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Fertility of Patients with Solitary Testes
THE JOURNAL OF UROLOGY
Copyright © 1973 by The Williams & Wilkins Co.
FERTILITY OF PATIENTS WITH SOLITARY TESTES DAVID M. WOODHEAD,* DONALD R. POHLt
AND
DOUGLAS E. JOHNSON:j:
From the Urology Service, Department of Surgery, Wilford Hall United States Air Force Medical Center, Lackland Air Force Base, San Antonio, Texas
in 5 of 19 patients who had previously undergone orchiopexy for unilateral cryptorchidism. 6 More attention has been given to this problem in the European literature. In addition to the aforementioned series, Hansen reported on a group of 24 untreated and 25 operated unilateral cryptorchids in which 10 and 8 patients, respectively, were considered to have a significant impairment of fertility. 7 Scott thought that 61 per cent of his series of, 34 postpuberal unilateral cryptorchids were subfertile8 and Mack found severe impairment of fertility in 59 per cent of a comparable group of 37 patients studied. 9 In a subsequent report Scott added 7 patients to his series and only two of these were considered fertile. 10 His cases, combined with others reported by that time (1962), made the total number of postpuberal unilateral cryptorchid patients investigated 125. Of this number 83 (68 per cent) were considered to be subfertile by one or more criteria. Since there is confusion in the literature and evidence does exist to suggest a high incidence of impaired fertility associated with unilateral cryptorchidism, a clinical study was carried out to further delineate the spermatogenic potential of individuals with this condition.
It is generally believed that the presence of a grossly normal scrotal testis in the unilateral cryptorchid is presumptive indication of relatively normal reproductive potential. Indeed, several studies have been performed, making use of the descended testis as a control in the evaluation of the contralateral cryptorchid testis. However, recent studies, including those establishing a disproportionate degree of subfertility in patients with unilateral varicocele, · suggest some degree of testicular interdependency. Testicular interrelationship is also suggested by the frequently observed phenomenon of compensatory hypertrophy seen in patients with unilateral cryptorchidism, patients with contralateral atrophy due to orchitis and those who have undergone unilateral orchiectomy. The recent establishment of an incidence of malignancy in the contralateral (normal) testis of the unilateral cryptorchid significantly higher than that found in the general population1 also suggests the existence of intertesticular or even genetic influence. In the American literature references to the fertility of the unilateral cryptorchids are infrequent and contradictory and consist primarily of limited observation and opinions. After histopathologic study of the descended testes of 5 unilateral cryptorchids, Hand considered the fertility potential poor in 2 cases. 2 Charny stated that the fertility of otherwise healthy men with unilateral cryptorchidism is normal.8 However, he quotes Hansen's series in which 11 of 35 untreated unilateral cryptorchids and 11 of 36 unilateral cryptorchids treated by orchiopexy were infertile. 4 In a subsequent publication, Charny stated that a spermatic deficiency exists in the normally descended testes of some unilateral cryptorchids. 5 Hortling and associates found oligospermia
METHOD
Forty-seven healthy postpuberal men, between 18 and 21 years old, with unilateral cryptochidism and no other abnormalities, were consecutively admitted to our urology service for evaluation. Investigation in each case consisted of 1 to 3 semen analyses. Each specimen was produced after a minimum of 3 days sexual abstention and obtained by masturbation and ejaculation into a chemically clean dry sterile container. Since no uniformity of criteria for fertility exists, the results of previous studies are frequently difficult to interpret. For simplicity and uniformity, 20 million sperm per milliliter was chosen as an arbitrary level of normality. Patients with counts less than this
Accepted for publication May 5, 1972. * Died July 13, 1972. t Current address: United States Air Force Hospital Maxwell, Maxwell Air Force Base, Alabama 36112.
