[Male fertility disorders. An actual and practical review]. / Andrologische Fertilitätsstörungen. Eine Bestandsaufnahme aus und für die urologische Praxis.

Because of both external and individual factors, nowadays more men seek clarification and consultation about their fertility. This article reviews the current diagnostic work-up of subfertile men and the evidence based treatment options. Also testicular biopsy and cryopreservation of sperm or testicular tissue are addressed. Finally, the issues of vasectomy reversal and aplasia of the vas deferens are discussed. The paper emphasizes practical issues and practicability in office urology.

History of the microscope and development of microsurgery: a revolution for reproductive tract surgery.

In the mid-1970s urologists in the field of paediatric and andrologic surgery felt that operating loupes did not provide sufficient magnification for their surgical work. Thus, urology finally introduced the operating microscope in the operating room, which was rather late in comparison to other surgical disciplines. Almost three decades later we can hardly imagine performing a vasovasostomy, a testicular autotransplantation or a penile reconstruction without the use of this sophisticated instrument. The following article from the history of medicine reveals the main steps in the technical development of the microscope, from early magnifying tools to the pioneering inventions of Carl Zeiss (1816-1888) and his successful company in Jena, Germany in the 19th century. Finally, the clinical application of microsurgery in the 20th century is described, focusing on reconstruction of the reproductive tract in andrology and gynaecology.

A questionnaire-based outcome analysis of the Stamey bladder neck suspension procedure for the treatment of urinary stress incontinence: the Hannover experience.

OBJECTIVES: To evaluate the long-term continence rate, including subjective satisfaction and therapy-associated morbidity, of patients undergoing Stamey bladder neck suspension. PATIENTS AND METHODS: Eighty-five women (median age 55 years, range 30-85) with urinary stress incontinence treated by Stamey bladder neck suspension at our institution between 1987 and 1995 were evaluated using an anonymous questionnaire over a mean (range) follow-up of 61 (13-93) months. RESULTS: Of the 85 patients, 44 (52%) reported an improvement in clinical symptoms at the evaluation and 29 (34%) were completely continent after the Stamey procedure. However, 53 (62%) patients reported subjective satisfaction with the result, because they had a durable improvement in continence for a mean (range) of 44 (10-79) months. There was no correlation between the number of previous urogynaecological operations undergone by the patients and the success of the Stamey procedure. However, the frequency of complications other than urinary retention was significant during and after surgery, at 27%, and in accord with the complication rate reported in earlier studies. CONCLUSIONS: Compared with other bladder neck suspension procedures, e.g. Burch colposuspension, the Stamey procedure appears to be associated with a higher frequency of postoperative recurrent urinary stress incontinence. Therefore, the Stamey procedure should only be used if the patient demands a minimally invasive surgical procedure for bladder neck suspension. Although approximately equal to 60% of patients were satisfied with the durable improvement in clinical symptoms, it is appropriate to inform patients before surgery of the high recurrence rate after Stamey bladder neck suspension.

Tasks of surgical andrology in current interdisciplinary reproductive medicine.

Although the controversy about varicocele treatment options and their benefit has not been resolved, evidence is increasing that a cautious use of varicocele surgery contributes to effective management of male factor subfertility. Moreover, timely varicocele treatment might be an equally valuable prevention of later subfertility as early treatment of cryptorchidism. In reconstructive surgery of the ductal system, a more frequent use of tubulovasostomy can prevent initial failure. Furthermore, the cryopreservation of spermatic fluid for intracytoplasmic sperm injection can obviate a repeat procedure, if patency is not reached with surgery. The surgical andrologist is also the 'retriever' of sperm cells for assisted reproduction in cases of irreparable damage of the male reproductive organs. Efforts to delimit critically the indications and the results of the different techniques with large multicentre and interdisciplinary studies should be emphasized. Finally, it is encouraging that andrology does not rely solely on the successes and possibilities of assisted reproduction, but continues to inquire into the causes of male subfertility (e.g. by implementing immunohistochemical techniques into clinical research).

Rejuvenation in the early 20th century.

