SUCCESSFUL MANAGEMENT OF INFERTILITY DUE TO RETROGRADE EJACULATION USING ASSISTED REPRODUCTIVE TECHNOLOGIES: A REPORT OF TWO CASES

Although retrograde ejaculation is a relatively uncommon cause of infertility, it is nonetheless the most common cause of ejaculatory dysfunction. Retrograde ejaculation is characterized by either all or part of the seminal fluid going into the bladder. The initial management of patients with ejaculatory dysfunction is medical therapy. In couples who have failed medical therapy, assisted reproductive techniques using sperm harvested from either the urine or the male reproductive tract would be the ultimate option. We report successful management of two couples, both men with advanced age and complete retrograde ejaculation, by intrauterine insemination in one and in vitro fertilization (IVF) using intracytoplasmic sperm injection (ICSI) in the other using sperm harvested from urine. The cases reported herein suggest that male infertility due to retrograde ejaculation may be successfully treated in men significantly older than the usual reproductive age and that traditional methods of hydration and urine alkalinization allow for the successful recovery of fertile sperm for ART. The selection of the method of ART must be individualized to the needs of each couple based upon both male and female factors.     

MSOME及IMSI技术在辅助生殖领域中的应用进展

精子形态与功能密切相关,精子形态异常是导致男性不育的重要原因之一。自1992年卵母细胞胞浆内单精子注射（ICSI）技术首次获得妊娠以来,许多男性因素不育夫妇通过该技术获得较为满意的妊娠结局。但在×400放大倍数下常规ICSI挑选的看似正常的精子仍可能存在超微结构的异常,这可能是导致ICSI周期失败的原因之一。活精子细胞器形态学检测（MSOME）技术是Bartoov在2001年创立的一项新技术,能在高放大倍数下更深入地观察精子细微结构,有助于挑选出形态正常的精子。精子形态选择性胞浆内单精子注射（IMSI）技术是在MSOME基础上结合传统ICSI技术发展而来,为卵母细胞ICSI提供了一个新方法。通过对MSOME和IMSI的文献进行综述,探讨其临床应用价值。     

Clinical evaluation of the infertile male with respect to genetic etiologies

Severe male factor infertility may have a presently identifiable genetic basis. Y chromosomal microdeletions (e.g., an AZFc microdeletion), karyotypic anomalies (e.g., Klinefelter Syndrome), and mutations in both alleles of the cystic fibrosis transmembrane conductance regulator (CFTR) gene may be found, depending upon the etiology of the reproductive compromise. Which patients should be tested, what are the tests that can be performed, when should those tests be ordered, and what might a positive outcome mean, are all critically valuable clinical questions for the couple that help guide evaluation and management. It is imperative that they be asked and results discussed prior to any intervention such as testis tissue extraction, microsurgical epididymal sperm aspiration, or intracytoplasmic sperm injection so that the couple can incorporate them in their decisions moving forward vis-à-vis their reproductive choices and options. The role of reproductive medicine clinicians should not be limited to just helping couples establish a pregnancy, but instead be expanded to educating them about the reasons and causes of their reproductive failure that affect not only them as individuals but also may have implications for their offspring.     

Clinical evaluation of the infertile male with respect to genetic etiologies

Severe male factor infertility may have a presently identifiable genetic basis. Y chromosomal microdeletions (e.g., an AZFc microdeletion), karyotypic anomalies (e.g., Klinefelter Syndrome), and mutations in both alleles of the cystic fibrosis transmembrane conductance regulator (CFTR) gene may be found, depending upon the etiology of the reproductive compromise. Which patients should be tested, what are the tests that can be performed, when should those tests be ordered, and what might a positive outcome mean, are all critically valuable clinical questions for the couple that help guide evaluation and management. It is imperative that they be asked and results discussed prior to any intervention such as testis tissue extraction, microsurgical epididymal sperm aspiration, or intracytoplasmic sperm injection so that the couple can incorporate them in their decisions moving forward vis-à-vis their reproductive choices and options. The role of reproductive medicine clinicians should not be limited to just helping couples establish a pregnancy, but instead be expanded to educating them about the reasons and causes of their reproductive failure that affect not only them as individuals but also may have implications for their offspring.     

