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Androgen receptor gene polymorphism in men with compromised spermatogenesis and in their male offspring
surgical subinguinal technique by the same surgeon at a university outpatient center. Results: We identified 278 men who underwent varicocele ligation for infertility reasons. The infertility work-up consisted of two semen analyses, FSH, LH, testosterone, prolactin, and antisperm antibody analysis. Of the 278 patients, 54 were found to be azoospermic or severely oligospermic and underwent a bilateral testicular biopsy at the time of varicocele ligation. The pathologic findings ranged from normal to sertoli cell only syndrome. We observed that the pathologic findings were similar regardless of laterality. Normal spermatogenesis was found in 5 (9.26%) on the left and 9 (16.66%) on the right; hypospermatogenisis in 17 (31.48%) on the left and 18 (33.33%) on the right; maturation arrest in 15 (27.78%) on the left and 13 (24.07%) on the right; hyalinization of seminiferous tubules in 9 (16.67%) on the left and in 8 (14.81%) on the right; and sertoli cell only syndrome in 8 (14.81%) on the left and 6 (11.11%) on the right. Chi-Square statistical analysis was performed to determine whether there was a difference between pathologic findings of the left and the right testicular biopsies (2 with 4df, 1.659; p⬍0.798). We were not able to demonstrate a difference between the pathologic findings of the left and the right testicular biopsies. This suggests that there are similar underlying causes leading to a pathologic progression from normal to sertoli cell only syndrome. Conclusion: The pathophysiology of varicoceles is poorly understood. We suggest that varicoceles disturb seminiferous tubular function in similar ways regardless of laterality. Better understanding of varicocele pathophysiology is needed and more research is warranted.
P-337 Androgen receptor gene polymorphism in men with compromised spermatogenesis and in their male offspring. Yukiko Katagiri, Queenie V. Neri, Takumi Takeuchi, Fred Moy, Zev Rosenwaks, Gianpiero D. Palermo. Cornell Univ, New York, NY. Objective: Normal steroid biosynthesis and functioning androgen receptors (AR) are required for normal male sexual development and spermatogenesis. The AR gene is located on the X chromosome at Xq11-12, and is encoded by eight exons. Exon 1 contains polymorphic glutamine (CAG) and glycine repetitive sequences. Normal CAG repeat length is 9 to 28 repeats. The length of these (CAG)n tract varies according to ethnicity, with an average of 21 repeats in white men, 18 in black, and 22 in Asian men. CAG repeat lengths influence AR function, resulting in enhanced androgen action at lower repeat lengths and decreased function at longer lengths. Therefore, it is possible that moderate expansions of the polyglutamine tract are associated with defective spermatogenesis through decreased AR function. In a prospective analysis, we determined the association of AR (CAG)n lengths in both fertile and infertile men, and in ICSI children. Design: Assessment of (CAG)n repeats in the AR was performed by gene sequence in fertile, infertile men, and ICSI children. Yq deletion was assessed by PCR. Chromosomal abnormalities on sperm were identified by FISH. Lymphocytes karyotyping was performed. Materials and Methods: DNA from 22 severely infertile men who were candidates for, or had been treated by ICSI, were amplified by PCR targeting the AR (CAG)n. A similar analysis was performed on 3 ICSI boys. DNA from 10 fertile men and 6 naturally conceived boys served as control. PCR-amplified DNA was sequenced directly using a genetic analyzer. In the AZF region of the Y chromosome, a total of 22 STSs were analyzed by multiplex PCR. In some cases, spermatozoa were analyzed for chromosomes 18, 21, X, and Y by FISH. Results: The average age was 43.6⫾6 years for infertile, 40.0⫾8 for fertile men, and 5.0⫾0.5 for all children. The mean sperm concentration in samples from severely oligozoospermic men (n⫽16) was 1.4⫾0.7*106/ml, in oligozoospermic men (n⫽5) was 8.2⫾4.1*106/ml, in a non-obstructive azoospermic man (n⫽1) was 0.002*106/ml. Results are reported as the