Jorge Hallak

VARICOCELECTOMY IMPROVES INTRAUTERINE INSEMINATION SUCCESS RATES IN MEN WITH VARICOCELE

PURPOSEnWe determined whether varicocele treatment before intrauterine insemination significantly affects intrauterine insemination success rates.nnnMATERIALS AND METHODSnA 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.nnnRESULTSnOn 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).nnnCONCLUSIONSnVaricocele 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.

Sperm cryopreservation in patients with testicular cancer.

OBJECTIVESnTo review a large experience with sperm cryopreservation in patients with testicular cancer and determine the effect of clinical stage and tumor histologic features on semen quality.nnnMETHODSnThe prefreeze and post-thaw sperm quality of 157 patients with testicular cancer was compared with that of 50 normal donors. The impact of tumor stage and histologic features (pure seminoma, pure embryonal, or mixed germ cell) was also determined. A computer-assisted semen analysis was performed before and after cryopreservation. The motile sperm count (MSC), motility, and motion characteristics were measured before and after cryopreservation and compared between groups.nnnRESULTSnPatients with testicular cancer had lower prefreeze and post-thaw MSC and motility compared with normal donors (P = 0.0001 for both). The curvilinear velocity and linearity were also significantly less in patients with testicular cancer (P <0.05 for both). The percentage of change in the semen characteristics did not differ between patients and donors, indicating that sperm from both patients and donors withstood the cryopreservation process equally well. Tumor stage (n = 143) and histologic features (n = 136) did not significantly influence semen quality. No individual histologic component significantly influenced MSC or motility.nnnCONCLUSIONSnThe effect of cryopreservation on sperm was similar in patients with testicular cancer and donors. Patients with poor prefreeze semen quality have poor post-thaw semen quality, and the effects of cryopreservation were not significantly affected by histologic features or stage. Our results indicate that routine sperm banking should be recommended for men with a diagnosis of testicular cancer to preserve future fertility potential.

INVESTIGATION OF FERTILIZING CAPACITY OF CRYOPRESERVED SPERMATOZOA FROM PATIENTS WITH CANCER

PURPOSEnThere are few published reports concerning fertilization and pregnancy outcomes achieved with cryopreserved spermatozoa from cancer patients. Controversy exists regarding the value of sperm banking for these patients before therapy, whether the spermatozoa are viable after long-term storage and whether they can fertilize the ovum. We assess fertilization and pregnancy outcomes achieved with cryopreserved spermatozoa from cancer patients using assisted reproductive techniques.nnnMATERIALS AND METHODSnWe studied 10 cancer patients who transferred cryopreserved semen specimens from our sperm bank to outside in vitro fertilization programs for assisted reproductive technique. Of these patients 5 had Hodgkins disease, 2 testicular cancer, 1 leukemia and 2 prostate cancer. The length of specimen storage ranged from 14 to 135 months (median 49, interquartile range 24 and 82).nnnRESULTSnThe median pre-freeze motility was 44% (interquartile range 36 and 55%) and the median total sperm count was 31.1 x 10(6) (interquartile range 6.3 and 53.9 x 10(6)). At 24 hours after banking the median post-thaw motility was 11% (interquartile range 6 and 35%) and the median total sperm count was 6.6 x 10(6) (1.2 and 17.1 x 10(6)). A total of 18 cycles of assisted reproductive technique were performed among 10 couples with an overall pregnancy rate of 50% per couple, with 2 deliveries, 1 ongoing pregnancy and 2 miscarriages. The pregnancy rate per cycle of in vitro fertilization and intracytoplasmic sperm injection was 36.4% with an implantation rate of 13%.nnnCONCLUSIONSnThese results indicate that poor quality cryopreserved spermatozoa from cancer patients, irrespective of the length of storage, may provide successful results with the latest micromanipulative techniques such as intracytoplasmic sperm injection.

Cryopreservation of sperm from patients with leukemia: is it worth the effort?

Intracytoplasmic sperm injection (ICSI) allows pregnancies to be established with a single sperm, improving the chances for men with severely impaired sperm quality to cause a pregnancy. Men with leukemia typically are of reproductive age and their fertility is threatened by initially impaired semen quality and cytotoxic chemotherapy. The authors examined the feasibility of sperm cryopreservation in men with leukemia before treatment and whether the type of leukemia is related to prefreeze or postthaw semen quality.

The effect of patient and semen characteristics on live birth rates following intrauterine insemination: a retrospective study.

AbstractPurpose: To identify characteristics of female patients andof semen that were associated with live birth followingintra-uterine insemination (IUI).nMethods: Retrospective review of medical and laboratoryresults from 533 women who underwent IUI with partnerssperm from 1993 through 1995.nResults: Among 1728 cycles, 116 (6.7%) resulted in livedeliveries. Among the 38 patient and semen variablesanalyzed, only 3 were associated with successful IUI outcome:female age <37.7 years at the time of treatment (P = 0.02);the absence of any corrective pelvic surgery (P < 0.001);and postwash sperm motility (P = 0.006). Couples withnone of these three risk factors achieved per-cycle pregnancyrates of 12.4%. Women with two risk factors (age and pelvicsurgery) achieved per-cycle pregnancy rates of 4.6% whensperm had good postwash motility. No pregnancies wereachieved when low postwash motility was combined withany other risk factor.nConclusions: Advanced female age, poor postwash spermmotility, and a history of corrective pelvic surgery aresignificant risk factors for poor IUI success rates. Poor postwashsperm motility in combination with either of these other tworisk factors resulted in no successful pregnancies.

