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  1. Home
  2. Books
  3. Infertility in the Male
  • Cited by 35
Publisher:
Cambridge University Press
Online publication date:
May 2010
Print publication year:
2009
Online ISBN:
9780511635656
DOI:
https://doi.org/10.1017/CBO9780511635656
Subjects:
Obstetrics and Gynecology, Reproductive Medicine, Medicine
Information

Book description

The new edition of this canonical text on male reproductive medicine will cement the book's market-leading position. Practitioners across many specialties - including urologists, gynecologists, reproductive endocrinologists, medical endocrinologists and many in internal medicine and family practice – will see men with suboptimal fertility and reproductive problems. The book provides an excellent source of timely, well-considered information for those training in this young and rapidly evolving field. While several recent books provide targeted 'cookbooks' for those in a male reproductive laboratory, or quick reference for practising generalists, the modern, comprehensive reference providing both a background for male reproductive medicine as well as clinical practice information based on that foundation has been lacking until now. The book has been extensively revised with a particular focus on modern molecular medicine. Appropriate therapeutic interventions are highlighted throughout.

Reviews

'More than any other book in the field, it presents the entire spectrum of clinical assessment, laboratory diagnosis, and treatment of the infertile male with an array of medical, surgical, and laboratory techniques.'

Source: Doody's Reviews

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Contents

Page 2 of 2

Contents
  • Chapter 25 - Nonsurgical treatment of male infertility:
    pp 438-453
  • empiric therapy
  • View abstract

    Summary

    This chapter reviews the current concepts and ongoing controversies regarding the pathophysiology, diagnosis, significance, and treatment of the varicocele. Varicocele may also affect reactive oxygen species generation, rendering the testicle and the sperm unable to handle oxidative stress, and resulting in reactive oxygen species buildup. Toxic agents and heavy metals accumulate in tissues undergoing apoptosis, several investigators has examined testicular tissue heavy-metal content in men with varicocele. A pencil-probe Doppler stethoscope has been advocated as an adjunctive tool in the examination of the varicocele. Ultrasonography has become an increasingly useful modality in the diagnosis of varicocele. Surgical varicocelectomy is the cornerstone of varicocele therapy. Several surgical approaches are available to accomplish varicocelectomy. The approaches include the scrotal approach, the subinguinal approach, the inguinal approach, the retroperitoneal approach, and the laparoscopic approach. Azoospermia has generally been regarded as a contraindication to varicocelectomy.
  • Chapter 26 - Abnormalities of ejaculation
    pp 454-473
  • View abstract

    Summary

    Reproductive endocrinologists use the concept of fecundability in addition to discussing pregnancy rates. Fecundability is a valuable clinical and scientific concept, as it creates the framework for the quantitative analysis of fertility potential. The factor affecting prognosis is the age of the female partner. An important part of the basic infertility evaluation is assessment of fallopian tube patency. A hysterosalpingogram (HSG) is the frequently utilized modality for tubal assessment. Patients who are prepared to enter into in-vitro fertilization (IVF) treatment are encouraged to undergo salpingectomy because of very low pregnancy rates after neosalpingostomy, high rate of recurrent occlusion, risk of ectopic pregnancy, and decreased success rates after IVF when hydrosalpinx is present. Ovarian reserve testing should be offered routinely to women over 35, as well as to those with unexplained infertility to respond to conventional infertility treatment, and to those contemplating assisted reproductive technologies (ART) therapy.
  • Chapter 27 - Male contraception and vasectomy
    pp 474-492
  • View abstract

    Summary

    This chapter summarizes various imaging modalities in the workup of male infertility with emphasis on indications and outcome interpretation. The conditions outlined in this chapter are commonly identified causes for oligospermia and azoospermia, and are the usual targets for imaging investigations. Color Doppler ultrasound (CDUS) has become the most frequently used imaging modality for varicocele detection. Ultrasound studies of spermatic veins have suggested that the presence of multiple large veins. In CBAVD the diagnosis is established clinically by the absence of the two vasa deferentia on palpation. Intratesticular cysts include cysts of the tunica albuginea, tubular ectasia of the rete testis, and testicular cysts. Testicular microlithiasis (TM) is characterized by the presence of numerous punctate calcifications within the testis. Transrectal ultrasound (TRUS)-guided echo-enhanced seminal vesiculography in combination with transurethral resection of the ejaculatory duct (TURED) is considered the best imaging method when treating ejaculatory duct obstruction (EDO).
  • Chapter 28 - Intrauterine insemination from the urologist’s perspective
    pp 493-499
  • View abstract

