Treatment of Male Infertility

Our insight into the mechanisms of the physiology of reproduction has experienced a swift and constant development these last few years. The advent of more sophisticated diagnostic methods and their relatively easy clinical application allow for the incorporation of that knowledge into the evaluation of the infertile couple. These facts, together with an obvious change in social psychology, have facilitated the development of different specialities dealing with the problems of infertility. It is now possible in medical centers all around the world to undertake a better disposition of the infertile husband to look for advice, to be studied, and treated. Confronted with this situation we are still unable to offer specific therapy in most cases; however, empirically based therapy abounds. Advances in therapy have not kept pace with our increased physio logical knowledge and improved diagnostic techniques. Patho physiological mechanisms and etiological factors in male infertility are largely unknown. This has significantly hampered both clinical evaluation and advances in treatment allowing for frequent non scientific therapeutic incursions into the armamentarium of the an drologist. Several factors have given birth to therapeutic "fashions", which are bound to survive as long as this state of lack of knowledge con tinues. For example, we may ask whether the treatment of varicocele constitutes a fashion? Though we accept the treatment of varicocele as the best available treatment of male infertility, we do not know its mechanism of action and so we cannot predict a therapeutic result.

Though we accept the treatment of varicocele as the best available treatment of male infertility, we do not know its mechanism of action and so we cannot predict a therapeutic result.

I. General Considerations.- Male Infertility: Problems in Assessing Response to Treatment.- II. Medical Treatment.- 1 Inflammation and Infection.- 1.1 Inflammation of Male Accessory Sex Organs.- 1.1.1 Genital and Rectal Examination.- 1.1.2 Collection and Processing of the Prostatic Vesicular Fluid (PVF).- 1.1.3 Cytological Examination of PVF.- 1.1.3.1 Cellular Elements of the PVF.- 1.1.3.2 Quantitative Changes of the PVF Cells During Inflammation.- 1.1.3.3 Qualitative Changes of Epithelial Cells During Inflammation.- 1.1.3.4 Cellular Patterns of the Smears.- 1.1.4 Molecular Tracers of the Inflammatory Process.- 1.1.4.1 Immunoglobulins.- 1.1.4.2 C3 Factor of the Complement System.- 1.1.4.3 Albumin.- 1.1.4.4 ?1-Antitrypsin.- 1.1.4.5 ?1-Acid Glycoprotein.- 1.2 Infectious Male Adnexitis.- 1.2.1 General Considerations.- 1.2.2 Qualitative and Quantitative Data on Genital Infection in Infertile Patients.- 1.3 Secretory Function of Accesory Glands and Male Adnexitis.- 1.4 Treatment of Male Adnexitis.- 1.4.1 Introduction.- 1.4.2 Therapeutic Procedures.- 1.4.3 Follow-Up.- 1.5 Gaps in Our Knowledge.- 1.6 References.- 2 Clomiphene Citrate in the Treatment of Male Infertility.- 2.1 Testicular Control and Function.- 2.2 The Clomiphene Test.- 2.3 Clomiphene Citrate in Male Infertility.- 2.3.1 Clomiphene Citrate Therapy.- 2.3.2 Material and Methods.- 2.3.3 Review of Results Obtained with Clomid.- 2.4 Side and Secondary Effect of Clomiphene Citrate.- 2.5 Discussion.- 2.6 References.- 3 Tamoxifen.- 3.1 Mode of Action.- 3.2 Patients.