Speciality
Spotlight

 




 

Urology


 

 




Infertility

   

  • JF Jr Donovan, M DiBause, AET Sparks, et al [ Univ of lowa City]


    Comparison of Microscopic Epididymal Sperm Aspiration and Intracytoplasmic Sperm Injection / In-vitro fertilization With repeat Microscopic Reconstruction Following Vasectomy : Is second Attempt Vas Reversal Worth the Effort ?


    Hum Reprod 13: 387-393, 1998

       


    conclusion – The effect of ICSI on the treatment of infertility in men with congenital absence of the vas deferens is profound. As efficacy rates increase and costs decline, the use of epididymal or testicular sperm retrieval may become the treatment of choice in men with obstructive azospermia.However, microsurgical reconstruction is currently the most appropriate approach for obstruction of the excurrent duct system, even in men who have failed previous
    vasovasostomy.

       

  • Madgar I, A Hourvitz, J Levron et al [ Tel Aviv Univ, Isreal; assuta Med Ctr, Tel Aviv, Israel]


    Outcome of In vitro fertilization and Intracytoplasmic Injection of Epididymal and Testicular Sperm Extracted from Patients with Obstructive and Nonobstructive Azoospermia


    Fertil Steril 69: 1080-1084, 1998

      


    Methods – 63 patients [103 cycles] with obstructive azoospermia underwent epididymal or testicular sperm retrieval [group 1], and 60 [75 cycles] with nonobstructive azoospermia underwent testicular sperm retrieval combined with in vitro fertilization treatment [group 2].

      


    Findings – Fertilization rates were 48.4% 41.5% in groups 1 & 2 respectively, a nonsignificant difference.

      


    The clinical pregnancy rates per embryo transfer cycle were 24% in group 1 and 17.7% in group 2. Oocyte fertilization rates with fresh and frozen thawed spermatozoa were 23.6% and 14.3% respectively and did not differ significantly between groups.

      

  • Rucker GB, Mielnik A, King P, et al [ New York Hosp-Cornell Med Ctr; Polulation Council New York]


    Preoperative Screening for Genetic Abnormalities in Men With Nonobstructive Azoospermia Before Testicular Sperm Extraction 


    J Urol 160: 2068-2971, 1998

      


    Results – There were 33 of 190 men [17%] with genetic abnormalities.

      


    21% had 9% had Y chromosomal partial deletion. Before testicular sperm extraction, genetic counseling was conducted in 32 men.

      


    In 21% of couples in which the man had a genetic abnormality, knowledge of the specific genetic detect resulted in a change of clinical management.

      


    In men with non obstructive azoospermia who are candidates for testicular sperm extraction with intracytoplasmic sperm injection, preoperative genetic screening is important. 

      

  • Bettocchi C, Parkinson MC, Ralph DJ, et al [Univ of Bari, Italy; Univ College London]


    Clinical Aspects Associated with Sertoli-Cell-Only Histology


    Br J Urol 82: 534-537, 1998

      


    Conclusions- sertoli cell only syndrome presents with varying phenotypes with or without Y-chromosomal microdeletions. 

      


    The likelyhood of sperm recovery with testicular sperm extraction in SCO is about 30%.

      


    It is advisable to perform concurrent testicular sperm extraction with cryopresevation at the time of diagnostic tests biopsy to identify those men in whom in vitro fertilization/intractoplasmic sperm injection may be feasible.

      

  • Zavos PM, Correa JR, Karagounis CS, et al [ Andrology Inst of Lexington, Ky; Univ of Salonika, Greece; Univ of Kentucky, Lexington]


    An Electron Microscope Study of the Axonemal Ultrastructure in Human Spermatozoa from Male Smokers and Nonsmokers


    Fertil steril 69: 430-434, 1998

      


    Conclusions – Compared with nonsmokers, smokers had changes in the number and arrangement of axonemal microtubules. The incidence of axonemal abnormalities was greater in spermatozoa from smokers than from nomsmokers.

      

  • Zavos PM, Correa JR, Antypas S, et al [ Andrology Inst of Lexington, Ky; Children’s Hosp “Ayia Sofia” , Athens, Greece, Greek-American Andrology Inst of Athens, Greece]


    Effects of Seminal Plasma from Cigarette Smokers on Sperm Viability and Longevity


    Fertil Steril 69: 425-429, 1998

      

    Findings – The quality of spermatozoa from non smokers was higher than that from smokers. The seminal plasma from the 2 groups had clear effect on the respective sperm quality. Beneficial for non-smokers and detrimental for non-smokers.