Poor semen quality from patients with malignancies does not rule out sperm banking

Abstract Cancer therapy can further impair the already poor semen quality in cancer patients. This study evaluated the prefreeze and postthaw semen quality before treatment of patients with malignancies to examine the rationale for sperm banking for these men. Records of nine patients with different malignant tumors, who had been referred for sperm cryopreservation between 1982 and 1997, were reviewed and the results were compared with those of 50 normal healthy donors. Patients did not differ from donors in age, ejaculate volume, or duration of sexual abstinence. The total motile sperm count (median and interquartile range) was significantly different between patients and donors for prefreeze specimens (P=0.026) and postthaw specimens (P=0.008). Also, the percent motility was significantly lower in the patients as compared with the donors in prefreeze (P=0.035) and postthaw specimens (P=0.005). The percentage change in motility after thawing was also larger for patient samples (−54% versus −47%,P=0.39). Other sperm motion characteristics did not significantly differ between the two groups except for postthaw curvilinear velocity (P=0.01). This study concludes that fresh and frozen–thawed semen from patients with malignant tumors is poor in quality but is still adequate for assisted reproductive techniques. As cancer therapy may further impair semen quality, patients should be offered the chance to bank sperm before undergoing cancer therapy.

Relationship Between Creatine Kinase Levels and Clinical Diagnosis of Infertility

Purpose:The creatine kinase level indicates sperm maturity and correlates with the spermatozoal fertilizing potential. The relationship between creatine kinase levels in subfertile men and their clinical diagnosis was examined.Methods:Patients with unexplained infertility (n = 34), varicocele (n = 20), postvasectomy reversal (n = 7), or cancer (n = 22) were included in this prospective clinical study. The control group consisted of healthy normal donors (n = 15).Results:The median and interquartile range values of creatine kinase for each group were as follows: normal donors, 0.061 U/108sperm (0.056 to 0.076 U/108sperm); idiopathic malefactor, 0.119 U/108sperm (0.061 to 0.190 U/108sperm); varicocele, 0.392 U/108sperm (0.209 to 1.494 U/108sperm); postvasectomy reversal, 0.589 U/108sperm (0.425 to 4.043 U/108sperm); and cancer, 0.068 U/108sperm (0.047 to 0.168 U/108sperm). Sperm creatine kinase levels were significantly higher in patients with varicocele compared to normal donors (P = 0.0001), cancer patients (P = 0.0002), and men with idiopathic infertility (P = 0.0009). Sperm concentration and creatine kinase level were inversely correlated in patients (r = −0.7,P < 0.001) but not in normal donors.Conclusions:Semen quality is poorer in subfertile patients with clinical varicocele and postvasectomy reversal than in cancer patients and patients with idiopathic male infertility. That the creatine kinase levels in cancer patients were similar to those of normal donors suggests that the final phase of spermatogenesis may not be altered in men with cancer; thus semen from these patients should be banked to ensure fertility after cancer treatment.

The effects of cryopreservation on semen from men with sarcoma or carcinoma.

AbstractPurpose: This study evaluated prefreeze and postthaw semenquality before treatment in patients with different types ofsarcomas and carcinomas to determine whethercryopreservation would be of value for these patients.nMethods: Semen specimens were obtained from 50 normaldonors and from 21 patients with carcinoma and from 14patients with sarcoma. The specimens were cryopreservedby a standard freezing procedure using TEST-Yolk buffer.Prefreeze and postthaw sperm motion characteristics weremeasured.nResults: Prefreeze total motile sperm count was significantlyhigher in donors (median: 129.6 × 106/ml) than in menwith carcinoma (46.9 × 106/ml, P < .001) or sarcoma(66.3 106/ml, P = .04). The percent motility and percent linearitywere significantly lower in patients with carcinoma. Inpostthaw specimens, total motile sperm count, curvilinearvelocity, and linearity were significantly lower in patients withcarcinoma.nConclusions: The two patient groups in this study had poorsemen quality when compared with healthy donors bothbefore and after cryopreservation. Sarcoma patients hadbetter semen quality than carcinoma patients. As cancertherapy in these men could significantly impair theirreproductive potential, these men should be advised to preservetheir semen before starting treatment.

Effect of Clinical and Semen Characteristics on Efficacy of Ovulatory Stimulation in Patients Undergoing Intrauterine Insemination

AbstractPurpose: We measured the effect of ovulatory stimulation(OS) upon intrauterine insemination (IUI) success rates,particularly among patients with risk factors for IUI failure.nMethods: Retrospective review of medical and laboratoryresults from 512 patients who underwent 1576 cycles ofIUI with partners sperm over a 3 year period. Data werecollected on 3 risk factors for IUI failure (advanced femaleage >37.7 years, prior corrective pelvic surgery, and poorpost-wash sperm motility), and on method of OS (none,clomiphene citrate, or gonadotropin).nResults: Patients who underwent OS had significantly higherpregnancy rates (7.6;pc) than those who did not (4.7%, p =0.02). However, when patients were stratified by their riskfactors, OS made a significant difference only for patientswithout risk factors. These patients had a 15.5% per cyclepregnancy rate with OS, compared to 7.9% in unstimulatedIUI cycles (p = 0.04).nConclusions: Ovulatory stimulation doubles IUI pregnancyrates among young patients without a prior pelvic surgeryand with good post-wash semen quality. The benefit of OSfor patients with risk factors for IUI failure is unclear. Thesepatients should be counseled that their chances for successwith IUI are limited, with or without OS.