[Echography in assisted reproduction techniques]. / L'ecografia nelle tecniche di riproduzione assistita.

The Authors describe the A.R.T. echoguided techniques, that can be routinely used in IVF/ET programs. All these techniques are simple and have replaced the previous ones. The echoguided oocyte recovery is now widely accepted instead of the laparoscopic way: the gamete intrafalloppian transfer can be easily performed under local anesthesia; the selective fetal reduction in cases of multiple pregnancies can be easily carried out on an outpatient basis.

New developments in the treatment of male sub-fertility by means of assisted fecundation techniques.

In the second bimester of 1990 we have performed IVF/ET in a group of patients who had previously been excluded from the IVF/ET programme for severe dyspermia and negative Pellet Swim-up Test (PST). This group consisted of 101 cases of whom 38 underwent semen treatment with Centrifugation on a Discontinuous Percoll Gradient (CDPG) and 63 with Pellet Swim-up (PS); the control group was made up of 31 normospermic patients where the semen was treated by PS. Furthermore, in the same period, we performed Tubal Embryo Stage Transfer (TEST) on 5 normospermic and on 2 dyspermic cases, as well as Zygote Intra-Fallopian Tubal Transfer (ZIFT) on 2 normospermic patients. In all these cases the sperm was always treated with PS. We obtained disappointing IVF/ET results in the dyspermic patients with negative PST where the semen was treated with PS, with only one pregnancy (pregnancy rate 1.6% per patient). Unexpected results were obtained in cases of severe dyspermia where the semen was treated with CDPG (5 pregnancies out of 38 cases; pregnancy rate 13.1% per patient) (chi square = 7.03, p 0.01). We obtained remarkable Test results: 4 pregnancies out of 5 cases of unexplained infertility and one pregnancy out of 2 cases of dyspermia. Moreover we obtained one pregnancy in the two ZIFT's performed. The use of CDPG, possibly associated with Test, will open new horizons in the treatment of dyspermic patients by means of assisted fecundation techniques.

[Role of intraoperative phlebography in the therapeutic approach of varicocele]. / Il ruolo della flebografia intraoperatoria nella tattica terapeutica del varicocele.

Personal experience of intraoperative anterograde phlebography of the internal spermatic vein is reported. The use of this technique is suggested for controlling the result of internal spermatic vein ligature in cases of type I varicocele according to Coolsaet, diagnosed by preoperative retrograde phlebography. Early data make it possible to conclude that intraoperative anterograde phlebography is a valuable aid in reducing the frequency of recurrences.

Varicocele and puberty. A transversal and longitudinal survey.

The interest for varicocele in the determination of male infertility has increased during the last decades. Most researchers consider varicocele as the primary cause of male infertility, but recently another group of authors give it a secondary role in the alteration of spermatogenesis. We think that the major part of the controversy depends on an absence of a systematic approach to the problem. We give a primary importance to an accurate epidemiological evaluation which consists in a transversal and longitudinal survey of male subjects in puberal age. Our data show that left varicocele is practically inexsistent before the onset of puberty; the percentage incidence of this alteration increases progressively with puberal maturity and the tends to decrease slightly when maturity is complete. By correlating this pathology with puberty we can obtain more precise informations than when it is correlated to the regestrated age. The young patients who result suffering from varicocele, must be controlled carefully and periodically for the evaluation of the period and the opportunity of a therapeutic treatment.

Urogenital inflammations: aetiology, diagnosis and their correlation with varicocele and male infertility.

The urogenital inflammations may be considered as "apparatus pathology". We analyze only inflammatory diseases of the prostate gland, because it may be extensible to the entire male genital apparatus. Among aethiological agents of infections an important role belongs to Chlamydia and Mycoplasma; we describe various methods for diagnosis of the Chlamydia and Mycoplasma infections. When objective clinical findings are poor or absent (such in prostatosis and prostatodynia) the transrectal ultrasonography demonstrates characteristic pictures useful for diagnosis and follow-up. Our clinical data and anatomo-pathological remarks suggest a real correlation between varicocele and genital inflammations (26%). This association doesn't represent the only cause of infertility, but frequently reduces the probability of male fertility.

IVF/ET and GIFT in andrology.

Improvement in both in-vitro fertilization/embryo transfer (IVF/ET) and gamete intra-Fallopian transfer (GIFT) procedures have led to a progressive extension of their use far beyond the indications represented by tubal problems. One of the most important examples of this is in the field of male infertility. Some researchers claim that IVF/ET is more efficient on the basis of the 'fertilization evidence', while others prefer the GIFT technique, stressing that as its results are clearly so much better that it should be used in all cases.

Prolactin (PRL) inhibiting substance in seminal plasma of infertile patients. Preliminary results.

The role of PRL in the control of the mechanisms of regulation of testicular function is still unclear. Indeed, hyperprolactinemia is usually associated with male hypofertility. Several studies have demonstrated that human seminal plasma (HSP) contains radioimmunoassayble PRL and than testis and prostate possess membrane receptors for PRL (Charreau et al. 1977; Aragona et al. 1977). Recently Demoulin and Franchimont have observed, in HSP, the presence of a substance capable of inhibiting PRL secretion by isolated rat pituitary cells (Demoulin et al. 1978). They abbreviated it SPIF (seminal plasma PRL inhibiting factor). The inhibition of PRL secretion was significant for concentrations equal to or higher than 4.2 l of HSP/ml of culture medium. This non steroidal substance is thermostable and trypsin resistant; the molecular weight is less than 10,000 Daltons. In this work, we have compared the SPIF activity with basal levels of LH, FSH, PRL, Testosterone and, after stimulation, in the serum of patients affected with various fertility problems.