      


    Exposing spermatozoa from non-smokers to seminal plasma of smokers significantly decreased sperm viability.

      


    Exposing spermatozoa from smokers to seminal plasma of non smoker significantly improved sperm viability.

      

  • GJ Matthews, ED Mattews, M Goldstein [New York Hosp-cornell Med Ctr]


    Induction of Spermatogenesis and Achievement of Azoospermia and Severe Oilgoasthenospermia


    Fertil Steril 70: 71-75; 1998 

      

    After vaicocele repair, 55% of the 22 men with azoospermia and 69% of the 51 men with no motile sperm before surgery had motile sperm in their ejaculate. The mean total number of motile sperm per ejaculate rose from 0.08 x 106 before varicocelectomy to 7.2 x 106 afterward.

      


    Conclusions – 31% of men with azoospermia or severe oligoasthenospermia should be considered for varicocele repair. In most men in this series, treatment resulted in induction or enhancement of spermatogenesis. Unassisted pregnancies after varicocele repair are, apparently, not possible when men have profound abnormalities of spermatogenesis. 

      

  • R Munkelwitz, BR Gilbert, [ State Univ of New York at Stony Brook]


    Are Boxer Shorts Really Better ? A Critical Analysis of the Role of Underwear Type in Male Subfertility


    J Urol 160: 1329-1333, 1998

      


    Conclusion – The hyperthermic effect of brief style underwear has been exaggerated. 

      


    Underwear type does not affect scrotal temperature. It is unlikely that male fertility is affected by underwear type. 

      


    Available scientific evidence does not support routinely advising infertility patients to wear boxer shorts.

      

  • TM Jaffe, ED Kim, TH Hoekstra, et al [ Baylor College of Medicine, Houston] 


    Sperm Pellet Analysis : A Technique to Detect the Presence of sperm in Men Considered to Have Azoospermia by routine semen Analysis


    J Urol 159: 1548-1550, 1998

      


    Background – Sperm may be identified after centrifuging semen from men with azoospermia detected by routine semen analyses. These sperm may be used for intracytoplasmic sperm injection. 

      


    Conclusions – Motile and nonmotile sperm were detected in 18.6% of men with obstructive azoospermia and 22.8% with nonobstructive azoospermia.

      


    Multiple sperm pelleting should be performed, especially in those with testicular failure because IVF with intracytoplasmic sperm injection is now widely available.

       

  • Royal College of Obstetrics and Gynaecologists, Clinical Guideline No.4. The Management of Infertility in Tertiary Care

    BJU International, volume 87, Number 1, January 2001, Pg.Nos. 213-217

     

    Recommendations Involving Male Factors In Infertility –



    Intracytoplasmic Sperm Injection –



    Guideline 21- The recognized indications for treatment by IVF and ICSI include :

    [a] Severe deficits in semen quality in the male partner

    [b] Obstructive azoospermia: and 

    [c] Non-obstructive azoospermia

    In addition, treatment by IVF/ICSI should be considered for couples in whom a previous IVF cycle has resulted in failed or very poor fertilization.



    Guideline 22 – Before considering treatment by ICSI , couples should undergo appropriate investigations, both to establish a diagnosis and to enable informed discussion about the complications of treatment.



    Guideline 23- Relevant genetic issues to be discussed :

    Where a specific genetic defect associated with male infertility is known or suspected [congenital bilateral absence of vas deferens, CBAVD] appropriate genetic counseling and testing should be offered.



    Where the indication for ICSI is severe deficit in semen quality, the male partner’s karyotype must be established.



    Testing for microdeletions in Y-chromosomes should not be considered as a routine investigation before ICSI.



    Guideline 24 – Couples should be given information on the health of offspring born of ICSI. In general, the available data are broadly reassuring on the short- term health of ICSI offspring, but no information available on long-term health. 



    Guideline 25 – A long term longitudinal follow-up of children born after ICSI is important and ideally should be coordinated on a national basis. 



    Guideline 26- Ejaculatory failure may be managed by a variety of techniques ranging from drug therapy to surgical recovery of sperm from the vas deferens. It 

    may be possible to restore fertility with no need for invasive methods of sperm retrieval or the use of assisted conception techniques.



    Guideline 27 – Sperm can be recovered surgically before ICSI using several different techniques depending on the pathology and wishes of the patient.



    Facilities for cryopreservation of spermatozoa should be available.



