chapter 21 Male Infertility Edmund Sabanegh, Jr., MD l Ashok Agarwal, PhD

Introduction: Definition and Other Testing Demographics of Infertility Diagnostic and Treatment Categories of History and Review of Systems Male Infertility Physical Examination Assisted Reproduction Laboratory Evaluation of Male Infertility

classic definition of infertility would suggest deferring medical INTRODUCTION: DEFINITION AND assessment until 12 months of unprotected intercourse, we support DEMOGRAPHICS OF INFERTILITY performance of a basic, cost-effective evaluation of both partners at the time of presentation for evaluation. Current recommenda- Over the past 50 years, we have witnessed dramatic advances in tions by the Practice Committees of the American Urological the understanding and treatment of male fertility. The introduc- Association and the American Society for Reproductive Medicine tion of intracytoplasmic sperm injection (ICSI) in 1992 (Palermo (Male Infertility Best Practice Committee Report, 2006a, 2006b) et al, 1992), a technique of in-vitro fertilization using direct inser- recommend infertility evaluation before 1 year if (1) male infertil- tion of a single sperm into an egg, offered the ability to bypass ity risk factors such as a history of bilateral cryptorchidism are even some of the most severe etiologies of male subfertility but known to be present, (2) female infertility risk factors including raised a variety of cost and safety issues. Growing understanding advanced female age (older than 35 years) are suspected, or (3) the of the genetics of fertility, environmental influences on gonado- couple questions the male partner’s fertility potential. A timely cytes, and the endocrine basis for germ cell development holds but limited evaluation provides early identification and correction promise to allow more targeted diagnostic and therapeutic inter- of factors that may reduce fertility, as well as reassurance in an ventions. Unlike many other disease states, fertility represents a emotionally difficult situation for couples. Alleviation of anxiety complex interaction between two individuals involving multiple related to infertility may in itself provide therapeutic value. organ systems. Attempts to isolate pathology to one gender are Perhaps more than in many other medical assessments, evalu- confounded by the fact that male fertility is not a clearly quantifi- ation of infertility requires a methodic approach involving a com- able parameter but is dependent on requirements of the individual prehensive medical history, review of systems, targeted physical female reproductive system. Older studies have related 20% of examination, and basic laboratory tests. An effective initial cases of infertility to purely male factor etiology, while an addi- approach should be rapid, cost-effective, and noninvasive. Con- tional 30% to 40% involve both male and female factor pathology current basic evaluation of the female partner is prudent given the (Simmons, 1956). Newer studies have shown little change in multifactorial etiology of infertility, as well as the potential need this distribution with more than 50% attributable to male factor, for assisted reproductive technologies (ARTs) to treat the male despite advances in the diagnosis and management of infertility factor. Initial male factor evaluation may suggest the need for (Mosher and Pratt, 1991; Thonneau et al, 1991). more advanced semen, genetic, endocrine, or radiologic tests to Knowledge of the inherent inefficiency of normal human repro- arrive at the correct diagnostic and treatment plan. duction is critical before we can define infertility. Studies of con- Whenever possible, treatment should involve correction of a ception in normal couples reveal that 60% to 75% will conceive specific problem rather than blanket application of costly assisted within 6 months of unprotected intercourse and 90% by 1 year reproductive technologies. ART use for male factor infertility in (Tietze et al, 1950; Spira, 1986). On the basis of this, the classic the United States has been estimated to cost almost $18 billion definition of infertility became the absence of conception after 12 dollars in 1 year alone (Meacham et al, 2007), underscoring the months of regular, unprotected intercourse, a definition supported need for addressing the specific cause of male factor infertility. by the Practice Committee of the American Society for Reproduc- More importantly, ART application without attention to the male tive Medicine (ASRM). Because a small number of normal couples factor may mask potentially significant and even life-threatening will conceive between 1 and 2 years, the World Health Organiza- conditions present in the infertile male, conditions that may occur tion (WHO) recommends 24 months of unprotected intercourse in up to 1.3% of men and that would only have been diagnosed as the preferred definition of infertility (Rowe, 1993). Geographi- with a complete medical evaluation (Kolettis and Sabenegh, 2001). cally diverse population-based studies have reported a remarkably However, ART retains an important role in the management of consistent 15% to 20% incidence of infertility (WHO, 1991; male factor infertility, especially where no etiology for infertility Gunnell and Ewings, 1994; Philippov et al, 1998). Although the can be identified or in the setting of noncorrectable causes. In 616 CHAPTER 21 ● Male Infertility 617

addition to assisted reproduction, donor sperm insemination and as fever, illness, or drug use in the several months before semen adoption remain excellent options for the management of non- testing should prompt repeat testing after an additional 3 months correctible infertility. to rule out transient detrimental effects. Reproductive history is of particular importance in the initial HISTORY AND REVIEW OF SYSTEMS evaluation. Details regarding any prior conceptions the patient may have caused with his present or prior partner, duration of Successful diagnosis and treatment of infertility requires careful infertility, method of reproductive timing, and prior contraceptive attention to obtaining a thorough history. A diverse variety of history should be obtained. Primary infertility is defined as the specific factors can affect subsequent fertility or sexual function failure to conceive at any time in the past with any prior partner, (Table 21–1). Although focus may be on long-term factors that can whereas secondary infertility indicates a prior conception with the affect fertility, human spermatogenesis is estimated to involve a current or previous partner. This simple classification can be 64-day cycle with an additional 5 to 10 days of epididymal transit helpful in narrowing the differential diagnoses because those time on the basis of radioisotope labeling studies (Clermont and with secondary infertility are presumed to have normal embryo- Heller, 1963; Franca et al, 2005; Misell et al, 2006). Factors such logic development of their reproductive tract and genetic complement. The timing and frequency of intercourse are an important com- Table 21–1. ponent of the reproductive history. In recent years, the ease and Pertinent History in Evaluation of the Infertile Male availability of ovulation predictor kits, which measure midcycle urinary luteinizing hormone (LH) surge as a predictor of impend- Infertility history ing ovulation, have allowed couples to approach reproductive Duration timing in a more informed and effective fashion. However, many Prior conceptions couples are not aware of the viability of spermatozoa within the Current or previous partner Outcome female reproductive tract with sperm surviving between 2 and 5 Previous fertility evaluation and treatment days in favorable cervical mucus (Wilcox, 1995). This finding is Sexual history the basis for the widely offered recommendation of intercourse Erectile function frequency every 2 days near the time of ovulation, maximizing Lubricants the chance that viable sperm are available to the oocyte (Tur- Frequency/timing of intercourse Kaspa et al, 1994). Intercourse that is too frequent does not allow Past history replenishment of adequate numbers of spermatozoa within the Childhood epididymis, whereas infrequent intercourse may miss the poten- Cryptorchidism tial window for fertilization. An assessment of erectile and ejacula- Onset of puberty tory function is also germane to the initial evaluation. Testicular pathology Torsion Use of vaginal lubricants is commonplace in reproductive-aged Trauma couples with almost one half of couples reporting intermittent Midline defects (cleft palate) use (Oberg et al, 2004). A number of commercially available lubri- Medical cants that are not marketed as spermicidal agents have been Diabetes mellitus shown to adversely affect sperm motility (Miller, 1994; Kutteh Neurologic disease et al, 1996; Anderson et al, 1998) and sperm deoxyribonucleic Spinal cord injury acid (DNA) integrity (Agarwal et al, 2008). Although some lubri- Multiple sclerosis cants such as vegetable oil, raw egg white, and Pre-Seed have Infection minimal spermicidal effect (Goldenberg and White, 1975; Urinary infections Edvinsson et al, 1983; Agarwal et al, 2008), it remains optimal to Sexually transmitted disease Epididymitis/prostatitis avoid lubricant use if possible and to use minimal concentrations Tuberculosis of the least toxic lubricant available, if required. Mumps orchitis A variety of pediatric conditions including cryptorchidism, post- Recent viral/febrile illness pubertal mumps orchitis, and testicular torsion or trauma can have Renal disease significant implications on eventual fertility. Although prepubertal Cancer mumps is unlikely to have detrimental effects on fertility, mumps Chemotherapy/radiotherapy occurring in the postpubertal timeframe is associated with unilat- Surgical eral or bilateral orchitis in up to 40% of children (Werner, 1950) Orchidopexy with potentially devastating testicular damage. Testicular torsion Retroperitoneal/pelvic surgery or trauma can result in testicular atrophy, as well as the develop- Herniorrhaphy Vasectomy ment of antisperm antibodies, which are detrimental to sperm Bladder neck/prostatic surgery function and motility (Bronson et al, 1984; Puri et al, 1985). Medications The timing of the onset of puberty may suggest underlying Gonadotoxins endocrinologic abnormalities. A history of delayed puberty, espe- Environmental exposures (pesticides, heavy metals) cially in conjunction with anosmia, is associated with the Radiation diagnosis of Kallmann syndrome, or primary hypogonadotropic Habits (tobacco, recreational drugs, anabolic steroids) hypogonadism. On the other hand, precocious puberty may be Family history secondary to congenital adrenal hyperplasia, which may affect Infertility future fertility. Cystic fibrosis Prior scrotal, inguinal, or retroperitoneal surgeries can obstruct Androgen receptor deficiency the ductal system or interfere with emission or ejaculation of 618 SECTION VI ● Reproductive and Sexual Function

sperm. Classic retroperitoneal lymphadenectomy for testicular dihydrotestosterone and are commonly used for treatment of cancer frequently results in sympathetic nerve injury leading to benign prostatic hypertrophy. Use of these agents has been associ- anejaculation or retrograde ejaculation (Kedia et al, 1977). Fortu- ated with reductions in semen volume, as well as erectile and nately, with modifications in the surgical template and intentional ejaculatory dysfunction (Giuliano, 2006). Psychotherapeutic med- nerve sparing, ejaculation can be preserved in almost all patients ications including the selective serotonin reuptake inhibitors with low-stage disease and in selected patients with more advanced (SSRI), monoamine oxidase inhibitors, phenothiazines, and disease (Donohue et al, 1990). Bladder neck surgery and transure- lithium can suppress the hypothalamic-pituitary-gonadal axis, thral resection of the prostate can lead to retrograde ejaculation impair ejaculation and erectile function, and reduce libido (Nudell due to bladder neck incompetence. In selected patients, transure- et al, 2002). Exogenous testosterone and steroid supplementation, thral incision of the prostate can allow preservation of antegrade whether medically prescribed or used for recreational purposes, ejaculation. Vasal injuries from inguinal surgery have seen resur- can have the most profound detrimental effects on spermatogen- gence with the popularity of polypropylene mesh hernia repairs, esis of the medical agents. Androgenic agents induce hypogonado- which can induce dense fibroblastic reactions leading to vasal tropic hypogonadism leading to azoospermia, which can last 6 obstruction (Shin, 2005). months or more after cessation of the supplements and, on Systemic diseases in adulthood can affect fertility through a occasion, may be irreversible (Sigman et al, 2006). Testosterone number of different mechanisms. Diabetes mellitus, spinal cord replacement therapy in hypogonadal men desiring fertility should injuries, and multiple sclerosis exert effects through impairment be avoided, and alternate regimens such as antiestrogens (clomi- of both ejaculatory and erectile function (Sønksen and Biering- phene citrate, tamoxiphene) should be considered instead. Recre- Sørenson, 1992; Sexton and Jarow, 1997). Diseases of the thyroid, ational drugs have also been implicated as gonadotoxic agents. both hyper and hypo function, affect both steroid hormone Marijuana use is associated with gynecomastia, reductions in metabolism and sperm quality and have been associated with serum testosterone, decreased sperm counts, and elevated seminal subfertility (Velazquez and Bellabarba, 1997; Abalovich et al, leukocytes (Harmon and Aliapoulios, 1972; Hembree et al, 1979; 1999; Krassas et al, 2002). Subclinical hypothyroidism does Close et al, 1990). Abnormal sperm morphology, decreased motil- not produce significant seminal abnormalities (Trummer et al, ity, and low sperm concentrations have been associated with 2001). cocaine use (Bracken et al, 1990; Hurd et al, 1992). Although long- Neoplasms in general can induce marked impairment of sper- term abuse of alcohol is associated with global suppression of the matogenesis due to endocrine disturbances, malnutrition, hyper- hypothalamic-pituitary gonadal axis and spermatogenesis, moder- metabolism with associated fever, and immunologic factors ate intake is not associated with significant deterioration in fertil- (Costabile and Spevak, 1998; Wong et al, 2000). In addition to the ity (Muthusami and Chinnaswammy, 2005). global effects of malignancy on reproductive health, specific Although the role of smoking in lung and heart diseases is malignancies such as Hodgkin disease (HD) and testicular germ widely established, the adverse effect of tobacco on male reproduc- cell tumors produce significant direct gonadotoxic effects (Petersen tive health is less well known by the general public. Smoking is et al, 1999; Rueffer et al, 2001). Pretreatment testicular dysfunc- associated with declines in basic semen parameters such as sperm tion associated with HD has been postulated to be due to a variety concentration, viability, forward motility, and morphology (Vine of mechanisms including genetic abnormalities at the germ cell et al, 1996; Künzle et al, 2003), as well as declines in sperm pene­ level, endocrinopathies, systemic release of cytokines injurious to tration ability and hence fertilization rates (Sofikitis et al, 1995). both the seminiferous tubules and the Leydig cells, and negative Defects in these parameters not only affect normal fecundity but local effects from intratesticular lymphatic tissue. Testicular tumors also lower assisted reproduction success rates (Joesbury et al, 1998; impair spermatogenesis by the destruction of surrounding tissue, Zitzmann et al, 2003). local secretion of HCG and other paracrine factors, intrascrotal The impacts of environmental and occupational exposures on temperature elevation, and alterations in the local blood flow. spermatogenesis are more difficult to prove and quantify. Certain Cancer treatments including chemotherapy and radiation produce agents such as heavy metals, pesticides such as dibromochloropro- direct toxicity on surviving germ cells, potentially depressing pane, organic solvents, and heat have been widely associated with spermatogenic function for many years if recovery occurs at all gonadotoxicity (Lipshultz and Corriere, 1980; Moreira and (Nalesnik et al, 2004; Ståhl et al, 2006). Lipshultz, 2008). Industrial lead exposure exerts direct negative A detailed history should include a comprehensive assessment effects on both seminiferous tubules and the hypothalamic pitu- of medications, recreational, environmental, and occupational itary axis, resulting in asthenospermia, oligospermia, teratosper- exposures that can impact fertility. Medications can impair fertil- mia, and ultimately reduced fertility (McGregor and Mason, 1990; ity by direct toxic effects on gonadocytes, disturbance of the Gennart et al, 1992; Shiau et al, 2004). hypothalamic-pituitary-gonadal axis, disruption of ejaculatory or Inflammatory diseases can have profound effects on the patency erectile function, and inhibition of libido. Antibiotics including of the genital tract and function of the spermatozoa. Infectious nitrofurantoin, erythromycin, tetracycline, and gentamycin diseases such as prostatitis or sexually transmitted infections exhibit direct gonadotoxicity or impair sperm function. Androgen such as Chlamydia or Neisseria gonorrhea are associated with ele- production is inhibited by spironolactone, ketoconazole, and vated seminal oxidative stress and leukocytospermia, resulting cimetidine (Griffin and Wilson, 1991). Treatments for ulcerative in abnormal bulk semen parameters, elevated sperm DNA frag- colitis such as sulfazalazine are associated with reversible reduc- mentation, and reduced fertility (Trum, 1998; Pasqualotto, 2000; tions in sperm concentration and motility (Toth, 1979). α Block- Aitken et al, 2007). A history of bilateral epididymitis with subse- ers, which are commonly used for treatment of benign prostatic quent azoospermia suggests the possibility of epididymal obstruc- hypertrophy and hypertension, are associated with retrograde tion. Epididymal granuloma may result from noninfectious ejaculation, an effect that may be more prominent with tamsulo- diseases such as sarcoidosis (Rao, 2009) or from the sequelae of an sin than with other selective α blockers (Giuliano, 2006). 5-α active tuberculosis infection. Epididymal sarcoidosis has been reductase inhibitors such as finasteride and dutasteride inhibit associated with azoospermia, which may be reversible with corti- conversion of testosterone to the metabolically active costeroid treatments (Svetec, 1998). CHAPTER 21 ● Male Infertility 619

Questions regarding a family history of infertility are an under- gynecomastia, and eunuchoid proportions. Abnormalities in these emphasized component of the initial assessment because of a areas suggest possible endocrinopathies to include low serum tes- misperception that genetic conditions that cause infertility are tosterone, hyperprolactinemia, abnormalities in the estrogen to inherently nontransmissible. A family history of cystic fibrosis testosterone ratio, adrenal dysfunction, and genetic syndromes may suggest the diagnosis of congenital bilateral absence of the associated with subvirilization to include Klinefelter syndrome vas deferens (CBAVD) with its associated vasal, epididymal, and (KS). Low androgen levels at the time of puberty may cause dis- seminal vesicle anomalies. Abnormalities of the androgen recep- proportionately long extremities due to delayed closure of the tors should be considered in the setting of a family history of epiphyseal plates. Palpation of the thyroid gland will occasionally intersex disorders. Today’s widespread use of assisted reproductive disclose nodules suggesting hyperfunction or hypofunction, technologies such as ICSI allow us to overcome subtle genetic which can affect fertility. Hepatomegaly on abdominal examina- abnormalities that may account for many cases of idiopathic male tion raises suspicion for hepatic dysfunction, which may induce subfertility. With up to 2% to 4% of European and more than 1% altered sex steroid metabolism. of U.S. children born today (Wright et al, 2007) as a result of these technologies, we would expect the genetic causes of infertility to Genital Examination represent a growing etiology of infertility as these men attempt to conceive in the future, further reinforcing the importance of Genital examination starts with a careful examination of the obtaining a comprehensive family history. phallus. Penile curvature, chordee, or hypospadias may interfere Finally, a complete history should also include an assessment of with semen deposition in the vaginal vault. A careful examination female factor fertility issues because almost two thirds of infertility of the scrotal contents is the most critical part of the examination. can be attributed to the female side, either wholly or in combina- The testes should be examined with the patient in both supine tion with male factors. Failure to incorporate these considerations and standing positions in a warm room to assist relaxation of the into the evaluation and management can result in ineffective and cremasteric muscle. The entire testicular surface should be care- unnecessarily expensive treatment courses. Risk factors for female fully palpated to assess consistency and rule out masses because subfertility include but are not limited to advanced age, irregular infertility has been consistently established as a risk factor for menstrual cycles, and a history of pelvic pathology including testicular carcinoma (Kolettis and Sabanegh, 2001). Testicular size endometriosis and pelvic infections. Fecundity begins to decline should be assessed with either an orchidometer, calipers, or sono- sharply after age 35 and is less than 5% by age 40 (Robins and graphic measurement. Normal adult testicular measurements have Carson, 2008). Ovulatory dysfunction occurs in 40% of infertile been established to be at least 4 × 3 cm or 20 mL in volume women, accounting for the largest single cause of female infertility (Charny, 1960). Because 85% of the testicular volume involves (Mosher and Pratt, 1991). A variety of tools are used to assess sperm production, decreased testicular size portends impaired ovulation; these include basal body temperature charts, midluteal spermatogenic potential (Lipshultz and Corriere, 1977). The epi- serum progresterone levels, endometrial biopsy, urinary LH predic- didymides should be carefully palpated for enlargement or indura- tion kits and transvaginal sonographic detection of ovarian folli- tion, which can indicate downstream obstruction or inflammatory cles. Tests of ovarian reserve involve an assessment of remaining conditions such as epididymitis. Granulomatous changes of ovulatory capability and a de facto assessment of ovarian aging. the epididymis have been associated with tuberculosis, bacile Standard testing includes basal hormone measurements of follicle- Calmette-Guerin (BCG) treatments, and sarcoidosis. Small cystic stimulating hormone (FSH) and estradiol, as well as dynamic lesions of the epididymis are common and are usually spermato- ovarian testing, which involves stimulation of ovulation using celes, which are often nonobstructing. Papillary cystadenomas are clomiphene citrate or gonadotropin (Hofmann et al, 1996). Abnor- less commonly seen and may present in conjunction with von malities of uterine cavity or tubal anatomy occur in up to 25% of Hippel-Lindau (VHL) disease. infertile women (Thonneau et al, 1991). Uterine and tubal patency Examination of the spermatic cord in the supine and standing can be assessed with hysterosalpingography (HSG) or laparoscopy position allows the detection of varicoceles, defined as abnormally with chromotubation. HSG testing involves transcervical injection dilated scrotal veins. Varicoceles are detected by palpation for of contrast material allowing assessment of intrauterine and tubal assymetry of the spermatic cord, or an impulse, during the Val- anatomy. In addition, a number of reports have suggested that the salva maneuver. Gentle traction on the testis during this examina- use of oil-based contrast materials may be therapeutic, in addition tion can be helpful in more difficult examinations such as patients to the diagnostic value (Al-Fadhli et al, 2006; Luttjeboer et al, with high riding testes or exaggerated cremasteric muscle response 2007). Laparoscopy allows confirmation of HSG findings by direct to Valsalva. Varicoceles are present in 15% of normal males, 19% observation of free spill of contrast (methylene blue or indigo to 41% in men presenting with primary infertility, and up to 81% carmine introduced via cervix) and detection of other pathologies of men with secondary infertility (Agarwal et al, 2007). Varicoceles such as endometriosis, fibrial phimosis, or peritubular adhesions. are graded by size with small grade I varicoceles, which are At the time of laparoscopy, tubal reconstruction and surgical detectable only during the Valsalva maneuver; moderate size grade ablation of endometriosis may be undertaken. II varicoceles, which can be palpated without Valsalva; and the large grade III varicoceles, which are visible through the scrotal skin and classically described as feeling like a “bag of worms.” Due PHYSICAL EXAMINATION to the right-angle insertion of the left gonadal vein into the renal General Examination vein with the resulting turbulent flow, varicoceles are more preva- lent on the left side with almost 90% presenting on the left side Because fertility issues can be a reflection of the general health, alone. Large unilateral right-side varicoceles and varicoceles that the physical examination should be comprehensive with special fail to decompress with the supine position suggest the possibility attention to the genital examination. Body habitus provides clues of retroperitoneal or caval pathology such as renal neoplasms and to the adequacy of virilization with androgen deficiency suggested warrant dedicated imaging. A variety of ancillary procedures by decreased body hair, absence of temporal pattern balding, including ultrasonography with and without Doppler 620 SECTION VI ● Reproductive and Sexual Function

