Semen Studies in Four Hundred Sterile Marriages1

SEMEN STUDIES IN FOUR HUNDRED STERILE MARRIAGES 1 OTAKAR J. POLLAK

AND

CHARLES A. JOti:L

The time of unrestricted accusation of the woman in a sterile marriage is gone, the role of the man being well recognized. A marriage is considered sterile after 2 years of regular sexual life without any attempts to prevent conception. The proportion of cases in which the one or the other sex should be held responsible for such a state is not known. The large bibliography concerning this subject gives rather a confusing picture. This paper is based upon the material gathered in 2 distant places and upon the analysis of 400 cases. It may contribute to the study of the role of the male in sterile marriage. Two hundred cases have been selected from the material examined in Czechoslovakia, and 200 from the cases studied in Palestine. The results of both series have been the same despite the influence of race, climate and diet, factors which are often overrated in relation to sex. The results vary only in 1 instance, the reason of which will be given with the interpretation of table l and the diagram (fig. 1). The 400 cases have been selected from a still larger material and only such cases are taken in consideration in which all the criteria upon a reliable semen examination have been fulfilled. These are (1) a careful family, personal and sexual history of both partners; (2) a complete clinical and laboratory examination of both partners; (3) about 7 days of sexual abstinence should precede the ejaculation of semen for the analysis; (4) the material should be furnished by a single interrupted coitus or by autoerotic manipulation; (5) the examination of fresh material should be started within 30 minutes after ejaculation; (6) finally, a second sample should be tested in any case the first findings are subnormal. The number of spermatozoa was always counted in the counting chamber, the motility observed with the help of Ehrlich's ocular diaphragm, revival experiments performed with isotonic glucose magnesia salt solutions, the cellular structures studied in supravital stained preparations, in smears stained with azure-eosin and with hemalum-eosin and in histological sections. 2 We considered the semen normal if the sperm count was higher than 60 millions spermatozoa in each cubic centimeter, the total number of spermatozoa, in a specimen higher than 250 millions, if more than 80 per cent of all spermatozoa were normokinetic, and if the number of abnormally formed spermatozoa was below 20 per cent, the number of immature cells of the spermatogenesis below 2 per cent. Aspermatism is the result of a complete obstruction of the seminal ducts. No germ cells are found in smears or in sections of the ejaculate. This condition 1 This paper was accepted for publication by Prof. H. Vignes, Paris. The French manuscript got lost in the events of the past year. This accounts for the publication of material collected in 1937-1939 in Czechoslovakia and in Palestine. 2 The technique used was described by the authors: Pollak, 0. J. and Joel, Ch. A.: Sperm examination according to the present state of research, J. A. M. A., 113: 395-398, 1939.

531

532

OTAKAR J. POLLAK AND CHARLES A. JO:EL

was present in 10 cases out of 400. This low figure is not surprising, as bilateral inflammations are not too frequent and as bilateral hypoplasia or testicular 1

TABLE

200

SPECIMENS FROM BRNO, CZECHOSLOVAKIA-POLLAK

CONDITION

100% Fertilization

-Aspermatism

2

Noorospermia

2

-

Azoospermia

16

Aathenospermia

29

Oligospermia

8

Hypokinesis

7 36

Normospermia

Semen

200

SPECrnENS FROM JERUSALEM, PALESTINE-JOEL

100% Fertilization

AVERAGE

Semen

100% Fertilization

--

3

impossible 20

abnormal 49

-2 --

impossible 9

4

improbable 29

35

possible 15

--

probable 36

-2 abnormal - 10 44

improbable 35

32

possible 19

--

11

''normal'' 51

Semen

2.5

8 37

impossible 14.5

improbable 32

9.5

"normal" 56

probable 37

abnorma! 46.5

7.5 36.5

possible 17

''normal" 53.5

probable 36.5

Normospermia Hypokinesi& : Oligospermia : : Asthenosp~rmi~ • : Azoospermia • Necrospermia : : : Aspermatism : : : :

.

.. ... ... .... ....

.. .. .... • ...... .•

.... ..... .... .• ..

... ... ....•

... .. •

... ... ..... •. ..• ..•• ••

a

Pollak, Czechoslovakia.

I

Jo81, .Palestine.

FIG. I

atrophy do not commonly result in aspermia, but similar to bilateral cryptorchism in azoospermia.