- 3.3 Results.- 3.3.1 Plasma Hormone Levels.- 3.3.1.1 Testosterone.- 3.3.1.2 Estradiol.- 3.3.1.3 Gonadotropins (LH and FSH).- 3.3.2 Sperm Characteristics.- 3.3.2.1 Sperm Concentration.- 3.3.2.2 Sperm Motility.- 3.3.2.3 Sperm Morphology.- 3.3.3 Biochemical Composition of Seminal Plasma.- 3.3.4 Pregnancy.- 3.3.5 Side Effects.- 3.4 Conclusions.- 3.5 References.- 4 LHRH and Its Analogs in the Treatment of Idiopathic Normogonadotropic Oligozoospermia.- 4.1 General Considerations.- 4.1.1 Hypothalamic Hormones.- 4.1.2 Male Infertility.- 4.2 Experience with LHRH and Its Analogs.- 4.2.1 Selection of Patients.- 4.2.2 Evaluation of Results.- 4.2.3 Experience with LHRH.- 4.2.4 D-Leucine6-LHRH-Ethylamide.- 4.2.5 D-Tryptophan6-LHRH.- 4.3 Conclusions.- 4.4 References.- 5 Hyperprolactinemia in Male Infertility: Treatment with Bromocriptine.- 5.1 Control of PRL Release: The Role of Dopamine and Estrogens.- 5.2 Modification of PRL Secretion by Pharmacological Agents and Drug Interaction.- 5.3 Physiology and Physiopathology of PRL in Men.- 5.4 Incidence and Causes of Male Hyperprolactinemia.- 5.5 Biological and Biochemical Effect of Excessive PRL Secretion in Men.- 5.6 Bromocriptine Treatment of Male Hypogonadism.- 5.7 Conclusions.- 5.8 References.- 6 Gonadotropin Therapy in Male Infertility.- 6.1 Gonadotropin Preparations.- 6.1.1 Pituitary Gonadotropins.- 6.1.2 hCG.- 6.1.3 FSH.- 6.2 Hypogonadotropic Hypogonadism.- 6.2.1 Treatment of Hypogonadotropics with hCG.- 6.2.2 Therapy with hMG.- 6.2.3 Therapy with hCG and hMG.- 6.3 Gonadotropin Treatment in Idiopathic Oligozoospermia.- 6.4 Conclusions.- 6.5 References.- 7 Androgen Therapy in Hypogonadism and Infertility.- 7.1 Mechanism of Testosterone Action.- 7.2 Pharmacology of Androgens.- 7.2.1 Free Testosterone.- 7.2.2 Parenteral Testosterone Esters.- 7.2.3 Testosterone Undecanoate.- 7.2.4 Synthetic Androgens.- 7.2.4.1 Methyltestosterone.- 7.2.4.2 Fluoxymesterone.- 7.2.4.3 Mesterolone.- 7.2.5 Testis Sicca and Testis Extracts.- 7.3 Clinical Application.- 7.3.1 Substitution of Endocrine Testicular Insufficiency.- 7.3.2 Idiopathic Delayed Puberty.- 7.3.3 Excessively Tall Boys.- 7.3.4 Androgens in Adavanced Age.- 7.3.5 Testosterone Rebound Therapy as Treatment of Male Infertility.- 7.4 References.- 8 Mesterolone: a New Androgen for the Treatment of Male Infertility.- 8.1 Properties of Mesterolone.- 8.2 Literature Review.- 8.3 Toleration and Function of the Liver.- 8.4 Conclusions.- 8.5 References.- 9 Kinin-Releasing Pancreatic Proteinase Kallikrein.- 9.1 Kallikrein-Kinin System.- 9.1.1 Biochemistry and Physiology.- 9.1.2 Reproductive Functions.- 9.2 Experimental Investigations.- 9.2.1 In Vitro Studies.- 9.2.2 Animal Studies.- 9.2.3 Biochemical and Endocrinological Studies in Men.- 9.3 Clinical Investigations and Application.- 9.3.1 Systemic Kallikrein Treatment.- 9.3.1.1 Open Clinical Trials.- 9.3.1.2 Double Blind Studies.- 9.3.1.3 Routes of Administration and Side Effects.- 9.3.2 In Vitro Improvement of Human Semen.- 9.4 Conclusions.- 9.5 References.- 10 Treatment of Male Infertility with Nucleotides.- 10.1 Structure and Metabolism.- 10.2 Clinical Studies.- 10.2.1 Procedure.- 10.2.2 Treatment.- 10.3 Results.- 10.4 Conclusion.- 10.5 References.- 11 Immunological Infertility in Men: Clinical and Therapeutic Considerations.- 11.1 The Different Types of Sperm Antibodies Observed in Men.