Editing Infertility: Management (section)

===Ejaculatory Stimulation===

==== Indications (1) ====
*'''<span style="color:#ff0000">Infertility due to ejaculatory dysfunction[https://pubmed.ncbi.nlm.nih.gov/33295257/ ★]'''
**'''<span style="color:#ff0000">Neurologic conditions associated with abnormal or absent seminal emission due to impaired sympathetic outflow (4):'''
**#'''<span style="color:#ff0000">Spinal cord injury'''
**#'''<span style="color:#ff0000">Demyelinating neuropathies (multiple sclerosis)'''
**#'''<span style="color:#ff0000">Diabetes'''
**#'''<span style="color:#ff0000">Iatrogenic (retroperitoneal lymph node dissection, pelvic surgery)'''
**'''With stimulation, motile sperm can be obtained for assisted reproduction techniques (IUI, IVF with ICSI).'''
***Semen collected from men with spinal cord injury is often initially senescent and of poor quality with a low sperm count and reduced sperm motility but may improve with subsequent ejaculations

==== Technique ====

*'''<span style="color:#ff0000">Stimulation can be done with penile vibratory devices or electroejaculation'''
**'''<span style="color:#ff0000">Approach depends on level of spinal cord lesion[https://www.ncbi.nlm.nih.gov/pubmed/12406364 §]'''
***'''<span style="color:#ff0000">If lesion above T10, ejaculatory reflex arc will be intact so can stimulate with penile vibratory devices'''
***'''<span style="color:#ff0000">If lesion T10 or below, consider electroejaculation'''
***'''If these fail, sperm retrieval is performed'''
**'''<span style="color:#ff0000">Ejaculatory stimulation for men with spinal cord injuries may result in autonomic dysreflexia'''
***'''<span style="color:#ff0000">Autonomic dysreflexia'''
****'''See [[CUA: Neurogenic Lower Urinary Tract Dysfunction (2019)|2019 CUA NLUTD Guideline Notes]]'''
****'''An uninhibited sympathetic reflex accompanied by headache, diaphoresis, hypertension, bradycardia, and diaphoresis'''
****'''More common with spinal cord injury at a level of T6 or above'''
****'''<span style="color:#ff0000">Can be life-threatening.'''
****'''Pretreatment, 15 minutes before the procedure, with 20 mg of sublingual nifedipine is used'''
****'''Should have intravenous access and their blood pressure and pulse should be monitored every 2 minutes before, during, and for 20 minutes after ejaculatory stimulation.'''
****'''In the event of a sympathetic outflow (autonomic dysreflexia), termination of the procedure should be sufficient to break the response; however, intravenous access allows for delivery of sympatholytic agents should they become necessary'''

==== Varicocele Repair/Varicocelectomy ====
*'''See [https://test.urologyschool.com/index.php/Varicocele Varicocele Chapter Notes]'''
*'''<span style="color:#ff0000">Indications</span>[https://pubmed.ncbi.nlm.nih.gov/33295257/ ★]'''
**'''<span style="color:#ff0000">Not recommend for males with non-palpable varicoceles detected solely by imaging</span>'''
***No demonstrable benefit of varicocele repair was observed in pregnancy or bulk seminal parameters with the exception of a possible small numerical effect on progressive sperm motility that is unlikely to be clinically important.
**'''<span style="color:#ff0000">Should be considered in males attempting to conceive who have (3):</span>'''
**#'''<span style="color:#ff0000">Palpable varicocele(s) AND</span>'''
**#'''<span style="color:#ff0000">Infertility AND</span>'''
**#'''<span style="color:#ff0000">Abnormal semen parameters, except for azoospermic males</span>'''
**#*Meta-analyses demonstrate higher estimated pregnancy rates for men treated with any approach for repair of clinical varicocele compared to no treatment
**#*'''For males with clinical varicocele and non-obstructive azoospermia, couples should be informed of the absence of definitive evidence supporting varicocele repair prior to ART.[https://pubmed.ncbi.nlm.nih.gov/33295257/ ★]'''
**#**Varicocele repair defers treatment with ART for at least six months