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Reproductive problems in the male contribute significantly to subfertility in heterosexual couples but can also impact on the ability of single or homosexual men to take part in donation or surrogacy. The main causes of reproductive problems in males can be classified as either (1) pre-testicular (those affecting the regulatory hormonal pathway); (2) testicular (those which relate to impaired testicular function); and (c) post-testicular, where there is a blockage of the male genital tract or other problems with associated ejaculation or sperm delivery; however, it is possible that there can be more than one cause. The main diagnostic procedures include physical examination, followed by semen analysis and, in some instances, endocrine tests (follicle-stimulating hormone and testosterone), genetic tests (karotyping, Y chromosome microdeletion testing and cystic fibrosis testing) and radiological investigations. In the case of secondary hypogonadism, medical treatment with human chorionic gonadotropin can improve sperm quality but in the majority of azoospermic men only various surgical interventions to recover sufficient sperm for intracytoplasmic sperm injection are of proven value.
Varicocele is the most common surgically correctable factor identified in infertile men. The negative impact of varicocele on testicular function, semen parameters and fertility potential have been well recognized for decades. Despite this, the role of varicocele repair in managing infertility remains controversial, especially since the advent of assisted reproductive technologies (ART). This chapter details the current status of varicocele in male infertility. We describe the anatomy, pathophysiology and diagnostics of varicocele and discuss the methods of repair. We then take a critical look at the efficacy and clinical utility of varicocele repair in infertile couples, with an emphasis on clinical benefits for couples undergoing ART.
This chapter introduces medical students, residents, fellows, and practicing urologists to surgical syndromes that can affect a man's reproductive potential. The most widely accepted theory of how varicocele affects testicular function is that of elevated testicular temperature. When obstructive azoospermia is present, sperm production by the testis remains normal and often epididymal tubules become quite dilated. The yield of sperm from the epididymis is logarithmically higher than the yield of sperm from the testis. The anatomy of the male reproductive tract is such that sperm exit the testes, travel through the epididymis, and enter the vas deferens. The vas deferens travels into the inguinal canal with the spermatic cord and then dives posteromedially to fuse with the seminal vesicles at the ampulla of the vas deferens. Any serious medical illness or surgery can result in impaired testicular function and disruption of normal ejaculatory function.
Patients with fertility problems may be referred for scrotal ultrasonography (US) to evaluate testicular size, to assess testicular parenchyma, to examine epididymal integrity, and to ascertain the presence of varicocele. The scrotal ultrasound scan is carried out with the patient in the supine position, exposing the scrotum with the thighs and the abdomen covered. The testis, epididymal head, epididymal body, and epididymal tail are examined sequentially. Pulsed Doppler is also utilized to detect a subclinical varicocele by demonstrating the presence as well as the duration of reverse venous flow in the testicular veins. The use of ultrasound-guided testicular sperm aspiration in azoospermic patients has been described. A 21-gauge butterfly needle is directed into the testicular regions to be sampled under real-time gray-scale and power Doppler sonographic guidance, avoiding the echogenic mediastinum testis and the vascular plexus of the tunica albuginea, as well as the prominent testicular parenchymal vessels.
This chapter summarizes various imaging modalities in the workup of male infertility with emphasis on indications and outcome interpretation. The conditions outlined in this chapter are commonly identified causes for oligospermia and azoospermia, and are the usual targets for imaging investigations. Color Doppler ultrasound (CDUS) has become the most frequently used imaging modality for varicocele detection. Ultrasound studies of spermatic veins have suggested that the presence of multiple large veins. In CBAVD the diagnosis is established clinically by the absence of the two vasa deferentia on palpation. Intratesticular cysts include cysts of the tunica albuginea, tubular ectasia of the rete testis, and testicular cysts. Testicular microlithiasis (TM) is characterized by the presence of numerous punctate calcifications within the testis. Transrectal ultrasound (TRUS)-guided echo-enhanced seminal vesiculography in combination with transurethral resection of the ejaculatory duct (TURED) is considered the best imaging method when treating ejaculatory duct obstruction (EDO).
This chapter reviews the current concepts and ongoing controversies regarding the pathophysiology, diagnosis, significance, and treatment of the varicocele. Varicocele may also affect reactive oxygen species generation, rendering the testicle and the sperm unable to handle oxidative stress, and resulting in reactive oxygen species buildup. Toxic agents and heavy metals accumulate in tissues undergoing apoptosis, several investigators has examined testicular tissue heavy-metal content in men with varicocele. A pencil-probe Doppler stethoscope has been advocated as an adjunctive tool in the examination of the varicocele. Ultrasonography has become an increasingly useful modality in the diagnosis of varicocele. Surgical varicocelectomy is the cornerstone of varicocele therapy. Several surgical approaches are available to accomplish varicocelectomy. The approaches include the scrotal approach, the subinguinal approach, the inguinal approach, the retroperitoneal approach, and the laparoscopic approach. Azoospermia has generally been regarded as a contraindication to varicocelectomy.
Rational treatment of the infertile male requires a correct and complete etiological diagnosis. Varicocele develops during puberty, and it is the most common cause of male infertility with prevalence varying between 30 and 60 percent. Thermography, endovascular treatment, and transcatheter embolization are treatment options for varicocele patients. Male accessory gland infection (MAGI) may result from infestation by sexually transmitted pathogens. The prevalence of immunological infertility is related to that of the diseases initiating the antibody formation, but it is no more than 5 percent in our population. Idiopathic sperm deficiency probably results from the combination of unfavorable external and lifestyle factors which includes conditions like idiopathic oligozoospermia, asthenozoospermia, or teratozoospermia. Intrauterine insemination (IUI) is an effective mode of treatment but if IUI remains unsuccessful after a maximum of four cycles, intracytoplasmic sperm injection (ICSI) should be recommended.
This chapter deals firstly with the anatomy and physiology of male reproduction, and then gives an account of the aetiology and management of male factor infertility. The male reproductive system consists of the penis, testes, ejaculatory ducts and accessory sex glands. The testis produces the majority (6-7 mg/day) of testosterone, although a small amount is also produced by the adrenal glands. Spermatogenesis and synthesis of testosterone are under control of the anterior pituitary gland. Prior to investigating the infertile male, the clinician must ensure that the female partner has been thoroughly evaluated. The World Health Organization has defined the minimal semen parameters for fertility. These parameters are volume, pH, sperm concentration, total sperm number, motility and morphology. The surgical causes of male infertility include varicocele and cryptorchidism. The infertile male should be managed in a tertiary centre where appropriate facilities exist for microsurgery, assisted conception techniques and cryostorage of sperm.
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