Quantitative pathologic changes in the human testis after vasectomy. A controlled study

Apoptotic frequency is increased in spermatogenic maturation arrest and hypospermatogenic states

PURPOSE

Increased testicular apoptosis has been observed in maturation arrest and hyposper-matogenesis states in rodent models, but this process has not yet been characterized in humans. We hypothesized that increased cell death present with accelerated apoptosis is significant in pathophysiology of many male infertility states associated with abnormal spermatogenesis. We examined frequency of apoptotic bodies in human testis biopsy specimens from infertile men using morphometric analysis of hematoxylin and eosin stained paraffin sections.

MATERIALS AND METHODS

Testis biopsy specimens were obtained for routine clinical purposes from azoospermic and severely oligozoospermic men and were stained with hematoxylin and eosin. Apoptotic bodies were identified using established morphometric criteria. Apoptotic indexes, defined as apoptotic bodies per total number of cells and per Sertoli cells, were calculated after counting all intratubular spermatogenic cells and Sertoli cells in 20 tubules.

RESULTS

A total of 51 biopsies was performed in 50 men. Significantly increased apoptotic body per total cell and apoptotic body per Sertoli cell ratios were observed in maturation arrest and hypospermatogenesis states in comparison to Sertoli cell only and normal spermatogenesis (p < 0.05, Mann-Whitney test).

CONCLUSIONS

Increased apoptosis in maturation arrest and hypospermatogenesis states compared to normal but obstructed spermatogenesis and Sertoli cell only were observed, indicating a prominent role for this form of programmed cell death in human male infertility.

Structure of small blood vessels in the testes of infertile men

In the testis, 'hyalinization' of the lamina propria of seminiferous tubules is often accompanied by similar changes within the walls of testicular blood vessels. The aim of our study was to investigate the structure of small blood vessels in hyalinized human testes by means of immunohistochemistry, electron microscopy and image analysis methods. Results of immunohistochemical analysis indicated that, despite hyalinization, testicular small blood vessels retained positive immunostaining for desmin and actin. Their basement membranes remained immunopositive for collagen IV and laminin. No proliferative (Ki-67) activity was observed in the blood vessel walls in testes from both control and infertile men. P-170 glycoprotein was found to be expressed only in primary spermatocytes. No difference in expression and localization of this antigen was observed between control and affected testes. Electron microscopy revealed a number of testicular arterioles with a notably narrow lumen due to enlarged endothelial cells in infertile men. Such arterioles also had a thickened subendothelial layer and an abundant tunica adventitia rich in connective tissue fibres and ground substance. Some venules in hyalinized testes displayed increased connective fibres and ground substance in the subendothelial layer, between the smooth muscle cells of the tunica media and the tunica adventitia. However, no changes were found in the capillary network, when compared to controls. Image analysis data showed a statistically significant increase in the surface of tunica intima and adventitia of arterioles and tunica media of venules. It is concluded that hyalinization mostly affects testicular arterioles and venules, but not capillaries. Our immunohistochemical data indicate that the 'nature' and/or extent of hyalinization in testicular small blood vessels differs from that described previously for the lamina propria of seminiferous tubules.

Electrovasography in normal and vasectomized men before and after vasectomy reversal

The electrical pattern of the vas deferens, or electrovasogram (EVG), was studied in 22 healthy volunteers, 20 vasectomy subjects and 18 individuals after vasectomy reversal. Their mean ages were 38.8 +/- 7.3, 44.3 +/- 7.9 and 58.6 +/- 6.6 years, respectively. Two electrodes were applied to the posterior aspect of the upper part of the scrotum. During the operation of vasectomy reversal, an electrode was applied directly to each of the two vasal segments before and immediately after vasovasostomy. The electrical activity and intravasal pressure were measured. In normal subjects, slow waves or pacesetter potentials (PP) were recorded. They had identical frequency and a regular rhythm from the two electrodes and were consistent in the individual subject on all test days. PP were followed randomly by bursts of action potentials (AP). In vasectomized subjects, PP from the proximal vasal segment exhibited an irregular rhythm (vasoarrhythmia). During operation for vasectomy reversal, the proximal vasal segment recorded vasoarrhythmia whereas the distal segment revealed a silent EVG. Intravasal pressure was normal (p > 0.05) in the distal segment but high (p < 0.05) in the proximal segment. EVG performed 1-6 years after vasectomy reversal showed a normal pattern in four subjects and diminished frequency and amplitude in three. These seven subjects had impregnated their wives and had an obstructive interval of < 3 years. The 11 subjects who did not produce a pregnancy had a vasoarrhythmic EVG and an obstructive interval of > 3 years. In conclusion, an EVG could be identified for normal subjects. Vasectomy resulted in a vasoarrhythmic EVG pattern which proved to be correctable by vasectomy reversal if the obstructive interval was short.