SEMEN STUDIES IN STERILE MARRIAGES

533

Among the men examined a primary anomaly of the genital organs is rare. They all are married men. An unilateral hypoplasia of the testicle was discovered once, a unilateral hypoplasia with a cryptorchism at the other side in a second case. Hypospadia of various degree was seen three times. Necrospermia is a rare finding provided that proper material is properly examined. The analysis of condom specimens, of old samples, and the lack of revival experiments are responsible for the frequent notes of necrospermia in publications. The condition may be the result of acute intoxication, or may be due to the production of primarily abnormal spermatozoa. vVe found the complete lack of motility of spermatozoa in 8 cases out of 400, and in all of them the spermatozoa show abnormal structures. Azoospermia must not be confused with aspermatism. Spermatozoa are not seen at the examination but the various cells of the spermatogenesis series are readily found in smears and at biopsy. The examination of unstained slides is not sufficient for the diagnosis of this condition. Centrifugalization of the specimen, staining of smears, and biopsy often allow the recovery of spermatozoa in cases in which they could not be seen in unstained slides. It is in this point that the 2 statistics prepared independently by the 2 authors disagree. Very often other cellular elements are seen beside the immature germ cells. Large, polygonal epithelial cells are present in the cases with a gonorrheal infection in the past. The fact that gonorrhea is less common among the religious population of Palestine than in Central Europe explains the difference in the statistics. Azoospermia was found in 8 men in Palestine. Six specimens revealed the mentioned cells, and 4 of these patients had a gonorrheal epididymitis; 1, epididymitis of undisclosed nature. Among the 32 cases of azoospermia in Europe were the two cases with hypoplasia of the testicle and with hypoplasia and cryptorchism respectively, further 2 cases with a traumatic epididymitis, 9 with gonorrheal epididymitis and 4 with a simple urethral gonorrhea in their history. In 12 of the remaining 15 cases the described epithelial cells were also seen and a gonorrheal episode seems highly probable in these patients in spite of their denial of infection. Asthenospermia characterized by a general deficiency of the semen, a subnormal sperm count, subnormal motility, abnormal amount of atypical spermatozoa, and finally an increase of immature germ cells, is a frequent condition. It was found in 128, or roughly in one third of our patients. The explanation of this condition which reaches various degrees is difficult. The constitution, subnormal health conditions such as undernourishment and physical exhaustion, various generalized or localized diseases such as chronic arthritis, nephritis, malaria, or tuberculosis, and also mental deficiency or illness may be held responsible for asthenospermia. On the other hand, in almost half of all these cases, an explanation for the testicular hypofunction could not be found. Oligospermia with a lowered sperm count but a normal motility of the spermatozoa and a normal spermiogram is less frequent. The reasons for these findings are much the same as for asthenospermia. The deviation from the normal is

534

OTAKAR J. POLLAK AND CHARLES A . JOEL

usually less than in the preceding group and of a more transitory character. Thirty eight samples gave this result repeatedly. Frequently, repeated examinations at later dates revealed a shift to the left in the spermiogram as a sign of regeneration and the original diagnosis and classification had to be corrected. Hypokinesis concerns only the degree of motility of the spermatozoa. The number of motile spermatozoa is about normal and so are the other findings. As in oligospermia, the condition is usually a temporary one. It may be based upon the same changes in the organism. It was found in 30 of our cases repeatedly. It is quite obvious that the deficiency of semen is mostly a generalized one and concerns all factors, the sperm count, motility and morphological structure of the spermatozoa. Normospermia, the ideal condition with normal findings at the semen examination, was found in 146 men. This is more than a third of all cases. The same number of normal men in sterile marriage was registered by both authors. Theoretically, none of all conditions is irreparable. Practically however, aspermatism, necrospermia and azoospermia, all permit the statement that fertilization is impossible. In the European material 20 per cent, in the material from Palestine 9 per cent of all men examined belong to these groups. Asthenospermia sometimes may be cured, usually with the removal of the disease or state responsible for the deficiency of the semen. At the time of examination the fertilization by a man of this group seems highly improbable. In our material, 29 per cent and 35 per cent of the men show such result. The 4 groups together represent the specimens of semen not suitable for fertilization: 49 per cent and 44 per cent, almost one-half of the examined material. In the cases with oligospermia and hypokinesis, the fertility is lowered but the fertilization may be well possible. These conditions may spontaneously give place to a normal one or they can be more easily cured than other changes. We find 15 per cent in the European and 19 per cent in the Palestinian material belonging into these 2 groups. N ormospermia was found in 36 per cent and 37 per cent of all examined. The 3 groups together represent the specimens suitable for fertilization: 51 per cent and 56 per cent, somewhat more than half of our samples. In about half of all cases of sterile marriage the man is responsible for the sterility, or may be responsible together with his wife. With the study of the group in which both the male and the female are found normal the statement just made must be corrected. Two thirds of the men with a normospermia had anatomically and functionally normal wives. The motility of the spermatozoa of these men in the cervical secretions of the corresponding females were normal. The sterility of these couples could not be explained. This situation occurs in 25 per cent of all sterile marriages, in 100 of our 400 couples. This figure is a high one and should encourage further research in the view of the fact that the numerous theories fail to explain the phenomenon of sterile marriage in fertile couples.

