bilateral vasovasostomy and bilateral epididymovasostomy with patency rates of 90% and 65%, respectively. Patients undergoing simultaneous sperm retrieval ...
Objective: As assisted reproductive technology (ART) is improving, treatment of male factor infertility becomes more applicable even in case of severely impaired semen samples. The choice of ART depends on the semen defects implicating that increase of the severity of the defect needs a technically more invasive and costly ART. Assuming that male infertility might be caused by the presence of a varicocele and that varicocele treatment increases the quality of semen, it might be useful to treat a varicocele in order to be able to apply a less invasive ART. Therefore the aim of this study is to investigate whether the treatment of varicocele improves semen quality leading to a less invasive infertility treatment. Design: We conducted a retrospective chart review of infertile male patients with a varicocele on physical examination combined with impaired semen characteristics between 1990 –2000. Materials/Methods: Semen characteristics before and after treatment were compared of those who underwent diagnosis and treatment of their varicocele by flebography and subsequent embolisation. Results: A varicocele was diagnosed by flebography in 61 male patients, of whom 50 underwent successful embolisation. In 11 patients embolisation was not performed due to complications or technical reasons. Mean improvement of semen parameters such as concentration (7.34 versus — 6.25 x 106 spermatozoa/ml), and motility after processing (3.74 versus — 0.50 x 106 progressively motile spermatozoa) were significantly higher in the successfully treated group than in the nontreatment group, p ⫽ 0.009 resp. p ⬍0.0001. In the successfully treated group, semen samples improved to levels requiring less invasive ART in 54% of the cases versus 13% in the non-treated group (p ⫽ 0.05). Deterioration of semen samples requiring more invasive techniques were resp. 13 versus 67% (p ⫽ 0.001). Conclusions: Treatment of varicocele may lead to significant improvement of semen quality requiring less invasive ART. More convincing is that treatment of varicocele seems to prevent deterioration of semen samples to levels requiring more invasive ART. Considering potential prevention of further deterioration of semen quality by varicocele treatment, embolisation might have a place in assisted reproductive technology. Supported by: None.
P-434 The effect of pentoxifylline (PF) in severe asthenozoospermia treatment on the results of ICSI program. Sohn Jie Ohn, Shin Ji Su, Lee Dong Ryul, Kim Thomas, Kim Hyun Joo, Cha Kwang Yul. Infertility Medical Ctr of CHA Gen Hosp, Seoul, South Korea; Los Angeles CHA Fertility Ctr, Los Angeles, CA. Objective: Intracytoplasmic sperm injection (ICSI) is now widely used for male factor treatment in human IVF/ET program. Although poor sperm parameters including count, sperm motility and morphology has been reported not important in ICSI program, sperm motility is a prerequisite indicator to find viable spermatozoa in the treatment of severe asthenozoospermia. Pentoxifylline (PF) and other methylxanthines are known to influence sperm metabolism and motility. Because of its enhancing effect on sperm motility and its role in facilitating the acrosome reaction, the agent is now commonly used in human ICSI program to easily find motile spermatozoa. It has been postulated that PF, being a phosphodiesterase inhibitor, increase sperm kinetic parameters and the number of spermatozoa exhibiting hyperactivated motility by raising the intracellular content of cAMP, a molecule involved in the generation of sperm energy. The aim of study was to evaluate the effect of PF on the conventional ICSI program undergone in severe asthenozoospermia. Design: A study was undertaken at the Infertility Medical Center, CHA General Hospital comparing the clinical results of ICSI between PF treated and PF untreated group. Materials/Methods: Total 348 cycles of ICSI program were undertaken at CHA General Hospital from January, 1996 to September, 2000, were divided into two groups: injected with PF treated sperm (PFT, 204 cycles) or non PF treated sperm (NPFT, 144 cycles) and the clinical results of PFT group were compared with those of NPFT. Results: PF-treatment on sperm increased their motility of normozoospermia and severe asthenozoospermia. Fertilization rate of PFT group was higher than those of ICSI programs undertaken using sperm of NPFT (69.7% vs. 62.9%, p ⬍0.01). And, embryo transfer and pregnancy rates of PFT were slightly higher than those of NPFT (93.1%, 44.2% vs. 90.3%, 36.2%).
