Cancer and male infertility.

An increasing proportion of boys and young men with cancer will survive their disease and desire fertility. Unfortunately, the cancer treatment, and in some cases the malignant disease itself, may have a negative and permanent impact on the individual's fertility potential. This effect is highly dependent on the type and dose of therapy as well as the age at which it has been given. Basic knowledge in this field is necessary to enable oncologists and fertility specialists to counsel these patients about their fertility prospects and, if appropriate, advise them to take precautions (e.g. the cryopreservation of semen) to safeguard their fertility. Another aspect of the relationship between cancer and infertility is the possibility that men with testicular dysfunction may have an increased risk of testicular cancer. Screening for early testicular malignancy may therefore be advisable in some groups of men with poor semen quality.     

Management of male infertility.

The causes of infertility are known in a small proportion of patients, and only a few are treatable: gonadotrophin deficiency, genital tract obstruction, sperm autoimmunity, coital dysfunction and reversible effects of toxins, drugs or intercurrent illnesses. Other patients have reduced sperm quality or function that may be associated with previous testicular damage, varicocele or non-specific genital tract inflammation. No treatments have been proved to increase semen quality and fertility in this group; intracytoplasmic sperm injection is the most appropriate management if a natural pregnancy is unlikely to occur. Apart from the transmission of genetic and chromosomal disorders and a small increase in the number of sex chromosomal aneuploidies associated with severe spermatogenic defects, the risk of serious adverse effects in intracytoplasmic sperm injection offspring is low. The pathogenetic mechanisms of the most common forms of defective sperm production are unknown, which prevents the logical development of effective treatment.     

Contemporary concepts in the evaluation and management of male infertility

Infertility in men is a common condition. At the core of the medical evaluation of the male partner in a couple who are unable to conceive is the history and physical examination. Special attention should be directed to the patient's developmental history and any use of testosterone products. The physical examination focuses on the genitals, and includes assessments of the size and consistency of the testicles, epididymis, vas deferens, and presence of varicoceles. Although many sophisticated tests are available, semen analysis is still the most important diagnostic tool used to assess fertility, and includes parameters such as sperm count, motility and viability. Treatment of male factor infertility can involve targeted agents, in the case of specific conditions such as hypogonadotropic hypogonadism, or it can be empirical-using medical therapy or assisted conception techniques-for patients in whom no underlying cause has been identified. Although an all-encompassing treatment for male factor infertility has not yet been developed, the field offers many promising avenues of research.     

Environment, lifestyle and male infertility.

Our understanding of the importance of environmental and lifestyle factors on sperm count and fertility is constrained by the extreme variation in sperm count between men and between ejaculates. The factors responsible for this variation provide a key to understanding what factors actually affect the sperm count. The relative importance of the various factors and the pathways via which they affect sperm count are discussed. The most important are Sertoli cell number, ejaculatory frequency, season, factors affecting scrotal heating (e.g. the time spent seated), a past history of reproductive tract disorders and ageing. The possible role of other environmental factors commonly supposed to affect sperm count (exposure to pesticides or endocrine disruptors) is discussed, although the evidence for a major influence of such factors is lacking. It is suggested that lifestyle changes, especially in the time spent seated, will exert an adverse effect on sperm production in a progressively larger group of men over the next decade.     

Incidence of sulphasalazine-induced male infertility.

Sperm analysis of 21 patients taking sulphasalazine for inflammatory bowel disease revealed that 86% had abnormal semen analysis and 72% had oligospermia.     

精索静脉曲张致男性不育症外科手术治疗进展

精索静脉曲张(varicocele,VC)是男性不育的最常见原因之一,其治疗的主要方法是外科手术(如传统开放手术、腹腔镜手术、显微外科手术等)。该文就外科手术治疗精索静脉曲张的手术方法、特点、适应证与并发症进行综述,为临床医师提供参考。     

Pyospermia and male infertility

Pyospermia is found on the semen analysis of up to 23% of men who are being investigated for infertility. The presence of significant numbers of white blood cells in the semen is correlated with poorer sperm parameters and diminished fertility. It is not known if these changes in sperm function are due to the white blood cells or to an underlying problem that may cause both pyospermia and altered sperm function. It is often assumed that pyospermia is an indication of an underlying genitourinary infection. However, studies have not shown an association between bacteria growing in reproductive tract fluids (semen, urine and expressed prostatic secretions) and pyospermia. Despite this, treating these patients with different antibiotics regimens appears to reduce temporarily the white blood cell count in the semen and improve the fertility rates. Well-controlled studies are needed to determine the role of antibiotics in the treatment of this significant cause of male infertility.     

