Male Infertility 6 Flashcards
Describe indications for and outcomes associated with microdissection testicular sperm extraction.
1
Q
What are some general principles of treatment of male infertility?
A
- Assisted reproductive techniques (IUI, IVF/ICSI) are often weighed against other forms of treatment
- Multiple factors come into play for patients as they make their decisions
- Financial, religious, social, moral, ethical considerations may enter the decision making process
- Clinicians should fully inform patients of all of their options and to guide them through this process.
- Female fertility specialists and male fertility specialists typically work together, taking both patients’ clinical status into account.
- Concurrent treatment or a multi-pronged approach has been shown in some instances to enhance fertility potential and potentially decrease the level of assisted reproductive techniques required. [i.e. varicocele ligation + IUI (Cayan et al 2002)].
2
Q
What are common medical treatments for male infertility?
A
- The mainstay of medical therapy involves treating endocrine disorders
- hCG and clomiphene citrate (off label use) are used to treat men with abnormally low serum testosterone levels; the aim is to thus increase intratesticular testosterone levels, which are typically 100-1000 times greater than serum levels
- Recombinant FSH is given to men with FSH deficits. Hyperprolactinemia is treated with carbergoline or bromocriptine
- Estradiol excess is treated with aromatase inhibitors (i.e. anastrozole, letrozole)
- Ejaculatory dysfunction is treated with sympathomimetic agents such as pseudoephedrine
3
Q
What is varicocele ligation and how does it treat male infertility?
A
- Dilation of the veins in the scrotal pampiniform plexus
- Disruption of spermatogenesis is primarily related to venous stasis with disruption of the scrotal countercurrent heat exchange mechanism
- This leads to overheating of the testis through a “radiator” effect from the engorged internal spermatic veins within the pampiniform plexus
- Ligation or embolization of the internal spermatic vessels corrects the venous stasis and thus often optimizes the pathophysiology
4
Q
What is the role of Transurethral Resection of Ejaculatory Duct(TURED) in treating male infertility?
A
- For men with documented ejaculatory duct blockage
- Much like a TURP, except one loop of tissue resected at the level of the ejaculatory ducts
- Outpatient surgical procedure
- Concurrent rectal pressure should be applied with extrusion of seminal vesicle fluid to demonstrate patency
- Can sample the fluid and inspect under microscope to detect sperm and thus demonstrate ejaculatory duct patency after TURED
5
Q
What is the role of testicular sperm extraction in treatment of male infertility?
A
- In the setting of azoospermia, sperm can be isolated from the male reproductive tract and subsequently used in the setting of IVF/ICSI to achieve pregnancies
- As noted below, this is the case whether the azoospermia is obstructive or nonobstructive in nature
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Nonobstructive Azoospermia: In the era of IVF/ICSI, even very low numbers of sperm can be sufficient to generate a pregnancy
- In patients with impaired spermatogenesis (testicular failure), sperm production in the testis can be very heterogeneous
- Patients may have rare and scant areas of focal spermatogenesis
- It is crucial to find these areas—sperm can be used for IVF/ICSI. Micro-TESE (Microdissection testicular sperm extraction) procedure now used → operating microscope helps identify normal looking seminiferous tubules
- Often like looking for a “needle in a haystack.” Sperm can be used fresh for IVF/ICSI or cryopreserved for later use in IVF/ICSI
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Obstructive Azoospermia: Sperm may be obtained from either the epididymis or the testicle and used in assisted reproductive techniques
- The key is to be “upstream” of the point of blockage in the male reproductive tract
- These procedures are typically office-based and can usually be performed under intravenous sedation and/or local anesthesia
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Nonobstructive Azoospermia: In the era of IVF/ICSI, even very low numbers of sperm can be sufficient to generate a pregnancy
6
Q
What is the role of intrauterine insemination in the treatment of male infertility?
A
- Typically requires at least 5 million total motile sperm
- Ejaculate is collected, processed (cleared of dead cells, debris), and inserted into partner’s uterus with a special catheter
- This is generally well tolerated, but success rates (overall 12-15% per attempt) are considerably lower than IVF/ICSI (overall 40-50% per attempt)
- Must consider the risk of multiple gestation pregnancies, especially with concurrent pharmacologic ovarian hyperstimulation in the female
- Often the first assisted reproductive technique used prior to IVF/ICSI due to lower cost, lower degree of invasiveness
7
Q
What is the role of In Vitro Fertilization(IVF)/Intracytoplasmic Sperm Injection(ICSI) in treatment of male infertility?
A
- The female is placed on ovarian hyperstimulation agents to drive the production of many follicles
- Oocytes are aspirated transvaginally from the follicles, and one sperm is injected into each egg to achieve fertilization and thus create an embryo
- Embryos are allowed to mature 3-5 days in laboratory incubator, then typically 1-2 embryos are replaced into the female’s uterus transvaginally with a special catheter
- Female age (i.e. age of the oocytes) is a critical factor in determining success
- Remaining or extra embryos can be cryopreserved for future use