Rodrigo Pagani

Age-related increase of reactive oxygen species in neat semen in healthy fertile men.

OBJECTIVES The effects of advancing paternal age on the male reproductive system are well known, but its effects on fecundity remain controversial. Although oxidative stress is associated with poor semen quality and function, a relationship with advancing male age has not been established. The objective of this study was to analyze the relationship between male age and seminal reactive oxygen species (ROS) levels in men presenting for voluntary sterilization. METHODS We prospectively evaluated 98 fertile men who were candidates for vasectomy. These were divided into 2 age groups: less than 40 years (n = 78) and 40 or more years (n = 20). We used 46 infertile patients as positive controls. Standard semen analysis, seminal leukocyte count and ROS levels were measured in all samples. Fertile men with leukocytospermia were excluded. RESULTS The mean age of the men was 35.1 +/- 5.6 years. Men 40 years and older had significantly higher ROS levels compared with younger men (P <0.001). We observed a positive correlation between seminal ROS levels and age (r = 0.20; P = 0.040). In addition, ROS was negatively correlated with sperm concentration (r = -0.48; P <0.001) and motility (r = -0.21; P = 0.030). CONCLUSIONS Reactive oxygen species levels are significant higher in seminal ejaculates of healthy fertile men older than 40 years. ROS levels in whole ejaculate are significantly correlated to age among fertile men. Because ROS are clearly implicated in the pathogenesis of male infertility, these data suggest that delayed fatherhood may reduce the chances of pregnancy as men become progressively less fertile with age.

The epidemiology and etiology of azoospermia

The misconception that infertility is typically associated with the female is commonly faced in the management of infertile men. It is uncommon for a patient to present for an infertility evaluation with an abnormal semen analysis report before an extensive female partner workup has been performed. Additionally, a man is usually considered fertile based only on seminal parameters without a physical exam. This behavior may lead to a delay in both the exact diagnosis and in possible specific infertility treatment. Moreover, male factor infertility can result from an underlying medical condition that is often treatable but could possibly be life-threatening. The responsibility of male factor in couples infertility has been exponentially rising in recent years due to a comprehensive evaluation of reproductive male function and improved diagnostic tools. Despite this improvement in diagnosis, azoospermia is always the most challenging topic associated with infertility treatment. Several conditions that interfere with spermatogenesis and reduce sperm production and quality can lead to azoospermia. Azoospermia may also occur because of a reproductive tract obstruction. Optimal management of patients with azoospermia requires a full understanding of the disease etiology. This review will discuss in detail the epidemiology and etiology of azoospermia. A thorough literature survey was performed using the Medline, EMBASE, BIOSIS, and Cochrane databases. We restricted the survey to clinical publications that were relevant to male infertility and azoospermia. Many of the recommendations included are not based on controlled studies.

The systematic use of intraoperative vascular Doppler ultrasound during microsurgical subinguinal varicocelectomy improves precise identification and preservation of testicular blood supply

OBJECTIVE To evaluate the impact of systematic use of intraoperative Doppler ultrasound during microsurgical subinguinal varicocele repair. DESIGN Prospective clinical study. SETTING Andrology laboratory and male infertility section of the urology department of a tertiary care hospital. PATIENT(S) Two hundred and thirteen men with clinical varicocele. INTERVENTION(S) Subinguinal microsurgical varicocele ligation using an intraoperative vascular Doppler flow detector. MAIN OUTCOME MEASURE(S) Number of veins ligated, lymphatic spared, arteries identified or accidentally ligated. RESULT(S) A statistically significant greater number of arteries were identified and preserved when intraoperative vascular Doppler was used. In addition, the average number of internal spermatic veins ligated was statistically significantly greater in the same group. Accidental artery ligation occurred in two cases (1.1%) in which the Doppler was not applied. There was no statistically significant difference in number of lymphatics spared between groups. CONCLUSION(S) Our findings showed that concomitant use of intraoperative vascular Doppler during microsurgical varicocelectomy allows more arterial branches to be preserved, and more internal spermatic veins are likely to be ligated. This device should be considered an attractive tool to improve surgical outcomes and safety.

Use of subinguinal incision for microsurgical testicular biopsy during varicocelectomy in men with nonobstructive azoospermia

OBJECTIVE To describe a subinguinal technique of microsurgical testicular biopsy performed during subinguinal varicocelectomy in men with nonobstructive azoospermia. DESIGN Prospective clinical study. SETTING Andrology laboratory at tertiary care hospital. Male infertility section, department of urology, at tertiary care hospital. PATIENT(S) Ten azoospermic men with clinical varicocele. INTERVENTION(S) Subinguinal microsurgical testicular biopsy and microsurgical varicocele repair. MAIN OUTCOME MEASURE(S) Safety, feasibility, and effectiveness of subinguinal testicular biopsy during varicocele repair. RESULT(S) All testes were easily delivered through the subinguinal incision, and testicular biopsies were successfully performed under microscopic view. After a median follow-up of 9 months, none of the patients had any discomfort, pain, or presented with testicular atrophy. No intraoperative or postoperative complications were observed. There was no incidence of wound infection or scrotal hematoma. CONCLUSION(S) The subinguinal approach is a safe and effective option for testicular biopsy during varicocele repair in men with nonobstructive azoospermia. This technique may be an attractive alternative to traditional biopsy because it obviates scrotal violation.

