Lawrence S. Ross

THE ROLE OF TESTICULAR BIOPSY IN THE MODERN MANAGEMENT OF MALE INFERTILITY

PURPOSE We evaluate the traditional role of isolated testicular biopsy as a diagnostic tool, as opposed to the value as a therapeutic procedure for azoospermic men. MATERIALS AND METHODS The medical records of azoospermic patients who were evaluated, and treated between 1995 and 2000 were retrospectively analyzed for history, physical examination findings, endocrine profiles, testicular histology and sperm retrieval rates. Based on these parameters, cases were placed into diagnostic categories that included obstructive or nonobstructive azoospermia. Diagnostic parameters used to distinguish obstructive from nonobstructive azoospermia were subjected to statistical analysis with the t-test, analysis of variance and receiver operating characteristics curve. RESULTS A total of 153 azoospermic men were included in our analysis. Of men with obstructive azoospermia 96% had follicle-stimulating hormone (FSH) 7.6 mIU/ml. or less, or testicular long axis greater than 4.6 cm. Conversely, 89% of men with nonobstructive azoospermia had FSH greater than 7.6 mIU/ml., or testicular long axis 4.6 cm. or less. Receiver operating characteristics analysis revealed that FSH, testicular long axis, and luteinizing hormone were the best individual diagnostic predictors, with areas 0.87, 0.83 and 0.79, respectively. CONCLUSIONS In the vast majority of patients obstructive azoospermia may be distinguished clinically from nonobstructive azoospermia with a thorough analysis of diagnostic parameters. Based on this result, we believe that the isolated diagnostic testicular biopsy is rarely if ever indicated. Men with FSH 7.6 mIU/ml. or greater, or testicular long axis 4.6 cm. or less may be considered to have nonobstructive azoospermia and counseled accordingly. These men are best treated with therapeutic testicular biopsy and sperm extraction, with processing and cryopreservation for usage in in vitro fertilization and intracytoplasmic sperm injection if they accept advanced reproductive treatment. Diagnostic biopsy is of no other value in this group. Men with FSH 7.6 mIU/ml. or less, or testicular long axis greater than 4.6 cm. may elect to undergo reconstructive surgery with or without testicular biopsy and sperm extraction, or testicular biopsy and sperm extraction alone depending on their reproductive goals.

In vitro fertilization outcomes after intracytoplasmic sperm injection with fresh or frozen-thawed testicular spermatozoa

OBJECTIVE To compare the outcomes of intracytoplasmic sperm injection (ICSI) and in vitro fertilization (IVF) with fresh and cryopreserved testicular spermatozoa in patients with obstructive and nonobstructive azoospermia. DESIGN Retrospective analysis of consecutive ICSI cycles. SETTING Large urban reproductive medicine program. PATIENT(S) Twenty-nine patients with obstructive and nonobstructive azoospermia undergoing testicular sperm extraction for a total of 46 IVF-ICSI cycles (12 fresh, 34 frozen). INTERVENTION(S) Testicular sperm extraction, cryopreservation, and IVF-ICSI with fresh or frozen-thawed spermatozoa. MAIN OUTCOME MEASURE(S) Fertilization rates, embryo cleavage rates, embryo implantation rates, clinical pregnancy rates per cycle and per embryo transfer, and delivery and spontaneous abortion rates. RESULT(S) No statistically significant differences were noted in any of the parameters examined between IVF-ICSI cycles from fresh or frozen-thawed testicular spermatozoa. Fertilization rates were 56% with fresh vs. 61% with frozen-thawed testicular sperm, cleavage rates 92% vs. 95%, implantation rates 26% vs. 17%, clinical pregnancy rates per cycle 33% vs. 41%, and pregnancy rates per embryo transfer 33% vs. 45%, respectively. Delivery rates were 75% with fresh vs. 69.2% with frozen-thawed testicular sperm, and spontaneous abortion rates 25% and 30.8%, respectively. CONCLUSION(S) No differences were found in IVF-ICSI outcomes between cryopreserved and fresh testicular sperm. In addition, cryopreservation provides several advantages for the patients and reproductive team.

