- Email: [email protected]
Surgical Management of Male Infertility: Results of a survey
FERTILITY AND STERILITY
Vol. 24, No.7, July 1973 Printed in U.S.A.
Copyright © 1973 by The Williams & Wilkins Co.
Current Perspectives SURGICAL MANAGEMENT OF MALE INFERTILITY: RESULTS OF A SURVEY PAUL L. GETZOFF, M.D., F.A.C.S.* Department of Urology, School of Medicine, University of California at Irvine, Irvine, California 92664
An interesting dichotomy will face future medical historians who attempt to reconcile today's wide acceptance of contraception and abortion with the present vast research efforts to correct impaired human fertility. Whereas many fertility problems in women have been benefited by endocrine therapy, the subfertile male has been less fortunate. In spite of large numbers of men having been treated with many varieties of hormones and other chemical agents, medical management of impaired spermatogenesis has had a low rate of success. 1, 2 Some of the pathologic problems encountered in selected subfertile men can be corrected by surgical methods. Over the past several years these procedures have been increasingly used. This is an encouraging sign, especially since a number of these procedures are not recent innovations but have been recommended by urologists for more than 35 years. The excitement that has been engendered by the more frequent use of these urologic technics is fraught with a potential danger. The pendulum may swing back as surgical failures begin to be reported. If such experiences occur in large numbers, cynicism will replace enthusiasm. The critical issue may be to insure that these procedures are properly utilized. This * Reprint requests: 435 N. Bedford Dr., Beverly Hills, CA 90210.
investigation was undertaken as an attempt to clarify the problem. The study was designed to summarize the experience and views of a large group of urologists whose know lege and judgment in the field of male fertility is a matter of record. Questionnaires were mailed to 200 urologists who have had wide experience in male fertility problems over many years. The return of 131 responses in less than 2 weeks was totally unexpected and proved to my satisfaction the intense interest in the surgical management of male subfertility. A total of 150 replies were received at the end of 4 weeks. More than threefourths of this group not only answered the questions but took the trouble to add shrewd and frequently pithy comments. I attempted to avoid the semantic pitfalls common to this type of investigation by first establishing the criteria of a "successful operation" (Question I). Less than one-third of the replies insisted that success of the operation could be measured only by the occurrence of pregnancy and the delivery of a normal viable infant. Almost 70% of the respondents added a comment that they could not accept the premise that a recent gynecologic evaluation had found the wife to be fertile and capable of a normal pregnancy. Most of these comments indicated the following viewpoints. 1. This stipulation is contrary to fact
553
554
Vol. 24
GETZOFF QUESTION 1. Criteria for Success
The criterion of a successful operation to correct male subfertility' should be one of the following;
The appearance of "some sperm" in the azoospermic man regardless of whether his wife fails to conceive The appearance of a normal semen analysis in the azoospermic or oligospermic man regardless of whether his wife fails to conceive The wife becomes pregnant regardless of whether she aborts the embryo or fetus The wife becomes pregnant and carries to term a normal viable infant
No.
%
13
8.7
64
42.6
28
18.7
45
30.0
* It is assumed that the wife has been found to be fertile and capable of a normal pregnancy in a recent gynecologic evaluation.
because the wife could still be the "defective partner in a barren marriage regardless of improvement in the semen quality." 2. Pregnancies resulting in a normal viable infant do occur in the absence of semen of normal quality (azoospermia excepted). As a corollary to this view, one reply stated, "A presumption that needs scientific confirmation is that only 'normal' spermatozoa will fertilize an ovum. Therefore, abortion is due to a defect in the ovum, uterus, or female hormonal environment." 3. The suggestion was made that there be four "subcriteria" for successful operation, utilizing the four alternatives contained in this part of the questionnaire. The disparity of these replies highlights the need for clarification of the concept of a successful operation. From this sampling, it appears that agreement is not in the immediate offing (Question II). An inconsistency becomes evident in comparing replies to the two parts of Question II. Almost one-third of the answers favored varicocelectomy for every subfertile man having a varicocele. Yet, onefourth of those who performed this proce-
dure had no success, and 38.8% had a success rate of 5% or less. Does this represent a desire to do something definitive in the hope that some subfertile patients will respond favorably? In that case, many have chosen to ignore MacLeod's criteria, perhaps because of their being unproven or too stringent. Future evaluation of varicocelectomy will determine whether good judgment was compromised by these surgeons. The potential danger in this situation is that, as long as varicocelectomy is performed indiscriminately, failures will continue to outweigh successes, and a procedure of proved effectiveness will meet with cynical rejection. The impressive fact is that more than half (55.3%) of the urologists canvassed in this inquiry never performed a varicocele operation to correct impaired fertility. Most of the comments of this group implied healthy skepticism, others held a conservative attitude of watchful waiting. Some typical remarks follow. "I am not certain whether my technician QUESTION II. Varicocelectomy
A worthless operation to correet impaired spermatogenesis Should be performed in every subfertile male with a varicocele Should be performed only in selected cases I have performed varicocelectomies* with: No success Rare (1%) success Occasional (5%) success Moderately encouraging success compatible with that reported in literature (40-50%) Never performed this operation for impaired fertility
*N
~
67.
No.
