Seminal improvement following repair of ultrasound detected subclinical varicoceles in patients with left grade III varicocele

Objective: To evaluate the FCM patterns of spermatogenesis in testis biopsy of infertile azoospermic men and to compare it with the conventional histopathology with correlation of hormonal profile. Design: A prospective study. Materials/Methods: This study was conducted upon 125 infertile azoospermic patients. Clinical evaluations were followed by radioimmunoassay of serum FSH, LH, total testosterone and prolactin with detection of testicular volume. Open testicular biopsy was taken for routine histopathology stained by HX &E and DNA flow-cytometry after staining the DNA with fluorochrome propidium iodide. Results: According to the diagnostic criteria by flow-cytometry, a significant difference was found between the two methods of testicular evaluation (p ⬍0.001) with an overall correspondence of 61.7%. The accuracy of histopathologic diagnosis in relation to FCM was 90% for normal spermatogenesis, 78.9% for SCO syndrome and the least in hypospermatogemesis (56%). For detection of spermatogenesis by FCM parameters, 1N and 2N were significant predictors of normal spermatogenesis (p ⬍0.001 and p ⬍0.01). Using receiver operating characteristic curve, 1N and 2N showed the highest specificity (98.6% and 91.1%) with corresponding sensitivity of 92% and 44% at the criterion value of 34.25% and 26.4% respectively (p ⬍0.001). FSH is still a good predictor of spermatogenesis. Conclusions: Flow cytometry may rapidly detect foci of spertmatogenesis more frequently than routine histopathology with characteristic patterns for each group and a cut-off value characteristic for normal spermatogenesis. However, FCM could not differentiate between spermatids and sperms and give no data regarding testicular morphometry. Also, the discrimination between cell populations in the diploid peak was not possible. So, it is better to combine the two methods to get the advantages of both on bilateral testes biopsies with development of markers for sperm, spermatid and non germ cells for more specific FCM scoring. Supported by: Egyptian Society of Andrology Mansoura Faculty of Medicine.

P-281 Electronically excited species (EES) indices in seminal plasma correlate with patient’s age and sperm parameters in ART. Zofnat Wiener Megnazi, Bronislava Grach, David Ishai, Sergei Schnizer, Shirly Lahav Baratz, Martha Dirnfeld. Carmel Medical Ctr, Haifa, Israel. Objective: Free radical activity has been associated with various processes, including aging, and may effect reproductive outcome. We evaluated the correlation between formation of EES in seminal plasma, patient’s age and sperm parameters in IVF, as measured by a novel thermochemiluminescence (TCL) analyzer (Lumitest, Haifa, Israel). Design: A prospective study. Materials/Methods: One hundred nineteen men undergoing semen analysis in an IVF unit were included in this prospective study. Semen analysis was performed according to the World Health Organization Laboratory Manual (2000). Semen was centrifuged for 10 minutes in 1,800 RPM to obtain seminal plasma, of which 0.05 ml was separated and tested for EES in the TCL analyzer. TCL curve slope reflects residual oxidative capacity, due to prior in vivo molecular oxidation. Statistical analysis was carried out by an SPSS package. Results: Mean patient’s age was 32.27 years (SD⫽6.65). TCL curve slope decreased with increasing patient’s age in a linear manner. A positive correlation was found between sperm concentration, the fractions of total motile sperm, rapid motility sperm and spermatozoa with abnormal morphology and TCL curve slope. Correlation was strongest when sperm concentration was less than 10 millions/CC. The concentration of white blood cells in seminal plasma positively correlated with TCL amplitude at 50 SEC. There was no correlation between TCL indices and patient’s FSH level. Mean TCL indices of azoospermic men were not different from those of normospermic or oligospermic men. Conclusions: TCL curve slope of seminal plasma, as a parameter of oxidative stress, decreases with age, which may reflect an increase in free radical activity. An association has been found between oxidative stress in seminal plasma and sperm parameters. Available simple and accurate measurements of oxidative stress may serve as an important tool to evaluate, treat and monitor patients with sperm motility disturbances. Supported by: Carmel Medical Center, Haifa, Israel.

