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The neglected male
FERTIUTY AND STERIUTY Copyright
0
Vol. 35, No.6, June 1981 Printed in U.8A.
1981 The American Fertility Society
THE NEGLECTED MALE
KAMRAN S. MOGHISSI, M.D. * Department of Gynecology and Obstetrics, Wayne State University and the C. S. Mott Center for Human Growth and Development, Detroit, Michigan 48201
Received February 4, 1981. *Reprint requests: Kamran S. Moghissi, M.D., C. S. Mott Center for Human Growth and Development, 275 East Hancock, Detroit, Michigan 48201.
Infertility should no longer be considered a condition affecting the male and female separately. Fortunately, the concept of evaluating and managing infertile couples as a unit is becoming well established among sophisticated physicians who are in the avant-garde of our discipline and in academically oriented institutions. Traditionally, gynecologists have been consulted by most couples who fail to reproduce. Many residency training programs in obstetrics and gynecology include a core curriculum in reproductive endocrinology and infertility in their teaching materials. Undoubtedly, the didactic and clinical exposure of residents to these subjects will be expanded. It is hoped, therefore, that the current and future generation of residents in obstetrics and gynecology will have sufficient knowledge in reproductive biology to enable them to initiate the basic infertility evaluation. The investigation and management of male-related infertility continues to be a cause for concern among physicians and lay public. The male partner of an infertile union is generally neglected. Most physicians refer their infertile males to a urologist for initial evaluation or management of specific problems. It is pertinent to examine the adequacy and competence of the average urologist in meeting this challenge. In most large communities and medical centers one can find a few urologists who have the expertise and experience to manage male infertility. Some of these physicians have even limited their entire practices to infertility and are among the most distinguished experts in the field. In general, however, many urology residency programs are deficient in subjects related to male reproductive biology and endocrinology. Urologists who are graduated from such programs are ill-prepared to provide care for infertile men. The regrettable result of the present system is that the male partner of the infertile couple receives little or no attention from the gynecologist and is also neglected by the urologist. In many localities it is common to see men who have been under the care of a physician for months and sometimes years without the benefit of adequate evaluation or treatment. The use of longdiscarded therapeutic modalities such as thyroid preparations for the treatment of oligospermia continues unabated. Another problem is the lack of laboratory facilities and trained technicians for semen analysis. 609
610
EDITOR'S CORNER
The unavailability of trained medical and laboratory personnel is only part of the problem. Our knowledge of the physiology of the male reproductive function is still rudimentary, and our diagnostic tools are crude. Semen analysis, even when it is performed serially in a sophisticated laboratory by a well-trained technician, is a rough measure of male reproductive ability. Satisfactory tests to assess the capability of sperm to effect migration and survival in the female reproductive tract and fertilize the ovum have not been developed. Solving these problems will be tedious, but steps must be taken toward this end. First, the level of training of both gynecologists and urologists in reproductive sciences must be improved. It matters little who is to be considered the primary physician for infertile couples, so long as he or she is adequately trained to provide proper care for the couple. Gynecologists need to become familiar with the male reproductive process, adept in evaluating infertile men, performing or supervising semen analyses, and managing simple medical problems related to male infertility. During their residency, urologists should be trained more extensively in the male reproductive process, becoming familiar with both medical and surgical aspects of male infertility. Fellowships in andrology should be established for those interested in additional training in infertility and reproductive biology. Ideally, a team of gynecologists and urologists with common interests in infertility should collaborate in providing care for infertile couples. Second, semen analysis should be performed in laboratories equipped to process the sample by trained technicians who will provide the physicia~ with a comprehensive report. Similar standards of performance should be expected when semen analysis is performed in office-based laboratories. The World Health Organization recently published a laboratory manual for the examination of human semen and semen-cervical mucus interaction in an effort to establish a standard for these tests. 1 Similar standards have been promulgated by The American Fertility Society.2 Finally, research in male reproductive biology must continue with the purpose of elucidating parameters which indicate functional disorders of spermatozoa, including their fertilizing ability. Very little is known about the abnormal deviations of spermatozoa or the constituents of seminal plasma relative to fertility. Sperm motility and morphology are currently considered to be better criteria of male fertility than sperm density.