    Summary

    This chapter focuses on the salient features of ductal obstruction of the male genital tract to allow the identification of the appropriate candidates for microsurgical treatment. It examines the role of microsurgical reconstruction in the era of assisted reproductive technology. Vasovasostomy may be performed using optical loupes or an operative microscope. Macrosurgical techniques suffer from higher rates of failure and are now of a historic nature. Two of the most widely accepted techniques, the modified one-layer and the multilayer vasal anastomosis, are described in this chapter. Special approaches for reconstruction are indicated when the vasal obstruction is outside of the scrotum. When sperm were absent from the intraoperative vasal fluid, patency and pregnancy results correlated with characteristics of vasal fluid with copious clear fluid portending the best outcomes. The absence of fluid or a thick, inspissated fluid suggests an epididymal obstruction, and a vasoepididymostomy should be considered.
  • Chapter 29 - In-vitro fertilization and micromanipulation for male infertility
    pp 500-515
  • View abstract

    Summary

    This chapter provides a comprehensive review of the available techniques for sperm retrieval, along with a brief description of the subtleties of each surgery. It describes the assessment of the outcomes associated with the various sperm retrieval techniques, based on the available literature. As in the obliterative microsurgical epididymal sperm aspiration (MESA) technique, inspection of epididymal tubules begins at the cauda and progresses proximally toward the head of the epididymis. Percutaneous epididymal sperm aspiration (PESA) may be performed to obtain sperm for in-vitro fertilization (IVF)/ intracytoplasmic sperm injection (ICSI). It can be done with a local anesthetic in an office setting. For cases of severe male-factor infertility such as nonobstructive azoospermia, or for obstructive azoospermia, testicular sperm may be used for IVF/ICSI. In the setting of normal spermatogenesis and vasal obstruction, either iatrogenic or congenital, sperm may be aspirated from the lumen of the testicular end of the vas deferens.
  • Chapter 30 - Psychological issues of infertility and assisted reproductive technology
    pp 516-527
  • View abstract

    Summary

    This chapter offers a discussion of basic normal ejaculatory duct embryology, anatomy, and physiology to lay a foundation for an understanding of the clinical findings and treatment of obstruction. In the male the mesonephric duct continues to develop into the epididymis, vas deferens, seminal vesicle, and ejaculatory duct. The remnant Müllerian structures in the male are the prostatic utricle and appendix testis, and in some men remnant Müllerian duct structures can be found in the midline of the prostate as Müllerian duct cysts. The ultrasonographic diagnosis of ejaculatory duct obstruction is based upon the finding of dilation of the seminal vesicles and abnormalities in the region of the ejaculatory ducts. Stricturing of the resected ejaculatory ducts may represent the most significant complication in regard to fertility, and may occur immediately or in a delayed fashion.
  • Chapter 31 - Legal issues in fertility preservation
    pp 528-540
  • View abstract

    Summary

    Many medications cause alterations in all categories of male infertility. Cimetidine, now an over-the-counter heartburn medication, suppresses the hypothalamic-pituitary-gonadal (HPG) axis in a reversible manner. Genitourinary infections in the male are an uncommon but potentially treatable source of infertility. Chlamydia trachomatis has long been studied as a putative disrupter of male fertility. Clomiphene citrate has been used since the early 1990s to stimulate spermatogenesis in the man with nonobstructive azoospermia. Kallmann syndrome is a rare subset of hypogonadotropic hypogonadism (HH) associated with other midline defects including anosmia. Another endocrine disorder, hyperprolactinemia, is also responsible for male infertility. Prolactin inhibits luteinizing hormone (LH) action on Leydig cells. Although the incidence of a prolactin-secreting pituitary adenoma is low, it is the most common functional pituitary tumor. Macroadenomas have warranted a referral to a neurosurgeon for transphenoidal or, more recently, endoscopic removal.
  • Chapter 32 - Analyzing male fertility data
    pp 541-549
  • View abstract