    Donor Insemination –

    Guideline 28 – Recognized indications for donor insemination include :-

    [a] Severe deficits in the semen quality of the male partner.

    [b] Obstructive azoospermia 

    [c] Unobstructive azoospermia

    [d] Genetic or infectious disease in male partner.

    [e] Severe rhesus isoimmunization.



    Guideline 29 – Equal access should be available to the couple for donor insemination and ICSI at a given centre.



    Guideline 30 – Units undertaking semen donor recruitment and the cryopreservation of spermatozoa for treatment purposes should follow the current guidelines issued by the British Andrology Society describing the selection and screening of donors.



    Guideline 31- Before starting treatment by donor insemination it is important to confirm that the female partner is ovulating. If the female partner has history suggestive to tubal damage, the tubes should be assessed before treatment. In women with no risk history, the tubes should be assessed after 6 cycles of unsuccessful treatment.



    Guideline 32 – [a] Because of the risks of multiple pregnancy, a minimum of 6 cycles of insemination with ovarian stimulation should be carried out in regularly ovulating women. 



    [b] If the anticipated pregnancy rate for intracervical insemination is < 6% per cycle, intrauterine insemination with or without ovarian stimulation should be considered.



    Guideline 33 – The measurement of LH surge is widely used to time intracervical in-semination, pregnancy rates are no better than with other methods of timing. LH surge methods may be beneficial in terms of clinic organization and costs.



    Guideline 34 – After 12 unsuccessful cycles of donor insemination other treatment options should be considered. 

       

  • Berger RE [Univ of Washington, Seattle]

    Triangulation End to Side Vasoepididymostomy

    J Urol 159: 1951-1053, 1998



    3 double-armed 10-zero nylon sutures are placed in the epididymis so that each suture creates 1 side of a triangle. The surgeon then makes an opening in the tubule between the sutures. The sutures are brought inside out invaginating the epididymal tubule into the vas deferens. 



    Conclusion – It represents a significant improvement in surgical technique in the most difficult male infertility operation. After surgery sperm was found in the ejaculate of 92% of patients.

       

  • Hutchon S, Thornton S, Hall J, et al [Nottingham Univ, England; City Hosp, Nottingham, England

    Frozen Thawed Epididymal Sperm is Effective for Intracytoplasmic Sperm Injection: Implications for the Urologist

    Br.J. Urol 81: 607-611, 1998



    In assisted reproduction units the current practice is to obtain sperm and oocytes on the same day to maximize the potential for fertilization. However undergoing surgery on the same day may be problematic for some couples. The pregnancy potential of frozen thawed surgically retrieved epidydimal sperm used with ICSI was investigated



    Twenty thawed sperm samples surgically retrieved and frozen after percutaneous or open aspiration in 19 patients were used for CISI between 1994 and 1997. 



    The fertilization cleavage and pregnancy rates resulting from those cycles were comparable with those of the same couples previous cycles using fresh sperm from the same collection. These rates were also comparable with the overall results of the NURTURE ICSI program. 

       

  • Spandorfer SD, Avrech OM, Colombero LT, et al [The New York Hosp-Cornell Univ]

    Effect of Parental Age on Fertilization and Pregnancy Characteristics in Couples Treated by Intracytoplasmic Sperm Injection

    Hum Reprod 13: 334-338, 1998



    Semen volume showed a significant linear decline with paternal aging, although concentration, motility, and morphology of the spermatozoa were unaffected. 



    The occurrence of digyny increased with parental aging, although there was no difference in single or bipronuclear fertilization. 



    Paternal age did not influence pregnancy outcomes, whereas maternal age did. 



    Advancing paternal age does not appear to affect clinically meaningful semen characteristics. 

       

  • Grimbizis G, Vandervorst M, Camus M, et al [ Dutchspeaking Brussels Free Univ, Belgium]

    Intracytoplasmic Sperm Injection, Results in Women Older Than 39, According to Age and the Number of Embryos Replaced in Selective or Non-Selective Transfers

    Hum Reprod 13: 884-889, 1998



    Background – The outcomes of intracytoplasmic sperm injection [ICSI] in a large cohort of women older than 39 years were reported.



    Findings – Advancing age was associated with a significant gradual decline in the number of embryos available for transfer, the number of good or excellent quality embryos available for transfer, pregnancy rates, clinical pregnancy rates, implantation rates, and viable pregnancy rates.



    No pregnancy occurred in women aged 45 years or older. 



    The rates of pregnancy, clinical pregnancy, implantation, and viable pregnancy significantly, increased gradually from nonselective to selective transfer. 





