PREVENTION OF MALE INFERTILITY: AN UPDATE

Fluoxetine-induced androgenic failure impairs the seminiferous tubules integrity and increases ubiquitin carboxyl-terminal hydrolase L1 (UCHL1): Possible androgenic control of UCHL1 in germ cell death?

The selective serotonin reuptake inhibitor fluoxetine has been used for the treatment of depression. Although sexual disorders have been reported in male patients, few studies have demonstrated the fluoxetine effect on the reproductive histophysiology, and the target of this antidepressant in testes is unknown. We evaluated the impact of short-term treatment with fluoxetine on the adult rat testes, focusing on steroidogenesis by Leydig cells (LC) and androgen-dependent testicular parameters, including Sertoli cells (SC) and peritubular myoid cells (PMC). Since UCHL1 (ubiquitincarboxyl-terminal hydrolase L1) seems to control spermatogenesis, the immunoexpression of this hydrolase was also analyzed. Adult male rats received 20 mg/kg BW of fluoxetine (FG) or saline (CG) for eleven days. In historesin-embedded testis sections, the seminiferous tubule (ST) and epithelial (Ep) areas, and the LC nuclear diameter (LCnu) were measured. The number of abnormal ST, androgen-dependent ST, SC and PMC was quantified. Testicular β-tubulin levels and peritubular actin immunofluorescence were evaluated. Serum testosterone levels (STL) and steroidogenesis by 17β-HSD6 immunofluorescence were analyzed, and either UCHL1-immunolabeled or TUNEL-positive germ cells were quantified. In FG, abnormal ST frequency increased whereas ST and Ep areas, androgen-dependent ST number, LCnu, 17β-HSD6 activity and STL reduced significantly. TUNEL-positive PMC and SC was related to decreased number of these cells and reduction in peritubular actin and β-tubulin levels. In FG, uncommon UCHL1-immunoexpression was found in spermatocytes and spermatids, and the number of UCHL1-immunolabeled and TUNEL-positive germ cells increased in this group. These findings indicate that LC may be a fluoxetine target in testes, impairing PMC-SC integrity and disturbing spermatogenesis. The increase of UCHL1 in the damaged tubules associated with high incidence of cell death confirms that this hydrolase regulates germ cell death and may be controlled by androgens. The fertility in association with the androgenic status of patients treated with fluoxetine should be carefully evaluated.

Adult-Onset Hypogonadism

In August 2015, an expert colloquium commissioned by the Sexual Medicine Society of North America (SMSNA) convened in Washington, DC, to discuss the common clinical scenario of men who present with low testosterone (T) and associated signs and symptoms accompanied by low or normal gonadotropin levels. This syndrome is not classical primary (testicular failure) or secondary (pituitary or hypothalamic failure) hypogonadism because it may have elements of both presentations. The panel designated this syndrome adult-onset hypogonadism (AOH) because it occurs commonly in middle-age and older men. The SMSNA is a not-for-profit society established in 1994 to promote, encourage, and support the highest standards of practice, research, education, and ethics in the study of human sexual function and dysfunction. The panel consisted of 17 experts in men's health, sexual medicine, urology, endocrinology, and methodology. Participants declared potential conflicts of interest and were SMSNA members and nonmembers. The panel deliberated regarding a diagnostic process to document signs and symptoms of AOH, the rationale for T therapy, and a monitoring protocol for T-treated patients. The evaluation and management of hypogonadal syndromes have been addressed in recent publications (ie, the Endocrine Society, the American Urological Association, and the International Society for Sexual Medicine). The primary purpose of this document was to support health care professionals in the development of a deeper understanding of AOH, particularly in how it differs from classical primary and secondary hypogonadism, and to provide a conceptual framework to guide its diagnosis, treatment, and follow-up.