- 11.2 Antibody Nature of Sperm-Agglutinating and Sperm-Immobilizing Activities.- 11.3 Causes of Sperm Antibody Production.- 11.4 The Significance of Sperm Antibodies in Men.- 11.5 Treatment of Men with Sperm Antibodies.- 11.5.1 Treatment of Men with Genital Infections.- 11.5.2 Surgical Treatment.- 11.5.3 Sperm Washing and Intrauterine Inseminations.- 11.5.4 Immunosuppressive Treatment.- 11.5.4.1 Low-Dose Corticosteroids.- 11.5.4.2 High-Dose Corticosteroids.- 11.5.4.3 Azathioprine.- 11.5.5 The Testosterone Rebound Phenomenon and Sperm Antibodies.- 11.6 Conclusions.- 11.7 References.- 12 Nonsurgical Treatment of Varicocele.- 12.1 Historical Background.- 12.1.1 Diagnosis of Varicocele.- 12.1.2 Treatment of Varicocele.- 12.2 Transcatheter Sclerosis of the Spermatic Veins.- 12.3 Technique.- 12.4 Observations in 88 Patients.- 12.5 Conclusions.- 12.6 References.- 13 Retrograde Ejaculation.- 13.1 Anatomy of the Male Urethra and Internal Genitalia.- 13.2 Physiology of Ejaculation.- 13.3 Etiology of Retrograde Ejaculation.- 13.4 Diagnosis of Retrograde Ejaculation.- 13.5 Treatment of Retrograde Ejaculation.- 13.5.1 Retrieval of Semen.- 13.5.1.1 Replacement of Bladder Urine with an Isotonic Alkaline Solution.- 13.5.1.2 Systemic Alkalinization of the Urine.- 13.5.1.3 Washing of Semen in Nutrient Alkaline Solution.- 13.5.2 Medication.- 13.5.3 Surgery.- 13.5.4 Miscellaneous.- 13.6 Conclusions.- 13.7 References.- 14 Sexual Dysfunction in the Male.- 14.1 Definition.- 14.1.1 Kinds of Sexual Dysfunction.- 14.1.1.1 Sexual Approach.- 14.1.1.2 Sexual Stimulation.- 14.1.1.3 Intromission and Preorgasmic Coitus.- 14.1.1.4 Orgasm.- 14.1.1.5 Postorgasmic Period.- 14.1.2 Circumstances of Occurrence.- 14.2 Interviewing Technique and Differential Diagnosis Between "Organic" and "Psychogenic" Male Sexual Dysfunction.- 14.2.1 Interviewing Technique.- 14.2.2 Differential Diagnosis.- 14.3 Etiology.- 14.3.1 Organic Sexual Dysfunctions.- 14.3.1.1 Libido Disturbances.- 14.3.1.2 Erectile Impotence.- 14.3.1.3 Ejaculatory Disturbances.- 14.3.2 Psychogenic Sexual Dysfunctions.- 14.4 Therapy.- 14.4.1 Therapy of Organic Sexual Dysfunctions.- 14.4.2 Therapy of Psychogenic Sexual Dysfunctions.- 14.4.2.1 Sexual Counseling.- 14.4.2.2 Partner Therapy.- 14.4.2.3 Psychoanalysis.- 14.4.2.4 Behavior Therapy.- 14.4.2.4.1 Therapy Concept and Format.- 14.4.2.4.2 Initial Results.- 14.4.2.4.3 Follow-up Studies.- 14.4.2.4.4 Conclusions.- 14.5 Effect of Psychological Factors on the Production and Action of Spermatozoa.- 14.6 References.- III. Surgical Treatment.- 15 Varicocele: Its Role in Male Infertility.- 15.1 Definition and Classification.- 15.2 Pathogenesis and Etiology.- 15.2.1 Metabolites.- 15.2.2 Heat.- 15.2.3 Hormonal Factors.- 15.2.4 Abnormal Gases.- 15.2.5 Epididymal Factors.- 15.3 Diagnosis.- 15.4 Indications for Treatment.- 15.5 Management.- 15.5.1 Surgical.- 15.5.2 Medical.- 15.6 Results.- 15.7 Discussion and Conclusions.- 15.8 References.- 16 Obstruction in the Male Reproductive Tract.- 16.1 Causes of Obstruction of the Male Reproductive Tract.- 16.1.1 Obstruction After Inflammation.- 16.1.2 Obstruction After Vasography.- 16.1.3 Aplasia or Hypoplasia of the Vas Deferens.- 16.1.4 Obstruction After Vasectomy.- 16.1.5 Obstruction After Herniotomy.- 16.2 Therapy and Results.- 16.2.1 Epididymovasostomy.- 16.2.2 Vasovasostomy.- 16.2.3 Alloplastic Spermatocele.