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How Involved Should the General Urologist be in the Evaluation and Management of Male Infertility?
How Involved Should the General Urologist be in the Evaluation and Management of Male Infertility? he field of male infertility has undergone significant changes in the last several decades. The use of genetic testing such as Y chromosome microdeletion testing, cystic fibrosis mutation screening and 5T polymorphism testing has become commonplace when evaluating the etiology of azoospermia. A variety of advanced sperm tests have been developed such as measurement of seminal reactive oxygen species and DNA integrity assays. The simple diagnostic testicular biopsy has gone the way of the dinosaur, and we are faced with sperm retrieval procedures with the acronyms TESA (testicular sperm aspiration), microTESE (microsurgical testicular excision sperm extraction), multiple TESE and PESA (percutaneous epididymal sperm aspiration). The ability to manipulate gametes has led to major advances in assisted reproductive techniques (ARTs). In vitro fertilization has advanced with the development of the ability to inject individual sperm into individual ova through intracytoplasmic injection. The resultant developing embryos may then be implanted into the uterus. This has led some ART centers to completely bypass the urologist, not evaluate the male and proceed directly to intracytoplasmic injection if any sperm are available. Even standard infertility surgery has changed with the operating microscope being used for most male infertility surgeries. Microsurgical subinguinal varicocele repairs have significantly lower recurrence rates and rates of subsequent hydrocele formation than more traditional nonmicrosurgical approaches. Vasectomy reversal has evolved with the development of end-to-side and, more recently, intussusception vasoepididymostomy techniques. With all of these changes what is a general urologist to do? Should he or she refer all infertility cases to subspecialists or just ignore the male and let the ART centers use the sperm as they see fit? Two articles in this issue of The Journal emphasize these issues (pages 2119 and 2129). Despite being a common procedure there remain no consistent national or international criteria to my knowledge for an appropriate postvasectomy semen analysis. Most physicians require no sperm to be identified in the specimen while others will accept low numbers of nonmotile sperm. The role of examination of a centrifuged pellet in this setting is also controversial. Steward et al address the issue of centrifugation in an analysis of data from a multinational study of vasectomies. They report that finding no sperm on examination of an uncentrifuged sample is highly predictive of finding no sperm or at least less than 100,000 sperm in a centrifuged pellet. Of note, in 4.8% of cases motile sperm were only seen in the centrifuged pellet and not in the uncentrifuged sample. Without national guidelines each physician performing vasectomy must be aware of the literature, know what technique the laboratory used when reporting no sperm seen and be able to discuss the significance of the results with patients.
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0022-5347/08/1805-1888/0 THE JOURNAL OF UROLOGY® Copyright © 2008 by AMERICAN UROLOGICAL ASSOCIATION
On the surgical side Boman et al emphasize that varicocele repair in appropriately selected patients still has a role in the management of male infertility. It is not only important to know how to perform varicocele repair, but also to know when to perform it as well as alternative management strategies. As reported by Boman et al intrauterine insemination may have a role in patients after varicocele repair. With the explosion of knowledge and techniques in medicine and surgery it has become impossible to master it all. Urology now has multiple subspecialties, albeit most not board certifiable. Despite this situation the basics of these specialties are part of general urology training. The basic evaluation and treatment of the infertile male is a required component of urology residency curriculums. Therefore, the general urologist starts out with the knowledge to perform a basic male infertility evaluation. In the practice of modern medicine there is an increased emphasis on outcomes and maintenance of skills. It has become clear that those individuals who perform larger volumes of particular procedures tend to be better at them. The skills required for microsurgery are only maintained by the regular performance of microsurgical procedures. Many general urologists may be quite comfortable performing microsurgical vasovasostomy but not vasoepididymostomy.1 It is quite reasonable for them to offer vasectomy reversal to those men who are unlikely to require the more complicated vasoepididymostomy after discussing the issue. While all of us finish residency training with a wide breadth of urological skills, as we enter practice many will narrow down the types of conditions and surgeries in which they are involved based on their interests and the local availability of others with specific expertise. The trend for urologists to practice within larger groups facilitates this approach. In many general urology practices certain individuals handle more complicated infertility cases for the group. While they are general urologists they may see an adequate volume of infertility cases to be quite comfortable treating a greater variety of infertility conditions before referral to a subspecialist. Those who want to maintain their involvement in the management of male infertility need to pursue continuing education in infertility during their practice lifetime. Options for education include journals, infertility lectures and courses held by organizations such as the American Urological Association and the Society for the Study of Male Reproduction. This education will allow them to obtain and maintain the skills required to offer patients up-to-date diagnostic and treatment options. For those who have limited interest and are not familiar with current infertility practice, early referral to someone with those skills is more appropriate. Expertise is a moving target and reliance on knowledge that may be years out of
1888
Vol. 180, 1888-1889, November 2008 Printed in U.S.A. DOI:10.1016/j.juro.2008.08.084
EVALUATION AND MANAGEMENT OF MALE INFERTILITY date is not only unacceptable but also will not be tolerated by patients or regulating agencies. Similarly ignoring current evaluation and management options and relying on ART centers to treat male factor infertility is also inappropriate.2 Urologists are the male infertility experts, and only by continuing our involvement with these patients will we maintain that position and offer the best medical care. Our first obligation is to the patient because, in the end, it is all about quality patient care.