Changes in the testes following vasectomy in the rat

Six months and more after unilateral vasectomy in the rat, ipsilateral (same side) and bilateral testicular atrophy are common; this paper investigates their etiology. Ipsilateral atrophy is associated with the presence of a sperm granuloma in the head of the corresponding epididymis and appears to be pressure-mediated. That sperm granulomas at the epididymal head fail to relieve intraluminal pressure in the epididymal duct of the rat was supported by a study of the effects of ligation of that region. No histological evidence was found to indicate that bilateral atrophy was the result of an immune response. A radiological study does not support the idea that compression or displacement of testicular blood vessels by sperm granulomas is responsible for bilateral atrophy.

Electrovasogram in normal and vasectomized men and patients with obstructive azoospermia and absent vas deferens

The electric activity of the vas deferens (VD) or the electrovasogram (EVG) was recorded in 34 healthy volunteers (mean age 39.3 +/- 7.6 [SD] years), 22 patients with obstructive azoospermia (mean age 38.8 +/- 9.2 years), 10 after epididymovasostomy performed for obstructive azoospermia (mean age 40.6 +/- 4.8 years), 9 with bilaterally absent vasa deferentia (mean age 36.6 +/- 7.4 years), 20 after vasectomy (mean age 44.3 +/- 7.9 years), and 18 after vasectomy reversal (mean age 58.6 +/- 6.8 years). Silver-silver chloride electrodes were applied to the posterior aspect of the upper part of the scrotum and a reference electrode was applied to the lower limb. The intravascular pressure was also measured in 18 subjects during vasectomy reversal operation. Normal EVG manifested as regular slow waves or pacesetter potentials (PPs) which had the same frequency, amplitude, and regular rhythm when the test was repeated in the individual subject. Mean frequency was 6.6 +/- 1.5 cycles/min, amplitude was 0.6 +/- 0.1 mV, and velocity was 5.6 +/- 1.1 cm/s. PPs were followed randomly by action potentials (APs). The EVG in obstructive azoospermia exhibited bradyvasa, i.e., diminished PP frequency, amplitude, and velocity, in 14 patients and a "silent" EVG in 8 patients. Eight of the 10 patients in whom azoospermia persisted after epididymovasostomy had a silent EVG, and the remaining 2 patients whose semen character normalized after the operation revealed normal EVG. A silent EVG was also recorded by the 9 patients with absent vasa deferentia. In vasectomized subjects, PPs from the proximal vasal segment exhibited an irregular rhythm (vasoarrhythmia). During vasectomy reversal, the proximal vasal segment exhibited vasoarrhythmia and high pressure (p < .05) and the distal segment showed a silent EVG and normal pressure (p > .05). EVG performed postvasectomy reversal by 1-6 years showed a normal pattern in 7 subjects who have impregnated their wives and vasoarrhythmic EVG in 11 who could not produce pregnancy. In conclusion, EVG could be characterized for normal and pathologic vasa deferentia. Electrovasography is a simple, noninvasive, and nonradiologic technique that might be used as a diagnostic tool in the investigation of VD disorders and infertility.

Fertility in cases of hypergonadotropic azoospermia

OBJECTIVE

To review the outcome of reconstructive microsurgery in men with hypergonadotropic azoospermia.

DESIGN

A retrospective study on patients with hypergonadotropic azoospermia who underwent scrotal exploration and bypass microsurgery.

SETTING

Male infertility microsurgery clinic affiliated with a tertiary university hospital.

PATIENTS

Thirty-one hypergonadotropic azoospermic men with evidence of spermatogenesis on testicular biopsy.

INTERVENTIONS

Microsurgical exploration of the testes, operative sperm aspiration, and bypass procedures: vasoepididymostomy or vasovasostomy.

MAIN OUTCOME MEASURES

Intraoperative aspirated sperm, postoperative ejaculated sperm, proof of fertilizing ability (fertilizations), and pregnancies.

RESULTS

Sperm were aspirated intraoperatively in all cases and were detected in postoperative ejaculations in 87%. Of the 14 patients with long-term follow-up data, 6 achieved pregnancies (8 children), and 3 more demonstrated the capacity for fertilization at IVF.

CONCLUSIONS

The observation of a high serum FSH in men with azoospermia does not rule out the possibility of obstruction and the capacity for fertility. Caution should be exercised particularly if unilateral testicular atrophy is present. A testicular biopsy should be performed to detect possible spermatogenesis and, if present, then a microsurgical bypass can lead to a successful pregnancy.

Epididymovasostomy

There are a variety of causes of epididymal obstruction, but the most frequent indication for epididymovasostomy today is obstruction following vasectomy. We have seen significant advances over the last few decades in our techniques for reconstructing the proximal excurrent ductal system in order to restore sperm to the ejaculate and fertility in men with azoospermia secondary to epididymal obstruction. The patency rates for epididymovasostomy have improved significantly with the use of microsurgical techniques and specific tubule anastomosis. The level of anastomosis plays a crucial role in eventual fertility. These microsurgical techniques are tedious and difficult to master but practice and meticulous attention to detail are rewarded by excellent results.

