An online Sexual Health and Rehabilitation eClinic (TrueNTH SHAReClinic) for prostate cancer patients: a feasibility study

Purpose

The primary objective was to determine the feasibility of implementing the TrueNTH SHAReClinic as a pan-Canadian sexual health and rehabilitation intervention for patients treated for localized prostate cancer.

Methods

The feasibility study was designed to evaluate the accessibility and acceptability of the intervention. Participants from five institutions across Canada were enrolled to attend one pre-treatment and five follow-up online clinic visits over 1 year following their prostate cancer (PC) treatment.

Results

Sixty-five patients were enrolled in the intervention. Website analytics revealed that 71% completed the intervention in its entirety, including the educational modules, with an additional 10% completing more than half of the intervention. Five thousand eighty-three views of the educational modules were made along with 654 views of the health library items. Over 1500 messages were exchanged between participants and their sexual health coaches. At 12 months, the intervention received an overall average participant rating of 4.1 out of 5 on a single item satisfaction measure.

Conclusion

Results support the TrueNTH SHAReClinic as highly acceptable to participants as defined by intervention adherence and engagement. The TrueNTH SHAReClinic demonstrated promise for being a feasible and potentially resource-efficient approach to effectively improving the sexual well-being of patients after PC treatment.

P–016 Using artificial intelligence to predict semen upgrading after microsurgical varicocele repair

Study question

Can we use artificial intelligence models to predict semen upgrading after microsurgical varicocele repair?

Summary answer

A machine learning model performed well in predicting clinically meaningful post-varicocelectomy semen upgrade using pre-operative hormonal, clinical, and semen analysis data.

What is known already

Varicocele repair is recommended in the presence of a clinical varicocele together with at least one abnormal semen parameter, and male infertility. Unfortunately, up to 50% of men who meet criteria for repair will not see meaningful benefit in outcomes despite successful surgery. Nomograms exist to help predict success, but these are based out of single-center databases, do not incorporate hormonal data, and are rarely designed to predict pre-defined, clinically meaningful improvements in semen parameters.

Study design, size, duration

Data were collected from an international, multi-center retrospective cohort. A total of 240 men were identified. Data from 160 men from Miami, USA and 80 men from Toronto, Canada were included. Data was collected from 2006 to 2020.

Participants/materials, setting, methods

We collected pre and postoperative clinical data following varicocele surgery. Clinical upgrading was defined as an increase in sperm concentration that would allow a couple to access new reproductive technologies/techniques. The tiers used for upgrading were 0–1million/cc (Intracytoplasmic Sperm Injection), 1–5 million (In Vitro Fertilization), 5–15 million (Intrauterine Insemination), and >15 million (Natural conception). Artificial intelligence models were trained and tested using R to predict which patients upgraded after surgery.

Main results and the role of chance

51% of men underwent bilateral varicocele repair. The majority of men had grade 2 varicocele on the left, and (when present) a grade 1 varicocele on the right. Overall, 47% of men experienced an upgrade following varicocele surgery, 47% did not change, and 6% downgraded. The data from Miami were used to create a random forest model for predicting clinically significant upgrade in sperm concentration. The most informative model parameters were preoperative FSH, sperm concentration, and surgical laterality. The model identified three clinical categories: men with unfavorable, intermediate, and favorable features to predict varicocele upgrade. On external validation using data from Toronto, the model accurately predicted upgrade in 87% of men with favorable features, and in 49% and 36% of men with intermediate and unfavorable features, respectively. Overall, the model performed well on external validation with an AUC of 0.72 and good calibration.

Calibration plots, using cross-validation, define how well the predicted probabilities match the actual probability of sperm concentration upgrade. The random forest model was run twelve times. All model characteristics are the mean of ten model runs with the highest and lowest performing runs removed.

The model was translated to an online calculator that can be used by clinicians.

Limitations, reasons for caution

One limitation to our study is that we were not able to predict total motile sperm count (TMSC), which has been shown to perform slightly better than concentration at predicting assisted reproduction outcomes. By focusing on clinically significant upgrading, this difference should be minimized.