TECHNICAL EXHIBITORS AT NEW YORK MEETING THE GOMCO SURGICAL MANUFACTURING CORPORATION (Booth 1) will exhibit their thermotic drainage pump. The automatic, attention-free operation of these pumps is exceptionally interesting to the urologists. Gomco will also show their line of electric centrifuges, hospital suction and ether units, and their universally used circumcision clamps. SCHERING CORPORATION (Booth 2) will have on display all the highly advanced Schering hormones. In addition, there are some other particularly interesting products, such as Sulamyd (Sulfacetimide) for the treatment of urinary tract infections, and Neo-iopax, the Council-accepted safe radiographic medium. Members of the Medical Research Division are present to discuss problems. BURROUGHS WELLCOME & CO. (U. S. A.), INC. (Booth 3) present a representative group of fine chemicals and pharmaceutical preparations, together with new and important therapeutic agents of special interest to urologists, BECTON, DICKINSON & CO. (Booths 4 and 5) will have a larger exhibit than usual. HOLLAND RANTOS CO. INC. will ccupy Booth 6. CAMERON SURGICAL SPECIALTY CO. (Booth 7) invite you to see the Cameron Radio-Knives and Spark-Gap Units, urethroscopic equipment, flexible gastroscopes, color Flash Clinical Camera, Mirrolite, Binocular Prism loupe and other new developments in electrically lighted diagnostic and operating instruments for all parts of the body. As all instruments work from dry cells as well as electric light current, in the event of a "black-out" or emergency failure of electric light current, the surgical work can proceed regardless. New York Sales office, 250 W. 57th St., convenient for service at all times for doctors in greater New York area. C. R. BARD INC. (Booths 8 and 9), since 1907 the leading importers of French catheters and bougies, will show their new line of American-made instruments. This comprehensive exhibit will include not only rubber catheters and drains, but also will display for the first time the new Bard-USCI line of woven catheters and bougies, both ureteral and urethral. A visit to Booths 8 and 9 will demonstrate conclusively that American doctors no longer are dependent on foreign-made urological instruments. LIEBEL-FLARSHEIM (Booth 22) will exhibit the famous Bovie electrosurgical units as well as the L-F short and ultra-short wave generators. Other new and interesting equipment and accessories for urologists will also be shown, and you are cordially invited to inspect them at Booth 22. WINTHROP CHEMICAL CO. INC. will occupy Booths 23 and 24.

EXHIBITORS AT NEW YORK MEETING

ABBOTT LABORATORIES (Booth 26). Here a hearty welcome awaits all who may stop in to inspect the comprehensive selection of specialties on display. Included are sulfonamides, Metaphen products, Mandelic Acid, Salihexin, Nembutal, Pentothal Sodium, Acrifl.avine, injectable Bismuth preparations, Neoarsphenamine, Trisodarsen, Aldarsone, Lubritine, Procains, Butyn and vitamin products. HAROLD SURGICAL CORP. of New York and Albany (Booth 27), will exhibit the latest type electrosurgical and therapeutic apparatus. In addition there will be on display a new type of autoclave, drainage pumps, in addition to a display of our line of catheters and urological instruments. In charge will be Mr. J. Shnitzer and Mr. S. Mehlinger. ALBA PHARMACEUTICAL CO. INC. will occupy Booth 28. E. R. SQUIBB & SONS (Booth 29) will feature a number of new and interesting vitamin, glandular, biological and chemotherapeutic specialties. Well informed Squibb representatives will be on hand to welcome you and to furnish any information desired on the products displayed. RICHARDSON ABDOMINAL SUPPORTER (Booth 30) will show models of surgical supporters which have been perfected after years of study and close co-operation with many of the country's best known surgeons. They will also show x-ray films demonstrating actual results obtained by the use of the kidney supporter. PHILIP MORRIS & COMPANY (Booth 31) will demonstrate the method by which it was found that Philip Morris cigarettes, in which diethylene glycol is used as the hygroscopic agent, are less irritating than other cigarettes. Their representative will be happy to discuss researches on this subject and problems on the physiological effects of smoking. THE RADIUM EMANATION CORPORATION (Booth 32) will exhibit a wide variety of instruments and applicators used in modern radium therapy, including permanent and removable composite, leak-proof radon seeds, and the latest types of Ametal rubber applicators for the treatment of carcinoma of the cervix in accordance with the Regaud technique. DAVIS & GECK, INC. (Booth 34) will display its complete line of sterile sutures including ... ribbon gut, developed in collaboration with Dr. Oswald Swinney Lowsley ... fine gauge (0000 and 00000) catgut ... a comprehensive group of sutures armed with swaged-on atraumatic needles and designed for specific surgical procedures ... Dermalon skin and tension sutures (processed from nylon) which, because of marked physical advantages and economy, are rapidly replacing silkworm gut and other non-absorbable materials. CIBA PHARMACEUTICAL PRODUCTS, INC. (Booth 36) will exhibit the well-known specialities of Ciba, including Perandren, Di-Ovocylin and Percorten. Of particular interest is some recent work with Trasentine in the

