The infertile couple

The varicocele argument resurfaces

A recent series of articles and reviews published in Fertility and Sterility have rekindled the more than half century debate on varicocelectomy. Every one of these articles favored strongly the repair of varicocele for male infertility. Since my review paper on this issue in 2001, published in Human Reproduction Update, and since advent of ICSI in 1993, I had thought that most reproductive physicians felt negatively about the benefit of varicocelectomy. However, more recent urological papers are causing this negative view to be re-evaluated. It is now advocated by some urologists that varicocelectomy improves sperm count and testosterone levels, and even improves the results with ICSI. Thus, it may be appropriate to revisit older studies again and review the newer ones in this never ending controversy. Newer studies are re-opening the door to review and possibly re-instate varicocelectomy. This dilemma may never be fully resolved, but it is important to keep an open mind.

Effects of Shao-Fu-Zhu-Yu-Tang on Motility of Human Sperm

Shao-Fu-Zhu-Yu-Tang (SFZYT) is reportedly beneficial to sperm. In this study, we examined sperm acrosomal activity and serum free radical changes to evaluate the possible mechanism of SFZYT. A clinical study evaluated the sperm count and motility in 36 patients with chronic prostatitis before and after treatment for 60 days. The results revealed a significant increase in sperm motility after treatment as evaluated by computer-assisted semen analysis (17.27 ± 9.00 versus 28.29 ± 10.00, p < 0.01). An increase in sperm quantity and quality was observed by count and morphology with a high-powered intravital microscope. To gain an understanding of the mechanisms that caused this effect, we assessed sperm acrosin activity levels before (10.6 μ lu /106) and after medication (28.6 μ lu /106)( p < 0.01). The levels of the free radicals was relatively higher before medication, 2144, compared to a normal value of 780 after medication ( p < 0.01). In conclusion, SFZYT increased the motility and quality of human semen and this increase is related to an increase in sperm acrosin activity. SFZYT also works as a sperm antioxidant and antiaging agent.

New concepts in operative andrology: a review

Several recently published, or about to be published, controversial issues in operative andrology are clarified and reviewed in this paper. The microsurgical technique for sperm retrieval for nonobstructive azoospermia, the round spermatid controversy and the varicocoele dilemma (why does everybody keep doing varicocoelectomy for male factor infertility?) are presented with salient points that have recently been presented elsewhere and referenced. Finally, at the end, we review briefly what is known about the likelihood of genetic transmission of infertility from male factor patients to their offspring as a result of the new ICSI technology.

Time to pregnancy among the wives of men exposed to organic solvents

OBJECTIVES

To assess whether paternal exposure to organic solvents is associated with decreased fertility.

METHODS

A retrospective time to pregnancy study was conducted among men biologically monitored for organic solvents. The workers were classified into exposure categories on the basis of work description and the use of solvents as reported in the questionnaires, and on biological exposure measurements. The relative fecundability density ratios (FDR--an analogue of incidence density ratio of clinically recognised pregnancies) were calculated with discrete proportional hazards regression.

RESULTS

After three mailings 316 (72.1%) wives of the monitored men participated. The final study population consisted of 282 couples who did not use contraception at the beginning of pregnancy. The FDRs, adjusted for potential confounders, were 0.80 (95% confidence interval (95% CI) 0.57 to 1.11) and 0.74 (95% CI 0.51 to 1.06) for high or frequent and low or intermediate exposure, respectively. High or frequent and low or intermediate exposure were related to decreased fecundability among primigravida (FDRs 0.36; 95% CI 0.19 to 0.66 and 0.53; 95% CI 0.27 to 1.04) but not among couples with at least one previous pregnancy (FDRs 0.96; 95% CI 0.62 to 1.49 and 0.77; 95% CI 0.47 to 1.24).

CONCLUSIONS

The findings of the study provide limited support for the hypothesis that paternal exposure to organic solvents might be associated with decreased fertility. Further studies with careful design are warranted.