The influence of vasectomy and vasovasostomy on testicular ATPases, cAMP, ABP and androgen receptor in rabbits

The present study was performed to further clarify the influences of vasectomy on functions of testis and to disclose the possible mechanisms of infertility after vasovasostomy (VV). Thirty-one rabbits were divided into sham-operated control group (C), vasectomy control group (V), VV fertility group (VaF) and VV infertility group (VaI). Serum testosterone (ST) level, testicular cAMP, androgen binding protein (ABP), nuclear androgen receptor (NAR) concentrations, testis cell membrane Na(+)-, K(+)-ATPase, Mg(2+)-ATPase activities, sperm density and testis weight were measured. Vasectomy resulted in significantly reduced cAMP, Na(+)-, K(+)-ATPase, Mg(2+)-ATPase, testis weight and increased ABP; VV completely restore testis weight in VaF and VaI, Na(+)-, K(+)-ATPase, Mg(2+)-ATPase in VaF, partly cAMP in VaF and VaI, Na(+)-, K(+)-ATPase, Mg(2+)-ATPase in VaI, but did not restore ABP. The NAR content in VaI was significantly lower than those in C, VaF and V. No statistical differences among 4 groups were seen in Kd values for [3H]-T. ST levels in VaF, VaI and V were insignificantly different compared with C, but the value in VaF was higher than that in VaI (p < 0.05). Sperm density after VV reached 122 +/- 62 x 10(6)/ml in VaF and 10 +/- 24 x 10(6)/ml in VaI, both in VaF and VaI were significantly low compared with C (p < 0.001), and the value in VaI was remarkedly lower than that in VaF (p < 0.001). It was shown that sperm density was positively correlated with cAMP content, Na(+)-, K(+)-ATPase, Mg(2+)-ATPase activities, but negatively with ABP. These results suggest that vasectomy gives rise to damage to the testis, and vasovasostomy does not appear completely effective in reversing testicular changes.

Epididymal micropuncture with in vitro fertilization and oocyte micromanipulation for the treatment of unreconstructable obstructive azoospermia

OBJECTIVE

To provide fertility to couples in whom the man has surgically unreconstructable obstructive azoospermia.

DESIGN

Prospective.

SETTING

Hospital-based IVF unit, including associated division of urologic microsurgery.

PATIENTS

Couples referred to our fertility unit for treatment of men with surgically unreconstructable reproductive tract obstruction, including congenital absence of the vas deferens.

MAIN OUTCOME MEASURES

Fertilization, pregnancies, and live births.

RESULTS

Of 51 cycles in which sperm and eggs were retrieved, 67% (34/51) resulted in fertilization and 27.5% (14/51) developed clinical pregnancy. Clinical pregnancy rate per couple was 33% (14/43). A total of 15 live births have been obtained in 11 couples with one ongoing pregnancy. Epididymal length was the best predictor of sperm quality and pregnancy results. For couples with at least the corpus epididymis present, 41% (9/22) of cycles resulted in clinical pregnancies.

CONCLUSIONS

Pregnancy rates are optimized using sperm retrieved from the epididymis by micropuncture and when micromanipulation is available for use during IVF.

Relationship between antisperm antibodies and testicular histologic changes in humans after vasectomy

OBJECTIVE

To determine whether or not there is an association between testicular histologic changes and antisperm antibodies in vasectomized men.

METHODS

Morphometry was performed on testicular biopsy specimens obtained from 19 vasectomized men and 21 fertile control subjects. Antisperm antibody status was determined on the serum of each patient and control subject using the indirect immunobead assay.

RESULTS

Significant increases in seminiferous tubule wall thickness (p < 0.001), focal interstitial fibrosis (p < 0.001), and percent composition of interstitium (p < 0.01) were observed in vasectomized men as compared with control subjects. Serum antisperm activity was present in 74 percent of the vasectomized men but none in the control subjects (p < 0.001). There was no association between testicular histologic changes and immune status.

CONCLUSIONS

Vasectomized men exhibit significant testicular histologic changes and increased autoimmune activity as compared with fertile control subjects. These histologic changes are not directly associated with antisperm antibody status, suggesting that some other pathophysiologic process must be responsible.

Objective assessment of spermatogenesis in men with functional and anatomic obstruction of the genital tract

Experimental rodent models simulating the condition of neurogenic infertility have drawn attention to the role of potential epididymal dysfunction as an underlying cause. This functional obstruction of the genital tract is comparable to the outcome of genital tract obstruction after vasectomy, and may explain the common finding of asthenospermia in both groups following either stimulated semen recovery or vasovasostomy, respectively. Since spermatogenic dysfunction has been reported in spinal cord injury, the relative roles of defective sperm production and sperm transport remain to be determined in men with neurogenic infertility. The objective of this study was to compare the levels of spermatogenesis in groups of vasectomized men and those with spinal cord injury, using objective measurement criteria for spermatogenesis. Groups of 10 spinal cord-injured and six vasectomized men matched for age and duration of disease, underwent incisional testicular biopsy. The specimens were divided equally for parallel quantitation of spermatogenesis by both quantitative cytometry and DNA flow cytometric analysis. Quantitative parameters showed similar values for both groups with reference to mean tubular wall thickness, mean tubular concentration of spermatids and Sertoli cells, as well as the mean spermatid: Sertoli cell ratio per tubule. Additionally, similar percentages of 1N, 2N and 4N cells, were found in both groups. Based on these preliminary findings this study provides a clinical correlation supporting the experimental observation that both anatomical and functional obstruction of the male genital tract exert a similar although minor spermatogenic insult, and that in both the putative cause for neurogenic infertility is more likely to be at the post-testicular level.