examination, radionucleotide scans such as technetium 99m pyro- be cleaned with a wet paper towel (soap should be avoided). Lubri- phosphate, thermography, and venography have been used to cant use is discouraged but, if necessary, should not be applied to corroborate clinical examination findings. In the absence of physi- the glans. A clean, sterile container should be used for specimen cal examination findings, varicoceles detected by these procedures collection. The container should be provided by the laboratory to alone are considered subclinical and not of clinical significance. avoid contamination or spermicidal effects. The main advantages Careful palpation of the vas deferens is also a critical compo- of this collection method are its simplicity, noninvasiveness, and nent of the spermatic cord assessment. Inability to palpate the vas inexpensiveness (Jeyendran, 2003). deferens is consistent with unilateral or bilateral vasal agenesis and Some men may not be able to achieve adequate erection and may have genetic or renal implications, which are discussed later ejaculation. Assistance can be provided to them by oral medica- in this chapter. Nodularity of the vas is also observed from prior tions such as phosphodiesterase type 5 inhibitors given 30 to 60 infections such as tuberculosis. Vasal thickening is associated with minutes before collection. Cavernosal and subcutaneous injec- prior scrotal surgery or downstream obstructions such as inguinal tions of prostaglandins are less popular but remain possible vasal obstruction, potentially from prior surgery or ejaculatory options for patients who have erectile dysfunction. Seminal duct obstruction. pouches that do not contain any spermicides allow the patient to Finally, a rectal examination should be performed to evaluate engage in sexual activity if he is incapable of or uncomfortable prostatic anatomy for midline cysts such as müllerian duct cysts, producing specimens by masturbation. Vacuum erection devices which can obstruct the ejaculatory ducts. Prostatic induration or can also be used to obtain erection by creating a vacuum around tenderness may be seen in acute or chronic prostatitis. Under the penis, generating a pressure differential that fills the corpora normal conditions, the seminal vesicles may not be palpable but with blood. Vibratory stimulation may be used for patients who may be prominent in the setting of ejaculatory duct obstruction. have suffered spinal cord injury, if the spinal cord lesion is T8 and After obtaining a thorough history and a comprehensive physical above (Brown et al, 2006). Rectal probe electro-stimulation induces examination, the clinician has a number of available tools to ejaculation by stimulation of the efferent fibers of the hypogastric further evaluate the infertile male, ranging from the basic semen plexus. Precautions for autonomic dysreflexia should be taken analysis to testicular biopsy, as well as imaging studies. while doing these procedures because some patients with high spinal cord lesions (T6 and above) can have life-threatening hypertension (Jeyendran, 2003). LABORATORY EVALUATION In order to allow liquefaction and mixing, semen is placed in a 37° C gently shaking incubator for 30 minutes. The semen sample OF MALE INFERTILITY should be examined within 1 hour of production and receipt in Semen Analysis the laboratory. Some of the semen parameters can be affected by a delay in assessment. Motility decreases significantly after 2 hours Semen analysis is one of the most important predictors in deter- and progressively diminishes afterwards as free radical activity mining the fertility potential of a man. Appropriate laboratory increases. testing of semen plays a key role in evaluation of men presenting The semen analysis characteristics can be classified into two with infertility. However, semen analysis does not allow for the groups: macroscopic and microscopic. definitive separation of patients into fertile and sterile, in case of azoospermia. It is important to understand that although the Macroscopic Assessment statistical chance of conception decreases as the semen quality The five macroscopic measurements in a standard sperm analysis declines, it does not reach zero. The basic semen testing is inex- have remained fairly constant, with the normal values remaining pensive and determines the quality and the quantity of the sper- relatively unchanged since the inception of the semen analysis in matozoa. More advanced testing is available to patients who suffer the 1950s (Table 21–2). Normal human semen is an off-white to from idiopathic infertility in order to determine specific causes. grayish-yellow opalescent fluid. In event of urine contamination, The analysis of semen evaluates a variety of parameters including the semen sample has a yellow discoloration. The semen may characteristics of spermatozoa, seminal plasma, and non–sperm appear pink in patients with urethral bleeding and yellowish in cells. jaundice patients. During the time of ejaculation, the spermatozoa are suspended in the secretions of prostate, seminal vesicles, Collection and Timing bulbo-urethral glands, and other accessory glands that form a Physicians should provide patients with standard guidelines for coagulum. The specimen usually liquefies within 30 minutes. the collection of semen because suboptimal sperm collection However, semen obtained from patients with congenital bilateral remains a frequent cause of error in semen analysis. There should absence of the vas usually does not form a coagulum and is acidic. be 2 to 7 days of sexual abstinence before collection. Two separate Liquefaction is aided by the proteolytic enzyme fibrinolysin, samples at least 7 days apart should be analyzed (Rowe, 2000; secreted by the prostate. Improper or prolonged liquefaction indi- Jeyendran, 2003). The duration of abstinence should be constant, cates an ejaculatory duct obstruction or poor prostatic secretion. if possible, because each additional day can add as much as 25% Viscosity and nonliquefaction are two different phenomena often in sperm concentration (Carlsen et al, 2004). Lubricants should be confused. Viscosity relates to the fluid nature of the sample. It is avoided because they may interfere with motility results. Coitus measured by dropping the semen sample into a container using a interruptus should be discouraged because it often leads to inac- pipette and observing the length of the thread formed. Increased curate results (i.e., the first part of the ejaculate, which contains viscosity is often associated with infertility because it is known to most of the sperm, may be lost). impair sperm movement. Semen samples that are highly viscous Masturbation in a clinical setting is the recommended proce- can be treated with enzymes such as trypsin before they are pro- dure. Collection is done in a private room in the same facility cessed for therapeutic purposes. Measurement of pH is a standard where the semen will be analyzed. The glans and the penis should component of semen analysis and is largely determined by the CHAPTER 21 ● Male Infertility 621

Table 21–2. Macroscopic Features of Semen Analysis PARAMETERS NORMAL VALUES ABNORMALITIES CLINICAL SIGNIFICANCE Ph 7.8 Acidic: <6.5-7 With low volume and noncoagulation: congenital bilateral absence of vas deferens Ejaculatory duct obstruction Partial retrograde ejaculation Coagulation/ Coagulates and liquefies within 20 No coagulation Congenital absence of the seminal vesicles liquefaction minutes at room temperature of Prolonged liquefaction Poor prostatic secretions 37° C Color Whitish-gray; pearl-white Yellowish color Jaundice, carotenemia, drugs Reddish brown Haemato-spermia secondary to urethral bleeding or inflammation of the seminal vesicles, exclude genitourinary tumors Viscosity 4-mm threading >6 mm Important when associated with low motility No threading Volume 2-4 mL 0 (aspermia) <2 mL Retrograde ejaculation (hypospermia) Incomplete collection >4 mL Partial retrograde ejaculation Short duration of sexual abstinence Prolonged sexual abstinence secretions from the seminal vesicles and the prostate. The normal important information if in-vitro fertilization (IVF) is being enter- range of pH has been defined as 7.2 to 8.0. Because the secretions tained as a treatment option. Foci of microdeletions in the Y of seminal vesicles are alkaline, acidic pH indicates congenital chromosome are associated with impaired spermatogenesis and, absence of the vas with the associated seminal vesicle hypoplasia depending on their location, may predict poor sperm retrieval seen in azoospermic patients (WHO, 1999). even with testicular biopsy. Karyotyping may also detect autoso- mal or X-linked genetic aberrations causing infertility. Knowledge Microscopic Assessment of the chromosome status is important because male offspring Sperm Agglutination. The microscopic examination starts with conceived with intracytoplasmic sperm insemination (ICSI) or the creation of a wet smear by placing a drop of semen on a slide even natural conception most likely will inherit the same micro- covered with a cover slip and observing it under 1000× magnifica- deletion (Krausz et al, 2000). tion. Sperm agglutination, sperm presence, and subjective motility Motility. Motility is recognized as the most important predictor can be assessed by this method. Sperm adhesion to nonsperm of the functional aspect of spermatozoa. Sperm motility is a reflec- elements (nonspecific agglutination) may indicate accessory gland tion of the normal development of the axoneme and the matura- infection. Sperm-to-sperm agglutination (site-specific agglutina- tion that it undergoes within the epididymis. This parameter is tion) can be secondary to antisperm antibodies; however, it should subject to significant potential for technical mistakes in the labora- be kept in mind that a small degree of agglutination is normal tory. The method most commonly employed by laboratories is the (WHO, 1999). When agglutination is observed, semen cultures simple estimation of the motility of sperm on several fields. This and antibody assessment should be performed. subjective assessment is prone to inaccuracy. Moreover, in-vitro Count and Concentration. Assessment of sperm concentration motility of sperm may not reflect the true motility within the (number of sperm per milliliter) and sperm count (number of female reproductive tract. The sperm motility is graded according sperm per ejaculate) is conducted after liquefaction. Multiple to the WHO as follows: A—Rapid forward progress motility; counting chambers are used for sperm count determination where B—Slow or sluggish progressive motility; C—Nonprogressive sperm are counted within a grid pattern. The normal sperm con- motility; and D—Immotility. The cutoff value for normal is 50% centration is reported as greater than or equal to 20 million sperm/ grade A+B or 25% grade A motility (Rowe, 2000). In addition to mL. Attention should be given to collection problems in order to organic causes, asthenospermia (sperm motility less than the rule out incomplete collection or a short abstinence period before WHO cutoff levels) can also be artifactual when spermicides, lubri- starting evaluation of oligospermia (<20 million sperm/mL). Azo- cants, or rubber condoms are used. Occasional clumps of aggluti- ospermia (absence of sperm) may be the result of abnormal sper- nated sperm are of no consequence. However, more than 10% to matogenesis, ejaculatory dysfunction, or obstruction. These 15% of clumping of spermatozoa is indicative of antisperm anti- specimens should be centrifuged and the pellet examined for the bodies (ASAs). ASA is known to reduce sperm motility and cause a presence of any sperm. Polyspermia (abnormally elevated sperm peculiar shaking pattern that prevents spermatozoa from penetrat- concentration), although rare, may be caused by a long period of ing through the cervical mucus. ASA testing must be performed to abstinence and is often associated with sperm of poor quality. rule out the presence of antibodies. Other potential causes of When oligospermia is reported, the levels of motility and mor- asthenospermia include prolonged abstinence periods, genital phology become especially important. Total motile sperm counts tract infection, partial ductal obstruction, and varicocele. Loss of guide decisions on appropriate therapies including the use of motility in all spermatozoa or less than 5% to 10% motility can ARTs. In cases of azoospermia and severe oligospermia, hormonal be caused by ultrastructural defects such as absence of axonemal evaluation (FSH and testosterone) should be requested. Karyotyp- dynein arms or dead sperm (necrospermia) (McLachlan, 2003). ing and Y microdeletion may provide valuable information regard- Morphology. Sperm morphology is the most subjective ing the etiology of the patient’s abnormal semen parameters and and most difficult-to-standardize semen parameter. Accurate 622 SECTION VI ● Reproductive and Sexual Function

assessment of morphology is critical in the evaluation of an infer- have intact cell membranes. Exposure of the sperm to hypo- tile male because it can be a significant predictor of pregnancy. osmotic fluid will cause water to flow into the viable cells seen as Normal sperm possess an oval head with a well-defined acrosomal swelling of the cytoplasmic space and curling of the sperm tail. region composing 40% to 70% of the head area. The dimensions Nonviable sperm with nonfunctional cell membranes will not of the head are 4 to 5.5 µm in length and 2.5 to 3.5 µm in width. exhibit this effect because they cannot maintain an osmotic gradi- The normal sperm are free from head, midpiece, or tail defects. ent. This reproducible and relatively inexpensive test aids in selec- Head defects include microcephalic head (approximately half the tion of viable sperm for use in IVF or ICSI, especially when no size of a normal sperm head), megalocephalic head (one-and-a- motile sperm are seen in the cryopreserved specimens (Check, half times the size of a normal sperm head), tapered head, round 2002). sperm (missing acrosome), and bicephalic or multicephalic head. Nonsperm Cells. Several nonsperm elements noted on seminal Neck defects include no tail or improper tail insertions. Midpiece microscopic examination are immature germ cells, epithelial cell, defects comprise elongated, distended, thin, or bent midpieces. and leukocytes (Branigan et al, 1995; Fedder, 1996). Epithelial cells Some of the tail defects commonly noted are short, multiple, bent, when present in high numbers are indicative of poor collection. or broken tails. One common defect includes coiled tail, which is Leukocytes are the most significant nonsperm cellular elements in indicative of osmotic stress (McLachlan, 2003). the semen and are a frequent finding in patients who have unex- Sperm morphology is expressed as percentage of abnormal plained infertility (Branigan et al, 1995). However, in the initial forms present in the semen. The two most common classifications microscopic analysis, the immature spermatozoa may be confused used for the assessment of sperm morphology are the WHO crite- with leukocytes. To confirm the presence of leukocytes, additional ria and Kruger’s strict criteria (Table 21–3). When correctable testing is therefore required when there are greater than five round causes of male infertility are not identified, couples with terato- cells per high-power field (HPF). Immunocytochemistry is the zoospermia (<15% normal morphology by WHO method) may be procedure of choice, but given its expense, it is not widely used directed to proceed with IVF and ICSI as compared with intrauter- in most laboratories. The Endtz test is a reliable alternative because ine insemination (IUI). Teratozoospermia may occur due to several it allows accurate identification of leukocytes that contain enzymes factors such as fever, varicocele, and stress. Some drugs that affect that will react with peroxide and can be visualized with the ortho- spermatogenesis are also known to cause morphologic abnormali- toluidine dye (Shekarriz et al, 1995). Initially considered solely as ties. With the advent of ICSI, which requires only one morpholog- a marker of genital tract infection, contemporary research has ically and functionally normal spermatozoa to fertilize an oocyte, shown that leukocytes can be present in the absence of other signs morphologic assessment is losing its significance (Zinaman, 2000). of infection or immune response (Lackner et al, 2006) and that Viability. When the motility is reported as less than 5% to 10%, they have intimate links with reactive oxygen species (ROS) (Aitken viability testing is recommended because profoundly low motility et al, 1994; Sharma et al, 2001; Saleh et al, 2002; Lackner may indicate dead sperm or necrospermia (McLachlan, 2003). The et al, 2006). The WHO has defined leukocytospermia as levels most common viability assessment involves staining with Eosin Y above 1 × 106 WBC/mL. Studies have shown, however, that ROS followed by counter staining with Nigrosin. The viable sperm with levels are elevated even at WBC counts of less than 0.2 × 106/mL, its intact cell membrane will not take up the dye and will remain suggesting that much lower levels of leukocytes are pathologic unstained. This test will differentiate necrospermia from immotile (Sharma et al, 2001; Athayde et al, 2007). In a 12-month sperm secondary to ultrastructural defects such as in Kartagener follow-up, men who had a negative Endtz test (zero) had a 23.7% syndrome and primary cilia dyskinesia. chance of initiating pregnancy, whereas leukocytes levels of less Hypo-osmotic swelling test (HOST) is an alternative method to than 1 × 106/mL lowered the chances to 15.5% (Athayde et al, assess sperm viability. It is based on the principle that viable sperm 2007). In many andrology laboratories, leukocytospermia

Table 21–3. Sperm Morphology Classification WORLD HEALTH STRICT WORLD HEALTH ORGANIZATION 3RD ORGANIZATION 4TH (KRUGER) Normal reference range >30% >14% Head Shape Oval Oval, smooth borders Acrosome 40%-70% of head surface 40%-70% head surface Size 4-5.5 mm length 3-5 mm length 2.5-3.5 mm width 2-3 mm width Length/width 1.5-1.75 Vacuoles <20% head area Up to 4 Midpiece Shape Straight regular outlined Slender, straight, regular outline Axially arched Axially arched 1 Size < 3 of head area <1 mm wide Length 1.5 × head 1 1 Cytoplasmic droplet < 3 of head area < 2 of head area Tail Appearance Slender, uncoiled Uniform, uncoiled Width Thinner than midpiece Length >45 mm 10 × head CHAPTER 21 ● Male Infertility 623