EXHIBITORS AT NEW YORK MEETING

treatment of neurogenic bladder disease. Two representatives and an executive of the firm will be in attendance to answer any questions. CLAY-ADAMS CO. (Booth 38) will feature their enlarged line of Cacoprene synthetic rubber catheters which are not affected by lubricants and have improved resistance to boiling, chemical· action and oxidation of the air; also Pezzer catheters and other styles made of Calatex, a special pure gum composition. The exhibit will include clinical model centrifuges and the newest design in the Safety-Head angle centrifuge. Anatomical models, charts, specimens, etc. for teaching and demonstration, as well as various urological specialties, will also be shown. RADIUM CHEMICAL CO. INC. (Booth 40) cordially invite physicians to visit the exhibit of radium and radon instruments for the treatment of urological conditions. The representatives in attendance will be pleased to give information in regard to the service rendered by the Company. HYNSON, WESTCOTT & DUNNING, INC. (Booths 41 and 42) will have an exhibit featuring Mercurochrome and various pharmaceutical specialties of their manufacture. There will also be a display of diagnostic apparatus and ampule solutions which have been developed in the firm's laboratories in cooperation with physicians. Competent representatives will be in attendance to demonstrate these products. Literature and samples will be available to physicians who are not already familiar with products exhibited. AMERICAN STERILIZER CO. (Booth 44) will have as the principal feature the Americanaire Ultraviolet Germicidal Unit for use in doctors' waiting rooms, surgeries, outpatient departments and all applications where a bactericidal application is indicated. Another feature of the display will be the well known American Major Operating Table adapted for transurethral surgery. The tray has been designed to fit into the conventional perineal cut-out in the seat section. The stirrups have been arranged so that they may be easily adjusted to any position. The arrangement is known as the Hess transurethral tray. KELLEY-KOETT MANUFACTURING CO. will occupy Booth 47. MERCK AND CO. INC. will occupy Booth 49. AMERICAN CYSTOSCOPE MAKERS, INC. (Booths 52, 53, 54, 55 and 56) extend a cordial invitation to make these booths your headquarters. We have served the medical profession in peace and in war for the past 45 years in producing cystoscopes, resectoscopes and many other instruments of a highly specialized nature. We are again privileged to serve our country whose war needs for technical optical instruments for fire directing instruments require about 75 per cent of our production facilities. Our Government requires as well vast quantities of cystoscopes, catheters and other life-conserving instruments. In spite of the urgency and demands on our facilities for more and more cystoscopes, catheters and urethroscopes, we are still able to serve you, perhaps

EXHIBITORS AT NEW YORK MEETING not as promptly as in peace time, but you know our country's needs come first. Booths 52 to 56 in the Astor Gallery are well filled with our products. Come in, browse around and make yourself at home. THE WILLIAMS & WILKINS CO. (Booth 57) publishers of the JouRNAL OF UROLOGY and the famous William Wood books, will exhibit many books worthy of examination. Urologists and syphilologists will be particularly interested in Dr. Reuben Kahn's authoritative new book on Serology in Syphilis Control with helpful suggestions on problems closely related to national defense. The Navy's practical little booklet by Bidgood on Urology in War will also deserve attention. Mueller-Deham's Internal Medicine in Old Age includes information for urologists, and many standard books such as Lowsley and Kirwin's Clinical Urology will be accessible. EMERSON DRUG CO. will occupy Booth 58.