Physiopathology of spermatogenic arrest

OBJECTIVE

To review the world literature on the etiology, physiopathology, and treatment of spermatogenesis arrest.

STUDY SELECTION

All the pertinent literature on spermatogenic arrest has been selected. Most studies related to this topic have been identified through Medline and through published literature.

PATIENTS

Spermatogenic arrest has been diagnosed by testicular biopsy in men of reproductive age who had either severe oligospermia (partial arrest) or azoospermia (complete arrest), normal testicular volume, and depending on the etiology normal, high, or low levels of gonadotropins.

INTERVENTIONS

The effects of heat, radiotherapy, and chemotherapy have been reported. Depending on the etiology of spermatogenic arrest, different hormonal treatments have been tested.

MAIN OUTCOME MEASURE

Level of interruption of germ cell differentiation in testicular biopsy have been determined. Improvement of the sperm count or appearance of mature sperm after an hormonal treatment have been observed.

RESULTS

Spermatogenic arrest can occur at spermatogonial level in case of gonadotropin insufficiency or after germ cell damage due to chemotherapy or radiotherapy. The arrest is most frequently observed at primary spermatocyte level. Reversible arrest at that level can be due to heat, infections, hormonal and nutritional factors. Irreversible arrest at primary spermatocyte or spermatid level have a genetic origin due to chromosomes anomalies either in somatic cells or in germ cells.

CONCLUSIONS

Spermatogenic arrest is usually due to genetic factors resulting in irreversible azoospermia. However some cases may be consecutive to hormonal, thermic, or toxic factors and may be reversible either spontaneously or after a specific treatment.

The value of quantitative testicular biopsy and deoxyribonucleic acid flow cytometry in predicting sperm recovery from electrostimulated ejaculates

Spermatogenic abnormalities have been reported in the majority of men following spinal cord injury, and they contribute to the multifactorial etiology of reproductive dysfunction. Thus far, few have studied the seminiferous epithelium in this group of patients by objective criteria. While quantitative micrometry and flow cytometric analysis are accurate and reproducible methods of quantitating spermatogenesis, the latter is simpler and permits needle aspiration for tissue recovery. The objective of this study is to determine the value of quantitative micrometry and flow cytometric analysis as methods of predicting total sperm yield in electrostimulated ejaculates. Incisional testicular biopsy was performed in 12 anejaculatory men, and the tissue specimens were divided for analysis by quantitative micrometry and flow cytometric analysis. Quantitative micrometry consisted of determining the mean tubular wall thickness, mean tubular concentration of the Sertoli cells and mature spermatids in a minimum of 10 round seminiferous tubules per patient. Specimens were prepared for flow cytometric analysis and the deoxyribonucleic acid histogram was analyzed to determine the percentage of cells in each ploidy compartment. Of the quantitative micrometry parameters analyzed a significant correlation resulted between the total sperm yield per electroejaculate and the mean tubular concentration of late spermatids (p = 0.001) as well as with the mean tubular ratio of late spermatids to Sertoli cells (p = 0.003). The tubular concentration of spermatids resulted in a sensitivity and specificity of 100% and 75%, respectively, to predict adequate sperm yield in semen. Likewise, the mean tubular ratio of spermatids to Sertoli cells resulted in a sensitivity and specificity of 75% and 87.5%, respectively, in its ability to predict normal sperm yield in the recovered ejaculate. Deoxyribonucleic acid flow cytometry analysis showed a normal haploid compartment in all 6 specimens studied, and each was associated with high numbers of sperm in recovered semen. Quantitative histometric parameters correlate significantly with the total sperm yield obtained in electrostimulated ejaculates and may have a role in the selection of candidates for treatment in reproductive rehabilitation programs.

Possible biological mechanisms for a relationship between vasectomy and prostatic cancer

Four hypotheses have been reviewed, each of which might serve as a hypothetical biological explanation for a relationship between vasectomy and prostate cancer. The endocrine hypothesis is the only one of these with any firm data to support it, although the majority of the available data does not lend credibility to that theory. The other hypotheses are purely speculative with no hard data to support them. In conclusion, it seems highly unlikely, but not impossible, that there is a biological mechanism supporting a relationship between vasectomy and prostate cancer.

