AMERICAN UROLOGICAL ASSOCIATION 93rd ANNUAL MEETING, MAY 30-JUNE4, 1998
SAN DIEGO, CALIFORNIA
In the couple with male factor infertility due to varicocele and with partner greater than age 35 there appears to be a benefit in pregnancy rates after varicocelectomy, even when those couple undergo IVF. The overall pregnancy rate for surgically treated group of patients (varicocelectomy and varicocelectomy with subsequent IVF/ICSI) was 60% ( Megerman E., McCullough AR)
Total motile sperm count increases after varicocele repair, but larger varicocele size was associated with significantly greater improvement. Strict morphology improvement did not seem to correlate with the size of varicocele. ( Snyder OB, Sandlow JI et al.)
Varicocele repair in subfertile male improves strict morphology by primarily improving head defects. Since the head of sperm is crucial to egg and sperm interaction, this decrease in head defects may be partially responsible for increase in pregnancy rates after varicocele repair ( Schatte EC, Kim ED et al.)
Varicocelectomy in patients with severe oligoastenoteratozoospermia or azoospermia has been previously reported to improve spermatogenesis and pregnancy rates. It was found to be possible in patients with such testicular biopsy patterns as maturation arrest or hypospermatogenesis. The efficacy of varicocele repair in patients with Sertoli-cell only pattern remain unclear. (Darby E., Gallo S. et al.)
In patients with bilateral (large left and small right) varicocele bilateral varicocelectomy resulted in mean increase of sperm concentration of 104.2% compare to 44.8% in unilateral (left) varicocelectomy. The increase in fertility index was 99.5% versus 42.5% respectively. It was suggested that men with bilateral palpable varicocele require bilateral repair. ( Scherr D., Goldstein M.)
Forty eight out of 114(42.1%) patients with left varicocele were found to have subclinical right varicocele by color Doppler ultrasound. Prospective randomized study of two groups with bilateral varicocelectomy (group 1) and only left varicocelectomy (group 2) revealed pregnancy rates after 1 year 42.9% and 23.5% respectively. The sperm count was significantly improved in group 1. It was suggested that subclinical varicocele have some effect on spermatogenesis (Okuno H.,Schichiri Y. et al.).
Varicocelectomy was found to be a reasonable therapeutic alternative to ICSI in men 45 years old or older, 56% of whom presented with secondary infertility. Natural pregnancy may occur in 20% of these men. ICSI may be less effective in this group because of usually older ages of the wives. ( Murphy DP., Glazier DB., Marmar JL.)
Varicocelectomy results in a decrease in maximal internal spermatic vein diameter as assessed by postoperative ultrasonography although it does not predict seminal improvement. (Noss MB., Papanikolaou F. et al.)
Percutaneous embolization was not effective in grade III varicocele with oligospermia. Nearly half of patient with grade III varicocele showed a significant improvement in semen morphology with surgical vaicocelectomy (Maillette A., Thabet M.).
Epididymal tubules were identified as having "spermatic motion" as possible marker of epididymal blockages using 10 MHz ultrasound transducers. Spermatic motion was seen in the epididymal head/corpus in 15/21(71%) and correlated with clinical findings of epididymal induration in 76.2% of patients. This may be clinically useful in cases of suspected epididymal obstruction to advice patients regarding microsurgical reconstruction vs. MESA. (Friedman W., Choi K. et al.)
Of 185 patients with spermatogenic failure, Y chromosomal deletions were found in 21 men (11.4%), karyotypic abnormalities- in 7%. Genetic testing should be offered to all males with severe spermatogenic deficiency. This critical information allows them to make an informed decision as to their plans for possible pregnancy. ( LaSalle MD., Chan A. et al.)
Blood level of testosterone decreased after multiple testicular biopsies performed for testicular sperm extraction in patients with non-obstructive azoospermia for about 1 year It may represent normal recovery period. (Manning M.,Junemann KP et al.)
A particular type of Y-chromosome microdeletion in patients with non-obstructive azoospermia may predict the absence of sperm with testicular sperm extraction. The deletion of AZFb region was found to be a significant adverse prognostic factor for sperm retrieval. These data may help in counceling patients prior to TESE (Brandell RA., Mielnik A., Liotta D, et al.).
Couples with male factor infertility and only isolated abnormal sperm morphology by strict criteria (<4%) considering IVF should be advice to undergo ICSI. ICSI results in better fertilization rate, although difference in pregnancy rates has not been assessed in this study (Hirshberg SJ., Fallick ML et al.)
No significant difference was found in fertilization rate, pregnancy rate per patient and pregnancy rate per cycle when comparing fresh and frozen testicular sperm obtained by TESE. These results suggest potential benefit of testicular sperm cryopreservation during reconstructive and diagnostic procedures (Seo R., Niederberger CS. et al.)