Meiotic recombination errors,the origin of sperm aneuploidy and clinical recommendations

Since the early 1990s male infertility has successfully been treated by intracytoplasmic sperm injection (ICSI), nevertheless concerns have been raised regarding the genetic risk of ICSI. Chromosome aneuploidy (the presence of extra or missing chromosomes) is the leading cause of pregnancy loss and mental retardation in humans. While the majority of chromosome aneuploidies are maternal in origin, the paternal contribution to aneuploidy is clinically relevant particularly for the sex chromosomes. Given that it is difficult to study female gametes investigations are predominantly conducted in male meiotic recombination and sperm aneuploidy. Research suggests that infertile men have increased levels of sperm aneuploidy and that this is likely due to increased errors in meiotic recombination and chromosome synapsis within these individuals. It is perhaps counterintuitive but there appears to be no selection against chromosomally aneuploid sperm at fertilization. In fact the frequency of aneuploidy in sperm appears to be mirrored in conceptions. Given this information this review will cover our current understanding of errors in meiotic recombination and chromosome synapsis and how these may contribute to increased sperm aneuploidy. Frequencies of sperm aneuploidy in infertile men and individuals with constitutional karyotypic abnormalities are reviewed, and based on these findings, indications for clinical testing of sperm aneuploidy are discussed. In addition, the application of single nucleotide arrays for the analysis of meiotic recombination and identification of parental origin of aneuploidy are considered.     

Meiotic recombination errors, the origin of sperm aneuploidy and clinical recommendations

Since the early 1990s male infertility has successfully been treated by intracytoplasmic sperm injection (ICSI), nevertheless concerns have been raised regarding the genetic risk of ICSI. Chromosome aneuploidy (the presence of extra or missing chromosomes) is the leading cause of pregnancy loss and mental retardation in humans. While the majority of chromosome aneuploidies are maternal in origin, the paternal contribution to aneuploidy is clinically relevant particularly for the sex chromosomes. Given that it is difficult to study female gametes investigations are predominantly conducted in male meiotic recombination and sperm aneuploidy. Research suggests that infertile men have increased levels of sperm aneuploidy and that this is likely due to increased errors in meiotic recombination and chromosome synapsis within these individuals. It is perhaps counterintuitive but there appears to be no selection against chromosomally aneuploid sperm at fertilization. In fact the frequency of aneuploidy in sperm appears to be mirrored in conceptions. Given this information this review will cover our current understanding of errors in meiotic recombination and chromosome synapsis and how these may contribute to increased sperm aneuploidy. Frequencies of sperm aneuploidy in infertile men and individuals with constitutional karyotypic abnormalities are reviewed, and based on these findings, indications for clinical testing of sperm aneuploidy are discussed. In addition, the application of single nucleotide arrays for the analysis of meiotic recombination and identification of parental origin of aneuploidy are considered.     

Treatment of male infertility

Male factor infertility is a general term that describes a situation in which the inability to conceive is associated with an alteration identified in the male partner. This dysfunction may be associated with low sperm concentration (oligozoospermia), poor sperm motility (asthenozoospermia) or abnormal sperm morphology (teratozoospermia); however, generally, a disturbance of all these variables, oligoasthenoteratozoospermia, is mostly frequent in male subfertility. For many andrological disorders, it is not possible to find a reasonable cause and various uncontrolled treatments have been applied to infertile men, often just on an empirical basis. More recently, after the explosive development of modern assisted reproduction techniques (ARTs), feasible with a single spermatozoon [intracytoplasmic sperm injection (ICSI)], the treatment of male infertility has received new meaning and andrologists are no longer expected to achieve a quantitative increase in sperm number but are instead asked to improve the fertility potential of the single sperm cell in order to achieve better results in both in vitro fertilization and ICSI. Additional prospective studies are needed to better understand the possible role of therapy in ART candidate patients.     

雄性生殖细胞冷冻保存研究进展

随着单精子及精子细胞卵胞浆内显微受精技术的发展,雄性生殖细胞冷冻保存技术已成为辅助生殖技术的重要内容,为男性因素不育患者的临床助孕提供了物质保障基础。目前,雄性生殖细胞冷冻方法包括程序化冷冻和玻璃化冷冻;冷冻保护剂可有效降低细胞的冷冻损伤,根据其特性分为渗透性保护剂和非渗透性保护剂两大类;冷冻载体中冷冻环、冷冻叶片等应用较广泛。雄性生殖细胞冷冻的效果与冷冻方法、冷冻保护剂和冷冻载体等密切相关。     

