Richard D. Amelar

Etiologic Factors in 1294 Consecutive Cases of Male Infertility

Between January 1965 and December 1970 1294 cases of male subfertility were analyzed. Varicoele which is probably secondary to retrograde flow of blood down the incomopetent internal spermatic vein and to premature sloughing of immature cells in the testes comprised 39% of the cases. Surgical correction where indicated resulted in a 48% pregnancy rate. Subfertility was associated with too low semen volume in 1.8% of the cases and with too high semen volume and poor semen quality in 10% of cases. Ejaculatory disturbances including retrograde ejaculation no ejaculation and congenital anatomic abnormality led to infertility in 2% of cases. Artificial homologous insemination was often sucessful in each of these classes. In this series 7.1% cases were secondary to low levels of pituitary gonadotropin. Treatment with gonadotropins as about 30% successful. Adrenogenital syndrome was diagnosed in .9% of the cases. Treatment with corticosteroids is effective. Thyroid problems were diagnosed in .6% of cases. Sexual problems with normal semen quality occurred in 5.1% of the cases. Epididymal obstruction with an infectious etiology often corrected by epididymovasostomy occurred in 4.4% of cases. Absent vasa deferentia due to an embryological growth were noted in 1.8% of cases. Men requesting repair of vasectomies comprised 1.2%. Success was near 40%. Testicular failure including germinal cell aplasia Klinefelters syndrome infantile testes mumps orchitis maturation arrest testis tumor and surgical injury occurred in 14% of cases. Azoospermia due to untreated nondescent of bilateral crytorchidism surgery after puberty or postsurgical atrophy was observed in 4.4% of cases. Early treatment is advocated. Other causes of subfertility were irreversible necrospermia (1.3%) high sperm density (.2%) sperm autoagglutination (.8%) high seminal viscosity (.1%) and unknown (5.4%).

Varicocelectomy: 986 cases in a twelve-year study.

Over a twelve-year period, surgical correction of varicocele was performed on 986 selected subfertile men. They were followed up for at least two years after surgery. Semen quality was improved in 70 per cent, and 53 per cent of the wives became pregnant. Statistically, the results were better in terms of semen quality improvement and pregnancy for patients who had preoperative sperm counts over 10 million per milliliter (85 per cent improved, 70 per cent pregnancy rate) than for patients who had preoperative sperm counts of less than 10 million per milliliter (35 per cent improved, 27 per cent pregnancy rate). The empirical use of postoperative human chorionic gonadotropin therapy in this latter group improved results significantly (55 per cent improved, 45 per cent pregnancy rate).

Varicocelectomy as Therapy in Male Infertility: A Study of 504 Cases

Over a ten-year period, surgical correction of varicocele was performed on 504 selected subfertile men. They were followed up for at least one year after surgery. Semen quality was improved in 71% and 55% of the wives became pregnant. Statistically, the results were better in terms of semen quality improvement and pregnancy for patients who had preoperative sperm counts over 10 million/ml (88% improved, 68% pregnancy rate) than for patients who had preoperative sperm counts of less than 10 million/ml (33% improved, 23% pregnancy rate). The empirical use of postoperative human chorionic gonadotropin therapy in this latter group improved results significantly (56% improved, 44% pregnancy rate).

Stimulation of Ejaculated Human Spermatozoa by Caffeine

Caffeine (1, 3, 7-trimethyl-2, 6-dioxypurine), a cyclic nucleotide phosphodiesterase inhibitor, increased the motility of ejaculated human spermatozoa. Both the percent motility and the grade of forward progression were significantly increased (P smaller than 0.001) and maintained in the presence of 6 mM of caffeine for up to five hours at 37 C. Increases in percent motility greater than two-fold occurred among the groups having low initial motility. Increases in samples with a high initial percent motility (greater than 60%) were not as dramatic, but they were still significant. In addition, the grade of motility or forward progression was increased in all groups up to one full unit. The longevity of the spermatozoa, judged by activity, was also increased for up to five hours.