Practice Patterns in Vasectomy Reversal Surgery:: Results of a Questionnaire Study Among Practicing Urologists

PURPOSE

Although vasectomy reversal surgery is a common procedure for male factor infertility, little is written on the common practice patterns of the practicing urologist. We designed a questionnaire to assess the practice patterns of community and academic urologists with respect to surgical technique, followup care, patient selection and the definition of success.

MATERIALS AND METHODS

A 20-question survey pertaining to vasectomy reversal surgery was mailed to members of the Western Section, American Urological Association and to members of the Society of Government Service Urologists. Survey results were tabulated in a computer data base and statistical analysis was performed.

RESULTS

A total of 1,508 questionnaires were mailed and 622 completed questionnaires were returned. Of the respondents 367 (59%) indicated that they perform vasectomy reversals, including 29 (8%) who were fellowship trained in infertility, 86 (23%) who were affiliated with residency training and 252 (69%) who practiced in a community setting. As expected, on average fellowship trained urologists performed more reversals yearly than academic or community urologists (26.4, 12.2 and 7, respectively). Patient selection criteria varied. Of fellowship trained urologists 12.5% would elect not to operate if it were greater than 15 years since vasectomy compared with 41.9% for academic and 57.1% of community urologists. Just more than half (50.2%) of respondents indicated they did not recommend routine gynecologic evaluation of the patient partner. When comparing fellowship, academic and community practitioners, an operating microscope was used in 93%, 65% and 56% of procedures (p <0.001), and vasal fluid was examined in 83%, 75% and 67%, respectively. Fellowship trained urologists also used finer suture material (p <0.001). An average of 8 anastomotic sutures were placed in 2 layers but significant differences existed between fellowship trained urologists, and their academic and community counterparts. Most urologists (71%) defined their success by the presence of sperm in the ejaculate. Only 10.9% of urologists recommended sperm cryopreservation at surgery and 90% recommended postoperative sexual abstinence (average 3 weeks). All urologists recommended postoperative semen analysis done at an average of 3 months.

CONCLUSIONS

The practice of vasectomy reversal varies among urologists. Differences in surgical technique, postoperative care and selection criteria exist. Knowledge of these variations may assist practicing urologists to tailor their practice patterns in the selection for and performance of vasectomy reversal.

Common medications and drugs: how they affect male fertility

Numerous drugs and medications have been shown to have adverse effects on male fertility, acting through diverse mechanisms. These drugs are summarized in Table 2. Mechanisms of impaired fertility include direct effects on germ cells or their supporting cells, effects on the delicately balanced HPG axis, effects on erectile or ejaculatory function, and effects on libido. In a thorough fertility evaluation of the male partner, the physician should determine what medication the patient is taking and his social habits involving alcohol consumption, tobacco, and recreational drug use. Most adverse effects from drugs and medications can be reversed by simply discontinuing the offending agents; however, in some instances, such as chemotherapeutic regimens, the medications cannot be discontinued, and pretreatment sperm cryopreservation remains critical. It is essential for urologists treating infertile men to be familiar with the more commonly encountered drugs and medications that may affect the potential for fertility.

[Role of the urologist in the management of infertile men at the time of sperm intracytoplasmic injection]

Although intracytoplasmic sperm injection (ICSI) revolutionized treatment and prognosis of male infertility, checkup (case history, clinical and paraclinical examinations) practiced by urologist in infertile man keeps all its place. Varicocele, congenital or acquired seminal duct obstruction, urogenital tract infection, or ejaculation disorder must be sought, because these affections remain accessible to treatment.