%of total
6
4.0
44
29.3
100
66.7
16 9 17 25
10.7 6.0 11.3 16.7
83
55.3
%of group'
23.9 13.4 25.4 37.3
July 1973
MALE INFERTILITY
or I would recognize a stress cell if we saw one." "My patients want guarantees, and I cannot guarantee a procedure that I do not understand. " "I need more proof-perhaps a five-year summation of the experience with a thousand of these so-called selected cases." COMMENT
In 1937, Wilhelm 3 published a monograph on male infertility in which he concluded that "the importance of varicocele as a factor in the etiology of partial and absolute sterility is commonly underestimated." However, he failed to substantiate his conclusion and apparently concerned himself only with "cases of bilateral varicocele with impaired or absent function of the testis." The role of the varicocele in the pathogenesis of male subfertility continued to be ignored until 1952, when Tulloch 4 reported the first successful case of correction of impaired spermatogenesis following varicocelectomy. His British colleagues 5, 6 were quick to recognize the value of Tulloch's contribution, and soon there followed reports of numerous successful cases as well as research studies into this previously unexplored area of male gonadal physiology. MacLeod 7 and Charny 8 brought the message back to the United States and became the prime movers in stimulating interest in varicocele operations in this country. Soon, equally encouraging results were being reported by Brown, Dubin, and Hotchkiss,9 by Dubin and Amelar,IO and others. In spite of intensive research into the manner in which varicocele affects male fertility, the rationale for this procedure still has not been conclusively pinpointed. In selecting candidates for varicocelectomy, it should be remembered that the best results have been achieved in patients whose seminal cytology has approximated
555
the standards set up by MacLeod. l l Such men consistently manifest poor sperm motility. He demonstrated a characteristic occurrence of a "stress pattern of sperm morphology (tapering and amorphous cells and the exfoliation of immature cells of the germinal line into the ejaculate)." Following varicocelectomy, sperm morphology definitely improves, although some "stress cells" might persist. The most striking response is a significant improvement in sperm motility. Although moderate to marked increase in sperm count may occur, this factor usually is relatively unaffected; improvement both in sperm morphology and motility has apparently been responsible for subsequent successful pregnancies. Ligation of the internal spermatic vein at the level of the internal inguinal ring has become the procedure of choice in varicocele operations. It is relatively simple, postoperative morbidity is minimal, and there is decreased danger of interfering with the arterial testicular blood supply, such as sometimes occurs with the classical scrotal technic. A thought-provoking observation was made by Hanley and Harrison 12 in 1962 and was confirmed more recently by Dubin and Amelar. 13 They found that small as well as large varicoceles can produce serious deleterious effects on spermatogenesis. All varicoceles, therefore, should be surgically corrected provided no contraindications are present. In analyzing the responses to Question III the following observations became readily apparent. 1. Some respondents (13.3%) have never performed this operation, and more than twice this number discourage it. 2. Almost half of those who had used the operation either reported no success or a rare incidence (1%) of success. 3. Although only 2.7% acknowledged moderately encouraging success compatible with that reported in the literature,
556
Vol. 24
GETZOFF
QUESTION III. Epididymovasostomy
I have performed this operation with: No success Rare (1%) success Occasional (5%) success Moderate (20%) success Moderately encouraging success compatible with that reported in the literature (50 to 70%) Never performed this operation When the indications are present that lend themselves to an epididymovasostomy: I encourage the operation I discourage the operation I acquaint the patient with a realistic concept of the procedure and its prognosis
No.
%
42
31 32
28.0 20.7 21.3
21
14.0
4
2.7
20
13.3
14 41
95
9.3 27.3 63.3
almost 10% of all respondents encourage this operation. 4. Occasional or moderate success was reported by 35%. 5. The predominant attitude (63.3%) was that the disappointing experiences with this procedure must be conveyed to the patient in advance. The following comment reflects this attitude: "I would be very frank with the patient and a bit on the pessimistic side-in fact, more than a bit." A summary of the experiences recorded by those who had moderate success, together with the few reporting encouraging success (16.7% of the total group), points to unresolved problems, indicating more fundamental reasons for lack of success than merely operative technic. Furthermore, the following comments are decidedly pertinent to operational success as defined earlier. 1. Variable amounts of spermatozoa (" a few to 60 million") appeared postoperatively in the ejaculate of formerly aspermic men. 2. After technically successful operation, sperm motility was poor, varying from
rare to less than 5%, regardless of sperm concentration. This' deficiency has been resistant to endocrine therapy and other forms of medical management. 3. The pregnancy rate was consistently disappointing in spite of postoperative appearance of sperm. Several of those queried remarked on the total ineffectiveness of the new "improved" semen used in artificial insemination. COMMENT
Epididymovasostomy was first described by Martin 14 in 1902. Hagner 15 (1936) in the United States and Bayle 16 (1958) in France later stimulated interest in this operation. The basic indication for epididymovasostomy is in azoospermic men with intact spermatogenesis and no interference in the continuity between the vas deferens and the ejaculatory duct. The aim is to create a permanent fistula between the globus major of the epididymis and the vas deferens. The operation consists of incising an elliptical window in the globus major and anastomosing it to a similar opening in the vas deferens. In essence, this creates a by-pass around the area of postinflammatory obstruction that commonly affects the globus minor of the epididymis and prevents sperm from entering the vas deferens. A successful operative result depends on several prerequisites. 1. Spermatogenesis must be intact. 2. Spermatozoa must be recovered from the epididymal opening at operation. 3. The vas deferens and the ejaculatory duct must be patent. 4. The blood supply to the anastamosed area as well as to the testicles and vas deferens must never be compromised. 5. Undue traction of the involved tissues must be avoided (Question IV). The following impressions are predicted on the experiences tabulated under Question IV. (1) About one-sixth of the replies reported successful surgical results in ex-
July 1973
cess of 50% of cases; however, more than half the respondents had either a low or a moderate rate of success. (2) The disappointment expressed by the others suggests at least two unfortunate situations. First, there are problems encountered in patients whose vasectomies resulted in technical difficulties which prevented a permanently patent reanastomosis. The second situation is perhaps of greater importance; it is the significantly low incidence of pregnancy in spite of postoperative reappearance of sperm in the semen. A further observation on this will be made in the following comments. Although 3 out of 10 urologists reported that they would attempt one repeat operation if the first vasovasostomy failed, almost two-thirds of the replies were unalterably QUESTION IV. Vasovasostomy
I have performed this procedure with: No success Rare (1 %) success Occasional (5%) success Moderate (20%) success Encouraging success compatible with that reported in the literature (50-70%) Never performed this operation If the first attempt at surgical reanastamosis of the vas deferens is a failure (i.e., no postoperative appearance of sperm), this operation should be repeated: Onetime Two times More than two times Should NOT be repeated When a patient consults me about the feasibility of a vasovasostomy: I encourage him to have it performed I discourage him from having it performed I acquaint him with a realistic concept of the procedure and its prognosis
557
MALE INFERTILITY
No.
