(State-of-the-art lecture on the topic of "Economic, Decision-making in Male Reproduction" was presented at the 2003 AUA meeting in Chicago on April 30, 2003. This article was originally published on AUANews, March 2003)
(The State-of-the-art lecture on this topic was presented at the 2003 AUA meeting in Chicago, April 30, 2003. This article was originally published on AUANews, March 2003)
Currently there are an estimated 6 million infertile couples in the United States alone, representing about 10% of adults of reproductive age. With appropriate evaluation male reproductive dysfunction is identified as the sole or contributing cause of subfertility in 50% of these couples. A small but clinically important subset of male patients is rendered subfertile as a direct result of previous medical or surgical therapy While in some instances iatrogenic decrease in male fertility is unavoidable (eg chemotherapy for malignancy), it frequently can be prevented.
Patients diagnosed with testicular cancer represent a particularly high risk group for iatrogenic impairment of fertility At baseline they have a higher incidence of semen abnormalities due to the disease itself with or without a history of cryptorchidism.1 Depending on clinical stage and histological findings, some patients will require adjuvant chemotherapy and/or radiotherapy, both of which may cause severe oligoasthenospermia or azoospermia. Because this toxicity may be irreversible, an patients requiring adjuvant therapy should be offered cryopreservation of sperm before treatment.
Other patients with testicular cancer may require retroperitoneal lymphadenectomy (RPLND) as part of the treatment regimen. During node dissection postganglionic sympathetic nerve fibers arising from the hypogastric plexus may be damaged, resulting in ejaculatory dysfunction, typically anejaculation. Use of a modified template dissection has been shown to preserve ejaculation in 80% to 90% of patients,2 and a meticulous nerve sparing dissection in skilled hands may decrease the risk of anejaculation even further. The risk of postoperative ejaculatory dysfunction is highest in patients who have received chemotherapy or who have bulky adenopathy clinical conditions that significantly increase the technical difficulty of the nerve sparing dissection.
Post-RPLND ejaculatory dysfunction, most commonly anejaculation, is typically managed with electroejaculation (EEJ). Occasionally retrograde ejaculation may be converted to antegrade ejaculation with the use of oral sympathomimetic medications. EEJ specimen quality may be adequate for intrauterine insemination. However, the relatively low monthly pregnancy rate (about 15%) and the need for general anesthesia with each EEJ prompt many couples to proceed directly to in vitro fertilization, a considerably more expensive but often more effective therapy.
Iatrogenic decrease in fertility potential has also been reported in patients who have undergone inguinal surgery, most commonly herniorrhaphy Ischemic atrophy of the testis is rare in primary repairs (less than 1%) but occurs in 5% of recurrent hernia repairs.3 Vasal obstruction, either by transection or more often compression of the inguinal vas, is far more common than vascular insult. Vasal transection is rare and, if recognized, may be treated with immediate microsurgical reconstruction. Vasal compression may result from improper intraoperative handling, improper mesh placement or delayed fibrosis of the mesh. To date no long-term studies on adult mesh hernia repair have investigated the effect of mesh on the inguinal vas, although case reports of inguinal obstruction from mesh herniorrhaphy have been published.4 Unfortunately attempts at vasal reconstruction are frequently futile secondary to extensive mesh related fibrosis and resultant devascularization of the vas.
Injury to the inguinal vas during pediatric hernia repair has been more clearly studied. Unilateral vasal injury occurs in approximately 10% to 15% of patients based on the reported 2% incidence of azoospermia in patients with a history of bilateral hernia repair in childhood.3 Unless the vasal defects are inordinately long, inguinal exploration and microsurgical reconstruction can be accomplished in the majority of cases. Because many of these patients have had long-standing obstruction, some may also require concomitant scrotal vasoepididymostomy for secondary obstruction.
Other inguinal surgeries of childhood, including orchiopexy and hydrocelectomy, are rarely associated with vasal injury. Scrotal surgery, either pediatric or adult, may also decrease fertility potential in male patients. During hydrocelectomy the vas or epididymis may be damaged inadvertently during plication of the tunica vaginalis. Rarely, a spermatocele or epididymal cyst may obstruct the epididymis before intervention but surgical excision of these lesions increases the risk of scarring and subsequent obstruction. Spermatocelectomy should be delayed until the patient is certain he no longer desires fertility.
In addition to surgical complications, some medical interventions can also inadvertently decrease male fertility. As mentioned previously, chemotherapeutic agents may temporarily or permanently damage the germinal epithelium. Hormonal therapy, typically testosterone, is occasionally incorrectly prescribed in an effort to improve sperm production. Normal spermatogenesis is dependent on adequate intratesticular levels of testosterone and well regulated pulsatile gonadotropin release. Exogenous testosterone replacement is occasionally prescribed in a misguided effort to increase intratesticular testosterone and, therefore, improve sperm production. However, exogenous testosterone use will reliably inhibit follicle-stimulating hormone and luteinizing hormone secretion, greatly decreasing or eliminating sperm production. Testosterone therapy is never an appropriate intervention in patients being treated for infertility. In patients in whom azoospermia develops during testosterone therapy prompt cessation of the hormone usually results in resumption of sperm production. Patients who are severely hypogonadal, including those with hypogonadotropic hypogonadism, should be treated with injectable gonadotropins in an effort to restore testosterone and sperm production.