Epididymo-testicular anomalies in the undescended testis. How important is their effect on infertility?

Infertility in subjects affected by undesceded testis occurs in from 25 to 100% of the cases according to the various Authors. This depends on whether one or both gonads are concerned and on the age when medical and/or surgical treatment of the condition was begun. Our study was made in two successive periods: first we studied the secretory causes of infertility by examining some histological parameters, (MTD, IFT), and endocrinological ones, (basal testosterone and then after HCG, basal gonadotropin and then after GnRH) in 43 subjects of ages ranging between 2 and 13 years who are affected by uni- or bilateral maldescension. We then analysed the excretory causes of infertility and classified and interpreted 108 epididymo-testicular malformations out of a total of 144 undescended testis observed during our last year of work. We conclude that from a histological point of view, from the third year after birth there is a steady progressive reduction in the tubular fertility index in undescended testis compared to scrotal testis. There is no significant reduction, however, in the mean tubular diameter up to the prepubertal phase. From the endocrinological point of view, we found a normal LH secretion and hypertonia in the pituitary secretion of FSH in bilateral maldescension, not found, however, in unilateral maldescension. Finally, anomalies concerning the epididymo-testicular relationship are found in 75% of undescended testis and of these 36% have a definite effect on infertility of the excretory type.

Hormones in the seminal fluid. The transport proteins of the thyroid hormones.

The study of the retention of titrated T3 on columns of Sephadex G-25, (Resin T3 Uptake), in the presence of untreated plasma, or plasma treated with charcoal, indicates that there are very small quantities of protein-hormone compounds present in the seminal fluid. In cases of phlogosis of the genital tract, the increase of albumin in the seminal fluid might determine an increase in the binding capacity with titrated T3. This would therefore give the possibility of a further test in the diagnostics of male infertility.

Hormones in the seminal plasma. Cortisol.

The data from previous studies on the seminal concentrations of proteic hormones result in the hypothesis that there exists a selective filter for these hormones, which is between the systemic circulation and the male genital canal. Previous data regarding sexual steroids are insufficient to verify if such a filter system also operates in the case of hormones of minor molecular weight. It would appear that the study of cortisol, a non-sexual steroid, will be more useful. The concentrations of this hormone in the peripheric blood (176 +/- 59, mean +/- ds, ng/ml) prove to be much greater than in the seminal plasma (20 +/- 9.6). No significant differences are found between normozoospermic and oligo-azoospermic subjects, either in the blood (173 +/- 184 +/- 53), or in the seminal plasma (21 +/- 12 versus 20 +/- 8). These data would seem to support the hypothesis under discussion.

Male fertility and thyroid hormones.

On the basis of the results in vitro, it seems that the testicle does not respond to the action of the thyroid hormones. The study of the relationship between the blood concentrations of these hormones and the reproductive function of the organ is being made by the Authors as a means of verifying this in vivo. The total blood concentrations of T4, (triioothyronine), and the index of free Thyroxine (IT4L) were therefore evaluated both in normal and infertile subjects. The concentrations of T4 showed a correlation both with the sperm count (r = 0.43, p = less than 0.02), and with the percentage of motile spermatozoa, (r = 0.48, p = less than 0.01). This type of correlation is not found, however, either for the T3 or for the IT4L. These data indicate that the function of the thyroid gland is linked to that of the hypothalamo-hypophyseotesticular axis. It would appear that the peripheric metabolism of the circulating hormones is not involved.

[Radiological picture Turner's syndrome]. / L'indagine radiologica nella sindrome di Turner.

A review of the relevant literature is followed by presentation of the radiological picture, particularly that of the skeleton, in 8 patients with the clinical and endocrinological features and the chromosome pattern of Turner's syndrome. An indication is given of the weight to be attached to the main and lesser radiological signs, especially in cases where the absence of somatic features and detectable hypogonadism impede early diagnosis.

Correlation between pituitary gonadotropin response to GnRH and testicular histology in subjects suffering from dyspermia.

No significant changes of LH in basal conditions and in response to GnRH stimulation were found in any of the subjects studied; the same applies to basal testosterone and testosterone after HCG stimulation. On the other hand, the pituitary response for FSH gonadotropin showed significant variations in the different groups of subjects examined. These variations were closely correlated to the stages at which spermatogenesis was arrested. The earlier the stage of spermatogenetic arrest, the more strongly enhanced the FSH response to GnRH stimulation. Further, the most significant change, and the one most liable to be suited for purposes of diagnosis, was the one observed when passing from the 1st to the 2nd degree arrest (spermatids-spermatocytes). This FSH pattern is a constant finding; so much so that in the view of some authors testicular biopsy can now be avoided in cases with strongly increased pituitary FSH reserve since in these conditions the seminal line has been shown not to go beyond the stage of the spermatocyte.

Incomplete type I male pseudohermaphroditism.

The observation of a case of male pseudohermaphroiditism offered the opportunity for an analytical review of this pathology. Clinical features and failure to respond to prolonged testosterone treatment allowed this case to be included in the group characterized by androgen resistance of which a recent classification distinguishes various types on the basis of phenotypic and hormonal features. Incomplete virilization of the external genitals and high testosterone and LH plasma levels were evidence in favour of the conclusion that the case should be classified as incomplete male type I pseudohermaphroditism.