Practical approaches to the surgical management of achalasia

Achalasia is a primary motor disorder of the esophagus characterized by an abnormal hypertensive, nonrelaxing lower esophageal sphincter (LES) and nonfunctioning, aperistaltic esophageal body resulting in significant regurgitation and dysphagia. The primary goal of treatment is palliation of symptoms. At present, all treatment techniques are directed at relieving the functional obstruction at the level of the LES by disruption or paralysis of the esophageal muscle constituting the LES. Destruction of the LES function also places the patient at risk for pathologic gastroesophageal reflux disease. Therefore, the treatment of patients with achalasia must strike a balance between the relief of dysphagia and potential creation of pathologic gastroesophageal reflux. The advent of laparoscopic esophageal myotomy for the treatment of achalasia over the past decade has resulted in most patients with the disease being referred to surgeons for definitive treatment. At the time of consultation the patient may present with a myriad of symptoms, investigative results, and previous treatments. Based on our experience of over 300 patients treated with surgery at our institution between 1990 and 2007, this review will address the practical problems encountered in the surgical management of achalasia.     

Microsurgical management of male infertility

The introduction of microsurgical techniques has revolutionized the treatment of male infertility. As a result of technical advances and innovation over the past 10-15 years, previously infertile couples are now able to conceive naturally or to parent their own biological children with the aid of assisted reproductive technologies. This article reviews the indications, techniques, and outcomes of the various microsurgical procedures currently used to optimize male fertility. The most up-to-date methods of microsurgical vasal and epididymal reconstruction, sperm retrieval, and varicocele repair are discussed.     

Plants in the management of male infertility

This review attempts to collate existing data and provide the perspectives for future studies on the effects of plants on the male gonads. For many of these medicinal plants such as Lepidium meyenii, Rupus coreanus, Tribulus terrestres, Panax ginseng, Petasites japonicas, Apium graveolens, Eurycoma longifólia, Pedalium murex, Corchorus depressus, Mucuna pruriens, Astragalus membranaceus, Nigella sativa, Crataegus monogyna, Fagara tessmannii, Phaleria macrocarpa, Anacyclus pyrethrum, Cynomorium songaricum and Morinda officinalis, the mechanism of actions of their active principles and crude extracts has been shown in both laboratory animals, in vitro, and human studies, and includes their antioxidant, anti-inflammatory, spermatogenesis-inducing, aphrodisiac, smooth muscle relaxing and androgenic properties. Several active chemical leads including glucosinolates, anthocyanins, protodioscin, ginsenosides, sesquiterpenes, phyto-oestrogens, quassinoids, diosgenin, thymoquinone, proanthocyanidins and bajijiasu isolated from these plants are known to have target effects on the testis, but efforts have been limited in their application at the clinical level. There still appear to be many more extracts of medicinal plants that have not been characterised to determine the phytochemicals unique to them that have target effects on the gonads. Further, collaborative efforts at isolating pro-drug candidates from medicinal plants for studies at the molecular, cellular and clinical level towards elucidating their mechanisms of action on the testes are therefore warranted in the light of the current male fertility crisis.     

代谢组学在男性不育诊疗中的应用研究

代谢组学是研究生物体内源性小分子代谢物的新兴学科。代谢组学通过对体液、细胞及组织的研究,在男性不育疗效评价中发挥着重要作用。这种高信息量、无创、快速的研究技术进入临床应用将成为未来的发展趋势。本文介绍了代谢组学及其分析技术和数据处理过程,并介绍了代谢组学对男性不育有害物质暴露、生物标志物和药物治疗等的研究,对其在男性不育病因探究和诊疗中的最新研究进展进行了综述,最后提出代谢组学在男性生殖领域的研究前景。     

Genetic causes and management of male infertility

Infertility affects approximately 15% of couples. With infertility such a common problem in a generally healthy age group, complete evaluation is needed of both men and women. Infertility work up for men includes a semen analysis, the results of which suggest various supplemental studies, including karyotype. Karyotype is indicated when a patient has findings on history or physical exam concerning for chromosomal abnormalities, azoospermia, or severe oligospermia (count <5 million/mL). The most common chromosomal numerical abnormality found on karyotype is Klinefelter syndrome which is classified as redundant sex chromosomes, with the most common chromosomal arrangement being 47, XXY. If a patient is found to have a chromosomal abnormality such as Klinefelter’s, there is still a chance of fertility using testicular sperm extraction and in-vitro fertilization.     

