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Infertility: Management: Difference between revisions

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*Benefits of supplements (e.g., vitamins, antioxidants, nutritional supplement formulations) are of questionable clinical utility[https://pubmed.ncbi.nlm.nih.gov/33295257/ §]
*Benefits of supplements (e.g., vitamins, antioxidants, nutritional supplement formulations) are of questionable clinical utility[https://pubmed.ncbi.nlm.nih.gov/33295257/ §]
===Treatment Selection'''<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/33295257/ ★]</span>'''===
===Treatment Selection'''<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/33295257/ ★]</span>'''===
*'''Testosterone monotherapy should not be prescribed for the male interested in current or future fertility[https://pubmed.ncbi.nlm.nih.gov/33295257/ §]'''
*'''<span style="color:#ff0000">Testosterone monotherapy should not be prescribed for the male interested in current or future fertility</span>[https://pubmed.ncbi.nlm.nih.gov/33295257/ §]'''
**Exogenous testosterone administration provides negative feedback to the hypothalamus and pituitary gland, which can result in inhibition of gonadotropin secretion.
**Exogenous testosterone administration provides negative feedback to the hypothalamus and pituitary gland, which can result in inhibition of gonadotropin secretion.
**Depending on the degree of testosterone-induced suppression, spermatogenesis may decrease or cease altogether, resulting in azoospermia.
**Depending on the degree of testosterone-induced suppression, spermatogenesis may decrease or cease altogether, resulting in azoospermia.
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****'''Any injury to the epididymis distal to the caput will result in complete obstruction of the entire system on that side'''
****'''Any injury to the epididymis distal to the caput will result in complete obstruction of the entire system on that side'''
**'''Hydrocelectomy and orchiopexy for torsion can result in iatrogenic injury to the epididymis'''
**'''Hydrocelectomy and orchiopexy for torsion can result in iatrogenic injury to the epididymis'''
*'''Ejaculatory Ducts'''
===Surgical Sperm Extraction===
**'''Obstruction of ejaculatory ducts can lead to azoospermia.'''
***'''Transurethral resection (TUR) of the ejaculatory ducts (TURED) can relieve the obstruction.'''
===Testicular Biopsy===
*Fresh, unfixed tissue is examined for the presence of sperm with tails and possible motility; if sperm are not found initially, examination of multiple samples is recommended.
*Fresh, unfixed tissue is examined for the presence of sperm with tails and possible motility; if sperm are not found initially, examination of multiple samples is recommended.
**Optimal care requires the availability, at the time of biopsy, of an andrology laboratory capable of processing and cryopreserving any sperm found at the time of biopsy.
** Optimal care requires the availability, at the time of extraction, of an andrology laboratory capable of processing and cryopreserving any sperm found at the time of biopsy
 
====Indications ====
==== Approaches ====
*'''Azoospermia (obstructive or non-obstructive)'''
 
*'''Ejaculatory dysfunction'''
*'''Open Testicular Biopsy: Microsurgical Technique'''
==== Options====
**'''<span style="color:#ff0000">Open biopsy remains the gold standard'''
=====Epididymal sperm retrieval=====
**Technique
*'''<span style="color:#ff0000">Techniques (2):'''
***May be performed using either general, spinal, or local anesthetic.
*#'''<span style="color:#ff0000">Microsurgical Epididymal Sperm Aspiration (MESA)'''
*'''Percutaneous Testicular Biopsy'''
*#'''<span style="color:#ff0000">Percutaneous Epididymal Sperm Aspiration (PESA)'''
**'''A blind procedure that could result in unintentional injury to either the epididymis or the testicular artery'''
=====Testicular sperm retrieval=====
**'''The midsection of the testis has relatively fewer vessels compared with superior or inferior areas'''
*'''<span style="color:#ff0000">Techniques (3):'''
**'''Should not be used when previous surgery has resulted in scarring and obliteration of normal anatomy'''
*#'''<span style="color:#ff0000">Open Testicular Sperm Extraction (TESE)'''
*'''Percutaneous Testicular Aspiration'''
*#*Allows retrieval of the largest number of sperm with potential for cryopreservation
**Technique
*#*'''Remains the gold standard'''
***Performed with a 23-gauge needle or angiocath sheath  
*#*Involves wide opening of the tunica albuginea to allow examination of multiple regions of testicular tissue, each of which are oriented in a centrifugal pattern in parallel to the intratesticular blood supply, allowing extensive search of nearly all areas of the testis with limited risk of devascularization of tissue.[https://pubmed.ncbi.nlm.nih.gov/33295257/]
**Less invasive and less painful than percutaneous biopsy
*#**'''<span style="color:#ff0000">Preferably done with an operating microscope (micro-TESE)'''
**'''Usually yields few tubules with poorly preserved architecture'''
*#***Conventional TESE has been associated with decreased postoperative testosterone levels, and males men with non-obstructive azoospermia have baseline testosterone deficiency levels.
 