:j: Current address: M. D. Anderson Hospital and Tumor Institute, Houston, Texas 77025. 1 Johnson, D. E., Woodhead, D. M., Pohl, D. R. and Robison, J. R.: Crytorchism and testicular tumorigenesis. Surgery, 63: 919, 1968. 2 Hand, J. R.: Fertility expectancy following prolonged extrascrotal residence of the testes. Fertil. Steril., 10: 15, 1959. 3 Charny, C. W. and Wolgin, W.: Cryptorchism. New York: Harper & Row, Publishers, p. 46, 1957. 4 Hansen, T. S.: Fertility in operatively treated and untreated cryptorchism. Acta Chir. Scand., 94: 117,
6 Hortling, H., Chapelle, A., de la, Johansson, C.-J., Niemi, M. and Sulamaa, M. : An endocrinologic followup study of operated cases of cryptorchism. J. Olin. Endocr., 27: 120, 1967. 7 Hansen, T. S.: Fertility in operatively treated and untreated cryptorchidism. Proc. Roy. Soc. Med.,
42: 645, 1949.
8 Scott, L. S.: Unilateral cryptorchidism; subsequent effects on fertility. J. Reprod. Fertil., 2:
54, 1961.
9 Mack, W. S.: Discussion on male infertility. Proc. Roy. Soc. Med., 46: 840, 1953. 10 Scott, L. S.: Fertility in cryptorchidism. :Proc. Roy. Soc. Med., 55: 1047, 1962.
1946.
Charny, C. W.: The spermatogenic potential of the undescended testis ,before and after treatment. J. Urol., 83: 697, 1960. 6
66
67
FERTILITY OF PATIENTS WITH SOLITARY TESTES
were considered to be oligospermic. Other less consistent and objective parameters of the semen analysis (morphology, motility, etc.) were not considered in the evaluation of this group. Because of the neoplastic potential of the undescended testis and its proved spermatogenic deficit· even after orchiopexy in the postpuberal male subject, it has been our policy to remove unilateral cryptorchid testes in all otherwise normal healthy men. Orchiectomy with open biopsy of the contralateral scrotal testis was performed in each of the patients studied. Detailed histopathologic study of this tissue is being performed and will be the subject of a subsequent report. RESULTS
All 34 retained testes were grossly abnormal in some way (small, soft, abnormal attachments, etc.). In 13 patients the vas deferens ended blindly or terminated in a rudimentary structure in which no recognizable testicular tissue was seen histologically. The number of oligospermic patients in each anatomical group is listed in the table. Essentially 36 per cent of the unilateral cryptorchids evaluated in this study were oligospermic. This is a significantly higher incidence of oligospermia than is encountered in the general population. 11 The presence or absence of functioning spermatogenic tissue in the excised cryptorchid testis seemed to have no influence on the spermatogenic potential of the contralateral scrotal testis. DISCUSSION
Although this study established that sperm productivity is impaired in more than a third of the in11 Hotchkiss, R. S., Brunner, E. K. and Grenley, P.: Semen analyses of two hundred fertile men. Amer. J. Med. Sci., 196: 362, 1938.
Oligospermia in men with uniiateral cryptorchidism Undescended Testicular Tissue Absent No. patients No. oligospermic % oligospermic
13
5 38.5
Present
Total
34 12 35.3
47 17 36.2
dividuals with apparently normal solitary scrotal testes, the etiology of this impairment of potential remains unclear. It has been suggested that a crypt?rchid testis, abnormally fo~med or positioned, may m some way exert a deleterious effect on spermatogenesis in the contralateral testis. The fact that spermatogenesis was equally impaired in the group devoid of any functioning recognizable testicular tissue in the cryptorchid position seems to indicate that this does not occur. Other etiological explanations for this impairment must be considered. A constitutional germ cell deficiency or defect in central hormonal stimulation could exist in these patients, although no definite evidence exists to support either of these possibilities. The cause of this impairment in spermatogenesis remains obscure. Treatment responses in subfertile patients with solitary testes have not been reported but such studies may provide a useful approach to the solution of this problem. SUMMARY
The incidence of oligospermia is significantly higher in individuals with an apparently normal solitary testis than in the general population. Influence of an abnormal contralateral testis is apparently not responsible for subfertility in such patients. Etiology of the defect and its appropriate treatment remain to be determined.
