Male Infertility (eBook)

Preface 6
Acknowledgments 8
Contents 10
Contributors 12
The Initial Consultation for Male Infertility 14
Introduction 14
Male Infertility 14
Sexual History 16
Developmental and Childhood History 17
Infection History 17
Medical History 18
Surgical History 20
Social History 20
Medications 21
Physical Exam 21
Summary 22
References 22
Interpretation of Basic Semen Analysis and Advanced Semen Testing 27
Introduction 27
Basic Semen Analysis 27
Macroscopic Parameters 28
Microscopic Parameters 28
Sperm Concentration 29
Sperm Motility 29
Sperm Morphology 29
Nonsperm Cellular Components 30
Sperm Motion Kinetics 30
Investigations for Antisperm Antibodies 31
Sperm Function Tests 31
Evaluation of Oxidative Stress 32
Assessment of DNA Integrity 32
Summary 33
References 33
Azoospermia: Diagnosis and Management 35
Introduction 35
Initial Evaluation 35
History and Physical Exam 35
Semen Analysis 36
Serum Hormonal Evaluation 36
Genetic Testing 37
Y Chromosome Microdeletions 37
Karyotype 37
CFTR Gene Mutation Screening 37
Diagnosis 37
Common Causes of Azoospermia 39
Obstructive Causes 39
Iatrogenic Causes 39
Ejaculatory Duct Obstruction 39
Congenital Bilateral Absence of the Vas Deferens 39
Nonobstructive Causes 40
Klinefelter’s Syndrome 40
Azoospermia Secondary to Cancer Therapy 40
Hypogonadotropic Hypogonadism 40
Ejaculatory Dysfunction 41
Summary 41
References 41
Ejaculatory Dysfunction 43
Introduction 43
Normal Ejaculation 44
Types of Ejaculatory Dysfunction 44
Premature Ejaculation 44
Idiopathic Anejaculation/Anorgasmia 44
Neurogenic Anejaculation 44
Retrograde Ejaculation 45
Evaluation of Ejaculatory Dysfunction 45
Interventions for Ejaculatory Dysfunction 46
Medications 46
Artificial Insemination for Retrograde Ejaculation 46
Penile Vibratory Stimulation 46
Electroejaculation 47
Surgical Sperm Retrieval 47
Choice of Sperm Retrieval Technique 47
Diagnostic and Treatment Algorithms 48
Summary 48
References 50
Genetic Issues with Male Fertility 51
Introduction 51
In Whom Do We Look? 51
What Are the Tests that Can Be Done? 52
What Does a Positive Result Mean? 53
What Can We Do About It? 55
Conclusion 56
References 56
Endocrinopathies in Male Infertility 58
Introduction 58
Physiologic Regulation of the Hypothalamic–Pituitary–Testicular Axis 59
Evaluation and Testing 59
Hyperprolactinemia 60
Hypogonadotropic Hypogonadism 60
Failure of Hypothalamus 60
Pituitary Insufficiency 60
Other Syndromes Leading to Hypogonadotropic Hypogonadism 60
Isolated Luteinizing Hormone or Follicle-Stimulating Hormone Deficiency 61
Hypergonadotropic Hypogonadism 61
Klinefelter Syndrome 61
Gonadal Toxicity 61
Inactivating Luteinizing Hormone–Follicle-Stimulating Hormone Receptor Mutations 61
Hypogonadism with Normal or Elevated Testosterone 62
Infertility Associated with Exogenous Testosterone Therapy 62
Androgen Receptor Defects and Androgen Insensitivity Syndromes 62
Congenital Adrenal Hyperplasia 62
Leydig Cell Tumors 63
Treatment Options 63
Treatment of Hyperprolactinemia 63
Treatment of Hypogonadotropic Hypogonadism 63
Treatment of the Endocrinopathy Associated with Klinefelter Syndrome 64
Conclusions 64
References 65
Female Fertility: Implications to Management of Male Factor 67
Evaluation 67
Ovulatory Dysfunction 68
Tubal Disease 69
Uterine Factors 70