number of CAG repeats per subject. The mean number was 23.1 ⫾ 3 (range 19-32) for infertile men and 19.2⫾6 (range 10-25) for fertile men. In the case of ICSI male children the AR (CAG)n lengths were 21.7⫾0.6 (range 21-22) versus 21.2⫾2 (range 18-24) for spontaneously conceived boys. There was a significant difference in CAG repeat length in severely oligo/ azoospermic men versus controls (P⫽0.01). The lymphocytes karyotypes of the fertile men and their children were all normal. Among 22 infertile men, a long CAG repeat (ranging 25-32) was found in six, of which only four fathered a child (by ICSI: 1 boys and 3 girls). One severely oligozoospermic man (CAG)32 had a Yq deletion of the entire AZFc region and FISH
FERTILITY & STERILITY威
analysis of his sperm showed that 3.6% had chromosomal abnormalities, with 2.9% gonosomal. All the karyotypes of the infertile group and their children were also normal. Conclusion: We conclude that compromised spermatogenesis is associated with an enhanced frequency of gonosomal abnormalities. Severely oligo-/azoospermic men had longer trinucleotide repeat length than fertile men, suggesting that a dysfunctional AR gene has a negative effect on spermatogenesis. However, the man with the highest repeat also had a complete AZFc deletion and a higher frequency of sperm chromosomal abnormalities, making the cause of his spermatogenic failure multifactorial.
P-338 Vasovasostomy in the convoluted vas deferens: Indications and outcomes. Jay I. Sandlow, Peter N. Kolettis. Univ of Iowa Hospitals and Clinics, Iowa City, IA; Univ of Alabama, Birmingham, AL. Objective: To examine the indications and outcomes for vasovasostomy (VV) in the convoluted vas deferens. Design: Retrospective chart review and patient contact of patients undergoing vasectomy reversals at 2 academic teaching centers. Materials and Methods: After obtaining IRB approval, we retrospectively analyzed the indications and outcomes of all vasectomy reversals performed by 2 fellowship-trained male infertility specialists. We reviewed the records and contacted patients for necessary follow-up that had undergone VV in the convoluted vas. A total of 45 patients were identified that had unilateral VV only or bilateral VV in the convoluted vas deferens. Indications for VV within the convoluted vas deferens were similar to those published elsewhere, and included clear fluid with or without sperm, presence of sperm (motile or non-motile), or sperm parts. Anastamoses were performed utilizing either a two-layer or modified one-layer technique, as per surgeon preference. Semen analysis was obtained between 4 weeks and 3 months postoperatively, and every 3 months until pregnancy occurred or patient elected to discontinue follow up. Patency was defined as motile sperm in the ejaculate postoperatively. Pregnancy data was calculated based upon natural pregnancy occurring within the first year postoperatively. Patients without postoperative semen analysis who achieved natural pregnancy were also considered patent. Follow up was obtained via clinic visits, phone follow up, and in some cases, written notes from patient. Results: A total of 45 patients underwent either bilateral VV in the convoluted vas deferens (35) or unilateral VV (6) in the case of an unreconstructable/atrophic contralateral side. Average age of the patients was 39 years old. Average age of female partner was 30 years old. Average obstructive interval was 9.8 yrs. Of the 45 patients, 40/45 had patency data and 29/45 had pregnancy data. The patency rate was 87.5% (35/40). The natural pregnancy rate was 41% (15/29). There was no difference in the outcomes based upon the quality of the vasal fluid. Conclusion: Vasovasostomy in the convoluted vas deferens is a more difficult procedure than standard VV. There is minimal muscle layer and a larger discrepancy between the abdominal and testicular ends. Nevertheless, postoperative results are typically comparable to those obtained via VV and superior to epididymovasostomy in many cases. Therefore, we recommend the use of VV in the convoluted vas deferens utilizing the same indications as those seen for standard VV in the straight portion of the vas deferens.
