Obstructions of the male reproductive tract: diagnosis and management

In this thesis several aspects of diagnosis and management of obstructive male infertility are discussed. The introduction gives a general overview of both male infertility and azoospermia. Diagnostic, genetic and therapeutic aspects of male infertility according to the current literature are discussed. The chapter on diagnosis of obstructions of the genital tract describes a study on the incidence and management of subtotal obstructions in men with severe oligozoospermia. Furthermore, genetic risk factors are investigated in tv.ro studies: in men with congenital bilateral absence of the vas deferens the relationship with cystic fibrosis is investigated and in men with either azoospermia or severe oligozoospermia cytogenetic abnormalities, Y chromosome deletions and cystic fibrosis gene mutations are determined. Practical advises for genetic investigations and genetic counselling are given. The chapter on management of male reproductive tract obstructions describes the results of transurethral resection of cystic lesions in the prostatic gland, causing ejaculatory duct obstruction. In a review on microsurgical treatment of the male genital tract, different operative techniques, outcome and prognostic factors are discussed extensively, including our own results. Finally. the technique of epididymal sperm extraction and intracytoplasmic sperm injection are presented together with the results of these combined treatments for men with irreparable obstructions of the seminal path. The scope of this thesis is to give an overview of recent developments in the diagnosis and treatment of obstructive male infertility, and to discuss the genetic risk factors associated with these forms of male infertility

Mannelijk hypogonadisme, een update

Male hypogonadism is a condition that can develop in every phase of life, with a higher prevalence in ageing men. This review presents an update on many aspects of male hypogonadism with emphasis on diagnosis and treatment of adult-onset hypogonadism. Low androgen levels after puberty and throughout adulthood can affect quality of life with infertility, decrease of sexual functions, muscle mass, strength and vitality, low mood and self-esteem, decrease of cognitive functions, osteoporosis and a change of metabolism with hyperlipidemia and insulin resistance. These effects can occur in every man, but especially to man with obesity and diabetes type 2. Low testosterone is regarded as a marker for poor general health and is an increased risk for cardiovascular disease and mortality. This review offers practical recommendations for urologists to recognize, diagnose and treat male hypogonadism and offers an overview of the indications and contraindications for testosterone therapy.Mannelijk hypogonadisme is een aandoening die zich op alle leeftijden kan voordoen. Het tijdstip waarop testosterondeficiëntie zich voordoet, bepaalt in hoge mate het fenotype van de man en de ziekteverschijnselen. Deze review geeft een update van de definitie, epidemiologie, etiologie, diagnostiek en behandeling van mannelijk hypogonadisme. Daarbij wordt onderscheid gemaakt tussen de diverse vormen van hypogonadisme, waarbij de nadruk ligt op de diagnostiek en behandeling van adult-onset hypogonadisme, bij uitstek het werkterrein van de uroloog. Bij de ouder wordende man treedt een geleidelijke daling op van het testosterongehalte, wat gevolgen kan hebben voor de kwaliteit van leven, zoals verminderde seksuele functies, verlies van spiermassa, kracht en vitaliteit, verminderde stemming en cognitieve functies, osteoporose en een veranderd metabolisme. Deze veranderingen treden versneld op bij mannen met obesitas en diabetes mellitus type 2. Een laag testosterongehalte is een marker voor een slechte algemene gezondheid en een verhoogde kans op hart- en vaatziekten en mortaliteit. Deze review geeft praktische aanbevelingen voor diagnose en therapie van symptomatisch hypogonadisme, met een overzicht van de indicaties en contra-indicaties voor testosterontherapie

The role of varicocele sclerotherapy in men with severe oligo-astheno-teratozoospermia

The aim of this study was to verify the role of antegrade scrotal sclerotherapy for the treatment of varicoceles in infertile men with severe oligo-astheno-teratozoospermia (OAT). The 59 patients with severe OAT in this study underwent antegrade scrotal sclerotherapy for the treatment of varicoceles. The outcome was assessed in terms of improvement in semen parameters and spontaneous conception rate. Semen parameters and reproductive hormones were evaluated before antegrade sclerotherapy (AS) and 6 months after AS. After an average follow-up time of 34.83.2 months, significant improvement was noted in the mean sperm concentration, motility and morphology in 36 patients (61%). Spontaneous pregnancy occurred in nine couples (15%). Six months after treatment, inhibin B levels were significantly higher (P<0.04), whereas follicle-stimulating hormone (FSH) levels were significantly lower (P<0.001) than before treatment. Antegrade internal spermatic vein sclerotherapy can significantly improve seminal parameters and hormonal parameters in men with severe OAT and may even result in spontaneous pregnancy in couples who would otherwise be candidates for intracytoplasmic sperm injection (ICSI)