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Conclusions: These results showed that treatment of PF has a beneficial role on selection of viable spermatozoa in severe asthenozoospermia.
P-435 The cost effectiveness of cryopreservation of sperm harvested intraoperatively during vasectomy reversal. Karen Elizabeth Boyle, Anthony J. Thomas Jr., Joel L. Marmar, Steven Hirshberg, Arnold M. Belker, Jonathan P. Jarow. The Dept of Urology, The Johns Hopkins Univ Sch of Medicine, The Johns Hopkins Hosp, Baltimore, MD; Section of Male Infertility, Dept of Urology, Cleveland Clin Fdn, Cleveland, OH; Div of Urology, Robert Wood Johnson Medical Sch at Camden and Cooper Hosp, Camden, NJ; The Toll Ctr for Reproductive Science and Dept of Urology, Temple Univ Hosp, Philadelphia, PA; Div of Urology, Dept of Surg, Univ of Louisville Sch of Medicine, Louisville, KY; Dept of Urology, The Johns Hopkins Univ Sch of Medicine, The Johns Hopkins Hosp, Baltimore, MD. Objective: To determine the most cost effective strategy in managing patients undergoing vasectomy reversal. Vasectomy reversal is a commonly performed operation with excellent results. Yet, some clinicians have advocated routine harvesting and cryopreservation of sperm at the time of vasectomy reversal in case it is unsuccessful. Design: Model of expected costs and results at five institutions. Materials/Methods: We established two models for vasectomy reversal, bilateral vasovasostomy and bilateral epididymovasostomy with patency rates of 90% and 65%, respectively. Patients undergoing simultaneous sperm retrieval with vasectomy reversal were assumed to undergo TESE with vasovasostomy and either MESA or TESE with epididymovasostomy. Patients undergoing sperm retrieval following unsuccessful vasectomy reversal were assumed to undergo either PESA or TESA at the time of oocyte retrieval for IVF. The costs at the five institutions were averaged. These costs include surgeon fee, anesthesia fee where applicable, IVF laboratory fees for processing, laboratory testing fees, cryopreservation fee, and transport fees where applicable. The duration of cryopreservation for sperm retrieved at the time of vasectomy reversal was assumed to be 3 years. Results: The median cost of TESE/cryopreservation performed at the time of bilateral vasovasostomy was $1,765 (range: $1,085—$2,800). The median cost of MESA or TESE with cryopreservation performed at the time of epididymovasostomy was $1,209 (range: $905—$2,488). The median cost of PESA or TESA for those patients with a failed vasectomy reversal was $500 (range: $400 —$1,455). However, since the majority of these patients will not require the procedure, their calculated financial risk following vasovasostomy is $50 and following epididymovasostomy is $175. Conclusions: Sperm retrieval with cryopreservation at the time of vasectomy reversal is not cost effective no matter how one looks at it. However, some patients may prefer to incur this cost for the peace of mind that they will not have to undergo any additional procedures despite how inexpensive or safe they may be. Supported by: None.
