Are boxer shorts really better? A critical analysis of the role of underwear type in male subfertility.

PURPOSE: Elevation of testicular temperature may result in arrest of spermatogenesis, abnormal semen parameters and sterility. It has been proposed that brief style underwear may produce scrotal hyperthermia and lead to clinical subfertility. Although this idea is regarded as dogma by many in the lay community and the changing of underwear type is a therapy frequently recommended by medical practitioners, there is a paucity of data measuring scrotal temperature as a function of underwear type. MATERIALS AND METHODS: Scrotal, core and skin temperatures were measured in 97 consecutive men presenting for evaluation of primary clinical subfertility. These cases were categorized by underwear type to boxer or brief group. Semen analyses were obtained in all patients. Individuals from each group were compared to ascertain differences in temperature when wearing and not wearing underwear. Baseline semen parameters also were compared. In 14 subjects (crossover group) underwear type was changed to the alternative type and scrotal temperature measurements were repeated. Literature regarding underwear type, testicular temperature and/or fertility was reviewed and critically analyzed. RESULTS: Mean scrotal temperature plus or minus standard deviation was 33.8 +/- 0.8 C and 33.6 +/- 1.1 C in the boxer and brief group, respectively. There were no significant temperature differences between the groups. Differential temperatures comparing core to scrotal temperature and semen parameters also were not significantly different. These observations remained constant in the crossover group. CONCLUSIONS: The hyperthermic effect of brief style underwear has been exaggerated. In our study there was no difference in scrotal temperature depending on underwear type. It is unlikely that underwear type has a significant effect on male fertility. Routinely advising infertility patients to wear boxer shorts cannot be supported by available scientific evidence.

Percutaneous testis biopsy: an alternative to open testicular biopsy in the evaluation of the subfertile man.

PURPOSE: We evaluated the safety and efficacy of percutaneous testis biopsy by comparing the ultrasound appearance and histological status of testicular parenchyma obtained to those noted after open testis biopsy. MATERIALS AND METHODS: A total of 51 consecutive infertile men with azoospermia or severely impaired semen quality, in whom ductal obstruction was suspected, underwent percutaneous (31) or open (20) testis biopsy, with 58 and 34 procedures performed, respectively. Scrotal ultrasound was performed preoperatively, and at 2 weeks and 1, 3 and 6 months after biopsy. In addition, immunoglobulins G and A antisperm antibody assays were obtained preoperatively and postoperatively. Two biopsy specimens were obtained from each testis for formal histological evaluation. A touch preparation was also performed and examined immediately for mature spermatozoa using phase contrast microscopy. RESULTS: All biopsies yielded adequate tissue for diagnosis and morphometric analysis. Of 58 percutaneous biopsies 4 (7%) demonstrated sonographic evidence of intratesticular bleeding, characterized by a hypoechoic region within the testicular parenchyma, which resolved by 6 months postoperatively. In contrast, 10 of 34 open biopsies (29%) showed evidence of intratesticular bleeding or a new area of increased echogenicity at 1 month after the procedure (intraparenchymatous scar). All intraparenchymatous scars persisted to 6 months postoperatively. No patient undergoing percutaneous or open testis biopsy had antisperm antibodies in the seminal fluid or serum (azoospermia cases) or on sperm postoperatively. Of the 32 and 20 patients undergoing percutaneous and open testis biopsy 3 (9%) and 14 (70%), respectively, required narcotic analgesia. All patients returned to routine activities within 24 hours after percutaneous testis biopsy. No postoperative infections or extratesticular hematomas were noted. Pathological study was diagnostic in all specimens. CONCLUSIONS: Percutaneous testis biopsy is well tolerated by the patient, with fewer apparent complications than and diagnostic value equal to open testis biopsy. Percutaneous testis biopsy should be considered an alternative to open biopsy.

Classification of male factor infertility relevant to in-vitro fertilization insemination strategies using mannose ligands, acrosome status and anti-cytoskeletal antibodies.

