Andrologische Diagnostik

Andrology was included as a further subject for continuing education in the Model Ordinance on Continuing Education at the 106th German Physicians Meeting in Cologne in 2003. In addition to fertility disorders, this discipline comprises medical care for men with fertility disorders, erectile dysfunction, disorders of libido, ejaculation and coitus, various forms of hypogonadism, and delayed puberty. Furthermore, this field also covers questions concerning male contraception, gynecomastia, and male senescence. Diagnostic procedures in andrology require close interdisciplinary cooperation between gynecologists, human geneticists, and specialists in psychosomatic medicine. They includes medical history, clinical examination, and laboratory analyses. Except for confirming azoospermia, it is not possible to make a definitive prognosis of fertility based on semen analysis. Functional tests allow a better assessment of the spermatozoa’s fertility since 25–30% of men desiring a child exhibit reduced spermatozoan functions which cannot be verified on routine semen analysis.     

Has the fertility of Danish men declined through the years in terms of semen quality? A comparison of semen qualities between 1952 and 1972

The semen analysis of 1,077 men examined in 1952 was compared with the semen analysis of 1,000 men examined in 1972 in order to assess if fertility in Danish men has declined during the period. The men on both occasions were examined because of a fertility problem. In 1952 6.2% of the men had azoospermia compared with 3.9% in 1972 (P less than 0.05). Between 1952 and 1972 there was a fall in sperm count (P less than 0.01, median 73.4, and 54.5 mill/ml), a deterioration in spermatozoa motility (P less than 0.001), an increase in number of abnormal spermatozoa (P less than 0.01, median 26.0%, and 44.8%), and a deterioration in fertility class according to the Hammen system (P less than 0.001). Semen volume and number of immobile spermatozoa did not change. This study of Danish men, like studies from other industrialized countries, indicates a fall in semen quality and male fertility since the early fifties.     

Workup for male infertility

Male infertility is evaluated primarily with the semen analysis. Infertile men can be classified as hypogonadotropic, hypergonadotropic or normal gonadotropic. Even normal results on the semen analysis, however, can indicate male infertility. The presence of infections or sperm antibodies can diminish fertilizing capacity. Subtle biochemical abnormalities can result in defects in the sperm head that can be detected with the hamster oocyte penetration assay. A thorough evaluation of the male partner is necessary in all cases of infertility. Reevaluation is important in men with a normal semen analysis when no cause of decreased fertility is apparent or when therapy in the woman fails to result in pregnancy.     

Mapping men’s anticipations and experiences in the reproductive realm: (in)fertility journeys

This paper examines men’s experiences of fertility/infertility against a backdrop of changing understandings of men’s role in society and medical possibilities. It presents findings from two qualitative research projects on men’s experiences of engagement with reproductive health services as they sought to become fathers and anticipate impending fatherhood. The findings from both projects provide insights into men’s experiences of (in)fertility and their engagement with services set against cultural ideals of masculinity. Discussions of reproduction have historically focused most centrally upon women’s bodies and maternal processes, leaving little space for consideration of men’s experiences and perspectives. While women’s experiences of infertility/fertility have been characterized in relation to productive or faulty biological processes, male infertility has been largely invisible and male fertility typically assumed. This context provides a difficult terrain for men in which to contemplate the potential of not being able to father a child. The findings discussed in this paper illuminate the ways in which men talk about and make sense of their reproductive journeys. In doing so, it challenges current understandings of masculinity and reproductive bodies and highlights the need to rethink how men are treated in reproductive spheres and how services to men are delivered.This paper examines the results of two interview studies that explored men’s experiences of fertility and infertility against a backdrop of changing understandings of men’s role in society and rapidly changing medical possibilities. It draws together two separate qualitative research projects that explored men’s experiences of seeking to become fathers. One followed men as they became fathers for the first time, the other was a study of men’s experiences of infertility. The findings from both projects are analysed to provide insights into men’s experiences of fertility and infertility and their engagement with health services, set against current social and cultural ideas of masculinity. Before the advent of fertility treatment, discussions of reproduction focused almost exclusively on the woman’s body. Pregnancy and childbirth was women’s business. There was little consideration of men’s experiences and perspectives. Although male factor infertility is now a leading cause of couples seeking treatment, the focus remains the woman. As assisted reproduction treatment has developed over the last half-century, most social and psychological research has explored the woman’s perspective. The findings discussed in this paper illuminate the ways in which men try and make sense of their own successful or unsuccessful reproductive journeys. In doing so it challenges current understandings of masculinity and reproductive bodies. It also highlights how we need to perhaps rethink how men are treated in reproductive spheres and how services to men are delivered.     