S208

Abstracts

P-282 The use of intra-operative sperm cryopreservation in men with obstructive azoospermia. Jennifer Allison Tash, Marc Goldstein. Dept of Urology, New York Weill-Cornell Univ Medical Ctr, New York, NY; Cornell Institute for Reproductive Medicine and Dept of Urology, New York Weill-Cornell Univ Medical Ctr, New York, NY. Objective: Fertilization with intracytoplasmic sperm injection (ICSI) of even a single viable sperm has greatly expanded the indications for sperm cryopreservation. Cryopreservation of sperm obtained intra-operatively at the time of surgical exploration in men with obstructive azoospermia provides back-up in case of unsuccessful reconstruction. In this study we evaluate the role of intra-operative cryopreservation of sperm and its impact on pregnancy rates. Design: One hundred consecutive men with obstructive azoospermia underwent intra-operative cryopreservation at the time of surgical exploration/reconstruction. Couples were followed post-operatively, and methods of conception were analyzed. The utility of intra-operative cryopreservation was assessed by evaluating which patient groups utilized their frozen samples for IVF/ICSI. Materials/Methods: Patient and partner ages were obtained, as were pre-operative diagnoses. Intra-operative parameters analyzed included volume, sperm concentration, percentage motility, and number of vials stored. Specific procedures undertaken and post-operative semen analyses were recorded. Patients were followed for methods of assisted reproduction and pregnancies. Results: Average patient age was 35.3 years, and average partner age was 32.2 years. Pre-operative diagnoses included epididymal obstruction in 44 men, vasal obstruction (s/p vasectomy) in 27, congenital absence of the vas deferens (CBAVD) in 17, ejaculatory duct obstruction in 2, and other causes in 10. 70 patients underwent surgical reconstruction including vaso-vasostomy (V-V, 9 patients bilateral, 3 unilateral) vaso-epididymostomy (V-E, 30 bilateral, 5 unilateral),V-E to the efferent ductule (13) or V-V on one side with a contralateral V-E (10). 21 men underwent primary epididymal sperm aspiration and/or marsupialization of epididymal cysts. 5 men underwent testis biopsies, 2 underwent electroejaculation, and 2 underwent transurethral resection of the ejaculatory ducts. An average of 5.4 vials of sperm were obtained per patient, and each had an average volume of 1.3 cc (including media), concentration of 21.5 ⫻ 106 sperm/mL, and motility of 23.1%. 45 of the 70 men who underwent reconstruction (64%) had sperm present in post-operative semen analyses. 34 couples have thus far carried at least one pregnancy to term. Of these, 10 couples underwent IVF/ICSI using sperm cryopreserved intra-operatively, 8 underwent IVF/ICSI with ejaculated sperm, and 3 required IVF/ICSI with repeat testicular sperm extraction (TESE) or percutaneous testicular biopsy. 2 couples required intra-uterine insemination (IUI), and 11 couples delivered after natural conception. Of the 10 deliveries that used cryopreserved sperm, 8 involved epididymal aspiration from men with CBAVD. Two were from men who had unsuccessful reconstructions with persistent post-operative azoospermia. These included one V-E to the efferent ductule and one combined V-V/V-E. Conclusions: Intra-operative cryopreservation of sperm at the time of epididymal aspiration allows for successful pregnancies for couples affected with CBAVD. Cryopreserved sperm is infrequently required after microsurgical reconstruction. Cryopreservation may be of value when the reconstruction performed is a complex one associated with a lower patency rate, such as V-E and V-E to an efferent ductule.

P-283 Seminal improvement following repair of ultrasound detected subclinical varicoceles in patients with left grade III varicocele. Fabio Firmbach Pasqualotto, Jorge Hallak, Antonio Marmo Lucon, Edson Borges Jr., Eleonora Bedin Pasqualotto, Sami Arap. Univ of Sao Paulo, Sao Paulo, Brazil. Objective: Although the association of clinical varicocele and subfertility has been well documented, the role of subclinical varicocelectomy is controversial. We determined whether repair of subclinical varicoceles detected by scrotal duplex ultrasonography results in significant seminal improvement. Design: Prospective study.

