Transplantation in reproductive medicine: previous experience, present knowledge and future prospects

The use of transplantation in reproductive medicine has been considered by physicians and scientists alike for many years. Despite being side-tracked into futile pursuits of rejuvenation in the early days, the possibility of usefulness remains, particularly for preserving fertility in patients undergoing ablative chemo- or radiotherapy. These aims have been enhanced by advances in tissue cryopreservation. When isolated primordial follicles are transferred in the mouse, or ovarian tissue slices are grafted into sheep, it is possible to obtain follicular survival with subsequent maturation and oestrogen secretion and even restore fertility to sterilized hosts. For preservation of fertility, autografts avoid both the immunological problems of allografts and the ethical dilemmas when using donor tissue. In the male, the concept of spermatogonial cell transfer after isolation and frozen storage of cells recovered from a testicular biopsy is most attractive, since it may provide another option for rescuing fertility in cancer patients, and provide a much needed one in children. Recent results demonstrate that gonocytes from immature mice injected into the tubules of sterilized hosts restore spermatogenesis and produce fertile spermatozoa. Furthermore, the gonocytes can be stored frozen prior to transfer and still produce fertile tubules. This review presents a broad history of transplantation in the male and female genital tracts as well as attempts to anticipate possible future developments.

Determinants of reproductive outcome after abdominal myomectomy for infertility

OBJECTIVE

To determine the effect of myomectomy as a therapy for infertility and to define the factors that influence reproductive outcome.

DESIGN

Retrospective study of a case series.

SETTING

An academic department specializing in conservative surgery.

PATIENT(S)

A total of 138 infertile women who underwent first-line conservative surgical treatment at laparotomy for uterine leiomyomas over an 8-year period.

INTERVENTION(S)

Data were collected on baseline clinical characteristics, surgical details, and subsequent reproductive history.

MAIN OUTCOME MEASURE(S)

Cumulative pregnancy rates at 24 months according to selected clinical and fibroid characteristics.

RESULT(S)

Pregnancy occurred in 76 women. The 24-month cumulative probability of conception according to the Kaplan-Meier method was 87% in patients <30 years of age, 66% in patients 30-35 years of age, and 47% in patients >35 years of age. The pregnancy rates in women with and without minor infertility factors in addition to myomas were 56% and 71%, respectively, and those in women with <2 years versus > or =2 years of infertility were 84% and 51%, respectively. The size and site of the largest myoma and the total number of tumors removed did not influence the outcome.

CONCLUSION(S)

Our results suggest a benefit of myomectomy in infertile patients. However, women should be counseled carefully before surgery because the determinants of outcome appear to be independent of treatment.

Hysteroscopy for treating subfertility associated with suspected major uterine cavity abnormalities

BACKGROUND

Observational studies suggest higher pregnancy rates after the hysteroscopic removal of endometrial polyps, submucous fibroids, uterine septum or intrauterine adhesions, which are detectable in 10% to 15% of women seeking treatment for subfertility.

OBJECTIVES

To assess the effects of the hysteroscopic removal of endometrial polyps, submucous fibroids, uterine septum or intrauterine adhesions suspected on ultrasound, hysterosalpingography, diagnostic hysteroscopy or any combination of these methods in women with otherwise unexplained subfertility or prior to intrauterine insemination (IUI), in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI).

SEARCH METHODS

We searched the Cochrane Menstrual Disorders and Subfertility Specialised Register (8 September 2014), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2014, Issue 9), MEDLINE (1950 to 12 October 2014), EMBASE (inception to 12 October 2014), CINAHL (inception to 11 October 2014) and other electronic sources of trials including trial registers, sources of unpublished literature and reference lists. We handsearched the American Society for Reproductive Medicine (ASRM) conference abstracts and proceedings (from January 2013 to October 2014) and we contacted experts in the field.

SELECTION CRITERIA

Randomised comparisons between operative hysteroscopy versus control in women with otherwise unexplained subfertility or undergoing IUI, IVF or ICSI and suspected major uterine cavity abnormalities diagnosed by ultrasonography, saline infusion/gel instillation sonography, hysterosalpingography, diagnostic hysteroscopy or any combination of these methods. Primary outcomes were live birth and hysteroscopy complications. Secondary outcomes were pregnancy and miscarriage.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion and risk of bias, and extracted data. We contacted study authors for additional information.