Medical and surgical management of myocardial infarction

The in-hospital and long-term mortality (18 to 56 months) of two groups of patients treated concurrently for acute transmural myocardial infarction are retrospectively compared. Group I (no. = 200) was given medical therapy, whereas Group II (no. = 187) underwent early coronary arterial bypass grafting. The groups were comparable in average age, incidence of previous myocardial infarctions, initial electrocardiographic findings (S-T segment elevation), area of electrocardiographic involvement, initial cardiac enzyme activity, coronary anatomy (when known) and Killip classes I to III on admission to the study. Significantly more patients in Group II were in Killip clinical class IV.

In-hospital mortality was lower in Group II than in Group I without (5.8 versus 11.5 percent) and with (1.2 versus 9.3 percent [P < 0.003]) exclusion of class IV patients from both groups. Long-term mortality during the observation period (18 to 56 months) was also lower in Group II without and with exclusion of class IV patients (11.7 versus 20.5 percent [P < 0.03] and 7.1 versus 18.1 percent [P < 0.005], respectively).

Group II was arbitrarily classified into two subgroups. Patients in subgroup IIA (no. 110) had abnormally elevated total creatine kinase (CK) activity (more than 90 IU) preoperatively and were placed on cardiopulmonary bypass 9.3 ± 2.6 hours (mean ± standard error of the mean) from the onset of symptoms. The in-hospital and long-term mortality rates were not significantly different from those in Group I (8.1 versus 11.5 percent and 17.2 versus 20.5 percent, respectively). Patients in subgroup IIB (no. = 77) had normal serum CK activity preoperatively and were placed on cardiopulmonary bypass 5.3 ± 1.4 hours from the onset of symptoms. The in-hospital and long-term mortality rates were significantly lower than those in Group I (2.6 versus 11.5 percent [P < 0.01] and 3.9 versus 20.5 percent [P < 0.001], respectively). In the 100 patients in Group II placed on cardiopulmonary bypass within 6 hours of symptoms regardless of CK activity, in-hospital and long-term mortality rates were significantly lower than in patients receiving medical therapy (2.0 versus 11.5 percent [P < 0.01] and 6.0 versus 20.5 percent [P < 0.001), respectively. Of the 100 patients, 46 were from subgroup IIA and 54 from subgroup IIB. The inhospital mortality rate was 2.1 percent (1 of 46) and 1.8 percent (1 of 54), respectively.

These preliminary data suggest that if the result of surgical reperfusion as treatment for acute evolving myocardial infarction is to be significantly different from that of medical management, reperfusion must be performed early in the course of infarction. A controlled randomized trial is suggested     

Medical and surgical management of severe colitis

The management of severe ulcerative colitis and Crohn's colitis remains a challenge, despite significant advances in medical and surgical therapy. Optimal management of the patient with severe colitis requires close collaboration between the gastroenterologist and surgeon. All patients with severe colitis should be hospitalized and treated with intravenous corticosteroids. If significant improvement does not occur within 7 to 10 days, then intravenous cyclosporine therapy or surgery is appropriate. Newer medical therapies, including heparin, tacrolimus, and other immunomodulatory agents, show promise for the treatment of severe colitis. When surgery is necessary, a total abdominal colectomy with ileostomy is the appropriate surgical intervention in most cases. In patients presenting with fulminant colitis, toxic megacolon, or perforation, earlier surgical intervention is indicated. The evaluation of and approach to the medical and surgical management of severe colitis will be reviewed.     

