Eleonora Bedin Pasqualotto

VARICOCELECTOMY IMPROVES INTRAUTERINE INSEMINATION SUCCESS RATES IN MEN WITH VARICOCELE

PURPOSE We determined whether varicocele treatment before intrauterine insemination significantly affects intrauterine insemination success rates. MATERIALS AND METHODS A total of 58 infertile couples, of whom the women had normal evaluations and men had abnormal semen analyses and a history of varicocele, were included in this study. They were identified after reviewing the charts of all women undergoing intrauterine insemination for male factor infertility at our center. Of the men 24 participated in 63 intrauterine insemination cycles without varicocele treatment, while in the remaining 34 varicocele was treated before a total of 101 intrauterine insemination cycles. Variables associated with pregnancy or live birth were analyzed using repeat measures logistic regression with generalized estimating equation techniques. An initial stepwise generalized estimating equation was performed without including varicocele treatment status. Subsequently varicocele treatment status and the significant associated factors were included in analysis. The semen characteristics of untreated and treated varicocele groups were compared with repeat measures analysis of variance. RESULTS On pre-wash semen analysis patients with untreated varicocele had significantly higher mean motility plus or minus standard error than patients whose varicoceles were treated (48.6% +/- 2.3% versus 38.1% +/- 1.8%, p = 0.02). However, no statistically significant difference was noted in the mean post-wash total motile sperm count in the treated and untreated groups (7.2 +/- 1.0 versus 14.8 +/- 2.6, p = 0.1). Despite these findings the pregnancy and live birth rates per cycle were significantly higher in patients in whom varicocele was treated than in those without varicocele treatment (11.8% versus 6.3%, p = 0.04 and 11.8% versus 1.6%, p = 0.007, respectively). CONCLUSIONS Varicocele treatment may not improve semen characteristics in all men but it appears to improve pregnancy and live birth rates among couples undergoing intrauterine insemination for male factor infertility. A functional factor not measured on routine semen analysis may affect pregnancy rates in this setting. Men should be screened for varicocele before intrauterine insemination is initiated for male factor infertility.

Poor Semen Quality and ROS-TAC Scores in Patients with Idiopathic Infertility

Introduction: To compare the semen quality score and the seminal oxidative stress reactive oxygen species (ROS) and total antioxidant capacity (ROS-TAC score) in men with idiopathic infertility with normal donors and to a known group of fertile and infertile men. Material and Methods: Principal component analysis was applied to provide a standardized score in 36 men with idiopathic infertility and 19 controls attending our infertility clinic. A logistic regression analysis comparing the fertile and infertile men was used. Results: Compared to controls, patients with idiopathic infertility had significantly lower sperm concentration, sperm motility and normal morphology (p < 0.05) and lower semen quality scores (83.0 ± 14.5 vs. 100.0 ± 10.0; p < 0.001). Compared to controls, the ROS levels were higher in the idiopathic infertility group (2.3 ± 0.21 vs. 1.3 ± 0.3; p = 0.006), whereas the TAC levels were lower in the idiopathic infertility (1,014.75 ± 79.22 vs. 1,653 ± 115.29; p = 0.001). Idiopathic infertility patients had lower ROS-TAC scores (32.8 ± 14.2) than controls (50.0 ± 10.0) (p < 0.001). 64% of men with idiopathic infertility will remain infertile during 1-year follow-up. Conclusions: Patients with idiopathic infertility have lower scores of semen quality and ROS-TAC.

