Surgical treatment of male infertility in the era of intracytoplasmic sperm injection - new insights

Assisted reproductive technology is an evolving area, and several adjuvant procedures have been created to increase a couple's chance of conceiving. For male infertility, the current challenges are to properly accommodate old and new techniques that are both cost-effective and evidence-based. In this context, urologists are expected to diagnose, counsel, provide medical or surgical treatment whenever possible and/or correctly refer male patients for assisted conception. Urologists are sometimes part of a multiprofessional team in an assisted reproduction unit and are responsible for the above-cited tasks as well as the surgical retrieval of sperm from either the epididymides or testicles. We present a comprehensive review of the surgical treatment options for infertile males, including the perioperative planning and prognostic aspects, with an emphasis on the role of microsurgery in the optimization of treatment results. This review also discusses current techniques for sperm retrieval that are used in association with assisted reproductive technology and includes sperm retrieval success rates according to the technique and the type of azoospermia. New insights are provided with regard to each surgical treatment option in view of the availability of assisted conception to overcome male infertility.

Obstrucción de conductos eyaculadores / Ejaculatory duct obstruction

BACKGROUND: Prostatic cysts are rare lesions with a reported incidence from 1 to 7.9%. They have been associated with primary infertility. The main characteristic is the benign course and positive prognosis after correct surgical management. CLINICAL CASES: We present three clinical cases, two with primary infertility and another with a history of primary infertility who presented with recurrent hemospermia and refractory medical treatment. All patients had hypospermia and alteration of the seminal parameters represented by moderate oligospermia (MOS), asteno- and teratozoospermia, in addition to hemospermia in two patients. Diagnosis was confirmed by transrectal ultrasound. Transurethral resection (TUR) of the cyst was performed in two cases and resection of the veru montanum in one, obtaining improvement in the seminal parameters after 1 month of follow-up and acceptable parameters for spontaneous conception at 6 months. CONCLUSIONS: Infertility associated with partially obstructed ejaculatory ducts may be suspected clinically by hypospermia. Transrectal ultrasound is essential to confirm the diagnosis. TUR of this lesion reestablishes the free passage of semen in almost all patients, with potential recovery of fertility 6 months after treatment.

Morphology of male reproductive system in three species of Trypoxylon (Trypargilum) Richards (Hymenoptera: Crabronidae) / Morfologia do sistema reprodutor masculino em três espécies de Trypoxylon (Trypargilum) Richards (Hymenoptera: Crabronidae)

Variations in the adult male reproductive system among different groups of Hymenoptera offer characteristics that help studies on behavior and phylogenetics. The objective of this study was to describe the adult male reproductive system of three Trypoxylon (Trypargilum) species. For that, tissues were disseced, fixed in 2.5 percent glutaraldehyde in 0.1 M sodium cacodylate buffer, pH 7.2 and postfixed in 1 percent osmium tetroxide. The material was dehydratated and embedded for light and electron transmission microscopes. The species have similar reproductive systems, which are formed by a pair of testes, each one with three fusiforme follicles, from which emerges an efferent duct that later joins forming a deferent duct. The deferent duct opens into an ejaculatory duct. The first half of the deferent duct is enlarged and differentiated in a region specialized in sperm storage, the seminal vesicle. The accessory gland flows in the post-vesicular region of the deferent duct. The testes and vesicles are both covered with a conjunctive capsule. Sexually mature individuals have all spermatogenesis stages in their follicles. Sperms are released from testes in bundles which are disorganized inside seminal vesicles.

Variações no sistema reprodutor entre os diferentes grupos de Hymenoptera oferecem caracteres que auxiliam nos estudos de comportamento e filogenia. O objetivo deste trabalho foi descrever o sistema reprodutor masculino de três espécies de Trypoxylon (Trypargilum). Para isso, os tecidos foram dissecados, fixados em glutaraldeído 2,5 por cento em tampão cacodilato de sódio 0,1 M, pH 7,2 e pós-fixados em tetróxido de ósmio a 1 por cento. O material foi desidratado e incluído para microscopias de luz e eletrônica de transmissão. As espécies possuem os sistemas reprodutores muito semelhantes, formados por um par de testículos, cada um com três folículos fusiformes, a partir dos quais emerge um ducto eferente que depois se juntam formando o ducto deferente. O ducto deferente termina no ducto ejaculatório. A primeira metade dos ductos deferentes é dilatada e diferenciada em uma região especializada no armazenamento de espermatozóides, a vesícula seminal. A glândula acessória desemboca na região pós-vesicular do ducto deferente. Testículos e vesículas seminais são envoltos por uma única cápsula conjuntiva. Indivíduos maduros sexualmente apresentam todos os estágios da espermatogênese em seus folículos. Os espermatozóides são liberados dos testículos em feixes, os quais estão desorganizados na vesícula seminal.

