Dominick J. Carbone

Partial obstruction, not antisperm antibodies, causing infertility after vasovasostomy

PURPOSE We determined whether men who may have partial obstruction and antisperm antibodies after vasovasostomy can be distinguished from other infertile men with antisperm antibodies only, and whether repeat microsurgical reversal is beneficial in such patients. MATERIALS AND METHODS A total of 412 patients underwent indirect immunobead testing for antisperm antibodies at our laboratory from December 1991 through July 1996. Of 95 patients with an assay greater than 20% binding 49 had normal partners and were grouped by history of vasovasostomy (20), varicocele (9), cryptorchidism (8) and epididymo-orchitis (12). Semen analysis characteristics and antisperm antibody binding variables were compared across histories. Pregnancy rates were compared between patients treated surgically for partial obstruction and those treated for antisperm antibodies. Mean followup was 33.8 months. RESULTS Compared to the other 3 groups, men with a history of vasectomy and reversal had significantly lower sperm concentration (p = 0.002), poorer motility (p < 0.001), lower overall binding on the indirect immunobead assay (p < 0.001) and lower IgA binding (p = 0.008). The clinical diagnosis of partial obstruction was based on a sense of epididymal fullness by palpation, as well as the aforementioned semen parameters. Of the 20 patients with a history of vasectomy and reversal 14 were diagnosed with partial obstruction and underwent repeat microsurgical reversal and 6 with a history of vasovasostomy but no evidence of obstruction received no further therapy and never established pregnancies. The remaining 29 patients underwent sperm washing and assisted reproduction. Of 14 patients 7 (50%) established pregnancies after repeat reversal compared to only 5 of 29 patients (17.2%) treated with assisted reproduction (P = 0.025). CONCLUSIONS Antisperm antibodies are not a significant factor in persistently infertile post-reversal cases with the aforementioned criteria. Repeat reversal appears to be the most successful treatment option in this setting.

MANAGEMENT OF SEVERE CORPOREAL FIBROSIS WITH IMPLANTATION OF PROSTHESIS VIA A TRANSVERSE SCROTAL APPROACH

PURPOSE We reviewed our experience in the management of severe corporeal fibrosis with placement of the AMS 700 CXM* prosthesis to determine the efficacy of this approach. MATERIALS AND METHODS The records of 26 men with severe corporeal fibrosis who underwent placement of the AMS 700 CXM prosthesis via a transverse scrotal approach between August 1991 and July 1996 were reviewed. RESULTS In all cases the AMS 700 CXM prosthesis was successfully implanted with primary closure of the tunica albuginea, although 2 patients required extended corporotomies. Followup data were available on all 26 men. At a mean followup of 22.5 months (range 3 to 63) 24 of the 26 men had a functional device (92%). One patient required explantation for infection and 1 underwent explantation for cylinder cross-over. CONCLUSIONS Implantation of the AMS 700 CXM prosthesis in patients with severe corporeal fibrosis produced good results at approximately 2 years of followup.

Role of electron microscopy of sperm in the evaluation of male infertility during the era of assisted reproduction

OBJECTIVES To determine whether there are indications for and benefits from electron microscopy (EM) of sperm during the era of assisted reproductive technology. METHODS The medical history, semen analyses, and EM findings of 55 patients with pure male-factor infertility were reviewed to determine: (1) which semen characteristics (seminal volume, sperm concentration, percent motility, and percent normal morphology) were associated with normal or abnormal ultrastructure as determined by EM, (2) whether EM findings correlated with success or failure of in vitro fertilization (IVF), and (3) whether EM could screen for potentially inheritable genetic disorders. RESULTS Principal EM diagnoses were normal sperm ultrastructure (11 of 55; 20%), tail abnormalities (21 of 55; 38%), necrospermia (12 of 55; 22%), acrosomal defects (9 of 55; 16%), neck abnormalities (1 of 55; 2%), and incomplete maturation (1 of 55; 2%). Every patient with an abnormal EM study had impaired motility (33% or below) and abnormal morphology (13% or lower normal forms by World Health Organization criteria). The percentage of normal sperm morphology differed significantly across EM diagnoses (P < 0.0001). Differences in motility across the groups could not be detected because EM was only performed on patients with impaired motility. Although the partner of 1 patient with a normal EM study who underwent IVF achieved pregnancy, 11 with abnormal EM studies failed to establish a pregnancy by IVF. Finally, 5 (11%) of 44 patients with abnormal EM findings were diagnosed with primary ciliary dyskinesia directly as a result of EM. In addition, 3 (6.8%) of the 44 patients with abnormal EM findings were diagnosed with complete acrosomal loss. CONCLUSIONS Patients with severely abnormal motility and morphology on routine semen analysis may benefit from EM study of sperm. Our data indicate that EM findings correlate with success or failure of IVF, and that EM can screen for potentially inheritable genetic disorders.

Improved motile sperm recovery by a hyperosmotic Percoll gradient.

Purpose: Our purpose was to investigate whether a new, relatively hyperosmotic Percoll gradient, Enhance-S, can improve total motile sperm recovery rates compared with the commonly used Percoll gradient Perception.Methods: Semen specimens from each of 17 donors were divided into two equal aliquots. One part was washed using Percoll Perception, while the other was prepared using Percoll Enhance-S.Results: Compared to the unwashed specimen, sperm motion characteristics (motility and velocity) improved significantly after Percoll separation using either the Perception or the Enhance-S gradient. There was no difference in motility or velocity in spermatozoa recovered after wash with either of the two preparations. However, the total motile sperm recovery was significantly higher using the Percoll Enhance-S gradient than with the Percoll Perception gradient (P < 0.0024).Conclusion: The new Percoll Enhance-S gradient provides significantly more total motile sperm than the Percoll Perception gradient.

Urinary and Sexual Complications

Genitourinary complications have long been recognized as some of the most serious extraintestinal manifestations of inflammatory bowel disease (IBD). In 1936, just four years after Crohn, Ginzburg and Oppenheimer’s original description of regional enteritis, Ten Kate recorded the first documented case of an enterovesical fistula secondary to IBD (1). This was followed in 1943 by Hyams’ original report of ureteral obstruction resulting from chronic ileitis and in 1962 by Deren’s paper on nephrolithiasis as a complication of ul-cerative colitis and regional enteritis (2,3). Other authors throughout this century have continued to emphasize significant genitourinary complications associated with or resulting from surgery for IBD (4,5).