%
12 17 30 58 24
8.0 11.3 20.0 38.7 16.0
9
6.0
47 7 3 93
31.3 4.7 62.0
13
8.7
8
5.3
129
86.0
2.0
opposed to a second performance. This is in sharp contrast to less than 7% who would advise the procedure two or more times. A small number (8.7%) encourage reanastomosis of the vas deferens. Only a few (5.3%) discourage this operation altogether. The majority opinion (86%) favored performing the operation after acquainting the patient with a realistic concept of the procedure and its prognosis. COMMENTS
The demand for vasectomy increased significantly following reports of unfavorable complications encountered in women taking oral contraceptives. In the United States the number of elective surgical sterilizations of men probably exceeds statistics previously reported by Davis and Hulka 17 (between 50,000 and 200,000 men yearly). The subject takes an added interest upon noting Hotchkiss' 18 estimate that 6-10% of these men will request reanastomosis at a later date. The performance of reanastomosis or vasovasostomy is relatively simple. Among the few pitfalls that beset the surgeon, the following are repeatedly emphasized. 1. Excessive mobilization of the proximal and distal ends of the vas can interfere with the blood supply and result in avascular necrosis at the site of anastomosis. 2. The vasal ends must be excised far enough to eliminate all evidence of fibrotic tissue reaction from the previous operation. 3. Excessive tension at the suture site must be avoided in cases where a long section of the vas had been originally excised. All attempts to compensate for such a wide gap are almost invariably doomed to failure. 4. The highest incidence of unsuccessful results Occurs when the vasectomy had been performed close to the epididymis. Now, as to the low incidence of pregnancy after vasovasostomy: Ansbacher 19 made a valuable contribution on post-
558
Vol. 24
GETZOFF
2. No one favored the use of cotton for vasectomy results in a 6-month follow-up of 48 men. Circulating sperm-agglutinating splinting. 3. Fourteen respondents preferred no antibodies were present in 26 men (54.2%), and ~perm-immobilizing antibodies were splinting. Most of those commenting on found in 15 (31.3%). Only one man had their choice agreed that whatever good a circulating antibodies before vasectomy splint might do, it is outweighed by the deleterious effects of foreign-body tissue (Question V). In view of the numerous ingenious inno- reaction and increased probabilities of invations that many surgeons utilize to im- fection. 4. Most respondents did not use drains. prove classical surgical technics, we de5. The overwhelming majority (93.6%) voted one phase of the questionnaire to some of the "tricks of the trade" used by decried the use of steroids. The feeling was experienced surgeons in epididymovasosto- that "an operation is doomed to failure if the integrity of the anastomosis is dependmies and vasovasostomies. The information in the returns for Ques- ent on steroids." Some pointed out the increased susceptibility to infection as a tion V may be summarized as follows. 1. A highly significant majority agreed complication of steroids, "especially in the that splinting the site of anastomosis was overpopulated bacterial atmosphere of the desirable. Silver wire left in place for 10 scrotum" (Question VI). The replies to this question reflect the days was the most popular choice. Nylon sutures used for the same period were the overwhelming negative attitude of urolosecond preference, followed by a variety of gists (70%) when asked to perform vasecthe other non absorbable materials listed. tomy in men who desire reassurance reSplints were never used for more than 14 garding the feasibility of a subsequent surgical reanastomosis. A few (3.3%) would days. QUESTION V. Surgical Technic (N
~
141) Period left in place
No.
When performing a vasovasos· tomy or epididymovasos· tomy, the following splint is used: Silver wire Silk suture Steel wire Nylon suture Silastic tubing Cotton Other No splint used Drainage: Operative site drained Operative site not drained Use of steroids: Steroid prescribed during p.o. period No steroid prescribed
65 1 4 43 12
%
5 days
10 days
14 days
51.1 0.8 3.2 33.8 9.5
9 1 4 2 4
40
16
35 5
6 3
2
4
3
2
1.6
14
9.9
21 120
14.9 85.1
9
16.4
132
93.6
More
2
July 1973
QUESTION VI. Vasectomy Predicated on Later Vasovasotomy
When a patient requests a vasectomy predicated on the possibility that he might one day desire vasovasostomy, do you: Encourage the vasectomy Discourage the vasectomy Acquaint him with a realistic concept of a vasovasostomy and its limited prognosis
559
MALE INI'ERTILITY
No.