20 jaar semencryopreservatie: haalbaarheid en verwijspatronen

Treatment of cancer can affect spermatogenesis resulting in infertility. Semen cryopreservation prior to gonadotoxic treatment can be offered to secure future fertility in male cancer patients. During 20 years 1,018 patients referred for semen cryopreservation in fertile age with Hodgkin disease (n = 194), non-Hodgkin lymphoma (n = 110), leukemia (n = 126) and testicular germ cell tumor (n = 588) were followed up. Incidence of these cancers and incidence of regional semen cryopreservation was used to calculate a referral rate. Semen cryopreservation was successful in 856 of 1,018 patients (84.1%). Median yearly referral rate was respectively 17% and 31% in hematological malignancies and testicular germ cell tumor. Regional referral rate in hematological malignancies dropped dramatically after 2005 to a minimum of 2% in 2009. The incidence of TGCT and referral rate for fertility preservation in these patients increased over time. Our result show that referral of for semen cryopreservation in patients with hematological malignancies in fertile age is suboptimal.Behandeling van kanker kan de spermatogenese aantasten, met infertiliteit tot gevolg. Semencryopreservatie voorafgaand aan gonadotoxische behandeling kan de vruchtbaarheid van mannelijke kankerpatiënten veiligstellen. Gedurende 20 jaar zijn 1.018 patiënten tussen 12 en 50 jaar oud, met Hodgkin-lymfoom (n= 194), non-Hodgkin lymfoom (n=110), leukemie (n= 126) of testiculaire kiemceltumoren (n= 588) verwezen naar één centrum voor semencryopreservatie. De incidentie van deze kankertypen in het adherentiegebied en de incidentie van regionale semencryopreservatie werd gebruikt om een verwijsratio te berekenen. Semencryopreservatie was succesvol bij 856 van de 1.018 patiënten (84,1%). De mediane jaarlijkse verwijsratio bij hematologische maligniteiten en testiculaire stamceltumoren was respectievelijk 17% en 31%. De regionale verwijzing bij hematologische maligniteiten daalde na 2005 fors, tot een minimum van 2% in 2009, terwijl deze toenam bij testiculaire kiemceltumoren. Onze resultaten tonen aan dat verwijzing voor semencryopreservatie bij patiënten met een hematologische maligniteit in de fertiele leeftijd suboptimaal is

Meiotic arrest occurs most frequently at metaphase and is often incomplete in azoospermic men

Objective: To establish which meiotic checkpoints are activated in males with severe spermatogenic impairment to improve phenotypic characterization of meiotic defects. Design: Retrospective observational study. Setting: University medical center research laboratory and andrology clinic. Patient(s): Forty-eight patients with confirmed spermatogenic impairment (Johnsen scores 3–6) and 15 controls (Johnsen score 10). Intervention(s): None. Main Outcome Measure(s): Quantitative assessment of immunofluorescent analyses of specific markers to determine meiotic entry, chromosome pairing, progression of DNA double-strand break repair, crossover formation, formation of meiotic metaphases, metaphase arrest, and spermatid formation, resulting in a novel classification of human meiotic arrest types. Result(s): Complete metaphase arrest was observed most frequently (27%), and the patients with the highest frequency of apoptotic metaphases also displayed a reduction in crossover number. Incomplete metaphase arrest was observed in 17% of the patients. Only four patients (8%) displayed a failure to complete meiotic chromosome pairin

Advances in male reproductive surgery: Robotic-assisted vasovasostomy

It is estimated that 3-6% of all vasectomised men request vasectomy reversal for different reasons. Microsurgical vasovasostomy is the gold standard technique of vasectomy reversal. However, the microsurgical technique is time-consuming and challenging to most urological surgeons. Therefore, alternative methods of vasal anastomosis have been studied including robotic-assisted vasovasostomy. This review discusses the feasibility and practice of robotic-assisted vasovasostomy. Based on the available studies robotic-assisted vasovasostomy is feasible. The reported rate of vasal patency associated with this new technique is similar to that of microsurgical vasovasostomy. There is no clear difference between the 2 approaches in terms of operating time. Robotic-assisted vasovasostomy does not appear to afford significant advantages in the era of vasectomy reversal