The first theoretical reflections concerning the relation of hormone production with the ageing process stemmed from Charles Edouard Brown-Séquard (1817 1894). At the age of 72 years he experimented on himself with an injection of animal testicular extract. The Viennese physiologist Eugen Steinach (1861 1944) gained world-wide acknowledgement for his theory of 'autoplastic' treatment of ageing. He deduced that after vasoligation, an increased incretory hormonal production would ensue following the cessation of the secretory output of the gonads. The first operation was performed in 1918 and resulted in a vasectomy boom over the next two decades. The Russian Serge Voronoff (1866 1951), working in Paris, was one of the first to transplant testicular tissue from a monkey into a human reproductive gland in 1920. Five years later he had already performed this procedure on 300 patients and attracted patients from all over the world. In America early efforts of human testicular transplantation were performed by Frank Lydston and V.D. Lespinasse. Steinach's vasoligation was taken over by many American doctors, e.g., Harry Benjamin and Charles H. Chetwood. Among the patients who underwent a rejuvenation operation according to Steinach's method were Sigmund Freud (1856 1939) and the Irish poet and Nobel Prize winner William Butler Yeats (1865-1939). Two caricatures from the German magazine Simplicissimus published in 1927, confirm that the rejuvenation operations were constantly in the limelight of the printed media. From 1935 onwards rejuvenation operations gradually lost their appeal due to the introduction of artificial androgens.

Vacuum erection device in spinal cord injured men: patient and partner satisfaction.

OBJECTIVE: To assess the efficacy of and patient and partner satisfaction with a vacuum erection device (VED) to treat erectile dysfunction of spinal cord injury. DESIGN: Case series. SETTING: University hospital outpatient clinic. PATIENTS: Twenty spinal cord injured men with erectile dysfunction and their heterosexual partners, recruited from outpatient population and by advertisement. INTERVENTION: Use of a VED to obtain erections for sexual activity. MAIN OUTCOME MEASURES: Efficacy in obtaining adequate penile erection, and patient and partner satisfaction with the device (survey). RESULTS: At 3 months, 93% of the men and 83% of the women reported rigidity sufficient for vaginal penetration, with an average duration of 18 minutes. These numbers decreased somewhat at the 6-month control. At 6 months, 41% of the men and 45% of the women were satisfied with the device, with premature loss of rigidity during intercourse the most commonly reported complaint. Sixty percent of men and 42% of women indicated an improvement of the sexual relationship. Minor side effects, such as petechiae and penile skin edema, occurred frequently, but there were no complications that required treatment. CONCLUSION: The VED is effective in many couples in the treatment of erectile dysfunction associated with spinal cord injury. The devices were not universally accepted, but had a significant impact on sexual activity and sexual satisfaction for nearly half the couples. Vacuum erection devices should be presented to SCI men along with other options for treatment of erectile dysfunction.

Successful combination of transrectal electroejaculation and intracytoplasmic sperm injection in the treatment of anejaculation.

We describe the case of a couple whose infertility was caused by the absence of seminal emission following retroperitoneal surgery for testicular cancer. Ejaculate could be retrieved from the husband by rectal probe electroejaculation (RPE) but sperm quality was so poor that conventional in-vitro fertilization was impossible. With intracytoplasmic sperm injection of spermatozoa retrieved by RPE - a combination not reported previously - we were able to induce a pregnancy with successful outcome.

Use of assisted reproductive techniques for treatment of ejaculatory disorders.

Ejaculatory disorders can interfere with the fertility of young adults who suffer from spinal cord injury, have type I diabetes mellitus or have undergone retroperitoneal or intrapelvic operations. Following an overview of causes and treatment of ejaculatory disorders, the data of our centre are presented. From a group of 37 patients with genuine loss of seminal emission, 15 men and their wives were offered a combined treatment of rectal probe electro-ejaculation and artificial reproductive techniques. No serious complications occurred. During 40 cycles with intracorporeal insemination and 11 cycles with extracorporeal fertilization techniques, seven pregnancies were achieved, representing a pregnancy rate of 46% per couple and 14% per cycle for all cycles. Five healthy children were born, all following extracorporeal insemination. The 'take-home baby rate' for this population and for this technique is 45%. In vitro fertilization (IVF) led to one birth, intracytoplasmic sperm injection (ICSI) achieved four live births out of three pregnancies, one being a twin gestation. Since our successes are due to the use of extracorporeal insemination techniques, these are now incorporated in a new, more rational treatment protocol.