    Conclusion – Treatment for women aged 45 years or older is not successful. Women with better ovarian response and more embryos available for transfer have a greater chance of conception. 

       

  • Su L-M, Palermo GD, Goldstein M, et al [New York Hosp-Cornell Med Ctr]

    Testicular Sperm Extraction With Intracytoplasmic Sperm Injection for Nonobstructive Azoospermia: Testicular Histology Can Predict Success of Sperm Retrieval

    J Urol 161: 112-116, 1998



    Conclusion – Clinical pregnancies were achieved in 55% of 47 cycles when sperm were retrieved, with ongoing pregnancies or live delivery in 43%. Sperm retrieval was successful in 79% of 19 men with maturation arrest and 24% of 21 men with a pure Sertoli-cell-only pattern.



    A critical examination of the most advanced pattern of spermatogenesis from open biopsy enables clinicians to predict the likelihood of sperm retrieval success with testicular sperm extraction.

       

  • Belker AM, Sherins RJ, Dennison -Lagos L, et al [ Univ. of Louisville, Ky: Genetics and IVF Inst, Fairfax, Va]

    Percutaneous Testicular Sperm Aspiration : A Convenient and Effective Office Procedure to Retrieve Sperm for In Vitro Fertilization With Intracytoplasmic Sperm Injection

    J Urol 160: 2058-2062, 1998



    Introduction- To facilitate the injection process in men with azoospermia, anejaculation, and necrospermia, a technique of percutaneous aspiration of sperm from the testis was developed, based on the success of in vitro fertilization with intracytoplasmic sperm injection using surgically extracted sperm.



    Methods – In all there were 69 testicular aspirations performed for diagnostic purposes and 179 performed to obtain sperm on the day of egg retrieval for couples having in vitro fertilization with intracytoplasmic sperm injection. 



    Results – In all men with obstructive azoospermia – including those with significant testicular atrophy and those with anejaculation or necrospermia – sperm adequate for intracytoplasmic sperm injection was obtained.



    In men with nonobstructive azoospermia, adequate numbers of sperm for intracytoplasmic sperm injection were retrieved less reliably.



    Of 69 men having diagnostic aspiration sperm was obtained in 43 men.



    Of 179 men having therapeutic aspiration sperm was obtained in 170 men.



    Sperm viability ranged from 55% to 85% and sperm motility ranged from 0% to 20%.

       

  • Josebury KA, Edirisinghe WR, Phillips MR, et al [PIVET Med Centre, Leederville, Australia; Curtin Univ of Technology, Australia]

    Evidence That Male Smoking Affects the Likelihood of a Pregnancy Following IVF Treatment: Application of the Modified Cumulative Embryo Score

    Hum Reprod 13: 1506-1513, 1998



    Conclusion – Men’s smoking appears to have a deleterious effect on IVF pregnancy outcomes. These data also provide evidence of an increased risk of reduced ovarian reserve, but not an increased risk of pregnancy loss, among women who smoke.

       

  • Schatte EC, Hirshberg SJ, Fallick ML, et al [ Baylor College of Medicine, Houston]

    Varicocelectomy Improves Sperm Strict Morphology and Motility

    J Urol 160: 1338-1340, 1998



    Results – After varicocelectomy, sperm motility, total number of motile sperm, and percentage and total number of sperm with normal strict morphology were significantly increased.



    There was also an increase in average density.



    There was significant improvement in the percentage of normal head strict morphology, but tail and neck morphology did not reflect similar changes.

       

  • Lemack GE, Uzzo RG, Schlegel PN, et al [ Rockefeller Univ, New York]

    Microsurgical Repair of the Adolescent Varicocele

    J Urol 160: 179-181, 1998



    Bilateral [n=12] or unilateral [n=18] microsurgical varicocelectomy was performed on 30 boys, aged 11-20 years, mainly for size disparity between testicles 2 mL or greater.



    There were no recurrences in patients followed as long as 48 months. A single hydrocele at 2 months resolved at 11 months. Scrotal pain in 1 patient resolved with medication. Treated testes grew on an average of 50.1% more than preoperative size, whereas untreated testes grew significantly less [ an average of 23%]. Testes of boys who had a bilateral procedure grew at a similar rate.



    Conclusion – Microsurgical procedure is associated with less complications.



    However absolute indications for surgery are few in this age group. Pain rarely occurs, fertility is not an immediate concern. Testicular function and atrophy are also rare.