Preservation of fertility may not be a critical concern for many patients being treated for serious medical conditions, especially malignancy. Nevertheless, iatrogenic reduction in fertility potential can often be prevented. Careful attention to surgical detail during retroperitoneal, inguinal and scrotal procedures can prevent inadvertent injury to sympathetic nerve fibers, vas deferens or epididymis. Because chemotherapy and/or radiotherapy may result in permanent sterility, it is imperative to offer sperm cryopreservation to all men before starting therapy. Fortunately, recent advances in urological microsurgery and assisted reproductive technology allow patients with even the most severe iatrogenic decrease in fertility to achieve paternity.
Reference:
1 Carrol, P. R, Whitmore, W. F, Herr, H. W. et al: Endocrine and exocrine profiles of men with testicular tumors before orchiectomy. J Urol, 137: 420, 1987
2 Richie, J. P.: Clinical stage I testicular cancer: the role of modified retroperitoneal lymphadenectomy. J Urol, 144: 160, 990
3 Wantz, G. E.: Complications of inguinal hernia repair. Surg Clin North Am, 64: 287,1984
4 Seifman, B. D., Ohi, D. A., Jarow, J. P. et al: Unilateral obstruction of the vas deferens diagnosed by seminal vesicle aspiration. Tech Urol, 5: 113, 1999
(The State-of-the-art lecture on this topic was presented at the 2003 AUA meeting in Chicago, April 30, 2003. This article was originally published on AUANews, March 2003)
2. Reviewing the Cover Page Article on the Journal of Urology, Vol.169,1924-1929, May 2003.- Microsurgical vasoepididymostomy: A prospective random study of 3 intussusception techniques in rats ( Peter TK. Chan, Philip S. Li and Marc Goldstein)
[For reviewing full text of this article please click this picture or "Cover Page Article" to PDF file of this article (fulltext.pdf)]
MICROSURGICAL INTUSSUSCEPTION VASOEPIDIDYMOSTOMY: TRICKS OF THE TRADE
Marc Goldstein, M.D., New York, NY
Peter T Chan, M.D., Montreal, PQ, Canada Philip S Li, M.D., New York, NY
Introduction and Objective: Microsurgical vasoepididymostomy is the most technically challenging procedure for the treatment of obstructive azoospermia. We present three techniques of intussusception microsurgical vasovasostomy that allow precise mucosal approximation and an atraumatic, leak-proof anastomosis.
Methods: The abdominal end of the vas is transected using a slotted-never-cutting clamp and an ultra-sharp micro-knife to provide a perfect transverse cut. In the triangulation technique, 3 double-armed 10-0 monofilament nylon sutures double-armed with 70 urn diameter fishhook shaped tapered needles are placed in a dilated epididymal tubule in a triangular fashion. In the two-suture technique, 2 sutures are placed in a transverse fashion in the epididymal tubule. In our new 2-suture longitudinal technique. 2 sutures are placed longitudinally in the tubule. To avoid collapse of the tubule due to leakage of fluid, each needle is left in the tubule without pulling through, until all needles are placed. Microdot-mapping technique is used by placing 6 evenly distributed microdots on the cut surface of the vas deferens for the 3 sutures technique and 4 for the 2 suture techniques, indicating the exit points of the mucosal sutures. The epididymal tubule is opened with a 15-degree microknife in the direction of the needles. The fluid is examined microscopically for sperm and cryopreservation. Upon tying the sutures, the epididymal tubule intussuscepts into the vasal lumen. The epididymal tunic and vasal sheath are approximated with 8-12 sutures of 9-0 nylon.
Results: The average operating time per anastomosis was 2 hours. The outcomes of the surgery in 54 consecutive men with obstructive azoospermia revealed a patency rate (sperm count > 10,000/ml) at 14 months post-op of 84%, with a crude pregnancy rate of 40%.
Conclusions: The advantages of the intussusception techniques over conventional end-side vasoepididymostomy are: 1) fewer micro-needles are required; 2) all needles can be easily placed in a distended epididymal tubule before opening. Furthermore, our longitudinal 2-suturc intussusception technique greatly simplifies the procedure and allows a larger epididymal luminal opening for anastomosis. Although a relative longer operating time and more meticulous techniques are required, a high patency rate and naturally conceived pregnancy rate are possible.
"This presentation is extremely well done with excellent visual presentation of the procedure. Congratulations on the production of this material. It is a first rate presentation!"
Arnold Belker, M.D.
Clinical Professor of Urology
Division of Urology
University of Louisville School of Medicine
Louisville, Kentucky
"These beautifully produced films are as close as you can get to being there, without actually sitting next to an experienced microsurgeon in the operating room."
Zev Rosenwaks, M.D.
Revlon Distinguished Professor of Reproductive Medicine
Director of the Center for Reproductive Medicine and Infertility
The Weill Medical College of Cornell University
"This is the ideal way to illustrate how this operation is performed. Any experienced urologists or urologists in training can benefit greatly from this teaching series."
E. Darracott Vaughan, M.D.
James J. Colt Professor of Urology and Chairman Emeritus of Urology
The Weill Medical College of Cornell University