determination still has to be requested separately. However, its colleagues, where morphology was reported to provide the highest significance and the ease of determination should place this test discriminating power in detecting subfertility among all the semen among the standard testing that accompanies a basic semen analy- variables. Clearly, each variable alone is neither a powerful sole sis. When leukocytospermia is identified, semen cultures should discriminator nor a predictor of fertility status, and they must be be performed. Furthermore, red blood cells (RBCs) are also often considered in the context of other parameters and the clinical present in semen. Although small amounts are usually a normal setting. There remains a need for further studies in larger popula- finding, they can be indicative of infection, inflammation, ductal tions and different demographics before a consensus can be obstruction, or rarely vascular abnormalities. reached on the necessity of resetting current values to increase the predictiveness and utility of the semen analysis (Table 21–4). Computer-Assisted Sperm Analysis Computer-assisted sperm analysis (CASA) is a semiautomated Sperm Function Assessment technique that provides data on sperm density, motility, straight- line and curvilinear velocity, linearity, average path velocity, Sperm-Mucus Interaction/Postcoital Test amplitude of lateral head displacement, flagellar beat frequency, Cervical mucus is a heterogenous fluid that is composed of 90% and hyperactivation. It has two distinct advantages over tradi- water. In order to reach the site of fertilization, the spermatozoon tional manual analyses: high precision and quantitative assess- must be able to successfully traverse the cervix and the cervical ment of sperm kinematics. Sperm concentration, samplepreparation, mucus. In-vitro penetration of spermatozoa through cervical and frame rate can, however, affect accuracy of the CASA (Mor- mucus is comparable to in-vivo conditions. The cervical mucus is timer, 1994). The use of some stains has also affected the accuracy shown to demonstrate cyclical changes in consistency and to be of determining the sperm morphology. Although this technology highly receptive around the time of ovulation. Increase in penetra- has theoretic advantages, it has not translated into benefits in bility is often observed one day before the LH surge. Cervical clinical practice. This test requires expensive equipment and still mucus has been shown to protect the spermatozoa from the requires the active participation of a technician. Therefore at hostile environment of the vagina. The penetrability of the sper- present, these machines are found commonly in andrology labo- matozoa through the cervical mucus can be detected by the cervi- ratories, not in general pathology laboratories, where most of the cal mucus migration assay. Some methods by which migration can initial semen analyses are analyzed (Amann and Katz, 2004). Pres- be detected include the postcoital test (PCT). This test can assess ently, the most important role of CASA is to provide standardized cervical environment as a cause of infertility. Accurate timing is aids in quality control and quality assurance in andrology labora- crucial because it must be conducted when the cervical mucus tories, as the emerging use of ICSI has diminished the role of is thin and clear just before ovulation. In this test, cervical mucus motility assessment in sperm selection (Amann and Katz, 2004). is examined 2 to 8 hours after normal intercourse. Progressively motile sperm greater than 10 to 20 per HPF is designated as Limitations of Semen Analysis normal. Practical guidelines of the American Society of Reproduc- The true litmus test for male fertility remains the ability to cause tive Medicine recommend PCT in the setting of hyperviscous pregnancy in vivo. Although the semen analysis is used as a sur- semen, unexplained infertility, or low-volume semen with normal rogate measure of a man’s fertility potential, it is not a direct sperm count (Van der Steeg et al, 2004). Medical history and measure by any means. Clinical research has shown that normal semen analysis can predict PCT results in half of the infertile semen analysis may not reflect defects in sperm function - (idio couples. Poor-quality semen most likely will have poor PCT. There- pathic infertility), and men with poor sperm parameters still may fore it is not recommended routinely for men who have abnormal cause spontaneous pregnancies. Only 50% of infertile men have semen analyses. Couples who show defective sperm mucus inter- recognizable causes detectable by the basic semen analysis action may be advised to proceed with IUI because additional (MacLachlan, 2003). The presence of several criteria further rein- tests are unlikely to affect the management (Guzick et al, 2001). forces the emerging opinion that the current standards do not However, abnormal PCT may result from inappropriate timing of reflect the true fertility potential of subjects. The current normal the test. Other causes of abnormal PCT include anatomic abnor- values fail to satisfy clinical and statistical standards (McLachlan, malities, semen or cervical mucus antisperm antibodies, inappro- 2003; Nallella et al, 2006) and pose the risk of misclassifying a priately performed intercourse, and abnormal semen. Persistently subject’s true fertility status. In fact, 20% of 18-year-olds would be abnormal PCT in the presence of reasonably good semen param- classified as subfertile using the WHO cutoff of 20 × 106 sperm/ eters should indicate poor cervical mucus quality. The finding of mL (Andersen et al, 2000). Studies on semen donors with known good-quality mucus with nonmotile spermatozoa or immobilized fertility status have revealed a significant overlap in the sperm characteristics between fertile and subfertile men (Li et al, 2006; Table 21–4. Nallella et al, 2006). Guzick and colleagues (2001) in a study of 1461 men found different cutoff levels in sperm concentration Characteristics of Normal Semen 6 6 (World Health Organization, 1999) (<13.5 × 10 in subfertile and 48 × 10 in fertile men), percent motility (<32% in subfertile and >63% in fertile men), and normal Color White, opalescent morphology (<9% in subfertile and >12% in fertile men). Nallella Specific gravity 1.028 and colleagues in 2006 did a similar study (n = 572) and used the pH 7.35-7.50 WHO and Tygerberg criteria on subjects with known fertility. They Volume 2-6 mL 6 noted that there is low sensitivity (0.48) in detecting subfertile Count 2 × 10 spermatozoa/mL or more subjects using WHO reference values for sperm concentration and Motility ≥50% motile (grades A + B) or 25% low sensitivity (0.83) using Tygerberg criteria for percentage of with progressive motility (grade A) Morphology >30% sperm with normal morphology normal morphology. Among the variables, motility had the least Viability ≥50% viable sperm overlap range and gave the best prediction of the subject’s fertility Pus cells <1 × 106/mL of semen potential. This is in contrast with the earlier study by Guzick and 624 SECTION VI ● Reproductive and Sexual Function sperm demonstrating shaking motion should lead to the evalua- Advanced Semen Testing tion of both partners for the presence of antisperm antibodies. Although it has fallen out of favor, this test may be useful in Antisperm Antibody Testing patients who are unable or unwilling to produce an ejaculate. The tight Sertoli-cell junctions provide the testis with a barrier that prevents the immune system from coming in contact with the Acrosome Reaction post-meiotic germ cells. However, in certain conditions such as The Acrosome is a membrane-bound organelle that covers the testicular torsion, vasectomy, and testicular trauma, this unique anterior two thirds of the sperm head. Acrosome reaction is an barrier can be violated, resulting in an immune response to sperm, important prerequisite for successful fertilization. It is an exocy- displayed as antisperm antibodies (ASABs). These antisperm anti- totic event that involves fusion of outer acrosomal membrane and bodies can be several types—sperm agglutinating, sperm immobi- sperm plasma membrane, which enables the exposure of acroso- lizing, or spermotoxic. The sperm agglutinating type causes mal contents through the formation of vesicles. The two impor- agglutination of spermatozoa, which reduces the availability of tant acrosomal enzymes that are required to digest the oocyte motile spermatozoa penetrating the cervical mucus. Sperm- cumulus cells and zona pellucida include acrosin and hyaluroni- immobilizing antibodies induce loss in motility of the sperm, dase. Acrosome reaction testing is not widely practiced in labora- which can be identified by the characteristic “shaking” pattern in tories and only remains a research interest. However, this test may motility on postcoital test. The spermotoxic type of ASAB causes be recommended in cases of profound abnormalities of head mor- a complement-dependent loss in viability of spermatozoa. phology or in the setting of unexplained fertility in patients with Approximately 10% of infertile men will present with ASA as poor IVF pregnancy rates. Normal semen samples demonstrate compared with 2% of fertile men (Guzick et al, 2001). Sperm spontaneous acrosome reaction rates of less than 5% and induced parameters are often normal in men with ASA (Munuce et al, acrosome reaction rates of 15% to 40%. Infertile populations have 2000). Hence it has been suggested to be tested routinely in all shown high spontaneous rates of acrosome-reacted sperm and low men undergoing infertility work-ups (McLachlan, 2003). Excessive rates of induced acrosome reactions. Although not widely prac- sperm agglutination or an abnormal PCT can suggest the presence ticed due to its cost and labor, the structure of the acrosome can of ASA. be studied under transmission electron microscopy. Other tech- The direct ASA test detects sperm-bound immunoglobulins. niques such as fluorescence microscopy and beads coated with Indirect testing detects the biologic activity of circulating antiacrosomal antibodies have been developed, but these tests are ASA. False positives can result from nonimmunologic factors also not readily available in standard laboratories. (Francavilla et al, 2007). Because only antibodies present on the sperm surface are clinically significant, most investigators prefer Sperm Penetration Assays/Sperm direct assays that determine sperm-bound antibodies instead of Zona Binding Tests indirect detection of serum antisperm antibodies. IgG-MAR (mixed The sperm penetration assay (SPA) or the hamster egg penetration antiglobulin reaction) and Sperm MAR are recommended screen- assay (HEPT) determines the functional capacity of the spermato- ing tests that are economical and readily available. Immunobead zoa necessary to fertilize an oocyte. It is based on the principle Test (IBT), which measures IgG, IgA, and IgM, may be additionally that normal spermatozoa can bind and penetrate the oocyte mem- recommended when either of the previous tests gives a positive brane, which is a prerequisite for the fusion of sperm and the result in order to determine if IgA are bound to sperm surface. oocyte. Zona pellucida is the outermost layer protecting the cyto- Acceptable normal values by WHO (1992) standards include less plasm of the oocyte. It plays an important role in the fertilization than 10% (IgG MAR) or 20% (IBT) of spermatozoa with adherent process and is shown to be the only physiologic inducer of acro- particles. some reaction. Sperm binds to the species-specific receptor, ZP3, Clinical implications of ASA on male infertility are varied. A which is found on the zona pellucida of the oocyte. The zona-free weakly positive IgG MAR/IBT in men who have low motile sperm hamster oocytes, in which the zona pellucida is stripped, are used rules out immunologic factors, and no further testing is necessary to allow cross-species fertilization. Human sperm penetration (Francavilla et al, 2007). ASA are present in 34% to 74% of vasec- assay with zona-free hamster eggs determines the ability of sperm tomized men and persist in 38% to 60% after vasectomy reversal to successfully undergo capacitation, acrosome reaction, mem- (Broderick et al, 1989; Francavilla et al, 2007). Routine ASA brane fusion with oocytes, and chromatin decondensation. The testing is not recommended in this setting because it is of uncer- assay is performed by incubating zona-free hamster oocytes in tain significance and usually does not affect the decision to do a sperm droplets for 1 to 2 hours. The oocytes are examined micro- vasectomy reversal. There are conflicting reports regarding ASA scopically for sperm penetration. Penetrations are indicated by levels after orchidopexy for cryptorchidism (Mirilas et al, 2003). swollen sperm heads within the oocyte cytoplasm. Normally, 10% In genitourinary infections, ASA is thought to be a consequence to 30% of ova are penetrated (WHO, 1999). Oligozoospermic and of the inflammatory process rather than cross reactivity to the severely teratospermic men have a higher number of defective microorganism (Francavilla et al, 2007). sperm-zona pellucida interactions, which may account for their The decision to proceed with IUI versus ICSI in immunologic low fertility potential in both spontaneous and IVF pregnancies infertility can be aided by a zona pellucida (ZP) test. If the sperm (Liu and Baker, 2004). Despite its low predictive power, SPA is cor- exhibit inability for ZP binding, ICSI is the procedure of choice. related positively with spontaneous pregnancy outcomes (Corson Presently, flow cytometry techniques are being developed to et al, 1988). Sperm capacitation index (SCI) is a variant of the SPA quantify ASA in individual spermatozoa (Shai et al, 2005). These test, assessing the mean number of penetrations per ovum. ICSI techniques are also being explored to identify sperm surface anti- has been recommended for couples with an SCI less than 5 instead gens for possible immunocontraceptive development. of standard IVF procedures (Ombelet et al, 1997). Compared with SPA, the zona binding test uses oocytes that failed to fertilize in Electron Microscopy IVF clinics. The need for human oocyte supply, however, remains Spermatozoa may test positive for viability even in the presence a limitation to the use of this test. of ultrastructural defects. Ultrastructural details of the sperm can CHAPTER 21 ● Male Infertility 625

only be seen under the electron microscope (EM). Patients who cutoff level had 95% specificity in identifying obstructive azo- have low sperm motility (<5% to 10%) with high viability (as ospermia. This suggests that the test can predict IUI response determined by HOST or Eosin-Nigrosin staining) and density may (higher pregnancy rate >78 U per ejaculate) because high levels be appropriate candidates for EM assessment. Subfertile men may indicate better zona-binding capacity (Comhaire et al, 2002). The demonstrate more serrated and blurred circular sulcus, less intact presence of commercial test kits using colorimetric methods prom- acrosome membrane, a bigger proportion of the spermatic head, ises to make testing accessible and affordable. and more droplets attached to the acrosome membrane. Mito- chondrial and microtubular defects that are not visible under the Reactive Oxygen Species usual Papanicolaou smear can be detected. Research conducted during the past decade has provided growing support for the concept that excessive production of reactive Biochemical Tests oxygen species (ROS) is related to abnormal semen parameters and Acrosin is a serine protease-like enzyme that exhibits a lectin-like sperm damage. Routine semen analysis remains the backbone of carbohydrate binding activity to the zona pellucida glycoproteins. clinical evaluation in male infertility, and determining the levels Low acrosin activity has been associated with low sperm density, and sources of excessive ROS generation in semen is currently not motility, and poor normal morphology (Xu and Zhan, 2006). included in the routine evaluation of subfertile men. However, the Zinc is necessary for chromatin stability and decondensation, diagnostic and prognostic capabilities of seminal oxidative stress as well as for head–tail detachment during fertilization. It is mea- measurement exceed the capabilities of conventional sperm sured by colorimetric methods with a reference value of 13 mmoL quality tests. An oxidative stress test may accurately discriminate per ejaculate (WHO, 1999). Reports on the effects of zinc in sperm between fertile and infertile men and identify those with a clinical function and semen parameters are quite conflicting. Mankad and diagnosis of male factor infertility who are likely to initiate a colleagues (2006) reported positive correlations between seminal pregnancy if they are followed over a period of time. In addition, zinc levels, alpha glucosidase, and sperm count; however, there such a test can help select subgroups of patients with infertility in are other reports that showed no significant changes in sperm which oxidative stress is an important factor and who may benefit count and motility with variations in zinc concentration (Abou- from antioxidant supplementation. Although consensus is still Shakra et al, 1989; Lewis-Jones et al, 1996; Sorensen et al, 1999). required about the type and dosage of antioxidants to be used, Zinc levels in seminal plasma are decreased, but spermatozoal zinc rationale and evidence exist supporting their use in infertile men levels are increased in asthenozoospermic and oligoasthenozoo- with elevated oxidative stress (Deepinder et al, 2008). spermic men (Zhao and Xiong, 2005). A low zinc-to-calcium ratio Currently, clinical practice as to the inclusion of ROS measure- has been shown to be associated with better motility than high ment is variable, primarily because of the lack of standardization ratio (Sorensen et al, 1999). However, dietary supplementation of of ROS analytic methods, equipment, and range of normal levels zinc did not improve semen variables (Agarwal and Said, 2004). of ROS in semen. The evidence defining high ROS levels as a cause The seminal vesicles contribute to the bulk of seminal fluid that or an effect of abnormal semen parameters and sperm damage is serves as the transport medium for sperm and contribute to the still insufficient on both sides of the question. However, ithas nutrition in the form of fructose. There is a positive correlation been reported that a high level of ROS is an independent marker between sperm motility and seminal fructose levels (Lewis-Jones, of male factor infertility in leukocytospermic samples after adjust- 1996). Low or absent fructose is seen in ductal obstruction and ment for semen characteristics. This finding suggests that ROS congenital conditions like CBAVD. Semen fructose testing may be may play an important role in the etiology of male factor infertil- requested when hypo-functioning seminal vesicles are suspected, ity and encourages the use of ROS measurement as a diagnostic although morphometric analysis of seminal vesicles using tran- tool in clinical practice, particularly in cases of idiopathic infertil- srectal ultrasound (TRUS) is the recommended test nowadays. ity. Although numerous assays for ROS measurement have been L-carnitine is secreted by the epididymis and is concentrated in introduced, the chemiluminescence assay, determining ROS levels the seminal plasma at up to 10 times the serum levels. It has a role in neat semen, has proven to be an accurate and reliable test for in sperm maturation. Low L-carnitine levels are found in oligoas- evaluating oxidative stress status. This technique accurately repre- thenozoospermic men (Agarwal and Said, 2004; Sigman et al, sents an individual’s true in vivo oxidative stress status and over- 2006). The levels of carnitine can possibly serve as indicators of comes the drawbacks of earlier methods that involve processing the level of obstruction in the ductal system. Extremely low con- semen, a step that may generate ROS by itself. The ROS level for centrations of L-carnitine are found in azoospermic men who have healthy donors with normal standard semen parameters is 1.5 × postepididymal obstructions, whereas normal levels are found in 104 cpm/20 million sperm/mL. Using this value as a cutoff, infer- azoospermic men who have intratesticular obstructions (Agarwal tile men can be classified as either oxidative stress positive (>1.5 and Said, 2004). Administration of L-carnitine supplements did not × 104 cpm/20 million sperm/mL) or oxidative stress negative (≤1.5 improve sperm density, but contrasting results have been reported × 104 cpm/20 million sperm/mL), regardless of their clinical diag- for sperm motility changes (Sigman et al, 2006). L-carnitine deter- nosis or standard semen analysis results (Deepinder, et al, 2008). minations remain far from becoming mainstream tests in male infertility until significant well-designed studies are conducted. Sperm DNA Damage Alpha glucosidase, tested by fluorimetric methods, has been DNA fragmentation was initially described in 1993 and has since used to distinguish nonobstructive from obstructive azoospermia. been researched as a test to aid fertility prediction in subfertile It is used as a specific marker for epididymal function and is males. The spermatozoal chromatin is a tightly packed structure believed to play a role in sperm maturation in the epididymis. A because of the disulfide cross linkages between protamines that cutoff value of 12 mIU/mL distinguishes ductal obstruction from allow compaction of the nuclear head and protect the DNA frag- primary testicular failure (Comhaire et al, 2002). The usefulness ments from stress and breakage. DNA damage is multifactorial and of this test was questioned by Krause and Bohring (1999), but theories on its etiology include protamine deficiency and muta- Comhaire and colleagues (2002), in their review, showed a strong tions that may affect DNA packaging or compaction during sper- association between α-glucosidase and semen parameters. The miogenesis (Agarwal and Said, 2003). Various factors found to be 626 SECTION VI ● Reproductive and Sexual Function

associated with increased sperm DNA damage include tobacco use, infertility (Verit et al, 2006). In addition, significant intraindi­ chemotherapy, testicular carcinoma, and other systemic cancers vidual variation exists making conclusions using SCSA problem- (Agarwal and Said, 2003). DNA damage is correlated positively with atic (Erenpreiss et al, 2006). There is a higher rate of DNA damage poor semen parameters, especially low sperm concentration and in ejaculated or epididymal sperm than in intratesticular sperma- low sperm motility, leukocytospermia, and oxidative stress (Eren- tozoa. Hence the use of intratesticular spermatozoa from high DFI preiss et al, 2002; Agarwal and Said, 2003; Zini and Libman, 2006). men is recommended for ICSI (Steele et al, 1999; Greco et al, Approximately 8% of subfertile men who have normal semen 2005). ICSI is advised when DFI is above cutoff levels. DNA parameters will have high abnormal DNA (Aitken et al, 1991). fragmentation testing can help couples decide on what fertility Many tests of sperm DNA damage are now available (Table modality and possible lifestyle modifications they can employ to 21–5). The use of these tests has been driven largely by the growing increase their chances of conception. use of assistive reproductive technologies and awareness that the integrity of the male genome plays an important role in IVF. Endocrine Sperm DNA damage can be measured directly (fragmentation, oxidation) or indirectly (sperm chromatin compaction). Direct Although an uncommon cause of male subfertility, up to 3% of assessment of DNA damage can be obtained by means of single- infertile men will have an underlying endocrinopathy (Sigman cell gel electrophoresis assay or “comet” assay (electrophoresis et al, 1997). Although some authors recommend routine screen- causes DNA fragments to migrate away from the central DNA core, ing of the male hypothalamic-pituitary-gonadal axis in all patients, revealing a “comet”), terminal deoxynucleotidyl transferase- the consensus opinion favors endocrine evaluation in men with mediated dUTP-nick end-labeling or “TUNEL” assay (the ends of (1) an abnormally low sperm concentration, especially if less than fragmented DNA are tagged), and liquid chromatography to 10 million/mL; (2) impaired sexual function; or (3) other clinical measure DNA oxidation levels. DNA damage can also be assessed findings suggestive of endocrinopathy such as marked reduction indirectly by means of sperm chromatin integrity assays and by in testicular size or gynecomastia (AUA/ASRM Practice Committee evaluation of nuclear protein levels. Sperm chromatin integrity Recommendations, 2006). assays include slide-based sperm nuclear protein stains (e.g., Initial endocrine evaluation in those with indications for aniline or toludine blue [detects histones], CMA3 [detects under- testing should include serum follicle-stimulating hormone (FSH) protamination]) and DNA stains (e.g., acridine orange [detects and morning serum testosterone measurements. Gonadotropins denatured or single-stranded DNA]). The sperm chromatin struc- and testosterone are secreted in a pulsatile manner, and some ture assay (SCSA) uses flow cytometry to estimate the percentage advocate pooled specimens drawn at 15 minute intervals to of spermatozoa with DNA denaturation (spermatozoa are stained increase accuracy, although most recommend screening with a with acridine orange). A cutoff rate of greater than 30% has been single morning specimen. Morning specimens are preferred due shown to be associated with a significant decrease in in-vivo fer- to a normal physiologic decline in testosterone levels throughout tilization rates (Evenson and Wixon, 2002). A DNA fragmentation the day. Table 21–6 demonstrates commonly observed endocrine index (DFI) of greater than 30% has a sensitivity of 15% and a patterns associated with various clinical diagnoses. Under normal specificity of 96%. Meta-analyses by Evenson and Wixon (2002) conditions, FSH secretion is under negative feedback control via and Li and colleagues (2006) showed that couples are twice as inhibin B, which is produced by the Sertoli cells (Fig. 21–1). likely to become pregnant with regular IVF methods if the DFI is Elevations in serum FSH are indicative of disturbances in sper- less than 30%. Contrasting reports, however, have failed to show matogenesis such as primary testicular failure (hypergonadotropic significant correlation between DNA damage and idiopathic hypogonadism), although normal FSH levels do not rule out sper- matogenic failure. Obstructive azoospermia is usually associated Table 21–5. with normal gonadotropin and testosterone levels. Low serum testosterone levels may indicate hypogonadism of pituitary or Commonly Used Tests of Sperm DNA Damage hypothalamic origin, as well as primary testicular failure. If initial TEST MEASURES CHARACTERISTICS testing is abnormal, further endocrine testing should be obtained Sperm chromatin Susceptibility of Objective, flow to include a repeated testosterone assay including free and total structure assay sperm DNA to cytometry–based, testosterone levels, serum luteinizing hormone (LH), and serum denaturation indirect assay, prolactin levels. Low FSH and LH levels indicate hypogonado- complex analysis, tropic hypogonadism such as Kallman syndrome and warrant a used clinically complete pituitary hormonal assessment including thyroid stimu- Nuclear protein Sperm histone Objective, gel lating hormone (TSH), adrenal corticotropic hormone (ACTH), composition (by and protamine electrophoresis and growth hormone assays. Direct measurement of serum protein levels assay, indirect assay, inhibin levels may provide a more accurate assessment of sper- separation) labor intensive matocytic health than FSH levels, although most find that the Sperm nuclear Chromatin Simple, maturity test (by compaction, semiquantitative, cost of this assay and lack of widespread availability limit its clini- nuclear staining) protamine slide-based, indirect cal utility (Sussman et al, 2008). content assay Hyperprolactinemia is usually associated with low serum testos- Comet assay (by Double-stranded Objective, quantitative, terone often without associated increases in LH levels, suggesting single-cell gel DNA breaks direct assay, complex that the hypothalamic-pituitary axis is unresponsive in the setting electrophoresis) (neutral assay) image analysis of elevated serum prolactin levels (Carter et al, 1978). Prolactin TUNEL assay Double-stranded Semiquantitative, direct tests should be repeated due to marked physiologic variability in DNA breaks assay, quantitative if serum prolactin levels. Mild serum prolactin elevations (<50 ng/ flow cytometry based mL) may be seen with medications, stress, and renal insufficiency DNA oxidation 8-hydroxy-2- Quantitative, direct or may be idiopathic. However, if the prolactin level is persistently deoxyguanosine assay, labor intensive elevated, a pituitary tumor such as a prolactinoma should be ruled CHAPTER 21 ● Male Infertility 627

Table 21–6. Patterns of Endocrine Testing by Diagnosis DIAGNOSIS FSH (mIU/mL) LH (mIU/mL) TESTOSTERONE (ng/dL) Normal Normal Normal Normal Obstruction Normal Normal Normal Primary Testicular Failure Histology Hypospermatogenesis High Normal or high Normal or low Germinal cell aplasia Very high High Low Maturation arrest Normal Normal Normal Klinefelter syndrome Very high High Low Hypogonadotropic Low Low Low Hypogonadism

FSH, follicle-stimulating hormone; LH, luteinizing hormone.