P-339 Can ejaculatory duct obstruction be due to unilateral blockage? Rajveer S. Purohit, Katsuto Shinohara, Paul Turek. UCSF, San Francisco, CA. Objectives: Ejaculatory duct obstruction due to bilateral blockage of the ducts is a well recognized and treatable cause of male infertility. In these cases, duct obstruction can be either complete (azoospermia) or partial (sperm in ejaculate) in nature. Through the use of functional diagnostic tests in addition to transrectal ultrasound, we have identified the fact that ejaculatory duct obstruction can result from unilateral instead of bilateral blockage within the ductal system and report our treatment findings in affected patients. Design: Prospective study of a consecutive series of male infertility patients in a single institution. Methods: Twelve male infertility patients with suspected EDO by clinical evaluation that included TRUS proceeded to further intraoperative evalua-
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P-337 Androgen receptor gene polymorphism in men with compromised spermatogenesis and in their male offspring. Yukiko Katagiri, Queenie V. Neri, Takumi Takeuchi, Fred Moy, Zev Rosenwaks, Gianpiero D. Palermo. Cornell Univ, New York, NY. Objective: Normal steroid biosynthesis and functioning androgen receptors (AR) are required for normal male sexual development and spermatogenesis. The AR gene is located on the X chromosome at Xq11-12, and is encoded by eight exons. Exon 1 contains polymorphic glutamine (CAG) and glycine repetitive sequences. Normal CAG repeat length is 9 to 28 repeats. The length of these (CAG)n tract varies according to ethnicity, with an average of 21 repeats in white men, 18 in black, and 22 in Asian men. CAG repeat lengths influence AR function, resulting in enhanced androgen action at lower repeat lengths and decreased function at longer lengths. Therefore, it is possible that moderate expansions of the polyglutamine tract are associated with defective spermatogenesis through decreased AR function. In a prospective analysis, we determined the association of AR (CAG)n lengths in both fertile and infertile men, and in ICSI children. Design: Assessment of (CAG)n repeats in the AR was performed by gene sequence in fertile, infertile men, and ICSI children. Yq deletion was assessed by PCR. Chromosomal abnormalities on sperm were identified by FISH. Lymphocytes karyotyping was performed. Materials and Methods: DNA from 22 severely infertile men who were candidates for, or had been treated by ICSI, were amplified by PCR targeting the AR (CAG)n. A similar analysis was performed on 3 ICSI boys. DNA from 10 fertile men and 6 naturally conceived boys served as control. PCR-amplified DNA was sequenced directly using a genetic analyzer. In the AZF region of the Y chromosome, a total of 22 STSs were analyzed by multiplex PCR. In some cases, spermatozoa were analyzed for chromosomes 18, 21, X, and Y by FISH. Results: The average age was 43.6⫾6 years for infertile, 40.0⫾8 for fertile men, and 5.0⫾0.5 for all children. The mean sperm concentration in samples from severely oligozoospermic men (n⫽16) was 1.4⫾0.7*106/ml, in oligozoospermic men (n⫽5) was 8.2⫾4.1*106/ml, in a non-obstructive azoospermic man (n⫽1) was 0.002*106/ml. Results are reported as the number of CAG repeats per subject. The mean number was 23.1 ⫾ 3 (range 19-32) for infertile men and 19.2⫾6 (range 10-25) for fertile men. In the case of ICSI male children the AR (CAG)n lengths were 21.7⫾0.6 (range 21-22) versus 21.2⫾2 (range 18-24) for spontaneously conceived boys. There was a significant difference in CAG repeat length in severely oligo/ azoospermic men versus controls (P⫽0.01). The lymphocytes karyotypes of the fertile men and their children were all normal. Among 22 infertile men, a long CAG repeat (ranging 25-32) was found in six, of which only four fathered a child (by ICSI: 1 boys and 3 girls). One severely oligozoospermic man (CAG)32 had a Yq deletion of the entire AZFc region and FISH
FERTILITY & STERILITY威
analysis of his sperm showed that 3.6% had chromosomal abnormalities, with 2.9% gonosomal. All the karyotypes of the infertile group and their children were also normal. Conclusion: We conclude that compromised spermatogenesis is associated with an enhanced frequency of gonosomal abnormalities. Severely oligo-/azoospermic men had longer trinucleotide repeat length than fertile men, suggesting that a dysfunctional AR gene has a negative effect on spermatogenesis. However, the man with the highest repeat also had a complete AZFc deletion and a higher frequency of sperm chromosomal abnormalities, making the cause of his spermatogenic failure multifactorial.