%
5
3.3 70.0 26.7
105
40
encourage vasectomy under these circumstances. A considerable number (26.7%) left the responsibility of risk to the patient after acquainting him with a realistic concept and prognosis of va sovas ostomy. This part of the questionnaire elicited many comments, most of which are typified by the following. "Complying with the request of a man who wants to keep his cake and eat it is irrational and spells trouble for the surgeon." "I perform vasectomies only after making an honest attempt to discourage the procedure. " "I discuss the vasectomy operation with the patient and his wife. If they inquire at great length about operations for restoring the husband's fertility should they have a change of heart, I refuse to touch him." "Why not? What I undo, I can put together again." SUMMARY AND CONCLUSIONS
This study revealed a wide disparity of opinions among urologists regarding the surgical correction of impaired male fertility. This fact alone reveals the weaknesses in the oft-quoted textbooks used as guidelines by perplexed and less-experienced urologists. The 150 competent specialists who responded to the questionnaire not only disagreed as to the proper selection of
suitable candidates for operation, but were confused about the most effective technics for correcting various pathologic entities. They could not even agree on a definition of what constitutes a successful operation. It may well be that surgeons have failed to appreciate the limitations of operative procedures in this area. An understanding of the immunologic aspect of male fertility would explain why even a technically perfect operation might be predestined to fail in achieving the desired goal. When antispermatic antibodies and sperm agglutinins, associated with traumatic or inflammatory changes or with congenital gonadal anomalies, are present, surgical correction of a mechanical fault in the male reproductive system cannot be effective. This investigation indicates an obvious lack of communication between those surgeons who have achieved moderately encouraging success in increasing male fertility and their less enchanted colleagues. It suggests a need for greater clarification of the problem involved and a wider discussion among urologists with experience in this field. REFERENCES 1. DAVIS, M. E. Management of infertility. JAMA 201:1030, 1967. 2. GETZOFF, P. L. "Infertility of the Male." In Current Therapy, Conn, H. F., Ed. Saunders, Philadelphia, 1969, p. 493. 3. WILHELM, S. F. Sterility in the Male. Oxford, London, 1937. 4. TULLOCH, W. S. Varicocele in subfertility. Results of treatment. Brit Med J 2:356, 1955. 5. HANLEY, H. G. The surgery of male subfertility. Ann Roy Coli Surg Eng 17:159, 1955. 6. SCOTT, L. S. Varicocele: A treatable cause of subfertility. Brit Med J 1:788, 1961. 7. MACLEOD, J. A possible factor in the etiology of human infertility: Preliminary report. Fertil Steril 13:29, 1962. 8. CHARNY, C. W. Effect of varicocele on fertility. Results of varicocelectomy. Fertil Steril 13:47, 1962. 9. BROWN, J. S., DUBIN, L., AND HOTCHKISS, R. S. The varicocele as related to fertility. Fertil Steril 18:46, 1967.
560
Vol. 24
GETZOFF
10. DUBIN, L., AND AMELAR, R. D. Etiologic factors in 1294 consecutive cases of male infertility. Fertil SteriI22:469, 1971. 11. MACLEOD, J. Seminal cytology in the presence of varicocele. Fertil Steril 16:735, 1965. 12. HANLEY, H. G., AND HARRISON, R. G. Nature and surgical treatment of varicocele. Brit J Surg
50:64, 1962. 13. DUBIN, L., AND AMELAR, R. D. Varicocele size and results of varicocelectomy in selected subfertile men with varicocele. Fertil Steril 21:606, 1970. 14. MARTIN, E., CARNE'IT, J. B., LEVI, J. V., AND PENNINGTON, M. E. The surgical treatment of sterility due to obstruction at the epididymis. Together with a study of the morphology of human spermatozoa. Univ Penn Med Bull 15:2, 1903.
15. HAGNER, F. R. The operative treatment of sterility in the male. JAMA 107:1851, 1936. 16. BAYLE, H. "Traitement Chirurgical de la Sterilite Masculine." In La Fonction Spermatogenetique du Testicule Humain, Bayle, H., Gourgou, C., and Guillon, G., Eds. Masson et Cie, Paris, 1958. 17. DAVIS, J. E., AND HULKA, J. F. Elective vasectomy by American urologists in 1976. Fertil Steril 21:615, 1970. 18. HOTCHKISS, R. S. The Male Factor-The Irresistible Force. Presented at the Pacific Coast Fertility Society Meeting, October 29 to November 1, 1970, Scottsdale, Ariz. 19. ANSBACHER, R. Sperm-agglutinating and spermimmobilizing antibodies in vasectomized men. Fertil Steril 22:629, 1971.
ERRATUM
On p. 285 of the April 1973 issue (Jones and Edgren), Table 2, lines 5, 6, and 9 should read as follows: Northisterone acetate Ethynodiol diacetate Hydrocortisone
573.0 p.g. 1,342.0 p.g. 10,000.0 p.g.