Wider implications of the findings: Predicting the chances of clinically significant semen upgrading after varicocele repair is essential for patients and clinicians to understand. Several men undergo surgery with no subsequent benefit, which may lead to a delay in definitive treatment with IVF/IUI. Understanding their chances will help couples make better informed decisions moving forward.

Trial registration number

Not applicable

An obstetric patient with neurocadiogenic syncope

We report the peripartum management of a 29-year-old primigravid patient with neurocardiogenic syncope, which had been diagnosed six years previously on tilt-table testing. General principles were applied to minimise the risk of precipitating syncopal episodes. She had an uneventful ventouse-assisted vaginal delivery under epidural anaesthesia in our obstetric high dependency unit. The optimum management of these patients has yet to be established.

Transcranial Doppler ultrasonography-directed intravenous glycoprotein IIb/IIIa receptor antagonist therapy to control transient cerebral microemboli before and after carotid endarterectomy

BACKGROUND

Patients with a transient focal neurological deficit, critical carotid stenosis and/or microemboli detected by transcranial Doppler ultrasonography (TCD) have a significant risk of stroke. The effect of tirofiban, a selective glycoprotein IIb/IIIa inhibitor, was assessed in patients with microembolic signals on TCD after transient ischaemic attacks or carotid endarterectomy (CEA).

METHODS

Thirty-three patients with microemboli on TCD (13 symptomatic preoperative, 19 postoperative, one both) were treated with tirofiban between 2002 and 2007. All patients had carotid stenosis greater than 70 per cent. TCD monitoring was used during and after tirofiban therapy.

RESULTS

The median (range) rate of microemboli decreased from 22 (4-260) per h before surgery and 81 (44-216) per h after surgery to 0 (0-9) per h in both groups (P < 0.001, Mann-Whitney U test). This occurred rapidly (preoperative median 30 min; postoperative median 45 min) and was well tolerated in all patients, with no serious adverse effects.

CONCLUSION

Cerebral microemboli were controlled by tirofiban both before and after CEA. Further study is required to compare the relative efficacy of tirofiban and dextran.

Catalase-like and superoxide dismutase-like activities in human seminal plasma

Human spermatozoa are highly susceptible to oxidative injury but are naturally protected from such injury by the antioxidant properties of seminal plasma. We measured catalase-like and superoxide dismutase (SOD)-like activities in the seminal plasma of fertile and vasectomized men in order to gain insight into the potential source(s) and function(s) of these antioxidants in semen. Semen samples were obtained from fertile men ( n=11) and men post-vasectomy ( n=16). Catalase-like activity was measured by the decrease in hydrogen peroxide concentration after incubation with seminal plasma. SOD-like activity was measured as the inhibition of nitroblue tetrazolium reduction due to superoxide anion generation by xanthine plus xanthine oxidase. Mean seminal catalase-like activity (+/-1SD) in the fertile group was not significantly different from that of the post-vasectomy group (389+/-163 and 325+/-119 U/ml, respectively). Similarly, mean seminal SOD-like activity in the fertile group was not significantly different from that of the post-vasectomy group (37+/-10 and 36+/-10 U/ml, respectively). Our data suggest that the testis and epididymis are not an important source of catalase-like and SOD-like activities in semen. These findings indicate that antioxidants in semen are primarily of post-testicular origin and probably serve to protect ejaculated spermatozoa from oxidative stress such as that which occurs in the female reproductive tract.

Quality of life post radical prostatectomy: a male perspective

The purpose of this qualitative study was to explore the meaning and effect of urinary incontinence and impotence on the quality of life for men with prostate cancer. The Cancer Recovery Model guided the study. This model is based on the assumption that the chronicity of cancer is a function of recovery as well as illness and focuses on the strength of an individual to regain his powers of survival until death. The study identified indicators for quality of life for men who have had a radical prostatectomy for cancer that should be included in developing discharge teaching plans and reinforced in community followup.

Biologic variability of sperm DNA denaturation in infertile men

OBJECTIVES

To examine sperm DNA denaturation (DD) in fertile and infertile men and assess the variability of conventional semen parameters and sperm DD in repeated semen samples from infertile men.