 

  

Speciality Spotlight

 

 
Urology
 

 

Infertility
   

  • JF Jr Donovan, M DiBause, AET Sparks, et al [ Univ of lowa City]
    Comparison of Microscopic Epididymal Sperm Aspiration and Intracytoplasmic Sperm Injection / In-vitro fertilization With repeat Microscopic Reconstruction Following Vasectomy : Is second Attempt Vas Reversal Worth the Effort ?
    Hum Reprod 13: 387-393, 1998
       
    conclusion – The effect of ICSI on the treatment of infertility in men with congenital absence of the vas deferens is profound. As efficacy rates increase and costs decline, the use of epididymal or testicular sperm retrieval may become the treatment of choice in men with obstructive azospermia.However, microsurgical reconstruction is currently the most appropriate approach for obstruction of the excurrent duct system, even in men who have failed previous vasovasostomy.
       

  • Madgar I, A Hourvitz, J Levron et al [ Tel Aviv Univ, Isreal; assuta Med Ctr, Tel Aviv, Israel]
    Outcome of In vitro fertilization and Intracytoplasmic Injection of Epididymal and Testicular Sperm Extracted from Patients with Obstructive and Nonobstructive Azoospermia
    Fertil Steril 69: 1080-1084, 1998
      
    Methods – 63 patients [103 cycles] with obstructive azoospermia underwent epididymal or testicular sperm retrieval [group 1], and 60 [75 cycles] with nonobstructive azoospermia underwent testicular sperm retrieval combined with in vitro fertilization treatment [group 2].
      
    Findings – Fertilization rates were 48.4% 41.5% in groups 1 & 2 respectively, a nonsignificant difference.
      
    The clinical pregnancy rates per embryo transfer cycle were 24% in group 1 and 17.7% in group 2. Oocyte fertilization rates with fresh and frozen thawed spermatozoa were 23.6% and 14.3% respectively and did not differ significantly between groups.
      

  • Rucker GB, Mielnik A, King P, et al [ New York Hosp-Cornell Med Ctr; Polulation Council New York]
    Preoperative Screening for Genetic Abnormalities in Men With Nonobstructive Azoospermia Before Testicular Sperm Extraction 
    J Urol 160: 2068-2971, 1998
      
    Results – There were 33 of 190 men [17%] with genetic abnormalities.
      
    21% had 9% had Y chromosomal partial deletion. Before testicular sperm extraction, genetic counseling was conducted in 32 men.
      
    In 21% of couples in which the man had a genetic abnormality, knowledge of the specific genetic detect resulted in a change of clinical management.
      
    In men with non obstructive azoospermia who are candidates for testicular sperm extraction with intracytoplasmic sperm injection, preoperative genetic screening is important. 
      

  • Bettocchi C, Parkinson MC, Ralph DJ, et al [Univ of Bari, Italy; Univ College London]
    Clinical Aspects Associated with Sertoli-Cell-Only Histology
    Br J Urol 82: 534-537, 1998
      
    Conclusions- sertoli cell only syndrome presents with varying phenotypes with or without Y-chromosomal microdeletions. 
      
    The likelyhood of sperm recovery with testicular sperm extraction in SCO is about 30%.
      
    It is advisable to perform concurrent testicular sperm extraction with cryopresevation at the time of diagnostic tests biopsy to identify those men in whom in vitro fertilization/intractoplasmic sperm injection may be feasible.
      

  • Zavos PM, Correa JR, Karagounis CS, et al [ Andrology Inst of Lexington, Ky; Univ of Salonika, Greece; Univ of Kentucky, Lexington]
    An Electron Microscope Study of the Axonemal Ultrastructure in Human Spermatozoa from Male Smokers and Nonsmokers
    Fertil steril 69: 430-434, 1998
      
    Conclusions – Compared with nonsmokers, smokers had changes in the number and arrangement of axonemal microtubules. The incidence of axonemal abnormalities was greater in spermatozoa from smokers than from nomsmokers.
      

  • Zavos PM, Correa JR, Antypas S, et al [ Andrology Inst of Lexington, Ky; Children’s Hosp “Ayia Sofia” , Athens, Greece, Greek-American Andrology Inst of Athens, Greece]
    Effects of Seminal Plasma from Cigarette Smokers on Sperm Viability and Longevity
    Fertil Steril 69: 425-429, 1998
      
    Findings – The quality of spermatozoa from non smokers was higher than that from smokers. The seminal plasma from the 2 groups had clear effect on the respective sperm quality. Beneficial for non-smokers and detrimental for non-smokers.
      