267.0- 1,681. 9 p.g. 671.3-10,935.4 p.g.
Vol. 24, No.7, July 1973 Printed in U.S.A.
Copyright © 1973 by The Williams & Wilkins Co.
Current Perspectives SURGICAL MANAGEMENT OF MALE INFERTILITY: RESULTS OF A SURVEY PAUL L. GETZOFF, M.D., F.A.C.S.* Department of Urology, School of Medicine, University of California at Irvine, Irvine, California 92664
An interesting dichotomy will face future medical historians who attempt to reconcile today's wide acceptance of contraception and abortion with the present vast research efforts to correct impaired human fertility. Whereas many fertility problems in women have been benefited by endocrine therapy, the subfertile male has been less fortunate. In spite of large numbers of men having been treated with many varieties of hormones and other chemical agents, medical management of impaired spermatogenesis has had a low rate of success. 1, 2 Some of the pathologic problems encountered in selected subfertile men can be corrected by surgical methods. Over the past several years these procedures have been increasingly used. This is an encouraging sign, especially since a number of these procedures are not recent innovations but have been recommended by urologists for more than 35 years. The excitement that has been engendered by the more frequent use of these urologic technics is fraught with a potential danger. The pendulum may swing back as surgical failures begin to be reported. If such experiences occur in large numbers, cynicism will replace enthusiasm. The critical issue may be to insure that these procedures are properly utilized. This * Reprint requests: 435 N. Bedford Dr., Beverly Hills, CA 90210.
investigation was undertaken as an attempt to clarify the problem. The study was designed to summarize the experience and views of a large group of urologists whose know lege and judgment in the field of male fertility is a matter of record. Questionnaires were mailed to 200 urologists who have had wide experience in male fertility problems over many years. The return of 131 responses in less than 2 weeks was totally unexpected and proved to my satisfaction the intense interest in the surgical management of male subfertility. A total of 150 replies were received at the end of 4 weeks. More than threefourths of this group not only answered the questions but took the trouble to add shrewd and frequently pithy comments. I attempted to avoid the semantic pitfalls common to this type of investigation by first establishing the criteria of a "successful operation" (Question I). Less than one-third of the replies insisted that success of the operation could be measured only by the occurrence of pregnancy and the delivery of a normal viable infant. Almost 70% of the respondents added a comment that they could not accept the premise that a recent gynecologic evaluation had found the wife to be fertile and capable of a normal pregnancy. Most of these comments indicated the following viewpoints. 1. This stipulation is contrary to fact
553
554
Vol. 24
GETZOFF QUESTION 1. Criteria for Success
The criterion of a successful operation to correct male subfertility' should be one of the following;
The appearance of "some sperm" in the azoospermic man regardless of whether his wife fails to conceive The appearance of a normal semen analysis in the azoospermic or oligospermic man regardless of whether his wife fails to conceive The wife becomes pregnant regardless of whether she aborts the embryo or fetus The wife becomes pregnant and carries to term a normal viable infant
No.
%
13
8.7
64
42.6
28
18.7
45
30.0
* It is assumed that the wife has been found to be fertile and capable of a normal pregnancy in a recent gynecologic evaluation.
because the wife could still be the "defective partner in a barren marriage regardless of improvement in the semen quality." 2. Pregnancies resulting in a normal viable infant do occur in the absence of semen of normal quality (azoospermia excepted). As a corollary to this view, one reply stated, "A presumption that needs scientific confirmation is that only 'normal' spermatozoa will fertilize an ovum. Therefore, abortion is due to a defect in the ovum, uterus, or female hormonal environment." 3. The suggestion was made that there be four "subcriteria" for successful operation, utilizing the four alternatives contained in this part of the questionnaire. The disparity of these replies highlights the need for clarification of the concept of a successful operation. From this sampling, it appears that agreement is not in the immediate offing (Question II). An inconsistency becomes evident in comparing replies to the two parts of Question II. Almost one-third of the answers favored varicocelectomy for every subfertile man having a varicocele. Yet, onefourth of those who performed this proce-
dure had no success, and 38.8% had a success rate of 5% or less. Does this represent a desire to do something definitive in the hope that some subfertile patients will respond favorably? In that case, many have chosen to ignore MacLeod's criteria, perhaps because of their being unproven or too stringent. Future evaluation of varicocelectomy will determine whether good judgment was compromised by these surgeons. The potential danger in this situation is that, as long as varicocelectomy is performed indiscriminately, failures will continue to outweigh successes, and a procedure of proved effectiveness will meet with cynical rejection. The impressive fact is that more than half (55.3%) of the urologists canvassed in this inquiry never performed a varicocele operation to correct impaired fertility. Most of the comments of this group implied healthy skepticism, others held a conservative attitude of watchful waiting. Some typical remarks follow. "I am not certain whether my technician QUESTION II. Varicocelectomy
A worthless operation to correet impaired spermatogenesis Should be performed in every subfertile male with a varicocele Should be performed only in selected cases I have performed varicocelectomies* with: No success Rare (1%) success Occasional (5%) success Moderately encouraging success compatible with that reported in literature (40-50%) Never performed this operation for impaired fertility
*N
~
67.
No.