METHODS

Twenty-one consecutive nonazoospermic, infertile men each submitted two semen samples, 2 to 6 weeks apart. We examined semen samples from consecutive fertile men (n = 10) presenting for vasectomy as controls. Standard semen parameters (World Health Organization criteria) and sperm chromatin structure (evaluated by flow cytometry analysis of acridine orange-treated spermatozoa and expressed as the percentage of spermatozoa with denatured DNA) were monitored.

RESULTS

Fertile men had a significantly higher sperm concentration and percentage of sperm motility and a significantly lower percentage of sperm with DD than did infertile men (36 +/- 5.2 x 10(6)/mL versus 12.5 +/- 2.2 x 10(6)/mL, 60.0% +/- 5.2% versus 30.1% +/- 4.1%, and 8.9% +/- 1.9% versus 20.3% +/- 2.5%, respectively, P <0.05). The sperm concentration, sperm motility, and percentage of spermatozoa with DD were not significantly different between the first and second semen samples from the infertile men. Sperm DD showed the lowest average within-subject coefficient of variation (SD/mean), followed by motility and concentration (coefficient of variation 21%, 24%, and 35%, respectively).

CONCLUSIONS

Our data demonstrate that infertile men have significantly higher sperm DD compared with fertile men and that sperm DD exhibits a low coefficient of variation ( approximately 20%) on repeated assessment. These data suggest that sperm DD has a relatively low degree of biologic variability.

Microsurgical varicocelectomy in the era of assisted reproductive technology: influence of initial semen quality on pregnancy rates

OBJECTIVE

To evaluate the natural history of infertile couples in whom the man underwent varicocelectomy.

DESIGN

Retrospective study.

SETTING

University infertility clinic.

PATIENT(S)

159 infertile couples.

INTERVENTION(S)

Microsurgical varicocelectomy.

MAIN OUTCOME MEASURE(S)

Standard semen parameters and pregnancy rates (assisted and unassisted).

RESULT(S)

Postoperative sperm concentration and motility increased significantly compared to before the varicocelectomy (28.9 +/- 3.0 vs. 22.5 +/- 2.1 x 10(6)/mL and 33.9 +/- 1.9 vs. 22.1 +/- 1.3%, respectively). Overall, 48% (76/159) of the couples achieved a spontaneous pregnancy at the mean of 30 months' follow-up. An additional 10% (16/159) and 11% (18/159) of couples achieved a pregnancy following intrauterine insemination and in vitro fertilization/intracytoplasmic sperm injection, respectively. Significantly higher spontaneous pregnancy rates were observed in couples in whom the man's initial sperm concentration was greater than or equal to 5 million sperm per milliliter compared to those in whom the man's initial sperm concentration was less than 5 million sperm per milliliter (61% vs. 8%, respectively).

CONCLUSION(S)

Our data demonstrate that, in couples in whom the man undergoes varicocelectomy for treatment of varicocele, close to 70% achieve a pregnancy. The initial sperm concentration is predictive of unassisted pregnancy outcome in this population.

Prioritizing resource allocation for clinical enhancement: a participative methodology

The allocation of hospital funding for new and expanded clinical programs can be a difficult but most important task to deal with during the development of the operating plan (budget). Like many other hospitals, York Central Hospital has struggled with this task each year. In order to address this challenge, the hospital has successfully designed and implemented a prioritization process that includes a standardized program proposal and peer evaluation. The process is grounded in the hospital's vision and strategic directions and built on a culture of evidence-based practice.

Influence of semen processing technique on human sperm DNA integrity

OBJECTIVES

To compare the effects of density-gradient centrifugation and swim-up technique on sperm DNA integrity.

METHODS

Semen samples (n = 22) were obtained from consecutive nonazoospermic men presenting for infertility evaluation. Individual samples were divided into three aliquots (whole semen, density-gradient centrifugation, and swim-up) for subsequent analysis of sperm motility and DNA integrity. Sperm DNA integrity was evaluated by flow cytometry analysis of acridine orange-treated spermatozoa and expressed as the percentage of spermatozoa demonstrating denatured DNA.