MAIN RESULTS

We retrieved 12 randomised trials possibly addressing the research questions. Only two studies (309 women) met the inclusion criteria. Neither reported the primary outcomes of live birth or procedure related complications. In women with otherwise unexplained subfertility and submucous fibroids there was no conclusive evidence of a difference between the intervention group treated with hysteroscopic myomectomy and the control group having regular fertility-oriented intercourse during 12 months for the outcome of clinical pregnancy. A large clinical benefit with hysteroscopic myomectomy cannot be excluded: if 21% of women with fibroids achieve a clinical pregnancy having timed intercourse only, the evidence suggests that 39% of women (95% CI 21% to 58%) will achieve a successful outcome following the hysteroscopic removal of the fibroids (odds ratio (OR) 2.44, 95% confidence interval (CI) 0.97 to 6.17, P = 0.06, 94 women, very low quality evidence). There is no evidence of a difference between the comparison groups for the outcome of miscarriage (OR 0.58, 95% CI 0.12 to 2.85, P = 0.50, 30 clinical pregnancies in 94 women, very low quality evidence). The hysteroscopic removal of polyps prior to IUI can increase the chance of a clinical pregnancy compared to simple diagnostic hysteroscopy and polyp biopsy: if 28% of women achieve a clinical pregnancy with a simple diagnostic hysteroscopy, the evidence suggests that 63% of women (95% CI 50% to 76%) will achieve a clinical pregnancy after the hysteroscopic removal of the endometrial polyps (OR 4.41, 95% CI 2.45 to 7.96, P < 0.00001, 204 women, moderate quality evidence).

AUTHORS' CONCLUSIONS

A large benefit with the hysteroscopic removal of submucous fibroids for improving the chance of clinical pregnancy in women with otherwise unexplained subfertility cannot be excluded. The hysteroscopic removal of endometrial polyps suspected on ultrasound in women prior to IUI may increase the clinical pregnancy rate. More randomised studies are needed to substantiate the effectiveness of the hysteroscopic removal of suspected endometrial polyps, submucous fibroids, uterine septum or intrauterine adhesions in women with unexplained subfertility or prior to IUI, IVF or ICSI.

Psychological reactions to the medical investigation and surgical treatment of infertility

The psychological effects of the medical investigation and surgical treatment of infertility were investigated. For 2 years 30 women with a diagnosis of tubal damage and 29 men were followed with repeated interviews. Negative effects on sexual life were recorded in all individuals and were associated with the planning of intercourse. Semen analysis was psychologically difficult to half of the men and feelings of shame and degradation were common. Fear and anxiety were increased before reconstructive tubal surgery and postoperative depression was observed in 10 women. Most couples overestimated their chances of having a child and half of them expected pregnancy to occur within a few months. After 2 years the need for professional support and counseling had increased. The medical procedure has psychological side effects in the infertile couple and may provoke anxiety. The investigation should be comprehensive and short, and psychologically traumatic investigations like basal body temperature records should be used with caution. During the period of somatic investigation and treatment repeated discussions about the marital relationship and sexual life should be initiated and psychosocial counseling should be offered to all couples.

Hysteroscopy for treating subfertility associated with suspected major uterine cavity abnormalities

BACKGROUND

Observational studies suggest higher pregnancy rates after the hysteroscopic removal of endometrial polyps, submucous fibroids, uterine septum or intrauterine adhesions, which are present in 10% to 15% of women seeking treatment for subfertility.

OBJECTIVES

To assess the effects of the hysteroscopic removal of endometrial polyps, submucous fibroids, uterine septum or intrauterine adhesions suspected on ultrasound, hysterosalpingography, diagnostic hysteroscopy or any combination of these methods in women with otherwise unexplained subfertility or prior to intrauterine insemination (IUI), in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI).

SEARCH METHODS

We searched the following databases from their inception to 16 April 2018; The Cochrane Gynaecology and Fertility Group Specialised Register, the Cochrane Central Register of Studies Online, ; MEDLINE, Embase , CINAHL , and other electronic sources of trials including trial registers, sources of unpublished literature, and reference lists. We handsearched the American Society for Reproductive Medicine (ASRM) conference abstracts and proceedings (from 1 January 2014 to 12 May 2018) and we contacted experts in the field.

SELECTION CRITERIA

Randomised comparison between operative hysteroscopy versus control for unexplained subfertility associated with suspected major uterine cavity abnormalities.Randomised comparison between operative hysteroscopy versus control for suspected major uterine cavity abnormalities prior to medically assisted reproduction.Primary outcomes were live birth and hysteroscopy complications. Secondary outcomes were pregnancy and miscarriage.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion and risk of bias, and extracted data. We contacted study authors for additional information.