%of total
6
4.0
44
29.3
100
66.7
16 9 17 25
10.7 6.0 11.3 16.7
83
55.3
%of group'
23.9 13.4 25.4 37.3
July 1973
MALE INFERTILITY
or I would recognize a stress cell if we saw one." "My patients want guarantees, and I cannot guarantee a procedure that I do not understand. " "I need more proof-perhaps a five-year summation of the experience with a thousand of these so-called selected cases." COMMENT
In 1937, Wilhelm 3 published a monograph on male infertility in which he concluded that "the importance of varicocele as a factor in the etiology of partial and absolute sterility is commonly underestimated." However, he failed to substantiate his conclusion and apparently concerned himself only with "cases of bilateral varicocele with impaired or absent function of the testis." The role of the varicocele in the pathogenesis of male subfertility continued to be ignored until 1952, when Tulloch 4 reported the first successful case of correction of impaired spermatogenesis following varicocelectomy. His British colleagues 5, 6 were quick to recognize the value of Tulloch's contribution, and soon there followed reports of numerous successful cases as well as research studies into this previously unexplored area of male gonadal physiology. MacLeod 7 and Charny 8 brought the message back to the United States and became the prime movers in stimulating interest in varicocele operations in this country. Soon, equally encouraging results were being reported by Brown, Dubin, and Hotchkiss,9 by Dubin and Amelar,IO and others. In spite of intensive research into the manner in which varicocele affects male fertility, the rationale for this procedure still has not been conclusively pinpointed. In selecting candidates for varicocelectomy, it should be remembered that the best results have been achieved in patients whose seminal cytology has approximated
555
the standards set up by MacLeod. l l Such men consistently manifest poor sperm motility. He demonstrated a characteristic occurrence of a "stress pattern of sperm morphology (tapering and amorphous cells and the exfoliation of immature cells of the germinal line into the ejaculate)." Following varicocelectomy, sperm morphology definitely improves, although some "stress cells" might persist. The most striking response is a significant improvement in sperm motility. Although moderate to marked increase in sperm count may occur, this factor usually is relatively unaffected; improvement both in sperm morphology and motility has apparently been responsible for subsequent successful pregnancies. Ligation of the internal spermatic vein at the level of the internal inguinal ring has become the procedure of choice in varicocele operations. It is relatively simple, postoperative morbidity is minimal, and there is decreased danger of interfering with the arterial testicular blood supply, such as sometimes occurs with the classical scrotal technic. A thought-provoking observation was made by Hanley and Harrison 12 in 1962 and was confirmed more recently by Dubin and Amelar. 13 They found that small as well as large varicoceles can produce serious deleterious effects on spermatogenesis. All varicoceles, therefore, should be surgically corrected provided no contraindications are present. In analyzing the responses to Question III the following observations became readily apparent. 1. Some respondents (13.3%) have never performed this operation, and more than twice this number discourage it. 2. Almost half of those who had used the operation either reported no success or a rare incidence (1%) of success. 3. Although only 2.7% acknowledged moderately encouraging success compatible with that reported in the literature,
556
Vol. 24
GETZOFF
QUESTION III. Epididymovasostomy
I have performed this operation with: No success Rare (1%) success Occasional (5%) success Moderate (20%) success Moderately encouraging success compatible with that reported in the literature (50 to 70%) Never performed this operation When the indications are present that lend themselves to an epididymovasostomy: I encourage the operation I discourage the operation I acquaint the patient with a realistic concept of the procedure and its prognosis
No.
%
42
31 32
28.0 20.7 21.3
21
14.0
4
2.7
20
13.3
14 41
95
9.3 27.3 63.3
almost 10% of all respondents encourage this operation. 4. Occasional or moderate success was reported by 35%. 5. The predominant attitude (63.3%) was that the disappointing experiences with this procedure must be conveyed to the patient in advance. The following comment reflects this attitude: "I would be very frank with the patient and a bit on the pessimistic side-in fact, more than a bit." A summary of the experiences recorded by those who had moderate success, together with the few reporting encouraging success (16.7% of the total group), points to unresolved problems, indicating more fundamental reasons for lack of success than merely operative technic. Furthermore, the following comments are decidedly pertinent to operational success as defined earlier. 1. Variable amounts of spermatozoa (" a few to 60 million") appeared postoperatively in the ejaculate of formerly aspermic men. 2. After technically successful operation, sperm motility was poor, varying from
rare to less than 5%, regardless of sperm concentration. This' deficiency has been resistant to endocrine therapy and other forms of medical management. 3. The pregnancy rate was consistently disappointing in spite of postoperative appearance of sperm. Several of those queried remarked on the total ineffectiveness of the new "improved" semen used in artificial insemination. COMMENT
Epididymovasostomy was first described by Martin 14 in 1902. Hagner 15 (1936) in the United States and Bayle 16 (1958) in France later stimulated interest in this operation. The basic indication for epididymovasostomy is in azoospermic men with intact spermatogenesis and no interference in the continuity between the vas deferens and the ejaculatory duct. The aim is to create a permanent fistula between the globus major of the epididymis and the vas deferens. The operation consists of incising an elliptical window in the globus major and anastomosing it to a similar opening in the vas deferens. In essence, this creates a by-pass around the area of postinflammatory obstruction that commonly affects the globus minor of the epididymis and prevents sperm from entering the vas deferens. A successful operative result depends on several prerequisites. 1. Spermatogenesis must be intact. 2. Spermatozoa must be recovered from the epididymal opening at operation. 3. The vas deferens and the ejaculatory duct must be patent. 4. The blood supply to the anastamosed area as well as to the testicles and vas deferens must never be compromised. 5. Undue traction of the involved tissues must be avoided (Question IV). The following impressions are predicted on the experiences tabulated under Question IV. (1) About one-sixth of the replies reported successful surgical results in ex-
July 1973
cess of 50% of cases; however, more than half the respondents had either a low or a moderate rate of success. (2) The disappointment expressed by the others suggests at least two unfortunate situations. First, there are problems encountered in patients whose vasectomies resulted in technical difficulties which prevented a permanently patent reanastomosis. The second situation is perhaps of greater importance; it is the significantly low incidence of pregnancy in spite of postoperative reappearance of sperm in the semen. A further observation on this will be made in the following comments. Although 3 out of 10 urologists reported that they would attempt one repeat operation if the first vasovasostomy failed, almost two-thirds of the replies were unalterably QUESTION IV. Vasovasostomy
I have performed this procedure with: No success Rare (1 %) success Occasional (5%) success Moderate (20%) success Encouraging success compatible with that reported in the literature (50-70%) Never performed this operation If the first attempt at surgical reanastamosis of the vas deferens is a failure (i.e., no postoperative appearance of sperm), this operation should be repeated: Onetime Two times More than two times Should NOT be repeated When a patient consults me about the feasibility of a vasovasostomy: I encourage him to have it performed I discourage him from having it performed I acquaint him with a realistic concept of the procedure and its prognosis
557
MALE INFERTILITY
No.