Ultrastructure of epididymal interstitial reactions following vasectomy and vasovasostomy

The response of the male reproductive tract to vasectomy includes inflammation of the interstitial tissue of the epididymis. The pathogenesis of epididymal interstitial reactions and characteristics of the responding cells were studied by electron microscopy in Lewis rats at intervals following bilateral vasectomy, vasectomy followed 1 month later by vasovasostomy, or sham operations. In areas of interstitial reaction, numerous macrophages, monocytes, lymphocytes, neutrophils, and plasma cells occupied the connective tissue. Macrophages, containing many lysosomes and vesicles, aggregated and assumed the appearance of epithelioid cells. Processes of adjacent macrophages interdigitated with one another and closely approached the surfaces of lymphocytes. Many plasma cells with distended rough endoplasmic reticulum appeared in the interstitium. The majority of animals in the vasectomy and vasovasostomy groups exhibited epididymal interstitial changes by 2-3 months; the cauda epididymidis was the region most often affected. The ultrastructural features were indicative of chronic granulomatous inflammation and were consistent with an immune response that includes antigen presentation by macrophages to lymphocytes, lymphocyte differentiation, and local antibody production by plasma cells. The nearly complete absence of sperm or recognizable parts thereof in the interstitial tissue in the areas of the reactions suggests that these lesions formed in response to soluble antigens leaking from the duct. Vasovasostomy was not effective in reversing or retarding epididymal inflammation at the intervals studied.

Testicular cancer after vasectomy: origin from carcinoma in situ of the testis

Vasectomy is a commonly used male contraceptive procedure. Reports have indicated that vasectomy is associated with an increased risk of development of germinal testicular cancer. Carcinoma in situ of the testis (CIS) is a preinvasive lesion which precedes germinal testicular cancer. CIS is almost always found in the tissue adjacent to a germinal testicular cancer. It is believed that CIS is a malignant gonocyte formed during embryogenesis. We have studied the testicular tissue from 5 previously vasectomised patients with testicular cancer and found CIS in the tissue adjacent to their cancer as well as changes in the epididymis of the patients. We discuss the findings and conclude that testicular cancers occurring after vasectomy is not an exception from the rule that testicular cancer originates from CIS. Thus, there is no causal relationship between vasectomy and testicular cancer, but vasectomy might precipitate the development of testicular cancer from the preinvasive CIS lesion.

Is vasectomy a risk factor for prostate cancer?

Recently, several case-control studies have suggested that vasectomy may predispose to prostate cancer. Other studies have found no increase in risk. All of these studies have a number of limitations. Taken together, these studies do not provide convincing evidence that vasectomy increases the risk of prostate cancer. However, in view of the high prevalence of prostate cancer and the growing worldwide importance of vasectomy as a form of contraception, further epidemiological research is warranted. After briefly commenting on the experimental studies we will examine the epidemiological studies in more detail. This will be done by first summarising the designs and main findings of the most relevant published studies and then discussing methodological issues relating to the studies taken as a whole. Finally, we will present conclusions and offer recommendations for future research.

Unilateral obstruction of the vas deferens caused by childhood inguinal herniorrhaphy in male infertility patients

OBJECTIVE

To study the incidence, diagnosis, and treatment of unilateral obstruction of the vas deferens caused by inguinal herniorrhaphy (IH) during childhood.

DESIGN

Retrospective.

SETTING

Kyoto University Hospital.

PATIENTS

Unilateral obstruction of the vas deferens after IH was diagnosed and treated in 10 of 724 subfertile patients.

INTERVENTIONS

Reanastomosis of the vas deferens using a microsurgical two-layer technique.

MAIN OUTCOME MEASURES

Follow-up seminal analysis of the patients and the occurrence of pregnancy in their wives.

RESULTS

The incidence of unilateral vas deferens obstruction caused by IH was 26.7% for subfertile patients with a history of IH during childhood. Unilateral vas deferens obstruction was detected through palpation of the scrotal vas deferens in 7 of the 10 patients. After vasovasostomy, the semen quality improved in 5 patients, and pregnancy was achieved by 2 patients.

CONCLUSIONS

The incidence of vas deferens obstruction was unexpectedly high in subfertile patients with a history of IH during childhood. Careful palpation of the scrotal content was a useful and noninvasive method to diagnose unilateral vas deferens obstruction, and microsurgical vasovasostomy was treatment of choice.

31P magnetic resonance spectroscopy for diagnosing abnormal testicular function

OBJECTIVE

To determine if testicular 31P magnetic resonance (MR) spectroscopy can be of additional clinical value.

DESIGN

A controlled study in three selected subjects groups.

SETTING

All participants were referred to the outpatient clinic of our Department of Obstetrics and Gynecology.

PARTICIPANTS

Normal healthy volunteers (n = 13), oligozoospermic (n = 14), and azoospermic patients (n = 17; 6 with epididymal obstruction and 11 with severe germ cell depletion) were selected on the basis of semen analysis, hormone determinations, and, if necessary, on operative exploration.

INTERVENTIONS

Magnetic resonance spectroscopy was performed on a Philips Gyroscan S15 (Philips Medical Systems, Best, the Netherlands).

MAIN OUTCOME MEASURE(S)

The routine clinical analyses were compared with the outcome of testicular MR spectroscopy to test the hypothesis that MR spectroscopy can be of additional value in the diagnosis of idiopathic oligozoospermic or azoospermic patients.

RESULTS

The MR spectra of normal volunteers were significantly different from oligozoospermic patients (P less than 0.001), from azoospermic patients with germ cell depletion (P less than 0.001), and from azoospermic patients with an obstruction (P less than 0.05). Between the two azoospermic groups also a significant difference was found (P less than 0.001).