Polyvalent mannose ligands in the presence of free mannose act as zona pellucida agonists which rapidly induce acrosome exocytosis in competent motile human sperm from fertile donors following in-vitro capacitation. Quantification of the binding patterns of fluorescein isothiocyanate-labelled mannosylated albumins and of specific antisera which recognize mannose receptors and other related integral sperm membrane proteins as well as the incidence of induced acrosome exocytosis after capacitation has allowed us to identify three categories of male infertility. Category 1 males have normozoospermic semen parameters, their spermatozoa have elevated sperm cholesterol values and fail to fertilize oocytes in vitro after standard short-term incubations. These spermatozoa do not bind mannose ligands and do not show spontaneous or induced acrosome reactions, but treatments to remove cholesterol from the spermatozoa (e.g. prolonged incubation in the presence of sterol acceptors) confer the ability to fertilize. Cholesterol loading and unloading experiments have demonstrated the reversible character of sperm membrane properties in category 1 male infertility. Category 2 males have normal-appearing spermatozoa in semen which express mannose ligand receptors on incubation, but fail to undergo acrosome reactions in response to mannose treatment. Interestingly, all category 2 males identified in this study have clinical varicocele. Category 3 males have semen which may be normozoospermic or teratozoospermic with, in some cases, high percentages of tapering spermatozoa in the absence of clinical varicocele. Spermatozoa from category 3 men are deficient in a superfamily of integral membrane proteins whose cytoplasmic tails have myosin motors as identified by amino acid sequence analysis and anti-myosin antibody reactivity. Their spermatozoa do not express mannose ligand receptors or undergo induced acrosome reactions. Fertilization with category 2 and 3 semen is only achieved by micromanipulation procedures. These findings illustrate the practical application of basic research for infertility classification.

Cystic fibrosis gene mutations do not affect sperm function during in vitro fertilization with micromanipulation for men with bilateral congenital absence of vas deferens.

OBJECTIVE: To assess the effects of cystic fibrosis transmembrane-conductance regulator (CFTR) gene mutations on sperm function and fertility in men with bilateral congenital absence of the vas deferens. DESIGN: Prospective. SETTING: Division of urologic microsurgery and associated hospital-based IVF unit. MAIN OUTCOME MEASURES: Fertilization and pregnancy rates. PATIENTS: Men referred to our fertility unit for treatment of bilateral congenital absence of the vas deferens, using sperm surgically retrieved from the epididymis with IVF and micromanipulation. RESULTS: Of 45 men with bilateral congenital absence of the vas, 54% (19/35) tested were found to be carriers of CFTR gene mutations, with one compound heterozygote. Epididymal sperm from men affected with CFTR mutations fertilized 19% (29/152) of oocytes, whereas men without mutations fertilized 22% (44/204) of oocytes. Pregnancy rates (PRs) were 36% (5/14) for cycles involving men with CFTR mutations and 33% (5/15) for other patients with congenital absence of the vas deferens but without detectable CFTR mutations. CONCLUSIONS: The presence of detectable CFTR mutations does not affect fertilization rates or PRs for men with bilateral congenital absence of the vas deferens when IVF and micromanipulation are applied.

The effect of calcium ion channel blockers on sperm fertilization potential.

OBJECTIVE: To evaluate the effects of calcium ion (Ca2+) channel blockers on male fertility potential. DESIGN: A case comparison of the surface expression of mannose-ligand receptors on motile spermatozoa from 10 known fertile males and from 10 normospermic men taking Ca2+ channel blockers who were seeking infertility treatment. Examination of the effects of in vitro exposure of sperm from fertile donors (n = 14) to antihypertensive medications. SETTING: Patients from a successful university hospital-based IVF-assisted reproductive technology program and from a male urology private practice. INTERVENTIONS: Prescription of alternate hypotensive medications for four male patients; cholesterol loading and unloading in vitro of fertile donor sperm. MAIN OUTCOME MEASURES: Motile sperm were tested for their ability to bind fluorescein isothiocyanate-labeled, mannosylated bovine serum albumin as an index of the surface expression of mannose-ligand receptors associated with fertility potential. Acrosome status was simultaneously evaluated by fluorescence microscopy with rhodamine-labeled Pisum sativum lectin. Sperm were assayed before and after an 18-hour or 3-day incubation under capacitating conditions in vitro. RESULTS: Motile spermatozoa of normospermic men taking calcium antagonists for hypertension control do not express head-directed mannose-ligand receptors at high frequency, nor do they undergo spontaneous acrosome loss. Unexpectedly, mannose-ligand receptor translocation from the subplasmalemmal space over the acrosome to the sperm surface and aggregation over the equatorial-postacrosomal regions occurred in acrosome-intact sperm. This differs from fertile controls in whom receptor translocation to the equatorial-postacrosomal segment is coupled with the acrosome reaction (AR). Discontinuation of calcium antagonists results in complete recovery of parameters associated with sperm fertilizing potential: time-dependent increases in the percentages of spermatozoa exhibiting surface mannose-ligand binding and spontaneous ARs in vitro. The effects of in vivo administration of calcium antagonists is mimicked in control fertile donor sperm by inclusion of a Ca2+ channel blocker in the media employed during capacitating incubations. CONCLUSIONS: Therapeutic administrations of calcium antagonists for hypertension control cause reversible male infertility associated with an IVF failure. A mechanism of inhibition of sperm fertilizing potential through insertion of lipophilic calcium ion antagonists into the lipid bilayer of the sperm plasma membrane is consistent with our in vitro studies.