Vol. 78, No. 3, Suppl. 1, September 2002

Materials/Methods: From July 1999 to April 2001, fifty patients with varicocele were submitted to a varicocelectomy. Patients were divided into two groups: Group I (left grade III varicocele, unilateral varicocelectomy; n ⫽ 30) and Group II (left grade III varicocele and right subclinical varicocele, bilateral varicocelectomy; n ⫽ 20). No differences were seen in the mean age, levels of LH, FSH and testosterone, nor in the mean volume of both testicles between the groups (p ⬎0.05). The mean operative room time was higher in Group II (121.65 ⫾ 33.07 minutes) compared to Group I (72.75 ⫾ 23.82 minutes; P ⫽ 0.03). The mean sperm concentration before treatment was higher in Group I (21.01 ⫾ 19.1) compared to Group II (5.7 ⫾ 10.7) (P ⫽ 0.04). A semen analysis after treatment was evaluated in all patients. Pregnancy data was available in 36 patients (18 in each group). Results: An improvement was detected in the left testis of patients in Group I (17 ⫾ 7.9 vs. 22.81 ⫾ 8.2; P ⫽ 0.04) and right testis of patients in Group II (18.4 ⫾ 6.2 vs. 22.3 ⫾ 6.5; P ⫽ 0.04). Although the mean post-operative sperm concentration in group I slightly increased (25.7 ⫾ 22.8), the mean sperm concentration in Group II increased significantly (30.32 ⫾ 9.8; P ⫽ 0.03). Also, the pregnancy rate was higher in Group II (66.7%) compared to Group I (33.3%). Conclusions: It appears that the detection of subclinical varicoceles may be warranted in infertile men with abnormal semen parameters. Supported by: None

P-284 Long term efficacy and compliance of sildenafil citrate following radical prostatectomy: SHIM (IIEF-5) analysis. Rupesh Raina, Ashok Agarwal, Craig D. Zippe. Cleveland Clin Fdn, Cleveland, OH. Objective: To evaluate long term efficacy and safety of sildenafil for the treatment of erectile dysfunction (ED) after radical prostatectomy. Design: Prospective study. Materials/Methods: Data from 46 patients who responded to sildenafil therapy at 1 year following RP were stratified according to the type of nerve sparing (NS) procedure: bilateral NS, unilateral NS, and non-NS. A telephone survey was conducted during the first year of sildenafil usage and repeated 3 years later. Sildenafil was prescribed at a dose of 50 mg, and increased to 100 mg, if needed. The responses to the abridged 5-item International Index of Erectile Function (IIEF) questionnaire, the number of patient’s attempts/successful intercourse, partner’s satisfaction, and side effects were assessed. Comparison of sildenafil effect at baseline - 1 year, and at 3 years after use

Variables

Baseline after surgery

At 1 yr of sildenafil use

At 3 yrs of sildenafil use

0 0

80 12.7 ⫾ 2.5

83 12.8 ⫾ 1.5

Able to penetrate (%) Mean duration of intercourse (min) IIEF-5 Questionnaire Q5 - Maintenance ability Q15 - Erection confidence Q4 - Maintenance frequency Q2 - Erection firmness Q7 - Intercourse satisfaction Total mean IIEF-5 score Spousal satisfaction (%)

1.34 ⫾ 0.13 3.42 ⫾ 0.36 4.12 ⫾ 0.19 1.11 ⫾ 0.04 3.87 ⫾ 0.29 3.91 ⫾ 0.28 1.17 ⫾ 0.06 3.81 ⫾ 0.06 4.31 ⫾ 0.22 1.20 ⫾ 0.08 3.57 ⫾ 0.12 3.85 ⫾ 0.29 0.36 ⫾ 0.12 3.85 ⫾ 0.40 3.98 ⫾ 0.28 5.18 ⫾ 0.43 18.52 ⫾ 1.23 20.01 ⫾ 1.26 0 74 78.6

Data are presented as mean ⫾ SD unless otherwise noted. P ⬍ 0.05 was considered as significant. Wilcoxon rank-sum test was used. Results: At 3 years, 71% (32/46) patients were still responding to sildenafil. Thirty-one percent (10/32) of these respondents had augmented their dose from 50 to 100 mg. The drop out rate was 29% with 50% (6/12) discontinuing because of the return of natural erection; only 5 patients dropped out because of gradual loss of efficacy. The abridged IIEF item shows no difference in 1 yr. and 3 yr. scores in either of the nerve-sparing