CONCLUSIONS

These results show that MR spectroscopy is a reliable technique to monitor the testicular function.

Quantitative testicular biopsy in spinal cord injured men: comparison to fertile controls

Spermatogenic abnormalities have been reported in the majority of spinal cord injured men on routine testicular biopsy. However, given the interim advances in their urological and rehabilitative care, a quantitative assessment of the germinal epithelium after spinal cord injury and comparison of these parameters to normal controls are warranted. Incisional testicular biopsy was performed in 14 spinal cord injured men. Quantitative micrometric techniques were applied to assess spermatogenesis and the results were compared to a normative data base of testicular biopsies previously obtained from a group of 15 fertile volunteers. From a minimum of 10 randomly selected round seminiferous tubules per subject the mean number of Sertoli cells, mature spermatids, tubular diameter and tubular wall thickness were determined in both groups and statistically analyzed. In the spinal cord injury group the mean number of spermatids per tubule was significantly lower and the mean number of Sertoli cells per tubule was significantly higher than in fertile controls (p less than 0.05). Moreover, the mean Sertoli cell-to-spermatid ratio per seminiferous tubule was significantly higher in the spinal cord injury group and discriminated between spinal cord injured men and controls, with a sensitivity of 93% and specificity of 100% (p less than 0.0001). Half of the spinal cord injury group showed a mean tubular spermatid density of less than 10. Compared to the fertile population, spinal cord injured men show significant differences in quantitative parameters of the germinal epithelium that may contribute to the reproductive dysfunction.

Injury to the pre-pubertal vas deferens. II. Experimental repair

We have previously shown that the human vas deferens does not change in cross-sectional size between birth and the middle of puberty. This suggests that if the human vas is injured prior to mid-puberty, repair by a traditional microsurgical vasovasostomy may be technically difficult. We propose that a chromic stent can be used to assist in the repair of vas injured before mid-puberty. This hypothesis was tested in Sprague-Dawley rats. At three weeks of age, male offspring were divided into three groups (eight to nine rats/group): 1) Sham group--a sham operation at three weeks, 2) VV group--bilateral transection of vasa at three weeks followed by a delayed repair at eight weeks by microsurgical vasovasostomy without a stent, 3) Stent group--bilateral transection of vasa at three weeks followed by immediate repair by aligning the lumens with a 6-0 chromic intravasal stent (suture) and holding the transected ends together with several seromuscular sutures. At four months all rats were fertility tested and a score was given to each rat (mean number of concepti among three females for each male rat). Analysis of anastomotic patency by flow rates and histology was performed. There was no statistical difference in the mean fertility score of 6.85 in the Stent group compared to 7.83 in the Sham group. However, a fertility score of 0.71 in the VV group was significantly decreased compared to the Stent and Sham group (p = .0003), despite no statistical difference between the groups in patency. This suggests that a recognized injury to the pre-pubertal human vas should be immediately repaired and the repair can be done using 6-0 chromic suture as an intravasal stent to help align the lumina of the smaller pre-pubertal vas.

Effect of vasectomy on in situ pH in rat testis and epididymis

The effect of bilateral vasectomy on in situ pH in seminiferous tubules, initial segments, proximal caput, middle corpus and proximal cauda epididymides of the rat has been studied employing in vivo microelectrode techniques. After bilateral vasectomy of four weeks duration, a significant increase in acidity of luminal fluid in the initial segments of the caput epididymides was observed. By eight weeks post vasectomy, luminal pH in the initial segments was significantly more acid as compared to sham-operated control animals or four weeks vasectomy while, in contrast, luminal pH in the proximal cauda epididymides was significantly more alkaline. The alteration of luminal fluid pH in the initial segments and proximal cauda epididymides after bilateral vasectomy may be the result of impairment of acid-base, as well as water transport pathways.

The effect of vasectomy on the production of plasma luteinizing hormone and follicle stimulating hormone in man

A prospective study of plasma luteinizing hormone (LH) and follicle stimulating hormone (FSH) in 51 men before vasectomy and 10 days and 3 months after vasectomy revealed a trend to rise in LH 10 days after vasectomy normalizing after 3 months. The literature concerning alterations in LH and FSH after vasectomy is reviewed and different theories are discussed.

The effects of testicular trauma on fertility in the Lewis rat and comparisons to isoimmunized recipients of syngeneic sperm

Adult male Lewis (LEW) rats were used to investigate the effects of unilateral testicular trauma on fertility. Comparisons were made between normal and experimental rats immunized with syngeneic sperm in Complete Freund's Adjuvant (CFA). Matings within the three groups yielded offspring to all normal males, no offspring to the immunized rats, and 27% (3/11) fertility in the trauma group (p less than 0.001). The contralateral testis demonstrated decreased volumes, various degrees of aspermatogenesis and smaller seminiferous tubular diameters, in both the trauma and immunized groups compared to the controls. Similar histopathologic findings of chronic granulomatous inflammation within contralateral testes in both the trauma and immunized groups suggested a common immune etiology for infertility via possible disruption of the blood-testis barrier.