Epididymal micropuncture with in vitro fertilization and oocyte micromanipulation for the treatment of unreconstructable obstructive azoospermia.

OBJECTIVE: To provide fertility to couples in whom the man has surgically unreconstructable obstructive azoospermia. DESIGN: Prospective. SETTING: Hospital-based IVF unit, including associated division of urologic microsurgery. PATIENTS: Couples referred to our fertility unit for treatment of men with surgically unreconstructable reproductive tract obstruction, including congenital absence of the vas deferens. MAIN OUTCOME MEASURES: Fertilization, pregnancies, and live births. RESULTS: Of 51 cycles in which sperm and eggs were retrieved, 67% (34/51) resulted in fertilization and 27.5% (14/51) developed clinical pregnancy. Clinical pregnancy rate per couple was 33% (14/43). A total of 15 live births have been obtained in 11 couples with one ongoing pregnancy. Epididymal length was the best predictor of sperm quality and pregnancy results. For couples with at least the corpus epididymis present, 41% (9/22) of cycles resulted in clinical pregnancies. CONCLUSIONS: Pregnancy rates are optimized using sperm retrieved from the epididymis by micropuncture and when micromanipulation is available for use during IVF.

Microsurgical inguinal varicocelectomy with delivery of the testis: an artery and lymphatic sparing technique.

Conventional techniques of varicocele repair are associated with substantial risks of hydrocele formation, ligation of the testicular artery, and varicocele recurrence. We describe a microsurgical technique of varicocelectomy that significantly lowers the incidence of these complications. The testicle is delivered through a 2 to 3 cm. inguinal incision, and all external spermatic and gubernacular veins are ligated. The testis is returned to the scrotum and the spermatic cord is dissected under the operating microscope. The testicular artery and lymphatics are identified and preserved. All internal spermatic veins are doubly ligated with small hemoclips or 4-zero silk and divided. The vas deferens and its vessels are preserved. Initially, we performed 33 conventional inguinal varicocelectomies in 24 men without delivery of the testis or use of a microscope. Postoperatively, 3 unilateral hydroceles (9%) and 3 unilateral recurrences (9%) were detected. For the next 12 cases 2.5x loupes were used resulting in no hydroceles but another recurrence (8%). We then performed 640 varicocelectomies in 429 men using the microsurgical technique with delivery of the testis. Among 382 men available for followup examination from 6 months to 7 years postoperatively no hydroceles and no cases of testicular atrophy were found. A total of 4 unilateral recurrent varicoceles (0.6%) was identified. The differences between the techniques in the incidence of hydrocele formation and varicocele recurrence are highly significant (p < 0.001). No wound infections occurred in any men. Four scrotal hematomas (0.6%), 1 of which required surgical drainage, occurred in the group with microsurgical ligation and delivery of the testis compared to none with the conventional technique. Preoperative and postoperative semen analyses (mean 3.57 analyses per patient) were obtained on 271 men. The changes in sperm count x 10(6) cc (36.9 to 46.8, p < 0.001), per cent motility (39.6 to 45.7%, p < 0.001) and per cent normal forms (48.4 to 52.10%, p < 0.001) were highly significant. The pregnancy rate was 152 of 357 couples (43%) followed for a minimum of 6 months postoperatively. Delivery of the testis through a small inguinal incision provides direct visual access to all possible avenues of testicular venous drainage. The operating microscope allows identification of the testicular artery, lymphatics and small venous channels. This minimally invasive, outpatient technique results in a significant decrease in the incidence of hydrocele formation, testicular artery injury and varicocele recurrence.

