oorL fertility potential if E$*

It seems that patients that have a treatment 0ith assisted reproductive technologies, especially

0ith I>SI, have a significantly higher risk that sperm 0ith fragmented D6: fertili"e an oocyte

that may lead to em&ryo death and higher rate of miscarriage.Ho0ever, high D7I inde does not preclude a normal full-time pregnancy. %here is still noa&solute cut-off point for S>S: that 0ill preclude success for natural pregnancy or for

IC7@I>SI

Fructose? 7ructose is androgen-dependent and is produced in the seminal vesicles. 7ructose

levels should &e determined in any patient 0ith a"oospermia and especially in those 0hose

e1aculate volume is less than 9 ml, suggesting seminal vesicle o&struction or atresia. :&senceof fructose, lo0 semen volume, and failure of the semen to coagulate indicate either congenital

a&sence of the vas deferens and seminal vesicles or o&struction of the e1aculatory duct.

Additional ealuation includes :ntisperm :nti&odies testing and advanced sperm functiontests ' Sperm !enetration :ssay, Hemi"ona :ssay, test for acrosome reaction e.t.c+

Endocrine ealuation.

ndocrine evaluation includes measurement of serum testosterone, follicle-stimulatinghormone'7SH+, luteini"ing hormone'2H+ and prolactin.

Testosteroneis good measure of 2eydig cells function.F0! &inds to Sertoli cells and stimulates #uantitatively normal spermatogenesis . 7SH

crudely reflects the status of seminiferous epithelium .:mong men presenting 0itha"oospermia, serum 7SH level that is greater than t0ice the upper limit of normal is

suggestive of intrinsic testicular failure..

L!is stimulatory to the 2eydig cells and testosterone production.

*rolactinlevel should &e o&tained in patients 0ith a history of galactorrhea, visual changes

and @or lo0 levels of testosterone, 7SH,2H levels. !rolactin is produced &y the cells of the

anterior pituitary. levated serum prolactin represents a pathological state that may indicate asignificant underlying pituitary a&normality contri&uting to male reproductive failure. %he

ma1ority of men 0ith elevated serum prolactin levels 0ill also manifest decreased serum

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testosterone. Significant elevation of prolactin may result from prolactin secreting pituitary

macroadenoma and 0hich re#uires head >% or MRI for the diagnosis.

Estradiol levels should &e o&tained in patients 0ith gynecomastia or in patients 0ith signs offemini"ation.

Thyroid diseasemay rarely result in infertility ',.)* of infertile men+, &ut this is usually

associated 0ith uncontrolled hypo-or hyperthyroidism

F0! L! T +iagnosis E"ample

!igh !igh Lo; !ypergonadotropic

!ypogonadism

GlinefelterHs

syndrome

Lo; Lo; Lo; !ypogonadotropic

hypogonadism

GallmannHs

syndrome

I>. +iagnostic procedures

Diagnostic testis $iopsy is indicated in patient 0ith a"oospermia or severe oligospermia,

normal testicular volume and consistency, palpa&le vas deferens and normal serum 7SHin

order to differentiate o&structive from non-o&structive a"oospermia. pen &ilateral &iopsy is

the safe techni#ue and performed through &ilateral 9-cm transverse scrotal incision, a0ay fromthe epididymis.%esticular &lood supply consists of internal spermatic artery'from a&dominalaorta+, deferential artery'from internal iliac or superior vesical artery+ and cremasteric artery

'from inferior epigastric artery+. Jiopsy incision is recommended in the upper medial and

lateral surfaces of the testis 0ith fe0er arteries in these areas. Incision is carried do0n totunica al&uginea. :fter opening of the tunica al&uginea the etruded tu&ules are cut 0ith sharp

iris scissors and immediately deposited into B,INs solution. NE>ER 0E F,RMALIN.If testis &iopsy revealed normal spermatogenesis in patient 0ith a"oospermia, o&struction of

the epididymis, vas deferens or e1aculatory duct should &e suspected. %estis &iopsy in patients

0ith nono&structive a"oospermia may reveal different histological patterns including Sertoli-

cell only, maturation arrest, hypospermatogenesis.

Recently diagnostic testicular &iopsy is mostly performed together 0ith therapeutic testis &iopsy

' sperm retrieval and cryopreservation + and not necessarily as a separate procedure

>asographyis radiological procedure, 0hich is used to evaluate patency of the vas deferens. Itshould &e performed ,NLYat the time of planned reconstruction. %he vas deferens is

approached via scrotal incision, hemitransected and cannulated 0ith /) gauge angiocath sheath

. Diluted 0ater-solu&le contrast media instilled for formal vasography and A-ray performed.