Surgical techniques for the management of male infertility

Evaluation and surgical treatment of male infertility has evolved and expanded, now leading to more precise diagnoses and tailored treatments with diminished morbidity and greater success. Surgeries for male infertility are divided into four major categories: (i) diagnostic surgery; (ii) surgery to improve sperm production; (iii) surgery to improve sperm delivery; and (iv) surgery to retrieve sperm for use with in vitro fertilization and intracytoplasmic sperm injection (IVF-ICSI). While today we are more successful than ever in treating male infertility, pregnancy is still not always achieved likely due to factors that remain poorly understood. Clinicians treating infertility should advocate for couple-based therapy, and require that both partners have a thorough evaluation and an informed discussion before undergoing specific surgical therapies.     

Modern concepts in the diagnosis and treatment of male infertility

The use of modern techniques to manipulate sperm has assisted many couples in their effort to achieve pregnancy. Use of the techniques is dependent upon adequate and complete diagnostic data to determine if the techniques would be beneficial for a particular couple. The participation of a urologist in these techniques can take many forms but should be active to assure the best treatment for the male patient with fertility difficulties and to prepare the sperm with the available techniques prior to use for insemination or in-vitro fertilization. The future looks exciting and is sure to bring many more new developments that will benefit couples with fertility problems.     

男性不育症诊治新进展

辅助生殖技术,特别是卵泡浆内精子注射技术应用于治疗男性不育,对难治性男性不育治疗取得突破性进展,但对于每一男性不育个体选择治疗时,仍应关注传统诊疗方法。对男性生殖相关的遗传学研究和干细胞工程研究受到重视。     

Clomiphene citrate in the management of male infertility.

There were 35 hypofertile men who underwent assay of serum follicle stimulating and luteinizing hormones, and testosterone, and were placed in a trial program using clomiphene citrate in a 25-day cycle, with 5-day rest periods. Therapy has been maintained for up to 9 months with a projected termination of 12 months. No relationship could be established between serum follicle stimulating hormone and spermatozoal number in this population. The spermatozoal count improved in 31 men while they were on therapy and 8 pregnancies have occurred. Clomiphene citrate seems to be effective in improving the quanttity of spermatozoa and the spermatozoal motility in these hypofertile men.     

Infection in the male reproductive tract. Impact, diagnosis and treatment in relation to male infertility

The following are the conclusions that can be derived from a review of the literature regarding the role of infection in the aetiology of male infertility. (i) Temporary inflammatory episodes in the male reproductive tract which are self-limiting are probably common. (ii) Caution should be exercised in the use of leukospermia or bacteriospermia as parameters for glandular infection. (iii) There is a need for alternative techniques for detecting non-symptomatic deep pelvic infections in the male; one technique of great promise is rectal ultrasound. (iv) Rectal ultrasound indicates that a large number of men with poor sperm quality have a non-symptomatic, chronic prostatovesiculitis. (v) Increasing evidence implicates Chlamydia trachomatis as being a major cause of chronic non-bacterial prostatitis. (vi) An important aspect of chlamydial infections in men may be that the male accessory sex glands may function as reservoirs for the organism, increasing the probability of infection in the female. (vii) Ureaplasma urealyticum may also play an important aetiological role in male infertility but its significance is confounded by its acknowledged function as a commensal in the reproductive tract. (viii) One of the manifestations of male reproductive tract infectiw is the induction of sperm autoantibodies. (ix) There is a need for more systematic controlled studies of the effects of antibiotic treatment on sperm quality with different preparations for extended periods using patient groups in which a glandular infection has been verified, e.g. by rectal ultrasonography.     

Surgical management of male infertility: an update

Male factor infertility is common, affecting 7% of the total population and up to half of couples who are trying to conceive. Various surgical and reconstructive options allow biological paternity depending on the etiology of the male factor issues. This article describes historical treatments and newer approaches, discussing the role for traditional open surgery, microsurgery and robotic surgery, as well as interventional radiologic procedures in the management of male infertility.     