Presence and distribution of leucocyte subsets in the murine epididymis after vasectomy

Male mice were vasectomized by 'open-ended' or 'closed' techniques. After 4 weeks the cell-mediated immune reactions were compared with those of sham-operated animals by immunohistochemical localization of leucocytes, using specific monoclonal antibodies. Macrophages and MHC class II antigen-positive cells were the major cell types to appear in all regions of the epididymis after both types of operation. There was recruitment of T-helper/inducer leucocytes but not of T-suppressor-cytotoxic cells. An increased presentation of macrophage-migration inhibiting factor antigen appeared in interstitial and peritubular locations. After 'closed' and 'open-ended' vasectomy granulomata developed in the epididymis. The sperm-containing lumen of these granulomata was invaded by macrophages, MHC class II-positive cells and T-helper/inducer lymphocytes. This mouse model thus reveals a significant epididymal inflammatory response of the epididymis to vasectomy.

Quantitative testicular biopsy in congenital and acquired genital obstruction

To determine if congenital obstruction of the genital tract is associated with significant testicular histopathological conditions compared to acquired forms of obstruction we performed testicular biopsy in 8 vasectomized men and 5 men with vasal agenesis. Quantitative analysis of the seminiferous tubular and epithelial parameters demonstrated a statistically significant increase in tubular wall thickness in the vasectomized group. There was no significant difference among the groups with reference to the mean number of late spermatids per seminiferous tubules, mean number of Sertoli cells per seminiferous tubules, mean number of seminiferous tubules per field (100 times) or mean seminiferous tubular diameter. We conclude that despite a lifelong duration of obstruction, men with vasal agenesis demonstrate a more favorable testicular histological status compared to men after vasectomy. This finding may have therapeutic implications when considering assisted pregnancy techniques as a method of treatment of male genital tract atresia.

Quantitative parameters of seminiferous epithelium in secretory and excretory oligoazoospermia

Testicular biopsy specimens from infertile men (sperm count, less than 10(6)/ml) were evaluated on 1-micron thick sections, and counts of stem cells and differentiated spermatogonia, primary spermatocytes, early and late spermatids, and Sertoli cells were compared to counts in six fertile men. Biopsy specimens were also compared for the appearance of seminiferous tubule wall, blood vessels, and interstitium. Infertile men were grouped according to the following diagnoses: hypospermatogenesis (n = 5), spermatocyte arrest of spermatogenesis (n = 5), and obstruction of the genital tract (n = 7). A low productivity of spermatogenesis in cases of hypospermatogenesis appeared to be due to an exaggerated degeneration of primary spermatocytes and to a yield of abnormal spermatids. A block of meiosis in spermatocyte arrest was associated with a degeneration of primary spermatocytes and with a reduced number of staminal spermatogonia. Abnormal spermiogenesis was observed in cases of obstruction of the genital tract and was associated with an increase in stem cell spermatogonia. A thickening of seminiferous tubule and blood vessel walls could be responsible for the limited functional capacity of Sertoli cells, causing altered spermiogenesis in cases of excretory azoospermia. A severe primitive failure of Sertoli cells in secretory oligoazoospermia could account for a deranged maturation and degeneration of premeiotic and postmeiotic germ cells.

Detection of testicular endocrine abnormalities and their correlation with serum antisperm antibodies in men following vasectomy

We measured the serum gonadotropin response to gonadotropin-releasing hormone in 25 men who underwent vasectomy 2 to 64 months before the study. Ten age-matched fertile men were used as controls. Baseline serum follicle-stimulating hormone, luteinizing hormone and testosterone levels were not significantly different between vasectomized men and controls. However, mean serum follicle-stimulating and luteinizing hormone responses to an intravenous bolus injection of 100 mcg. gonadotropin-releasing hormone were significantly greater in the vasectomy group (p equals 0.008 and 0.003, respectively). There was no correlation between these responses and the interval after vasectomy. Serum antisperm antibodies were present in 13 vasectomized men (52 per cent) using enzyme-linked immunosorbent assay and microagglutination techniques. A significant correlation (p equals 0.003) was found between the presence of serum antisperm antibodies and a normal follicle-stimulating hormone response to gonadotropin-releasing hormone stimulation. Of 13 patients with demonstrable antisperm antibody titers 9 (69 per cent) had normal follicle-stimulating hormone responses, compared to only 1 of 12 (8 per cent) without identifiable antisperm antibody titers. Our data suggest that certain men following vasectomy have abnormalities in seminiferous tubule and Leydig cell functions of the testes. These abnormalities are unrelated to the interval after vasectomy and are not identifiable with routine static hormonal measurements. In addition, serum antisperm antibodies are most likely to be present in men who demonstrate normal seminiferous tubular activity after vasectomy.

Evaluation of vasovasostomy candidates by deoxyribonucleic acid flow cytometry of testicular aspirates

Flow cytometry can be performed on testicular aspirates of vasovasostomy candidates preoperatively. On the basis of ploidy ratios and debris components, DNA histograms can be classified as normal or abnormal. Using this method, the likelihood of the presence of sperm may be predicted.