    Summary

    This chapter reviews the empiric therapies available today for male infertility and discusses their mode of action. It reviews published literature on outcomes available and analyzes the evidence for use and dosing recommendations. With the exception of low-dose vitamin supplementation and aromatase inhibitors, empiric therapy is seldom recommended in the treatment of the infertile male. Gonadotropin-releasing hormone (GnRH) stimulates the synthesis and release of the gonadotropic hormones, luteinizing hormone (LH) and follicle-stimulating hormone (FSH), in the anterior pituitary. Treatment of hypogonadotropic hypogonadism with exogenous gonadotropins or GnRH has produced good results compared with treatment of other male infertility problems. Exogenous testosterone therapy can produce azoospermia or severe oligospermia through the inhibition of gonadotropin secretion. Glutathione therapy has been used in various pathologic conditions in which reactive oxygen species are thought to play a pathogenic role. Administration of high-dose antioxidants has a potential beneficial effect on male fertility.
  • Chapter 33 - Semen analysis
    pp 550-573
  • View abstract

    Summary

    Ejaculatory dysfunction obviously becomes important in the younger male when fatherhood is of concern but, even then, its role in fertility is often looked at only as a problem in transport of sperm. The organs involved in the process of ejaculation are the epididymides, vasa deferentia, prostate, seminal vesicles, bladder neck, and bulbourethral glands. Neural control of ejaculation consists of the ejaculatory reflex, which is mediated at the thoracolumbar level and involves a coordinated interaction of the sympathetic and parasympathetic autonomic nervous systems. Premature ejaculation and delayed ejaculation are the two conditions of importance. Men with a nerve-sparing retroperitoneal lymph node dissection (RPLND) will have innervation of the ejaculatory organs, and the stimulation afforded by drug therapy may be enough to allow seminal emission or bladder neck closure. Penile vibratory stimulation (PVS) is usually recommended as the first line of treatment for anejaculation in men with spinal cord injury (SCI).
  • Chapter 34 - Strict criteria for sperm morphology
    pp 574-581
  • View abstract

    Summary

    Vasectomy is typically performed as an outpatient procedure using local anesthetics. The technique employed for occlusion of the vasal lumina may influence the incidence of recanalization. Suture ligature, still the common method employed worldwide, may result in necrosis and sloughing of the cut end distal to the ligature. Hematoma is the common complication of vasectomy, with an average incidence of 2%. Sperm granulomas form when sperm leak from the testicular end of the vas. Sperm are highly antigenic, and an intense inflammatory reaction occurs when sperm escape outside the reproductive epithelium. The concept of male hormonal manipulation for contraception predated the era of female hormonal contraception by 20 years. Progestins have been used in multiple small studies for suppression of spermatogenesis and testosterone production in men. Along with hormonal manipulation, immunocontraception appears to offer reasonable hope for a nonsurgical contraceptive option in men.
  • Chapter 35 - Sperm processing techniques
    pp 582-592
  • View abstract

    Summary

    Intrauterine insemination (IUI) is indicated for couples with unexplained infertility, mild to moderate male-factor infertility, or certain female factors, such as antisperm antibodies or a hostile cervical environment. Pre-screening for couples attempting an IUI procedure includes testing for infectious diseases, genetic abnormalities, and general medical problems, such as anemia. Oligospermic men have an increased likelihood of harboring genetic anomalies, such as Y-chromosome microdeletions. The use of fertility drugs has been associated with neoplasia, particularly borderline ovarian tumors. Pregnancy complications include multiple gestations, birth defects, low birthweight, and ectopic pregnancies. Chain of custody is a concept that dictates exactly which person or facility has physical control of a laboratory specimen from the time it leaves the patient's body until it arrives at its ultimate destination. In IUI, the initial specimen is the man's ejaculate and the final destination is his designated partner's uterus.
  • Chapter 36 - Sperm banking:
    pp 593-602
  • indications and techniques
  • View abstract

    Summary

    In-vitro fertilization (IVF) has rapidly become a treatment for male factor infertility. Mature oocytes are inseminated in a Petri dish and examined 18 hours later for morphologic proof of fertilization. Gamete intrafallopian transfer (GIFT) is designated for women who have at least one functioning fallopian tube. Micromanipulation procedures progressed because of discouraging results with IVF for the male-factor patient. Although application of acid solutions or enzymes, and mechanical opening of the human zona pellucida have been developed, only partial zona dissection (PZD) has been successful in humans. One of the most significant risks associated with ART is the ovarian hyperstimulation syndrome (OHSS). Preimplantation genetic screening (PGS) for aneuploidies has been performed in patients with advanced maternal age, unexplained recurrent miscarriage, recurrent implantation failure, nonobstructive and obstructive azoospermia (NOA and OA), and severe sperm morphology anomalies.
  • Chapter 37 - Tests for antisperm antibodies
    pp 603-612
  • View abstract