16the WORLD CONGRESS ON FERTILITY AND STERILITY AND 54the ANNUAL MEETING OF THE AMERICAN SOCIETY FOR REPRODUCTIVE MEDICINE, San Francisco, 1998
Patient requesting vasectomy reversal after vasectomy are generally younger (20-29 years), with employed wife. This group of patients should receive thorough counseling about other birth control options, sperm banking before vasectomy, high cost of vasectomy reversal and results of reversal surgery ( Pasqualotto, Agarwal, Thomas, Potts)
A testicular tumor was identified in 5 of 2145 patient presenting to a tertiary infertility clinic, which is higher than the incidence of testicular tumor for age-matched population in the area. All male patients of infertile couple are suggested to have thorough urological evaluation to identify possible significant medical pathology ( Logarakis, Bedard, Zini, Buckspan, Jarvi)
Prospective review of 6 pregnancies and seven children arising from ICSI with sperm from azoospermic (TESE-ICSI) or severely oligospermic (ICSI) men with diagnosed Y-chromosome deletions revealed that de novo Y-chromosome deletions do not prevent the delivery of normal offspring. Y-chromosome deletions were transmitted to the male offspring of these azoospermic or oligospermic men. One boy was found to have severe tricuspid and pulmonary atresia, which, probably is not related to the Y chromosome deletions ( Silber, Brown, Alagappan, Pooler, Page)
38% of patients with ejaculatory duct obstruction were found to have secondary epididymal obstruction. TRUS-guided aspiration of seminal vesicles is recommended before transurethral resection of ejaculatory ducts. Absence of sperm in the aspirated fluid is suspicious of concurrent epididymal obstruction. These patients should be treated with microsurgical vasoepididymostomy at the time of TURED ( Fallick, Tripp, Jaffe, Lipshultz)
Testicular sperm retrieval was successfully performed in patients with azoospermia of different etiology and different testicular histology including normal spermatogenesis, hypospermatogenesis, Sertoli cell only, maturation arrest and fibrosis. Testicular sperm retrieval was recommended for men with azoospermia regardless of the etiology or testicular histology ( Madgar, Seidman et al)
Fine needle biopsy mapping of the testis was used to establish which anatomical areas of the testis contain more sperm than others. Retrospective analysis revealed no such predominant areas in patients with non-obstructive or obstructive azoospermia, which may guide local sperm retrieval ( Turek, Cha, Ljung)
Spermatozoa retrieved from epdidiymis or testicle were found to give similar fertilization rates as spermatozoa from ejaculate in 207 ICSI cycles performed between 1993 and 1997. No malformations were observed in 55 babies born after ICSI with epididymal and testicular sperm. ( Lejeune, Vanderzwalmen, Nijs et al.)
The pregnancy rate for vasectomy reversal exceeds the clinical pregnancy rate for one cycle of sperm retrieval/ICSI in couples with obstructive azoospermia for all post-vasectomy obstructive intervals up to 15 years. Vasectomy reversal, therefore, may be a cheaper and better choice for couples with 0-14 years after vasectomy. Age of the female partner is the important factor and, if greater than 38, should prompt to perform sperm retrieval/ICSI rather than vasectomy reversal ( Sharlip)
Retrospective analysis of semen analysis data from 1996-1998 revealed significant variation in sperm count and motile count, which were higher during cooler months ( Centola)
AMERICAN SOCIETY FOR REPRODUCTIVE MEDICINE AND CANADIAN FERTILITY AND ANDROLOGY SOCIETY
September 25-30, 1999
S.E.Smith, J.R.Richard et al. Fertilization, pregnancy and implantation rates are similar between fresh and frozen epididymal IVF/ICSI cycles. Therefore, if a fresh IVF/ICSI cycle is not an option, epididymal sperm can be cryopreserved and used at a later date with similar IVF outcome.
Aboulghar M.A., Mansour R.T. et al. A prospective study of 206 babies born after ICSI revealed that incidence of multiple pregnancy and premature delivery is comparable to that in general population. The incidence of chromosomal abnormalities (4.8%0 was higher than in general, population (0.5%)
Pang M.G., Hoegerman S.F. et al. Males with severe oligoasthenoteratozoospermia donating sperm for ICSI are at risk of transmitting genetic abnormalities to their offspring. There was significant increase in aneuploidy rate and total cytogenetic abnormalities in sperm from 54 patients with oligoasthenoteratozoospermia (33-74% vs. 3.9-9% in normal fertile control)
Silverberg K.M., Ormand R.A.et al. Clomiphene citrate improved sperm quality and fertility in hypogonadal and oligospermic males. Sperm motility, concentration as well as FSH, LH and testosterone concentration rose significantly. There was no significant increase in normal sperm morphology. 14 of 24 couples conceived while in treatment
Esteves S.C. and Nakazato L.T. Subinguinal Microsurgical varicocele repair improved strict sperm morphology and increased unassisted pregnancy rate, mostly in patients with profound morphology abnormalities.