1889 Mark Sigman Division of Urology Brown University Providence, Rhode Island
REFERENCES 1. Thomas AJ Jr: Infertility. J Urol 2004; 172: 829. 2. Jequier AM: Clinical andrology—still a major problem in the treatment of infertility. Hum Reprod 2004; 19: 1245.
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0022-5347/08/1805-1888/0 THE JOURNAL OF UROLOGY® Copyright © 2008 by AMERICAN UROLOGICAL ASSOCIATION
On the surgical side Boman et al emphasize that varicocele repair in appropriately selected patients still has a role in the management of male infertility. It is not only important to know how to perform varicocele repair, but also to know when to perform it as well as alternative management strategies. As reported by Boman et al intrauterine insemination may have a role in patients after varicocele repair. With the explosion of knowledge and techniques in medicine and surgery it has become impossible to master it all. Urology now has multiple subspecialties, albeit most not board certifiable. Despite this situation the basics of these specialties are part of general urology training. The basic evaluation and treatment of the infertile male is a required component of urology residency curriculums. Therefore, the general urologist starts out with the knowledge to perform a basic male infertility evaluation. In the practice of modern medicine there is an increased emphasis on outcomes and maintenance of skills. It has become clear that those individuals who perform larger volumes of particular procedures tend to be better at them. The skills required for microsurgery are only maintained by the regular performance of microsurgical procedures. Many general urologists may be quite comfortable performing microsurgical vasovasostomy but not vasoepididymostomy.1 It is quite reasonable for them to offer vasectomy reversal to those men who are unlikely to require the more complicated vasoepididymostomy after discussing the issue. While all of us finish residency training with a wide breadth of urological skills, as we enter practice many will narrow down the types of conditions and surgeries in which they are involved based on their interests and the local availability of others with specific expertise. The trend for urologists to practice within larger groups facilitates this approach. In many general urology practices certain individuals handle more complicated infertility cases for the group. While they are general urologists they may see an adequate volume of infertility cases to be quite comfortable treating a greater variety of infertility conditions before referral to a subspecialist. Those who want to maintain their involvement in the management of male infertility need to pursue continuing education in infertility during their practice lifetime. Options for education include journals, infertility lectures and courses held by organizations such as the American Urological Association and the Society for the Study of Male Reproduction. This education will allow them to obtain and maintain the skills required to offer patients up-to-date diagnostic and treatment options. For those who have limited interest and are not familiar with current infertility practice, early referral to someone with those skills is more appropriate. Expertise is a moving target and reliance on knowledge that may be years out of
1888
Vol. 180, 1888-1889, November 2008 Printed in U.S.A. DOI:10.1016/j.juro.2008.08.084
EVALUATION AND MANAGEMENT OF MALE INFERTILITY date is not only unacceptable but also will not be tolerated by patients or regulating agencies. Similarly ignoring current evaluation and management options and relying on ART centers to treat male factor infertility is also inappropriate.2 Urologists are the male infertility experts, and only by continuing our involvement with these patients will we maintain that position and offer the best medical care. Our first obligation is to the patient because, in the end, it is all about quality patient care.
1889 Mark Sigman Division of Urology Brown University Providence, Rhode Island
REFERENCES 1. Thomas AJ Jr: Infertility. J Urol 2004; 172: 829. 2. Jequier AM: Clinical andrology—still a major problem in the treatment of infertility. Hum Reprod 2004; 19: 1245.