%
12 17 30 58 24
8.0 11.3 20.0 38.7 16.0
9
6.0
47 7 3 93
31.3 4.7 62.0
13
8.7
8
5.3
129
86.0
2.0
opposed to a second performance. This is in sharp contrast to less than 7% who would advise the procedure two or more times. A small number (8.7%) encourage reanastomosis of the vas deferens. Only a few (5.3%) discourage this operation altogether. The majority opinion (86%) favored performing the operation after acquainting the patient with a realistic concept of the procedure and its prognosis. COMMENTS
The demand for vasectomy increased significantly following reports of unfavorable complications encountered in women taking oral contraceptives. In the United States the number of elective surgical sterilizations of men probably exceeds statistics previously reported by Davis and Hulka 17 (between 50,000 and 200,000 men yearly). The subject takes an added interest upon noting Hotchkiss' 18 estimate that 6-10% of these men will request reanastomosis at a later date. The performance of reanastomosis or vasovasostomy is relatively simple. Among the few pitfalls that beset the surgeon, the following are repeatedly emphasized. 1. Excessive mobilization of the proximal and distal ends of the vas can interfere with the blood supply and result in avascular necrosis at the site of anastomosis. 2. The vasal ends must be excised far enough to eliminate all evidence of fibrotic tissue reaction from the previous operation. 3. Excessive tension at the suture site must be avoided in cases where a long section of the vas had been originally excised. All attempts to compensate for such a wide gap are almost invariably doomed to failure. 4. The highest incidence of unsuccessful results Occurs when the vasectomy had been performed close to the epididymis. Now, as to the low incidence of pregnancy after vasovasostomy: Ansbacher 19 made a valuable contribution on post-
558
Vol. 24
GETZOFF
2. No one favored the use of cotton for vasectomy results in a 6-month follow-up of 48 men. Circulating sperm-agglutinating splinting. 3. Fourteen respondents preferred no antibodies were present in 26 men (54.2%), and ~perm-immobilizing antibodies were splinting. Most of those commenting on found in 15 (31.3%). Only one man had their choice agreed that whatever good a circulating antibodies before vasectomy splint might do, it is outweighed by the deleterious effects of foreign-body tissue (Question V). In view of the numerous ingenious inno- reaction and increased probabilities of invations that many surgeons utilize to im- fection. 4. Most respondents did not use drains. prove classical surgical technics, we de5. The overwhelming majority (93.6%) voted one phase of the questionnaire to some of the "tricks of the trade" used by decried the use of steroids. The feeling was experienced surgeons in epididymovasosto- that "an operation is doomed to failure if the integrity of the anastomosis is dependmies and vasovasostomies. The information in the returns for Ques- ent on steroids." Some pointed out the increased susceptibility to infection as a tion V may be summarized as follows. 1. A highly significant majority agreed complication of steroids, "especially in the that splinting the site of anastomosis was overpopulated bacterial atmosphere of the desirable. Silver wire left in place for 10 scrotum" (Question VI). The replies to this question reflect the days was the most popular choice. Nylon sutures used for the same period were the overwhelming negative attitude of urolosecond preference, followed by a variety of gists (70%) when asked to perform vasecthe other non absorbable materials listed. tomy in men who desire reassurance reSplints were never used for more than 14 garding the feasibility of a subsequent surgical reanastomosis. A few (3.3%) would days. QUESTION V. Surgical Technic (N
~
141) Period left in place
No.
When performing a vasovasos· tomy or epididymovasos· tomy, the following splint is used: Silver wire Silk suture Steel wire Nylon suture Silastic tubing Cotton Other No splint used Drainage: Operative site drained Operative site not drained Use of steroids: Steroid prescribed during p.o. period No steroid prescribed
65 1 4 43 12
%
5 days
10 days
14 days
51.1 0.8 3.2 33.8 9.5
9 1 4 2 4
40
16
35 5
6 3
2
4
3
2
1.6
14
9.9
21 120
14.9 85.1
9
16.4
132
93.6
More
2
July 1973
QUESTION VI. Vasectomy Predicated on Later Vasovasotomy
When a patient requests a vasectomy predicated on the possibility that he might one day desire vasovasostomy, do you: Encourage the vasectomy Discourage the vasectomy Acquaint him with a realistic concept of a vasovasostomy and its limited prognosis
559
MALE INI'ERTILITY
No.