    Exposing spermatozoa from non-smokers to seminal plasma of smokers significantly decreased sperm viability.
      
    Exposing spermatozoa from smokers to seminal plasma of non smoker significantly improved sperm viability.
      

  • GJ Matthews, ED Mattews, M Goldstein [New York Hosp-cornell Med Ctr]
    Induction of Spermatogenesis and Achievement of Azoospermia and Severe Oilgoasthenospermia
    Fertil Steril 70: 71-75; 1998 
      
    After vaicocele repair, 55% of the 22 men with azoospermia and 69% of the 51 men with no motile sperm before surgery had motile sperm in their ejaculate. The mean total number of motile sperm per ejaculate rose from 0.08 x 106 before varicocelectomy to 7.2 x 106 afterward.
      
    Conclusions – 31% of men with azoospermia or severe oligoasthenospermia should be considered for varicocele repair. In most men in this series, treatment resulted in induction or enhancement of spermatogenesis. Unassisted pregnancies after varicocele repair are, apparently, not possible when men have profound abnormalities of spermatogenesis. 
      

  • R Munkelwitz, BR Gilbert, [ State Univ of New York at Stony Brook]
    Are Boxer Shorts Really Better ? A Critical Analysis of the Role of Underwear Type in Male Subfertility
    J Urol 160: 1329-1333, 1998
      
    Conclusion – The hyperthermic effect of brief style underwear has been exaggerated. 
      
    Underwear type does not affect scrotal temperature. It is unlikely that male fertility is affected by underwear type. 
      
    Available scientific evidence does not support routinely advising infertility patients to wear boxer shorts.
      

  • TM Jaffe, ED Kim, TH Hoekstra, et al [ Baylor College of Medicine, Houston] 
    Sperm Pellet Analysis : A Technique to Detect the Presence of sperm in Men Considered to Have Azoospermia by routine semen Analysis
    J Urol 159: 1548-1550, 1998
      
    Background – Sperm may be identified after centrifuging semen from men with azoospermia detected by routine semen analyses. These sperm may be used for intracytoplasmic sperm injection. 
      
    Conclusions – Motile and nonmotile sperm were detected in 18.6% of men with obstructive azoospermia and 22.8% with nonobstructive azoospermia.
      
    Multiple sperm pelleting should be performed, especially in those with testicular failure because IVF with intracytoplasmic sperm injection is now widely available.
       

  • Royal College of Obstetrics and Gynaecologists, Clinical Guideline No.4. The Management of Infertility in Tertiary Care
    BJU International, volume 87, Number 1, January 2001, Pg.Nos. 213-217
     
    Recommendations Involving Male Factors In Infertility –

    Intracytoplasmic Sperm Injection –

    Guideline 21- The recognized indications for treatment by IVF and ICSI include :
    [a] Severe deficits in semen quality in the male partner
    [b] Obstructive azoospermia: and 
    [c] Non-obstructive azoospermia
    In addition, treatment by IVF/ICSI should be considered for couples in whom a previous IVF cycle has resulted in failed or very poor fertilization.

    Guideline 22 – Before considering treatment by ICSI , couples should undergo appropriate investigations, both to establish a diagnosis and to enable informed discussion about the complications of treatment.

    Guideline 23- Relevant genetic issues to be discussed :
    Where a specific genetic defect associated with male infertility is known or suspected [congenital bilateral absence of vas deferens, CBAVD] appropriate genetic counseling and testing should be offered.

    Where the indication for ICSI is severe deficit in semen quality, the male partner’s karyotype must be established.

    Testing for microdeletions in Y-chromosomes should not be considered as a routine investigation before ICSI.

    Guideline 24 – Couples should be given information on the health of offspring born of ICSI. In general, the available data are broadly reassuring on the short- term health of ICSI offspring, but no information available on long-term health. 

    Guideline 25 – A long term longitudinal follow-up of children born after ICSI is important and ideally should be coordinated on a national basis. 

    Guideline 26- Ejaculatory failure may be managed by a variety of techniques ranging from drug therapy to surgical recovery of sperm from the vas deferens. It 
    may be possible to restore fertility with no need for invasive methods of sperm retrieval or the use of assisted conception techniques.

    Guideline 27 – Sperm can be recovered surgically before ICSI using several different techniques depending on the pathology and wishes of the patient.

    Facilities for cryopreservation of spermatozoa should be available.