FERTILITY & STERILITY威

groups (see table). Eighty-three percent of patients were sexually satisfied and 95% were able to achieve and maintain erection in more than 65% of attempts. The most common side effect at 3 years was: headache (12%), flushing (10%), and abnormal color vision (2%). No patient discontinued the drug at 3 years because of side effects. Conclusions: Following radical prostatectomy, patients with erectile dysfunction that respond to sildenafil continue to show excellent long-term efficacy and compliance. Supported by: Pfizer Pharmaceuticals.

P-285 Testicular fine needle aspiration in non-obstructive azoospermia: Our results. Alessandra Tallarini, Andrea Borini, Maria Antonietta Bonu, Vincenzo Distratis, Andrea Maccolini, Elena Sereni. Tecnobios Procreazione, Bologna, Italy. Objective: The aim of this study is to evaluate the efficacy of testicular fine needle aspiration (TEFNA) as technique for spermatozoa retrieval in non obstructive azoospermia and ICSI results utilizing testicular spermatozoa obtained with this technique. Design: Retrospective analysis of ICSI treatment using TEFNA as method for spermatozoa retrieval in non obstructive azoospermic patients. Materials/Methods: Between February 1996 and March 2001 a total of 263 men with irreparable non obstructive azoospermia underwent TEFNA. Azoospermia was confirmed by repeated ejaculate examination. We found mature spermatozoa in 162 cases (recovery rate: 61.5%). We selected for treatment only men with presence of spermatozoa in pre treatment TEFNA specimen. In cases with no sperm retrieval after multiple aspirations (at least 3) per each testis we recommend surgical testis approach for spermatozoa recovery. A total of 162 couples, in whom the male partner had nonobstructive azoospermia and had FNA to recover testicular spermatozoa, underwent a total of 223 ICSI cycles. The mean age of male patients was 35 years (range 25 to 48 years), females 34 years (range 23 to 43). The mean duration of infertility was 5.8 years (range 1 to 18). Results: The recovery rate in this selected group of non obstructive azoospermia was 100%. Fertilization rate was 57%: out of 2001 mature oocytes injected, 1141 with 2 pronuclei fertilized. 1038 embryos were obtained (embryo cleavage rate: 96%) and 363 embryos were transferred for an average of 2.6 embryos transferred per patient. Cryopreservation of 509 embryos was possible. In this group we recorded 35 clinical pregnancies (pregnancy rate per transfer 17.7%), with 40 gestational sacs, for an implantation rate of 11%. Two abortions of singleton pregnancies occurred (5.5%) and two blighted ova as well as an ectopic pregnancy (2.8%). No side effects, such as haematoma or infection, were recorded. Almost all patients reported less pain than they expected and only two patients reported pain two days after TEFNA which resolved the week after. Conclusions: Our data show that TEFNA execution before treatment is useful to predict sperm recovery at oocyte retrieval time, the technique is safe, simple, well tolerated and less invasive of surgical approach. Our results suggest this technique could be adopted as first method for spermatozoa recovery for ICSI in non obstructive azoospermia and only in cases of no recovery with this technique biopsy would be recommended. Supported by: TECNOBIOS PROCREAZIONE.

P-286 Sperm survival in liquid nitrogen. Jerry Hall, Jaroslav Marik. Institute for Reproductive Medicine and Genetic Testing, Los Angeles, CA. Objective: Freezing of reproductive tissue and cells has been practiced for a considerable length of time. Spermatozoa were successfully frozen since mid-50s and embryos, oocytes, and ovarian and testicular tissue in recent years. The length of survival of reproductive tissue in the frozen state while stored in liquid nitrogen is not known, but obviously very important for family-building reasons. Design: At the patients request their semen was removed from liquid nitrogen and evaluated for changes in morphology, motility, and viability after many years of cryopreservation. Materials/Methods: In the 50s, 60s, and 70s semen was frozen primarily using glycerol solution or a cryoprotectant. The glass vials, and later plastic vials to avoid spontaneous breakage of the glass ampoules, were kept in

S209