Vasectomy: AUA Guideline

PURPOSE The purpose of this guideline is to provide guidance to clinicians who offer vasectomy services. MATERIALS AND METHODS A systematic review of the literature using the search dates January 1949-August 2011 was conducted to identify peer-reviewed publications relevant to vasectomy. The search identified almost 2,000 titles and abstracts. Application of inclusion/exclusion criteria yielded an evidence base of 275 articles. Evidence-based practices for vasectomy were defined when evidence was available. When evidence was insufficient or absent, expert opinion-based practices were defined by Panel consensus. The Panel sought to define the minimum and necessary concepts for pre-vasectomy counseling; optimum methods for anesthesia, vas isolation, vas occlusion and post-vasectomy follow up; and rates of complications of vasectomy. This guideline was peer reviewed by 55 independent experts during the guideline development process. RESULTS Vas isolation should be performed using a minimally-invasive vasectomy technique such as the no-scalpel vasectomy technique. Vas occlusion should be performed by any one of four techniques that are associated with occlusive failure rates consistently below 1%. These are mucosal cautery of both ends of the divided vas without ligation or clips (1) with or (2) without fascial interposition; (3) open testicular end of the divided vas with MC of abdominal end with FI and without ligation or clips; and (4) non-divisional extended electrocautery. Patients may stop using other methods of contraception when one uncentrifuged fresh semen specimen shows azoospermia or ≤ 100,000 non-motile sperm/mL. CONCLUSIONS Vasectomy should be considered for permanent contraception much more frequently than is the current practice in the U.S. and many other nations. The full text of this guideline is available to the public at http://www.auanet.org/content/media/vasectomy.pdf.

Optimization of spermatogenesis-regulating hormones in patients with non-obstructive azoospermia and its impact on sperm retrieval: A multicentre study

Study Type – Therapy (outcomes)

Diagnosis and management of testicular sarcoidosis.

We report testicular sarcoidosis in a patient who had known systemic involvement with this disease. The literature is reviewed and a protocol is presented to delineate specific indications for biopsy rather than orchiectomy to preserve testicular function.

Varicocele Vein Ligation in 565 Patients Under Local Anesthesia: A Long-Term Review of Technique, Results and Complications in Light of Proposed Management by Laparoscopy

Several recent reports have suggested that laparoscopic internal spermatic vein ligation provides a simpler, less debilitating and more cost efficient method of varicocele ligation than conventional surgical techniques. We analyzed the results of open varicocele ligation using local anesthesia in 565 patients for 10 years. All surgery was performed in the outpatient setting using 0.5% lidocaine. In most patients 50 to 200 mcg. fentanyl or 3 to 7 mg. midazolam were used for intravenous sedation. The average operating time, including the administration of anesthesia, was 39 minutes for unilateral and 71 minutes for bilateral procedures. All patients returned to light duty work in 24 to 48 hours and full strenuous physical activity within 1 week. The only complications encountered were 2 wound hematomas (0.3%), 4 minor wound separations (0.7%) and 41 hydroceles (7.3%). Semen improvement and pregnancy rates were similar to those reported in prior series. This study demonstrates that varicocele vein ligation can be done rapidly, efficiently and safely using local anesthesia with time of recovery and return to work comparable to those reported for laparoscopic techniques.

