Male infertility: the impact of assisted reproductive technologies.

Spermatozoal abnormalities are present in up to 40% of infertile couples. Multiple etiologies may be responsible for these disorders, including pretesticular, testicular, and ductal causes. An adequate andrologic consultation, including history, physical examination, and repeated semen analysis, should be performed routinely in these cases. Evaluation of the basic sperm parameters, including sperm concentration, motion parameters (as evaluated by computer-assisted semen analysis), and sperm morphology (as judged by strict criteria), constitute the first obligatory step for a critical evaluation of male factor patients. Patients in whom fertilization disorders are suspected should be evaluated through bioassays of sperm-oocyte interaction, including the heterologous sperm penetration assay and hemizona assay, a bioassay of sperm-zona binding capacity highly predictive of in vitro fertilization outcome. Male disorders can be subjected to specific therapies (surgical or medical), or to empiric therapeutic modalities. Assisted reproductive technologies have enhanced our understanding of the physiopathology of spermatozoal disorders and also have ostensibly improved pregnancy rates in male factor patients.

Müllerian duct cysts: conservative management.

Three cases of the unusual entity, müllerian duct cyst, are presented. Each was managed differently, demonstrating that with appropriate patient selection either aspiration alone, aspiration and instillation of a sclerosing agent, or transurethral resection of bladder base to establish communication and cyst drainage are successful.

Evaluation of erectile dysfunction in patients with Peyronie's disease.

Of 62 hospitalized patients with Peyronie's disease 18 (29 per cent) had abnormal nocturnal penile tumescence studies that were characterized as indicating organic impotence. However, the majority of these patients had some underlying disease or factor other than the plaque itself to explain the altered nocturnal penile tumescence. In only 5 per cent of these patients could the abnormal nocturnal penile tumescence be attributable to the plaque itself. Primary excision of the plaque and dermal grafting improved erectile function in all except a minority of patients who required insertion of a penile prosthesis to alleviate continued erectile impotence. For this reason we do not recommend insertion of a penile prosthesis during plaque excision. The plaque of Peyronie's disease does not appear to impede vascular flow distal to the plaque. However, previous excision may result in altered hemodynamics that can result in erectile impotence.

The treatment of psychogenic impotence after dermal graft repair for Peyronie's disease.

We studied 20 men who failed to resume coitus after a dermal graft repair for Peyronie's disease. Psychogenic causes were found in 15 men, 10 of whom were treated locally by the sex counselors who interviewed all the couples. Psychogenic dysfunction was related to waiting for healing or for a specified period, then approaching first coitus either with idealized expectations or as if it were a test. Of the 10 treated men 3 also had marital conflict and 5 others had lack of a partner or poor motivation, including 1 who also suffered some instability of erection possibly of structural cause. In most of the treated men relief of anxiety and conflict proved effective, and coitus was restored. We are now evaluating possible improved results in new operative candidates through preoperative and postoperative counseling, which emphasizes a less pressured approach to coitus postoperatively.

Clitoromegaly and megalourethra in idiopathic female intersex.

Idiopathic female intersex can present with a varying phenotypic expression but generally includes clitoromegaly in association with either urogenital and/or cloacal anomalies. Additionally, absence of corporeal bodies may exist, resulting in either a markedly enlarged empty phallus or a megalourethra if developmental anomalies of the urogenital sinus occur in association with corporeal agenesis. Herein we report 2 cases to illustrate the spectrum of this disorder.

Hypospadias cripples.

The term "hypospadias cripple" is an apt one. The successful surgery of this condition requires radical correction of all deformities, preferably in a single stage. In doing this one must be conversant with virtually all the existing methods of hypospadias repair and be able to apply them appropriately.

Rhabdomyolysis associated with urethral stricture repair: report of a case.

A case is reported of rhabdomyolysis and acute tubular necrosis following an exaggerated knee-chest position to repair a urethral stricture. To our knowledge this is the first case reported of this syndrome occurring after a urologic procedure.

Utricular configuration in hypospadias and intersex.

To evaluate the incidence and significance of an enlarged prostatic utricle in hypospadiac patients without underlying intersex 44 patients with the meatus located in the perineum, penoscrotal junction or proximal two-thirds of the penis were evaluated with cystourethroscopy immediately before the operation. There was an abnormally enlarged utricle in 57 per cent of the perineal, 10 per cent of the penoscrotal and none of the penile hypospadias and intersex revealed a high incidence of enlarged utricle or the presence of a vagina masculinus. Utricular enlargement in itself doses not indicate intersexuality but careful cystoscopic examination of its vault needs to be undertaken, searching for a cervix. An enlarged utricle can be a manifestation of delayed mullerian duct regression or decreased androgenic stimulation of the urogenital sinus.

Utricular configuration in hypospadias and intersex.