    Donor Insemination –
    Guideline 28 – Recognized indications for donor insemination include :-
    [a] Severe deficits in the semen quality of the male partner.
    [b] Obstructive azoospermia 
    [c] Unobstructive azoospermia
    [d] Genetic or infectious disease in male partner.
    [e] Severe rhesus isoimmunization.

    Guideline 29 – Equal access should be available to the couple for donor insemination and ICSI at a given centre.

    Guideline 30 – Units undertaking semen donor recruitment and the cryopreservation of spermatozoa for treatment purposes should follow the current guidelines issued by the British Andrology Society describing the selection and screening of donors.

    Guideline 31- Before starting treatment by donor insemination it is important to confirm that the female partner is ovulating. If the female partner has history suggestive to tubal damage, the tubes should be assessed before treatment. In women with no risk history, the tubes should be assessed after 6 cycles of unsuccessful treatment.

    Guideline 32 – [a] Because of the risks of multiple pregnancy, a minimum of 6 cycles of insemination with ovarian stimulation should be carried out in regularly ovulating women. 

    [b] If the anticipated pregnancy rate for intracervical insemination is < 6% per cycle, intrauterine insemination with or without ovarian stimulation should be considered.

    Guideline 33 – The measurement of LH surge is widely used to time intracervical in-semination, pregnancy rates are no better than with other methods of timing. LH surge methods may be beneficial in terms of clinic organization and costs.

    Guideline 34 – After 12 unsuccessful cycles of donor insemination other treatment options should be considered. 
       

  • Berger RE [Univ of Washington, Seattle]
    Triangulation End to Side Vasoepididymostomy
    J Urol 159: 1951-1053, 1998

    3 double-armed 10-zero nylon sutures are placed in the epididymis so that each suture creates 1 side of a triangle. The surgeon then makes an opening in the tubule between the sutures. The sutures are brought inside out invaginating the epididymal tubule into the vas deferens. 

    Conclusion – It represents a significant improvement in surgical technique in the most difficult male infertility operation. After surgery sperm was found in the ejaculate of 92% of patients.
       

  • Hutchon S, Thornton S, Hall J, et al [Nottingham Univ, England; City Hosp, Nottingham, England
    Frozen Thawed Epididymal Sperm is Effective for Intracytoplasmic Sperm Injection: Implications for the Urologist
    Br.J. Urol 81: 607-611, 1998

    In assisted reproduction units the current practice is to obtain sperm and oocytes on the same day to maximize the potential for fertilization. However undergoing surgery on the same day may be problematic for some couples. The pregnancy potential of frozen thawed surgically retrieved epidydimal sperm used with ICSI was investigated

    Twenty thawed sperm samples surgically retrieved and frozen after percutaneous or open aspiration in 19 patients were used for CISI between 1994 and 1997. 

    The fertilization cleavage and pregnancy rates resulting from those cycles were comparable with those of the same couples previous cycles using fresh sperm from the same collection. These rates were also comparable with the overall results of the NURTURE ICSI program. 
       

  • Spandorfer SD, Avrech OM, Colombero LT, et al [The New York Hosp-Cornell Univ]
    Effect of Parental Age on Fertilization and Pregnancy Characteristics in Couples Treated by Intracytoplasmic Sperm Injection
    Hum Reprod 13: 334-338, 1998

    Semen volume showed a significant linear decline with paternal aging, although concentration, motility, and morphology of the spermatozoa were unaffected. 

    The occurrence of digyny increased with parental aging, although there was no difference in single or bipronuclear fertilization. 

    Paternal age did not influence pregnancy outcomes, whereas maternal age did. 

    Advancing paternal age does not appear to affect clinically meaningful semen characteristics. 
       

  • Grimbizis G, Vandervorst M, Camus M, et al [ Dutchspeaking Brussels Free Univ, Belgium]
    Intracytoplasmic Sperm Injection, Results in Women Older Than 39, According to Age and the Number of Embryos Replaced in Selective or Non-Selective Transfers
    Hum Reprod 13: 884-889, 1998

    Background – The outcomes of intracytoplasmic sperm injection [ICSI] in a large cohort of women older than 39 years were reported.

    Findings – Advancing age was associated with a significant gradual decline in the number of embryos available for transfer, the number of good or excellent quality embryos available for transfer, pregnancy rates, clinical pregnancy rates, implantation rates, and viable pregnancy rates.

    No pregnancy occurred in women aged 45 years or older. 

    The rates of pregnancy, clinical pregnancy, implantation, and viable pregnancy significantly, increased gradually from nonselective to selective transfer. 


