Update On Clinical Andrology
Volume 1 Issue 1 Winter 1995

A Newsletter addressing contemporary issues in male fertility and male sexual function

Editor:
BRUCE R. GILBERT,M.D.,PH.D.
Associate Professor of Urology - Cornell University Medical College
Associate Professor of Urology - SUNY at Stony Brook
Diplomate American Board of Urology
Diplomate American Board of Bioanalysis
Fellow American College of Surgeons
email: bruce.gilbert@verizon.net

INSIDE THIS ISSUE

Clinical practice: Is the evaluation of the male necessary in the age of microfertilization?

Laboratory practice: Semen analysis...how reliable are the results?

Late Breaking News:
Evaluating The Male In The Age Of Microfertilization-How much evaluation is necessary?

The number of spermatozoa required for fertilization in vitro continues to decrease. In fact, men without any spermatozoa and only mature spermatids, have fertilized their partners oocytes through the new technique termed ROSNI (round spermatid nucleus injection). This has led some to ask the question: Is evaluation of the male necessary? The answer should not only be a definitive "yes" but rather a resounding "even more than ever!"

The goal of fertility treatment should always be to assist the couple to conceive on their own. Assisted reproductive technology should be used as a secondary and not a primary treatment modality and certainly should not replace evaluation of either the male or female partner. 93% of men with significant medical pathology can be diagnosed by a comprehensive male evaluation (Fertil.Steril, 62:1028,1994). Thus a comprehensive evaluation is not only cost effective but also in the patient's best interest.

Advancements in the evaluation and treatment of male subfertility have paralleled those in gamete manipulation. For example:

Transrectal ultrasonography has allowed us to diagnose disorders of the seminal vesicles and ejaculatory ducts. Wide spread use of transrectal ultrasonography with prostate evaluation has alerted us to this common problem. These men have always presented with severely impaired semen quality, however the lack of an easy diagnostic modality has hampered diagnosis. Now men with primary or secondary obstructions of the ejaculatory ducts are easily diagnosed and treated, often with a significant improvement in semen quality and a return to normal fertility.

Refinements in semen analysis have significantly improved the clinical value of this test. 'Strict' morphologic criteria, an assortment of useful sperm function tests and a wide assortment of analytic instruments have greatly added to our understanding and treatment of men with impaired semen quality.

Advancements in microsurgical instrumentation and techniques have markedly improved the success rate of ductal reconstruction with vasovasotomy patency rates as high as 98% and vasoepididymostomy rates 70% (J.Urol.,154:2070,1995). In addition, the microsurgical formation of an epididymal sperm reservoir (of particular use with men with vas aplasia) has allowed percutaneous collection of sperm for IUI. Also, advancements in cryopreservation techniques have allowed intraoperative collection of sperm for later use in assisted reproduction procedures.

Therefore, evaluation of the male partner of a subfertile couple is essential and should be done together with evaluation of the female. With the multitude of sophisticated diagnostic procedures and therapeutic options available, we can offer encouragement to couples who wish for a biological child.
Semen Analysis.....How reliable are the results?

Semen analysis is often the first step in the evaluation of the subfertile male. However, how the test is performed as well as the experience of the laboratory performing the test is critical. One of the greatest difficulties in andrology today is how to define an impaired semen specimen. The two most commonly used standards are the WHO (World Health Organization) classification and Norfolk's 'strict criteria'. Using the 'strict criteria' the patient group that behaves normally in in vitro fertilization has greater than 14% normal forms. When the % normal forms is less than 14% two subgroups have been identified; those showing between 5 and 14% normal forms (a "G" or good prognosis pattern) and those demonstrating less than 4% normal forms (a "P" or poor prognosis pattern). The P pattern demonstrated the worse performance in in-vitro fertilization. Unfortunately, semen analysis is often performed by a commercial lab not familiar with these standards. Therefore, the reported results are at best lacking and at worse misleading.

In addition, an understanding of male reproductive physiology is essential to interpret the results and to make recommendations. Let me give two examples seen in my practice:

Mr. S was a 32 year old gentlemen referred to me for 3 years of primary subfertility. Three semen analyses from a large commercial laboratory demonstrated a low volume specimen with an extremely low count. Intrauterine inseminations (IUI) with this impaired semen specimen did not result in conception. We first performed a fructose test, which confirmed the presence of seminal vesicles, and a post ejaculate urine which diagnosed his retrograde ejaculation. Once this was determined, the total number of sperm used for IUI increased ten fold (by simply retrieving sperm from his post ejaculate urine). This resulted in a pregnancy after two cycles of IUI.

Mr. G was a 35 year old was treated for 3 months with antibiotics for a "prostate" infection diagnosed when two outside semen analyses determined his specimen to have a large number of "round cells," thought by that laboratory to be leukocytes. However, when the semen specimen was stained and examined to differentiate leukocytes from round germ cells, these "round" cells were, in fact, immature germinal cells. In addition, the prior analyses were reported to have 85% normal forms. When reviewed, there were over 40% of sperm with tapered heads. Clinical evaluation of this patient revealed a large varicocele which was corrected surgically with a marked improvement in semen quality.

Therefore, in order to get the most out of a semen analysis report make sure that your referral lab reports results as defined by one of the well accepted standards. In addition, the value of the report can be greatly enhanced by comments made by a knowledgeable laboratory director.

LATE BREAKING NEWS:

Japanese group obtains "Pregnancy and delivery after intracytoplasmic injection of an immobilized, killed spermatozoon into an oocyte" (J. Assist Reprod. Genetics,11:325,1994)

Round Cell Nucleus Injection (ROSNI) results in fertilization and birth from mature spermatids in men with maturation arrest (ASRM Annual Meeting; Seattle, Washington, Oct. 95).

Penile injection therapy becomes 'respectable' with FDA approval of Upjohn's Caverject, an injectable Prostaglandin E1 system for the treatment of erectile dysfunction.

Update on Clinical Andrology is a privately published, nonprofit newsletter. It's purpose is to update health care professionals and our patients on "state-of-the-art" issues relating to male fertility and male sexual dysfunction. Content is at the sole discretion of the editor. Please direct comments and/or articles for publication to the editor. Dr. Gilbert is a Urologist, whose private practice is limited to microsurgery, male subfertility and erectile dysfunction. He is also director of the Men's Fertility Laboratory, a licensed NYS Clinical Andrology Laboratory.