MAIN RESULTS

Two studies met the inclusion criteria.1. Randomised comparison between operative hysteroscopy versus control for unexplained subfertility associated with suspected major uterine cavity abnormalities.In women with otherwise unexplained subfertility and submucous fibroids, we were uncertain whether hysteroscopic myomectomy improved the clinical pregnancy rate compared to expectant management (odds ratio (OR) 2.44, 95% confidence interval (CI) 0.97 to 6.17; P = 0.06, 94 women; very low-quality evidence). We are uncertain whether hysteroscopic myomectomy improves the miscarriage rate compared to expectant management (OR 1.54, 95% CI 0.47 to 5.00; P = 0.47, 94 women; very low-quality evidence). We found no data on live birth or hysteroscopy complication rates. We found no studies in women with endometrial polyps, intrauterine adhesions or uterine septum for this randomised comparison.2. Randomised comparison between operative hysteroscopy versus control for suspected major uterine cavity abnormalities prior to medically assisted reproduction.The hysteroscopic removal of polyps prior to IUI may have improved the clinical pregnancy rate compared to diagnostic hysteroscopy only: if 28% of women achieved a clinical pregnancy without polyp removal, the evidence suggested that 63% of women (95% CI 45% to 89%) achieved a clinical pregnancy after the hysteroscopic removal of the endometrial polyps (OR 4.41, 95% CI 2.45 to 7.96; P < 0.00001, 204 women; low-quality evidence). We found no data on live birth, hysteroscopy complication or miscarriage rates in women with endometrial polyps prior to IUI. We found no studies in women with submucous fibroids, intrauterine adhesions or uterine septum prior to IUI or in women with all types of suspected uterine cavity abnormalities prior to IVF/ICSI.

AUTHORS' CONCLUSIONS

Uncertainty remains concerning an important benefit with the hysteroscopic removal of submucous fibroids for improving the clinical pregnancy rates in women with otherwise unexplained subfertility. The available low-quality evidence suggests that the hysteroscopic removal of endometrial polyps suspected on ultrasound in women prior to IUI may improve the clinical pregnancy rate compared to simple diagnostic hysteroscopy. More research is needed to measure the effectiveness of the hysteroscopic treatment of suspected major uterine cavity abnormalities in women with unexplained subfertility or prior to IUI, IVF or ICSI.

Hysteroscopy for treating subfertility associated with suspected major uterine cavity abnormalities

BACKGROUND

Observational studies suggest higher pregnancy rates after the hysteroscopic removal of endometrial polyps, submucous fibroids, uterine septum or intrauterine adhesions, which are detectable in 10% to 15% of women seeking treatment for subfertility.

OBJECTIVES

To assess the effects of the hysteroscopic removal of endometrial polyps, submucous fibroids, uterine septum or intrauterine adhesions suspected on ultrasound, hysterosalpingography, diagnostic hysteroscopy or any combination of these methods in women with otherwise unexplained subfertility or prior to intrauterine insemination (IUI), in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI).

SEARCH METHODS

We searched the Cochrane Menstrual Disorders and Subfertility Specialised Register (6 August 2012), the Cochrane Central Register of Controlled Trials (T he Cochrane Library 2012, Issue 7), MEDLINE (1950 to October 2012), EMBASE (1974 to October 2012), CINAHL (from inception to October 2012) and other electronic sources of trials including trial registers, sources of unpublished literature and reference lists. We handsearched the American Society for Reproductive Medicine (ASRM) conference abstracts and proceedings (from January 2008 to October 2012) and we contacted experts in the field.

SELECTION CRITERIA

Randomised comparisons between operative hysteroscopy versus control in women with otherwise unexplained subfertility or undergoing IUI, IVF or ICSI and suspected major uterine cavity abnormalities diagnosed by ultrasonography, saline infusion/gel instillation sonography, hysterosalpingography, diagnostic hysteroscopy or any combination of these methods. Primary outcomes were live birth and hysteroscopy complications. Secondary outcomes were pregnancy and miscarriage.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed studies for inclusion and risk of bias, and extracted data. We contacted study authors for additional information.