Accuracy of preoperative diagnostic tools and outcome of hysteroscopic management of menstrual dysfunction

STUDY OBJECTIVES To review diagnoses, complications, and surgical findings in women treated for abnormal uterine bleeding by operative hysteroscopy, and to assess the accuracy of preoperative transvaginal ultrasound (TVS), saline-infusion sonography (SIS), diagnostic hysteroscopy, and endometrial biopsy. DESIGN Retrospective study (Canadian task force classification II-2). SETTING Tertiary care academic medical center. PATIENTS Three hundred seventy-five women. Intervention. Operative hysteroscopy for abnormal uterine bleeding. MEASUREMENTS AND MAIN RESULTS Main indications for hysteroscopy were postmenopausal bleeding (164 patients, 43.7%) and abnormal premenopausal uterine bleeding (211, 56.3%). Main pathology findings were endometrial polyps (172, 45.9%) and submucous myomas (105, 28%). Polyps had histologic abnormalities in 18 patients. Sensitivity of preoperative diagnostic tools for all intrauterine abnormalities and specifically for myomas and polyps was TVS 74% and 39%, SIS 96% and 96%, hysteroscopy 100% and 99%, and Pipelle biopsy 24% and 10%. The complication rate was 1.3%. Postmenopausal women felt significantly more improvement in symptoms (p = 0.02), and were more satisfied (p </=0.001) than premenopausal women. Only 10 women had repeat surgery for the problem. CONCLUSION Operative hysteroscopy is a safe outpatient procedure and is associated with high satisfaction in carefully selected patients. Hysteroscopy and SIS are better diagnostic tests for intracavitary abnormalities than TVS and endometrial biopsy.

Relationship of total motile sperm count and percentage motile sperm to successful pregnancy rates following intrauterine insemination

Purpose:This study sought (i) to investigate the relationship between postwash total motile sperm count and postwash percentage motile sperm in predicting successful intrauterine insemination and (ii) to determine the minimal postwash total motile sperm count required to achieve pregnancy with intrauterine insemination.Methods:Five hundred four women, who underwent 1636 intrauterine insemination cycles with their partners sperm for infertility treatment from 1993 through 1995, were included in this retrospective study. All patient charts were reviewed for age, infertility etiology, ovarian stimulation regimens, semen characteristics, and treatment outcome. To determine the relationship between total motile sperm count and intrauterine insemination outcome, patients were grouped as (1) less than 0.5 million, (2) 0.5 to 1 million, (3) 1 to 5 million, (4) greater than 5 million, and (5) greater than 20 million.Results:Similar live birth rates (per cycle) were seen among the postwash total motile sperm count groups: group 1, 3.5%; group 2, 2.4%; group 3, 7.0%; group 4, 6.9%; and group 5, 7.0% (P = 0.37). However, regardless of the postwash total motile sperm count, the postwash motility predicted intrauterine insemination success at a cutoff value of 40%.Conclusions:The percentage of postwash sperm motility, and not the postwash total motile sperm count, can predict successful intrauterine insemination outcome. Such information can be useful in counseling patients regarding their chance of success with intrauterine insemination and in determining when alternate methods of assisted reproduction may be a better approach.

Risk factors for multiple gestation in women undergoing intrauterine insemination with ovarian stimulation.

OBJECTIVE To identify whether sperm characteristics after washing and/or ovulation induction cycle characteristics can predict the occurrence of multiple conception in patients undergoing ovarian stimulation and IUI. DESIGN Retrospective study. SETTING A gynecology clinic and an andrology laboratory at a tertiary care facility. PATIENT(S) One hundred patients with single pregnancies and 22 patients with multiple pregnancies. INTERVENTION(S) Patients underwent ovarian stimulation and IUI with their partners sperm. MAIN OUTCOME MEASURE(S) Relation of patient characteristics, ovarian stimulation, and sperm characteristics after washing to the occurrence of multiple pregnancy. RESULT(S) The mean serum E2 level on the day of hCG injection was significantly higher in the multiple conception group, but the number of follicles was not. The total sperm count, total motile sperm count, and sperm motility after washing did not differ between the groups. However, couples with multiple pregnancies had sperm with a significantly higher amplitude of lateral head movement than couples with single pregnancies. A peak E2 level of >583 pg/mL on the day of hCG injection and sperm with an ALH of >4 microm after washing predicted the occurrence of multiple pregnancy. CONCLUSION(S) Sperm with an amplitude of lateral head movement of >4 microm and a peak E2 level of >583 pg/mL are significant risk factors for multiple pregnancy in patients undergoing IUI.