附睾精子抽吸术结合卵细胞浆内单精子注射治疗阻塞性无精子症所致男性不育的研究

目的:探讨附睾精子抽吸术(ESA)结合卵细胞内单精子注射(ICSI)技术治疗阻塞性无精子症所致男性不育的治疗效果。方法:选择2002年1月~2003年12月到我院治疗不育症确诊为阻塞性无精子症男性不育患者,采用ESA方法吸取男性附睾液,分离精子用于ICSI;同时按常规体外受精-胚胎移植方法(IVF-ET),采用GnRH-α+FSH/hMG+hCG促排卵方案对女性进行促排成熟卵细胞(M II)用于显微注射授精,受精卵体外培养3 d后移植回子宫内。结果:采用MESA结合ICSI技术治疗32周期阻塞性无精子症所致不育的夫妇,所获成熟卵(M II)162个,受精率66.28%,卵裂率62.21%,临床妊娠率31.20%。结论:采用ESA结合ICSI技术治疗阻塞性无精子症所致男性不育获得良好的效果,该方法为阻塞性无精子症男性不育患者提供了一种快速、方便、无痛、有效的治疗方法。     

精子发生障碍的遗传学研究进展

不孕不育影响着约10%～15%的夫妇,其中男性因素约占一半。精子发生障碍是男性不育的主要病因,主要表现为无精子症或少弱精子症。大量研究已经确定Y染色体及Yq微缺失与男性不育的相关性。X染色体因其在男性仅有单拷贝而在精子生成过程中表达特殊,对精子发生障碍有重要意义。对畸精子症和弱精子症患者的研究表明,位于常染色体的4个基因（SPATA16,PICK1,CATSPER和AURKC）可能与精子发生障碍有关。虽然经全球范围的努力,预期在不久的将来可提供新的基因检测技术来检测精子发生障碍的遗传学原因,但目前可用于精子发生障碍的基因测试仍然有限。     

THE GENETICS OF MALE INFERTILITY: A FIELD OF STUDY WHOSE TIME IS NOW

Idiopathic male infertility is often associated with genetic and epigenetic abnormalities. Such abnormalities include chromosome translocations and aneuploidies, Y chromosome microdeletions, and mutations of the CFTR gene. The unraveling of the human genome and ongoing animal transgenic studies have identified numerous other genes likely to be associated with male infertility. Initial reports from human studies have identified several candidate genes, including the protamine genes, SPO11, EIF5A2, USP26, ACT, and others. In addition to gene mutations and polymorphisms, damage to the chromatin resulting in single and double strand DNA breaks affects fertility. Recent studies are highlighting the role of such abnormalities in male infertility, and point to protamine defects as one cause of DNA damage. Epigenetic abnormalities also are being investigated, including the role of residual sperm mRNA in embryogenesis, and the effects of abnormal spermatogenesis on gene imprinting. These studies are pointing to complex etiologies and clinical ramifications in many infertile men.     

The importance of transmission electron microscopy analysis of spermatozoa: Diagnostic applications and basic research

This review is aimed at discussing the role of ultrastructural studies on human spermatozoa and evaluating transmission electron microscopy as a diagnostic tool that can complete andrology protocols. It is clear that morphological sperm defects may explain decreased fertilizing potential and acquire particular value in the field of male infertility. Electron microscopy is the best method to identify systematic or monomorphic and non-systematic or polymorphic sperm defects. The systematic defects are characterized by a particular anomaly that affects the vast majority of spermatozoa in a semen sample, whereas a heterogeneous combination of head and tail defects found in variable percentages are typically non-systematic or polymorphic sperm defects. A correct diagnosis of these specific sperm alterations is important for choosing the male infertility’s therapy and for deciding to turn to assisted reproduction techniques. Transmission electron microscopy (TEM) also represents a valuable method to explore the in vitro effects of different compounds (for example drugs with potential spermicidal activity) on the morphology of human spermatozoa. Finally, TEM used in combination with immunohistochemical techniques, integrates structural and functional aspects that provide a wide horizon in the understanding of sperm physiology and pathology.Abbreviations: transmission electron microscopy: TEM; World Health Organization: WHO; light microscopy: LM; motile sperm organelle morphology examination: MSOME; intracytoplasmic morphologically selected sperm injection: IMSI; intracytoplasmic sperm injection: ICSI; dysplasia of fibrous sheath: DFS; primary ciliary dyskinesia: PCD; outer dense fibers: ODF; assisted reproduction technologies: ART; scanning electron microscopy: SEM; polyvinylpirrolidone: PVP; tert-butylhydroperoxide: TBHP     

卵胞浆内单精子显微注射技术的临床应用

目的:探讨男性因素不育症和常规体外受精(IVF)失败者采用卵胞浆内单精子显微注射(ICSI)治疗的临床效果.方法:对51例男性因素不育症和常规体外受精(IVF)失败者共计59个ICSI治疗周期进行了回顾性分析.结果:59个ICSI治疗周期共取卵596个,MⅡ期卵母细胞471个,MⅡ期卵母细胞正常受精率82.21%,卵裂率89.04%,临床妊娠19例,周期临床妊娠率为32.20%.结论:对男性因素不育症和常规体外受精(IVF)失败者ICSI是一种有效的治疗方法.     