Varicocelectomy as therapy in male infertility: a study of 504 cases.

During a 10-year period 504 selected subfertile men underwent surgical correction of varicocele and had a followup of at least 1 year. Improved semen quality was reported in 71 per cent of the men and 55 per cent of the wives became pregnant. Statistically, results were better in terms of semen quality improvement and pregnancy in patients who had preoperative sperm counts greater than 10 million per cc (88 per cent improved, 68 per cent pregnant) compared to patients who had preoperative sperm counts of less than 10 million per cc (33 per cent improved, 23 per cent pregnant). The impiric use of postoperative human chorionic gonadotropin therapy in the latter group of patients improves results significantly (56 per cent improved, 44 per cent pregnant).

Semen analysis: An office technique

Semen analysis can be performed in the physicians office. An outline is provided of the technique used in our urologic office-laboratory for semen analysis.

Prolactin, fructose, and zinc levels found in human seminal plasma.

Fructose, zinc, and prolactin determinations were performed on the seminal plasma of normospermic (n = 30), oligospermic (n = 30), and azoospermic (n = 30) men to determine whether there was a correlation between any of these substances and seminal quality. None of these azoospermic men had congenital bilateral absence of the vasa, but in a separate group of such men (n = 10) these same studies were performed. Fructose was determined photometrically, zinc by atomic absorption, and prolactin by radioimmunoassay. Zinc and fructose levels in all three groups showed no statistical differences. Prolactin was found to be significantly higher in the seminal plasma of normospermic men than was found in the seminal plasma of oligospermic or azoospermic men. In men with congenital bilateral absence of the vasa and seminal vesicles, zinc was elevated, fructose was absent, and prolactin was markedly depressed.

RELAXIN IN HUMAN SEMINAL PLASMA

While relaxin is known as a hormone of pregnant females, it has been identified in rooster l and boar testes.g A recent report described immunoreactive relaxin in human seminal p l a ~ m a . ~ Relaxin is a structural homologue of insulin and other growth factors.* Epidermal growth factor and nerve growth factor are found in secretions of male salivary glands and the genitourinary Seminal plasma is rich in proteins and contains other peptide hormones, including growth hormone,8 p ro la~ t in ,~ and insulin.10 In this report, we characterize the immunoreactive relaxin-like substance in seminal plasma as bioactive relaxin and determine its source of production.

Right varicocelectomy in selected infertile patients who have failed to improve after previous left varicocelectomy

In the past 8years we found 41 infertile men with poor semen quality in whom an overlooked right varicocele might have been the reason for failure to improve after previous left varicocelectomy. None had ever fathered a child. After we performed sequential right varicocelectomy in these 41 patients, semen quality improved in 23 (56%). Twenty-seven pregnancies have been achieved to date by the wives of 18 (43%) of the patients whose semen improved. No pregnancies were caused by those whose semen failed to improve. Infertile men should be carefully examined for varicoceles on both sides, and bilateral varicocelectomy should be performed when indicated. Selected infertile patients who have failed to improve after left varicocelectomy and are found subsequently to have a right varicocele may yet improve following correction of the right varicocele.

Circulating Sperm-Agglutinating Antibodies in Azoospermic Men with Congenital Bilateral Absence of the Vasa Deferentia *

Congenital bilateral absence of the vasa deferentia has been found to be the cause for azoospermia in 101 patients who have been examined in our urologic practice since 1956. This represents approximately 2% of the 5112 patients seen during that time because of problems relating to infertility. Of these 101 men, 29 have had their sera tested for the presence of circulating sperm-agglutinating antibodies. The Shulman15 modification of the macroscopic gelatin sperm-agglutination test of Kibrick et al6 was used. None of these patients had had testicular biopsy. Significantly high titers (1:32 or greater) of antibodies were found in 18 (62.1%) men, low titers (1:16 or less) in five (17.2%), and no antibodies in six (20.7%).