Endorectal magnetic resonance imaging in persistent hemospermia

OBJECTIVE: To present the spectrum of abnormalities found at endorectal magnetic resonance imaging (E-MRI), in patients with persistent hemospermia. MATERIALS AND METHODS: A review of E-MRI findings observed in 86 patients with persistent hemospermia was performed and results compared with those reported in the literature. Follow-up was possible in 37 of 86 (43 percent) patients with hemospermia. RESULTS: E-MRI showed abnormal findings in 52 of 86 (60 percent) patients with hemospermia. These findings were: a) hemorrhagic seminal vesicle and ejaculatory duct, isolated (n = 11 or 21 percent) or associated with complicated midline prostatic cyst (n = 10 or 19.0 percent); b) hemorrhagic chronic seminal vesiculitis, isolated (n = 14 or 27 percent) or associated with calculi within dilated ejaculatory ducts (n = 2 or 4 percent); c) hemorrhagic seminal vesicle associated with calculi within dilated ejaculatory duct (n = 4 or 7.7 percent) or within seminal vesicle (n = 4 or 7.7 percent); d) non-complicated midline prostatic cyst (n = 6 or 11.5 percent); and e) prostate cancer (n = 1 or 2 percent). Successful treatment was more frequent in patients with chronic inflammatory and/or obstructive abnormalities. CONCLUSION: E-MRI should be considered the modality of choice, for the evaluation of patients with persistent hemospermia.

Ultrasonido transrectal como guía para el diagnóstico y tratamiento de la obstrucción de los conductos eyaculadores / Transrectal us for diagnosis and treatment of ejaculatory duct obstruction

Introducción: La infertilidad masculina es causada en el 10 por ciento de los casos por obstrucción de las vías seminales (ViS). Cuando la obstrucción ocurre a nivel de los conductos eyaculadores (OCE) la resección transuretral (RTU) del verumontanum resulta una terapéutica efectiva. El objetivo de este trabajo es demostrar la utilidad del ultrasonido transrectal (USTr) intraoperatorio y la inyección transrectal contrastada de las ViS bajo radioscopia (RX) para determinar la causa y localización de la OCE y facilitar la RTU guiando al resectocopio en forma precisa hacia el sitio de obstrucción. Material y métodos: Entre junio 2001 y abril 2004 se evaluaron 7 pacientes con sospecha de OCE. Todos presentaban examen físico normal, espermograma con hipospermia (5= oligospermia y 2= azoospemia) y dilatación de las vesículas seminales (ViS). La técnica consistió en la punción de la porción dilatada de las ViS y la inyección de contraste iodado y azul de metileno bajo USTr, RX y uretroscopia. Una vez determinado el sitio de obstrucción se realizó la RTU, cuyo trayecto y magnitud fueron determinados por el USTr. El éxito terapéutico fue determinado en base a la mejoría del espermograma. Resultados. En todos (7/7) se arribó a un diagnóstico, encontrándose quistes de la línea media (n=4) estenosis del conducto eyaculador (ECE) bilateral (n=1), unilateral (n=1) e hipotonía de VS (n=1). Excepto este último (obstrucción funcional) todos fueron sometidos a RTU sin complicaciones. En todos los pacientes tratados (6/7) los espermogramas mejoran a los valores deseados. Conclusión: El USTr es un método útil para determinar la causa y el sitio de obstrucción de las ViS. Permite guiar la punción diagnóstica y facilita la labor de la RTU determinando en forma precisa y tiempo real el sitio y trayecto a resecar. De esta forma se realizan cirugías dirigidas con menor área de resección y menor número de potenciales complicaciones

Histological and histochemical aspects of the penial glands of Girardia biapertura Sluys, 1997 (Platyhelminthes, Tricladida, Paludicola)