The use of sperm penetration assay in evaluation of men with varicocele

In order to study the ability of the sperm penetration assay (SPA) to correctly classify the fertility status of men, we prospectively examined the results of the SPA performed on the semen of three groups of men of known fertility status. The groups included 67 normal men without varicoceles whose wives were pregnant (VARN), 51 men with a palpable varicocele whose wives were pregnant (VARF), and 30 infertile men with varicoceles (VARI). Two SPAs were done on each subject. Ninety-seven percent of the VARIs showed less than 15% penetration on a single test, and 91% showed less than 15% on both tests. On a single test 61% of the VARNs and 68% of the VARFs were less than 15%. If 0 penetration were used as the criteria of infertility, then 40% of the VARIs, 27% of the VARFs, and 12% of the VARNs would be classified as being infertile. These data suggest that the SPA cannot independently define male fertility status and should be used in conjunction with the standard semen analysis and clinical evaluation of the couple to assess male fertility potential.     

Management of weight loss in obesity-associated male infertility: a spotlight on bariatric surgery

In recent years, there has been a paralleled increase between male obesity and infertility rates. Obesity is associated with impaired hypothalamic-pituitary-gonadal axis, aberrant semen parameters, and subfertility or infertility. Weight loss is strongly recommended for the management of obesity-associated infertility. Lifestyle modifications that include caloric restriction and increased physical activity have a short-lived impact. Bariatric surgery is a better and more durable weight loss alternative. Comprehensive information about the benefits of weight loss on obesity-associated male infertility following bariatric surgery is still emerging. In this review, we discuss the hormonal, physical and environmental mechanism contributing to obesity-associated infertility. We then assess weight loss approaches, which include lifestyle modification, medical and surgical approaches, that can improve fertility in obese men. This review focuses also on bariatric surgery for the management of obese men seeking fertility treatment. Anecdotal evidence suggesting that bariatric surgery can impair fertility is also discussed.     

Effects of male age on semen quality and fertility: a review of the literature

OBJECTIVE: To review the literature on the association between male age and semen quality (semen volume, concentration, motility, and morphology) and fertility status (pregnancy rate and time to pregnancy/subfecundity). METHOD(S): Review of English language-published research over the last 20 years from January 1, 1980, through December 31, 1999, using MEDLINE and Biosis databases. Studies with insufficient numbers of subjects, case reports, case series, or anecdotal data were excluded. RESULT(S): Among the methodologically stronger studies, decreases in semen volume of 3%-22%, decreases in sperm motility of 3%-37%, and decreases in percent normal sperm of 4%-18% were likely when comparing 30-year-old men to 50-year-old men. Most studies examining fertility status suggest a relationship between male age and fertility, but the results are most likely confounded by female partner age. Among studies that did control for female age, comparisons between men under 30 and men over 50 found relative decreases in pregnancy rates between 23% and 38%. A comparison of the various age categories showed that the increased risks for subfecundity ranged from 11% to 250%. CONCLUSION(S): The weight of the evidence suggests that increased male age is associated with a decline in semen volume, sperm motility, and sperm morphology but not with sperm concentration.     

