Data show why urologists need to evaluate infertility

August 15, 2008

What role should urologists play in the evaluation and management of couples who have difficulty conceiving?

Key Points

This is the paramount question for clinicians who specialize in diagnosing and treating the infertile male, said Dr. Niederberger, head of urology at the University of Illinois at Chicago. It is one of three significant infertility-related messages Dr. Niederberger identified for Urology Times.

Mismatches in DNA may predispose men to infertility and certain cancers. Using data from large cancer registries and comparing it against data from infertility centers, researchers found that infertile men had increased rates of prostate cancer and melanoma. Further, although male factor infertility is present in half of all infertile men, few fertility clinics appreciate the role of the urologist in treating infertility.

Part of the answer was provided by University of California, San Francisco researchers, who found that DNA mismatches may predispose men to infertility and certain cancers. Culling data from large cancer registries and comparing it with similar data from infertility centers, they found that infertile men had increased rates of both prostate cancer and melanoma.

"Urologists know men and men's health best, so this is a really excellent example of why we need to continue to pay attention to evaluating men with infertility," said Dr. Niederberger. "It may be that 'bad' DNA causes infertility and cancer, and transmission of DNA is the basic function of the reproductive system.

"So DNA gone awry can play out either as reproductive failure, as the development of malignancy, or both. DNA mismatches are a possible mechanism."

Still, it is undoubtedly true that male factor infertility continues to be largely overlooked. It is present in 50% of infertile men, but one analysis found that only 58% of fertility clinic web sites mention it. Moreover, a mere 16% of such sites mention vasectomy reversal as an option, and a lowly 7% include urologists on the fertility team.

This would seem to suggest a need to educate patients and other medical specialists about the role of the urologist in treating fertility.

Some urologists have been reluctant to treat men with nonobstructive azoospermia (NOA), thanks in large part to the belief that outcomes with these men will be poor. But evidence is accumulating that such patients can be treated with a high degree of success.

A Japanese team reported similar fertilization and pregnancy rates among men with and without obstructive azoospermia when retrieving sperm using microdissection testicular sperm extraction (TESE). They concluded that microdissection TESE might contribute to a high retrieval rate of fresh, motile testicular sperm, even in NOA patients.

"This is yet another reason to consider having microdissection TESE in your armamentarium of surgical techniques," Dr. Niederberger said.

Encouragingly, TESE's success in men with NOA can be predicted, according to a separate study conducted by Turkish investigators. They reported that increased testis size, higher free and total testosterone levels, and lower FSH and LH levels were the most important indicators for positive sperm retrieval.

In a separate retrospective series of 80 azoospermic patients who underwent microdissection TESE, men with chromosomally normal analyses experienced no decline in serum microdissection, but those with Klinefelter's syndrome showed a significant and persistent decline in testosterone levels. This would suggest a greater likelihood of injury among Klinefelter's patients and an increased need to monitor them.

Updated efficacy data support the use of the two-stitch microsurgical longitudinal intussusception vasoepididymostomy in achieving patency. Further, a new nomogram can help predict the need for vasoepididymostomy before vasectomy reversal.

Urologic surgeons from Montreal and New York provided a much-needed update in outcomes from microsurgical longitudinal intussusception vasoepididymostomy (LIVE). They demonstrated long-term efficacy using the two-stitch approach, with a 92% patency rate, 74% early patency rate, 31% natural pregnancy rate, and 39% pregnancy rate with in vitro fertilization/intracytoplasmic sperm injection.

"When you talk to couples about the outcomes of vasoepididymostomy, you're using data that is almost 2 decades old," Dr. Niederberger said. "That could unfairly influence outcomes downward. Now we have good information for microsurgeons counseling couples about outcomes, should they need to have the procedure."

Finally, researchers from Houston and Cleveland have developed a nomogram to predict the need for vasoepididymostomy that was based on certain preoperative patient characteristics, such as the number of years since vasectomy and the presence of sperm granuloma.