Occupational hazards for the male reproductive system

The etiology of male infertilities is largely undetermined, and our knowledge of exogenous factors affecting the male reproductive system is still limited. In particular, the role of specific environmental and occupational factors is incompletely elucidated. Various occupational (physical and chemical) agents have been shown to affect male reproductive functions in animals, but large differences in reproductive function and/or xenobiotic handling between species limit extrapolation to humans. When available, human data are often conflicting and, except in a few instances, usually refer to broad and heterogenous occupational categories or to groups of agents (e.g., solvents). It is often difficult to elucidate the role of a single agent because occupational exposure conditions are often complex and various confounding factors related to lifestyle (smoking, alcohol, and diet) or socioeconomic state may also affect sperm quality, fertility, or pregnancy outcomes. The objective of this work is to summarize the main epidemiological and, where relevant, experimental findings pertaining to agents (physical and chemical) encountered in the occupational environment that might affect the male reproductive system (sperm count, motility and morphology, libido, and fertility) and/or related pregnancy outcomes (spontaneous abortion, stillbirth, low birth weight, and birth defects and childhood malignancy in offspring). Some methodological issues related to research on the reproductive effects of toxicants are also discussed briefly.

Air-conditioned environments do not prevent deterioration of human semen quality during the summer

OBJECTIVE

To determine if air conditioning might mitigate summer reductions in semen quality.

DESIGN

Prospective study of semen quality in summer and winter.

SETTING

Normal human volunteers were studied in the setting of a fertility laboratory.

PATIENTS, PARTICIPANTS

Two groups of volunteers were selected from the vicinity of New Orleans: 64 men who worked indoors during the summer in air-conditioned environments and 76 others who worked outdoors.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Parameters of manual semen analysis were examined for seasonal and group differences.

RESULTS

Remarkably similar reductions in semen quality during summer as compared with winter were observed in both indoor and outdoor workers, respectively, with regard to the following parameters of semen quality: 19% and 19% in sperm concentration, 25% and 27% in total sperm per ejaculate, 17% and 20% in motile sperm concentration, 13% and 15% in percent sperm with normal morphology, and 23% and 23% in concentration of morphologically normal motile sperm.

CONCLUSIONS

These findings do not support the hypothesis that the heat of the summer is detrimental to male reproductive capacity. The available evidence suggests instead a possible role of photoperiod in causing the seasonal changes in semen quality.

Differences in the quality of semen in outdoor workers during summer and winter

BACKGROUND AND METHODS

In warm climates throughout the world, there is a deficit of births during the spring season. To determine whether this deficit might reflect a deleterious effect of heat on the male reproductive capacity during the previous summer, we obtained semen specimens in summer and winter from normal men who worked outdoors in the vicinity of San Antonio, Texas, and we performed automated semen analyses with an image-analysis system.

RESULTS

Pairwise comparisons among 131 men without azoospermia who contributed specimens in both summer and winter revealed significant reductions during the summer in sperm concentration, total sperm count per ejaculate, and concentration of motile sperm. The mean decreases in these values after adjustment for potential confounding characteristics were 32 percent (95 percent confidence limits, 28 and 44 percent), 24 percent (95 percent confidence limits, 18 and 43 percent), and 28 percent (95 percent confidence limits, 24 and 44 percent), respectively (P less than 0.0001). The lower a subject's average sperm concentration and motile-sperm concentration, the greater the reduction. We found no correlation, however, between the number of hours per day spent working during summer in settings without air conditioning and either the summer sperm concentration or the difference in concentration between summer and winter. Among the children of the men in the study whose wives were living near San Antonio during the year before they gave birth, a disproportionately low number were born during the spring.

CONCLUSIONS

Semen quality deteriorates during the summer. This phenomenon may account at least in part for the reduction in the birth rate during the spring in regions with warm climates.

Diagnostic value of sperm function tests and routine semen analyses in fertile and infertile men

The results of routine semen analyses, the zona-free hamster oocyte penetration test, the hypoosmotic swelling test, and semen adenosine triphosphate levels were studied in 66 fertile and 130 infertile men. Multivariate discriminant analysis demonstrated that routine semen parameters including semen volume, sperm count, percent sperm motility, and percent normal spermatozoa in combination could predict the fertility of these patients with 70.4% accuracy. Of the three sperm function tests evaluated, the zona-free hamster oocyte penetration test and the hypoosmotic swelling test were selected by the multivariate discriminant analysis as variables capable of providing significant information on the fertility status of the patients. However, the addition of the results of these two tests to the routine semen analysis did not significantly improve the predictability of fertility. The overall correct prediction rate was 77.6% after incorporation of the results of these two sperm function tests. In this group of subjects, the presently available sperm function tests did not predict the fertility status of a patient with a high degree of accuracy.