Assisted reproductive technologies for male factor infertility

Experience in the diagnosis and treatment of infertility has led to an increased understanding of the prominent role male factors play in many couples' inability to conceive. While many forms of male factor infertility are amenable to treatment, for some patients there is no corrective therapy available. For this reason, a great deal of attention has been focused on developing technologies for semen processing and sperm utilization in cases of decreased semen quality. One area of research is the development of more sophisticated methods of assessing sperm function, as well as methods of sperm preparation. Progress is also being made in the application of technologies such as intrauterine insemination and in vitro fertilization in the treatment of male factor infertility. Such developments have improved prospects for fertility among patients suffering from decreased semen quality, as well as those suffering from such disorders as ejaculatory failure and congenital vasal agenesis. Current research also offers promise for future applications such as gamete micromanipulation. This technology holds potential for improving fertility even among patients suffering from profound male factor disorders. The following is a summary of recent publications pertaining to the application of these assisted reproductive technologies in the management of male factor infertility.     

Current options for preservation of fertility in the male

Modern cancer therapies have greatly improved survival rates in men of reproductive age and younger; however, surgery, chemotherapy, and irradiation may lead to male infertility. Men with cancer should be counseled about fertility preservation before initiating therapy, when possible. Currently, options for male fertility preservation include cryopreservation of semen or testicular tissue. However, prepubertal boys pose a special problem in this area.     

Reliability and accuracy of the zona-free hamster ova assay in the assessment of male fertility

Summary. The efficacy of the zona-free hamster ova assay in assessing male fertility was studied in 22 men of proven fertility, 16 of unproven fertility, and 31 who were members of infertile couples. The mean hamster ova penetration rates were significantly higher in males of proven fertility (34%) and unproven fertility (30%) than in infertile males (11%). Sperm from 21 of 22 men of proven fertility penetrated >15% of ova; one man had a zero penetration rate. Sperm from 8 of 16 men of unproven fertility and 24 of 31 men of infertile couples penetrated <15% of ova. There was no correlation between penetration rates and any of the traditional measures of semen analysis. Two assays were performed on every male and six assays were performed on six males. There was good interassay reliability in all 69 males ( r =0·86) and in the six males with six tests ( r =0·97). The mean interassay variation was 8·6%.     

Environmental toxicants and male fertility

Semen quality has declined especially among Western men. Experimental and epidemiological studies have shown potential links between exposure to environmental toxicants and poor male fertility. Some environmental exposures in utero can disrupt fetal testicular function and result in cryptorchidism, low semen quality, low serum testosterone levels, and low fertility. Environmental exposure in childhood and adulthood can also adversely affect germ cells, Sertoli cells, Leydig cells, or the hypothalamic-pituitary-testicular axis, resulting in impaired male fertility. In this review, we report the latest results from human studies that investigated the role of endocrine disrupting chemicals, heavy metals, tobacco smoking, alcohol drinking, and use of marijuana in low semen quality and impaired male fertility. Current evidence suggests the relationship between these environmental factors and low male fertility; however, some factors showed conflicting results which need further investigation.     

Deterioration of semen parameters over time in men with untreated varicocele: evidence of progressive testicular damage.

OBJECTIVE: To report observations of semen parameters in men with untreated varicocele over time. DESIGN: Semen parameters in 13 men with varicoceles were obtained at initial presentation, and re-evaluated at a 9 to 96-month interval because of persistent infertility. SETTING: Outpatient male fertility clinic. PATIENTS, PARTICIPANTS: Thirteen men who presented for fertility evaluation and who were found to have varicocele(s) and normal semen parameters. Re-evaluation was performed because of continued fertility problems. INTERVENTIONS: None. MAIN OUTCOME MEASURE: Semen parameters, especially sperm density, sperm mobility, and total sperm. RESULTS: Statistically significant deterioration was noted from normal to abnormal. CONCLUSION: In males with varicocele(s), normal semen parameters should not routinely be expected to remain normal over time.     