*#***Less effect on testosterone levels is seen after micro-TESE than with conventional TESE, but testosterone deficiency requiring testosterone replacement remains a risk, even after micro-TESE.
==== Adverse Events ====
*#*Contraindications
*'''<span style="color:#ff0000">Most serious potential complication: inadvertent biopsy of the epididymis'''
*#**Sertoli-only cell syndrome
**If histologic evaluation of the biopsy material reveals epididymis with sperm within the epididymal tubule, obstruction of the epididymis at the site of the biopsy is certain.
*#**Spermatogenic arrest
***If there are no sperm within the epididymal tubules, the patient is either obstructed above the level of the epididymal biopsy site or has primary seminiferous tubular failure and no harm has been done.
*#*Adverse events
*'''Most common potential complication: hematoma'''
*#** Decreased postoperative testosterone levels
 
*#'''<span style="color:#ff0000">Percutaneous core biopsy'''
===Surgical Sperm Extraction===
*#*Uses the same 14-gauge biopsy gun used for prostate biopsy
====Indications====
*#*'''A blind procedure that could result in unintentional injury to either the epididymis or the testicular artery'''
#'''<span style="color:#ff0000">Azoospermia (obstructive or non-obstructive)'''
*#*'''The midsection of the testis has relatively fewer vessels compared with superior or inferior areas'''
#'''<span style="color:#ff0000">Ejaculatory dysfunction'''
*#*'''Should not be used when previous surgery has resulted in scarring and obliteration of normal anatomy'''
*#'''<span style="color:#ff0000">Percutaneous aspiration (testicular sperm aspiration [TESA])'''
*#*Done with a high-suction glass syringe and a 23-gauge needle or angiocath sheath
*#*'''Least invasive and least painful procedure but usually yields few tubules with poorly preserved architecture and often requires 10 to 20 passes to obtain an adequate yield'''
* '''Adverse Events'''
**'''Most common complication is hematoma'''
====Approach====
====Approach====
*'''<span style="color:#ff0000">Classified: Testicular vs. Epididymal'''
*'''<span style="color:#ff0000">If azoospermia'''
*'''<span style="color:#ff0000">Testicular sperm retrieval'''
**'''<span style="color:#ff0000">Due to obstruction, sperm may be extracted from either the testis or the epididymis.[https://pubmed.ncbi.nlm.nih.gov/33295257/ ★]'''
**Mainstay in the management of the man with non-obstructive azoospermia[https://pubmed.ncbi.nlm.nih.gov/33295257/ §]
*** Fertilization, pregnancy, and live birth rates similar for epididymal and testicular derived sperm in men with azoospermia due to obstruction
**'''Techniques (3):'''
**'''<span style="color:#ff0000">Without obstruction (non-obstructive azoospermia), microdissection testicular sperm extraction (TESE) should be performed.</span>[https://pubmed.ncbi.nlm.nih.gov/33295257/ ★]'''
**#'''Open Testicular Sperm Extraction (TESE)'''
**#*A surgical procedure that involves wide opening of the tunica albuginea to allow examination of multiple regions of testicular tissue, each of which are oriented in a centrifugal pattern in parallel to the intratesticular blood supply, allowing extensive search of nearly all areas of the testis with limited risk of devascularization of tissue.[https://pubmed.ncbi.nlm.nih.gov/33295257/]
**#**'''Preferably done with an operating microscope (micro-TESE)'''
**#***Conventional TESE has been associated with decreased postoperative testosterone levels, and many men with non-obstructive azoospermia have baseline testosterone deficiency levels.
**#***Less effect on testosterone levels is seen after micro-TESE than with conventional TESE, but testosterone deficiency requiring testosterone replacement remains a risk, even after micro-TESE.
**#*Contraindications
**#**Sertoli-only cell syndrome
**#**Spermatogenic arrest
**#*'''Allows retrieval of the largest number of sperm with potential for cryopreservation'''
**#'''Percutaneous core biopsy'''
**#*Uses the same 14-gauge biopsy gun used for prostate biopsy
**#'''Percutaneous aspiration (testicular sperm aspiration [TESA])'''
**#*Done with a high-suction glass syringe and a 23-gauge needle.
**#*'''Least invasive procedure but often requires 10 to 20 passes to obtain an adequate yield'''
*'''Epididymal sperm retrieval'''
**'''Techniques (2):'''
***'''Microsurgical Epididymal Sperm Aspiration (MESA)'''
***'''Percutaneous Epididymal Sperm Aspiration (PESA)'''
*'''<span style="color:#ff0000">Selection of approach</span>'''
