The Practice Guidelines Committee of the American Urological Association, Inc. (AUA) commissioned a Male Infertility Best Practice Policy Committee (MIBPPC) in 1998 to bridge the gap in male infertility between leading edge science and clinical practice, and provide urologists, gynecologists, reproductive endocrinologists, primary care practitioners, reproductive researchers and other health care providers with guidance for excellence of care in this rapidly changing field. The MIBPPC chose not to create a comprehensive treatise on male infertility, but rather to focus on areas that are new, poorly understood, poorly standardized, controversial and/or rapidly changing. The MIBPPC divided its efforts into 4 interrelated sections: 1) optimal evaluation of the infertile male, 2) evaluation of the azoospermic male, 3) management of obstructive azoospermia, and 4) varicocele and infertility. A separate report was created for each topic. The reports were submitted to peer review by 125 physicians and researchers from the disciplines of urology, gynecology, reproductive endocrinology, primary care and family medicine, andrology and reproductive laboratory medicine. The reports were then reviewed and approved by the Practice Guidelines Committee of the AUA the Practice Committee of the American Society for Reproductive Medicine (ASRM) and the boards of the 2 organizations. The reports were printed and distributed jointly by the AUA and ASRM in 2001. We reviewed each report of the MIBPPC.

OBJECTIVE:To determine whether antisperm autoantibody production after prepubertal vas injury is influenced by immediate repair of the vas compared to delay of the reanastomosis until sexual maturity.DESIGN:Animal study comparing early repair, late repair, and sham-operated groups.SETTING:Research laboratory in a medical school.PATIENT(S):Lewis rats.INTERVENTION(S):After division of the vas deferens in juvenile rats, animals in an early repair group had the vasa repaired immediately by using an absorbable intraluminal stent. Animals in a late repair group had vasa obstructed by ligation until after puberty, when they underwent microsurgical vasovasostomy (age 60 days).MAIN OUTCOME MEASURE(S):Antisperm antibodies were assayed by ELISA. The weights of reproductive organs were determined, and samples of testis were studied by light microscopy.RESULT(S):The antisperm antibody response was less when the vas was repaired immediately than if the repair was delayed until after puberty. There was a low incidence of testicular alteration in the repair groups and none in sham-operated animals.CONCLUSION(S):If the vas deferens is injured or obstructed prepubertally, there may be a benefit to considering immediate repair to reduce the likelihood of developing antisperm autoantibodies, which have been associated with reduced fertility.

Objective: To determine the effect of experimental left varicocele on the anatomy of the veins serving the rat testis and to compare that anatomy to known patterns of vascular drainage from the human testis with and without varicocele.Design: Vascular maps were made of the effluent vessels from the rat testis in the control animals and those with a 30-day experimental left varicocele. Consensus maps were arrived at and these were compared to published reports of the pertenent venous anatomy in humans with and without varicocele.Setting: Research laboratory.Results: The major route of blood leaving the rat testis was confirmed to be the spermatic vein, but nine common collaterals were also found to exist. Four of these collaterals became more pronounced with experimental varicocele as did several dilated perineal veins. These latter vessels all led to the iliac vein. The vasculature of the rat experimental varicocele model shares some important anatomical features with human varicocele anatomy.Conclusions: Varicocele in humans and in the rat models causes a redistribution of blood flow from a route primarily out to the spermatic vein to routes leading to the iliac vein. The redistribution is similar but not identical.

The influence of treatment with a glucocorticoid on antisperm antibodies and fertility after vasectomy and vasovasostomy was studied in Lewis rats. Animals received a bilateral vasectomy followed 4 weeks later by bilateral vasovasostomy. Treatment with methylprednisolone for two months beginning at the time of the vasovasostomy resulted in a decrease in antisperm antibodies compared with nontreated vasovasostomized animals, but there was no difference in fertility between treated and nontreated vasovasostomized groups. However, when fertile vasovasostomized animals from treated and nontreated groups were compared with infertile vasovasostomized animals, antisperm antibodies were found to be significantly lower in fertile rats 2, 4 and 8 weeks after vasectomy, while antibodies did not differ between fertile and infertile animals at the end of the study (12 weeks). The observation that differences in antisperm antibodies appeared shortly after vasectomy, preceding either vasovasostomy or treatment, suggests that changes occurring very early after vasectomy have far-reaching effects and are among the factors that influence future fertility after vasovasostomy.