RESULTS

Mean sperm motility (+/-SEM) improved significantly after processing with two-layer density-gradient and swim-up compared with whole semen (65.6% +/- 4.0% and 73.0% +/- 3.0% versus 52.0% +/- 3.6%, respectively, P <0.005), with no significant difference in motility between Percoll-treated and swim-up-treated spermatozoa. In contrast, the percentage of spermatozoa with denatured DNA was reduced significantly in swim-up-treated but not in Percoll-treated spermatozoa compared with whole semen (4.8% +/- 1. 2% and 13.6% +/- 3.6% versus 10.1% +/- 2.3%, respectively, P <0. 0001).

CONCLUSIONS

Although density-gradient centrifugation is comparable to swim-up technique in recovering spermatozoa with enhanced motility, spermatozoa recovered after swim-up possess higher DNA integrity. These data urge us to reexamine our current sperm processing techniques in order to minimize sperm DNA damage.

Influence of initial semen quality on the integrity of human sperm DNA following semen processing

OBJECTIVE

To examine and compare the effects of density-gradient centrifugation on the integrity of sperm DNA from the semen of both fertile and infertile men.

DESIGN

Prospective, observational study.

SETTING

University infertility clinic.

PATIENTS

Forty-four nonazoospermic, infertile men and nine fertile controls.

INTERVENTIONS

Semen samples were processed by density-gradient centrifugation. Sperm motility and sperm chromatin structure (evaluated by flow cytometry analysis of acridine orange-treated spermatozoa) were monitored before and after semen was processed.

MAIN OUTCOME MEASURES

Sperm motility and DNA integrity.

RESULTS

Following density-gradient centrifugation, mean sperm motility (+/-SEM) improved significantly compared to whole semen in samples from fertile and infertile men, respectively (71 +/- 6 vs. 49 +/- 7% and 56 +/- 3 vs. 44 +/- 3%, P<0.05). However, the percentage of sperm with denatured DNA increased compared to whole semen after processing of samples from infertile (25 +/- 3 vs. 15 +/- 2%, P<0. 01) but not fertile men (9 +/- 3 vs. 8 +/- 2%, P>0.05).

CONCLUSIONS

Our data indicate that the potential detrimental effect of density-gradient centrifugation on sperm DNA integrity is related to the initial semen quality. These data urge us to examine our current sperm-processing techniques to minimize sperm DNA damage.

Smoking is associated with the retention of cytoplasm by human spermatozoa

OBJECTIVES

To determine whether cigarette smoking is associated with the abnormal retention of residual sperm cytoplasm in infertile men.

METHODS

Semen samples were obtained from 87 consecutive non-azoospermic men with idiopathic infertility (18 smokers and 69 nonsmokers) and from 20 men presenting for vasectomy (fertile controls). Standard semen parameters and the percentage of spermatozoa with residual cytoplasm (on Papanicolaou smears) were recorded.

RESULTS

Subject age, semen volume, and sperm density, motility, and morphology were not significantly different between the two groups of infertile men. However, a significant difference was found in the mean +/- SEM percentages of sperm with cytoplasm droplets between smokers and nonsmokers (12.9% +/- 1.7% and 8.1% +/- 0.9%, respectively; P < 0.001).

CONCLUSIONS

Our data suggest that cigarette smoking is associated with retention of sperm cytoplasmic droplets in infertile men, a morphologic characteristic associated with impaired sperm function.

Varicocele is associated with abnormal retention of cytoplasmic droplets by human spermatozoa

OBJECTIVE

To determine whether varicocele is associated with retention of sperm cytoplasmic droplets in infertile men.

DESIGN

Retrospective study.

SETTING

University infertility clinic.

PATIENT(S)

Nonazoospermic men with idiopathic (n = 69) and varicocele-associated infertility (n = 73), and 20 fertile controls presenting for vasectomy.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURES(S)

Standard semen parameters and percentage of spermatozoa with cytoplasmic droplets on Papanicolaou smears.