**'''<span style="color:#ff0000">If azoospermia due to obstruction, testicular or epididymal extraction</span>[https://pubmed.ncbi.nlm.nih.gov/33295257/ ★]'''
***Fertilization, pregnancy, and live birth rates similar for epididymal and testicular derived sperm in men with azoospermia due to obstruction
**'''<span style="color:#ff0000">If non-obstructive azoospermia, microdissection testicular sperm extraction (TESE) should be performed.</span>[https://pubmed.ncbi.nlm.nih.gov/33295257/ ★]'''
**#Micro-TESE was observed to result in successful extraction 1.5 times more often than non-microsurgical testis sperm extraction
**#Micro-TESE was observed to result in successful extraction 1.5 times more often than non-microsurgical testis sperm extraction
===Vasography===
===Vasography===
*'''Absolute indications (must have all 3):'''
*'''Absolute indications (must have all 3):'''
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**Hematoma
**Hematoma
**Sperm granuloma
**Sperm granuloma
===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
===Vasovasostomy/Vasoepididymostomy===
===Vasovasostomy/Vasoepididymostomy===
*Microsurgical reconstruction is done by anastomosing the vas to the most distal site in continuity with the testis, documented by identifying sperm at this region of the reproductive tract. [https://pubmed.ncbi.nlm.nih.gov/33295257/ '''★''']
*Microsurgical reconstruction is done by anastomosing the vas to the most distal site in continuity with the testis, documented by identifying sperm at this region of the reproductive tract. [https://pubmed.ncbi.nlm.nih.gov/33295257/ '''★''']
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***'''If the fluid expressed from the vas is found to be thick, white, water insoluble, and toothpaste-like''' in quality, microscope examination rarely reveals sperm. Under these circumstances, '''the tunica vaginalis is opened and the epididymis inspected. If clear evidence of obstruction is found—that is, an epididymal sperm granuloma with dilated tubules above and collapsed tubules below—vasoepididymostomy is performed.''' When in doubt, or if not very experienced with vasoepididymostomy, vasovasostomy should be performed.
***'''If the fluid expressed from the vas is found to be thick, white, water insoluble, and toothpaste-like''' in quality, microscope examination rarely reveals sperm. Under these circumstances, '''the tunica vaginalis is opened and the epididymis inspected. If clear evidence of obstruction is found—that is, an epididymal sperm granuloma with dilated tubules above and collapsed tubules below—vasoepididymostomy is performed.''' When in doubt, or if not very experienced with vasoepididymostomy, vasovasostomy should be performed.
****Vasoepididymostomy should only be performed on an epididymal tubule containing sperm
****Vasoepididymostomy should only be performed on an epididymal tubule containing sperm
**'''See Table 67-2 CW12th edition for relationship between gross apperance of vasal fluid and microscopic findings'''
**'''Relationship between gross appearance of vasal fluid and microscopic findings'''
***'''UrologySchool.com Summary'''
***'''UrologySchool.com Summary'''
****'''Clear/thin, water vasal fluid: vasovasostomy'''
****'''Clear/thin, water vasal fluid: vasovasostomy'''
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*'''<span style="color:#ff0000">Stimulation can be done with penile vibratory devices or electroejaculation'''
*'''<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§'''
**'''<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 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'''
***'''<span style="color:#ff0000">If lesion T10 or below, consider electroejaculation'''
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**'''<span style="color:#ff0000">Ejaculatory stimulation for men with spinal cord injuries may result in autonomic dysreflexia'''
**'''<span style="color:#ff0000">Ejaculatory stimulation for men with spinal cord injuries may result in autonomic dysreflexia'''
***'''<span style="color:#ff0000">Autonomic dysreflexia'''
***'''<span style="color:#ff0000">Autonomic dysreflexia'''
****'''See 2019 CUA NLUTD Guideline Notes'''
****'''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'''
****'''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'''
****'''More common with spinal cord injury at a level of T6 or above'''
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****'''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'''
****'''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
===Assisted Reproductive Technology===
===Assisted Reproductive Technology===
====Indications====
====Indications====
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