Occupational risk for male infertility: a case-control study of 218 infertile and 227 fertile men

The aim of the study was to determine if certain occupations pose an increased risk for infertility (of no known cause) among a group of infertile men compared with a group of fertile men. A total of 640 consecutive men whose spouses were unable to conceive were recruited from an infertility clinic. Of these, 218 men (cases) were found to have no known cause for their infertility. A total of 227 men whose spouses were pregnant at the time of the study were recruited as controls. The Singapore Standard Occupational Classification was used to code the subjects' occupations. Semen parameters (density, total sperm counts, motility, viability, and normal morphology) in all of the cases were significantly poorer than those in the controls. The risk for infertility is associated with smoking adjusted odds ratio (OR) 2.85 and 95% confidence interval (CI) 1.91 to 4.24. Work, independently, is not a risk factor for infertility. Engineering technicians (adjusted OR, 2.75; 95% CI, 1.36 to 5.54), finance analysts (adjusted OR, 4.66; 95% CI, 1.90 to 11.40), corporate and computing managers (adjusted OR, 2.49; 95% CI, 1.04 to 5.98), and teachers (adjusted OR, 7.72; 95% CI, 1.86 to 32.10) were at a greater risk of infertility compared with "services and clerical workers." Using services and clerical workers as a reference group, certain occupations are at a higher risk for infertility. Higher work demands and possible electromagnetic field exposure could be contributory factors for infertility.

Factors associated with male infertility: a case-control study of 218 infertile and 240 fertile men

OBJECTIVE

To determine the likely risk factors, such as smoking and drinking habits, and occupational groups, for infertility in a group of infertile men with no known cause, compared with a group of fertile men; and to examine the effects of the semen parameters, such as volume, density, motility, viability and normal morphology, on fertility.

DESIGN

A case-control study.

SETTING

The department of obstetric and gynaecology of a tertiary general hospital.

PARTICIPANTS

Six hundred and forty consecutive male partners of couples trying to conceive were recruited from an infertility clinic. Of these, the cases comprised 218 men who had no known cause for their infertility. Two hundred and forty men whose wives were pregnant at the time of the study were recruited as controls.

RESULTS

The semen parameters (e.g. density, total sperm counts, motility, viability and normal morphology) of all cases were significantly poorer than that of the controls. The risk of infertility is associated with smoking (crude OR 2 x 82, 95% CI 1 x 93-4 x 13; adjusted OR 2 x 96; 95% CI 1 x 98-4 x 42). Technicians (adjusted OR 2 x 81; 95% CI 1 x 51-4 x 24) and professional, senior officials and managers were also at a greater risk of infertility (adjusted OR 2 x 36; 95% CI 1 x 26-4 x 40), compared with service and clerical workers. The significant factors predicting infertility were smoking, density of sperm, and viability of sperm. Smoking increased the odds of being infertile. Higher sperm counts and larger percentage of viable sperm decrease the odds of infertility. Based on the multiple logistic regression model, the odds ratio for infertility = (94 x 70) x (2 x 88(smoking)) X (0 x 29(logdensity)) X (0 x 95(viability)).

CONCLUSION

Smoking, density of sperm and the viability of sperm are significant predictors for infertility among men.

Assessment of adolescent varicocele

Varicocele is the most important male factor responsible for decreased fertility potential in married couples. From March through June 1994, 2,470 school boys aged 10-20 years were examined to establish the incidence of consecutive grades of varicocele and to develop a protocol for diagnosis and treatment of adolescents with varicocele. Grade 1 varicocele was found in 18%, grade 2 in 12%, and grade 3 in 5% of the population examined. An original protocol of ultrasonographic (US) examination (previously verified by angioscintigraphy) was introduced to assess boys with clinically diagnosed varicocele. The volume of each testis, testicular volume decrease (TVD), pampiniform vein diameter (PVD), and basal (BBF) and maximum blood flow (MBF) velocities were measured in 625 boys. In 74 cases a semen analysis was performed. The statistical analysis revealed that the presence of venous reflux and PVD correlated with the grade of varicocele. Decreases in testicular volume were highly dependent on the grade of varicocele, PVD, and BBF and MBF velocities. Analysis of the relationship between spermatic (boys over 17 years) and US findings revealed that the quality of spermatogenesis can be predicted by US examination in adolescents with varicocele. The authors recommend multiparametric US examination as a reliable, objective, and repeatable technique for establishing criteria for operative treatment in boys under 18 years of age with varicocele as well as for postoperative evaluation.