- •Introduction
- •1. Andrological investigations and spermatology
- •2.2 Sperm chromosomal abnormalities
- •2.3 Sex chromosome abnormalities
- •2.4 Autosomal abnormalities
- •2.6 Cystic fibrosis mutations and male infertility
- •2.7 Unilateral or bilateral absence or abnormality of the vas and renal anomalies
- •2.8 Unknown genetic disorders
- •2.9 Genetic counselling and icsi
- •2.10 Conclusions
- •10. Guttenbach m, Michelmann hw, Hinney b, Engel w, Schmid m.
- •12. Foresta c, Galeazzi c, Bettella a, Stella m, Scandellari с
- •15. Santen rj, Paulsen ca.
- •16. Tincello dg, Saunders pt, Hargreave тв.
- •20. Dinauer mc, Orkin sh.
- •26. Kent-First m, Muallem a.
- •35. Simoni m, Gromoll j, Dworniczak b, Rolf c, Abshagen k, Kamischke a, Carani c, Meschede d, Behre hm, Horst j, Nieschlag e.
- •46. Donat r, McNeill as, Fitzpatrick dr, Hargreave тв.
- •3.2 Aetiology
- •3.3 Testicular morphology
- •3.4 Biopsy techniques
- •3.5 Treatment
- •3.6 Tese techniques
- •3.7 Icsi with cryopreserved testicular spermatozoa
- •3.8 Tese and icsi in Klinefelter's syndrome
- •3.9 Testicular spermatid injection in combination with icsi
- •3.10 Conclusions
- •3.11 References
- •26. Chen su, Ho hn, Chen hf.
- •31. Kim ed, Gilbaugh jh 3rd , Patel vr, Turek pj, Lipshultz li.
- •35. Gil-Salom m, Romero j, Minguez y, Molero md, Remohf j, Pellicer a.
- •38. Gottschalk-Sabag s, Weiss db, Folb-Zacharow n, Zukerman z.
- •55. Silber sj, Van Steirteghem ac, Liu j, Nagy z, Tournaye h, Devroey p.
- •62. Perraguin-Jayot s, Audebert a, Emperaire jc, Parneix I.
- •76. Antinori s, Versaci c, Dani g, Antinori m, Pozza d, Slman ha.
- •4.3 Diagnostic management
- •4.4 Treatment
- •4.5 Conclusions
- •4.6 References
- •5.1 Conclusion
- •5.2 Vasectomy reversal
- •5.3 References
- •6.1.5 Treatment
- •6.1.6 Conclusions
- •6.1.7 Recommandations
- •6.1.8 References
- •19. EversJl
- •6.2.2 Hypogonadotrophic hypogonadism
- •6.2.3 Hypergonadotrophic hypogonadism
- •6.2.4 Conclusion
- •9. Daniell hw.
- •10. Finkelstein js.
- •6.3 Cryptorchidism2
- •6.3.1 Impact on fertility
- •6.3.2 References
- •7.4 Conclusions
- •12. Kessopoulou e, Powers hj, Sharma kk, Pearson mj, Russelll jm, Cooke id, Barratt cl.
- •8.1.3 Prostatitis
- •8.1.4 Therapy
- •8.1.5 Conclusions
- •8.2.2 Epididymitis
- •8.2.3 References
- •12. Osegbe dn.