Pathologic Changes in The Kidneys and Other Organs of Dogs Undergoing Extracorporeal Shock Wave Lithotripsy with A Tubless Lithotripter

Extracorporeal shock wave lithotripsy (ESWL) is an accepted method of treatment for renal calculi. Complications are rare, although most patients experience temporary hematuria. Shock waves generated by a spark plug in a tubless lithotripter administered to stones placed into the renal pelves of dogs, resulted in interstitial renal hemorrhage developing acutely, and interstitial fibroblastic reactions chronically. The latter were linear, and were in the cortex and/or medulla. They resulted from organisation of the interstitial hemorrhages. In addition interstitial nephritis was present and this could be the result of the surgery, the stones, preexisting infection or the ESWL. Other organs were intact, with the exception of a hematoma in the large bowel of one dog. Lithotripsy, in this dog model, produced a spectrum of kidney injury.

Prevalence of Sperm Bound Antibodies in Infertile Men with Varicocele: The Effect of Varicocele Ligation on Antibody Levels and Semen Response

An increased level of antisperm antibodies has been demonstrated in infertile men with varicocele compared with normal fertile men, suggesting a possible cause and effect relationship. To evaluate the possible etiological role of antisperm antibodies in varicocele patients, we performed a prospective study of 32 infertile men undergoing varicocele ligation. Semen analyses and antisperm antibodies as measured by the immunobead test were performed preoperatively and postoperatively at 3 and 6 months. Of the infertile men with varicocele 28% had a positive immunobead test compared with 0% of normal fertile men. The average total motile sperm count was significantly different (p < 0.05, 2-tailed t test) for 9 varicocele patients with sperm-bound antibody (3.2 x 10(6)) compared with 23 without antibody (8.4 x 10(6)). Postoperatively, 68% of all patients exhibited improved semen parameters, with no change in antibody status in either group. Among the antibody positive group 71% showed an increase in motile sperm per ml. of 2.8 x 10(6) to 17.2 x 10(6) (525% increase, p < 0.05), while in the antibody negative group 67% showed an increase of 3.8 x 10(6) to 24.9 x 10(6) (553% increase, p < 0.05). Our study suggests that there is an increased incidence of sperm-bound immunoglobulin in infertile varicocele patients and an apparent adverse effect on semen parameters in these patients. However, the presence of sperm-bound immunoglobulin did not affect the percentage response to surgical correction, nor can we postulate an immunological mechanism as a major etiological factor in varicocele induced infertility.

Results in the United States with Sperm Micro-Aspiration Retrieval Techniques and Assisted Reproductive Technologies

AbstractImproved methods of urological microsurgery and of various assisted reproductive technologies have resulted in the ability to achieve pregnancies with sperm aspirated microsurgically from men with bilateral congenital absence of the vasa deferentia or with ductal obstructions that cannot be surgically reconstructed. A survey was conducted of the results of such procedures performed in the United States during approximately 2 years. Female partner ovarian stimulation was initiated in 219 instances at 22 centers. Of the 219 procedures 23 (11%) were terminated without attempting any form of gamete fertilization or insemination of the wife for various reasons (no sperm or too few sperm retrieved, poor to absent sperm motility or poor quality eggs). The etiology of azoospermia in the 219 procedures was congenital absence of the vasa deferentia in 115 cases (52%), other congenital conditions in 15 (7%), failed vasectomy reversal in 37 (17%), infection in 4 (2%), other conditions (mainly ejaculatory dysf...

Microsurgical Epididymovasostomy: Predictors of Success

The results of microsurgical epididymovasostomy for congenital and acquired vasoepididymal obstruction were retrospectively reviewed in 22 patients in an attempt to determine what preoperative or intraoperative factors might predict surgical success. The overall success rate, defined as sperm on postoperative semen analysis, was 48%. The presence of sperm on an intraoperative touch preparation from the epididymis was significantly correlated with response (chi-square 3.24, p < 0.10) and no patient without sperm on touch preparation had sperm on subsequent semen analyses. Testicular biopsy positive for spermatogenesis and presence of motile sperm on intraoperative touch preparation were not statistically significant predictors of response. These results suggest that presence or absence of sperm on intraoperative touch preparation is the only significant prognosticator of successful microsurgical epididymovasostomy.