Copyright © 1973 by The Williams & Wilkins Co.
FERTILITY OF PATIENTS WITH SOLITARY TESTES DAVID M. WOODHEAD,* DONALD R. POHLt
AND
DOUGLAS E. JOHNSON:j:
From the Urology Service, Department of Surgery, Wilford Hall United States Air Force Medical Center, Lackland Air Force Base, San Antonio, Texas
in 5 of 19 patients who had previously undergone orchiopexy for unilateral cryptorchidism. 6 More attention has been given to this problem in the European literature. In addition to the aforementioned series, Hansen reported on a group of 24 untreated and 25 operated unilateral cryptorchids in which 10 and 8 patients, respectively, were considered to have a significant impairment of fertility. 7 Scott thought that 61 per cent of his series of, 34 postpuberal unilateral cryptorchids were subfertile8 and Mack found severe impairment of fertility in 59 per cent of a comparable group of 37 patients studied. 9 In a subsequent report Scott added 7 patients to his series and only two of these were considered fertile. 10 His cases, combined with others reported by that time (1962), made the total number of postpuberal unilateral cryptorchid patients investigated 125. Of this number 83 (68 per cent) were considered to be subfertile by one or more criteria. Since there is confusion in the literature and evidence does exist to suggest a high incidence of impaired fertility associated with unilateral cryptorchidism, a clinical study was carried out to further delineate the spermatogenic potential of individuals with this condition.
It is generally believed that the presence of a grossly normal scrotal testis in the unilateral cryptorchid is presumptive indication of relatively normal reproductive potential. Indeed, several studies have been performed, making use of the descended testis as a control in the evaluation of the contralateral cryptorchid testis. However, recent studies, including those establishing a disproportionate degree of subfertility in patients with unilateral varicocele, · suggest some degree of testicular interdependency. Testicular interrelationship is also suggested by the frequently observed phenomenon of compensatory hypertrophy seen in patients with unilateral cryptorchidism, patients with contralateral atrophy due to orchitis and those who have undergone unilateral orchiectomy. The recent establishment of an incidence of malignancy in the contralateral (normal) testis of the unilateral cryptorchid significantly higher than that found in the general population1 also suggests the existence of intertesticular or even genetic influence. In the American literature references to the fertility of the unilateral cryptorchids are infrequent and contradictory and consist primarily of limited observation and opinions. After histopathologic study of the descended testes of 5 unilateral cryptorchids, Hand considered the fertility potential poor in 2 cases. 2 Charny stated that the fertility of otherwise healthy men with unilateral cryptorchidism is normal.8 However, he quotes Hansen's series in which 11 of 35 untreated unilateral cryptorchids and 11 of 36 unilateral cryptorchids treated by orchiopexy were infertile. 4 In a subsequent publication, Charny stated that a spermatic deficiency exists in the normally descended testes of some unilateral cryptorchids. 5 Hortling and associates found oligospermia
METHOD
Forty-seven healthy postpuberal men, between 18 and 21 years old, with unilateral cryptochidism and no other abnormalities, were consecutively admitted to our urology service for evaluation. Investigation in each case consisted of 1 to 3 semen analyses. Each specimen was produced after a minimum of 3 days sexual abstention and obtained by masturbation and ejaculation into a chemically clean dry sterile container. Since no uniformity of criteria for fertility exists, the results of previous studies are frequently difficult to interpret. For simplicity and uniformity, 20 million sperm per milliliter was chosen as an arbitrary level of normality. Patients with counts less than this
Accepted for publication May 5, 1972. * Died July 13, 1972. t Current address: United States Air Force Hospital Maxwell, Maxwell Air Force Base, Alabama 36112.