Girardia biapertura was described with sperm ducts penetrating the penis bulb, subsequently opening separately at the tip of the penis papilla and receiving the abundant secretion of penial glands. In the present work, the penial glands of this species have been histologically and histochemically analysed, and four types of secretory cells are distinguished. The openings of the penial glands into the intrabulbar and intrapapillar sperm ducts, designated here as intrapenial ducts, allow for the distinction between three histologically differentiated regions. The most proximal region possibly corresponds to the bulbar cavity of other freshwater triclads whereas the median and distal portions correspond to the ejaculatory duct. The proximal region of the intrapenial ducts receives mainly the openings of a secretory cell type (type I) that produces a proteinaceous secretion. A second type of secretory cell (type II) that secretes neutral mucopolyssacharides opens into the median region of the intrapenial ducts. The distal portion of the ducts receives two types of secretory cells (types III and IV) which secret glycoprotein and glycosaminoglycans, respectively. Types III and IV open also directly into the male atrium through the epithelium of the penis papilla. A comparison with the results presented here and those of other authors for species of Girardia is provided and the importance of the study of the penial glands for taxonomic characterisation of freshwater triclads is emphasised

Ultra-sonografia transretal no diagnóstico da obstruçäo ejaculatória em pacientes inférteis / Transrectal ultrasonography in the diagnosis of ejaculatory obstruction in infertile patients

A ultrasonografia transretal de próstata realizada em 47 pacientes inférteis foi anormal em 19 (40,45 por cento). Os achados foram anormais em 5 (55,5 por cento) de 9 pacientes azoospérmicos, em 6 (42,8 por cento) de 14 oligozoospérmicos e em 8 (33 por cento) de 24 normozoospérmicos. Näo havia diferença estatística significativa entre os volumes seminais dos pacientes com e sem anormalidades ultra-sonográficas. Cistos pélvicos únicos foram encontrados em 11 pacientes e associados a outras patologias em 2 outros; em 4 casos existiam apenas vesículas seminais anormais e os 2 últimos pacientes tinham somente anormalidades em dutos ejaculatórios. Conclui-se que a possibilidade de achados sujestivos de obstruçäo ejaculatória pelo exame ultra-sonográfico é mais esperada entre os azoospérmicos com volumes seminais baixos ou normais baixos, que entre os oligos e normozoospérmicos com essas mesmas características seminais

Linfadenectomía lumboaórtica radical con preservación de nervios y eyaculación / Radical lumboaortic lymphadenectomy with preservation of nerves and ejaculation

La Linfadenectomía lumboaórtica, como terapia del Ca de testículo no seminomatoso,ha sido cuestionada durante los últimos años por su iatrogenia (cercana al 100 por ciento) que consiste en la pérdida de la eyaculación. Desde 1988 se ha desarrollado una técnica de Linfadenectomía lumboaórtica radical bilateral con preservación por disección, de estructuras nerviosas responsables de la eyaculación, de acuerdo a un protocolo quirúrgico personal basado en los estudios anatómicos del Dr. Lange P. (2) y propuestas del Dr.Donohue J. (3). Se analiza los fundamentos y se describe la técnica desarrollada. Se presentan los resultados de una serie de 27 pacientes portadores de Ca. testicular no seminomatosos, de bajo estadío clínico, en que se efectuó Linfadenectomía con la técnica propuesta. Se conservó la eyaculación en el 100 por ciento de los pacientes. Se constató 29 por ciento de estadío II (metástasis linfática). No se ha registrado progresión abdominal de la enfermedad en observación de uno a seis años. Esta propuesta demuestra la factibilidad de conservar la eyaculación, sin perder el cárácter radical de la linfadenectomía lumboaórtica (L.L.A.), en el tratamiento de Ca de testículo no seminomatoso

Ausencia funcional de conductos eyaculadores / Functional absence of ejaculatory ducts

Se realizó un estudio retrospectivo de muestras de semen procedentes de 5 159 pacientes que se consultaron por infertilidad en un período de 8 años y 4 meses. En 188 casos se comprobó azoospermia (muestras seminales con ausencia de espermatozoides) y en 23 de los azoospérmicos se presentaron características seminales del síndrome de ausencia funcional de los conductos eyaculadores. Se compararon los valores bioquímicos del plasma seminal (fructosa, fosfatasa ácida, y glicerilfosforilcolina) de los pacientes con las características del síndrome con igual número de normozoospérmicos infértiles y azoospérmicos no obstructivos. Pudo comprobarse diferencia altamente significativa en los 3 indicadores (p < 0,005) entre los pacientes con el sídrome y los otros 2 grupos. Los resultados indican que estas determinaciones bioquímicas son útiles en el diagnóstico del síndrome sin necesidad de utilizar métodos quirúrgicos