    Conclusion – Treatment for women aged 45 years or older is not successful. Women with better ovarian response and more embryos available for transfer have a greater chance of conception. 
       

  • Su L-M, Palermo GD, Goldstein M, et al [New York Hosp-Cornell Med Ctr]
    Testicular Sperm Extraction With Intracytoplasmic Sperm Injection for Nonobstructive Azoospermia: Testicular Histology Can Predict Success of Sperm Retrieval
    J Urol 161: 112-116, 1998

    Conclusion – Clinical pregnancies were achieved in 55% of 47 cycles when sperm were retrieved, with ongoing pregnancies or live delivery in 43%. Sperm retrieval was successful in 79% of 19 men with maturation arrest and 24% of 21 men with a pure Sertoli-cell-only pattern.

    A critical examination of the most advanced pattern of spermatogenesis from open biopsy enables clinicians to predict the likelihood of sperm retrieval success with testicular sperm extraction.
       

  • Belker AM, Sherins RJ, Dennison -Lagos L, et al [ Univ. of Louisville, Ky: Genetics and IVF Inst, Fairfax, Va]
    Percutaneous Testicular Sperm Aspiration : A Convenient and Effective Office Procedure to Retrieve Sperm for In Vitro Fertilization With Intracytoplasmic Sperm Injection
    J Urol 160: 2058-2062, 1998

    Introduction- To facilitate the injection process in men with azoospermia, anejaculation, and necrospermia, a technique of percutaneous aspiration of sperm from the testis was developed, based on the success of in vitro fertilization with intracytoplasmic sperm injection using surgically extracted sperm.

    Methods – In all there were 69 testicular aspirations performed for diagnostic purposes and 179 performed to obtain sperm on the day of egg retrieval for couples having in vitro fertilization with intracytoplasmic sperm injection. 

    Results – In all men with obstructive azoospermia – including those with significant testicular atrophy and those with anejaculation or necrospermia – sperm adequate for intracytoplasmic sperm injection was obtained.

    In men with nonobstructive azoospermia, adequate numbers of sperm for intracytoplasmic sperm injection were retrieved less reliably.

    Of 69 men having diagnostic aspiration sperm was obtained in 43 men.

    Of 179 men having therapeutic aspiration sperm was obtained in 170 men.

    Sperm viability ranged from 55% to 85% and sperm motility ranged from 0% to 20%.
       

  • Josebury KA, Edirisinghe WR, Phillips MR, et al [PIVET Med Centre, Leederville, Australia; Curtin Univ of Technology, Australia]
    Evidence That Male Smoking Affects the Likelihood of a Pregnancy Following IVF Treatment: Application of the Modified Cumulative Embryo Score
    Hum Reprod 13: 1506-1513, 1998

    Conclusion – Men’s smoking appears to have a deleterious effect on IVF pregnancy outcomes. These data also provide evidence of an increased risk of reduced ovarian reserve, but not an increased risk of pregnancy loss, among women who smoke.
       

  • Schatte EC, Hirshberg SJ, Fallick ML, et al [ Baylor College of Medicine, Houston]
    Varicocelectomy Improves Sperm Strict Morphology and Motility
    J Urol 160: 1338-1340, 1998

    Results – After varicocelectomy, sperm motility, total number of motile sperm, and percentage and total number of sperm with normal strict morphology were significantly increased.

    There was also an increase in average density.

    There was significant improvement in the percentage of normal head strict morphology, but tail and neck morphology did not reflect similar changes.
       

  • Lemack GE, Uzzo RG, Schlegel PN, et al [ Rockefeller Univ, New York]
    Microsurgical Repair of the Adolescent Varicocele
    J Urol 160: 179-181, 1998

    Bilateral [n=12] or unilateral [n=18] microsurgical varicocelectomy was performed on 30 boys, aged 11-20 years, mainly for size disparity between testicles 2 mL or greater.

    There were no recurrences in patients followed as long as 48 months. A single hydrocele at 2 months resolved at 11 months. Scrotal pain in 1 patient resolved with medication. Treated testes grew on an average of 50.1% more than preoperative size, whereas untreated testes grew significantly less [ an average of 23%]. Testes of boys who had a bilateral procedure grew at a similar rate.

    Conclusion – Microsurgical procedure is associated with less complications.

    However absolute indications for surgery are few in this age group. Pain rarely occurs, fertility is not an immediate concern. Testicular function and atrophy are also rare.

 

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