Pathophysiology of the aging kidney.

It is the alterations in renal function associated with age that necessitate physicians treating geriatric patients to have an understanding of the fragile senescent kidney. This article examines the physiologic impact of the aging kidney on homeostasis and includes a discussion of altered pharmacodynamics occurring with impaired renal function. We also discuss the limitations of various quantitative methods of measuring renal function and present several "bedside techniques" for the assessment of renal function.

Correlation of sperm-bound immunoglobulins with impaired semen analysis in infertile men with varicoceles.

Sperm-bound immunoglobulins were found in 27 (32%) of 84 infertile men with palpable varicoceles. These men were divided into two groups based on the presence (group I; 32%) or absence (group II; 68%) of sperm-bound immunoglobulins, as measured by an enzyme-linked immunosorbent assay. Circulating antisperm antibodies were identified in 52% of patients with sperm-bound immunoglobulins and 14% of group II patients. The presence of sperm-bound immunoglobulins was associated with a small but significant decrease in both sperm concentration and motility. Sperm-bound immunoglobulins are present in a greater percentage of infertile men with varicoceles than infertile men without varicoceles. Their presence may be a marker for damage to the seminiferous epithelia in men with varicoceles and may also contribute to varicocele-associated infertility.

Intraoperative sonography: application in renal cell carcinoma.

Our ability to detect and potentially to treat renal tumors earlier has increased exponentially during recent years, in part owing to the introduction of more sophisticated imaging modalities. We report 2 cases in which intraoperative sonography was used to localize tumors not palpable at operation. In both cases surgery was performed on solitary kidneys for renal cell carcinoma in otherwise healthy patients.

Extracorporeal shock wave lithotripsy and its effect on renal function.

Extracorporeal shock wave lithotripsy has become a major treatment modality for symptomatic upper tract renal stone disease. Although proved to be effective in disintegrating stones the short-term and long-term effects on renal function are not yet known. We evaluated several basic physiological parameters, namely creatinine clearance, fractional sodium excretion, protein excretion and urine osmolality before and after extracorporeal shock wave lithotripsy in 26 consecutive patients in an attempt to quantitate changes in renal function. In addition, a 3 to 6-month followup study of patients showing excessive protein excretion with extracorporeal shock wave lithotripsy also is reported. Our data suggest that with extracorporeal shock wave lithotripsy transient nephrotic range proteinuria occurs immediately after treatment, returning to normal values within 3 to 6 months after treatment without a change in the glomerular filtration rate. The glomerular filtration rate increases after successful extracorporeal shock wave lithotripsy in patients with kidneys obstructed by the treated stone before the start of the procedure, and the kidney appears to maintain its ability to dilute urine and to conserve sodium after treatment.

New directions in male reproductive microsurgery.

During the past decade, microsurgery has become a urologic subspecialty. Historically, vascular and vasal anastomosis have formed the foundation of genitourinary microsurgery. With the advent of improved instrumentation and the interest of devoted urologic microsurgeons, a multitude of new applications of microsurgery in urology have developed. In this paper, we discuss some of the new directions in male reproductive microsurgery.

Indium-111 labeled leukocyte uptake: false-positive results in noninfected pseudoaneurysms.

Indium-111 (In-111) leukocyte scintigraphy was performed in two patients with postsurgical pseudoaneurysms as part of preoperative evaluation for evidence of graft infection. Despite positive In-111 uptake by the pseudoaneurysms, surgical and pathologic examinations failed to reveal any evidence of infection. The most likely explanation for the false-positive results is the labeling of "contaminating" platelets and erythrocytes in the leukocyte mixture. Caution must be exercised in interpretation of In-111 leukocyte scans in patients with postsurgical pseudoaneurysms.

Indium-111 white blood cell scan for infectious complications of polycystic renal disease.

This case report describes the localization of a unilateral renal abscess with [111In]oxine-labeled autologous leukocyte scanning in a febrile patient with polycystic renal disease, after other noninvasive imaging procedures failed to identify a source of infection. In polycystic renal disease, leukocyte scans have advantages over standard diagnostic modalities and are very helpful in planning appropriate therapy.