Temporal patterns of IgM and IgG autoantibodies to sperm proteins were studied by western blot analysis at intervals after bilateral vasectomy, vasectomy followed one month later by vasovasostomy, or sham operations. Responses were detected to eight major autoantigens at 21–23, 36, 41, 51, 57, 63, 68–71 and 75–83 kDa, by study of staining patterns of sequential serum samples from individual animals and by analysis of the incidence of reaction to each protein. The four lower molecular weight antigens (21–23, 36, 41 and 51 kDa) provoked mainly IgG responses. The strongly stained set of higher molecular weight antigens (57, 63, 68–71 and 75–83 kDa) tended to show more clearly defined temporal patterns of IgM followed by IgG response, including a high incidence of IgM antibody at the 2-week interval. Three of the larger peptides (57, 63 and 68–71 kDa) appeared highly immunogenic, since some reactions were detected even in sham-operated rats. The classical patterns of IgM and IgG antibody responses to the majority of the dominant sperm autoantigens are in accord with the hypothesis that vasectomy mimics immunization with spermatozoa. The high incidence of IgM antibodies in the earliest sample, taken 2 weeks after vasectomy, suggests that the initial immunizing event takes place within about a week after the operation. Vasovasostomy did not bring about a decrease in antisperm antibodies. Instead, some animals demonstrated an increased reaction to certain antigens after reversal of vasectomy, even though the vasovasostomies were anatomically successful.

Increased urinary mucus is common after urinary tract reconstruction involving the use of bowel segments. This mucus can prove troublesome when it interferes with emptying of the bladder reservoir, particularly in the prepubertal boy, in whom a small catheter must be used. We report a rapidly effective, nontoxic, inexpensive method of dissolving urinary mucus by periodic instillation of a concentrated urea solution.

Four hypotheses have been reviewed, each of which might serve as a hypothetical biological explanation for a relationship between vasectomy and prostate cancer. The endocrine hypothesis is the only one of these with any firm data to support it, although the majority of the available data does not lend credibility to that theory. The other hypotheses are purely speculative with no hard data to support them. In conclusion, it seems highly unlikely, but not impossible, that there is a biological mechanism supporting a relationship between vasectomy and prostate cancer.

There is very little information in the literature on the development of the human vas deferens. Therefore, the age at which the pre- or para-pubertal vas deferens becomes large enough for a vasovasostomy to be technically feasible is unknown. To determine the age or degree of sexual maturity at which a microscopic vasovasostomy is technically feasible, we collected surgical or autopsy vasa from 34 young males over a three year period, and correlated vasal size to age and Tanner stage (degree of sexual maturity ranging from 1-childhood to 5-adult). The specimens were embedded and sectioned transversely in glycol methacrylate. Using image analysis, the total transverse area and diameter, and luminal area and diameter was determined for each specimen.Surprisingly, there was no change in vasal size from birth up through 11 years. From age 15 years and on, the vas was adult in size. The vas develops to adult size between Tanner stages 2 and 3. The average external and luminal diameters of pre-midpuberty specimens (Tanner stages 1 and 2) were 1.0 and 0.19 (mm.) and the diameters of post-midpuberty specimens were 2.1 and 0.43 (mm.), respectively.These results suggest that, in the event of a recognized iatrogenic injury to the vas deferens after midpuberty, a repair by a traditional microsurgical vasovasostomy is possible. If the vas is injured before midpuberty it may be technically difficult to repair by traditional microsurgical methods.

We have previously shown that the human vas deferens does not change in cross-sectional size between birth and the middle of puberty. This suggests that if the human vas is injured prior to mid-puberty, repair by a traditional microsurgical vasovasostomy may be technically difficult. We propose that a chromic stent can be used to assist in the repair of vas injured before mid-puberty. This hypothesis was tested in Sprague-Dawley rats. At three weeks of age, male offspring were divided into three groups (eight to nine rats/group): 1) Sham group - a sham operation at three weeks, 2) VV group - bilateral transection of vasa at three weeks followed by a delayed repair at eight weeks by microsurgical vasovasostomy without a stent, 3) Stent group - bilateral transection of vasa at three weeks followed by immediate repair by aligning the lumens with a 6-0 chromic intravasal stent (suture) and holding the transected ends together with several seromuscular sutures. At four months all rats were fertility tested and a score was given to each rat (mean number of concepti among three females for each male rat). Analysis of anastomotic patency by flow rates and histology was performed. There was no statistical difference in the mean fertility score of 6.85 in the Stent group compared to 7.83 in the Sham group. However, a fertility score of 0.71 in the VV group was significantly decreased compared to the Stent and Sham group (p = .0003), despite no statistical difference between the groups in patency. This suggests that a recognized injury to the pre-pubertal human vas should be immediately repaired and the repair can be done using 6-0 chromic suture as an intravasal stent to help align the lumina of the smaller pre-pubertal vas.

