Urology

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Infertility Outcomes: 2003-2010

Jay Sandlow, MD, Vice Chairman and Professor of Urology

 

In 2003, the Department of Urology, in conjunction with the Department of Obstetrics and Gynecology, initiated a novel concept in the management of the infertile couple by establishing a joint infertility clinic within the Froedtert & The Medical College of Wisconsin Reproductive Medicine Center. This center evaluates couples simultaneously, thus improving communication and treatment coordination. Over the past seven years, the Reproductive Medicine Center has expanded dramatically, providing cutting-edge, team-based care for infertile couples.

This is an update on the outcomes of some of the procedures offered at Froedtert & The Medical College. A more in-depth view of infertility/andrology services will be covered in the next newsletter. Below, we demonstrate examples of our outcomes data for fertility procedures.

Varicocele Ligation


Varicocele is the most common reversible cause of male factor infertility. The majority of men who undergo repair will see significant improvement in their semen parameters, with many couples subsequently achieving natural conception. Since 2002, we have

averaged approximately 50+ procedures per year. We have presented our findings at numerous meetings, with

 

Normal Weight
BMI 18.5-24.9

Overweight
BMI 25-29.9

Obese
BMI 30

Normal vs. Overweight
p-value

Normal vs. Obese
p-value

Significant Improvement on
SA (>50% Increase in TME)

71.1%

61.0%

58.7%

0.214

0.172

Pregnancy Rates

43.8%

41.3%

41.5%

0.673

0.668

data demonstrating the outcomes of varicocele repair based on varicocele size, laterality and body mass index.

In a study that evaluated the impact of body mass index (BMI) on the outcome of varicocelectomy, 143 patients were examined1.  Patients were divided into three groups based on BMI: normal-A (<25), overweight-B (25-29.9), and obese-C (>30).  No significant differences existed among patients in these three groups in terms of total motile sperm/ejaculate (TME), female partner age, or other parameters. Significant improvements in TME on semen analysis (SA) were 71.1 percent (A), 61 percent (B) and 58.7 percent (C).  Pregnancy rates were 36.8 percent (A), 22.0 percent (B) and 26.1 percent (C). There were no statistically significant differences in improvement in TME (p = 0.214, p = 0.172) or pregnancy rate (p = 0.088, p = 0.273) among the normal weight group and the overweight or obese groups. Thus, it appears that in patients with clinically palpable varicoceles, BMI does not significantly impact outcome.
 

Vasectomy Reversal


As more couples utilize vasectomy as their primary form of contraception, more are also requesting vasectomy reversals. Approximately 6 percent of couples will ultimately undergo reversal. We are currently performing approximately 35 reversals/year, with an overall

Obstructive Interval

Repeat Reversal

VV

VV-EV

EV

Total

Patency Rates

Natural Pregnancy Rates

<10 yrs

11

3

5

19

16/18 (89%)

7/12 (58%)

>10 yrs

17

6

5

28

20/25 (80%) (P=0.6797)

7/18 (39%)
(P=0.2641)

Total

 

 

 

 

40/47 (85%)

14/32 (44%)

VV=vasovasostomy; EV=vasoepididymostomy

patency rate of >90 percent (98 percent for bilateral vasovasostomy, or VV) and a natural pregnancy rate of more than 50 percent (65 percent for vasovasostomy). In a study that examined the impact of repeat vasectomy reversals, 49 men underwent repeat vasectomy reversal2. The average obstructive interval for the original reversal was 10.5 years and the average time between the original and the repeat procedure was 2.7 years. Pregnancy data was available on 32 couples, with 14 (44 percent) achieving natural pregnancy. An additional two couples conceived via in vitro fertilization (IVF). The data are presented below. Nineteen patients out of 49 (34 percent) required at least a unilateral vasoepididymostomy, or EV, if they had a VV as the first procedure. Patients with at least a unilateral VV had patency and pregnancy rates of 91 percent and 48 percent respectively (data not shown). Eight out of 19 patients (42 percent) with an obstructive interval of less than 10 years required at least unilateral EV, with 89 percent patency after the repeat reversal. Eleven out of 28 patients (39 percent) with an obstructive interval of greater than 10 years required at least unilateral EV, with 80 percent patency after repeat reversal. The requirement for at least a unilateral EV and patency rates did not differ between the two groups. The pregnancy rate was not different for those with obstructive intervals of less than 10 years versus 10 years or greater, although the number of patients with pregnancy data was small (58 percent versus 33 percent).

Sperm Acquisitions

With the improvement in assisted reproductive technology, most notably intracytoplasmic sperm injection (ICSI) and in vitro fertilization (IVF), the number and quality of sperm needed to achieve a pregnancy has changed dramatically.  Whereas motile sperm were required to

Summary of ICSI outcomes after TESA

Number

Percentage

Procedures

40

 

Female Age (years)

32.8

 

Male Age (years)

39.1

 

Mature Sperm Isolated

39/40

97.5%

Average Vials Cryopreserved

5

 

Fertilization Rate

 

58%

Clinical Pregnancy Rate

27/34

79%

Miscarriages

5

 

Ongoing Pregnancies

5

 

Live Deliveries

17

 

fertilize an egg, now non-moving (but viable) testicular sperm are able to produce healthy embryos. Our lab is quite adept at the use of fresh and frozen testicular sperm. We have taken it a step further and no longer need to do open biopsies. We have performed nearly 150 percutaneous testicular aspirations, most for obstructive azoospermia, and published the results of our first 403. This technique is minimally invasive, effective and inexpensive. It does not require any special equipment or an operating room. We have expanded this for use in the diagnosis of azoospermia to help determine if a patient has an obstruction or spermatogenic failure in those cases where it is not clear. 

The field of male infertility is expanding rapidly, and we are committed to staying at the forefront of this area. With our newly formed fellowship program, coordinated team approach, and superior outcomes, we have established ourselves as a national resource for male infertility diagnosis, treatment and research.

Physicians of the Reproductive Medicine Center see and treat patients at Froedtert & The Medical College of Wisconsin in Milwaukee.  To refer a patient to Milwaukee, please call 800-272-3666.

Physician-to-physician phone consultations are welcomed at 877-804-4700.

Patient consultations are also offered at the Reproductive Medicine Center – Appleton Clinic in Appleton, WI.  To refer a patient to the Appleton location, please call 920-380-1161. More information is available at froedtert.com/fertility.

REFERENCES

  1. Pham KN, Sandlow JI. The Effects of Body Mass Index on the Outcomes of Varicocelectomy. Fert Steril 94:4 (supp pg. 129); P123, 2010.
  2. Hollingsworth MR, Sandlow JI, Schrepferman CG, Brannigan RE, Kolettis PN. Repeat vasectomy reversal yields high success rates. Fert Steril 88:217-219, 2007.
  3. Garg T, LaRosa C, Strawn E, Robb P, Sandlow JI. Outcomes after Testicular Aspiration and Testicular Tissue Cryopreservation in Obstructive Azoospermia. J Urol 180:2577-80, 2008. 
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