MAIN RESULTS

Two studies met the inclusion criteria and neither reported the primary outcomes of live birth and complications from the procedure. In women with otherwise unexplained subfertility and submucous fibroids, there is no evidence of benefit with hysteroscopic myomectomy compared to regular fertility-oriented intercourse during 12 months for clinical pregnancy (odds ratio (OR) 2.4, 95% confidence interval (CI) 0.97 to 6.2, P = 0.06, 94 women) and miscarriage (OR 1.5, 95% CI 0.47 to 5.0, P = 0.47, 94 women) (very low-quality evidence). The hysteroscopic removal of polyps prior to IUI increases the odds of clinical pregnancy (experimental event rate (EER) 63%) compared to diagnostic hysteroscopy and polyp biopsy only (control event rate (CER) 28%) (OR 4.4, 95% CI 2.5 to 8.0, P < 0.00001, 204 women, high-quality evidence).

AUTHORS' CONCLUSIONS

Hysteroscopic myomectomy might increase the odds of clinical pregnancy in women with unexplained subfertility and submucous fibroids, but the evidence is at present not conclusive. The hysteroscopic removal of endometrial polyps suspected on ultrasound in women prior to IUI might increase the clinical pregnancy rate. More randomised studies are needed to substantiate the effectiveness of the hysteroscopic removal of suspected endometrial polyps, submucous fibroids, uterine septum or intrauterine adhesions in women with unexplained subfertility or prior to IUI, IVF or ICSI.

Operative laparoscopy: American Association of Gynecologic Laparoscopists' 1993 membership survey

The American Association of Gynecologic Laparoscopists' 1993 membership survey on operative laparoscopy had 825 respondents reporting 45,042 procedures. The most frequent indication was pelvic pain (56% of procedures), followed by infertility (38%). There were 7382 laparoscopically assisted hysterectomies reported. Compared with 1988 and 1991 survey data, the rates of unintended laparotomy, hemorrhage, and bowel or urinary tract injury increased, but the overall complication and death rates remained essentially unchanged.

Cost considerations with infertility therapy: outcome and cost comparison between health maintenance organization and preferred provider organization care based on physician and facility cost

Of 98 retrospectively selected patient couples insured under one scheme (group I) who, based on performance of a hysterosalpingogram (HSG), were assumed to be under active infertility care, 96 were confirmed as infertile. These were matched by date, patient age and time of HSG to 96 patients under infertility care (group II). Both patient populations were then prospectively evaluated for outcome and cost of treatment. Total physician charges for groups I and II were similar. However, charges per achieved clinical pregnancy were higher in group I than group II since group I patients demonstrated a lower pregnancy rate (28/96, 29%) than group II patients (41/96, 43%) (P=0.05). Within group I, pregnancy rates were identical, whether treatment was provided by generalists or subspecialists. In group II, all care was provided by specialists. The number of days of treatment did not vary between groups I and H, though generalists in group I provided significantly fewer treatment days than specialists in either group I (P=0.003) or in group II (P=0.021). This was primarily due to a significantly higher patient drop-out rate in group I patients, and especially amongst those who received care from generalists (P < 0.0019). Group I patients also encountered significantly more surgical procedures than group H patients (P=0.0016). If physician charges are discounted and customary surgical facility costs are added, the actual cost structure for fertility care in group I patients was dramatically higher than in group II patients. The most cost-effective format to provide infertility care of high quality appears to be a managed care setting in which subspecialists provide a majority of care and in which patient choice is restricted to those subspecialists.

[Uterine malformations and reproduction]

The frequency of uterine malformations impacting on reproduction seems not easy to determine. Their diagnosis needs specific explorations (hysterosalpingography, hysteroscopy and laparoscopy). Spontaneous fertility may be impaired in relation with uterine abnormalities. All these abnormalities could have repercussions on the conceptus' evolution like abortion, preterm delivery, vascular pathologies and intrauterine growth restriction. Ovarian function does not seem to be altered even though implantation rate could be reduced. Surgery, especially endoscopy, allows a precise diagnosis, a prognostic evaluation and an adequate treatment improving conception rates and pregnancy outcome. Mainly hysteroscopic septum section and expansion metroplasty were regularly described.

Hydrosalpinx and assisted reproduction: options and rationale for treatment

Salpingoscopy during laparoscopy yields the best prognosis in patients with hydrosalpinx. It has been demonstrated that in-vitro fertilization (IVF) patients with hydrosalpinx have decreased pregnancy rates as compared with control individuals. If a patient with hydrosalpinx is to be treated with IVF, then the communication between the uterine tube and the uterine cavity should be blocked via salpingectomy or proximal tubal ligation, with or without distal tubal fenestration. This is because there is evidence that hydrosalpinx, especially when it is bilateral and visible by ultrasonography, impacts negatively on pregnancy and implantation rates after IVF cycles.