Lass A., Akagbosu F. et al. Men with malignant disease generally have a reduced sperm quality at the time of diagnosis of their illness. Non-seminomatous germ cell tumors of the testis and Hodgkin lymphoma affect sperm quality more than any other types of cancer.
Hariprashad J., Schlegel P.N. et al. Evaluation of 200 testicular spermatozoa (TESE), 5115 epididymal spermatozoa (MESA) and 12132 ejaculated spermatozoa (control) revealed higher rate of chromosomal abnormalities in nonobstructive azoospermia (13.6%) and obstructive azoospermia (1.5%) compare to control group (0.7%). Patients with obstructive and nonobstructive azoospermia should receive appropriate counseling and adequate screening of the resulting pregnancies.
Pasqualotto F.F., Kobayashi H. et al. Patients with primary infertility may be at higher risk for testicular tumors. They need to be thoroughly investigated to rule out any other serious illness along with infertility
Nudell D.M., Lee D.M. et al. Embryo quality does not appear to be compromised by the source of aspirated sperm (epididymal or testicular) in male factor IVF/ICSI cases
Teloken C, Badalotti M. et al. Statistically significant decrease in sperm motility by sildenafil (Viagra) was demonstrated in vitro. There was no significant impact on sperm viability. Further studies are warranted to evaluate the effect of sildenafil on sperm membrane integrity.
Daitch J.A., Pasqualotto E.B. et al. Varicocele obliteration may not improve semen parameters in all men. Review of the medical records of patients with varicocele who underwent varicocele repair with subsequent intrauterine insemination (group I) and patients with untreated varicocele (group II) revealed higher pregnancy and live birth rates in group I (11.3% Vs 4.2% and 11.3% vs. 2.1%)
Agarwal A., Pasqualotto F.F. et al. Retrospective study of 19 patients with different cancer who cryopreserved their sperm and performed IVF, IVF/IVCI and IUI. Fertilization and pregnancy rates were not different irrespective of the tumor type. Oncologist should advise sperm cryopreservation to their patients before cancer treatment.
Meng M.V., Turek P.J. Although patients with Congenital bilateral absence of the vas deferens are assumed to have normal spermatogenesis and infertility simply from obstruction, cases with impaired sperm production were found, If testis is atrophic, testicular biopsy and testicular sperm extraction may be the only option for sperm retrieval.
Carillo A.J., Risch P.P. TESA samples obtained from men with obstructive azoospermia develop marked improvement in motility after 1-2 days in vitro incubation. Scheduling of TESA 1-2 days prior to the oocyte retrieval reduces time required to find and retrieve sperm because motility is more vigorous.
Silber S.J., Alagappan R. et al. The size and location of the Y chromosome deletion may predict the presence or absence of sperm but not a testicular histology. Deletions involving AZFa were unusual and caused Sertoli cell only
Onel E., Niederberger C.S., Ross L.S. Diagnostic testicular biopsy combined with sperm retrieval and cryopreservation is cost-effective in patients with nonobstructive azoospermia. Single procedure may decrease emotional stress, scheduling difficulties and testicular risk
Sofikitis N., Mio Y et al. Human spermatogonia transplanted into animal seminiferous tubules can complete meiosis and differentiate up to the spermatozoon stage. Human spermatozoa generated within animal seminiferous tubules have capacity to expose forward motility after epididymal passage. Rat or mouse Sertoli cells can regulate human spermatogenesis. Rat or mouse epididymis can induce human sperm maturation process. It may serve as unique mode of treatment for non-obstructive azoospermia patients with premeiotic block in spermatogenesis.
Hariprashad J, Tsai M.C. et al. The presence of antisperm antibodies has no deleterious effect on thew fertilization or pregnancy rates in procedures involving ICSI. Neither type nor location of the immunoglobulins on the sperm cell appeared has predictive value regarding the outcome. ICSI should be considered as a treatment of choice when dealing with immunological factor infertility.
Sandlow J I., Westefeld J.S. et al. Most men contemplated vasectomy less than 1 year prior to scheduling an appointment. Their decision was supported by their partners who often helped with the decision-making process. The Major source of anxiety is fear of pain bout 50% of men were unaware of the possibility of vasectomy reversal. The pre-vasectomy counseling is needed, particularly in the area of postoperative expectations and reversibility.