Quantitative ultramorphological (QUM) analysis of human sperm: diagnosis and management of male infertility.

The advantages of quantitative ultramorphological (QUM) sperm analysis in the diagnosis and treatment of male infertility are presented. QUM methodology is based on three elements: (1) complementary SEM and TEM observations of 7 sperm cell subcellular organelles: acrosome, postacrosomal lamina, nucleus, neck, axoneme, mitochondrial sheath, and outer dense fibers; (2) systematic classification of the specific ultramorphological malformations into 4 pathological and the normal categories, which indicate the morphological state of each subcellular organelle; and (3) comparison between well-defined reference groups with opposite fertility status or treatment conditions. QUM analysis has enabled the establishment of two indices that optimally express the in vivo and in vitro male fertility potential: The Natural Fertility Index (NFI), which allowed an accurate prediction (97% sensitivity and 90% specificity) of 80% of the naturally fertile and suspected infertile male patients, and the in vitro fertilization (IVF) score, which enabled prediction of 76% of the nonfertilizing and 90% of the fertilizing IVF groups. Validation tests confirmed these data. QUM also enabled assessment of ultramorphological indications for varicocele and radiation exposure: Both male factor etiologies indicated a persistent effect on the natural fertility potential, as expressed by structural changes in the nucleus. Varicocele was found to cause defects in the sperm head organelles related to early spermatid development, whereas ionizing radiation resulted in amorphous head shape. Criteria for specific non-in vitro therapeutic interventions such as varicocelectomy, follicle-stimulating hormone (FSH) administration, and acupuncture treatment were established. A varicocele index, which enabled the correct classification of 79 and 89% of the patients pre- and post-high ligation, respectively, was suggested to be a good indicator for varicocele which affects the fertility potential. Males exhibiting idiopathic impairment of sperm acrosome and nucleus were found to be potential responders to FSH treatment, whereas patients exhibiting low sperm activity proved to be good candidates for acupuncture treatment. Indications for selecting the optimal appropriate assisted reproduction technique (ART) procedure were found: Patients with a low Natural Fertility Index should be recommended for ART. A first choice ART selection should be performed according to an ART index based on the ultramorphological examination of the tail axoneme. The above index enabled correct prediction of 78% of the patients who achieved pregnancy following conventional ART (intrauterine insemination or IVF) and 74% of those whose wives conceived only following intracytoplasmic sperm injection. QUM sperm analysis is clinically informative, nontraumatic, and in the long run also cost-effective. This analysis should be performed when the male infertility factor cannot be clearly diagnosed by routine tests and prior to the first ART trial.     

A comprehensive approach to the management of male infertility following spinal cord injury.

OBJECTIVES: To review the outcomes of management of male infertility following spinal cord injury in a specialised fertility clinic. STUDY DESIGN: Retrospective review of medical records. SETTING: The Fertility Clinic of a 45-bed spinal cord injury service in New South Wales, Australia. METHODS: The medical and fertility clinic records of 113 males who attended the clinic between 1987 and 1997 were reviewed. RESULTS: The rates of semen retrieval using vibroejaculation and electroejaculation were 67% and 97% respectively. Thirty-one individuals (37%) and their partners sought assistance with the primary aim of achieving a pregnancy. Intravaginal insemination (IVI) undertaken at home following vibroejaculation resulted in a pregnancy rate per cycle of 22%. Electroejaculation and IVI proved less successful with a pregnancy rate per cycle of only 5%, although with intrauterine insemination (IUI) this rate improved to 30%. Micromanipulation in vitro fertilisation (IVF) procedures, primarily intracytoplasmic sperm injection, were used in 18 couples resulting in a pregnancy rate per cycle of 19%. In the 31 couples there have been a total of 17 pregnancies in 97 cycle attempts for an overall pregnancy rate per cycle of 18% and a cumulative pregnancy rate per couple of 55%. Twelve of the pregnancies have resulted in 14 live births (including two sets of twins), there were three pregnancies ongoing at the date of review and there have been two spontaneous abortions. CONCLUSION: The benefits of a specialised fertility clinic offering a comprehensive, client-focused approach with education, fertility assessment and a range of semen retrieval and assisted reproduction options, are highlighted.