- 16.3 Discussion and Conclusions.- 16.4 References.- 17 Hydrocele, Spermatocele, and Peyronie's Disease.- 17.1 Hydrocele.- 17.1.1 Definition and Etiology.- 17.1.2 Symptoms.- 17.1.3 Diagnosis.- 17.1.4 Hydrocele and Testicular Tumors.- 17.1.5 Treatment.- 17.2 Spermatocele.- 17.2.1 Definition and Etiology.- 17.2.2 Symptoms.- 17.2.3 Diagnosis.- 17.2.4 Spermatocele and Epididymal Tumors.- 17.2.5 Treatment.- 17.3 Peyronie's Disease (Induratio Penis Plastica).- 17.3.1 Definition and Etiology.- 17.3.2 Symptoms.- 17.3.3 Diagnosis.- 17.3.4 Nonsurgical Treatment.- 17.3.5 Surgical Treatment.- 17.3.5.1 Excision of the Plaques.- 17.3.5.2 Implantation of Penile Prosthesis.- 17.4 Conclusion.- 17.5 References.- IV. Cryopreservation and Insemination.- 18 Cryopreservation and Pooling of Spermatozoa.- 18.1 History.- 18.2 Application of Cryobanking.- 18.3 The Biological Process in Cryopreservation.- 18.4 Sperm Freezing and Insemination Techniques.- 18.4.1 Freezing Methods.- 18.4.2 Preparation for Freezing.- 18.4.3 Storage of Semen.- 18.4.4 Insemination with Frozen Semen.- 18.5 Enhancing Sperm Motility After Thawing.- 18.6 Conclusions.- 18.6.1 Pooling and Storing of Semen.- 18.6.2 Suggested Freezing Methods.- 18.6.3 The Future.- 18.7 References.- 19 Enhancement of Sperm Motility: Selecting Progressively Motile Spermatozoa.- 19.1 Techniques.- 19.1.1 Caffeine Stimulation of Motility for Cryopreservatio6n.- 19.1.2 Selection of Motile Spermatozoa.- 19.1.2.1 Glass Wool Filtration.- 19.1.2.2 Active Selection of Motile Spermatozoa in BWW Medium.- 19.1.2.3 Selection of Motile Spermatozoa on Albumin Columns.- 19.1.3 Techniques for the Concentration of Spermatozoa.- 19.1.3.1 Millipore Filter Absorption of Water.- 19.1.3.2 Centrifugation.- 19.1.4 Techniques of Semen Analysis.- 19.1.4.1 Motility of Spermatozoa.- 19.1.4.2 Sperm Density.- 19.2 Results.- 19.2.1 Caffeine Stimulation and Cryopreservation.- 19.2.2 Selection of Motile Spermatozoa.- 19.2.2.1 Glass Wool Filtration.- 19.2.2.2 BWW Selection.- 19.2.3 Concentration Procedures.- 19.2.3.1 Millipore Filter Concentration.- 19.2.3.2 Centrifugation.- 19.2.3.3 BWW Plus Centrifugation.- 19.3 Discussion.- 19.4 References.- 20 Artificial Homologous Insemination.- 20.1 Indications for AIH.- 20.1.1 Subnormal Semen.- 20.1.1.1 Oligozoospermia.- 20.1.1.2 Asthenozoospermia.- 20.1.1.3 Teratozoospermia and Debris-Contaminated Semen.- 20.1.1.4 Increased Seminal Viscosity and Delayed Seminal Liquefaction.- 20.1.1.5 Hypospermia.- 20.1.2 Deposition Failure.- 20.1.2.1 Impotence and Anejaculation.- 20.1.2.2 Vaginismus.- 20.1.2.3 Deformed Female or Male Genital Organs.- 20.1.3 Failure of Sperm Migration.- 20.1.4 Cryopreserved Semen.- 20.2 Technique of Artificial Insemination.- 20.2.1 Intravaginal Insemination.- 20.2.2 Pericervical and Intracervical Insemination.- 20.2.3 Cap Insemination.- 20.2.4 Intrauterine Insemination.- 20.3 Timing of Insemination.- 20.4 Contraindications for AIH.- 20.5 Results of AIH.- 20.6 The Value of Split Insemination.- 20.7 Conclusions.- 20.8 References.- 21 In Vitro Fertilization: Future Treatment for Male Infertility.- 21.1 In Vitro Fertilization.- 21.1.1 Background.- 21.1.2 Human IVF.- 21.2 IVF and Male Infertility.- 21.2.1 Rationale.- 21.2.2 Ovum Retrieval and Sperm Capacitation.- 21.2.3 Sperm Characteristics.- 21.3 Conclusion.- 21.4 References.- V. Closing Remarks.- The Last Word-For Now.