Microfluidics: The future of microdissection TESE?

Non-obstructive azoospermia (NOA) is a severe form of infertility accounting for 10% of infertile men. Microdissection testicular sperm extraction (microTESE) includes a set of clinical protocols from which viable sperm are collected from patients (suffering from NOA), for intracytoplasmic sperm injection (ICSI). Clinical protocols associated with the processing of a microTESE sample are inefficient and significantly reduce the success of obtaining a viable sperm population. In this review we highlight the sources of these inefficiencies and how these sources can possibly be removed by microfluidic technology and single-cell Raman spectroscopy.     

Hormonal therapy (hCG and rhFSH) for infertile men with adult-onset idiopathic hypogonadotropic hypogonadism

Abstract

Adult-onset idiopathic male hypogonadotropic hypogonadism (IMHH) is a very rare but treatable disease. This study was conducted to examine the efficacy and safety of a combination of human chorionic gonadotropin (hCG) and recombinant human follicle-stimulating hormone (rhFSH) for inducing spermatogenesis in men with adult-onset IMHH. Seven men (34–45 years of age) with azoospermia and/or sexual dysfunction, with a low serum testosterone concentration, and apulsatile secretion of luteinizing hormone, were referred to our hospital for infertility. All had normal secondary sexual characteristics. Thorough endocrinologic examination and magnetic resonance imaging revealed no identifiable cause of hypogonadotropic hypogonadism. Adult-onset IMHH was diagnosed in all cases and treatment was started with 150?IU rhFSH and 5,000?IU hCG, both administered two times per week. Spermatogenesis was restored in five of the seven patients. During treatment one patient achieved spontaneous pregnancy with his wife, and spermatozoa recovered from the other four patients were frozen for future use in intracytoplasmic sperm injection.     

无精子症患者基因检测分析

目的:利用全外显子测序技术,筛选无精子症患者相关基因,丰富男性不育基因库。方法:抽取20例无精子症患者外周血,提取DNA,使用杂交捕获方法构建DNA文库,采用高通量测序技术检测人类全外显子组中20099个基因的外显子区及旁侧内含子区(20bp),将测序数据与人类基因组hg19参考序列进行比对,筛选变异基因,变异位点进行Sanger测序验证。结果:共计筛选出26个基因43个变异位点,排除15个常染色体隐性遗传的单个变异位点及13个与精子运动相关的变异位点,剩余11个基因的15个变异位点可能与精子发生障碍相关,其中包括FAM71B、STARD9、CLTCL1、PCBP3、S100PBP等5个在睾丸组织高表达基因,SYCE3、EFCAB6、DDX4、KDM5D、RGS22、MTL5等6个基因可能与精子发生障碍相关。结论:通过研究筛选到可能影响男性不育的基因,为男性不育的基因诊断研究提供参考。     

High incidence of sperm dysfunction in a varicocele infertile man: case report

Studies indicate abnormal semen indicators among varicocele infertile men can be reversed to normal status after surgical repair. While semen indicators and DNA damage of sperms are reported frequently, sperm function tests are rarely performed to assess the functional status of sperms among these individuals. We report a 35-year-old male with 4 years of primary infertility who otherwise has a normal sexual life. Various analyses performed revealed the interplay of multiple abnormalities leading to the observed phenotype. The individual was diagnosed with severe sperm defects, bilateral varicocele (grade II) and endocrinopathy. The percentage of functionally normal sperms were found to be 24% for hypo-osmotic swelling, 28% for acrosome reaction and 21% for nuclear chromatin decondensation test. Cytogenetic analyses showed normal karyotype and sequence-tagged-site markers based PCR showed no deletions involving key candidate genes of the Y chromosome. A thorough investigation of infertile subjects and simple diagnostic tests are essential to detect the treatable defects, in general as well as severe infertile cases, which can improve the chances of normal conception or the success rates of in-vitro fertilization and intracytoplasmic sperm injection.     