Testicular adrenal rest tumor in infertile man with congenital adrenal hyperplasia: case report and literature review

CONTEXT Synthesis of cortisol and aldosterone is impaired in patients with congenital adrenal hyperplasia (CAH) because of 21-hydroxylase deficiency. Men with CAH have low fertility rates compared with the normal population, and this is related to testicular adrenal rest tumors. Findings of azoospermia in combination with a testicular tumor on ultrasound are likely to have a mechanical cause, especially when in the testicular mediastinum. The preferred treatment method consists of intensive corticoid therapy. However, when the tumor is unresponsive to steroid therapy, surgical treatment should be considered. CASE REPORT We present the case of a male patient with CAH due to 21-hydroxylase deficiency who presented a testicular tumor and azoospermia. Treatment with low daily corticoid doses had previously been started by an endocrinologist, but after 12 months, no significant change in sperm count was found. Although the adrenocorticotrophic hormone and 17-hydroxyprogesterone levels returned to normal values, the follicle-stimulating hormone (FSH), luteinizing hormone and testosterone levels remained unchanged. Ultrasound examination confirmed that the testicles were small and heterogenous bilaterally, and revealed a mosaic area at the projection of the testis network bilaterally. Magnetic resonance imaging confirmed the finding. Testicular biopsy revealed the presence of preserved spermatogenesis and spermiogenesis in 20% of the seminiferous tubules in the right testicle. The patient underwent testis-sparing tumor resection. After 12 months of follow-up, there was no tumor recurrence but the patient still presented azoospermia and joined an intracytoplasmic sperm injection program.

Sclerotherapy of hydroceles and spermatoceles with alcohol: results and effects on the semen analysis

PURPOSE To evaluate the success rates of sclerotherapy of the tunica vaginalis with alcohol for the treatment of hydroceles and/or spermatoceles, as well as, evaluation of pain, formation of hematomas, infection and its effects in spermatogenesis. MATERIALS AND METHODS A total of 69 patients, with offsprings and diagnosis of hydrocele and/or spermatocele, were treated during the period from April 2003 to June 2007. Semen analysis was obtained from patients who were able to provide us with samples. The sclerotherapy with alcohol at 99.5% was undertaken as outpatient procedure. RESULTS The average volume drained pre-sclerotherapy was 279.82 mL (27 to 1145). The median follow-up was 43 months (9 to 80). A total of 114 procedures were performed on 84 units, with an average of 1.35 procedures/unit and an overall success rate of 97.62%. Of the 69 patients, 7 (10.14%) reported minor pain immediately after the procedure, 3 (4.35%) moderate pain and 2 (2.89%) intense pain. Post-Sclerotherapy spermograms revealed reduction of the parameters regarding: concentration, motility and morphology up to 6 months post procedure, with return to normal parameters 12th months after procedure. CONCLUSIONS Sclerotherapy of hydroceles and spermatoceles with 99.5% alcohol is an efficient procedure that can be performed without difficulties, cost-effectiveness, with few side effects and which may be performed in patients who wish fertility.

General Endocrine Therapy

Testis must not be seen as a static organ, but rather as a dynamic organ that might respond by increasing its function, both steroidogenesis and spermatogenesis, in response to proper stimuli. Furthermore, these two testicular functions are interchangeable and intrinsically related to each other. The hypothalamic–pituitary–gonadal (HPG) axis acts in the Leydig cell through the secretion of luteinizing hormone (LH) and in the Sertoli cell through the action of the follicle-stimulating hormone (FSH), and knowing its physiology allow the proper management of male infertility.

Disorders of Sex Determination and Development

Disorders of sex development (DSD) are congenital diseases in which the chromosomal, gonadal, or anatomical sex is abnormal and embraces a wide-ranging spectrum of phenotypes classified in five different groups ( Hughes et al., 2006 ). The first class involves disorders of gonadal differentiation; the second comprehends ovotesticular DSD (formerly known as true hermaphroditism); the third includes 46,XX DSD (formerly known as female pseudohermaphroditism); the fourth encloses 46,XY DSD (formerly known as male pseudohermaphroditism); and the fifth group consists of unclassified forms. When such a child is born, both the parents and a multidisciplinary medical staff are opposed to demanding decisions regarding gender assignment, genital surgery, and fertility issues. In this article, only conditions where testes are involved is going to be addressed.