Endometriosis 71
Unexplained Infertility 71
References 72
Varicocele: To Fix or Not to Fix 74
Introduction 75
Incidence 75
Etiology of Varicocele 76
Pathophysiology and Typical Testicular Histological Abnormalities in Men with Varicocele 77
Seminal Reactive Oxygen Species/Antioxidants Imbalance (Oxidative Stress) 78
Varicocele – Is it a Reason for Infertility? 79
Diagnosis of Varicocele 79
Clinical Treatment for Varicocele – When and Which Drug? 80
Subclinical Varicocele: A Different Entity 80
Surgical Versus Embolization Approach 80
Azoospermia and Varicocele 81
Improvement in Semen Parameters After Varicocelectomy: Is There an Improvement with Assisted Fertilization? 81
Varicocele in the Adolescent 82
There Is a Benefit of Surgery for Couples with a Clear Indication of Assisted Fertilization 83
Best Patient to Benefit from Surgery 83
Conclusions 84
References 84
Medical Management of Male Infertility 89
Introduction 89
Endocrinopathies 89
Hormonal Deficiency 90
Hypogonadotropic Hypogonadism 90
Hypothyroidism 90
Hormonal Excess 91
Androgen Excess 91
Estrogen Excess 91
Thyroid Excess (Hyperthyroidism) 91
Prolactin Excess (Hyperprolactinemia) 91
Infection and Inflammation 92
Ejaculatory Dysfunction 93
Erectile Dysfunction 94
Medications and Substances That Impair Male Fertility 94
Conclusion 94
References 95
Surgical Reconstructions for Obstruction 97
Introduction 97
Anatomy, Physiology, and Pathology of the Excurrent Ductal System 98
Etiology of Ductal Obstruction 99
Reconstructive Procedures 99
Types of Reconstruction: Vasovasostomy(VV) Vs. Vasoepididymostomy(VE) 99
Operative Planning 99
Modified One-Layer Vasovasostomy (Fig. 2) 100
Multi-Layer Vasovasostomy (Fig. 3) 100
Microscopic Vasoepididymostomy (Fig. 4) 101
Microsurgical Reconstruction Outcomes 103
Summary 104
References 105
Techniques for Sperm Harvest 107
Introduction 107
Ejaculatory Dysfunction 107
Technique of Rectal Probe Electrostimulation 108
Obstructive Azoospermia 109
Percutaneous Sperm Retrieval Techniques 109
Microsurgical Epididymal Sperm Aspiration 110
Nonobstructive Azoospermia 110
Fine Needle Aspiration with mapping 111
Open Testicular Sperm Extraction 111
Processing of Testicular Tissue Samples 113
Summary 113
References 114
Sperm Banking: When, Why, and How? 115
Why and When Do Men Need to Bank Their Sperm? 116
Couples 116
Patients with Cancer 117
Factors That Prevent Patients from Sperm Banking 118
How Does Sperm Banking Work: Techniques of Semen Cryopreservation 118
Preparation and Preselection 119
Rapid Freezing 119
Slow Freezing 119
Vitrification 121
Advantages and Disadvantages of Cryoprotectants 121
Glycerol 121
TEST-Yolk Buffer 122
The Effect of Cryopreservation on Sperm Characteristics 122
ART Outcomes with Banked Semen Specimens 123
Advantages of ICSI and Use of Cryopreserved Spermatozoa 123
Challenges and Risks Associated with Cryopreservation 124
Conclusion 124
References 124
Assisted Reproduction and Male Factor Fertility: Which Type Is Right? 127
Intrauterine Insemination 127
IUI Outcomes 128
In Vitro Fertilization/Intracytoplasmic Sperm Injection 129
Summary 130
References 130
Ethical Dilemmas in Male Infertility 132
In Vitro Fertilization and Intracytoplasmic Sperm Injection 132
Posthumous Sperm Retrieval 133
Donor Insemination 134
Conclusion 135
References 135
Index 136