RESULT(S)

No statistically significant differences were found between the fertile and infertile groups with respect to semen volume. Fertile controls had significantly greater mean percent sperm motility and normal morphology than infertile men. The mean percentage of sperm with residual cytoplasm was statistically significantly different in all three groups. Infertile men with varicocele had the highest percentage of sperm with cytoplasmic droplets, the next highest level being in men with idiopathic infertility and the lowest level in fertile controls (11.7 +/- 1.0, 8.1 +/- 0.9 and 3.2 +/- 0.4%, respectively, P<.0001).

CONCLUSION(S)

Our data show that idiopathic and even moreso, varicocele-related male infertility are conditions associated with impaired disposal of residual sperm cytoplasm by the testis and/or epididymis. These data provide a possible mechanism for the observed semen abnormalities and reduced fertility potential associated with varicocele and idiopathic male infertility.

Behind the scenes: partners' perceptions of quality of life post radical prostatectomy

The purpose of this study was to determine the effects of the experience of a radical prostatectomy on the partners of men with prostate cancer. The women described the effects of the experience on their lives and on their partner's life. Descriptions included how they were informed of their partner's diagnosis, emotions at the time of the initial diagnosis, and the sources of information and the decision process that they and their partners used that lead to surgery. The effect of the experience on their quality of life including interpersonal and sexual relationships with their partner and the information that was needed to facilitate self-care after surgery were described. The women provided clear directions for improving the health care system in managing the cancer experience using a family-centered approach.

Effect of adult microsurgical varicocelectomy on testicular volume

OBJECTIVES

To re-examine the potential influence of varicocelectomy on testicular volume using scrotal ultrasonography, because it has been reported that total testicular volume (assessed by physical examination) increases after adult varicocele ligation.

METHODS

A retrospective review of the testicular volume and semen parameters of 61 men who underwent microsurgical varicocelectomy between 1996 and 1998 was performed. Ultrasound-derived testicular volumes and total motile sperm counts were compared before varicocelectomy and at a mean of 7.2 months postoperatively.

RESULTS

Bilateral varicocelectomy was performed in 22 men; 39 men underwent a left-sided procedure only. Overall, no significant change was found in the mean total testicular volume after varicocelectomy compared with preoperatively (24.0 versus 23.9 mL, respectively; P = 0.74). Similarly, the testicular volumes did not change significantly after left or bilateral varicocelectomy (P >0.05). Overall, the mean total motile sperm count increased significantly after varicocelectomy (17. 9 to 25.4, P = 0.05).

CONCLUSIONS

This was the first study to examine the effect of adult varicocelectomy on testicular volume using ultrasound-derived measurements of volume. Unlike previous findings, our data suggest that although adult varicocelectomy improves semen quality in most infertile men, it does not result in a significant increase in testicular volume.

Potential adverse effect of semen processing on human sperm deoxyribonucleic acid integrity

OBJECTIVE

To examine the effect of standard Percoll density-gradient centrifugation on human sperm DNA denaturation.

DESIGN

Prospective, observational study.

SETTING

University-based infertility clinic.

PATIENT(S)

Twenty-five nonazoospermic men.

INTERVENTION(S)

Semen samples (n = 25) were obtained from consecutively seen nonazoospermic men presenting for infertility evaluation. Samples were processed by two-layer and four-layer Percoll density gradients. Sperm motility and sperm chromatin structure (evaluated by flow cytometry analysis of acridine orange-treated spermatozoa) were monitored before and after semen processing. Sperm chromatin integrity was expressed as the percentage of spermatozoa that demonstrated denatured DNA.

MAIN OUTCOME MEASURE(S)

Sperm motility and DNA integrity.

RESULT(S)

Mean sperm motility improved significantly after processing with two-layer and four-layer Percoll gradients compared with whole semen (54% and 57% motility versus 44% motility, respectively). In contrast, the percentage of sperm with denatured DNA increased after processing with two-layer and four-layer Percoll gradients compared with whole semen (34% and 32% versus 18%, respectively).

CONCLUSION(S)

Our data demonstrate that the improvement seen in sperm motility after Percoll processing is not associated with a similar improvement in sperm DNA integrity. These data suggest that we reexamine current sperm processing techniques to minimize sperm DNA damage and the potential transmission of genetic mutations in assisted reproductive cycles.