The best infertility treatment for vasectomized men: assisted reproduction or vasectomy reversal?

In men with prior vasectomy, microsurgical reconstruction of the reproductive tract is more cost-effective than sperm retrieval with in vitro fertilization and intracytoplasmic sperm injection if the obstructive interval is less than 15 years and no female fertility risk factors are present. If epididymal obstruction is detected or advanced female age is present, the decision to use either microsurgical reconstruction or sperm retrieval with in vitro fertilization and intracytoplasmic sperm injection should be individualized. Sperm retrieval with in vitro fertilization and intracytoplasmic sperm injection is preferred to surgical treatment when female factors requiring in vitro fertilization are present or when the chance for success with sperm retrieval and intracytoplasmic sperm injection exceeds the chance for success with surgical treatment.

Detection of testicular cancer in men presenting with infertility

PURPOSE Infertility is one of the less common presenting features associated with testicular tumors. We evaluated the histologic and biochemical findings, and pregnancy outcome in patients presenting with infertility who were found to have testicular tumors. METHODS Seven patients with infertility were found to have testicular cancer over a 15-year period. All patients had a testicular ultrasound evaluation. The indications for the ultrasound were testicular pain in 2 patients, suspicious palpable mass in 4, and to rule out the presence of germ cell neoplasia in a patient with carcinoma in situ detected on a previous biopsy. Physical exam, histological findings, hormonal levels, tumor markers, and pregnancy outcome results were recorded from the patients medical charts. RESULTS Two men had elevated serum follicle stimulant hormone and luteinizing hormone levels, 1 of them had an abnormally low serum testosterone level. Tumor markers were normal in all patients. In 4 patients the tumor was on the right side and in 3 on the left. The histological diagnoses were seminoma (n = 5), Leydig cell tumor (n = 1), and carcinoma in situ (n = 1). Of the 7 patients, 5 underwent adjuvant radiation therapy. Two patients had sperm cryopreserved. Follow up on fertility status was available in 6 cases. One patient has established a pregnancy and 5 did not achieve a pregnancy after treatment for their cancer. CONCLUSIONS Most of the men who have testicular cancer and male infertility have a seminona. Therefore, men who present with infertility should be thoroughly investigated to rule out such serious, concomitant diseases along with their infertility.

Results of microsurgical anastomosis in men with seminal tract obstruction due to inguinal herniorrhaphy

UNLABELLED The incidence of vasal injury during inguinal herniorrhaphy is estimated at 0.5%. We sought to assess the patency rates and long-term fertility outcome after microsurgical repair of vasal obstruction related to prior inguinal herniorrhaphy. METHODS Twenty procedures were performed on 13 men diagnosed with infertility and vasal injury secondary to previous inguinal herniorrhaphy. Eight of these men had undergone bilateral and 5 unilateral inguinal herniorrhaphy. Twelve procedures were vasovasostomies, 3 were crossover vasovasostomies, 2 were vasoepididymostomies, and 3 were crossover vasoepididymostomies. Eight patients were azoospermic, 2 were severely oligospermic (<1 M/mL), 1 was oligospermic, and 2 were asthenospermic. Patency data was obtained on all 13 patients, and pregnancy data was available for 10 couples (77%), with a mean follow-up of 69.5 months. RESULTS The overall patency rate was 65%. In the vasovasostomy group, the patency rate was 60% (9/15), and in the vasoepididymostomy group it was 80% (4/5). Among the azoospermic patients, 13 procedures were performed. The patency rate was 42.9% for the vasovasostomy (3/7), and 100% for the vasoepididymostomy procedure (4/4). The overall pregnancy rate was 40%. Of the men who underwent vasoepididymostomy, 80% (4/5) established a pregnancy. CONCLUSIONS Microsurgical vasovasostomy after inguinal vas injury results in a reasonable patency rate but a lower pregnancy rate than that after vasectomy reversal. When microsurgical vasoepididymostomy was possible, it resulted in high patency and pregnancy rate. Crossover vasoepididymostomy, when appropriate, can be a useful alternative to inguinal vasovasostomy.