P-436 Testicular growth and pregnancy outcome following varicocelectomy based on testicular histology. Fabio Firmbach Pasqualotto, Antonio Marmo Lucon, Plinio Moreira Goes, Edson Borges Jr., Jorge Hallak, Sami Arap. Univ of Sao Paulo, Sao Paulo, Brazil. Objective: The association between male subfertility and varicoceles has been known for the last century. Many parameters such as grade of varicocele and sperm concentration before treatment has been related with semen parameters as well as with pregnancy rates after varicocelectomy. The purpose of this study was to evaluate two patterns of testicular histology namely germ-cell aplasia and maturation arrest and the treatment outcome following varicocele repair. Design: Prospective study. Materials/Methods: From July 1999 to November 2001, sixty patients underwent a varicocelectomy. Patients were divided into two groups according to the testicular histology: Group I (germ-cell aplasia; n ⫽ 28) and Group II (maturation arrest; n ⫽ 32). No differences were seen in the mean age, mean grade of varicocele, levels of LH, FSH and testosterone between
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the groups (p ⬎0.05). However, the mean right testicle was lower in Group I patients (16.62 ⫾ 1.87) compared to Group II (20.37 ⫾ 8.02; P ⫽ 0.02). Also, the mean left testicle was lower in Group I patients (13.62 ⫾ 1.91) compared to Group II (19.46 ⫾ 9.65; P ⫽ 0.01). The mean sperm concentration before treatment was lower in Group I (9.82 ⫾ 5.9) compared to Group II (19.97 ⫾ 22.34) (P ⫽ 0.03). No differences were seen in sperm motility before treatment (44.3 ⫾ 25.6 vs. 38.5 ⫾ 23.1) (p ⬎0.05). A semen analysis after treatment was evaluated in all patients. Pregnancy data was available in 16 patients in Group I and 26 in Group II. Results: Although no improvement in both testicular size was seen in Group II (right, 20.3 ⫾ 6.9; and left, 20.5 ⫾ 6.8), the mean volume of right testis in Group I increased (19.6 ⫾ 9.1; P ⫽ 0.02) as well as in the left testis (16.02 ⫾ 4.8; P ⫽ 0.03). Although the mean post-operative sperm concentration and motility in group II did not increase, the mean sperm concentration in Group I increased (12.05 ⫾ 4.8; P ⫽ 0.04). However, the pregnancy rate was higher in Group II (53.8%) compared to Group II (25%). Conclusions: Patients with germ-cell aplasia have an improvement in testicular size following varicocele repair compared to patients with maturation arrest. However, the pregnancy rate was higher in patients with maturation arrest compared to patients with germ-cell aplasia. Supported by: None.
P-437 Comparison of VIDAS testosterone assay with chemiluminescence and RIA methods. Lucia Grasso, Francesca Fragomeni, Elisabetta Cecconi, Maurizio Gasperi. Univ of Pisa, Pisa, Italy. Objective: purpose of the study was to compare the results of testosterone (T) evaluation by VIDAS, a new enzyme linked fluorescent assay (ELFA) with those obtained by chemiluminescence and RIA, in different clinical situations. Design: 69 sera were analysed in duplicate: 15 were from hypogonadal male subjects, 16 sera were from patients after HCG stimulation test, 17 from hypogonadal male patients during T therapy and 21 from hirsute women. Materials/Methods: Commercial kits were used for assays: VIDAS Testosterone (BioMerieux sa), Total Testosterone IMMULITE 2000, TESTOCTK, Dia Sorin s.r.l., Results: Overall, a very good correlation was found between VIDAS results and those obtained by the other two methods (r⫽0.939 and r⫽0.925 vs IMMULITE and TESTO-CTK, respectively). Considering different patient groups, correlation was again very strong in hypogonadal males (r⫽0.851 and r⫽0.890), during HCG (r⫽0.974 and r⫽0.968) and during substitution therapy (r⫽0.889 and r⫽0.868). in hirsute female correlation was somewhat lower (r⫽0.774 and r⫽0.443 vs IMMULITE and TESTOCTK, respectively) Conclusions: ELFA T assay is a good diagnostic tool, particularly in male hypogonadism both in absence of treatment and during therapy. Regarding hirsutism, in the present study diagnosis had been made on clinical grounds and most of the patients where affected by so-called idiopathic hirsutism, which is charachterized by androgen levels within normal limits. The estrogen status, as well as the levels of sex hormone binding globulin (SHBG) in these patients, had not been investigated: an interference of these factors in the assay system cannot be ruled out and should be looked for in the future.