Effect of varicocelectomy on the abnormal retention of residual cytoplasm by human spermatozoa

Abnormal retention of cytoplasmic residues by human spermatozoa is associated with the generation of reactive oxygen species (ROS) in semen and defective sperm function. We have examined the effect of varicocelectomy on the retention of residual cytoplasm by human spermatozoa. Clinical reports of 43 men who underwent microsurgical varicocelectomy at our institution during a 1 year period beginning July 1996 were reviewed. Standard semen parameters (concentration, motility and morphology) and residual cytoplasm retention (monitored by Papanicolaou stain) were assessed before and 6 months after varicocelectomy. The percentage of spermatozoa with residual cytoplasm decreased significantly following varicocelectomy compared to pre-operatively (25.8 versus 18.1% respectively). The percentages of motile spermatozoa and normal forms increased significantly (P = 0.0003, P = 0.005 respectively) following varicocelectomy (22.6 versus 32.9% and 46.4 versus 54.4% respectively). Our data suggest that varicocelectomy can improve the disposal of residual sperm cytoplasm by the testis and/or epididymis in infertile men with varicocele. These data also suggest that varicocelectomy reduces the potential for ROS generation by human spermatozoa in these men.

Seminal plasma biochemical markers and their association with semen analysis findings

OBJECTIVES

To examine the clinical value of six seminal plasma components in the evaluation of sperm quality and in the differential diagnosis of men with infertility.

METHODS

We analyzed 202 seminal plasmas for prostate-specific antigen, glucose, pepsinogen C, insulin-like growth factor binding protein-3, prostaglandin D synthase (PGDS), and BRCA1-like immunoreactive protein (BRCA1-LIP) using quantitative immunofluorometric procedures. The semen donors were categorized in four clinical groups: normal, oligospermic, azoospermic, and vasectomy patients. We then evaluated whether any of these biochemical markers were associated with other parameters of sperm quality, including patient age, total cell concentration, percentage of motility, and percentage of normal morphology.

RESULTS

We found that only PGDS concentration was significantly associated with other parameters of sperm quality. PGDS concentration correlated positively with total cell concentration (r = 0.55), percentage of motility (r = 0.31), and percentage of normal morphology (r = 0.31). Median PGDS concentration in seminal plasma decreased progressively from normal to oligospermic to azoospermic to vasectomy patients (P <0.001). There was no overlap between seminal plasma PGDS concentration of normal subjects versus vasectomy patients. The only other parameter that was moderately decreased in vasectomy patients was BRCA1-LIP. The source of PGDS in seminal plasma was determined with various techniques, including immunohistochemistry. This protein is produced and secreted by the Sertoli cells.

CONCLUSIONS

Our findings suggest that PGDS concentration in seminal plasma correlates with other known indicators of semen quality and is a new marker of post-testicular obstruction. This biochemical parameter could be used to aid in the differential diagnosis of obstructive and nonobstructive azoospermia in men with infertility.

Heterogeneity of reproductive tract abnormalities in men with absence of the vas deferens: role of cystic fibrosis transmembrane conductance regulator gene mutations

OBJECTIVE

To determine if the types of reproductive tract abnormalities linked to absence of the vas deferens varies with the cystic fibrosis transmembrane conductance regulator (CFTR) genotype.

DESIGN

Prospective data gathering.

SETTING

University infertility clinic.

PATIENT(S)

Forty-six infertile men with absence of the scrotal vas deferens and no signs of cystic fibrosis.

INTERVENTION(S)

All had blood taken for CFTR gene analysis, 33 had scrotal ultrasounds, and 25 had transrectal ultrasounds.

MAIN OUTCOME MEASURE(S)

The frequency of testicular, seminal vesicle, and ampullae of the vas deferens malformations was compared between subgroups of men with two, one, or no CFTR gene mutations.

RESULT(S)

None (0 of 21) of the men with at least one CFTR gene mutations had normal ampullae of the vas or seminal vesicles bilaterally. Two (50%) of 4 men with no CFTR gene mutations had normal ampullae of the vas deferens bilaterally, and 50% had normal bilateral seminal vesicles (statistically significantly different). There was no correlation between testicular malformations and CFTR genotype.