Superovulation and intrauterine insemination in cases of treated mild pelvic disease

Purpose: Our purpose was to examine the effect of treated mild pelvic disease on the outcome of superovulation with intrauterine insemination (SO/IUI).Methods: Three hundred cycles of SO/IUI were retrospectively reviewed for 118 women with laparoscopically treated minimal/mild endometriosis and 67 cycles for 28 women with minimal/mild distal tubal disease/adnexal adhesions and compared with 265 cycles in 111 couples with idiopathic infertility.Results: The monthly fecundity rate (MFR) of 6.8% and live birth rate (LBR) of 6% in the endometriosis group were significantly lower (P = 0.002) than those in the idiopathic infertility group (MFR = 13.5%, LBR = 12.1%). The 10.9% MFR and 7.5% LBR in the minimal/mild tubal/adnexal disease were not significantly different from those in the other two groups.Conclusions: MFR and LBR were higher after SO/IUI in idiopathic infertility compared to those for treated mild/minimal endometriosis or mild/minimal tubal/adnexal adhesions. However, SO/IUI still remains a reasonable option for both these groups prior to IVF-ET.

1516: Relationship between Cigarette Smoking and the Levels of Antioxidants and Leukocytes in Infertile Men: A Prospective Study

Introduction and Objective: Cigarette smoke is a known somatic cell mutagen and carcinogen and it is known to adversely affect male reproductive health. Even though studies have shown the harmful effets of smoking on sperm quality, a handful of studies have found no association between smoking and sperm function or sperm nuclear DNA damage. Superoxide dismutase (SOD) and catalase are important antioxidant enzymes that can quench excess free radicals such as: superoxide anion and hydrogen peroxide respectively. The objective of our study was to evaluate and correlate the seminal antioxidant enzymatic activity (SOD and catalase levels) among fertile and infertile men who are cigarette smokers. Methods: The Institutional Review Board approved this study. Ten fertile donors and 112 infertile patients were included in the study. Semen analysis was performed according to the World Health Organization guidelines and sperm morphology according to Kruger strict criteria. Superoxide dismutase and catalase levels were determined with a spectrophotometer. Results: A significant difference was noted in the number of cigarettes smoked/day between infertile (4.8 ± 0.9) and fertile men (1.5 ± 0.5; p = 0.03). Significantly lower levels of SOD (14.67 ± 12.27 and 38.03 ±21.65) and catalase (14.87 ± 16.95 and 34.03 ± 20.65) were seen in infertile patients compared to fertile donors (P <0.0001). A significant correlation between catalase and SOD was observed (r = 0.461, P = 0.0001). Superoxide dismutase was significantly correlated with sperm concentration (r = 0.204, P = 0.034) and negatively correlated with leukocytospermia (r = -0.228, P = 0.021). Cigarette smoking was inversely correlated with SOD levels (r = -0.251, P = 0.01), but not with catalase levels (r = -0.147, P = 0.130). Conclusions: Decreased antioxidant enzyme levels are associated with male infertility. The detrimental effects of cigarette smoking on sperm motility and antioxidant levels (negative correlation with SOD) may be a possible reason for infertility in men who smoke cigarettes. As low antioxidant levels are linked to decreased fertility, physicians should advise infertile patients who smoke cigarettes to quit smoking. Author Disclosure Block: E.B. Pasqualotto, None; F.M. Umezu, None; A. Agarwal, None; M. Salvador, None; F.F. Pasqualotto, None.