Does fertility improvement after varicocele treatment justify preventive treatment at puberty?

Evolution of fertility parameters in 374 patients who underwent surgical intervention (Palomo technique) for varicocele was studied. Preoperative motility, morphology, and concentration of spermatocytes did not correlate with degree of varicocele. Statistically postoperative parameters all were significantly improved and the left testicle volume increased. However, improvement did not correlate with degree of varicocele, age at intervention, or pregnancy rate. Extrapolation of results to subclinical varicoceles and treatment of varicoceles in adolescents still remains questionable.

Pelviscopic tubal surgery: the acceptable vogue

A retrospective analysis undertaken at the University of Kiel by the Department of Obstetrics and Gynaecology, consisted of a 3-year study of cases of tubal surgery with operative pelviscopy (laparoscopy). In the period from 1987 to 1989, 529 patients underwent selective operative laparoscopy specifically because of a tubal factor of infertility. The type of surgery performed was aimed at the conservation and salvaging of the tubes whenever possible, according to the principles of 'Minimally Invasive Surgery'.

Advanced surgical instrumentation needed for intra-abdominal application of the carbon dioxide laser in reproductive biology

Rapidly expanding laser technology has created a void in surgical instrumentation when the carbon dioxide laser is applied to intra-abdominal microlaser fertility-promoting procedures. By using proper instruments, the laser microsurgeon will be able to enhance his surgical technique as well as reduce his frustrations.

Advances and applications of germ cell transplantation

When male germ line stem cells are transplanted from the testis of a fertile donor animal to the testis of an infertile recipient they can establish donor-derived spermatogenesis in the recipient testis, and the resulting sperm can transmit the genotype of the donor to the offspring of the recipient. Germ cell transplantation provides a bioassay to study the biology of these stem cells, to develop systems for spermatogonial stem cell isolation and culture, to examine defects in spermatogenesis and to correct male infertility. Although most widely studied in rodents, germ cell transplantation has been applied to larger mammals, including primates. A potential clinical application is restoration of fertility in patients that underwent cytotoxic treatments for cancer. As an alternative to transplantation of isolated germ cells to a recipient testis, ectopic grafting of testis tissue from diverse mammalian donor species, including primates, into a mouse host represents a novel possibility to study spermatogenesis, to investigate the effects of toxins or drugs with the potential to enhance or suppress male fertility, and to produce fertile sperm from immature donors. Therefore, transplantation of germ cells or xenografting of testis tissue are uniquely valuable approaches for the study, preservation and manipulation of male fertility in mammalian species.

The undescended testis in children and adolescents part 2: evaluation and therapeutic approach

Undescended testis (UDT) is defined as failure of a testis to descend into the scrotum and it is a common reason for consultation in pediatric urology. As extensively discussed in "The undescended testis in children and adolescents: part 1", the failure of a testis to descend alters testicular germ-cells development, increasing the risk of infertility and testicular cancer in adulthood. Here, we present the second part of our review and analysis of this topic with the aim to propose an updated and well-informed approach to UDT together with a treatment flow chart that may be useful to guide pediatric surgeons and urologists in the care of these patients. The main goal of the management of patients with UDT is to diminish the risk of infertility and tumor development and is based on the clinical findings at the time of diagnosis.

Syndrome of inappropriate secretion of thyroid-stimulating hormone in a subject with galactorrhea and menstrual disorder and undergoing infertility treatment: Case report

RATIONALE

Syndrome of inappropriate secretion of thyroid-stimulating hormone (SITSH) is a rare cause of hyperthyroidism. Thyroid-stimulating hormone (TSH) levels are usually normal or high, and triiodothyronine (FT3) and free thyroxine (FT4) levels are usually high in subjects with SITSH.

PATIENT CONCERN

A 37-year-old woman had experienced galactorrhea and menstrual disorder for a couple of years before. She had undergone infertility treatment in 1 year before, hyperthyroidism was detected and she was referred to our institution.

DIAGNOSIS

She was suspected of having SITSH and was hospitalized at our institution for further examination. The data on admission were as follows: FT3, 4.62 pg/mL; FT4, 1.86 ng/dL; TSH, 2.55 μIU/mL. Although both FT3 and FT4 levels were high, TSH levels were not suppressed, which is compatible with SITSH. In addition, in brain contrast-enhanced magnetic resonance imaging, nodular lesions were observed in the pituitary gland with a diameter of approximately 10 mm. In the thyrotropin-releasing hormone load test, TSH did not increase at all, which was also compatible with TSH-secreting pituitary adenoma. In the octreotide load test, the TSH levels were suppressed. Based on these findings, we diagnosed this subject as SITSH.