:j: Current address: M. D. Anderson Hospital and Tumor Institute, Houston, Texas 77025. 1 Johnson, D. E., Woodhead, D. M., Pohl, D. R. and Robison, J. R.: Crytorchism and testicular tumorigenesis. Surgery, 63: 919, 1968. 2 Hand, J. R.: Fertility expectancy following prolonged extrascrotal residence of the testes. Fertil. Steril., 10: 15, 1959. 3 Charny, C. W. and Wolgin, W.: Cryptorchism. New York: Harper & Row, Publishers, p. 46, 1957. 4 Hansen, T. S.: Fertility in operatively treated and untreated cryptorchism. Acta Chir. Scand., 94: 117,
6 Hortling, H., Chapelle, A., de la, Johansson, C.-J., Niemi, M. and Sulamaa, M. : An endocrinologic followup study of operated cases of cryptorchism. J. Olin. Endocr., 27: 120, 1967. 7 Hansen, T. S.: Fertility in operatively treated and untreated cryptorchidism. Proc. Roy. Soc. Med.,
42: 645, 1949.
8 Scott, L. S.: Unilateral cryptorchidism; subsequent effects on fertility. J. Reprod. Fertil., 2:
54, 1961.
9 Mack, W. S.: Discussion on male infertility. Proc. Roy. Soc. Med., 46: 840, 1953. 10 Scott, L. S.: Fertility in cryptorchidism. :Proc. Roy. Soc. Med., 55: 1047, 1962.
1946.
Charny, C. W.: The spermatogenic potential of the undescended testis ,before and after treatment. J. Urol., 83: 697, 1960. 6
66
67
FERTILITY OF PATIENTS WITH SOLITARY TESTES
were considered to be oligospermic. Other less consistent and objective parameters of the semen analysis (morphology, motility, etc.) were not considered in the evaluation of this group. Because of the neoplastic potential of the undescended testis and its proved spermatogenic deficit· even after orchiopexy in the postpuberal male subject, it has been our policy to remove unilateral cryptorchid testes in all otherwise normal healthy men. Orchiectomy with open biopsy of the contralateral scrotal testis was performed in each of the patients studied. Detailed histopathologic study of this tissue is being performed and will be the subject of a subsequent report. RESULTS
All 34 retained testes were grossly abnormal in some way (small, soft, abnormal attachments, etc.). In 13 patients the vas deferens ended blindly or terminated in a rudimentary structure in which no recognizable testicular tissue was seen histologically. The number of oligospermic patients in each anatomical group is listed in the table. Essentially 36 per cent of the unilateral cryptorchids evaluated in this study were oligospermic. This is a significantly higher incidence of oligospermia than is encountered in the general population. 11 The presence or absence of functioning spermatogenic tissue in the excised cryptorchid testis seemed to have no influence on the spermatogenic potential of the contralateral scrotal testis. DISCUSSION
Although this study established that sperm productivity is impaired in more than a third of the in11 Hotchkiss, R. S., Brunner, E. K. and Grenley, P.: Semen analyses of two hundred fertile men. Amer. J. Med. Sci., 196: 362, 1938.
Oligospermia in men with uniiateral cryptorchidism Undescended Testicular Tissue Absent No. patients No. oligospermic % oligospermic
13
5 38.5
Present
Total
34 12 35.3
47 17 36.2
dividuals with apparently normal solitary scrotal testes, the etiology of this impairment of potential remains unclear. It has been suggested that a crypt?rchid testis, abnormally fo~med or positioned, may m some way exert a deleterious effect on spermatogenesis in the contralateral testis. The fact that spermatogenesis was equally impaired in the group devoid of any functioning recognizable testicular tissue in the cryptorchid position seems to indicate that this does not occur. Other etiological explanations for this impairment must be considered. A constitutional germ cell deficiency or defect in central hormonal stimulation could exist in these patients, although no definite evidence exists to support either of these possibilities. The cause of this impairment in spermatogenesis remains obscure. Treatment responses in subfertile patients with solitary testes have not been reported but such studies may provide a useful approach to the solution of this problem. SUMMARY
The incidence of oligospermia is significantly higher in individuals with an apparently normal solitary testis than in the general population. Influence of an abnormal contralateral testis is apparently not responsible for subfertility in such patients. Etiology of the defect and its appropriate treatment remain to be determined.