The epididymides of Lewis rats were studied at intervals up to 7 months after vasectomy, vasectomy followed 3 months later by vasovasostomy, or sham operations. Epididymal histology was related to testicular alterations and to serum antisperm antibodies as determined with an enzyme-linked immunosorbent assay. In vasectomy and vasovasostomy groups. 13 of 33 rats had testicular alterations, which consisted mainly of pronounced depletion of germ cells. Over half of the rats with testicular alterations also had severe epididymal lesions that included interstitial changes characteristic of an inflammatory response. These consisted of aggregates of mononuclear cells, including lymphocytes, plasma cells, and macrophages. The lumina of epididymides with interstitial changes contained polymorphonuclear leukocytes and/or macrophages. All animals with altered testes had greatly decreased numbers of epididymal sperm. In many instances, the lumen of the proximal cauda epididymidis was collapsed, and columnar cells of the epididymal epithelium contained many very large lysosomes. The distal cauda epididymidis was distended with sperm and debris. None of the rats that lacked testicular alterations showed epididymal changes. Mean serum antisperm antibody levels were significantly higher for rats with epididymal interstitial changes than for animals without such epididymal alterations. Infiltrations of inflammatory cells into the epididymal interstitium and lumen are part of the constellation of changes that occurs after immunization with testicular homogenates to produce experimental allergic orchitis. The observations reported here support the hypothesis that reproductive tract alterations after vasectomy in this model have an immune basis.

To delineate the natural history of fetal multicystic dysplastic kidneys (MDKs), all cases that were prenatally detected in the Prenatal Diagnosis Center of the University of Virginia from September 1985 to 31 August 1988 were reviewed. All patients were followed through the Center with serial ultrasound evaluations at approximately 4-week intervals, and each liveborn infant was evaluated and followed by one of the authors (S.S.H.). Of the 14 cases detected, ten were detected in the second trimester, the earliest at 16.5 weeks' gestation. Of the nine fetuses with non-lethal disease, there were two cases in which the lesion remained unchanged during observation. Both had an initial diagnosis in the third trimester. In those cases diagnosed in the second trimester (7), all showed an initial increase in the size and number of cysts, followed by involutional changes either in utero (2) or in the neonatal period (3). Two infants had immediate surgical removal of the MDK, one because of respiratory compromise, and the other because of an uncertain diagnosis on renal scan. Abnormalities of the contralateral kidney were found in 7 of 14 fetuses. Five were lethal conditions. Associated non-renal abnormalities were common in bilateral MDK (80 per cent), but rare in unilateral MDK (11 per cent).

Serum antisperm antibodies were studied in Sprague-Dawley rats after vasectomy and vasovasostomy. Animals received a bilateral vasectomy, a vasectomy followed 3 mo later by vasovasostomy, or sham operations. Blood samples were obtained at 1, 3, 4, and 7 mo, and antisperm antibodies were assayed by an enzyme-linked immunosorbent assay. After vasectomy reversal was performed at 3 mo, antisperm antibodies were significantly higher in rats in the vasovasostomy group at 4 mo than in animals that had a persisting vasectomy or sham operations. At 7 mo, the antisperm antibody level for the vasovasostomy group was approximately double that for the vasectomized rats. Spermatic granulomas occurred in 76% of rats after vasovasostomy. Antisperm antibody levels were higher in vasovasostomized animals with granulomas than in those lacking granulomas. The results suggest that vasovasostomy may stimulate an antibody response to sperm rather than lead to a reduced response, as was anticipated upon removal of the obstruction. Spermatic granulomas may serve as sires for continued antigenic challenge. The observed increase in antisperm antibodies after vasovasostomy in Sprague-Dawley rats may be related to their relatively low immunologic responsiveness to vasectomy, with vasovasostomy serving as a second major immunologic challenge, aided by the formation of an additional granuloma. In the more responsive Lewis strain, we previously observed a rise in antisperm antibodies after the initial vasectomy, with no further increase after vasovasostomy.

No AccessJournal of Urology1 Feb 1989This Month in Investigative Urology: Diuretic Renograms and the Whitaker Test Stuart S. Howards Stuart S. HowardsStuart S. Howards More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(17)40778-6AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "This Month in Investigative Urology: Diuretic Renograms and the Whitaker Test." The Journal of Urology, 141(2), p. 386 © 1989 by The American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 141Issue 2February 1989Page: 386 Advertisement Copyright & Permissions© 1989 by The American Urological Association Education and Research, Inc.MetricsAuthor Information Stuart S. Howards More articles by this author Expand All Advertisement PDF DownloadLoading ...