MESA and TESE: experiences of the German section of urological microsurgery.

The introduction of microsurgical epididymal sperm aspiration (MESA) and testicular sperm extraction (TESE) followed by intracytoplasmic sperm injection (ICSI) has enlarged the therapeutic options for irreparable azoospermia. After standardization of the indications and surgical procedure, the German section for urological microsurgery combined the data of all groups performing assisted reproduction. The indication for MESA or TESE is given in cases of congenital aplasia of the vas deferens, irreparable obstruction of the reproductive tract, failure after refertilization, in combination with tubulovasostomy for subsequent cryopreservation and for conservatively untreatable ejaculatory disturbances. Until October 1995, 87 couples were treated by MESA and conventional IVF; the embryo transfer rate (ET) was 4.6%, the pregnancy rate 1.1%. One child (1.1%) was born. 179 couples were treated by MESA and ICSI, the ET was 68.2%, the pregnancy rate 18.4%, and 11 children (6.1%) were born. TESE in combination with ICSI was performed in 65 cases, the ET was 84.6%, the pregnancy rate 23.1% and 6 children (9.2%) were born. Modern technological developments in reproductive medicine and increasing experience in andrological surgery have stabilized the position of interdisciplinary therapeutic concepts for the treatment of infertile couples.

[Fournier's gangrene. Experiences and changes in the disease picture since its initial description]. / Die Fournier'sche Gangrän. Erfahrungen und Veränderung des Krankheitsbildes seit der Erstbeschreibung.

Fournier's disease mostly occurs in immunosuppressed men in the 5th to 7th decade of life. Bacteria from the urogenital or colorectal tract lead to a rapid spreading soft tissue infection. Painful scrotal or perineal swelling and a black spot as a sign of beginning necrosis are guiding symptoms. Involved bacteria are grampositive cocci, enterobacteriaceae and anaerobes. Main principles of therapy are immediate radical debridement and broad spectrum antibiotics. Sepsis renders the prognosis more infaust.

Electroejaculation does not impair sperm motility in the beagle dog: a comparative study of electroejaculation and collection by artificial vagina.

Sperm samples obtained by electroejaculation (EEJ) in men with anejaculatory infertility have a markedly lower quality than those obtained by normal ejaculation. An electrical effect of the EEJ procedure has been implicated by some investigators as a direct cause of low sperm quality. To determine whether the EEJ procedure causes direct sperm damage, we compared ejaculates obtained from dogs by EEJ and by artificial vagina (AV). In seven adult beagle dogs, semen was collected weekly, alternating between the two procedures. The average (antegrade) sample from AV had a volume of 2.6 ml., sperm concentration of 150.1 x 10(6) per ml., total sperm count of 381.7 x 10(6) and motility of of 26.3%. The average antegrade sample from EEJ had a volume of 1.8 ml., a concentration of 129.6 x 10(6) per ml., a total sperm count of 166.8 x 10(6) and a motility of 30.1%. Of these differences only the total sperm counts and the total motile sperm counts were statistically significant (p < 0.05). There were no significant differences between the antegrade motilities, total sperm counts (antegrade plus retrograde-381.7 versus 243.4 x 10(6), for AV and EEJ, respectively) or the total motile sperm counts from the two procedures (103.9 versus 78.0 x 10(6)). There were no differences in the average curvilinear velocity (VCL) measured by computer-assisted sperm motion analysis (56.9 mu. per second for AV, 47.4 mu. per second for antegrade EEJ specimens and 41.7 mu. per second for retrograde EEJ specimens). Since routine semen parameters between artificial vagina and electroejaculation did not differ in dogs, we conclude that the electroejaculation procedure is not responsible for the gross semen abnormalities reported in electroejaculation of anejaculatory men.

Orchitis following mumps vaccination in an adult.