INTERVENTIONS

Hardy surgery was performed after the final diagnosis. In TSH staining of the resected pituitary adenoma, many TSH-producing cells were observed. These findings further confirmed the diagnosis of pituitary adenoma producing TSH.

OUTCOMES

Approximately 2 months after the operation, TSH, FT3, and FT4 levels were normalized. Approximately 3 months after the operation, she became pregnant without any difficulty.

LESSONS

We should consider the possibility of SITSH in subjects with galactorrhea, menstrual disorders, or infertility. In addition, we should recognize that it is very important to repeatedly examine thyroid function in subjects with galactorrhea, menstrual disorder, or infertility.

Bliss procedure for undescended ovaries

OBJECTIVE

To highlight a novel surgical approach for the management of undescended ovaries in those presenting with infertility, to allow for potential transvaginal egg retrieval. The video demonstrates a novel surgical approach for mobilization and oophoropexy of undescended ovaries to allow for future transvaginal egg retrieval in the context of artificial reproductive technology (ART).

DESIGN

Case report. Institutional Review Board approval is not required because this was not a human study. Patient consent was obtained for video footage.

SETTING

Hospital.

PATIENTS

We present a 26-year-old nulligravid woman with a unicornuate uterus, a high riding-right ovary, and an undescended left ovary with prior laparoscopic remnant uterine horn resection. Because of her 9 years of infertility and a prior unsuccessful ovarian mobilization and oophoropexy, she was referred for consideration of a repeat laparoscopic bilateral ovarian mobilization and oophoropexy.

INTERVENTION

Surgical intervention for undescended ovaries.

MAIN OUTCOME MEASURES

Postoperative ovarian location and postoperative pain.

RESULTS

The patient reported minimal pain postoperatively at 6 weeks. Multiple follow-up imaging revealed both ovaries behind the uterus (antral follicle counts 15), with easy transvaginal access for future ART.

CONCLUSION

Undescended ovary is uncommon and usually requires no treatment. However, intervention may be required in the context of infertility and ART, where transvaginal egg retrieval is impossible because of the location of the ovaries. This is the first educational video to our knowledge highlighting a novel surgical approach for the management of undescended ovaries.

An atypical erectile dysfunction patient with infertility treated with penile prosthesis implantation and testicular epididymal sperm aspiration (TESA)-intracytoplasmic sperm injection (ICSI): A case report

RATIONALE

Erectile dysfunction (ED) is common in middle-aged and elderly men, affecting more than 100 million males worldwide. Most ED cases can be attributed to organic and/or psychological factors. Here we report an atypical ED case with no clear manifestation fitting the diagnosis for recognized types of ED.

PATIENT CONCERNS

The 35-year-old male is unable to have normal erection since puberty, and unable to complete intercourse with his wife. He had no history of trauma, surgery or psychiatric/psychological disease. The patient has a normal male karyotype. There is no significant finding in physical examination, nocturnal penile tumescence test, and ultrasound measurement of penis vascular functions. The serum levels of major hormones are all in normal ranges.

DIAGNOSES

Atypical ED, psychogenic ED not excluded; infertility.

INTERVENTIONS

Oral phosphodiesterase inhibitors Tadalafil (20 mg, BIW) or Sildenafil (50 mg, BIW) had no effect in this patient. Penile prosthesis implantation helped the patient to acquire normal sexual life, but did solve the ejaculation failure and infertility. Motile sperms were obtained by testicular epididymal sperm aspiration under the guidance of ultrasound, and intracytoplasmic sperm injection was performed with occytes retrieved from his wife.

OUTCOMES

The patient sexual life was significantly improved after penile prosthesis implantation; the patient wife is currently in the first trimester of pregnancy as the result of in vitro fertilization.

CONCLUSIONS

The no response to phosphodiesterase type 5 inhibitors (PDE5) treatment may suggest an impediment of PDE5-related pharmacological pathways or the presence of defect/injury in the neural system. This special case raises a question if some patients with persistent ED may have similar manifestations and can be treated with the same procedures.

Laser instrumentation for intra-abdominal microlaser gynecologic surgery

With proper laser instrumentation, the gynecologic microlaser surgeon enhances his ability to accomplish intra-abdominal fertility-promoting procedures in a safe and efficient manner.