P-438 The efficacy and safety of the use of sildenafil as an aid to ejaculatory failure at the time of in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI). Alexis Adler, Andrew McCullough, Rupa Patel, Lewis C. Krey. Program for IVF, Surg and Infertility and Dept of Urology, NYU Sch of Medicine, New York, NY. Objective: The stress of having to produce a semen sample on the day of an IVF/ICSI cycle can result in erectile and ejaculatory failure. A vicious cycle of increasing anxiety, anger, humiliation, frustration and persistent failure may result in cycle cancellation unless there is a urologist available to perform a testicular biopsy (TESE). Since 1998 we have been using sildenafil (Viagra 威) to help the anejaculatory male, achieve an erection to facilitate his semen production and potentially avoid a TESE. Although
FERTILITY & STERILITY威
sildenafil has not been shown to affect sperm function as assessed by seminal parameters, the effect on the fertilization process is unclear. We report our IVF/ICSI results in 12 cycles in which men used sildenafil to facilitate their erections and ejaculation. Design: Retrospective analysis of 12 IVF cycles at a University-based IVF program. Materials/Methods: Five men (mean age: 45 years) anticipated a ejaculatory problem and self-administered 50 mg sildenafil previously prescribed for erectile dysfunction. Five others (mean age: 37 years) failed an initial unassisted attempt to ejaculate and were offered a repeated attempt(s) at ejaculation one hour after administration of 50 mg sildenafil. All men were in a low cardiac risk category according to the Princeton Concensus Guidelines. TESE was offered to the men who were unable to ejaculate after sildenafil administration. Results: In 9 of 12 IVF/ICSI cycles (75%), the men were able to ejaculate after sildenafil administration. Two men went on to TESE and one couple cancelled the retrieval. In men who were able to ejaculate, the fertilization rate was 62% with a “take home baby” rate of 55% (5/9). The pregnancy rates for the self-administered men and for the men with ejaculatory failure were 43% (3/7) and 75% (3/4), respectively. ICSI was performed in 7 of the 11 completed cycles (64%). Despite no difference in maternal age between the non-ICSI and ICSI groups, the “take home baby” rate was 42% (3/7) in the ICSI group and 75% (3/4) in the non-ICSI group. Four pregnancies resulted in multiple live births (2 triplets and 2 twins) and all the babies were healthy. Conclusions: Sildenafil is a useful option that enables the situationally anejaculatory male to produce an ejaculate at the time of IVF. Sildenafil does not appear to negatively impact fertilization or pregnancy rates since the rates in this study were comparable to a contemporary series at our institution. The safety of sildenafil is evidenced by the fact that all babies born were healthy. Sildenafil should be offered as a first option to the man with ejaculatory failure prior to offering TESE as long as he is not using organic nitrates. Supported by: N/A.
P-439 Seminal oxidative stress (OS) is highly correlated with sperm DNA damage in men with idiopathic and male-factor infertility. Ramadan A. Saleh, Ashok Agarwal, Essam A. Nada, Mohamed H. El-Tonsy, Donald P. Evenson, Kjersten Larson. Cleveland Clin Fdn, Cleveland, OH; South Valley Univ, Sohag, Egypt; al-Minya Univ, al-Minya, Egypt; South Dakota State Univ, Brookings, SD. Objective: Seminal OS is due to an imbalance between reactive oxygen species (ROS) and total antioxidant capacity (TAC) in semen and is involved in many aspects of male infertility. Our group has recently introduced the composite ROS-TAC score as an accurate measure of seminal OS. In this study, we examined the correlation of seminal OS with sperm DNA damage and standard sperm parameters in infertile men with idiopathic and male-factor infertility. Design: Prospective study. Materials/Methods: The study included 92 infertile men, with a normal female partner, and 16 fertile donors as a control. All men had a genital exam by a male infertility specialist (AJT). Standard semen analysis (SA) was performed as per the World Health Organization guidelines (WHO, 1999). Sperm DNA damage was assessed by sperm chromatin structure assay and results expressed as DNA fragmentation index (DFI). Levels of seminal ROS and TAC were determined using a chemiluminescence assay. The composite ROS-TAC score was calculated as a measure of OS. Low score indicates high OS and vice versa. Results: Patients were classified as idiopathic (normal SA and genital exam; n ⫽ 23) (group 1) and male-factor infertility (abnormal SA with/ without abnormal genital exam; n ⫽ 69) (group 2). Comparisons between groups are shown in the table. The ROS-TAC scores were correlated positively with sperm concentration (r ⫽ 0.37; P ⫽ 0.001), motility (r ⫽ 0.39; P ⫽ 0.0007), and normal sperm forms (r ⫽ 0.44; P ⫽ 0.0001), and negatively with seminal leukocyte concentrations (r ⫽ -0.57; P ⬍0.0001) and DFI (r⫽ -0.27; P ⫽ 0.009).
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