Casography site has to &e closed microsurgically.

Transrectal ltrasound %TR0)@ %he principal application of %R;S in infertile men is to

evaluate the patency of distal ecurrent duct system of the male genitalia. %he prostate, seminalvesicles, ampulla of the vas deferens may &e easily visuali"ed &y transrectal ultarsonography.

%R;S is indicated in patients 0ith a"oospermia, normal testicular si"e, normal 7SH and lo0

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#entromere

AJFa

AJF$

AJFc

0RY

AJF region containing +AJ

The Y2#hromosome and Male Infertility

AJF region containing +AJ

e1aculate volume in 0hom o&structive etiology of a"oospermia is suspected. Dilated seminal

vesicles' E9.) cm 0ide+ may &e aspirated and fluid eamined microscopically. !resence of

sperm confirms o&struction of the e1aculatory ducts and the a&sence of epididymalo&struction.

>.-ENETI# ,F MALE INFERTILITY

Specific genetic a&normalities are associated 0ith a"oospermia@severe oligospermia in men

A. #ystic fi$rosis gene mutations. >ongenital &ilateral a&sence of the vas deferens '>J:CD+ isfound in 9-/* of the infertile male population, and J:CD 0ill have one ormore cystic fi&rosis gene mutations detecta&le. >onversely, ()* of men 0ith cystic fi&rosis

manifest infertility due to &ilaterally a&sent vasa. In addition, up to


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spermatogenesis. 6on-o&structive a"oospermia or poor sperm production may occur 0hen this

gene is deleted.verall prevalence of Y chromosome microdeletions - =* '9*-$)*+. D:Ogene 'Deleted in :"oospermia+ 0as found to &e a&sent in 9$* of a"oospermic men. D:O gene0as proposed as a candidate gene for :O7. %hree relatively discreet regions of Y# 'AJFa/ AJF$/

and AJFc+ 0ere found to &e deleted in non-o&structive a"oospermia and severe oligospermia.:particular type of Y-chromosome microdeletion in patients 0ith non-o&structive a"oospermiamay predict the a&sence of sperm 0ith testicular sperm etraction.AJFa and AJF$

microdeletions have &een associated 0ith more severe testicular changes inclduing Sertoli cell-only and spermatogenic arrest and less chances in finding sperm. AJFcmicrodeletions have

&een associated 0ith less testicular changes and higher success in sperm retrieval. Since Y-chromosome a&normalities are passed on to any offspring produced &y assisted

reproduction, these offspring are at risk of infertility. Since the fathers are usually other0ise

healthy, the presence of ma1or medical illness transmitted 0ith Y-chromosome microdeletionsappears unlikely. Ho0ever, the ans0er to this #uestion may &e delayed for years 0hen children

&orn from assisted reproduction gro0 up.

All men ;ith aKoospermia or seere oligospermia should $e tested ;ith ?aryotype

analysis / #ystic Fi$rosis % $oth partners) and Y2chromosome microdeletions ealuation

prior to the application of I>FDI#0I. *atients ;ith diagnosed genetic a$normalities must

hae detailed genetic counseling.

TREATMENT ,F MALE INFERTILITY

I. 0pecific treatment @ Identifia$le causes

% e.g. ,$struction/ >aricocele/E6aculatory dysfunction

Endocrinopathy/ Infection)

II. Empirical Medical treatment @ Idiopathic Infertility

III. Assisted reproduction technologies@ 0perm retrieal

>aricocele

Caricocele is the most common identifia&le and treata&le cause for male factor infertility.It is an a&normal dilatation of veins that drain the testis. Caricocele is found in 9)* of men

in general population &ut in a&out $)* of men &eing evaluated for infertility.

Caricocele has &een sho0n to affect all seminal parameters ' sperm concentration, motilityand morphology+ , sperm function, testicular si"e and histology. : varicocele may also cause

progressive testicular dysfunction over time, 0hich is more dramatic than the small changes

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epected &y aging alone. Some studies indicate adverse effect of varicocele in

hormonal' mainly testosterone+ production.

%he pathophysiology of varicocele remains unclear, although the most likely mechanism ispro&a&ly elevation of scrotal temperature.

!atients 0ith larger varicocele eperience significantly greater seminal improvement

postoperatively. Recent studies also confirmed the effect of su&linical varicocele repair onpregnancy rates .

2imited controlled randomi"ed studies sho0ed improvement in seminal parameters and

pregnancy rates after surgical repair of the varicocele compare to control group.