%
5
3.3 70.0 26.7
105
40
encourage vasectomy under these circumstances. A considerable number (26.7%) left the responsibility of risk to the patient after acquainting him with a realistic concept and prognosis of va sovas ostomy. This part of the questionnaire elicited many comments, most of which are typified by the following. "Complying with the request of a man who wants to keep his cake and eat it is irrational and spells trouble for the surgeon." "I perform vasectomies only after making an honest attempt to discourage the procedure. " "I discuss the vasectomy operation with the patient and his wife. If they inquire at great length about operations for restoring the husband's fertility should they have a change of heart, I refuse to touch him." "Why not? What I undo, I can put together again." SUMMARY AND CONCLUSIONS
This study revealed a wide disparity of opinions among urologists regarding the surgical correction of impaired male fertility. This fact alone reveals the weaknesses in the oft-quoted textbooks used as guidelines by perplexed and less-experienced urologists. The 150 competent specialists who responded to the questionnaire not only disagreed as to the proper selection of
suitable candidates for operation, but were confused about the most effective technics for correcting various pathologic entities. They could not even agree on a definition of what constitutes a successful operation. It may well be that surgeons have failed to appreciate the limitations of operative procedures in this area. An understanding of the immunologic aspect of male fertility would explain why even a technically perfect operation might be predestined to fail in achieving the desired goal. When antispermatic antibodies and sperm agglutinins, associated with traumatic or inflammatory changes or with congenital gonadal anomalies, are present, surgical correction of a mechanical fault in the male reproductive system cannot be effective. This investigation indicates an obvious lack of communication between those surgeons who have achieved moderately encouraging success in increasing male fertility and their less enchanted colleagues. It suggests a need for greater clarification of the problem involved and a wider discussion among urologists with experience in this field. REFERENCES 1. DAVIS, M. E. Management of infertility. JAMA 201:1030, 1967. 2. GETZOFF, P. L. "Infertility of the Male." In Current Therapy, Conn, H. F., Ed. Saunders, Philadelphia, 1969, p. 493. 3. WILHELM, S. F. Sterility in the Male. Oxford, London, 1937. 4. TULLOCH, W. S. Varicocele in subfertility. Results of treatment. Brit Med J 2:356, 1955. 5. HANLEY, H. G. The surgery of male subfertility. Ann Roy Coli Surg Eng 17:159, 1955. 6. SCOTT, L. S. Varicocele: A treatable cause of subfertility. Brit Med J 1:788, 1961. 7. MACLEOD, J. A possible factor in the etiology of human infertility: Preliminary report. Fertil Steril 13:29, 1962. 8. CHARNY, C. W. Effect of varicocele on fertility. Results of varicocelectomy. Fertil Steril 13:47, 1962. 9. BROWN, J. S., DUBIN, L., AND HOTCHKISS, R. S. The varicocele as related to fertility. Fertil Steril 18:46, 1967.
560
Vol. 24
GETZOFF
10. DUBIN, L., AND AMELAR, R. D. Etiologic factors in 1294 consecutive cases of male infertility. Fertil SteriI22:469, 1971. 11. MACLEOD, J. Seminal cytology in the presence of varicocele. Fertil Steril 16:735, 1965. 12. HANLEY, H. G., AND HARRISON, R. G. Nature and surgical treatment of varicocele. Brit J Surg
50:64, 1962. 13. DUBIN, L., AND AMELAR, R. D. Varicocele size and results of varicocelectomy in selected subfertile men with varicocele. Fertil Steril 21:606, 1970. 14. MARTIN, E., CARNE'IT, J. B., LEVI, J. V., AND PENNINGTON, M. E. The surgical treatment of sterility due to obstruction at the epididymis. Together with a study of the morphology of human spermatozoa. Univ Penn Med Bull 15:2, 1903.
15. HAGNER, F. R. The operative treatment of sterility in the male. JAMA 107:1851, 1936. 16. BAYLE, H. "Traitement Chirurgical de la Sterilite Masculine." In La Fonction Spermatogenetique du Testicule Humain, Bayle, H., Gourgou, C., and Guillon, G., Eds. Masson et Cie, Paris, 1958. 17. DAVIS, J. E., AND HULKA, J. F. Elective vasectomy by American urologists in 1976. Fertil Steril 21:615, 1970. 18. HOTCHKISS, R. S. The Male Factor-The Irresistible Force. Presented at the Pacific Coast Fertility Society Meeting, October 29 to November 1, 1970, Scottsdale, Ariz. 19. ANSBACHER, R. Sperm-agglutinating and spermimmobilizing antibodies in vasectomized men. Fertil Steril 22:629, 1971.
ERRATUM
On p. 285 of the April 1973 issue (Jones and Edgren), Table 2, lines 5, 6, and 9 should read as follows: Northisterone acetate Ethynodiol diacetate Hydrocortisone
573.0 p.g. 1,342.0 p.g. 10,000.0 p.g.
267.0- 1,681. 9 p.g. 671.3-10,935.4 p.g.