Table 21–7. Factors That Impact Sex Hormone Binding Globulin Levels INCREASE DECREASE Estrogen Obesity Medications Medications Anticonvulsants Progestins Thyroid replacement Insulin Glucocorticoids Hyperthyroidism Hypothyroidism Cirrhosis Acromegaly Aging Nephrotic syndrome

intake, they are more commonly associated with morbid obesity due to the peripheral aromatization of testosterone to estradiol in adipose cells. Estradiol stimulates sex steroid hormone binding globulin (SHBG) production in the liver, which reduces levels of bioavailable testosterone. SHBG levels are also influenced by a number of other conditions (Table 21–7). On rare occasions, endocrinopathies involving adrenal or thyroid functions may present with male subfertility. Patients with congenital adrenal hyperplasia (CAH) present with a history of precocious puberty and short stature due to premature closure of the epiphyseal plates. The common variant involving 21- hydroxy deficiency will have elevated serum levels of17- hydroxyprogesterone and urinary pregnanetriol. Although CAH patients may retain fertility, many will have reduced testicular function due to suppression of gonadotropin levels from direct feedback inhibition of the pituitary from the excessive adrenal androgens. Thyroid disease, both hyperfunction and hypofunction, may occasionally be associated with male factor infertility, although subclinical hypothyroidism does not impact semen parameters (Trummer et al, 2001). Thyroid function testing of the infertile male is not justified for routine screening but should be reserved Figure 21–1. The hypothalamic-pituitary-testicular axis. Gonadotropin-releasing hormone (GnRH) is released from the for patients with clinical symptoms of thyroid dysfunction. hypothalamus, stimulating luteinizing hormone (LH) and follicle- stimulating hormone (FSH) release. The gonad is stimulated with FSH inducing stimulation of germinal cell epithelium and LH Genetic Testing inducing testosterone production by the Leydig cells. Both Genetic testing is important for establishment of the etiology of testosterone (T) and inhibin (IN) downregulate gonadotropin release. infertility, identification of potential future medical issues for the patient, prediction of therapeutic efficacy from various fertility out with a focused neurologic examination including visual field interventions such as varicocele repair and sperm retrieval, and testing and magnetic resonance imaging of the pituitary fossa. counseling information to couples regarding transmission risk to Estrogen excess may be manifested by gynecomastia, decreased offspring. Clinically relevant genetic testing for the infertile male libido, erectile dysfunction, and low serum testosterone levels. include karyotype and y-linked microdeletion assessment, which Although elevated serum estradiol levels may be from exogenous are used for evaluation of both nonobstructive azoospermia (NOA) 628 SECTION VI ● Reproductive and Sexual Function

and severe oligospermia, as well as the cystic fibrosis transmem- brane conductance regulator (CFTR) gene, which is assessed in men with obstructive azoospermia due to CBAVD. Almost 7% of infertile men will have structural or numeric chromosomal abnor- malities. The incidence of karyotype anomalies is inversely pro- portional to the sperm concentration with a prevalence of 10% to 15% in azoospermia, 5% in oligospermia, and less than 1% in patients with normal sperm counts (De Braekeleer and Dao, 1991; Samli et al, 2006). Microdeletions of the Y chromosome have been described in 10% to 15% of patients with severe oligospermia or azoospermia (Pryor et al, 1997). CFTR mutations have been identi- fied in 88% of patients with CBAVD (Ratbi, 2007). Specific genetic syndromes are reviewed later in this chapter.

OTHER TESTING Imaging Studies Radiographic evaluation of the infertile male focuses on identifica- tion of patients with genital tract obstruction in the vas deferens or ejaculatory duct, as well as ruling out associated pathologies in certain individuals such as testicular masses or renal anomalies. The tests described here are not required in most individuals but should be used judiciously in those with appropriate indications. Figure 21–2. Transrectal ultrasound (sagittal image) demonstrating a dilated ejaculatory duct culminating in an Transrectal Ultrasonography ejaculatory duct cyst. TRUS provides excellent definition of the prostate, seminal vesi- cles, ampulla of the vas deferens, and the ejaculatory ducts. TRUS ejaculatory ducts at the time of seminal vesicle chromotubation, is primarily employed to examine patients suspected to have ejac- noting that men with EDO have higher mean ejaculatory duct ulatory duct obstruction (EDO). These patients usually have low- opening pressures, 116 cm H2O versus 33 cm H2O in fertile con- volume azoospermia (volume <1 mL) with acidic pH and negative trols (Eisenberg, 2008). Despite these advances in diagnostic tech- semen fructose. TRUS typically employs the 5- to 7-MHz endocavi- niques, criteria for diagnosis of complete EDO remain unclear and tary probe with scanning in both the longitudinal and transverse those for partial EDO remain controversial. planes. Careful examination of verumontanum may identify midline prostatic cysts such as müllerian or wolffian duct cysts or Scrotal Ultrasonography stones obstructing the ejaculatory duct (Fig. 21–2). Often the ejac- Scrotal ultrasound for the infertile male is primarily used to ulatory duct may not be well visualized, but dilation of the seminal confirm the presence of clinical varicoceles, although it also pro- vesicles serves as a de facto sign of ejaculatory duct obstruction. vides high-quality imaging of scrotal contents that offers the Although not always present with ejaculatory duct obstruction, advantage of widespread availability without exposure to ionizing seminal vesicle width in excess of at least 12 to 15 mm or ejacula- radiation. Although clinical varicoceles do not require confirma- tory duct diameter greater than 2.3 mm is considered suggestive tion with ultrasound examination, color Doppler ultrasound may of obstruction (Carter et al, 1989; Vazquez-Levin et al, 1994; Smith be required when the clinical examination is difficult due to body et al, 2008). habitus or when the examination is equivocal. Demonstration of Seminal vesicle aspiration using a 20-gauge needle at the time reversal of venous blood flow with the Valsalva maneuver or sper- of TRUS has been used to further increase the specificity of the matic vein diameters of 3 mm or greater (Fig. 21–3A and B) support diagnostic techniques. Significant quantities of sperm are not nor- the diagnosis of varicocele (Meacham et al, 1994). Scrotal ultra- mally present in the seminal vesicles. Findings of three or more sound is not recommended for screening for subclinical varico- sperm per HPF in the seminal vesicle aspirate support the diagno- celes because repair of these has not been demonstrated to be of sis of EDO (Jarow, 1994). Test accuracy is improved by performing clinical benefit. aspiration within 24 hours of ejaculation (Jarow, 1996). In addition, ultrasound examination provides excellent ana- Seminovesiculography using transrectal injection of radio­ tomic details of the epididymis and testis, potentially disclosing a opaque contrast (50% renograffin) into the seminal vesicles under number of conditions that may affect fertility. Epididymitis is TRUS guidance with postinjection radiographs can provide excel- associated with epididymal enlargement with diffuse hypoecho- lent anatomic detail of the seminal vesicles and ejaculatory ducts. genicity and is often associated with a reactive hydrocele. Doppler Seminal vesicle chromotubation is a variation of seminovesiculog- ultrasound will often reveal increased vascularity in the involved raphy using the injection of dilute indigo carmine or methylene epididymis or adjacent testicular region. Epididymal cysts or sper- blue (1:5 dilution with saline) into the seminal vesicles via TRUS matoceles appear as simple or minimally complex cysts and may guidance followed by cystoscopic inspection of the ejaculatory cause epididymal outflow obstruction. Testicular germ cell tumors ducts in the prostatic urethra to confirm patency. The dynamic are noted with increased frequency in the subfertile population, tests of chromotubation and seminal vesiculography offer higher and even small, nonpalpable lesions (<0.5 cm) are well visualized specificity for detection of EDO than static TRUS imaging alone with ultrasonography (Fig. 21–4). Testicular microlithiasis are (Purohit et al, 2004). The newest adjunctive technique, ejacula- diffuse 1- to 2-mm hyperechogenic nonshadowing foci and have tory duct manometry, involves hydraulic assessment of the been reported in 3% of subfertile men (Thomas et al, 2000). CHAPTER 21 ● Male Infertility 629

A B

Figure 21–3. Scrotal ultrasound of varicocele. A, Dilated veins in spermatic cord. B, Color Doppler image revealing typical venous reflux with Valsalva maneuver.

with CBAVD, renal anomalies are unlikely and routine abdominal imaging is not indicated. However, up to 20% of men with CFTR mutation-negative vasal agenesis will have ipsilateral renal anom- alies, most commonly renal agenesis, and should have routine abdominal ultrasonography as part of their evaluation. Vasography Vasography remains the gold standard test for assessing the patency of the male ductal system. Although procedures such as TRUS, seminal vesicle aspiration, and seminal vesiculography offer minimally invasive imaging to diagnose obstruction, properly per- formed vasography provides unequalled anatomic detail of the vas deferens, seminal vesicles, and ejaculatory ducts. Vasography is indicated for determination of the site of obstruction in the azo- ospermic patient with confirmed normal spermatogenesis on testis biopsy. On occasion, it may be used for the severely oligospermic patient in whom there is a high clinical suspicion of unilateral Figure 21–4. Testicular ultrasound—small nonpalpable testicular vasal obstruction from iatrogenic injury such as prior inguinal mass (seminoma) noted on fertility evaluation. hernia repair (Matsuda, 2000). Vasography may also be used to rule out ejaculatory duct obstruction in the setting of ejaculatory pain. However, it should be emphasized that vasography is not Although originally thought to represent a radiologic precursor to necessary in oligospermic patients who do not have clinical evi- the development of germ cell tumors, it is now known that tes- dence or history (i.e., inguinal surgery) that suggests unilateral ticular microlithiasis is common and does not represent a risk obstruction. factor for germ cell tumor development or necessitate continued Vasography is ideally performed at the time of anticipated medical surveillance (Costabile and Spevak, 1998). reconstruction due to the potential to cause vasal scarring at the vasogram site, although this complication has not been observed Abdominal Ultrasonography in large series (Payne et al, 1985). For antegrade vasography, Abdominal ultrasound imaging in the infertile male is primarily the straight portion of the vas deferens is isolated in the scrotal indicated to rule out associated renal anomalies in patients with region, immediately adjacent to the convoluted vas to allow vasal agenesis. Vasal agenesis is theorized to result from one of two maximum length of vas deferens if a reconstruction such as a mechanisms—either mutations in the CFTR gene that do not vasoepididymostomy is eventually required. Either a puncture or incur associated renal anomalies or improper morphogenesis of vasotomy technique may be used to inject contrast into the vas the mesonephric duct before week 7 of gestation, which causes deferens. The puncture technique is preferred if possible because vasal agenesis and unilateral renal agenesis. it avoids a full-thickness vasotomy, which necessitates subsequent The CFTR gene is responsible for regulation of chloride ion microsurgical closure, although it is technically more difficult to transport across epithelial cell membranes. Dysfunction in this enter the vasal lumen than with the vasotomy method. With the transport results in abnormal luminal fluid quality during vasal puncture procedure, a 30-gauge lymphangiogram needle is inserted morphogenesis with resulting vasal agenesis (Oates and Amos, directly into the proximal vas lumen and contrast is injected in 1993). In patients with proven CFTR gene mutation in association an antegrade fashion (Fig. 21–5A). Alternatively, a microsurgical 630 SECTION VI ● Reproductive and Sexual Function

A B

C D

Figure 21–5. Vasography—examples of technique and findings. A, Technique for antegrade injection of contrast into proximal vas deferens. B, Normal vasogram with clearly defined vas deferens (VD), seminal vesicles (SV), ejaculatory duct (ED), and contrast spilling into bladder. C, Obstruction of left inguinal vas deferens due to prior herniorrhaphy. D, Ejaculatory duct obstruction with large cyst (arrow).

scalpel may be used to make a hemivasotomy incision through mixed with contrast (1:10 dilution) to guide the depth of trans- the anterior wall of the vas deferens to expose the vasal lumen urethral resection if the vasogram is performed at the time of and allow placement of a 25-gauge angiocatheter for contrast ejaculatory duct resection. On occasion, contrast will not flow and injection (Fig. 21–5B). This techique allows examination of the a 2-0 monofilament suture may be passed in an antegrade fashion intravasal fluid for presence of sperm to confirm epididymal to identify the level of obstruction. patency. If a hemivasotomy technique is used for the vasogram, A properly performed vasogram will opacify the scrotal and the vas will require reconstruction at the end of the procedure inguinal portions of the vas deferens with subsequent filling of with 9-0/10-0 nylon interrupted sutures using standard microsur- the ipsilateral seminal vesicle and the bladder (Fig. 21–5C). Failure gical technique. Once the vasal lumen has been intubated, 5 to to opacify the bladder represents either insufficient injection of 10 mL of full- or half-strength contrast (Renografin) is injected in contrast or evidence of obstruction (Fig. 21–5D). an antegrade fashion. Retrograde injection is not recommended due to the potential for subsequent epididymal scarring or obstruc- Venography tion. Vasography images are obtained using either standard radio- Venography of the internal spermatic veins has been used to diag- graphs or fluoroscopy. Methylene blue or indigo carmine may be nose and treat varicoceles. As a diagnostic test, venography is CHAPTER 21 ● Male Infertility 631

A B

Figure 21–6. Venography for evaluation and treatment of varicoceles. A, Venogram demonstrates reflux through incompetent venous valves of the left internal spermatic vein consistent with left varicocele. Inset reveals inguinal plexis of gonadal veins. B, Venous embolization procedure with catheter tip (white arrow) and deployed coils (black arrow). arguably the most sensitive imaging modality but specificity nonobstructive testicular pathology and therapeutic for sperm remains its limitation. Although nearly 100% of clinical varicocele harvest with the intention of use for ICSI. Sperm retrieval tech- patients will demonstrate reflux on venographic examination, left niques are discussed later in the chapter and reviewed in detail in internal spermatic vein reflux has been reported in up to 70% of Chapter 22. patients without a palpable varicocele (Ahlberg et al, 1966; Diagnostic testicular biopsy is primarily indicated for evaluation Narayan et al, 1980). False-positive studies may be due to exami- of the azoospermic patient presenting with a clinical picture sug- nation technique factors such as high-pressure contrast instilla- gestive of obstruction to include normal testicular size and con- tion or placement of the catheter tip through a valve in the sistency and normal serum FSH levels. Although some have proximal portion of the internal spermatic vein. Because of the suggested testicular biopsy for moderate oligospermia (<5 to 10 high false-positive rate and the invasive nature of the test, venog- million/mL), most clinicians do not find that this provides useful raphy is not indicated for routine screening in the subfertile male. prognostic or therapeutic information. On occasion, a diagnostic It does have utility in patients with presumed postvaricocelectomy biopsy may be performed in a patient with clinical evidence of recurrence both for confirmation of the diagnosis and emboliza- testicular failure (small-volume testes, high serum FSH level) to tion of persistent vessels (Fig. 21–6A and B). assess ability to perform sperm harvest for ICSI in the future. Percutaneous embolization of varicoceles has been described However, in this setting, a diagnostic biopsy should be coupled using deployed coils, balloons, and sclerotherapy. Although it may with sperm retrieval and cryopreservation to mitigate the need for be used for initial treatment, higher recurrence rates than surgical a repeat biopsy in the future. Men with known obstructive etiolo- repair and unsuccessful procedure rates support embolization as a gies such as prior vasectomy or vasal agenesis do not require second-line therapy (Khera and Lipshultz, 2008). In addition, rare routine testicular biopsy. Unilateral testicular biopsy is usually safety issues such as balloon migration, femoral vein injury, and sufficient to assess the azoospermic patient for obstruction. Bilat- anaphylactic reactions to contrast material further reinforce the eral biopsy may be performed if there is suggestion of asymmetric recommendation that embolization is not the initial procedure of pathology such as unilateral testicular failure from a situation such choice (Matthews et al, 1992; Zini et al, 1997). However, emboliza- as cryptorchidism and contralateral obstruction such as from prior tion does have a role in the management of patients with a inguinal surgery with vasal injury. Although testicular biopsy may persistent or recurrent varicocele after varicocele ligation. Ante- be performed concurrently with planned reconstruction, recon- grade scrotal sclerotherapy has also been described as first-line struction is often performed at a later surgery to allow permanent varicocele therapy with success rates as high as 95%, although section analysis of the tissue by pathologists. Frozen sections of this technique awaits validation with larger series and with long- the testis or touch preparations of testicular tissue have less accu- term follow-up (Tauber and Johnson, 1994; Ficarra et al, 2002). racy for identification of normal spermatogenesis than permanent sections. Testicular biopsy specimens should be placed in specific Testicular Biopsy solutions such as Bouin’s, Zenker’s, or buffered glutaraldehyde because the normal formalin tissue preservative will introduce Testicular biopsy has two roles in the management of male infer­ distortion artifacts into the specimen, making histologic analysis tility: diagnostic for the differentiation of obstruction from less accurate. 632 SECTION VI ● Reproductive and Sexual Function

Interpretation of testicular biopsies requires an experienced normal to germ cell aplasia with hypospermatogenesis and matura- pathologist because analysis is descriptive rather than quantitative tion arrest in between. Although single patterns may be seen in nature. Electron microscopy of the germinal epithelium has not throughout the biopsy, multiple patterns may often be identified. been shown to provide clinical benefit over standard light micros- copy. A variety of objective histologic scoring methods have been Normal described in an effort to quantify spermatogenesis and predict More than 85% of testicular volume consists of seminiferous outcomes from surgical reconstruction for obstruction, but these tubules made up of progressively maturing germ cells and their have not gained widespread acceptance due to the time-consuming supporting Sertoli cells. Blood vessels and Leydig cells in the inter- nature of the analysis and the lack of validated studies (Johnsen, stitial areas provide the rest of the cellular complement. Spermato- 1970; Silber and Rodriguez-Rigau, 1981). DNA flow cytometry has genesis proceeds in an orderly fashion from spermatogonia along also been employed to quantify spermatogenesis, but this has not the basement membrane to spermatocytes and finally mature gained popularity for similar reasons (Kaufman and Nagler, 1987; spermatozoa adjacent to the tubular lumen (Fig. 21–7A). Type A Hellstrom et al, 1990). At the present time, the most commonly spermatogonia provide the stem cell complement and have a used system for analysis of testicular biopsy remains the histologic diploid complement of chromosomes (2N). These cells undergo classification across a spectrum of standard patterns ranging from a mitotic division to replenish the stem cell complement and

B

A

C D

Figure 21–7. Diagnostic findings on testicular biopsy. A, Normal. B, Hypospermatogenesis. C, Maturation arrest. D, Germinal cell aplasia (Sertoli cell–only pattern). CHAPTER 21 ● Male Infertility 633

provide type B spermatogonia (2N). Type B spermatogonia undergo characteristic histologic findings for end-stage testes. These DNA synthesis, resulting in spermatocytes that have a tetraploid patients will have azoospermia with profoundly small, soft testes complement of chromosomes (4N). Two subsequent meiotic divi- (2- to 3-mL volume). Although this is characteristic of KS, some sions result in spermatids with the final haploid number of chro- patients may still have small foci of retained spermatogenesis, mosomes (1N). Further maturation results in a progression from which may be identified by micro-TESE. This histology may also round to elongated spermatids and then to the final product, be seen with cryptorchid testes. mature spermatozoa. Human testes exhibit multiple stages of sper- matogenesis in a single tubular section (patchwork pattern), unlike DIAGNOSTIC AND TREATMENT other mammalian testes, which produce waves of spermatogenesis CATEGORIES OF MALE INFERTILITY progressing along a tubule. In the setting of azoospermia, a normal testicular biopsy is Upon completion of a focused physical and laboratory examina- considered pathognomonic of ductal obstruction. Although focal tion, patients may be grouped into common patterns on the basis areas of hypospermatogenesis and maturation arrest have been of seminal parameters (Table 21–8) and etiologic categories (Table observed in the presence of obstruction, particularly in the 21–9). In the following sections, we review diagnostic criteria and setting of prior vasectomy, these are not classic findings for appropriate therapy for specific diseases. obstruction (Joshi et al, 1972; Perera, 1978). Dilated tubules with The goal of the infertility evaluation is to cause a successful intraluminal debris are also commonly noted in patients exhibit- pregnancy in the safest, most natural, expeditious, and cost- ing obstruction. effective manner possible. Although advanced ART technologies such as ICSI are helpful tools in the armentarium for the manage- Hypospermatogenesis ment of infertility, all attempts should be made to correct underly- Hypospermatogenesis is associated with reduced numbers of all ing male factor etiologies before proceeding with these treatments. germ cells, but all stages of spermatogenesis remain present in the The high cost of these technologies, the shifting of treatment histologic section (Fig. 21–7B). The degree of reduction determines burden of male factor to the female partner, and intrinsic safety whether the patient is oligospermic or azoospermic. A critical level issues with ICSI mandate a complete exploration of correctable of sperm production is required before sperm can be detected in male factor issues before proceeding with ICSI. the ejaculate, accounting for the common observation of hypo- spermatogenesis in the azoospermic patient.