P-338 Vasovasostomy in the convoluted vas deferens: Indications and outcomes. Jay I. Sandlow, Peter N. Kolettis. Univ of Iowa Hospitals and Clinics, Iowa City, IA; Univ of Alabama, Birmingham, AL. Objective: To examine the indications and outcomes for vasovasostomy (VV) in the convoluted vas deferens. Design: Retrospective chart review and patient contact of patients undergoing vasectomy reversals at 2 academic teaching centers. Materials and Methods: After obtaining IRB approval, we retrospectively analyzed the indications and outcomes of all vasectomy reversals performed by 2 fellowship-trained male infertility specialists. We reviewed the records and contacted patients for necessary follow-up that had undergone VV in the convoluted vas. A total of 45 patients were identified that had unilateral VV only or bilateral VV in the convoluted vas deferens. Indications for VV within the convoluted vas deferens were similar to those published elsewhere, and included clear fluid with or without sperm, presence of sperm (motile or non-motile), or sperm parts. Anastamoses were performed utilizing either a two-layer or modified one-layer technique, as per surgeon preference. Semen analysis was obtained between 4 weeks and 3 months postoperatively, and every 3 months until pregnancy occurred or patient elected to discontinue follow up. Patency was defined as motile sperm in the ejaculate postoperatively. Pregnancy data was calculated based upon natural pregnancy occurring within the first year postoperatively. Patients without postoperative semen analysis who achieved natural pregnancy were also considered patent. Follow up was obtained via clinic visits, phone follow up, and in some cases, written notes from patient. Results: A total of 45 patients underwent either bilateral VV in the convoluted vas deferens (35) or unilateral VV (6) in the case of an unreconstructable/atrophic contralateral side. Average age of the patients was 39 years old. Average age of female partner was 30 years old. Average obstructive interval was 9.8 yrs. Of the 45 patients, 40/45 had patency data and 29/45 had pregnancy data. The patency rate was 87.5% (35/40). The natural pregnancy rate was 41% (15/29). There was no difference in the outcomes based upon the quality of the vasal fluid. Conclusion: Vasovasostomy in the convoluted vas deferens is a more difficult procedure than standard VV. There is minimal muscle layer and a larger discrepancy between the abdominal and testicular ends. Nevertheless, postoperative results are typically comparable to those obtained via VV and superior to epididymovasostomy in many cases. Therefore, we recommend the use of VV in the convoluted vas deferens utilizing the same indications as those seen for standard VV in the straight portion of the vas deferens.
P-339 Can ejaculatory duct obstruction be due to unilateral blockage? Rajveer S. Purohit, Katsuto Shinohara, Paul Turek. UCSF, San Francisco, CA. Objectives: Ejaculatory duct obstruction due to bilateral blockage of the ducts is a well recognized and treatable cause of male infertility. In these cases, duct obstruction can be either complete (azoospermia) or partial (sperm in ejaculate) in nature. Through the use of functional diagnostic tests in addition to transrectal ultrasound, we have identified the fact that ejaculatory duct obstruction can result from unilateral instead of bilateral blockage within the ductal system and report our treatment findings in affected patients. Design: Prospective study of a consecutive series of male infertility patients in a single institution. Methods: Twelve male infertility patients with suspected EDO by clinical evaluation that included TRUS proceeded to further intraoperative evalua-
S233