Characteristics of semen parameters of Malawian men from couples seeking assisted reproduction

AIM: To profile semen parameters of Malawian men seeking fertility testing. METHODS: Semen analysis is a key element in the fertility evaluation of men and permits male reproductive potential to be evaluated. Semen samples were collected from consenting men after 3-5 d of sexual abstinence. The samples were collected from 130 males; 78 were male partners of infertile couples while 52 were healthy semen donors. Seminal volume, motility and morphology were assessed. The results were analyzed on Prism 5. All data are expressed as mean ± SD. Student’s t-test was used for statistical analysis. Differences were regarded as statistically significant if P < 0.05. RESULTS: Semen volume, sperm concentration, progressive motility and normal morphology were significantly higher in the control group when compared to the participant group. On the other hand, no statistically significant difference was found between the control group total sperm motility when compared to the participant group. Oligozoospermia was found in 25 cases, teratozoospermia detected in 17 cases and abnormal seminal plasma in 16 cases. Asthenozoospermia and azoospermia were found in 12 and 8 participants, respectively. This study has shown that most of the infertile patients seeking fertility testing had oligozoospermia. Teratozoospermia was the second most common abnormality found in the patients seeking fertility testing. CONCLUSION: Our study is in agreement with previous studies which reported that these parameters have been shown to be good predictors for fertilization.     

Sperm viral infection and male infertility: focus on HBV,HCV, HIV,HPV, HSV,HCMV, and AAV

Chronic viral infections can infect sperm and are considered a risk factor in male infertility. Recent studies have shown that the presence of HIV, HBV or HCV in semen impairs sperm parameters, DNA integrity, and in particular reduces forward motility. In contrast, very little is known about semen infection with human papillomaviruses (HPV), herpesviruses (HSV), cytomegalovirus (HCMV), and adeno-associated virus (AAV). At present, EU directives for the viral screening of couples undergoing assisted reproduction techniques require only the evaluation of HIV, HBV, and HCV. However, growing evidence suggests that HPV, HSV, and HCMV might play a major role in male infertility and it has been demonstrated that HPV semen infection has a negative influence on sperm parameters, fertilization, and the abortion rate. Besides the risk of horizontal or vertical transmission, the negative impact of any viral sperm infection on male reproductive function seems to be dramatic. In addition, treatment with antiviral and antiretroviral therapies may further affect sperm parameters. In this review we attempted to focus on the interactions between defined sperm viral infections and their association with male fertility disorders. All viruses considered in this article have a potentially negative effect on male reproductive function and dangerous infections can be transmitted to partners and newborns. In light of this evidence, we suggest performing targeted sperm washing procedures for each sperm infection and to strongly consider screening male patients seeking fertility for HPV, HSV, and HCMV, both to avoid viral transmission and to improve assisted or even spontaneous fertility outcome.     

Prevalence of behaviour-related fertility disorders in a clinical sample: results of a pilot study

Introduction

There is no doubt that lifestyle factors can be detrimental to fertility. The aim of the present pilot study was to identify initial prevalence rates for behaviour-related fertility disorders in a clinical sample of couples wanting a child.

Methods

Between February 2010 and August 2010, all patients coming for the first time to Heidelberg University’s Women’s Hospital for consultation on involuntary childlessness were asked to fill out a questionnaire designed by the authors of this article. The questionnaire was based on a review of the relevant literature, with special reference to the latest research findings on behaviour detrimental to fertility. Of the 156 couples addressed, 110 women and 100 men took part in the study.

Results

For behaviour-related infertility, 9?% of the women and 3?% of the men in our sample were classified on the basis of BMI <18.5, sexual disorders, or abuse of anabolic steroids. If we include smokers, these figures increase: 11?% female smokers and 18?% male smokers. A further 19?% of the women practised sport to an excessive degree; and 26?% of the women and 53?% of the men had a BMI ≥25.

Discussion

The prevalence of behaviour-related fertility disorders should not be underestimated. For the prevention of behaviour-related fertility disorders, it is important to inform the population about lifestyle-mediated fertility risks.     

Differentiation of round cells in semen by means of monoclonal antibodies and relationship with male fertility.

