Cornell University Weill Medical College Cornell Institute for Reproductive Medicine
Center for Male Reproductive Medicine and Microsurgery
"State-of-the-Art Compassionate Care for the Infertile Couple"
What's New at 2004 AUA Meeting
Take Home Message: Male Infertility
This "Take Home Message" was prepared by Dr. Gail S. Pins (Chicago. Illinois)
(Following summary of the Take Home Message delivered on the final day of 2004 American Urologic Association Meeting (http://www.aua2004.org) . The purpose of these messages is to provide an overview of presentations on selected topics. For other topics and abstracts, please find them at Journal of Urology, suppl., 171:1-611, 2004)
There was a wealth of male infertility research presented at the AUA annual meeting in San Francisco. However, a few topics clearly stood out as areas of
intense interest and I will briefly highlight those findings.
Investigations on varicoceles continue, particularly with regard to predictive measures for successful outcomes following treatment, the issue of adolescent varicocele repair and the introduction of new approaches for varicocelectomy in this patient population.
Okubo et al examined glutathione S-transferase (GST) polymorphisms in infertile males with varicoceles and found that the GST-M1 genotype is associated with increased susceptibility to varicocele induced infertility while the GST-T1 genotype was a useful predictor of seminal improvement following varicocelectomy (#1390).
Marmar et al performed testes biopsies followed by molecular marker assessment in men undergoing varicocelectomy and, compared to controls, observed that varicocele was associated with increased germ cell apoptosis (#1400). Furthermore, increase testicular Cd/Ca channel microdeletions and absence of CREM-tau were associated with poor varicocelectomy outcomes (post-surgical semen improvement), suggesting that limited biopsy with selected markers may be useful for varicocele evaluation before surgery.
Bach et al presented data from a large group of men with varicoceles to indicate that baseline follicle-stimulating hormone (FSH) is a strong predictor of the GnRH test outcome and suggested that the GnRH test could be easily substituted by the inexpensive FSH assay in patients with varicoceles (1568). However, O'Brien found in a large retrospective study that the GnRH stimulation test is of no clinical value in the management of varicocele bringing into question the need for either of these tests (#1559). In another predictive assessment McCullough et al used color Doppler to document the persistence of venous flow in 16% of men after varicocelectomy (#1589). However, preoperative flow values did not predict postoperative flow persistence.
Adolescent varicocele was the topic of a lively debate in the Point-Counterpoint session with Kass arguing in favor of repair and Diamond providing the negative viewpoint. On this same topic the microsurgical subinguinal approach was found to be extremely effective in varicocele repair in the adolescent patient in presentations by Sigman et al (#1597) and Cayan (#1604) who showed marked semen improvement with no complications.
An interesting study by Raman and Goldstein at Cornell showed for the first time that men with congenital absence of the vas deferens (CAVD) have normal sized vasal arteries and veins in the spermatic cord which are sufficient to provide adequate venous return following spermatic vein ligation (#1592). Thus, men with CAVD who present with varicoceles can be treated with varicocelectomy to improve testicular sperm quality for future in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI).
Testicular sperm extraction (TESE) was another topic of high interest among presenters at the meeting who are also looking for improved techniques and diagnosis as well as predictive markers. Schrader et al found that testes biopsy histological diagnosis was improved by the addition of reverse transcriptase-polymerase chain reaction (RT-PCR) for telomerase and the kinase CcnA1 in the testicular tissue since both accurately reflect the presence of haploid germ cells (#1376). Similarly Weikert et al showed that survivin expression in testes tissues by RT-PCR correlated with the histopathological diagnosis
and could be used as an adjunct test for the identification of germ cells (#1382).
Using currently available tests, Matsumiya et al developed a predictive formula for successful sperm retrieval in non-obstructive azoospermia cases based on testes size, FSH, total testosterone and inhibin B (#1585). Recent work has shown that patients with Klinefelter's syndrome can achieve pregnancies after TESE and Okada et al warned that this must be attempted before age 35 years since there is a sharp decline in focal spermatogenesis with age (#1934). Testes biopsy attempts for sperm retrieval were shown to markedly improve following tissue perfusion analysis with color Doppler ultrasound since it identifies areas of spermatogenesis (#1397 and #1566). Finally, a new surgical technique for TESE was presented - the single seminiferous tubule technique - which isolates a single seminiferous tubule for sperm extraction and is atraumatic yet as successful as open biopsy (#1935).
A noteworthy study related to TESE was presented by Kassabian et al who showed that similar IVF pregnancy outcomes are achieved with or without ICSI when sperm morphology is poor, ie 3% and 4% normal Kruger classification (strict criteria)
(#1599). Thus, this large analysis questions the overuse of the ICSI procedure at many assisted reproductive technology clinics.
A new approach to infertility surgery was introduced by Goldstein Group (Schiff, Li and Goldstein) in a prospective study on rats comparing the da Vinci robot (Intuitive Surgical, Mountain View, California) to standard microsurgery for vasovasostomy and vasoepididymostomy (#1594). They showed that the robotic microsurgical approach yielded improved outcomes in shorter times which open the possibility of remote location surgery by an experienced microsurgeon.
Stem cell transplants for the treatment of male infertility were the topic of a state-of-the-art plenary lecture by Brugh. While this approach in men is still in the future, current basic research with animal models, as presented by Lamb et al, attests to the speed at which this exciting field is moving (#1372). We look forward to this progress and its promise of new treatment modalities for the infertile male.