Author *atients *regnancy rate

-oldstein/ (&&1/(&& 0urgery

#ontrol

75:

(:

Marmar/ (&&7 0urgery

#ontrol

5ARI#,#ELE RE*AIR

I. !ersistent a&normalities in count, motility or morphology

II. Decreased testicular si"e ' /* and more+III. Scrotal discomfort@pain

%he &est method for diagnosing a varicocele is a good physical eamination in standing

position.. :dditional tests are helpful in certain e#uivocal clinical situations and include

Doppler sonography, venography, thermopgraphy and radionuclide scrotal scan.

:ll these methods are not a gold standard and have a high range of false-positive and false

negative results.%he goal of treatment is to o&struct the refluing venous drainage to the testis 0hile

maintaining arterial inflo0 and lymphatic drainage.

Techni4ues of >aricocelectomy

Techni4ue Artery

presered

!ydrocele Failure *otential for

serious

mor$idity

Retroperitoneal No : (8218: NoInguinal No 5259: 82(8: No

Laparoscopic Yes (1: 382(8: Yes

Radiographic

em$oliKation

Yes 9: (8218: Yes

Microscopic

su$inguinal

Yes 9: (: No

7or each couple, the relative risks and &enefits of varicocelectomy must &e 0eighed against

alternative treatment 0ith assisted reproductive techni#ues' I;I, I7C, IC7@I>SI+

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AKoospermia

&structive 6ono&structive

Epididymis

>as deferens

E6aculatory ducts

0permatogenic failure

Retrograde E6aculation

'I>SI+, treatment of most men 0ith a"oospermia can no0 &e considered, even if the a"oospermia

is caused &y testicular failure. !rior to initiating treatment for a couple in 0hom the man hasa"oospermia, it is important to distinguish 0hether the lack of sperm in the e1aculate is from an

o&structive or non-o&structive process.

,$structie aKoospermiamay &e congenital '>J:CD- >ongenital :&sence of the CasDeferens,+ or ac#uired' infection, stricture, vasectomy+ , repara&le or nonrepara&le.

&struction of the ecurrent duct system may occur at any level from efferent ductules to

e1aculatory duct. :&sence of sperm should &e confirmed &y centrifugation of semen specimen.&structive a"oospermia is suggested in patients 0ith normal testicular volume, full

epididymis and normal hormonal studies. 6et step is testicular &iopsy, 0hich should confirm

the presence of normal spermatogenesis.>ongenital a&sence of the vas deferens in most of thecases may &e diagnosed &y physical eam and testicular &iopsy is not indicated. 1aculatory

duct o&struction is suspicious in men 0ith lo0 volume ' less than 9 cc+ or a&sent e1aculate,

negative fructose test, acidic semen pH, normal 7SH and normal testicular volume .%ransrectal ultrasound may confirm dilatation of seminal vesicles ' .9.) cm+ or midline

prostatic cyst.

hen a diagnosis of o&structive a"oospermia is esta&lished, a 0ide variety of treatment

options may &e considered &efore an optimal treatment option is determined for an individualcouple8s situation. %reatment options include microsurgical reconstruction 'vasovasostomy

and vasoepididymostomy+, transurethral resection of the e1aculatory ducts '%;RD+ and

assisted reproductive technologies ':R%+. Sperm retrieval 0ith :R% 'IC7-I>SI+ is thetreatment of choice for men 0ith reproductive tract o&struction 0hen restoration of genital tract

continuity is not possi&le or associated 0ith etremely lo0 success rates 'congenital anomalies,

severe loss of vasal length, failed multiple reconstructive procedures, female factors re#uiring

assisted reproduction+. :lthough sperm retrieval techni#ues may &e universally applied to anypatient 0ith o&structive a"oospermia, :R% may not &e advisa&le 0hen specific, more cost-

effective treatment is availa&le.

%he principles of microsurgical reconstruction are to approimate healthy tissue,maintain a good &lood supply 0ithout tension on the anastomosis, using accurate mucosa to

mucosa approimation.Microsurgical asoasostomy %>>) is performed to correct

repara&le o&struction of the vas deferens.

12

2ittle more than a decade ago,patients 0ith a"oospermia 0ere

often una&le to &e successfully

treated. Since the introduction ofintracytoplasmic sperm in1ection


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>asoepididymostomy%>E)is indicated for cases of

epididymal o&struction. !resently most common thechni#ue is

microsurgical end-to side invagination' triangulation or < pointinvagination 0ith longitudinal or transverse incision of the

epididymal tu&ule+. : microsurgical approach is necessary to

allo0 accurate approimation of the vasal mucosa to that of a

single epididymal tu&ule. Casoepididymostomy is a complemicrosurgical procedure re#uiring significant eperience to

achieve optimal results. It should only &e undertaken &y

surgeons 0ith epertise in this techni#ue.