Mitochondria-related male infertility

Approximately 15% of human couples are affected by infertility, and about half of these cases of infertility can be attributed to men, through low sperm motility (asthenozoospermia) or/and numbers (oligospermia). Because mitochondrial genome (mtDNA) mutations are identified in patients with fertility problems, there is a possibility that mitochondrial respiration defects contribute to male infertility. To address this possibility, we used a transmitochondrial mouse model (mito-mice) carrying wild-type mtDNA and mutant mtDNA with a pathogenic 4,696-bp deletion (DeltamtDNA). Here we show that mitochondrial respiration defects caused by the accumulation of DeltamtDNA induced oligospermia and asthenozoospermia in the mito-mice. Most sperm from the infertile mito-mice had abnormalities in the middle piece and nucleus. Testes of the infertile mito-mice showed meiotic arrest at the zygotene stage as well as enhanced apoptosis. Thus, our in vivo study using mito-mice directly demonstrates that normal mitochondrial respiration is required for mammalian spermatogenesis, and its defects resulting from accumulated mutant mtDNAs cause male infertility.     

Chromosomal alterations and male infertility

Reduced male fertility can be caused by genetic factors affecting gamete formation or function; in particular, chromosome abnormalities are a possible cause of male subfertility as shown by their higher frequency in infertile men than in the general male population. Meiotic studies in a number of these males have shown spermatogenesis breakdown, often related to alterations in the process of chromosome synapsis. Indeed, any condition that can interfere with X-Y bivalent formation and X-chromosome inactivation is critical to the meiotic process; furthermore, asynapsed regions may themselves represent a signal for the meiotic checkpoint that eliminates spermatocytes with synaptic errors. We performed cytogenetic, hormonal and seminal studies in 333 infertile patients selected because azoospermic, severely oligozoospermic or normozoospermic with failure to fertilize the partner's oocytes in an in vitro fertilization (IVF) program. Our findings: 1) confirm the high incidence of chromosomal anomalies among infertile males; 2) highlight the relevance in male infertility of quantitative/positional modifications of the constitutive heterochromatin; and 3) underline the relevance of cooperation between andrologists and cytogenetists prior to every kind of assisted reproduction, above all prior to intracytoplasmic sperm injection, in which selective hurdles eliminating abnormal germ cells are bypassed.     

Sulphasalazine and male infertility: reversibility and possible mechanism.

Earlier observations on infertility related to sulphasalazine treatment were extended and semen samples obtained from 28 patients with inflammatory bowel disease on treatment with sulphasalazine at 2-4 g per day. Semen was examined for changes in density, motility, and morphology before, during, and after withdrawal of sulphasalazine. Gross semen abnormalities were seen in 18 patients on this drug for more than two months. Semen quality improved after sulphasalazine had been withdrawn for more than two months and 10 pregnancies are reported after sulphasalazine withdrawal. Preliminary endocrine and acetylator phenotype studies do not elucidate the mechanism of this important new side-effect of this drug. The time course of the drug's effect on semen quality is consistent with the hypothesis that sulphasalazine or a metabolite, possibly sulphapyridine, is directly toxic to developing spermatozoa. These studies confirmed the preliminary report and suggest that prolonged treatment with sulphasalazine may universally depress semen quality and cause reversible infertility.     

Medical and surgical management of portal hypertension in children

The treatment of portal hypertension in children has undergone considerable evolution in the past decade. The treatment offered depends on the cause of the hypertension and the underlying health of the liver. The diagnosis of portal hypertension often can be made by the history and physical examination. Upper gastrointestinal bleeding in the presence of splenic enlargement is pathognomonic for portal hypertension. Bleeding and hypersplenism are the principal symptoms. Treatment of bleeding starts with confirming the diagnosis with esophageal and gastric endoscopy. The patient is admitted to an intensive care unit and started on intravenous octreotide. Banding or sclerosis of esophageal varices will result in cessation of the bleeding but not a permanent cure. A careful investigation for the cause of the portal hypertension should be done. This includes imaging studies of intra-abdominal arteries and veins, a liver biopsy, and liver function tests, including coagulation studies. For patients with extrahepatic portal vein thrombosis, early consideration should be given to surgical treatment with a meso-Rex bypass. Patients with Liver disease should be treated For the underlying disorder and undergo regular endoscopic monitoring for recurrence of varices. Patients with well-compensated cirrhosis should be considered for selective surgical shunting, and those with advanced disease for liver transplantation. The benefit of long-term beta blockers in children has not been proven by clinical trials.