- •9.3 Diagnosis
- •9.5 Conclusions
GUIDELINES
ON INFERTILITY
G. M. Colpi, T. B. Hargreave, G. K. Papp, J. M. Pomerol, W. Weidner.
TABLE OF CONTENTS PAGE
INTRODUCTION 5
1. ANDROLOGICAL INVESTIGATIONS AND SPERMATOLOGY 5
Ejaculate analysis 5
Advanced diagnostic spermatological tests 5
Andrological status 5
References 5
2. GENETIC DISORDERS IN INFERTILITY 6
Chromosomal abnormalities 6
Sperm chromosomal abnormalities 6
Sex chromosome abnormalities 6
Autosomal abnormalities 6
Genetic defects 7
Cystic fibrosis mutations and male infertility 10
Unilateral or bilateral absence or abnormalilty of the vas and renal anomalies 11
Unknown genetic disorders 11
Genetic counselling and ICSI 11
Conclusions 11
References 11
3. PRIMARY SPERMATOGENIC FAILURE 14
3.1 Definition 14
Aetiology 15
Testicular morphology 15
Biopsy techniques 18
Treatment 18
TESE techniques 19
ICSI with cryopreserved testicular spermatozoa 19
TESA and ICSI in Klinefelter's syndrome 20
Testicular spermatid injection in combination with ICSI 20
Conclusions 20
References 20
4. OBSTRUCTIVE AZOOSPERMIA 24
Definition 24
Classification 24
Diagnostic management 25
Treatment 26
Conclusions 28
References 28
5. VASECTOMY AND VASECTOMY REVERSAL 30
Conclusion 30
Vasectomy reversal 30
References 31
6. SPECIAL PROBLEMS IN THE TREATMENT OF MALE INFERTILITY 32
6.1 Varicocele 32
Introduction 32
Classification 32
Diagnosis 32
Basic considerations 32
Treatment 33
Conclusions 34
Recommendations 34
References 34
6.2 Hypogonadism 36
Introduction 36
Hypogonadotrophic hypogonadism 36
Hypergonadotrophic hypogonadism 36
Conclusion 37
References 37 6.3 Cryptochidism 37
Impact on fertility 37
References 38
7. IDIOPATHIC OLIGOASTHENOTERATOZOOSPERMIA 38
Introduction 38
Diagnosis 38
Treatment 38
Conclusions 41
References 41
8. UROGENITAL INFECTIONS AND DISTURBED MALE FERTILITY 42
8.1 Urethritis and prostatitis 42
Introduction 42
Urethritis 42
Prostatitis 43
Therapy 45
Conclusions 46
References 46
8.2 Orchitis and epididymitis 48
Orchitis 48
Epididymitis 49
References 50
9. DISORDERS OF EJACULATION 51
Definition 51
Classification and aetiology 51
Diagnosis 53
Treatment 54
Conclusions 56
References 56
10. ABBREVIATIONS USED IN THE TEXT 57
Introduction
The following guidelines are aimed at providing a consensus view on special topics in urological andrology, which seem to the EAU Infertility Group to be key points in the daily work of urologists dealing with infertility. These topics reflect our literature review and rating, debates of the pros and cons, and final recommendations of our expert group, with special focus on the different national views and clinical practice in European countries.
The group is aware of the fact that infertility in particular has to be discussed as an original interdisciplinary subject, with paternity in a sterile partnership being the primary goal of all clinical work. This understanding implies the cooperation with non-urologists in all aspects of infertility in daily work, and knowledge of other pertinent guidelines, issued by well-accepted authorities such as WHO, the ESHRE Andrology Special Interest Group and the European Academy of Andrology. Accepting these recommendations, our group is convinced that the following guidelines will help European urologists in their interdisciplinary situation to focus on their special skills and knowledge and to understand better the outcome for the patient and the couple.
W. Weidner (Chairman)
1. Andrological investigations and spermatology
1.1 Ejaculate analysis
Ejaculate analysis has been standardized by the World Health Organization (WHO) and propagated by continuing work and publications in the Laboratory Manual for Human Semen and Sperm-Cervical Mucus Interaction, which is in its fourth edition [1]. The consensus is that modern spermatology has to follow these guidelines without exclusions.
1.2 Advanced diagnostic spermatological tests
Computer-assisted sperm analysis (CASA), acrosome reaction tests, zona-free hamster egg penetration tests and sperm-zona pellucida bindings tests are not covered in toto by these guidelines, but are discussed with regard to relevance and clinical importance [2]. A critical assessment of these specialized tests using standardized laboratory techniques is absolutely necessary for given diagnostic situations.
1.3 Andrological status
Andrological status assessment has to consider the suggestions for the standardized investigation, diagnosis and management of the infertile man made by the WHO [3], so implementing evidence-based medicine in this interdisciplinary field of reproductive medicine.
1.4 References
1. World Health Organization.
WHO laboratory manual for the examination of human semen and sperm-cervical mucus interaction. 4th edition, Cambridge, Cambridge University Press, 1999.
2. ESHRE Andrology Special Interest Group.
Consensus workshop on advanced diagnostic andrology techniques. Hum Reprod 1996; 11:1463-1479.
3. World Health Organization.
WHO manual for the standardized investigation, diagnosis and management of the infertile male. Cambridge, Cambridge University Press, 2000.
2. GENETIC DISORDERS IN INFERTILITY1
A knowledge of genetic abnormalities in infertility is mandatory for every urologist working in andrology.
2.1 Chromosomal abnormalities
In a survey of pooled data from 11 publications, including a total of 9,766 infertile men, the incidence of chromosomal abnormalities was found to be 5.8% [1]. Of these, sex chromosome abnormalities accounted for 4.2% and autosomal abnormalities for 1.5%. In comparison, the incidence of abnormalities in pooled data from three series totalling 94,465 newborn male infants was 0.38%, of which 131 (0.14%) were sex chromosome abnormalities and 232 (0.25%) were autosomal abnormalities [2]. The possibility of abnormalities increases with increasing severity of impaired spermatogenesis [1,3]. By means of in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) it is now possible for men with very low sperm counts to be given a reasonable chance of paternity (see below Idiopathic oligoasthenoteratozoospermia).
Standard karyotype analysis should be offered to all men with damaged spermatogenesis who are seekingfertility treatment by IVF/ICSI.
1 With support by Ch. Gosk, Dept of Urology, Western General Hospital Edinburgh, UK.