Semen quality in papaya workers with long term exposure to ethylene dibromide

To examine whether long term occupational exposure to ethylene dibromide (EDB) affects semen quality a cross sectional study of semen quality was conducted among 46 men employed in the papaya fumigation industry in Hawaii, with an average duration of exposure of five years and a geometric mean breathing zone exposure to airborne EDB of 88 ppb (eight hour time weighted average) and peak exposures of up to 262 ppb. The comparison group consisted of 43 unexposed men from a nearby sugar refinery. Statistically significant decreases in sperm count per ejaculate, the percentage of viable and motile sperm, and increases in the proportion of sperm with specific morphological abnormalities (tapered heads, absent heads, and abnormal tails) were observed among exposed men by comparison with controls after consideration of smoking, caffeine and alcohol consumption, subject's age, abstinence, history of urogenital disorders, and other potentially confounding variables. No effect of exposure to EDB on sperm velocity, the overall proportion of sperm with normal morphology, or YFF bodies was observed. These data strongly suggest that EDB may increase the risk of reproductive impairment in workers at exposure levels near the National Institute for Occupational Safety and Health recommended limit of 45 ppb (as an eight hour time weighted average) and far below the current standard of the Occupational Safety and Health Administration of 20 ppm.

Fecundability rates from an infertile male population

From a computer file of 955 couples attending hospital because of an infertile marriage, 279 were identified where the female partner had normal investigation results. Follow-up information was available for all couples and the fecundability (conception rate per month) for the first year of follow-up has been calculated, stratified according to the husband's investigation results. The fecundability of couples where the wife had normal investigation results but the husband had reduced sperm density ranged from 0.4% for wives with azoospermic husbands to 5.9% when the husband had at least 10 million motile sperm/ml. For any given number of motile sperm the fecundability was also strongly dependent on the duration of involuntary infertility as recorded at the time of initial clinic attendance. In view of the lack of effective treatment for most male infertility the fecundability rates reported herein are likely to represent those that would be found in an untreated population and should be useful as a base line when evaluating results of new treatments.

The lack of discriminant seminal and endocrine variables in the partners of fertile and infertile women

Seminal and endocrinological investigations were done on 50 fertile men whose wives became pregnant spontaneously (Group I), on 100 men from our fertility clinic whose wives conceived after treatment of the couple (Group II) and in 100 infertile men whose wives failed to become pregnant even after 5-year treatment of the couple (Group III). Patients with azoospermia were excluded. While there were no significant differences in the mean sperm density and total sperm count of the men from all three groups, mean sperm motility and sperm morphology were significantly better (p less than 0.001) in both Group I and Group II men than in the infertile Group III men. The mean serum LH and FSH concentrations were significantly lower in Group I than in the two other groups. However, there were no differences between Groups II and III. The mean serum concentrations of prolactin, testosterone, and estradiol were similar in all three groups. Based on semen and hormone data, stepwise multiple discriminant analysis could allocate 80% of the Group I men correctly, whereas only 50% of Groups II and III could be correctly classified. Although overall differences in sperm motility and morphology as well as in serum gonadotrophin concentrations were noted, no specific seminal or hormonal variable could be identified as being of value in predicting the fertility of an individual man.

Monitoring techniques for improved pregnancy rates during clomiphene ovulation induction

Despite the introduction of new ovulation-inducing agents, CC remains the drug of choice for most anovulatory patients. Before initiating therapy, patients should be evaluated to determine the cause of anovulation. Patients with ovarian failure, hyperprolactinemia, hypothyroidism, or forms of CAH should be treated with the appropriate replacement therapy. Evaluation of male factor and tubal patency should be obtained. Once CC therapy is initiated, careful monitoring should be continued. Confirmation of ovulation by endometrial biopsy or serum P levels is essential. CC doses should be increased monthly until normal luteal function is demonstrated. If the patient does not conceive in three ovulatory cycles, her treatment should be further evaluated by postcoital testing, repeat serum P measurement, and review of her endocrine findings. Patients with poor cervical mucus may benefit from midcycle estrogen. Patients with elevated T may benefit from prednisone suppressive therapy. Patients with abnormal HSGs should have laparoscopy and surgical correction if feasible. After six ovulatory cycles without conception, all patients should undergo laparoscopy. If laparoscopy is normal, therapy can be continued for a total of 10 to 12 cycles. Patients with reduced fecundability (male factor, minimal endometriosis, or minimal tubal adhesions) may require a longer time to conceive.