CONCLUSION(S)

This study indicates that the severity of the malformations in the testis is unrelated to the CFTR genotype, whereas the frequency and severity of wolffian duct malformations are related directly to the CFTR genotype.

Adverse effects on vasoepididymostomy outcomes for men with concomitant abnormalities in the prostate and seminal vesicle

PURPOSE

Following microsurgical vasoepididymostomy as many as 85% of men have sperm in the ejaculate, yet only 30 to 50% will spontaneously father children. We examined the possibility that there may be concomitant abnormalities in the prostate and seminal vesicle, which may be associated with low pregnancy rates.

MATERIALS AND METHODS

Transrectal ultrasound was performed in azoospermic men with suspected epididymal obstruction, excluding those who had undergone vasectomy, to identify abnormalities of the seminal vesicles and ejaculatory ducts. Microsurgical vasoepididymostomy was attempted in all men.

RESULTS

Transrectal ultrasound revealed ejaculatory duct dilatation in 13 of 40 men (33%), although only 3 had accompanying seminal vesicle dilatation. Two men had atrophic seminal vesicles with normal ejaculatory ducts. At surgery 8 of 40 patients (20%) were deemed to have irreparable conditions. For the 27 men followed at least 6 months postoperatively patency and pregnancy rates were 75 and 22%, respectively. Mean sperm counts plus or minus standard deviation were significantly higher in men without compared to those with seminal vesicle or ejaculatory duct abnormalities (43 +/- 68 versus 5.7 +/- 6.9 x 10(6) sperm per ml., respectively), and so was the percentage of motile sperm (30 +/- 16% versus 1.2 +/- 2.2%, respectively). Pregnancy rates were also higher in men without (6 of 19, 32%) than with (0 of 8, 0%) seminal vesicle or ejaculatory duct abnormalities.

CONCLUSIONS

Transrectal ultrasound detected abnormalities of the seminal vesicles and ejaculatory ducts are common in men with suspected epididymal obstruction. These abnormalities are associated with a poor outcome for vasoepididymostomy. We recommend that all men with suspected epididymal obstruction undergo transrectal ultrasound before any attempted reconstruction.

Loss of left testicular volume in men with clinical left varicocele: correlation with grade of varicocele

It is reported that a clinical left varicocele is associated with loss of ipsilateral testicular volume. We have examined the loss of left testicular volume in infertile men with clinical left varicocele using ultrasound-derived measurements of testicular volume. We have reviewed the testicular volumes, maximum internal spermatic vein diameters, and the clinical reports of 404 men presenting for infertility evaluation at our institution between 1992 and 1996. Men with bilateral or subclinical varicoceles were excluded from the study. Subclinical varicoceles were diagnosed by the ultrasonographic demonstration of one or more veins having a maximal diameter of more than 3 mm. In men with clinical left varicocele, mean left testicular volume was less than right testicular volume (12.7 vs. 13.8 mL, P < .001). This finding was not observed in men without varicocele (12.3 vs. 12.6 mL, P > .05). In men with left varicocele, the difference between right and left testicular volume (right minus left) increased with increasing varicocele grade. Our data demonstrate that a left varicocele is associated with loss of left testicular volume. The results also show that the degree of left testicular hypotrophy is proportional to the clinical grade of the varicocele.

Outcome of microsurgical reconstruction in men with suspected epididymal obstruction

PURPOSE

Approximately 3 to 6% of all men presenting with infertility (excluding those with a history of vasectomy) are suspected of having epididymal obstruction. However, other anatomical abnormalities within the male reproductive tract are often encountered. In this study we attempted to define the range and frequencies of anatomical abnormalities in the reproductive tract and the outcome of surgical reconstruction in men with suspected epididymal obstruction and no history of vasectomy.

MATERIALS AND METHODS

Between July 1992 and July 1996, 80 azoospermic men with suspected epididymal obstruction underwent scrotal exploration. The anatomical findings and outcomes of reconstructive surgery were reviewed.