OBJECTIVE: To differentiate round cells in semen samples of subfertile men and evaluate the clinical significance during infertility investigation. PATIENTS: One hundred and eight randomly chosen couples with a median duration of infertility of 4 (range, 1 to 20) years presenting at the outpatient infertility clinic of the University of Heidelberg, Germany. MAIN OUTCOME MEASURES: Differentiation of round cells in semen by means of monoclonal antibodies (mABs) and a streptavidin-biotin system for staining. Correlation of results with medical history, outcome of clinical examination, sperm analysis, microbial screening of both partners, evaluation of sperm functional capacity in vivo by means of the postcoital test (PCT) and in vitro with the standardized crossed sperm-cervical mucus penetration test (SCMPT) and the subsequent fertility in a prospective study. RESULTS: The method used for differentiation of round cells proved to be practical and suitable for routine use. The percentage of leukocytes ranged from 0% to 58% with a median of 3%. Number of round cells and percentage of leukocytes did not differ markedly with regard to andrologic history, clinical findings, for example, varicocele, results of standard sperm analysis, and microbial colonization of semen samples. However, high rates of leukocytes of the round cells correlated with reduced sperm count and morphology and results of PCT. Leukocyte-positive (> 15% leukocytes) specimens were also significantly more frequent in case of inadequate SCMPT and reduced sperm penetration ability in vitro. CONCLUSIONS: In asymptomatic patients (in terms of genital tract infection), the majority of round cells consist of immature germ cells and < 5% are white blood cells. The streptavidin-biotin system and the mABs used in this study proved to be useful to identify patients with elevated rates of leukocytes in semen possibly reflecting subclinical genital tract infection with influence on sperm functional capacity and subsequent fertility. Thus the procedure can be recommended to be included in a comprehensive evaluation of male fertility.     

Varicocelectomy: twenty-five years of experience

The effectiveness of varicocelectomy in the therapy of male infertility has been well documented. We favor a modification of the Ivanissevich procedure. It is simple and can be done well by the average surgeon, and results have been excellent. Surgery is indicated by poor sperm motility and immaturity. The presence of a varicocele with the absence of this combination of semen defects would not be sufficient indication for surgery. The actual effects of varicocele on fertility are still unknown, for many men with varicocele have normal semen qualities and adequate fertility. The study of our varicocelectomy failures does not reveal any preoperative differences between them and those that show improvement after surgery.     

Evaluación de la fertilidad masculina en casa

Evaluation of the male factor is critical when a couple consults with a fertility specialist. However, for many men the process of collecting a semen sample for laboratory analysis can be stressful, which is why home semen tests are now available. This narrative review aimed to present the tests available to evaluate male fertility at home.Eleven tests on the market provide information on one or 2 seminal parameters. Likewise, tests can be found that use smartphones to obtain sperm concentration and motility results; some use the parameters stipulated by the World Health Organization and their price range is between USD 15 and USD 90. They have the advantage of privacy and comfort.Their limitations include the fact that they provide little information, and that collection and handling can affect the results. In conclusion, home tests can be used in the first instance to reveal alterations in sperm quality, especially when there are risk factors. However, these tests are not a substitute for laboratory analysis, therefore they can be used as an adjunct in evaluating the male factor.     

Prior fertility in the male partner does not predict a normal semen analysis

A history of male fertility is not an accurate predictor of a normal semen analysis result. The semen analysis should remain part of the evaluation of the infertile couple even in cases where a history of male fertility is reported.     

The value of anamnestic information regarding previous genital infection in male fertility investigation.

The study was designed to assess the value of information from male subjects under fertility investigation, regarding previous genital infection, in clarifying the causes of depressed sperm quality. Information was gathered using a questionnaire which was sent to 312 men who had previously attended our laboratory for semen analysis. A previous sexual transmitted disease (STD) in the male partner did not significantly influence the sperm quality or the pregnancy rate. However, a previous STD in the female was generally associated with a lower pregnancy rate. Previous episodes with urethral discharge, dysuria, pain with ejaculation or suprapubic discomfort had little relevance for the subsequent sperm quality. The results indicate that, in general, information provided by men under fertility investigation, regarding previous genital infections or symptoms, is only of limited value in elucidating the cause of impaired sperm quality.