An acute epididymo-orchitis, followed by a viral arthritis of the left hand, occurred as complications of a mumps vaccination. In the last 17 years 4 certain cases of orchitis following vaccination have been published in Germany. We describe an additional case and discuss the possible consequences.

The management of penile Mondor's phlebitis: superficial dorsal penile vein thrombosis.

Superficial dorsal penile vein thrombosis was diagnosed 8 times in 7 patients between 19 and 40 years old (mean age 27 years). All patients related the onset of the thrombosis to vigorous sexual intercourse. No other etiological medications, drugs or constricting devices were implicated. Three patients were treated acutely with anti-inflammatory medications, while 4 were managed expectantly. The mean interval to resolution of symptoms was 7 weeks. Followup ranged from 3 to 30 months (mean 11) at which time all patients noticed normal erectile function. Only 1 patient had recurrent thrombosis 3 months after the initial episode, again related to intercourse. We conclude that this is a benign self-limited condition. Anti-inflammatory agents are useful for acute discomfort but they do not affect the rate of resolution.

Motility longevity of sperm samples processed for intrauterine insemination.

This study demonstrates that sperm from men with male factor infertility and sperm obtained by electroejaculation have reduced motility longevity when compared with normal specimens. After 24 hours, normal samples lost only 34% of initial motility, whereas male factor patients lost 48%, and electroejaculation patients dropped 66%. Based on these data and previous clinical studies of insemination timing, it is recommended that sperm retrieval and artificial insemination for male factor infertility, especially when electroejaculation is necessary, be performed 24 to 36 hours after urinary detection of the LH surge or as close to the time of ovulation as possible.

Fertility of spinal cord injured males: effect of genitourinary infection and bladder management on results of electroejaculation.

Thirty-eight men undergoing electroejaculation (EEJ) procedures for anejaculatory infertility were examined for the presence or absence of infection in urine and semen. In 29 spinal cord injury patients, a high incidence of infected urine and infected semen (41% and 56%, respectively) was seen, in contrast to patients with normal bladder function (0% and 11%). Urinary infection was associated with slightly lower sperm quality and lower pregnancy rates (10% vs 30% in the presence of sterile urine). Semen infection had no effect on sperm counts or pregnancy rates. If intermittent self-catheterization (ISC) was used to empty the neurogenic bladder, slightly better sperm quality was seen, the total failure rate was less, and much better pregnancy rates (44%) resulted than for patients using an alternative bladder management (7%). Antibiotics did not reduce the incidence of urine or semen infection, but did improve sperm counts slightly. Continuous prophylaxis was associated with bacterial resistance to many oral antibiotics and had no advantage over a short course of antibiotics prior to the procedure. Despite the above associations, the sperm quality in our patient population was never normal compared with that of men who ejaculate normally. We conclude that the low sperm quality seen in electroejaculation specimens from spinal cord injured males is not due entirely to infection or to the type of bladder management. Short courses of antibiotics, instead of continuous antibiotic prophylaxis, may be beneficial. Intermittent catheterization is superior to other methods of neurogenic bladder management in maintaining the fertility of spinal cord injured men.

Functional characteristics of sperm obtained by electroejaculation.

Sperm obtained by electroejaculation in 32 anejaculatory men were examined for functional characteristics. Raw specimens showed high sperm counts but motility averaged only 11%. Average viability was 10% for antegrade and 5% for retrograde fractions. Bovine cervical mucus penetration was normal (30 mm. or more in 30 minutes) in only 24% of the electroejaculation samples but it was normal in all of the donor samples tested. Processed sperm motility averaged 30% with 71% forward progression. At 20 hours patient samples retained 46% of the original motility, while donor controls retained 81%. In the hamster egg penetration assay patient sperm penetrated 14% of the oocytes while donor sperm penetrated 40%. Therefore, we identified 4 characteristics of sperm obtained by electroejaculation: 1) low viability, 2) poor survival after overnight incubation, 3) moderately impaired cervical mucus penetration and 4) moderately poor fertilizing capability as measured by the hamster egg penetration assay. Poor sperm survival and impaired function may explain the low pregnancy rates from insemination with electroejaculated sperm.