!atency rates follo0ing CC and C are (* and 3-*

respectively 0hen motile sperm are found. Ho0ever, pu&lishedpregnancy rates range from )-* after vasovasostomy and only /-SI. :ll of these procedures may &e performed undergeneral or local anesthesia.

TFNA. Testicular Fine Needle Aspiration involves placing a //-gauge needle into the testis.

Significant negative pressure is applied 0ith a 7ran"en needle holder and the needle is passed

in and out the testicle in order to disrupt the seminiferous tu&ules. %his procedure should &eperformed using a single puncture of the tunica al&uginea to minimi"e the risk of in1ury to

testicular vessels under the tunica al&uginea. Several ad1acent regions of the testis may &e

sampled through a single needle hole.*TNB% *ercutaneous testis needle $iopsy). %his is

a minimally invasive small &iopsy that is rapid,

simple and easy to learn. e use a 9


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syringe is inserted into the caput epididymis and 0ithdra0n gently until fluid is seen entering

the tu&ing of the aspiration set. %he procedure is repeated until ade#uate amounts of

epididymal fluid 0ith motile sperm are retrieved.

ME0A% Microsurgical epididymal sperm aspiration). Microsurgical epididymal sperm

aspiration involves a linear incision in the epididymal tunic and se#uentially puncturing

individual epididymal tu&ules under an operating microscope at 9-/) po0er. : siliconi"edglass micropipet attached to an aspiration device consisting of a 9 cc glass syringe and a 9 cc

plastic tu&erculin syringe may &e used. Microliter #uantities of epididymal fluid pass into themicropipet, through the silastic tu&ing and the plastic syringe. Se#uentially more proimal

punctures 0ere performed until optimal sperm #uality 'motility+ 0as o&served. MS: is anopen surgical procedure that re#uires microsurgical eperience &ut it allo0s sperm retrieval

from over ((* of men 0ith o&structive a"oospermia, even if etensive scarring is present from

multiple prior scrotal procedures. MS: also allo0s retrieval of an ade#uate num&er andmotility of sperm to relia&ly cryopreserve sperm for su&se#uent fertility attempts.

!ercutaneous procedures are less invasive and do not re#uire microsurgical skill.

Ho0ever, sperm are not relia&ly retrieved from the epididymis using percutaneous approaches,and sufficient sperm num&er and #uality are also not typically o&tained from the testis for

cryopreservation. %he pregnancy rates achieved after retrieval of testicular spermato"oa 0ith

I>SI have ranged from /* to )*. !regnancy rates 0ith percutaneous epididymal spermretrieval or MS:-I>SI have ranged from /


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preserved. It commonly seen in patients 0ith dia&etes. Diagnosis re#uires poste1aculate urine

analysis 0hich reveals high sperm concentration

+rug +ose

*seudoephedrine hydrochloride hang %SB? %he testis, epididymis,and ductus deferens, in !hysiology of

Male reproduction, >hapter alsh et al.,eds. >amp&ell8s;rology, Seventh

dition, .J.Saunders >o., !hiladelphia, !:, 9((5. Sigman M? 2a&oratory testing in the evaluation of male infertility. orld 4 ;rol

9(($P99?(3

7. orld Health organi"ation 'H+ Manual for amination of Human Semen and Semen-

>ervical Mucus Interaction.9((/, >am&ridge, ngland?>am&ridge ;niversity !ress

8. !olansky, 7.7., 2am&, .4.? Do the Results of Semen analysis !redict 7uture 7ertilityQ :

Survival analysis. 7ertil Steril 9(==Plin 6orth :m 9(=P9


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4. ;rol 9(=(P9


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/

5. Hopps >C, 5oldstein M, Schlegel !6.%he diagnosis and treatment of the a"oospermic

patient in the age of intracytoplasmic sperm in1ection. ;rol >lin 6orth :m. //6ovP/('lin 6orth

:m. /$ 7e&P$'9+?9ell ndocrinol. // 4an /)P9=3'/+?93$-.

79. ood S, 2e0is-4ones I, %roup S, Desmond :, Bingsland >.Surgical sperm retrieval? arevie0 of current practice. Hum 7ertil '>am&+. // 7e&P)'9+?9-//

7(. Marmar 42 %he pathophysiology of varicoceles in the light of current molecular andgenetic information. Hum Reprod ;pdate. /9 Sep-ctP')+?lin ndocrinolMeta&. / 4unP9

1 Male Infertility

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