June 1981
Recently, several new techniques for the investigation of functional defects in human spermatozoa have been developed. Hembree and Overstreet3 studied the ability of sperm to penetrate the zona pellucida, and found that penetration by sperm from infertile men was significantly reduced. Barros et al. 4 and Rogers et al. 5 reported an in vitro fertilization assay employing zona-free hamster eggs. Although useful, this assay requires a great deal of expertise and is timeconsuming. The correlation between in vitro fertilizing capacity using this system and actual fertility as determined by pregnancy needs documentation. A third approach is to assay the level of acrosin, a trypsin-like enzyme which is essential for zona penetration, in sperm obtained from individual ejaculates. In preliminary studies, Mohsenian et a1. 6 found that the level of this enzyme as measured by radioimmunoassay or the fluorometric enzyme method is significantly higher in spermatozoa collected from fertile men than the level in spermatozoa obtained from infertile men or men in unions with unexplained infertility. These novel approaches may expand considerably our ability to detect subtle abnormalities of spermatozoa and their fertilizing capacity. We are still far from understanding the basic pathology underlying disorders of sperm fertilizing capacity, and farther still from therapy of these disorders. However, one can hope that recognition of these new entities will eventually lead to treatment modalities. REFERENCES 1. Belsey MA, Eliasson R, Gallegos AJ, Moghissi KS,
2.
3.
4.
5. 6.
Paulson CA, Prasad MRN: Laboratory Manual for the Examination of Human Semen and Semen-Cervical Mucus Interaction. Geneva, World Health Organization, 1980 The American Fertility Society: How To Organize a Basic Study of the Infertile Couple. Birmingham, Ala, American Fertility Society, 1980 Hembree WC, Overstreet JW: Defect in human sperm function in clinical infertility. Reduced zona pellucida penetration in vitro. In The Testis in Normal and Infertile Men, Edited by P. Troen, HR Nankin. New York, Raven PreBB, 1977, P 513 Barros C, Gonzalez J, Herrera E, Bustos-Obregon E: Human sperm penetration into zona free hamster oocytes as a test to evaluate the sperm fertilizing ability. Andrologia 11:197, 1979 Rogers BJ, Van Campen H, Ueno M, Lambert H, Bronson R, Hale R: Analysis of human spermatozoal fertilizing ability using zona-free ova. Fertil Steril 32:664, 1979 Mohsenian M, Syner FN, Moghissi KS: Study of sperm acrosin in patients with unexplained infertility (abstr). Fertil Steril 35:255, 1981
0
Vol. 35, No.6, June 1981 Printed in U.8A.
1981 The American Fertility Society
THE NEGLECTED MALE
KAMRAN S. MOGHISSI, M.D. * Department of Gynecology and Obstetrics, Wayne State University and the C. S. Mott Center for Human Growth and Development, Detroit, Michigan 48201
Received February 4, 1981. *Reprint requests: Kamran S. Moghissi, M.D., C. S. Mott Center for Human Growth and Development, 275 East Hancock, Detroit, Michigan 48201.
Infertility should no longer be considered a condition affecting the male and female separately. Fortunately, the concept of evaluating and managing infertile couples as a unit is becoming well established among sophisticated physicians who are in the avant-garde of our discipline and in academically oriented institutions. Traditionally, gynecologists have been consulted by most couples who fail to reproduce. Many residency training programs in obstetrics and gynecology include a core curriculum in reproductive endocrinology and infertility in their teaching materials. Undoubtedly, the didactic and clinical exposure of residents to these subjects will be expanded. It is hoped, therefore, that the current and future generation of residents in obstetrics and gynecology will have sufficient knowledge in reproductive biology to enable them to initiate the basic infertility evaluation. The investigation and management of male-related infertility continues to be a cause for concern among physicians and lay public. The male partner of an infertile union is generally neglected. Most physicians refer their infertile males to a urologist for initial evaluation or management of specific problems. It is pertinent to examine the adequacy and competence of the average urologist in meeting this challenge. In most large communities and medical centers one can find a few urologists who have the expertise and experience to manage male infertility. Some of these physicians have even limited their entire practices to infertility and are among the most distinguished experts in the field. In general, however, many urology residency programs are deficient in subjects related to male reproductive biology and endocrinology. Urologists who are graduated from such programs are ill-prepared to provide care for infertile men. The regrettable result of the present system is that the male partner of the infertile couple receives little or no attention from the gynecologist and is also neglected by the urologist. In many localities it is common to see men who have been under the care of a physician for months and sometimes years without the benefit of adequate evaluation or treatment. The use of longdiscarded therapeutic modalities such as thyroid preparations for the treatment of oligospermia continues unabated. Another problem is the lack of laboratory facilities and trained technicians for semen analysis. 609