    Summary

    Many couples whose infertility treatment requires in-vitro fertilization (IVF) also need intracytoplasmic sperm injection (ICSI) as a part of the procedure. In many respects ICSI has revolutionized infertility treatment as a whole. Both research data and clinical experience have shown that providing a sperm sample during this crucial stage of IVF/ICSI treatment could increase performance anxiety for both fertile and infertile men. The successful use of assisted reproductive technologies over the past 25 years or more has brought with it procedures that allow couples who cannot conceive using their own gametes the alternative of achieving pregnancy through the use of donated oocytes, donated sperm, and even donated embryos. The psychological evaluation is also intended to rule out gross psychopathology and depression, potential substance abuse, as well as a history of current or past family violence or abuse. Marital stability is also assessed within the context of the consultation.
  • Chapter 38 - Semen white blood cell assay
    pp 613-617
  • View abstract

    Summary

    This chapter discusses the legal issues and the efforts that legislatures, courts, professional guidelines, programs, and patients have made to resolve them, in the hope of giving professionals some guidance in these evolving areas. Preserving male fertility through sperm collection and freezing is the most commonly recognized, and likely most frequently performed, of all fertility preservation measures. Donor gametes have also been involved with legal claims regarding embryo donation, discard, or custody of resulting children. Use of donor insemination to create a family raises additional legal issues for infertile men, their spouses or partners, and the sperm donors involved. Donor screening is required under a variety of state and federal laws, as well as professional guidelines. Posthumous reproduction raises additional legal complexities, including determination of the legal status of any resulting child under applicable law, which varies from jurisdiction to jurisdiction, within the United States as well as internationally.
  • Chapter 39 - Determination of seminal oxidants (reactive oxygen species)
    pp 618-632
  • View abstract

    Summary

    This chapter reviews the basics of probability, statistics, and computer modeling, with special attention to problems relating to male infertility. A probability distribution describes how the probabilities of all possible outcomes of an event are divided or distributed. Mathematically, the utility of a test can be described by various parameters, the most commonly used being sensitivity, specificity, positive predictive value, and negative predictive value. The problem confronting the andrologist is the multifactorial nature of male infertility. One reason for the popularity of logistic regression is that inferential statistical tests exist to determine if the weights are statistically significant. This allows researchers to report the predictive variables, and ignore the others in the predictive model. In discriminant function analysis, the observed data are used to create a Gaussian probability distribution centered at the multidimensional mean of each group and with the appropriate standard deviations.
  • Chapter 40 - Measurement of DNA fragmentation in human spermatozoa
    pp 633-641
  • View abstract

    Summary

    Semen specimens usually are collected by masturbation into a wide-mouthed polypropylene container from a batch or lot tested for lack of sperm toxicity. Mixing a semen sample thoroughly is critical for accurate sperm counts, both initially and throughout each step of semen analysis. Sperm viability testing typically uses a nuclear exclusion stain to determine whether non-motile sperm are alive and not able to move. The component of sperm morphology is one of the most predictive measures of fertility potential and therapeutic outcome. The semen should be examined microscopically for the presence of bacteria, round cells, debris, agglutination, or aggregation. The influence of the female partner in human fertility plays a huge confounding role in both defining fertility and interpreting the association of specific semen analysis measures with fertility. Sperm motility quality controls are available in two formats: frozen aliquots of semen or video recordings on CD-ROM, tape, or digital file.
  • Chapter 41 - A look towards the future:
    pp 642-653
  • advances in andrology expected to revolutionize the diagnosis and treatment of the infertile male
  • View abstract

    Summary

    Sperm morphology assessed by strict criteria, along with other male-factor analyses, was reported to be a good predictor of fertilization. Strict criteria for sperm morphology have been widely accepted, their usefulness remains an issue of contention. Sperm morphology assessed by strict criteria, along with other male-factor analyses, was reported to be a good predictor of fertilization. Improved sperm morphology observed surgical correction of varicocele, is probably the result of influencing spermatogenesis. Sperm morphology tends to vary less than sperm count and sperm motility in the same male. Morphology, count, and motility may be likened to a fingerprint, except when some acute process produces a temporary change, and morphology may therefore be an indicator of the health of the germinal epithelium. In the absence of other male or female factors, a very high percentage of spermatozoa need to be abnormal before strict criteria can provide a definitive assessment of infertility.

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