The relationship between alterations in testicular histology and antisperm antibodies was studied after vasectomy and vasovasostomy in Sprague-Dawley rats, which are immunologically relatively non-responsive to vasectomy. Testes were prepared for histologic study at intervals up to seven months after vasectomy, vasectomy followed three months later by vasovasostomy, or sham operations. Antisperm antibodies were assessed with an ELISA. Testicular alterations, which were observed in a minority of animals after vasovasostomy, consisted mainly of depletion of germ cells. Mean serum antisperm antibody levels were greater for animals with altered testes than for rats with normal testicular histology. In addition, the proportion of rats that showed a positive antisperm antibody response was greater among animals with testicular changes than among those with unaltered testes. When the present results on Sprague-Dawley rats were compared with previous findings on the highly responsive Lewis strain, it was evident that the incidence of testicular changes and the proportion of positive antibody responders were greater in the Lewis strain. However, elevated antisperm antibodies and testicular alterations appeared to be more tightly linked in the less responsive Sprague-Dawley rats. (J. Urol., 140:627–631, 1988)

An indirect enzyme-linked immunosorbent assay (ELISA) was employed to monitor antisperm autoantibodies in 16 Lewis rats for up to 36 weeks following vasectomy. This assay was capable of discriminating all prevasectomy from postvasectomy sera at a 1:16 dilution. Weekly serum samples were obtained for the first 13 weeks and bimonthly samples thereafter. Half of the animals developed a positive antisperm autoantibody response by the end of the first postoperative week. By the end of the second week, 81% of the animals had positive responses. The greatest proportion (88%) of animals having a positive response over the course of the study was found at the end of the seventh postoperative week and the highest mean absorbance value for all 16 animals was observed at this time. Only 25% of the animals had positive responses for antisperm autoantibody at the end of the 35th week of the study. These findings indicate that circulating antisperm autoantibodies arise in the Lewis rat earlier than has been generally appreciated. The time course is similar to that of antibody titers to infectious agents or arising from inoculation of rats with spermatozoa. These findings on autoantibody levels in the Lewis rat are compared with the dynamics of antisperm autoantibody formation in man.

The clinical experience is presented of 4 United States centers at which extracorporeal shock wave lithotripsy was used for the treatment of renal calculi in 38 children 12 months to 16 years old. Patient characteristics, treatment specifics and followup data are detailed. Complete fragmentation of calculi was obtained in 97 per cent of those treated, with a 5 per cent complication rate. This experience demonstrates that with proper safeguards, extracorporeal shock wave lithotripsy can be performed safely and effectively in the pediatric population.

Unilateral varicocele has been associated with diminished male fertility in humans and with bilateral physiologic and histologic changes in the testis of humans and laboratory animals. In particular, left varicocele in Sprague-Dawley rats results in bilateral increases in testicular temperature and blood flow. The mechanism by which unilateral varicocele can cause testicular changes is not known. The purpose of the present study was to determine whether or not the presence of either the ipsilateral or contralateral testicle is necessary for these effects of the varicocele to occur in the opposite testis. Varicoceles were created in adult, male rats by partial constriction of the left renal vein. Bilateral testicular blood flow was measured by a radiolabelled microsphere distribution technique and testicular temperature was taken with a needle probe thermometer. Right or left orchiectomies were performed on selected animals at the time of surgery to establish the unilateral left varicocele. Animals were studied 30 days after surgery. Mean testicular blood flow was significantly increased (P less than 0.01) in all animals having a left varicocele when compared with animals not having a varicocele regardless of whether a unilateral orchiectomy was performed. Likewise, the mean difference between intraabdominal temperature and intratesticular temperature (delta T) was significantly decreased in all groups of animals having varicoceles when compared with groups without varicoceles whether or not an orchiectomy had been performed. Thus, the studied bilateral effects of left-sided, experimental varicocele in the rat are not dependent upon the presence of a left testicle.

No AccessJournal of Urology1 Jun 1987Fertility in the Lewis Rat Following Microsurgical Vasectomy Reversal E. Scott Yarbro, Peter O. Carey, Stuart S. Howards, and Terry T. Turner E. Scott YarbroE. Scott Yarbro More articles by this author , Peter O. CareyPeter O. Carey More articles by this author , Stuart S. HowardsStuart S. Howards More articles by this author , and Terry T. TurnerTerry T. Turner More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(17)75382-7AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Fertility in the Lewis Rat Following Microsurgical Vasectomy Reversal." The Journal of Urology, 137(6), p. 161A © 1987 by The American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 137Issue 6June 1987Page: 161A Advertisement Copyright & Permissions© 1987 by The American Urological Association Education and Research, Inc.MetricsAuthor Information E. Scott Yarbro More articles by this author Peter O. Carey More articles by this author Stuart S. Howards More articles by this author Terry T. Turner More articles by this author Expand All Advertisement Loading ...