|
NEW ORLEANS, LA (UroToday.com) -From the American Society of Reproductive Medicine (ASRM) Annual Meeting, New Orleans, LA - Ocober 23, 2006
Controversies in the treatment of Male Infertility: When to treat and when to send to ART," was the title of a lively interactive session chaired by Harris M. Nagler, MD, Chair, Sol and Margaret Berger Department of Urology, Beth Israel Medical Center. The participants in this session were Robert Oates, Professor of Urology at Boston University School of Medicine and Dr. Richard Paulson, Director of USC Fertility, Professor of Obstetrics and Gynecology and Chief of the Division of Reproductive Endocrinology and Infertility at the University of Southern California Keck School of Medicine.
The goals of this session:
- Understand importance of evaluating the infertile male
- Understand opportunities of urologists to improve sperm production
- Understand the opportunities of ART
- Understand the opportunity for collaborative approach to the infertile couple
The approach:
- Present Background Positions of:
- Urologists
- Reproductive Endocrinologists
- Case Presentations
- Highlighting areas of controversy and or consensus
- Invite discussion and questions
The concern outline:
- Increased Use of IVF/ICSI
- Increased Costs of Treatment
- Hidden Costs of
- Higher order gestations
- The unresolved issues of increased birth defects
- Failure to diagnose significant medical conditions
Dr Oates presented his views of the Team Approach to Care of the infertile couple and emphasized his belief that all males of infertile couples need to be evaluated at the onset of treatment because he may be able to :
- Improve their chances naturally
- Improve their chances with IUI
- Improve their chances with ICSI
- Improve his overall health
- Improve the health of the offspring
- Improve their chances for future conception
He then highlighted some of the issues that may be discovered by urologic evaluation such as:
- Gonadotoxins
- Smoking
- Obesity and sperm density
- Marijuana
- Anabolic steroid use
The importance of a urologic examination for the early detection of testes cancer and it increased incidence in the infertile male and the detection of varicoceles which are diagnosed by physical examination and not semen analyses or hormonal studies. Dr Oates stated that varicocelectomy:
- Increases chance of natural pregnancy
- Now and in future
- Increases chance of IUI, not IVF
- Increase chances of sperm in ejaculate in NOA (nonobstructive azoospermic patients)
- ASRM Guidelines, in fact,
- Recommend male evaluation
- Recommend varicocele repair
Dr Oates then emphasized the importance of Genetic evaluation (including karyotype, microdeletion studies, CF mutation analysisand counseling for men with severe oligospermia or nonobtructive azoospermia. He also alerted the audience about the potential importance of increased paternal age leading to:
- Progeria
- APKD
- Schizophrenia
- Achondroplasia (> 50yrs 7.8x 25-29yrs)
- Apert syndrome
- MEN2
- Autism
Benefits of reconstruction as outlined by Dr Oates included:
- Opportunity for natural conception
- Opportunity for more children later on
- Opportunity for pregnancy each month
- Avoids ICSI
- Decreased Costs
- Decreased morbidity to the female partner
The presentation then went on to review the benefits of Vasectomy Reversal / Reconstruction compared to testicular sperm acquisition followed by IVF/ICSI. Dr Oates presented his view that reconstruction was:
- Quite successful
- More cost-effective than aspiration/ICSI
- Gives couples multiple opportunities
- Each and every month till menopause
- Better for the older woman
- Chances of conception per month/ICSI less
- Provides her with multiple opportunities
Dr. Paulson then responded with the views of the reproductive endocrinologist. He framed his discussion with a historical perspective outlining the time frame of the major innovations which form the foundation of the debate.
- 1970's Microsurgical vasovasostomy
- 1978 Louise Joy Brown, first IVF baby in the world
- 1981 Elizabeth Carr, first IVF baby in USA
- 1985 First birth from cryopreserved embryo
- 1988 First attempts at ICSI
- 1992 First human birth after ICSI
- 1990's Surgical sperm retrieval and ICSI
- 2000's Sequential culture media
+ soft transfer catheters = IVF success
He reviewed the available data of ART results from the 2003 SART data base. He acknowledged concerns or questions that have been associated with IVF including multiple gestations, decreasing success with increasing age, low birth rate and increased chromosomal abnormalities and imprinting disorders. Dr. Paulson highlighted the serious flaw that exists when comparing IVF results and reconstructive data. The results of reconstruction that are generally quoted are from published "master surgeons" and series and that these results may not be generalizable. Whereas IVF data is reported and available on a program basis. He also introduced the concept of fecundibility indicating that the conception rate per cycle does not decrease with additional cycles. Additionally, he contended that the time to conception with TESE and ART was shorter than after reconstruction and this was an important consideration for older couples. He analyzed the reported data and extrapolated funcidibility rates 2.3% per cycle as compared to higher fecundibility rates of ART.
After the presentations cases scenarios were presented and debated. A consensus evolved that couples deserved and needed a coordinated approach to the management of infertility which provided couples with appropriate information so that they may fully understand all options including risks, benefits and alternatives.
From the American Society of Reproductive Medicine (ASRM) Annual Meeting, New Orleans, LA - Ocober 23, 2006
Please log-in or register in order to submit comments. Powered by AkoComment! |
Male Infertility & Reproduction 
