Farjaad M. Siddiq

A new look at the medical management of infertility.

Effective therapies are available for the treatment of infertility owing to specific causes. Most hormonal imbalances can be readily identified and successfully treated. The treatment of men with unexplained idiopathic infertility remains difficult. The availability of a multitude of agents ranging from hormones to nutritional supplements emphasizes the fact that none are consistently effective. There is no good way to predict which patients will respond to a specific treatment. Idiopathic infertility may result from multiple discrete defects in sperm generation and maturation that are as yet unidentified. A better understanding of these defects will yield more effective treatment options and appropriate triage of patients to specific therapeutic regimens. Assisted reproductive techniques remain an option for patients with idiopathic male infertility; however, they are expensive and treat the female partner for a male problem. Multiple gestations and other complications are not infrequent. Initial management should be directed at improving the quality of semen to facilitate natural conception. Specific abnormalities should be corrected. If empiric pharmacologic therapy is to be used, treatment should last at least 3 to 6 months to incorporate a full 74-day spermatogenic cycle. The infertile couple should be advised of the inconsistent response to therapy and the low conception rate that may follow when compared with the results of ART. When empiric therapy is decided upon, antiestrogens may be used and are effective in a subset of patients. The authors prefer to use clomiphene citrate, 25 mg per day. The dose may be increased to 50 or 75 mg to raise testosterone levels to the upper normal range. Lack of a significant improvement in semen parameters or of a pregnancy after a 3- to 6-month treatment period may be an indication to proceed with ART.

Ectopic Vas Deferens Opening Into The Bladder Found During Routine Evaluation Of Male Factor Infertility

Ectopic vas deferens is a rare congenital anomaly that is frequently associated with anorectal malformations, ureteral ectopia and renal abnormalities. Diagnosis is usually made in the child with urinary tract infection, epididymitis or scrotal swelling. Less commonly this anomaly can be found in an older patient with infertility. We report on a patient with azoospermia who was found to have an ectopic vas deferens inserting into the bladder.

A RETAINED URETERAL STUMP WITH CALCULI

Augmentation cystoplasty is a commonly used method to treat patients with inadequate bladder capacity. Calculus formation within the altered urinary tract has been a frequent complication. We report the unique finding of calculi within a retained ureteral stump in a patient who had undergone enterocystoplasty. CASE REPORT A 29-year-old female presented with recurrent urinary tract infections that were refractory to treatment. The patient had been born with sacral agenesis and imperforate anus. Neurogenic bladder and vesicoureteral reflux had subsequently developed, and the patient underwent ileal conduit formation for management of progressive bilateral hydroureteronephrosis as a young child. At age 15 years she underwent urinary undiversion with ileocecoplasty to the native bladder. Videourodynamics were repeated at age 28 years and revealed a volume capacity of 700 ml., and bilateral grade V vesicoureteral reflux and reflux into the retained ureteral stumps. The patient performed clean intermittent catheterization every 2 to 4 hours to minimize the post-void residual urine volume. Recurrent urinary tract infections were managed with outpatient oral antibiotic therapy. In addition, in 1999 a bladder calculus had developed in the bowel segment of the bladder. The stone was managed with cystolithotripsy, with complete stone removal. In 2001 urinary tract infections recurred despite appropriate antibiotic coverage for each recurrent infection and antibiotic prophylaxis. Symptoms consisted of painful urethral catheterizations, small urethral catheterized volumes and pyuria. Plain x-ray of the kidneys, ureters and bladder demonstrated multiple calcified densities in the pelvis (see figure). In preparation for cystolithotripsy, cystoscopy of the native and augmented bladder was performed, which showed an absence of bladder calculi. However, a dilated and patulous right ureteral orifice was identified. Retrograde ureterogram revealed several filling defects in the right ureteral stump that correlated with the calcifications seen on x-ray. The ureteral stump measured approximately 8 cm. The calculi were fragmented via semirigid ureteroscopy with holmium laser lithotripsy and basket stone extraction. The bladder was copiously irrigated. The patient was discharged home on the same day with postoperative instructions to perform bladder irrigation twice daily in addition to clean intermittent catheterization. Stone analysis demonstrated calcium phosphate. DISCUSSION