Maturation Arrest Table 21–8. As the name suggests, maturation arrest involves a block of sperm Distribution of Seminal Parameters in Patients maturation at a specific stage anywhere along the path of- sper Presenting for Infertility Evaluation matogenesis (Fig. 21–7C). Maturation arrest most commonly occurs at the primary spermatocyte or late spermatid stages. Late TYPE INCIDENCE (%) maturation arrest may be difficult to distinguish from a normal Abnormal semen parameter 37 biopsy, but the presence of mature sperm on testicular touch prep Motility 26 supports the diagnosis of normal spermatogenesis. Complete mat- Asthenospermia 24 uration arrest will produce azoospermia, whereas patients with Oligospermia 8 partial maturation arrest may present with severe oligospermia. Agglutination 2 The remaining testicular architecture including the Sertoli and Volume 2 Morphology 1 Leydig cells, as well as the basement membranes, are usually Azoospermia 8 normal. Interestingly, maturation arrest is often associated with All parameters normal 55 normal endocrine profiles such as FSH and inhibin levels due to an intact hypothalamic-pituitary-gonadal negative feedback From Lipshultz L. Subfertility. In: Kaufman JJ, editor. Current urologic therapy. system. Thus the clinical presentation of maturation arrest and Philadelphia: WB Saunders; 1980. ductal obstruction may be similar because both are associated with normal testicular volume and similar endocrine profiles. Germinal Aplasia Table 21–9. Germinal aplasia, also called Sertoli cell-only syndrome, has small Distribution of Etiology of Male Infertility seminiferous tubules that are completely devoid of germ cells (Fig. CATEGORY NUMBER PERCENT (%) 21–7D). The interstitial component, as well as the Sertoli cells and Varicocele 603 42.2 basement membranes, are normal. The diagnosis of germinal Idiopathic 324 22.7 aplasia is suggested in an azoospermic patient with small-volume Obstruction 205 14.3 testes and elevated levels of FSH consistent with primary testicular Normal/female factor 119 7.9 failure. Although there are no current treatments to repopulate Cryptorchidism 49 3.4 the testis with germ cells, low levels of spermatogenesis may be Immunologic 37 2.6 seen in other areas of the testis, which forms the basis for the use Ejaculatory dysfunction 18 1.3 of microsurgical dissection testis biopsy (micro-TESE) to retrieve Testicular failure 18 1.3 sperm in some of these patients for eventual ICSI use. Drug/radiation 16 1.1 Endocrinopathy 16 1.1 End-Stage Testes Others (all <1%) 31 2.1

Thickened basement membranes, tubular and peritubular Data from Nagler HM, Martinis FG. Varicocele. In: Lipshultz LI, Howards S, editors. sclerosis, and absence of both germ cells and Sertoli cells are Infertility in the male. St. Louis: Mosby Year Book; 1997. p. 336–59. 634 SECTION VI ● Reproductive and Sexual Function

Although there is a myriad of causes of azoospermia, etiologies Semen Parameter Categories fall into three general categories: pretesticular, testicular, and post- testicular. Causes can usually be differentiated on the basis of Azoospermia semen volume (low vs. normal), physical exam findings of testicu- Azoospermia is defined as the absence of sperm in the ejaculate lar volume and presence of vas deferens as well as serum FSH level and is identified in 10% to 15% of infertile males (Jarow et al, (Fig. 21–8). 1989). Before proceeding with further diagnostic procedures, the Pretesticular causes, also called secondary testicular failure, are diagnosis of azoospermia should be confirmed with at least two usually endocrine in nature and relate to either congenital centrifuged semen specimens to rule out severe oligospermia. The (Kallman syndrome) or acquired hypogonadotropic hypogonad- finding of even small quantities of sperm in the centrifuged speci- ism, which are addressed in detail later in this chapter. men rules out complete ductal obstruction such as CBAVD and Testicular etiologies, broadly termed as primary testicular failure, also offers the potential for immediate sperm cryopreservation for are intrinsic disorders of spermatogenesis. Direct testicular pathol- ICSI cycles. ogy may derive from genetic abnormalities such as Y-chromosome

Azoospermia

Semen volume

Normal volume Low volume

Testis size Vasa absent Vasa present Atrophy Normal

FSH FSH Bilateral vasal TRUS agenesis Low High Abnormal Normal

Hypogonadotropic 1° testicular Failure of hypogonadism failure CFTR testing emission

LH, prolactin TEST/IVF PESA/IVF Ejaculatory Sympathomimetics Cranial CT/MRI AID AID duct electroejaculation Gonadotropins adoption adoption obstruction TESE/IVF

Normal High

TUREJD Testicular Abnormal 1° testicular biopsy failure

Normal

Obstruction TESE/IVF AID adoption

Vasoepididymostomy or vasovasotomy

Figure 21–8. Algorithm for evaluation and treatment of azoospermia. AID, artificial insemination by donor semen; CFTR, cystic fibrosis transmembrane conductance regulator; CT/MRI, computed tomography/magnetic resonance imaging; FSH, follicle-stimulating hormone; IVF, in-vitro fertilization; LH, leuteinizing hormone; PESA, percutaneous epididymal sperm aspiration; TESE, testicular sperm extraction; TRUS, transrectal ultrasound; TUREJD, transurethral resection of the ejaculatory ducts. CHAPTER 21 ● Male Infertility 635

microdeletions or chromosomal abnormalities, varicocele-induced obstruction (EDO), although rarely, ejaculatory dysfunction can testicular damage, gonadotoxic effects from medications or envi- cause a similar presentation. Disorders of ejaculation such as ret- ronmental exposures, and idiopathic infertility, which constitute rograde ejaculation will more frequently cause oligospermia in the majority. conjunction with low semen volume and are readily diagnosed by Ejaculatory dysfunction or obstruction of the genital tract the presence of sperm in a postejaculation urine specimen. The account for the post-testicular pathologies, which constitute 40% diagnosis of EDO is suggested by low semen volume with acidic of cases of azoospermia (Best Practice Committees of American pH and absent semen fructose. TRUS will often reveal midline Urological Association and American Society for Reproductive prostatic cysts, dilated ejaculatory ducts, or dilated seminal vesicles Medicine, 2006). Pretesticular and post-testicular causes are often (>1.5 cm in width), and seminal vesicle aspiration may produce amenable to treatment, which may restore fertility, whereas the large numbers of sperm. Ultimately, EDO may be confirmed by success rates for intervention in testicular pathology are much vasography at the time of planned transurethral resection of the more modest. ejaculatory ducts (TUREJD) to relieve the obstruction. Although both primary and secondary testicular failure will be associated with marked reduction in testicular volume, these enti- Oligospermia ties can be distinguished by serum endocrine testing to include Oligospermia is defined as a sperm density of less than 20 million/ FSH, LH, testosterone, and prolactin levels. High serum FSH levels, mL. Unlike the situation with azoospermia, the number of poten- typically greater than two times normal, are indicative of primary tial diagnoses causing oligospermia can be quite vast and the etiol- testicular failure, and diagnostic testicular biopsy is not required ogy is often idiopathic. Oligospermia is rarely seen as an isolated to rule out obstructive etiologies. Primary testicular failure in con- seminal abnormality but is usually associated with disturbances in junction with azoospermia, commonly termed nonobstructive azo- motility and morphology. Endocrinopathies are rarely observed in ospermia (NOA), is best managed with testicular sperm harvest for patients with concentrations higher than 10 million/mL, so eventual ICSI. The absolute degree of serum FSH elevation has not routine endocrine screening with serum testosterone and FSH proven predictive of success rates for sperm retrieval (Vernaeve levels are reserved for counts lower than 10 million (Sigman and et al, 2004; Hibi et al, 2005; Harris and Sandlow, 2008). Azoosper- Jarow, 1997). Testis biopsy is not indicated in the setting of mild mic patients with normal testicular size, palpable vas deferens, and to moderate oligospermia, although it can be considered in normal serum FSH levels require a diagnostic testicular biopsy to patients with sperm concentrations under 1 million/mL in whom differentiate genital tract obstruction from disorders of spermato- ductal obstruction is considered on the basis of history or physical genesis such as maturation arrest. examination findings. Obstructive azoospermia accounts for 40% of cases of azoosper- mia (Practice Committee, American Society of Reproductive Medi- Seminal Quality Abnormalities cine, 2008). A normal testicular biopsy is pathognomonic for Isolated defects may occur in motility or morphology, known as genital tract obstruction. If these patients desire restoration of asthenospermia or teratospermia, respectively, while global sperm patency, they will require scrotal exploration and vasography at quality abnormalities are described with the term oligoasthenotera- the time of planned reconstruction to identify the site of obstruc- tospermia (OAT). Asthenospermia may be iatrogenic from delayed tion. Genital tract obstruction may occur anywhere along the processing in the laboratory or may be due to a prolonged absti- sperm transport system to include the rete testis, efferent ductules, nence period. Persistent asthenospermia in a properly processed epididymis, vas deferens, or ejaculatory ducts. Obstruction at the specimen, while often idiopathic, may be seen in association with level of the epididymis or vas deferens may be successfully treated varicoceles, genital tract infections, ultrastructural cilia abnormali- with microsurgical reconstruction, either vasoepididymostomy for ties such as immotile cilia syndrome, and immunologic infertility epididymal obstruction or vasovasostomy for vasal obstruction. in association with antisperm antibodies. Elective vasectomy remains the leading cause of obstructive azo- Teratospermia is a common finding, especially with use of the ospermia and subsequent infertility. In the absence of prior injury strict morphologic criteria (Tygerberg or Kruger) applied by many to the vas either intentionally from vasectomy or iatrogenic injury andrology laboratories. Bizarre morphologies of the sperm head of inguinal vas from hernia repair, most men with idiopathic such as pinhead sperm, multiheaded sperm, or round-headed ductal obstruction will be obstructed at the level of the epididy- sperm, which suggest acrosome deficiency, undoubtedly have clini- mis. Epididymal obstruction may be due to prior trauma, infec- cal significance, although there is growing controversy regarding tion, or the result of downstream vasal obstruction from an the predictive utility of abnormal morphology in general, largely elective vasectomy. Although vasectomy usually results in a single due to the subjective nature of the test making it difficult to stan- obstructive site, the development of high intraluminal pressures dardize (Agarwal et al, 2008). Abnormal sperm morphology has not after a vasectomy can result in rupture of the delicate epididymal been correlated with recurrent spontaneous miscarriages or abnor- tubule with secondary obstruction in the epididymis. Epididymal malities in offspring (Rosenbusch et al, 1992; Hill et al, 1994). obstruction rarely occurs within 4 years of a vasectomy but is Low ejaculate volume may also be a contributing factor to sub- present in more than 60% of patients on one or both sides after fertility. Reduction in ejaculate volume is most commonly due to 15 years of vasal obstruction (Fuchs and Burt, 2002). The absence improper specimen collection but may be associated with CBAVD of proximal vasal fluid or thick, viscous, pastelike fluid is indica- with associated hypoplasia of the seminal vesicles, hypoandrogen- tive of a concurrent epididymal obstruction and such patients will ism, retrograde ejaculation, or obstruction of the ejaculatory duct. require a vasoepididymostomy for their reconstruction. The Relative acidity of the seminal pH and low semen fructose suggest outcome of reconstruction in vasectomized men depends on a absence of seminal vesicle contribution to the semen, pointing to number of factors including the obstructive interval, the quality either CBAVD or EDO as lead possible causes of subfertility. of the fluid from the proximal vas at the time of surgery, and the surgeon’s microsurgical experience (Sabanegh, 2009). Normal Bulk Semen Parameters Azoospermia in conjunction with low semen volumes and Up to 50% of men presenting for an infertility evaluation will palpable vas deferens is most likely caused by ejaculatory duct have normal bulk semen parameters, representing a particularly 636 SECTION VI ● Reproductive and Sexual Function

difficult population to be assigned an etiology for subfertility and Treatment of varicoceles in the subfertile patient has produced reinforcing the inherent inability of standard semen analyses to variable results on the basis of the definition of the varicocele assess sperm function. In these couples, particular attention (subclinical vs. clinical) and the method of intervention used. The should be given to identifying occult female factor fertility issues, various methods of varicocele treatment all involve ligation or as well as assessing coital frequency to optimize reproductive occlusion of dilated gonadal veins. Surgical ligation has been timing for conception. On occasion, antisperm antibodies in the approached through retroperitoneal, inguinal, and subinguinal cervical mucus may inhibit sperm motility in vivo and prevent dissection, whereas embolization is a radiologic procedure. These fertilization. This situation can be quantified with indirect anti- techniques are discussed in depth in a later chapter. The most sperm antibody testing of the cervical mucus, although an in-vivo current guidelines in 2008 by the Best Practice Committee of the assessment of compatibility of sperm with the cervical mucus can American Society for Reproductive Medicine recommend treat- be provided with the postcoital test (PCT). Couples with an abnor- ment of a varicocele in the infertile patient when all of the follow- mal PCT may benefit from intrauterine insemination, which ing conditions are met: (1) varicocele is palpable on physical bypasses the hostile cervical factors. examination; (2) the couple has known infertility; (3) the female partner has normal fertility or a potentially treatable cause of infer- Varicocele tility; and (4) the male partner has abnormal semen parameters or abnormal results from sperm function tests. Patients with subclini- Varicoceles represent the most common attributable cause of cal varicoceles are not candidates for varicocele treatment due to primary and secondary infertility in the male (see Table 21–9). a lack of demonstrated efficacy in this population (Yamamoto Although there is a large body of research on varicoceles dating et al, 1996). On occasion, large varicoceles will produce clinical back to Tulloch’s first report of varicocele ligation for male infertil- symptoms such as dull hemiscrotal discomfort or sense of heavi- ity in 1955, much of the subsequent research has suffered from ness and these patients will benefit from varicocele treatment. methodologic flaws, lack of standardized definitions for varico- Adolescent males with unilateral or bilateral clinical varicoceles celes, and failure to control confounding issues such as concurrent and ipsilateral testicular hypotrophy are also candidates for vari- female factor infertility. Despite these limitations, varicocele treat- cocele repair. Although there remains controversy with the thresh- ment remains the most commonly performed surgery for the old for testis size reduction to support varicocele intervention in correction of male factor subfertility. the adolescent, authors have suggested 2-mL volume or 20% Varicoceles have been attributed to turbulent venous flow volume decrement from the contralateral testis as evidence of related to the right angle insertion of the left testicular vein into significant varicocele-induced damage (Gargollo and Diamond, the left renal vein, an explanation supported by the left-sided 2009). Further support can be provided by pretreatment semen predominance of these lesions. The insertion of the right testicular analysis, although this can be challenging to obtain in the adoles- vein directly into the inferior vena cava is believed to provide less cent patient. Recovery of testicular volume, so called “catch-up flow turbulence and back pressure, which translates into a lower growth,” has been reported to occur in up to 80% of boys with incidence of venous dilation in the right spermatic cord. In addi- grade II or III varicoceles (Kass and Belman, 1987; Gershbein et al, tion, incompetent or absent venous valves in the gonadal veins 1999), although this has been challenged by a more recent study allow retrograde reflux of blood into the scrotum with the stand- that suggests testicular growth will occur spontaneously in conser- ing position (Braedel et al, 1994). On rare occasions, a “nutcracker vatively managed patients with varicoceles (Kolon et al, 2008). In phenomenon” has been described where the left renal vein may the absence of testicular growth retardation, adolescents with vari- be compressed between the superior mesenteric artery and the coceles should be followed with annual testicular size assessments, aorta producing elevated pressure in the left gonadal vein and as well as semen analysis if possible to assist early identification resulting in a varicocele. and intervention of varicocele-induced testicular damage. The mechanism of varicocele-induced impairment of sper- Outcomes of varicocele treatment remain the subject of some matogenesis remains the subject of much debate. The lead theory controversy, although substantial evidence exists to support inter- postulates that testicular cellular processes are exquisitely tem- vention in patients with clinical varicoceles and abnormal semen perature dependent. Venous pooling from a varicocele produces quality. The bulk of studies (Table 21–10) has shown improve- elevated intrascrotal temperature resulting in reductions in tes- ments in seminal parameters with varicocele repair (Schlesinger tosterone synthesis by Leydig cells, injury to germinal cell mem- et al, 1994) and specific functional testing to include sperm pen- branes, altered protein metabolism, and reduced Sertoli cell etration assay (Ohl et al, 2007), sperm DNA fragmentation levels function (Khera and Lipshultz, 2008). Varicocele ligation has (Zini et al, 2005), and oxidative stress levels (Mostafa et al, 2001). been demonstrated to be associated with reductions in intrascro- A recent meta-analysis incorporating studies using current clinical tal temperature (Wright et al, 1997). It has also been suggested guidelines for varicocele repair reported mean increases in sperm that free reflux of renal and adrenal metabolites from the left density of 9.7 million/mL, motility increases of 9.9%, and WHO renal vein are directly gonadotoxic. Spermatic cord blood cate- sperm morphology improvement by 3% (Agarwal et al, 2007). cholamine and prostaglandin levels appear elevated in varicocele Semen quality has been reported to improve in 51% to 78% of patients, although the direct gonadotoxic effects of these com- infertile men after varicocele treatment (Turek, 2005). The impact pounds remain to be established in humans (Comhaire et al, of varicocele grade on post-treatment semen quality remains 1974; Ito et al, 1982). Other proposed mechanisms for varicocele- unclear, although the bulk of studies suggests that larger varico- induced subfertility include impaired venous drainage with celes produce more significant impairment in semen parameters resulting hypoxia, poor clearance of gonadotoxins, and elevated and the repair of bilateral varicoceles produced increased benefit levels of oxidative stress. The level of seminal oxidative stress over the repair of unilateral varicoceles (Richardson et al, 2008). correlates with varicocele grade and improves with treatment of In the setting of underlying genetic abnormalities associated with the varicocele (Allamaneni et al, 2004; Khera et al, 2007). the subfertility, varicocele treatment does not appear to produce Although conflicting evidence exists for each theory, it appears significant improvement in outcomes (Cayan et al, 2001). Azo- that the mechanism of varicocele damage is multifactorial. ospermic patients with varicoceles have shown some potential for CHAPTER 21 ● Male Infertility 637

Table 21–10. Outcomes of Varicocele Treatment in Nonazoospermia Men (Controlled Trials) for Clinical Varicoceles VARICOCELE PREGNANCY RATE (%) PREGNANCY RATE (%) STUDY PATIENTS (No.) GRADE TREATMENT CONTROL ODDS RATIO Nilsson (1979) 96 III 8 18 0.394 Baker (1985) 651 I-III 47 21 3.37 Madgar (1995) 45 II-III 60 40 13.5 Nieschlag (1998) 125 I-III 29 25 1.20 Grasso (2000) 68 I 3 6 0.485 Krause (2002) 67 I-III 16 18 0.875

Table 21–11. Outcomes of Varicocele Treatment in Azoospermic Men MEAN POSTOPERATIVE SPERM STUDY PATIENTS (No.) CONCENTRATION (MILLION/mL) PREGNANCY RATE (%) Matthews (1998) 22 2.2 14 Kim (1999) 28 1.2 NR Pasqualotto (2003) 15 2.54 7 Esteves (2005) 17 1.5 NR Gat (2005) 32 3.81 NR Pasqualotto (2005) 28 Germinal cell aplasia 12.05 53.8 32 Maturation arrest 24.76 25

NR, not reported. return of sperm to their ejaculate after varicocele treatment (Table exact effect on fertility from unilateral versus bilateral cryptorchi- 21–11), although studies have been relatively small with modest dism and the protective effect and timing of orchidopexy. Early conception results. The vast majority of azoospermic patients with studies reported significant detrimental effects on semen param- return of sperm postvaricocele treatment will still require advanced eters with even unilateral cryptorchidism (Kogan, 1985; Cendron, ART such as in-vitro fertilization to obtain conception. 1989), but newer work suggests that unilateral cryptorchidism Spontaneous pregnancy rates after varicocele treatment have may be associated with modest or no significant impact on fertility been reported to average between 30% and 50% in the larger series (Lee, 2005; Murphy, 2007). The level of the cryptorchid testis is (Abdulmaaboud et al, 1998; Segenreich et al, 1998; Perimenis predictive of spermatogenic impairment with germinal cell aplasia et al, 2001) with pregnancies occurring at an average of 8 months found in 20% to 40% of inguinal testes versus 90% of intra- after treatment (Pryor, 1987). A recent meta-analysis after surgical abdominal testes (Hadziselimovic, 1984). One epidemiologic varicocelectomy noted that the odds of spontaneous pregnancy study comparing fertility in men with either unilateral or bilateral were 2.87 times higher over the nontreatment group (Marmar cryptorchidism versus age-matched controls reported paternity et al, 2007). Cost-benefit analyses have generally been supportive rates of 89% in unilateral cryptorchidism, 93% in age-matched of varicocele treatment over ART techniques (Schlegel, 1997). In controls, and 65% in patients with a history of bilateral cryptor- addition, 30% to 50% of couples who are felt to require ART due chidism (Lee, 2005). Some studies have suggested that orchiopexy to low semen quality may be able to avoid this after varicocele at younger ages, typically younger than 4 years of age, is associated treatment (Cayan et al, 2002) or have improved efficacy with with improved fertility outcomes (Coughlin et al, 1999; Lee, post-treatment intrauterine insemination (Daitch et al, 2001). 2002), although the question still awaits large longitudinal studies.