Treatment of anejaculation with electroejaculation.

Male infertility caused by anejaculation is common after spinal cord injury (SCI) and following retroperitoneal lymph node dissection (RPLND) for testicular cancer. Other conditions sometimes associated with neurogenic ejaculation loss are diabetes mellitus, multiple sclerosis, extensive pelvic surgery and adult myelodysplasia. Primary absence of ejaculation also has been described. Few treatment options exist for these patients, if they wish to father a child. With electroejaculation (EEJ), or the low-current stimulation of the ejaculatory organs via a rectal probe, emission of semen can be initiated in these men. In non-SCI-patients EEJ requires general anaesthesia. The collected semen is washed and the motile sperm fraction isolated before artificial insemination (AI) of the partner. At the University of Michigan 198 men have been treated between 1986 and December 1991. An ejaculate could be obtained from nearly all patients. A major obstacle to success is the severe asthenozoospermia and the poor functional quality of the obtained sperm samples. This can be caused by the EEJ-technique itself, as well as by the long anejaculatory status. A semen sample with at least 10 million progressively motile sperm cells, useful for AI, was obtained in 75% of the SCI men and in 87% of the men following RPLND. In the couples wishing insemination, 49 pregnancies were induced, accounting for an overall pregnancy rate of 35% per couple. Thirty five healthy babies have been born. Only three complications were encountered. At Hannover Medical School only few patients have been stimulated to date. We could obtain an adequate sperm sample for AI from all of them. No complications were seen. As the first couple has just entered the phase of AI with husband sperm, an analysis of these results would be premature. Electroejaculation combined with artificial insemination is an efficient and safe treatment of male infertility due to neurogenic anejaculation.

[Hydraulic penis prosthesis in fibrosis of the cavernous body. The alloplastic tunica albuginea]. / Hydraulische Penisprothesen bei Schwellkörperfibrose. Die alloplastische Tunica albuginea.

Fibrosis of the cavernous bodies is a rare but serious condition resulting in erectile impotence. When the fibrosis is extensive a simple penile prosthesis sometimes cannot be implanted. In addition, perforation of the tunica albuginea is not uncommon in damaged cavernous bodies, and this will compromise a reimplantation. In such cases, the use of an alloplastic vascular prosthesis permits replacement of lost cavernous wall tissue and insertion of an inflatable penile implant. We used this technique in 10 patients with severely damaged cavernous bodies. In 7 of them, surgery was successful and enabled satisfactory intercourse. This type of surgery, however, should be reserved for selected cases of penile prosthetic surgery.

Electroejaculation following retroperitoneal lymphadenectomy.

Transrectal electroejaculation was performed in 24 men who were anejaculatory from retroperitoneal lymphadenectomy. Of the men 23 had undergone retroperitoneal lymphadenectomy because of testis cancer. Seminal emission was achieved in all patients. In 21 patients greater than 10 x 10(6) progressively motile sperm with normal morphology were obtained. The average sperm count and motilities obtained were 289 x 10(6) and 18%, respectively, for the antegrade fractions, and 2,051 x 10(6) and 13%, respectively, for the retrograde fractions. Of the 3 azoospermic failures 2 had chemotherapy-induced testicular damage and 1 had carcinoma in situ of the remaining testis. A total of 19 couples underwent artificial insemination with electroejaculated sperm. There were 7 pregnancies achieved in 74 insemination cycles (36.8% of the couples conceived for a 9% cycle fecundity). Routine semen parameters could not predict which couples would be successful in achieving pregnancy. There were 2 first trimester spontaneous abortions. Five healthy children have been born. Electroejaculation is an excellent treatment for anejaculation that persists following retroperitoneal lymph node dissection.

Absence of antisperm antibodies in anejaculatory men.

Antisperm antibodies were assessed in the serum samples of 73 men unable to ejaculate naturally and on the sperm cells of 13 of these men. None of the serum samples were found to be positive by sperm agglutination or sperm immobilization methods and antibodies were detected by an immunobead assay on the sperm cells of one of the 13 men examined.