Undescended testis and infertility-Is hormonal therapy indicated?

PURPOSE: The purpose of this chapter is to review hormonal therapy in cryptorchidism in boys to improve fertility. METHODS: Multiple searches, primarily in PubMed, were performed using various combinations of the terms: cryptorchidism, undescended testis (UDT), hormonal therapy, fertility, infertility, germ cell numbers, spermatogonia and semen analyses. In additions the pertinent articles from the reference lists in these papers were also obtained and reviewed. RESULTS: Data on fertility in unilateral cryptorchidism does not reveal a significant risk for infertility. Testes biopsies in childhood do not correlate with fertility parameters in adulthood. In bilateral cryptorchidism there is a significant risk of infertility. Results of hormonal treatment were not reported separately for bilateral cryptorchidism. Current data is insufficient to know if hormonal therapy is efficacious in bilateral UDT. CONCLUSIONS: Hormonal therapy should not be used in childhood to improve fertility in cases of unilateral cryptorchidism. Testes biopsies in childhood to identify those at risk for infertility should not be performed in unilateral cryptorchidism. More data are needed to answer whether hormonal therapy is beneficial in bilateral UDT. There is insufficient data to establish that testis biopsies are helpful in bilateral cryptorchidism in identifying the subgroup with risk for infertility. They should not be performed in the routine clinical setting but may have a role in a research protocol.

Outcome of pregnancy in women with a history of vesico-ureteric reflux.

OBJECTIVES: To review the evidence relating to the outcome of pregnancy in women with vesico-ureteric reflux (VUR) or a previous history of VUR and to identify the factors contributing to morbidity in pregnancy, with particular emphasis on the role of renal scarring. METHODS: Searches were carried out in Medline, Pubmed and MD Consult using various combinations of the keywords including: vesicoureteral reflux and pregnancy, maternal vesicoureteral reflux, vesicoureteral reflux in adulthood, reflux nephropathy and pregnancy. All data quoted in this review are from original articles. RESULTS: The published studies showed that women with VUR that was not associated with renal scarring had no increase in the incidence of gestational hypertension, pre-eclampsia or fetal morbidity, regardless of whether their VUR was diagnosed in childhood or adulthood. However, women with VUR and normal kidneys did have higher incidence of urinary tract infection during pregnancy, which was not modified by ureteric re-implantation. Renal scarring was the primary risk factor for morbidity during pregnancy and this risk was independent of the presence or absence of VUR at the time of pregnancy. CONCLUSION: The evidence does not support the practice of correcting low-grade VUR in girls with unscarred kidneys because this will reduce their risk of complications in pregnancy. The presence of renal scarring rather than the presence or absence of reflux is the principal determinant of morbidity during pregnancy.

Screening siblings for vesicoureteral reflux.

PURPOSE: Publications on screening the siblings of patients with reflux were reviewed to determine the overall incidence and severity of reflux and renal scarring in siblings, and identify factors that predict siblings more likely to have reflux. MATERIALS AND METHODS: A MEDLINE search for 1985 to the present was performed. Of 34 articles on familial reflux only 11, including 1 abstract, on sibling screening were used in this analysis. RESULTS: The mean incidence of reflux in siblings in all studies was 32% (570 of 1,768). Of the siblings with reflux approximately two-thirds had grades I to II disease. Only 22 of 1,051 siblings (2%) had reflux greater than grade III. Reflux was unilateral in 162 of 307 cases (53%). Certain factors predicted the chance of sibling reflux. Sibling age varied inversely with the incidence of reflux. A twin relationship and absent dysfunctional voiding symptoms in the index patient may predict a higher chance of reflux in a sibling. The mean incidence of renal abnormality in siblings with reflux was 11%. The incidence of reflux and renal abnormality in the sibling population undergoing screening was 3%. In more than half of the siblings with an abnormal renal evaluation there was no history of urinary tract infection. CONCLUSIONS: The studies reveal an incidence of reflux in siblings greater than in the general population. These data do not prove that screening and treating asymptomatic siblings decreases infectious renal scarring. Studies in a control group that consider sibling age are still needed to determine the benefit of screening asymptomatic siblings.