Cryptorchidism Endocrinopathies Cryptorchidism is a relatively common condition noted in 2.7% Endocrine-derived causes of infertility may occur at the hypotha- of newborns and up to 0.8% of 1 year olds (Score, 1964). It is lamic, pituitary, or gonadal levels. Originally believed to be a rare a well-known etiology for subfertility and has been associated cause of infertility, growing evidence suggests that hypogonadism, with reduced testicular size and sperm concentration, as well as as defined by the U.S. Food and Drug Association (FDA),- estab reductions in serum inhibin and elevations in serum FSH levels lished normal testosterone level of 300 ng/dL may be highly prev- (de Gouveia Brazao et al, 2003; Caroppo et al, 2005). It is impor- alent in infertile males, occurring in 45%, 43%, and 35% of men tant to distinguish cryptorchid testes from retractile testes, a con- with nonobstructive azoospermia, oligospermia, and normal dition involving hyperactive cremasteric muscles causing the testis semen parameters, respectively (Sussman et al, 2008). to periodically reside in the inguinal canal or high scrotum. Primary hypogonadism, also called primary testicular failure or Although retractile testes have been associated with depressed hypergonadotrophic hypogonadism, is defined as low serum testoster- spermatogenesis, more severe reductions in semen quality have one and elevated gonadotropin level consistent with organ func- been identified in cryptorchid patients (Caroppo et al, 2005). tion failure at the level of the testes. Suggested mechanisms for cryptorchidism-induced subfertility Secondary hypogonadism, also called hypogonadotropic hypogo- include testicular dysgenesis, impaired endocrine axis, immuno- nadism, has low testosterone levels in conjunction with low logic damage, and obstruction. Controversies remain as to the gonadotropin levels. 638 SECTION VI ● Reproductive and Sexual Function

The time of onset of hypogonadism induces variable clinical other clinical features may include midline facial defects such as presentations. Failure of testosterone surge at the expected time cleft palate; gynecomastia; neurologic abnormalities (mental retar- of puberty produces delayed or absent puberty, growth retarda- dation, oculomotor defects, deafness, and synkinesia); unilateral tion, and small, soft testis. Patients with onset of hypogonadism renal agenesis; cryptorchidism; micropenis; and pes cavus after puberty will have normal secondary sexual characteristics (Sussman et al, 2008). Kallman syndrome results from failure to and body habitus but small firm testis consistent with possible secrete gonadotropin-releasing hormone (GnRH) by the hypo- fibrosis after normal testicular development. thalamus, leading to low gonadotropin levels and ultimately, failure to transition the prepubertal testis to postpubertal level of Hypogonadotropic Hypogonadism function. The GnRH deficiency noted with Kallman syndrome is Isolated gonadotropin deficiency or hypogonadotropic hypogo- the result of failed embryonic migration of neuroendocrine GnRH nadism (HH) is a relatively rare cause of subfertility accounting for cells from the olfactory epithelium to the forebrain. Absence or less than 1% of cases of male infertility and may be congenital or hypoplasia of the olfactory bulbs accounts for the concurrent acquired (Sigman and Jarow, 1997). anosmia. Kallman syndrome represents a genetically diverse group Acquired causes of hypogonadotropic hypogonadism include of diseases with both X-chromosome linked inheritance via muta- pituitary disease, which may result from prior surgery, infarction, tions in the KAL1 gene, as well as autosomal dominant inheritance tumors, or infection; metabolic disorders; and a variety of other via mutations in the fibroblast growth factor receptors 1 and 8 medical conditions (Table 21–12). (FGFR1, FGFR8), the prokineticin receptor-2 (PROKR2), and the Although variants of congenital hypogonadotropic hypogonad- prokineticin-2 (PROK2) genes. Mutations in these five genes are ism have been described (Table 21–13), the anosmic form or found in less than 30% of Kallman syndrome patients reinforcing Kallman syndrome is the most commonly reported, occurring in the need for further genetic study on these complex patients between 1:10,000 and 1:60,000 births (Oates, 1997). In addition (Dode, 2009). to the anosmia and azoospermia noted with Kallman syndrome, Prader-Willi syndrome (PWS), another form of congenital hypo- gonadotropic hypogonadism, has features that include infantile hypotonia, obesity, cryptorchidism, short stature, and mental Table 21–12. retardation. It is caused by microdeletions or mutations on the Acquired Causes of Hypogonadotropic paternal chromosome 15 at the q11 or q13 location (Smeets et al, Hypogonadism 1992). Because of concurrent medical problems in these patients, most do not seek treatment for infertility. Central nervous system (CNS) derived Hypogonadotropic hypogonadism usually presents in the late CNS developmental abnormalities teenage years when the patient fails to undergo the usual pubertal Head trauma changes with secondary virilization. It is of critical importance to Pituitary tumors distinguish HH from constitutional delay of growth and puberty Autoimmune disease Parasitic diseases (CGDP) because they share many clinical and hormonal features Crohn disease and yet require markedly different treatments. Usually, CGDP Beta-thalassemia/hemoglobinopathy patients will attain spontaneous puberty by age 18 or may require Hemochromatosis transient androgen replacement for puberty induction but then Disorders of lipid metabolism will progress through normal development and fertility. HH patients will require lifelong androgen replacement for mainte- nance of virilization and episodes of exogenous gonadotropin treatment off androgen therapy for fertility induction as described Table 21–13. later. Because differentiation is not always possible on the basis of Variants of Congenital Hypogonadotropic serum testosterone and gonadotropin levels, a number of physi- Hypogonadism ologic and stimulatory tests have been described to discriminate Congenital idiopathic hypogonadism these conditions to include serial serum LH measurements, pro- Anosmic (Kallman syndrome) lactin response to TRH, and GnRH and human chorionic gonado- Nonanosmic tropins (HCG) stimulation tests (Segal, 2009). Patients with CGDP Congenital adrenal hypoplasia often demonstrate LH pulses with serial overnight blood draws Fertile eunuch syndrome and gonadotropin surge in response to GnRH stimulation. HH Genetic defects of the gonadotropin subunits patients have minimal variability in LH levels and do not demon- Follicle-stimulating hormone–β mutations strate significant increases in gonadotropins levels with adminis- Luteinizing hormone–β mutations tration of GnRH. Mutations in leptin and leptin receptor genes In general, treatment of HH syndromes is directed to two ulti- Hypogonadotropic hypogonadism with other associated pituitary mate goals: (1) induction of normal serum androgen levels to hormone deficiencies PROP-1 mutations allow appropriate virilization and bone growth and (2) the induc- HERS1 mutations tion of spermatogenesis and, ultimately, fertility. During adoles- Syndromes associated with hypogonadotropic hypogonadism cence, puberty and virilization are usually initiated with exogenous Prader-Willi syndrome androgen treatment. Various effective methods of testosterone Congenital spherocytosis replacement therapy exist including intramuscular testosterone Moebius syndrome enanthate or cypionate (200 mg every 2 weeks), transdermal Cerebellar ataxia patches (5 to 10 mg/day), testosterone gel, or buccal tablets. Ade- Retinitis pigmentosa quacy of replacement can be assessed by serum testosterone levels, From Sussman EM, Chudnovsky A, Niederberger CS. Hormonal evaluation of the which should be within the midrange of normal, and observation infertile male: has it evolved? Urol Clin North Am 2008;35(2):147–55. of the desired phenotypic response to therapy. Exogenous CHAPTER 21 ● Male Infertility 639

testosterone is effective in induction of virilization but will inhibit enzyme accounts for 90% of cases of CAH. Although severe defi- spermatogenesis, so alternate therapies will be required when the ciency in 21-hydroxylase activity can present in the neonatal patient desires fertility. period with salt wasting, milder deficiencies present more - com Induction of spermatogenesis in the HH patient requires the monly in childhood with phallic enlargement, precocious puberty, maintenance of intratesticular testosterone levels that are expo- and advanced skeletal maturation. Elevated levels of serum nentially higher than that obtainable with conventional androgen 17-hydroxyprogesterone (often >1000 ng/dL) and urinary preg- replacement therapy. To obtain such levels, the usual first-line nanetriol support the diagnosis of 21-hydroxylase deficiency. The therapy for HH involves treatment with human chorionic gonado- impact on subsequent fertility is variable, depending on the degree tropin (hCG), which is biologically similar to LH, inducing Leydig of androgen excess. Treatment for CAH consists of glucocorticoid cell production of testosterone. hCG is administered subcutane- replacement, which reduces ACTH levels and adrenal androgen ously at a dose of 1500 to 2000 IU two to three times per week production. In one small series of adult patients with CAH, 60% for 4 to 6 months. When testicular volume and serum testosterone of men were able to cause pregnancies either with treatment or levels are stable without significant further improvement, FSH even in the absence of CAH treatment (Urban, 1978). stimulation is added to the treatment regimen to induce spermato- Anabolic steroids represent a growing etiology of male subfertil- genesis. FSH may be administered in the form of human meno- ity with a similar mechanism of spermatogenic disruption to that pausal gonadotropin (hMG), a compound that contains both FSH observed with CAH. It remains problematic to accurately predict and LH in equal doses or with recombinant human FSH formula- the impact of these agents because of the variety of performance- tions. Human menopausal gonadotropin is administered at a dose enhancing substances used, as well as the variation in doses of 75 IU two to three times per week, and recombinant FSH usually employed. Older studies of semen quality in athletes using high uses doses of 37.5 to 75 IU three times per week. FSH therapy is doses of anabolic steroids revealed severe impairment of sperm continued until attainment of sperm concentrations of at least 5 concentration, motility, and morphology (Knuth et al, 1989). million per mL in the ejaculate or pregnancy is obtained. The vast Although cessation of use allowed normalization of seminal majority of patients will be able to conceive after gonadotropin parameters in an average of 4 months, cases of persistent azoosper- therapy, although 71% of the patients with subsequent fertility mia have been reported occurring more than 1 year later (Jarow, have sperm concentrations considerably lower than normal, sug- 1990). To avoid the fertility-related side effects, anabolic steroid gesting that these patients are often able to conceive with low users have employed modified regimens that add hCG with steroid counts (Burris et al, 1988). Interestingly, 10% of patients may to protect spermatogenesis. These combinations, although causing maintain normal serum testosterone levels after cessation of all transient impairment in semen quality, seem to allow preservation endocrine therapy, implying that HH may be reversible in some of spermatogenesis in some patients (Karila et al, 2004). In patients (Raivio et al, 2007). Prior treatment of HH patients with patients with persistent azoospermia or severe oligospermia after testosterone does not affect success with future gonadotropin steroid abuse, hCG alone or in combination with hMG has been therapy (Ley and Leonard, 1985; Hamman and Berg, 1990). successfully used to restore spermatogenesis (Pundir, 2008). Hypogonadotropic hypogonadism patients with intact pituitary function can also be effectively treated with pulsatile GnRH Hyperprolactinemia therapy supplied via subcutaneous infusion from portable pump Because of its low yield, screening serum prolactin measurements or intranasal administration (Klingmuller, 1985; Aulitzky, 1988). in the infertile male is not indicated unless associated with erectile Although direct GnRH therapy is effective, inconvenience of dysfunction, low serum testosterone levels, or decreased libido. administration and expense do not justify this choice over tradi- Although often idiopathic, hyperprolactinemia can be associated tional gonadotropins therapy at the present time (Liu, 1988). In with medications, physiologic stress, and pituitary tumors. Because addition, selected patients with HH presenting after puberty with of the marked physiologic variability noted with serum prolactin intact pituitary function may respond to clomiphene citrate, an levels, elevated levels should be confirmed by at least one - addi antiestrogen therapy (Whitten et al, 2006). tional measurement. If elevated prolactin levels are confirmed (>18 ng/dL), anatomic imaging of the sella turcica is required, Androgen Excess usually with magnetic resonance imaging with gadolinium con- Excess systemic levels of androgen paradoxically inhibit spermato- trast. Although macroadenomas may require surgical excision, genesis due to direct feedback inhibition of gonadotropin secre- microadenomas are usually responsive to dopamine agonist tion at the level of the hypothalamus and pituitary. This ultimately therapy with either bromocriptine or cabergoline. Cabergoline results in low intratesticular levels of testosterone, which are inad- offers advantages over bromocriptine to include longer half-life, equate for the maintenance of spermatogenesis, an observation allowing less frequent dosing and an improved side effect profile that provides the impetus for growing research examining the without compromising therapeutic efficacy. Despite limited data potential contraceptive role of exogenous testosterone. on the therapeutic efficacy of dopamine agonist therapy for the Excess states may result from either endogenous production or infertile male with hyperprolactinemia, several small studies have exogenous administration of androgens. Elevations in endoge- reported improvements in sperm concentration and motility, as nous production of androgens may be caused by congenital well as normalization of serum prolactin levels with treatment abnormalities of steroid metabolism such as congenital adrenal (Laufer et al, 1981; Mancini et al, 1984). hyperplasia or androgen-producing tumors of the testis or adrenal gland. Congenital adrenal hyperplasia (CAH), the most common Estrogen Excess endogenous etiology of androgen excess, encompasses a variety of Regardless of the source of the estrogen excess, estrogens inhibit specific enzyme defects in cortisol and aldosterone synthesis. Inad- GnRH secretion by the hypothalamus and gonadotropin release equate systemic cortisol levels result in excessive pituitary release by the pituitary. In addition to the effects on the hypothalamic- of ACTH leading to hyperstimulation of the adrenal gland with pituitary-gonadal axis, elevations in serum estrogen levels produce subsequent release of adrenal androgens and suppression of direct deleterious effects on spermatogenesis (Hammoud et al, pituitary gonadotropin release. Deficiency in the 21-hydroxylase 2008). Hormonal evaluation in the infertile patient will reveal low 640 SECTION VI ● Reproductive and Sexual Function

levels of serum FSH, LH, and testosterone with elevations in serum language deficiencies, as well as fine motor developmental delays estrone and estradiol (E2). (Youings et al, 2000; Fales et al, 2003). KS patients have been In the male, hyperestrogenemia may result from hepatic disease, described to have as much as a 50-fold increased risk of breast estrogen-producing tumors, or, most commonly, obesity. Sertoli or cancer development reinforcing the need for monthly breast self- Leydig cell testicular tumors and adrenal cortical tumors may examination and screening in this population (Swerdlow et al, rarely produce elevated estrogen levels. In the obese patient, eleva- 2005). They have also been noted to have an increased risk of tions in serum estrogen derive from elevated peripheral aromatiza- non-Hodgkin lymphoma and extragonadal mediastinal germ cell tion of androgen to estrogen occurring in adipose tissue via an tumors (Aguirre et al, 2006; Oates, 2008). The underlying hypo- aromatase enzyme. The level of serum androgen inversely corre- gonadism in KS patients predisposes them to the development of lates with the degree of obesity (Giagulli et al, 1994; Tchernof metabolic syndrome with the associated findings of abdominal et al, 1995). This provides the scientific basis for the use of selec- obesity, hyperlipidemia, diabetes mellitus, and cardiovascular tive medical therapy with aromatase inhibitors in men with disease with an associated increase in risk of mortality from reduced testosterone-to-estrogen ratios, which are discussed later diabetic or cardiovascular complications (Lanfranco et al, 2004; in this chapter. In the obese patient, weight loss and bariatric Ishikawa, 2008). surgery have been associated with improvements in endocrine Although most KS patients will present with azoospermia, rare profiles (Kaukua et al, 2003; Globerman et al, 2005), although cases of unassisted paternity in these patients exist, reinforcing the the ultimate effect on fertility remains subject to further study. need for careful semen analysis of centrifuged specimens to assess for severe oligospermia, or cryptospermia. The predominant tes- ticular histology in these patients is germinal cell aplasia with semi- Genetic Syndromes niferous tubular sclerosis, but there can be small areas of residual complete spermatogenesis. Advances in testicular biopsy tech- Disorders of Sex Chromosome Number niques including microsurgical dissection have allowed successful and Structure sperm retrieval in up to 69% of KS patients (Denschlag et al, 2004; Klinefelter Syndrome (47,XXY). KS, or 47,XXY male syndrome, is Gonsalves et al, 2005; Schiff et al, 2005). These techniques are the most common genetic cause of nonobstructive azoospermia covered in detail in Chapter 22. Sperm retrieved from KS patients (NOA), accounting for up to 10% of these cases (Oates, 2003; is associated with high fertilization rates with ICSI, although there Visootsak and Graham, 2006). It has been reported to occur in have been isolated reports of KS genotypes in offspring (Ron-El between 1:500 and 1:1000 live male births (Nielsen and Wohlert, et al, 2000; Komori et al, 2004; Okada et al, 2005). This reinforces 1991; Simpson et al, 2003). The majority of KS patients have a the need for all KS patients to be offered genetic counseling before pure 47,XXY karyotype due to nondisjunction during the meiotic proceeding with surgical sperm retrieval, both for their own health phase of the parental gametes, although 10% of patients are issues and the potential implications for offspring. mosaic if the nondisjunction occurs during the mitotic cell divi- 46,XX Male Syndrome. Also called the sex reversal syndrome, sion of embryogenesis (Therman et al, 1993). The extra X chromo- 46,XX male syndrome has an incidence of 1:20,000 male babies some may be of maternal or paternal origin, but advancing (de la Chapelle, 1972). Although sharing some similarities in pre- paternal age is a risk factor for sperm with an XY complement and sentation with KS including small testicular size, gynecomastia, subsequent KS offspring. The frequency of XY sperm was reported and azoospermia, these patients have shorter stature than average to be 10%, 31%, and 160% higher in men in their 30s, 40s, and men, an increased incidence of hypospadias, and normal levels of 50s, respectively, as compared with men in their 20s (Lowe et al, cognitive function (Vorona et al, 2007). In 90% of these patients, 2001; Eskenazi et al, 2002). the testis-determining (SRY) gene including a small distal portion Although the exact mechanism of the subfertility induced by of the short arm of the Y chromosome (Yp) has been translocated the supernumerary X chromosome remains to be defined, this to either one of the X chromosomes or to an autosome allowing karyotype results in severe spermatogenic and androgenic failure. differentiation of the bipotential gonads into testes (Schiebel In 1942 Klinefelter originally described a triad of gynecomastia, et al, 1997). In the remaining 46,XX men, the SRY gene is not hypergonadotropic hypogonadism, and infertility (Klinefelter identified and it is presumed that other Y-chromosome genes have et al, 1942). Since the original report, KS has been identified with translocated to an autosome (Rajender et al, 2006). Unlike KS a wide spectrum of clinical presentations. The most severe form patients, these men are missing the AZFa, AZFb, and AZFc genetic presents with delayed or absent puberty, incomplete virilization, regions, resulting in a complete absence of spermatogenesis. At and eunuchoid appearance. These patients tend to have tall, the current time, there are no reports of successful sperm harvest slender statures with long legs, narrow shoulders, and proportion- and testicular biopsy is not recommended for prognostic or thera- ately shorter torsos. Often they present for medical attention peutic purposes. during adolescence and may be placed on testosterone replacement 47,XYY Syndrome. Found in 0.1% of male births, the 47,XYY to induce puberty. On the other end of the developmental spec- karyotype is characterized by a normal male phenotype and endo- trum are patients who have adequate androgen levels to induce crine profile (Oates, 2002). This syndrome has been associated puberty but are noted to have KS during a fertility evaluation in with reduced intelligence and antisocial behavior, although its their adulthood. Both extremes of presentation share common mechanism has been controversial (Oates, 1997). These patients features of small testicular size (<8 to 10 mL testis volume), elevated typically retain some degree of spermatogenesis, although they serum gonadotropin levels, and azoospermia, although mosaic may have severe oligospermia or complete azoospermia. Fortu- patients may occasionally have rare sperm identified in semen. nately, only a small percentage of spermatogonia have an abnor- In addition to the detrimental effects on testicular function, KS mal genetic complement (0.35% 24,XY; 0.43% 24,YY) suggesting is associated with significant developmental, neoplastic, and meta- a low risk of genetic abnormalities in spontaneous or ICSI- bolic implications. Early studies suggested severe cognitive and derived offspring of these patients (Egozcue et al, 2000). It is still behavioral abnormalities in KS patients, yet more recent reports recommended that these patients receive genetic counseling have identified only mild cognitive impairment with speech and before any testicular sperm harvest or ART procedure. CHAPTER 21 ● Male Infertility 641