Microrecanalization after vasectomy in man

Previously spermatozoa in the semen of vasectomized men were reported in 62 of 63 specimens from 24 men 2 to 31 years postvasectomy (Freund and Couture, 1982). A morphologic basis and term, "microrecanalization," was proposed for this observation. Serial sections (5 mu at 200-mu intervals) of 40 specimens removed at vasovasostomy from 20 men (2 to 14 years postvasectomy) were examined and microcanals (small epithelial-lined channels) were demonstrated in 27 specimens from 18 men. In nine of the 27 specimens, spermatozoa or sperm heads were found within the microcanals. Microcanals occurred in smooth muscle, connective tissue and scar tissue, in each segment, testicular, central and abdominal, in the presence or absence of the vas deferens. Microcanal continuity was traced for 200 to 1140 microns by computerized image analysis. Microrecanalization is characterized by the absence of inflammation or sperm extravasation and is histologically distinct from vasitis nodes or sperm granuloma. Microrecanalization provides morphologic and physiologic bases for the protection of the testis and maintenance of spermatogenesis in man after vasectomy.

Applications of microsurgery in urology

The applications of microsurgery in urology have increased in the decade since urologists first used such techniques. The primary uses for microsurgery in urology at first were vasovasostomy, vasoepididymostomy, and testicular autotransplantation. Penile revascularization has recently become another procedure for which microsurgery is used with increasing frequency. As more urologists learn the techniques, other urologic applications for microsurgery surely will develop.

Testicular alterations are linked to the presence of elevated antisperm antibodies in Sprague-Dawley rats after vasectomy and vasovasostomy

The relationship between alterations in testicular histology and antisperm antibodies was studied after vasectomy and vasovasostomy in Sprague-Dawley rats, which are immunologically relatively non-responsive to vasectomy. Testes were prepared for histologic study at intervals up to seven months after vasectomy, vasectomy followed three months later by vasovasostomy, or sham operations. Antisperm antibodies were assessed with an ELISA. Testicular alterations, which were observed in a minority of animals after vasovasostomy, consisted mainly of depletion of germ cells. Mean serum antisperm antibody levels were greater for animals with altered testes than for rats with normal testicular histology. In addition, the proportion of rats that showed a positive antisperm antibody response was greater among animals with testicular changes than among those with unaltered testes. When the present results on Sprague-Dawley rats were compared with previous findings on the highly responsive Lewis strain, it was evident that the incidence of testicular changes and the proportion of positive antibody responders were greater in the Lewis strain. However, elevated antisperm antibodies and testicular alterations appeared to be more tightly linked in the less responsive Sprague-Dawley rats.

Effect of age on the composition of seminiferous tubular boundary tissue and on the volume of each component in humans

Seminiferous tubular boundary tissue thickens with age. The objective was to characterize the composition of boundary tissue in 16 young adult (20 to 29 years) and 18 older adult (51 to 84 years) men. Testes were perfused with glutaraldehyde, placed in osmium, and embedded in Epon 812 (Ladd Research Industries, Burlington, VT). Paired testicular weight, length of tubules, volume of seminiferous epithelium, and daily sperm production were significantly reduced in older men. Although the thickness of boundary tissue was greater (P less than 0.01) in older men, the volume of boundary tissue per man was similar between age groups. The percentages and volumes per man of boundary tissue myoid cells, collagen, microfibrils, and other components also were similar (P greater than 0.05) between age groups. This study confirms that age-related thickening of boundary tissue occurs without the new deposition (augmentation) of collagen or other extracellular components.

A comparative study of the effects of non-union of testis and epididymis and cryptorchidism on testicular development and spermatogenesis in the rat

Malunion of testis and epididymis is a congenital anomaly of human undescended testicles which may be of considerable clinical importance. In an experimental model in rat the effects of early disconnection of testis and epididymis (16 days) on testicular development have been testis and puberty. The results are compared with corresponding effects of cryptorchidism and sham-operation. The testes were weighed, and the relative proportions of haploid, diploid and tetraploid cells were quantified by DNA flow cytometry. The histology was evaluated by light and electron microscopy. The non-union operated testes showed a close to normal weight development until about 40 days of age, whereafter a decline occurred. The progression of the maturation division was only slightly reduced at 30 and 37 days of age, but later the spermatogenesis was significantly inhibited. At 58 days of age the maturation division had practically ceased in non-union operated testes. In cryptorchid animals the onset and progression of maturation divisions were almost totally depressed, and only traces of haploid cells were seen in some specimens. The transient increase in tetraploid cells, reflecting primary spermatocytes seen at about 30 days during normal testicular development, was neither depressed in non-union operated nor in cryptorchid animals. This indicates that the major block in spermatogenesis in both situations is at the stage of the primary spermatocytes. At 58 days of age the testicular histology was similar in non-union operated and cryptorchid testicles with many tubular sections showing only Sertoli cells. Scattered and partly degenerated germinal cells were seen in some sections. No histological signs of increased intratubular fluid pressure were detected, suggesting that pressure atrophy is not decisive for the reduced spermatogenesis in non-union operated gonads.