To evaluate the incidence and significance of an enlarged prostatic utricle in hypospadiac patients without underlying intersex 44 patients with the meatus located in the perineum, penoscrotal junction or proximal two-thirds of the penis were evaluated with cystourethroscopy immediately before the operation. There was an abnormally enlarged utricle in 57% of the perineal, 10% of the penoscrotal and none of penile hypospadiacs, for an over-all incidence of 14%. Concurrent analysis of a series of phenotypic male patients with hypospadias and intersex revealed a high incidence of enlarged utricle or the presence of a vagina masculinus. Utricular enlargement in itself does not indicate intersexuality but careful cystoscopic examination of its vault needs to be undertaken, searching for a cervix. An enlarged utricle can be a manifestation of delayed müllerian duct regression or decreased androgenic stimulation of the urogenital sinus.

Leydig and Sertoli cell function in normal and oligospermic males: a preliminary report.

Sertoli and Leydig cell function was evaluated in patients with oligospermia. Testicular biopsy specimens were incubated in vitro with follicle-stimulating hormone (FSH) or luteinizing hormone (LH), and the amount of cyclic adenosine 3':5'-monophosphate (cyclic AMP) generated was measured. Cyclic AMP has been shown to be intracellular mediator for the pituitary gonadotropins FSH and LH. The amount generated by the Sertoli cells response to FSH, and by the Leydig cells in response to LH, was contrasted with that in age-matched, normal control subjects. The Leydig cell response was similar in both groups. However, the amount of cyclic AMP generated by the Sertoli cells from oligospermic males was much less when compared with normal control subjects. This finding suggests a possible metabolic abnormality in the Sertoli cells of patients with oligospermia which might, in turn, alter spermatogenesis.

In vitro stimulation of adenosine 3',5'-monophosphate in unilateral undescended testes of humans by follicle-stimulating hormone and luteinizing hormone.

The in vitro effects of FSH and LH on cAMP generation by unilateral undescended testes and contralateral descended testes were investigated. Biopsy tissue was preincubated at 37 C for 5 min in 1 ml Krebs-Ringer bicarbonate buffer (KRB) containing 10 mM aminophylline. Half of each specimen was frozen in liquid nitrogen to assess basal levels of cAMP. The other half was incubated for 20 min at 37 C in 1 ml fresh KRB containing aminophylline and FSH (10 microgram) or LH (10 microgram). The mean concentration of cAMP in the descended testes was 1.03 +/- 0.04 pmol/mg protein, whereas in the undescended testes the level was 1.98 +/- 0.07 pmol/mg protein (P less than or equal to 0.01). After the 20-min incubation period with FSH the concentrations of cAMP in the descended and undescended testes were 10.85 +/- 0.86 pmol/mg protein and 11.21 +/- 1.1 mol/mg protein, respectively. Incubation with LH resulted in the generation of equivalent levels of cAMP in both the descended (2.76 +/- 0.30 pmol/mg protein) and undescended (3.0 +/- 0.17 pmol/mg protein) testes. Although marked histological differences were observed in the germinal epithelium, the appearance and numbers of Leydig and Sertoli cells were comparable. The data suggest that the Sertoli cell is the primary receptor for FSH. Leydig and Sertoli cell functions of the undescended testes, at least in terms of cAMP generation, are similar to normal descended testes.

Pediatric hypertension as a delayed sequela of reflux-induced chronic pyelonephritis.

Chronic pyelonephritis secondary to vesicoureteral reflux has been shown to cause occasionally systemic hypertension. The hypertension may occur in the presence or absence of bacterial urinary infection, is renin-mediated and may develop years after ureteral reimplantation. Surgical excision of a scarred atrophic renin-producing segment may result in amelioration of the hypertension or at least provide better medical control with less toxic antihypertensive agents. Surgical removal of renal tissue is not recommended in patients with depressed renal function unless the hypertension is malignant and uncontrolled.

Malignant hypertension in children secondary to chronic pyelonephritis: laboratory and radiologic indications for partial or total nephrectomy.

Severe renin-mediated hypertension was noted in 2 children as a result of selective renal damage from vesicoureteral reflux during the early years of life. In each case the reflux had been corrected successfully long before hypertension developed. In 1 case the late damage involved only 1 kidney and nephrectomy resulted in immediate relief of the hypertension. In the second case, even though both kidneys showed segmental scarring from calicectasis and chronic pyelonephritis, removal of the atrophied lower pole of 1 kidney made hypertension amenable to medical treatment and reduced excessive renin output to a fraction of the original high levels. The mechanism of renin-mediated hypertension in kidneys with segmental scars of chronic pyelonephritis is believed to be ischemia of the relatively normal renal cortex in proximity to areas of interstitial fibrosis, within which are tortuous interlobular and smaller arterioles with severe intimal thickening. Hypertrophy of normal renal segment occurs in young patients with segmental chronic pyelonephritis. To accommodate this enlargement the original calix develops an extension or elongation readily distinguishable from other dilated calices.