610
EDITOR'S CORNER
The unavailability of trained medical and laboratory personnel is only part of the problem. Our knowledge of the physiology of the male reproductive function is still rudimentary, and our diagnostic tools are crude. Semen analysis, even when it is performed serially in a sophisticated laboratory by a well-trained technician, is a rough measure of male reproductive ability. Satisfactory tests to assess the capability of sperm to effect migration and survival in the female reproductive tract and fertilize the ovum have not been developed. Solving these problems will be tedious, but steps must be taken toward this end. First, the level of training of both gynecologists and urologists in reproductive sciences must be improved. It matters little who is to be considered the primary physician for infertile couples, so long as he or she is adequately trained to provide proper care for the couple. Gynecologists need to become familiar with the male reproductive process, adept in evaluating infertile men, performing or supervising semen analyses, and managing simple medical problems related to male infertility. During their residency, urologists should be trained more extensively in the male reproductive process, becoming familiar with both medical and surgical aspects of male infertility. Fellowships in andrology should be established for those interested in additional training in infertility and reproductive biology. Ideally, a team of gynecologists and urologists with common interests in infertility should collaborate in providing care for infertile couples. Second, semen analysis should be performed in laboratories equipped to process the sample by trained technicians who will provide the physicia~ with a comprehensive report. Similar standards of performance should be expected when semen analysis is performed in office-based laboratories. The World Health Organization recently published a laboratory manual for the examination of human semen and semen-cervical mucus interaction in an effort to establish a standard for these tests. 1 Similar standards have been promulgated by The American Fertility Society.2 Finally, research in male reproductive biology must continue with the purpose of elucidating parameters which indicate functional disorders of spermatozoa, including their fertilizing ability. Very little is known about the abnormal deviations of spermatozoa or the constituents of seminal plasma relative to fertility. Sperm motility and morphology are currently considered to be better criteria of male fertility than sperm density.
June 1981
Recently, several new techniques for the investigation of functional defects in human spermatozoa have been developed. Hembree and Overstreet3 studied the ability of sperm to penetrate the zona pellucida, and found that penetration by sperm from infertile men was significantly reduced. Barros et al. 4 and Rogers et al. 5 reported an in vitro fertilization assay employing zona-free hamster eggs. Although useful, this assay requires a great deal of expertise and is timeconsuming. The correlation between in vitro fertilizing capacity using this system and actual fertility as determined by pregnancy needs documentation. A third approach is to assay the level of acrosin, a trypsin-like enzyme which is essential for zona penetration, in sperm obtained from individual ejaculates. In preliminary studies, Mohsenian et a1. 6 found that the level of this enzyme as measured by radioimmunoassay or the fluorometric enzyme method is significantly higher in spermatozoa collected from fertile men than the level in spermatozoa obtained from infertile men or men in unions with unexplained infertility. These novel approaches may expand considerably our ability to detect subtle abnormalities of spermatozoa and their fertilizing capacity. We are still far from understanding the basic pathology underlying disorders of sperm fertilizing capacity, and farther still from therapy of these disorders. However, one can hope that recognition of these new entities will eventually lead to treatment modalities. REFERENCES 1. Belsey MA, Eliasson R, Gallegos AJ, Moghissi KS,
2.
3.
4.
5. 6.
Paulson CA, Prasad MRN: Laboratory Manual for the Examination of Human Semen and Semen-Cervical Mucus Interaction. Geneva, World Health Organization, 1980 The American Fertility Society: How To Organize a Basic Study of the Infertile Couple. Birmingham, Ala, American Fertility Society, 1980 Hembree WC, Overstreet JW: Defect in human sperm function in clinical infertility. Reduced zona pellucida penetration in vitro. In The Testis in Normal and Infertile Men, Edited by P. Troen, HR Nankin. New York, Raven PreBB, 1977, P 513 Barros C, Gonzalez J, Herrera E, Bustos-Obregon E: Human sperm penetration into zona free hamster oocytes as a test to evaluate the sperm fertilizing ability. Andrologia 11:197, 1979 Rogers BJ, Van Campen H, Ueno M, Lambert H, Bronson R, Hale R: Analysis of human spermatozoal fertilizing ability using zona-free ova. Fertil Steril 32:664, 1979 Mohsenian M, Syner FN, Moghissi KS: Study of sperm acrosin in patients with unexplained infertility (abstr). Fertil Steril 35:255, 1981