RESULTS

Of a possible 160 reproductive tract units (2 per patient) we thoroughly examined 147 with suspected epididymal obstruction. Epididymal obstruction was found in 52.7% of the cases with other anatomical abnormalities accounting for the remaining 47.3%. Of the patients 49 (61%) had sperm identified in the epididymis on at least 1 side and underwent vasoepididymostomy, and 3 (4%) had sperm unilaterally in the proximal vas but had ipsilateral distal vasal obstruction. These 3 men underwent crossed vasovasostomy. We were more likely able to perform reconstruction in men whose obstruction was due to an infectious etiology (13 of 14, 93%) compared to either a surgical (5 of 7, 71%) or idiopathic (34 of 59, 58%) etiology. In 28 patients (35%) no sperm was identified in the epididymis or they had no other abnormalities that precluded successful reconstruction on either side. Of those patients who underwent vasoepididymostomy for epididymal obstruction 61% had sperm in the ejaculate postoperatively.

CONCLUSIONS

In nearly half the men with suspected epididymal obstruction other reproductive tract abnormalities were detected, most of which precluded successful vasoepididymostomy. Other reproductive tract abnormalities are much less likely to be found, and the outcomes of reconstruction are better if the cause of the obstruction is infectious compared to surgical or idiopathic.

The influence of clinical and subclinical varicocele on testicular volume

OBJECTIVE

To examine the possible loss of testicular volume in infertile men with clinical and subclinical varicocele by using ultrasound (US)-derived measurements of testicular volume.

DESIGN

Retrospective review of clinical and scrotal US reports.

SETTING

University infertility clinic.

PATIENT(S)

Infertile men (n = 404) presenting for evaluation from 1992 to 1996.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Presence of clinical or subclinical varicocele, US-derived measurements of testicular volume.

RESULT(S)

In men with clinical left or subclinical left varicocele, left testicular volume was significantly less than right testicular volume (12.9 versus 14.1 and 13.2 versus 14.7 mL, respectively). This finding was not observed in men with bilateral clinical or bilateral subclinical varicoceles or in men without varicocele.

CONCLUSION(S)

Our data confirm previous reports showing that a clinical left varicocele can negatively impact on left testicular volume and for the first time show that a subclinical varicocele is also associated with decreased left testicular volume.

Polymerase chain reaction-based detection of bacteria in semen

OBJECTIVE

To determine if the presently used bacterial detection techniques provide accurate and complete profiles of microorganisms found in human semen.

DESIGN

Routine bacterial cultures and molecular biology techniques using polymerase chain reaction (PCR), with a universal eubacterial primer, cloning, then sequence analysis were used to detect bacteria (culturable or nonculturable) in the semen.

SETTING

University and hospital-based research laboratory.

PATIENTS

Thirty infertile men and nine semen donors, all with no symptoms of a urinary tract infection, donated semen for the study.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Detection of bacteria using routine cultures and molecular biology techniques.

RESULTS

Using PCR, we found > 10(4) bacteria/mL in the semen of 66% of the infertile asymptomatic men and 66% of the semen donors. This contrasts with our routine culture results which detected "significant" bacteriospermia in only 27% of the infertile men and in none of the preselected semen donors. From four of these semen specimens, DNA sequence analysis identified an average of nine different bacterial species per specimen, with close to 90% of the species being anaerobes.

CONCLUSIONS

These data indicate that the present microbiologic detection methods underestimate the incidence of significant bacteriospermia, particularly anaerobic bacteria. The molecular biologic methods should help researchers confirm or refute the role of infection in male infertility.

Pyospermia and male infertility

Pyospermia is found on the semen analysis of up to 23% of men who are being investigated for infertility. The presence of significant numbers of white blood cells in the semen is correlated with poorer sperm parameters and diminished fertility. It is not known if these changes in sperm function are due to the white blood cells or to an underlying problem that may cause both pyospermia and altered sperm function. It is often assumed that pyospermia is an indication of an underlying genitourinary infection. However, studies have not shown an association between bacteria growing in reproductive tract fluids (semen, urine and expressed prostatic secretions) and pyospermia. Despite this, treating these patients with different antibiotics regimens appears to reduce temporarily the white blood cell count in the semen and improve the fertility rates. Well-controlled studies are needed to determine the role of antibiotics in the treatment of this significant cause of male infertility.