Noonan Syndrome. Noonan syndrome (NS) is commonly loci. The critical spermatogenic gene in the AZFb region is the referred to as male Turner syndrome because both syndromes share RNA-binding motif (RBM) gene, which produces an RNA-binding numerous clinical features. Unlike the female Turner syndrome protein localized to germ cell nuclei (Ma et al, 1993). Microdele- (45X0), the inheritance pattern for NS is autosomal dominant tion in the AZFc region is the most most commonly noted, in up with a normal 46,XY karyotype. Although the exact chromosomal to 13% and 6% of azoospermic and severely oligospermic men, locus remains to be determined, studies have implicated chromo- respectively (Reijo et al, 1996). The AZFc region is the location for some 12 in some cases (Jamieson et al, 1994; Robin et al, 1995). the Deleted in Azoospermia (DAZ) gene, which encodes an RNA- The syndrome is characterized by short stature, webbing of the binding protein noted primarily in spermatogonia (Saxena neck, cubitus valgus, pulmonary stenosis, hypertrophic cardiomy- et al, 2000; Collier et al, 2005). Isolated AZFc microdeletion por- opathy, low-set ears, and ptosis. Fertility may be normal, but 77% tends a better prognosis because more than 50% of azoospermic of these patients will have cryptorchidism with resulting sper- men will have successful sperm retrieval (Silber et al, 1998; Oates matogenic failure and elevated gonadotropin levels (Sharland 2002). et al, 1992). Considering the fact that Y chromosome microdeletions do not Y-Linked Microdeletions. Testing for Y chromosome micro­ have direct health implications to patients other than in the fertil- deletion is indicated in men with presumed nonobstructive ity arena, couples should receive genetic counseling before obtain- etiology of azoospermia and severe oligospermia (concentration ing and using surgically retrieved sperm for ICSI. The male < 5 million/mL) to assess the prognosis for surgical sperm retrieval offspring of these patients will be phenotypically normal but will and to assist genetic counseling for affected couples. Normal harbor the father’s microdeletion and thus are expected to have molecular anatomy of the Y chromosome is critical both for similar fertility challenges in their adulthood (Silber and Repping, gonadal development and function. The Y chromosome is an 2002). acrocentric chromosome with an off-center centromere creating asymmetric short (Yp) and long (Yq) arms incorporating 60 million Disorders of Internal Ductal Development base pairs (Morton, 1991). The Y chromosome has two important Congenital Bilateral Absence of the Vas Deferens. CBAVD repre- regions—the euchromatic zone, which includes Yp, the centro- sents the mildest phenotypic presentation of cystic fibrosis trans- mere, and the proximal portion of Yq, and the heterochromatic membrane conductance regulator (CFTR) dysfunction with cystic zone, which comprises the distal Yq. The heterochromatic region fibrosis at the severe end of the spectrum (Oates, 2008). The cystic does not appear to have transcriptional function, while the fibrosis (CF) gene is located on chromosome 7 and encodes for euchromatic zone has a number of important genetic loci that are CFTR, a membrane-spanning protein that assists transmembrane critical to the development of normal spermatogenesis (Fig. 21–9). chloride ion transport, which is critical for the maintenance of Of particular importance is the sex-determining region Y (SRY) epithelial-lined lumen. If only one CF allele is mutated, the patient gene located on Yp, which is critical in initiating the cascade that may present with CBAVD without the pulmonary and pancreatic converts the embryonic bipotential gonad to the eventual testis. manifestations described in classic cystic fibrosis. However, if both Deletions or mutations of critical areas of the Y chromosome alleles manifest mutations and critically reduce the CFTR reserve, may cause profound disruption of spermatogenesis. Early cytoge- patients may exhibit full-blown CF, although the degree of dys- netic analysis of infertile men suggested the presence of a specific function depends on the nature of the CF gene mutations involved. region on Yp termed the azoospermia factor (AZF), which is of para- CBAVD accounts for 6% of cases of obstructive azoospermia. mount importance for normal spermatogenesis (Tiepolo and The descriptive name incorporates only a portion of the associated Zuffardi, 1976). Subsequent advances in chromosomal molecular anomalies because these patients will also have a prominent caput mapping allowed the identification of three regions of Y- with absence of the distal two thirds of the epididymis, atrophy, chromosome microdeletion: AZFa, AZFb, and AZFc (Vogt, 1998). or hypoplasia of the seminal vesicles in addition to the character- Deletions in the AZFa region have been reported in 1% of men istic vasal agenesis. In the absence of seminal vesicle contribu- with nonobstructive azoospermia. This region contains two genes, tions, the ejaculate will be azoospermic with low volume (typically DDX3Y (also known as DBY) and USP9Y, which are felt to be <0.5 mL) and acidic pH (6.5) due to unbuffered scant prostatic important for normal spermatogenesis (Kamp et al, 2000). AZFa secretions. Although TRUS can be used to confirm the seminal microdeletion is associated with germinal cell aplasia histology of vesicle anomalies, the diagnosis of CBAVD can usually be made the testis, and current literature suggests that an attempt at testicu- on the basis of clinical and semen findings. Spermatogenesis is lar sperm retrieval (TESE) is not indicated because the success rate is normal and biopsy is not required unless undertaken for sperm poor (Blagosklonova et al, 2000; Hopps et al, 2003; Oates, 2008). retrieval for eventual ICSI. Renal anatomy is usually normal except Like AZFa, microdeletions in the AZFb region are uncommon in cases of non-CF mutation CBAVD, as discussed later. and are associated with poor surgical sperm retrieval success rates, Development of vasal agenesis is secondary to one of two especially if associated with concurrent microdeletion in other genetic transmission patterns, either CF gene mutation or aberrant development of the early mesonephric duct. Almost 80% of men with CBAVD will have at least one detectable CF mutation with more than 500 types identified to date (Claustres, 2005). The most common mutation observed in CBAVD patients is a three-base pair deletion called delta-508, which accounts for almost 70% of CFTR mutations (Kerem et al, 1989). In CBAVD men without identifiable CF mutation, the syndrome is probably secondary to yet unidentified CF mutations or to improper morphogenesis of the mesonephric duct. These patients should be screened with a renal imaging study because up to 40% will have renal agenesis Figure 21–9. Y chromosome with azoospermia factor (AZF) or fusion anomalies (Oates, 2002). Renal screening is not necessary region. for CBAVD patients testing positive for CF mutations. Clearly, all 642 SECTION VI ● Reproductive and Sexual Function

patients with CBAVD should have thorough genetic counseling that it be combined with calcium ionophore oocyte activation to before proceeding with fertility treatment. improve fertilization rates (Rybouchin et al, 1997; Kilani et al, Because spermatogenesis is usually normal in these patients, 1998; Dirican et al, 2007). sperm retrieval techniques via a percutaneous or open surgical Fibrous Sheath Dysplasia. Fibrous sheath dysplasia (FSD), also route from either the caput epididymis or testis are usually known as the Stump-tail syndrome, describes a malformation of the successful in extracting excellent quality spermatozoa for ICSI fibrous sheath investing the sperm tail, resulting in structural and (Phillipson, 2000). Cryopreserved sperm from these patients functional impairment (Rawe et al, 2001). Spermatozoa have a produce equally high pregnancy rates with ICSI similar to those distinctive morphologic appearance with coiled or markedly observed with fresh specimens (Oates, 1996). shortened tails and are immotile. Although the genetic basis of FSD has not yet been established, there are troubling reports that Ultrastructural Sperm Anomalies the sperm have higher rates of diploidy and sex chromosomal Primary Ciliary Dyskinesia. Primary ciliary dyskinesia (PCD), also disomy, suggesting the need for genetic counseling before pro- known as the immotile cilia syndrome, encompasses a spectrum of ceeding with fertility treatment (Baccetti et al, 2005; Moretti and disorders involving ultrastructural abnormalities of the flagellum Collodel, 2006). Despite these concerns, ICSI has been used suc- affecting all ciliated cells including the lining of the respiratory cessfully for patients with FSD (Olmedo et al, 2000). and sinus tracts, as well as sperm motility. Normal ciliary axone- mal structure involves a 9 + 2 microtubular arrangement with 9 Ejaculatory Dysfunction pairs surrounding a central doublet with axonemal bridges that connect the outer doublet to the central pair. Movement genera- Although an uncommon cause of male infertility, ejaculatory dys- tion requires intact ATPase function that localizes to the dynein function is responsive to a variety of therapies allowing restoration complex located in the peripheral doublets. Electron microscopy of fertility in most patients. Ejaculation is a complex process studies have demonstrated a variety of abnormalities in PCD requiring coordinated inputs from both the central and peripheral including absence of outer and inner dynein arms, radial spokes, neural systems to produce expulsion of semen from the urethra. and central doublet. Of these, the lack of both dynein arms is the There are three distinct phases of semen production: emission, most commonly observed deficiency (Rott, 1979). closure of the bladder neck, and ejaculation. In response to visual Typically, affected patients may rarely present with infertility or sensory erotic stimulation to the cerebral cortex, signals are as their initial complaint. They will rather initially present in child- conducted down the thoracolumbar sympathetic nerves, resulting hood with chronic bronchiectasis and sinusitis due to dysfunc- in contraction of prostatic smooth muscle, seminal vesicles, and tional movement of mucus through the upper airways and sinuses. the vas deferens and allowing deposition of pre-ejaculatory fluid Kartagener syndrome is a variant of PCD with three compo- into the posterior urethra, a process called emission. Bladder neck nents including chronic sinusitis and bronchiectasis, situs inver- closure occurs concurrently with emission in response to sympa- sus, and infertility as manifested by low or absent sperm motility. thetic innervations. Finally, semen is propelled in an antegrade The prevalence of PCD and Kartagener syndrome are 1 in 20,000 fashion from the posterior urethra in response to rhythmic con- and 1 in 40,000, respectively (McClure, 1997). Ciliary dyskinesia tractions of the periurethral and pelvic floor muscles. has also been described in association with retinitis pigmentosa, Various classifications of ejaculatory dysfunction have been presumably due to the axonemal support requirements of retinal described, but three broad categories account for most of the dis- cells (van Dorp et al, 1992). The genetic basis for PCD has been turbances observed in the infertile male: functional, neurogenic, elusive due to the heterogeneous nature of the syndrome and the and retrograde. multitude of substructures required for ciliary function. Most cases appear to be inherited in an autosomal recessive pattern, Functional Ejaculatory Dysfunction although there have been isolated reports of autosomal dominant Functional disorders include premature and delayed ejaculation. or X-linked transmission (Yokota et al, 1993; Narayan et al, 1994; Premature ejaculation (PE) is a common form of male sexual dys- Blouin et al, 2000). Diagnosis can be confirmed by electron function, occurring in more than 30% of men between the ages microscopy examination of ciliary axonemal structure. Although of 18 and 60 (Laumann et al, 1999). PE may cause significant there is no cure for the ultrastructural defects, sperm have been emotional distress in couples, yet the vast majority of patients will used successfully for ICSI with resulting normal births (Kay and still have intravaginal ejaculation minimizing the infertility impli- Irvine, 2000). Genetic counseling is highly recommended before cations of this condition. If ejaculation is consistently occurring pursuing ICSI in these patients. before intromission, semen may be collected by the couple and Globozoospermia. Globozoospermia, also called the round- used for intravaginal insemination at home. headed sperm syndrome, is an unusual condition noted in less than Delayed ejaculation is defined as persistent difficulty or inability 0.1% of infertile males (Dam et al, 2007a). Although sperm con- to ejaculate despite the presence of sexual desire and erection. No centration and motility are normal, spermatozoa have a charac- clear neurologic basis for this condition has yet been established teristic circular head due to the absence of the acrosomal cap and and it is widely believed to represent a psychogenic issue (Ohl enzyme package including acrosin. This deficiency prevents the et al, 2008). Some authors have described an association with sperm from penetrating the zona pellucida and outer investment strict religious upbringing and frequent use of masturbation of the oocyte and from obtaining fertilization. Morphologic (Stewart and Ohl, 1989; Perelman, 2006). Some men may benefit abnormalities have also been described in the nuclear chromatin, from sex therapy or vibratory stimulation to induce ejaculation, midpiece, and mitochondrial sheath. Familial studies strongly but many will require electroejaculation or surgical sperm retrieval argue for genetic transmission with some evidence suggesting a for eventual fertility. mutation in the SPATA16 gene, which is a spermatogenesis-specific locus, although the exact mode remains to be described (Carrell Neurogenic Anejaculation et al, 1999; Dam et al, 2007b). Standard ICSI has been successfully Neurogenic anejaculation is usually the result of a spinal cord used for these patients, although some authors have suggested injury (SCI). In addition to the ejaculatory dysfunction in these CHAPTER 21 ● Male Infertility 643

patients, many will also have erectile dysfunction and deficiencies ejaculates adequate for intrauterine insemination in 71% of men in spermatogenesis related to thermal dysregulation of the testes, with SCI and 87% of patients with anejaculation postretroperito- stasis of spermatozoa, and chronic genital tract infections. Oral neal lymph node resection (Ohl, 1989, 1995). therapies are rarely of value in these patients and most require Regardless of the etiology of anejaculation, surgical sperm penile vibratory stimulation (PVS), electroejaculation (EEJ), or retrieval via either percutaneous or open biopsy of the epididymis surgical sperm retrieval to circumvent the lack of ejaculation. or testis remains an effective option for management. One study Penile vibratory stimulation involves direct vibratory stimula- conducted a cost-benefit analysis of EEJ coupled with intrauterine tion of the penile frenular region using specially designed insemination versus ICSI using surgical sperm retrieval in SCI equipment. Specific vibratory parameters including a vibration patients, noting that EEJ was the cost-effective approach if the amplitude of 2.5 at 100 Hz appear optimal for ejaculation induc- procedure could be performed without anesthesia. However, in tion in SCI men (Sønksen, 1994). The best candidates for PVS are those patients requiring anesthesia for the EEJ, the cost-benefit patients with complete SCI who have an intact ejaculatory reflex analysis favored surgical sperm retrieval via local anesthetic fol- system: Specifically, patients with complete upper motor neuron lowed by ICSI (Ohl, 2001). lesions above T10 with preservation of sacral efferents, thoraco- lumbar sympathetic outflow, and intact communication between Retrograde Ejaculation sacral and thoracolumbar segments will exhibit the best response Retrograde ejaculation occurs when seminal fluid preferentially to PVS because approximately 70% of these patients will have flows into the bladder, instead of the normal antegrade direction ejaculation in response to treatment (Ohl et al, 1996; Bird et al, due to failure of the bladder neck to close. The diagnosis is con- 2001). Men with incomplete spinal cord lesions may have poor firmed by identification of 10 to 15 sperm per HPF in a centrifuged response to PVS because of cortical inhibition of the reflex arc specimen of postejaculation urine. The causes of retrograde ejacu- preventing ejaculation. In addition, patients with lower spinal lation include incompetence of the bladder neck usually from cord lesions or peripheral neural root injuries are unlikely to prior surgery such as transurethral resection of the prostate gland, respond to PVS. The most serious adverse event associated with medications including α blockers and antidepressants, and dis- both PVS and EEJ is autonomic dysreflexia, a massive sympathetic eases causing neurologic pathology such as diabetes and multiple discharge generally associated with SCI above the T6 level. Blood sclerosis. Before initiating therapy, potential reversible etiologies pressure monitoring is essential during any procedure on SCI such as medications should be removed if possible. In the absence patients. Men who are prone to autonomic dysreflexia may be of correctible etiologies, a trial of sympathomimetic medication given sublingual nifedipine, 10 to 20 mg 10 minutes before the therapy may be useful in increasing sympathetic tone of the procedure to minimize the blood pressure elevation (Steinberger bladder neck and vas deferens, especially in patients with slowly et al, 1990). In general, PVS is well tolerated and can even be progressive disease such as diabetic neuropathy or in those with performed by the patient at home in the absence of autonomic failure of emission due to disruption of retroperitoneal sympa- dysreflexia. Sønksen reviewed the efficacy of PVS in SCI men thetic innervation from prior surgery. Table 21–14 lists some of reporting 102 pregnancies in 619 couples using home vaginal the standard medication regimens described. Medical therapy can insemination or clinic intrauterine insemination (Sønksen and produce a spectrum of results including conversion of retrograde Biering-Sørenson, 1992). PVS remains the first-line therapy for SCI to antegrade ejaculation, increase in ejaculatory volume, and patients, producing better ejaculate quality than noted with EEJ development of retrograde ejaculation in a previously anejacula- procedures (Brackett et al, 1997; Ohl et al, 1997). tory patient (Brooks et al, 1980; Kamischke and Nieschlag, 2002). Electroejaculation may be used for SCI men who have failed a These regimens must be used judiciously because side effects trial of PVS and is usually effective for any level of spinal cord include tachycardia and hypertension, which may be particularly injury, as well as in men with anejaculation from a variety of other concerning in the diabetic patient at risk for occult cardiovascular mechanisms including retroperitoneal nerve injury from prior disease. surgery such as retroperitoneal lymphadenectomy, diabetic neuro­ Patients with retrograde ejaculation who do not respond to pathy, multiple sclerosis, spina bifida, and psychogenic anejacula- medical therapy may have sperm recovered from the bladder for tion. In the EEJ procedure, a rectal probe is inserted and pulsed use in intrauterine insemination as detailed earlier. With proper direct electrical stimulation is applied to induce ejaculation. preparation of the bladder to retain sperm viability and laboratory Although SCI patients often do not require an anesthetic during sperm processing, this technique is an effective and economical the procedure, men who retain normal pelvic and perirectal sensa- method of treatment (Van der Linden, 1992). tion will need general or spinal anesthesia. Because retrograde ejaculation often results, patients should have bladder catheteriza- Immunologic Infertility tion before the procedure to minimize urine contact with the ejaculate. In addition, instillation of a sperm-friendly buffered Immunologic mechanisms of infertility remain poorly understood medium into the bladder, systemic alkalinization with sodium and controversial, both in cause and treatment. The development bicarbonate, and hydration before the procedure will improve sperm survival in the bladder. Antegrade ejaculate is collected and the patient is again catheterized at the end of the procedure to Table 21–14. recover any retrograde ejaculate. Sigmoidoscopy is also performed Medication Regimens for Treatment before and after the procedure to evaluate for preexisting rectal of Retrograde Ejaculation pathology that could interfere with the EEJ procedure, as well as MEDICATION DOSE identify any injuries resulting from the electrical stimulation of the rectal wall. Rectal injuries are rare, occurring in less than 0.1% Phenylpropanolamine 75 mg po bid of EEJ procedures, but they require prompt identification and Ephedrine 25-50 mg po qid Pseudoephedrine 60 mg po qid or 120 mg po bid treatment to minimize morbidity (Ohl and Sønksen, 1997). Imipramine 25 mg po bid Electroejaculation procedures have been reported to produce 644 SECTION VI ● Reproductive and Sexual Function