Oxidative stress, male infertility and the role of carnitines

Oxidative stress has been shown to be a major cause of male infertility; a large proportion of infertile men have elevated levels of seminal reactive oxygen species (ROS). High concentrations of ROS cause sperm pathology such as ATP depletion leading to insufficient axonemal phosphorylation, lipid peroxidation and loss of motility and viability. L-carnitine, a naturally occurring enzymatic antioxidant, is a necessary factor in the utilization of long chain fatty acids to produce energy. Furthermore, it plays a pivotal role in the maturation of spermatozoa within the male reproductive tract. Epididymal plasma contains the highest levels of L-carnitine found in the human body, and initiation of sperm motility occurs in parallel to L-carnitine increase in the epididymal lumen. It is known that L-carnitine prevents the formation of ROS, scavenges free radicals and protects cells from peroxidative stress. Moreover, it plays a key role in sperm metabolism by providing readily available energy for use by spermatozoa, which positively affects sperm motility, maturation and the spermatogenic process. L-carnitine and its derivatives have been proposed recently for treatment of male infertility, and a number of controlled and uncontrolled human and animal studies have been conducted to indicate their possible application. As a result, antioxidant therapy with carnitines may represent a new nonhormonal option within a broader therapeutic strategy in men with ROS-mediated infertility.     

Urinary trichloroacetic acid levels and semen quality: A hospital-based cross-sectional study in Wuhan, China

Toxicological studies indicate an association between exposure to disinfection by-products (DBPs) and impaired male reproductive health in animals. However, epidemiological evidence in humans is still limited. We conducted a hospital-based cross-sectional study to investigate the effect of exposure to DBPs on semen quality in humans. Between May 2008 and July 2008, we recruited 418 male partners in sub-fertile couples seeking infertility medical instruction or assisted reproduction services from the Tongji Hospital in Wuhan, China. Major semen parameters analyzed included sperm concentration, motility, and morphology. Exposure to DBPs was estimated by their urinary creatinine-adjusted trichloroacetic (TCAA) concentrations that were measured with the gas chromatography/electron capture detection method. We used linear regression to assess the relationship between exposure to DBPs and semen quality. According to the World Health Organization criteria (<20 million/mL for sperm concentration and <50% motile for sperm motility) and threshold value recommended by Guzick (<9% for sperm morphology), there were 265 men with all parameters at or above the reference values, 33 men below the reference sperm concentration, 151 men below the reference sperm motility, and 6 men below the reference sperm morphology. The mean (median) urinary creatinine-adjusted TCAA concentration was 9.2 (5.1) μg/g creatinine. Linear regression analyses indicated no significant association of sperm concentration, sperm count, and sperm morphology with urinary TCAA levels. Compared with those in the lowest quartile of creatinine-adjusted urinary TCAA concentrations, subjects in the second and third quartiles had a decrease of 5.1% (95% CI: 0.6%, 9.7%) and 4.7% (95% CI: 0.2%, 9.2%) in percent motility, respectively. However, these associations were not significant after adjustment for age, abstinence time, and smoking status. The present study provides suggestive but inconclusive evidence of the relationship between decreased sperm motility and increased urinary TCAA levels. The effect of exposure to DBPs on human male reproductive health in Chinese populations still warrants further investigations.     

Reduced fertility among overweight and obese men

BACKGROUND: Overweight and obese men have been reported to have lower sperm counts and hormonal changes, but data are lacking regarding effects on couple fertility. METHODS: We examined the relationship between male body mass index (BMI) and infertility in couples enrolled in the Agricultural Health Study in the United States. The analysis sample was limited to couples (wife <40 years old) with an attempt at pregnancy in the last 4 years based on pregnancy and fertility data provided by wives. Infertility was defined as not conceiving a pregnancy after at least 12 months of unprotected intercourse regardless of whether or not a pregnancy ultimately occurred. Self-reported weight and height were used to calculate BMI (kg/m). Adjusted odds ratios (aORs) for infertility associated with increases in male BMI were calculated with logistic regression. RESULTS: Adjusting for potential confounders, a 3-unit increase in male BMI was associated with infertility (aOR = 1.12; 95% confidence interval = 1.01-1.25; n = 1329). There was a dose-response relationship, and the BMI effect was stronger when the data were limited to couples with the highest-quality infertility data. The association between BMI and infertility was similar for older and younger men, suggesting that erectile dysfunction in older men does not explain the association. CONCLUSIONS: This report of lower fertility in overweight and obese men needs replication. If the findings are robust, programs to prevent obesity may improve men's reproductive health and save medical costs for infertility treatment.