of antisperm antibodies (ASA) results from a variety of conditions postfertilization development. Fertilization and cleavage rates that cause disruption of the blood-testis immune barrier, resulting with ICSI treatment appear to be similar in ASA-positive and ASA- in exposure of sperm antigens to the systemic immune system. negative men (Lahteenmaki et al, 1995). However, ASA may have Elevated levels of ASA have been associated with gonadal trauma, direct negative effects on developing embryos as manifested by testicular torsion, cryptorchidism, varicocele, genital infections, higher embryonic degeneration and miscarriage rates than those and prior testicular biopsy, although it has long been recognized observed in ASA-negative men (Naz, 2004). that many patients will have no clear inciting event (Ansbacher and Gangai, 1975; Koskimies and Hovatta, 1982; Witkin and Toth, Idiopathic Infertility 1983; Golomb et al, 1986). Prior vasectomy is a leading cause of clinically significant immunologic infertility with ASA develop- Despite the diagnostic advances in the field of male infertility, ment reported in 34% to 74% of vasectomized men and persisting more than 30% of patients will still have no discernible cause for in 38% to 60% after vasectomy reversal (Broderick et al, 1989; abnormal semen analyses (Nieschlag, 1997). Although it is antici- Francavilla et al, 2007). The potential detrimental effects of ASA pated that future developments will allow identification of the depend on the location of binding to the sperm and include etiology for subfertility in these patients, at present they are con- impaired sperm motility, reduced binding and penetration of the sidered idiopathic disorders that defy specific treatment recom- zona pellucida, inhibition of the acrosome reaction, and reduced mendations. In the absence of obvious causality, therapy involves sperm survival in the female reproductive tract. The degree of the employment of empiric medical therapy or assisted reproduc- fertility impairment is related to the amount of antibody binding, tive techniques to be discussed later. Empiric pharmacologic treat- with one series noting IVF fertilization rates of 27% in men with ments have usually involved endocrine agents, with a variety of 80% or more of sperm bound with IgG or IgA versus 78% in different tested therapies (Table 21–15). Although small series patients with less than 80% binding (Clarke et al, 1985). provide support for some empiric therapies, large placebo- A critical assessment of effective treatment options for immu- controlled trials are lacking in this area, further confounding deci- nologic infertility is hampered by a lack of controlled, prospective sion making in this difficult population, especially in the context studies and the absence of a standard definition of the disease. of a 26% background pregnancy rate for untreated couples Current treatment strategies use two main approaches: immuno- with abnormal semen parameters (Collins et al, 1983; Siddiq and suppressive therapy or assisted reproduction using laboratory Sigman, 2002). techniques to lower antibody levels. Immunosuppression using corticosteroid therapy remains the most commonly used thera- Empiric Medical Therapy peutic approach with reported pregnancy rates ranging from 6% Gonadotropin-Releasing Hormone Agonists. The justification for to 50% despite consistent reductions in antibody titers (Turek and use of gonadotropin-releasing hormone agonists (GnRHs) involves Lipshultz, 1994). Many different regimens have been employed the observation that these agents are effective for treatment of in uncontrolled studies, making it difficult to critically compare hypogonadotropic hypogonadism, implying that stimulation of results. Hendry conducted a 6-month randomized trial using high- FSH elevation may be beneficial even in the absence of known dose prednisolone given on days 1 through 10 of the female deficiency. Although multiple studies of empiric GnRH therapy partner’s cycle followed by a rapid taper over 2 days (Hendry have yielded conflicting results, two small controlled studies et al, 1990). Pregnancy rates were 31% in the treatment group failed to show significant improvements in semen parameters compared with 9% in the untreated men. A more recent double- (Badenoch et al, 1988; Crottaz et al, 1992). In addition, most blind, placebo-controlled study using methylprednisolone treat- studies have not shown significant increases in pregnancy rates, ment for three cycles reported a significant reduction in further reinforcing the conclusion that the expense of the therapy sperm-associated IgG titers but no significant improvement in is not justified by improvements in fertility outcomes. pregnancy rates in the treated group (Haas and Manganiello, 1997). Although therapy may be helpful in some patients, this therapeutic benefit must be weighed against the potential risks Table 21–15. of steroid treatment including fluid retention, bone loss, gastro- Empiric Pharmacologic Therapy intestinal bleeding, and aseptic necrosis of the femoral head (Naz, 2004). Gonadotropin-releasing hormone Assisted reproduction strategies for immunologic infertility Gonadotropins have centered on using semen processing techniques to attempt Luteinizing hormone (human chorionic gonadotropin) removal of ASA for IUI and IVF. Simple sperm wash and percoll Follicle-stimulating hormone (human menopausal gonadotropin) gradient methods of sperm preparation do not reliably remove Antiestrogens Clomiphene citrate ASA attached to the sperm surface (Haas and D’Cruz, 1988; Windt Tamoxifen citrate et al, 1989; Almagor et al, 1992). Despite the persistent presence of Aromatase inhibitors ASA after sperm processing, studies have suggested that IUI may be Testolactone an effective and economical treatment for ASA-mediated infertility Anastrozole in some couples. One series reported a pregnancy rate of 64% after Other three cycles of IUI in men with ASA who produced ejaculate into a Antioxidant vitamins sterile medium (Ombelet et al, 1997). These results were consider- L-carnitine ably better than the conception rates per cycle of 3% to 10% Kallikrein reported in ASA-positive men using untreated sperm (Haas,1991; Thyroid hormone Francavilla et al, 1992). Intracytoplasmic sperm injection appears Dopamine agonist for hyperprolactin-associated infertility Bromocriptine to be an effective treatment for ASA-mediated infertility when IUI Cabergoline fails, although there have been some concerning reports regarding CHAPTER 21 ● Male Infertility 645

Gonadotropins. Multiple studies employing various formula- not reported. Although these reports are intriguing, the expense tions to include hCG, hMG and recombinant forms of of these agents and the absence of large controlled studies will gonadotropins have yielded conflicting results. A Cochrane meta- limit use until further study. analysis suggested a modest 9% increase in pregnancy rates in the Antioxidant Therapy. With growing awareness of the role of oxi- 3-month GnRH treatment group over controls, although even this dative stress in idiopathic male infertility, antioxidant supplemen- analysis was underpowered to allow definitive assessment of tation has become a common form of empiric therapy. The impact due to lack of studies meeting selection criteria (Attia antioxidant vitamins α-tocopherol (vitamin E), ascorbic acid et al, 2006). Studies of GnRH treatment in men before ICSI (vitamin C), and the retinoids (vitamin A), as well as L-carnitine, have not shown significant improvements in pregnancy rates an amino acid important for mitochondrial metabolism, have all (Ashkenazi et al, 1999; Baccetti et al, 2004). been postulated to have therapeutic benefit for male subfertility. Antiestrogens. Antiestrogens remain the most commonly Various studies of antioxidant vitamin supplementation have employed medical therapy for idiopathic male infertility. The two yielded conflicting conclusions on both semen parameter and main formulations, clomiphene citrate and tamoxifen citrate, are pregnancy rate results (Suleiman et al, 1996; Rolf et al, 1999; nonsteroidal selective estrogen receptor modulators. By blocking Keskes-Ammar et al, 2003). More recent studies in infertile men the estrogen receptors at the hypothalamus and pituitary levels, with elevated levels of sperm DNA fragmentation revealed this class of agents minimizes the estrogenic-mediated inhibition improvements in fragmentation rates and increased rates of ICSI- of gonadotropin release, resulting in elevation of gonadotropin derived pregnancy following vitamin C and E supplementation levels. Numerous clinical trials with both agents have been con- (Greco et al, 2005a-c). Randomized double-blind studies examin- ducted with conflicting results. Although some controlled studies ing the effect of L-carnitine administration in men with idiopathic with clomiphene citrate have shown improvement in semen asthenospermia have yielded contrasting results on post-treatment parameters (Ronnberg, 1980; Wang et al, 1983; Micic and Dotlic, semen parameters, preventing definitive conclusions on the effi- 1985), others have failed to show significant changes (Abel et al, cacy of supplementation (Balercia et al, 2005; Sigman et al, 2006). 1982; Sokol et al, 1988; WHO, 1992). A meta-analysis of available studies did not reveal a significant improvement in pregnancy ASSISTED REPRODUCTION rates with clomiphene therapy (Liu, 2003). Similar randomized controlled trials using tamoxifen therapy have not conclusively Assisted reproductive techniques have become increasingly supported efficacy in either improved semen parameters or preg- popular for the management of idiopathic male infertility, unex- nancy rates (Torok, 1985; Krause et al, 1992). A Cochrane meta- plained infertility, or in cases in which no therapy is available or analysis combining 10 clomiphene and tamoxifen randomized has effectively resulted in conception. These techniques involve controlled studies failed to show improvements in pregnancy rates the manipulation of sperm, ova, or both in an attempt to improve with therapy (Vandekerckhove et al, 2000). A more recent study the chances of conception. Controlled ovarian hyperstimulation examined combination therapy with tamoxifen (20 mg/day) and is used to induce simultaneous development of multiple ova testosterone replacement (120 mg/day testosterone undecanoate) in females by giving oral clomiphene citrate or parenteral for patients with idiopathic oligoteratospermia, noting improve- gonadotrophins. ments in semen parameters and pregnancy rates (Adamopoulos et al, 2003). These results remain to be confirmed in other large Artificial Insemination controlled studies. Other investigators used clomiphene therapy for men with nonobstructive azoospermia, titrating the dose to Artificial insemination is an assisted conception method that can elevate serum testosterone levels to between 600 and 800 ng/dL be used to alleviate infertility in selected couples. The rationale (Hussein et al, 2005). In this noncontrolled trial, 64% had spon- behind the use of artificial insemination is to increase the gamete taneous return of sperm to the ejaculate with mean density of 3.8 density near the site of fertilization. Several different techniques million/mL. In those with persistent azoospermia, testicular biopsy have been used for artificial insemination. The original technique was successful in retrieving sperm for ICSI in all cases. used for more than a century was intravaginal insemination, Aromatase Inhibitors. Aromatase inhibitors suppress the activity where an unprocessed semen sample is placed high in the vagina. of aromatase, a cytochrome P-450 enzyme concentrated in the In the latter half of the 20th century, the cervical cap was devel- testes, liver, brain, and adipose tissue. Aromatase is responsible for oped to maintain the highest concentration of semen at the exter- the conversion of testosterone to estradiol, so blockade produces nal os of the cervix. It was soon discovered that placing the semen functional effects similar to the antiestrogen class of medications. sample into the endocervix (intracervical insemination) resulted Aromatase inhibitors have been postulated to have incremental in pregnancy rates similar to that obtainable using a cervical cap benefit over antiestrogens in patients with lower serum testoster- and superior to those seen with high vaginal insemination. one to estradiol ratios (<10) and in obese patients. Testolactone The effectiveness of artificial insemination has been clearly and anastrozole are the two main agents that have been used for established in specific subsets of infertile patients such as those the treatment of idiopathic infertility. Although one study using with idiopathic infertility, infertility related to a cervical factor, or testolactone noted improvement in semen parameters in men a mild male factor infertility (Keck et al, 1997; Cohlen, 2004). An with severe idiopathic oligospermia (Pavlovich et al, 2001), a con- accepted advantage of artificial insemination is that it is generally trolled crossover trial failed to identify treatment benefit over less expensive and less invasive than other assisted reproductive placebo (Clark and Sherins, 1989). A newer study by Raman exam- technology (ART) procedures (Goverde et al, 2000). The source of ined subgroups of infertile men with abnormal testosterone to semen for artificial insemination can be either from the woman’s estradiol (T/E2) ratios treated with either testolactone or anastro- male partner or a donor, who usually remains anonymous. In the zole (Raman and Schlegel, 2002). Men in both treatment groups past, the only available options for couples with severe male factor had significant improvements in their T/E2 ratios, sperm concen- infertility including severe oligospermia or failure to conceive tration, morphology, and motility, although pregnancy rates were using partner insemination were either donor insemination or 646 SECTION VI ● Reproductive and Sexual Function

adoption. Since the widespread availability of IVF using ICSI, Follicular development is monitored ultrasonically, and ova are many couples with severe male factor infertility have chosen to harvested before ovulation with the use of ultrasound-guided procreate their own genetic children using these techniques. needle aspiration. The recovered oocytes are mixed with processed However, donor insemination remains an option when IVF/ICSI semen to perform in-vitro fertilization. The developing embryos has been unsuccessful. Alternatively, many candidates for IVF/ICSI are incubated for 2 to 3 days in culture and then placed transcervi- initially choose donor insemination because it is less invasive and cally into the uterus. Generally, only 20% to 30% of transferred ultimately more likely to achieve pregnancy for couples with embryos result in clinical pregnancies. limited resources. Some women choose donor insemination Notwithstanding the broad success of in-vitro fertilization (IVF), because they are not candidates for IVF/ICSI. Perhaps the most failure to achieve fertilization still plagues a substantial group of obvious situation is women without male partners who seek preg- patients, with sperm abnormalities being the main culprit. In the nancy. The use of donor insemination is also indicated when the 1980s, several micromanipulation procedures were adopted from male partner has no viable sperm or when IVF/ICSI fails to achieve animal husbandry to assist gamete interaction, and this resulted fertilization. Finally, men with a known genetic disorder often in the development of intracytoplasmic sperm injection (ICSI), a choose donor insemination to avoid transmission to their procedure through which an oocyte can be fertilized indepen- children. dently of the morphology and/or motility of the single spermato- Thorough evaluation of all potential sperm donors other than zoon injected. The procedure was first used in cases of fertilization sexually intimate partners is necessary to avoid inadvertent trans- failure after standard IVF or when an inadequate number of sperm mission of sexually transmitted diseases or known genetic syn- cells were available. The consistency of fertilization independent dromes (ASRM, 1990). All donors should undergo a review of of the functional quality of the spermatozoon has extended the relevant medical records, personal and family history, and a physi- application of ICSI to immature spermatozoa retrieved surgically cal examination. Determination of normal semen characteristics from the epididymis and testis. Moreover, the need to denude the is extremely important. In addition, blood grouping and karyotyp- oocyte has allowed assessment of the nuclear maturity of the ing are performed. Each donor must be screened for risk factors oocyte. ICSI is also preferred in conjunction with preimplantation and clinical evidence of communicable diseases including human genetic diagnosis and has recently been used to treat HIV- immunodeficiency virus types 1 and 2; human T-lymphotropic discordant couples, where there is a pressing need to minimize the virus types I and II; hepatitis B and C; cytomegalovirus; human exposure of the oocyte to a large number of spermatozoa. For all transmissible spongiform encephalopathy (including Creutzfeldt- ages and with all the different sperm types used, fertilization after Jakob disease); Treponema pallidum; Chlamydia trachomatis; and ICSI is at approximately 70% to 80% and it ensures a clinical Neisseria gonorrheae. If the donor is deemed acceptable and is aware pregnancy rate of up to 45%. These results have made ICSI a pro- of the ethical and legal implications, semen can be collected. All cedure comparable in popularity with IVF and have minimized donor semen samples are cryopreserved and quarantined for 6 the need for couples suffering from all forms of male infertility to months. Before a donor sample is used for insemination, the resort to adoption or the use of donor sperm (Palermo et al, 2009). donor is retested and his eligibility is determined. Presently, there is no general consensus as to the best sperm preparation technique for IUI. In general, swim-up, simple sperm washing, density gradient centrifugation, and glass wool filtration Key Points methods all effectively produce adequate sperm samples. However, some preparation techniques appear better suited for particular l Male factor infertility accounts for almost 50% of types of samples; thus the technique chosen should be tailored to infertility. individual samples. The preparation techniques most commonly l There are three different approaches to treat male infertility used today are the double-density gradient centrifugation and the depending on the cause: glass wool filtration sperm washing techniques. These techniques s Treat the man to maximize his fertility have been shown to improve the number of morphologically s Extract sperm for use in assisted reproduction if optimiza- normal spermatozoa with grade A motility and normal chromatin tion is not possible condensation in the prepared sample (Erel et al, 2000; Sakkas s Use donor sperm or adoption and Tomlinson, 2000; Hammadeh et al, 2001). In addition, these l Comprehensive male factor evaluation is critical to identify techniques best reduce the amount of reactive oxygen species and factors that may affect the man’s health, as well as that of leukocytes in the prepared sample and provide spermatozoa with his offspring. minimal chromatin and nuclear DNA anomalies and high nuclear maturity rates. For semen samples with normal or near-normal sperm parameters, it has been shown that swim-up and density SUGGESTED READINGS gradient techniques result in higher pregnancy rates compared Agarwal A, Deepinder F, Cocuzza M, et al. Efficacy of varicocelectomy in with the washing, swim-down, and refrigeration/heparin tech- improving semen parameters: new meta-analytical approach. Urol niques (Carrell et al, 1998). For poor samples, the density gradient 2007;70(3):532–9. centrifugation and glass wool filtration techniques appear to be Agarwal A, Said TM. Role of sperm chromatin abnormalities and DNA superior. In cases of very low sperm counts, simple sperm washing damage in male infertility. Hum Reprod Update 2003;9(4):331–45. will recover the highest number of sperm, both motile and Aitken RJ, West K, Buckingham D. Leukocytic infiltration into the human ejaculate and its association with semen quality, oxidative stress, and nonmotile. sperm function. J Androl 1994;15(4):343–52. Bird VG, Brackett NL, Lynne CM, et al. Reflexes and somatic responses as In-Vitro Fertilization/ICSI predictors of ejaculation by penile vibratory stimulation in men with spinal cord injury. Spinal Cord 2001;39(10):514–19. IVF involves using controlled ovarian hyperstimulation to recruit Claustres M. Molecular pathology of the CFTR locus in male infertility. multiple oocytes during each cycle from the female partner. Reprod Biomed Online 2005;10(1):14–41. CHAPTER 21 ● Male Infertility 647

Dam AH, Feenstra I, Westphal JR, et al. Globozoospermia revisited. Hum Oates RD. The genetic basis of male reproductive failure. Urol Clin North Reprod Update 2007;13(1):63–75. Am 2008;35(2):257–70. Deepinder F, Cocuzza M, Agarwal A. Should seminal oxidative stress mea- Palmero G, Joris H, Devroey P, et al. Pregnancies after intracytoplasmic surement be offered routinely to men presenting for infertility evalua- injection of single spermatozoon into an oocyte. Lancet 1992;340(8810): tion? Endocr Pract 2008 May–Jun;14(4):484–91. 17–18. Donohue JP, Foster RS, Rowland RG, et al. Nerve sparing retroperitoneal Palermo GD, Neri QV, Takeuchi T, Rosenwaks Z. ICSI: where we have been lymphadenectomy with preservation of ejaculation. J Urol 1990;144(2): and where we are going. Semin Reprod Med 2009;27(2):191–201. 287–91. Samli H, Samli MM, Solak M, et al. Genetic anomalies detected in patients Evenson DP, Larson KL, Jost LK. Sperm chromatin structure assay: its clini- with non-obstructive azoospermia and oligospermia. Arch Androl cal use for detecting sperm DNA fragmentation in male infertility and 2006;52:263–7. comparisons with other techniques. J Androl 2002;23(1):25–43. Schiff JD, Palermo GD, Veeck LL, et al. Success of testicular sperm extraction Gargollo PC, Diamond DA. Current management of the adolescent varico- [corrected] and intracytoplasmic sperm injection in men with Klinefelter cele. Curr Urol Reports 2009;10:144–52. syndrome. J Clin Endocrinol Metab 2005;90(11):6263–7. Greco E, Scarselli F, Iacobelli M, et al. Efficient treatment of infertility due Sharma RK, et al. Relationship between seminal white blood cell counts to sperm DNA damage by ICSI with testicular spermatozoa. Hum Reprod and oxidative stress in men treated at an infertility clinic. J Androl 2005a;20(1):226–30. 2001;22(4):575–83. Guzick DS, Overstreet GW, Factor-Litvak P, et al. Sperm morphology, motil- Sigman M, Jarow JP. Endocrine evaluation of infertile men. Urology ity, and concentration in fertile and infertile men. N Engl J Med 1997;50(5):659–64. 2001;345(19):1388–93. Spira A. Epidemiology of human reproduction. Hum Reprod 1986;1(2): Haas Jr GG, Manganiello P. A double-blind, placebo-controlled study of 111–15. these of methylprednisolone in infertile men with sperm-associated Sussman EM, Chudnovsky A, Niederberger CS. Hormonal evaluation of the immunoglobulins. Fertil Steril 1997;47:295–301. infertile male: has it evolved? Urol Clin North Am 2008;35(2):147–55. Harris SE, Sandlow JI. Sperm acquisition in nonobstructive azoospermia: Vandekerckhove P, Lilford R, Vail A, et al. Clomiphene or tamoxifen for what are the options? Urol Clin North Am 2008;35(2):236. idiopathic oligo/astheno-spermia. Cochrane Database Syst Rev 2000;(2): Jeyendran RS. Sperm collection and processing methods: a practical guide. CD000151. Cambridge (UK): Cambridge University Press; 2003. p. viii, 160. WHO laboratory manual for the examination of human semen and sperm- Khera M, Lipshultz LI. Evolving approach to the varicocele. Urol Clin North cervical mucus interaction. 4th ed. Cambridge (UK): Published on behalf Am 2008;35(2):183–9. of the World Health Organization by Cambridge University Press; 1999. Kolettis PN, Sabanegh E. Significant medical pathology discovered during p. x, 128. a male infertility evaluation. J Urol 2001;166(7):178–80. Yamamoto M, Hibi H, Hirata Y, et al. Effect of varicocelectomy on sperm Lanfranco F, Kamischke A, Zitzmann M, et al. Klinefelter’s syndrome. parameters and pregnancy rate in patients with subclinical varicocele: a Lancet 2004;364:273–83. randomized prospective controlled study. J Urol 1996;155(5):1636–8. Mortimer D. The essential partnership between diagnostic andrology and modern assisted reproductive technologies. Hum Reprod 1994;9(7): REFERENCES 1209–13. The complete reference list is available online at www.expertconsult.com. Nallella KP, Sharma RK, Aziz N, Agarwal A. Significance of sperm charac- teristics in the evaluation of male infertility. Fertil Steril 2006;85(3): 629–34.