Atlas of Clinical Andrology

Chapter 5. Testicular dysfunction and male infertility

There are various anatomical syndromes of male infertility which include those due to absence of the vas deferens, one testis being non-palpable, spermatocele, absence of epididymis, failure of union of epididymis-testis and other related anomalies. These anomalies are associated with testicular feminization syndrome or male hermaphroditism (Figures 5.1 and 5.2). Testicular dysfunction is due to spermatogenesis anomalies, anatomical/ultrastructural parameters, genetic factors and testicular tumors.

ANATOMICAL/ULTRASTRUCTURAL PARAMETERS

Cryptorchidism

Exposure to compounds with estrogenic or anti- androgenic activities may cause deleterious effects on male reproduction, a decrease in sperm production and an increased incidence of testicular carcinoma and/or increased cryptorchidism (Table 5.1). Any form of cryptorchidism at birth, regardless of the outcome, should be considered to be a risk factor for testicular cancer and/or male infertility. Most cases of cryptorchidism diagnosed at birth resolve spontaneously during the first years of life (natural course of cryptorchid testes). The risk of cryptorchidism is higher for boys born to young mothers (< 20 years). The risk also increases with the first birth, Cesarean section or toxemia, infants small for gestational age and in boys with low birth weight and when estrogens (estradiol, diethylstilbestrol (DES) and estrone) have been administered during gestation (Thonneau et al., 2003).

Cryptorchidism is associated with an increased risk of developing testicular cancer, decreased sperm count and infertility. Infertility occurs in 60% of men with bilateral, and in 35% of men with unilateral, cryptorchidism. Cryptorchidism is caused by interaction of endocrine disorders, anatomical abnormalities, and environmental and genetic factors. Genes in the achromatic region of the long arm of the Y chromosome (Yq11) are required for normal spermatogenesis. Y-chromosome microdeletions are an important genetic cause of primary testiculopathies (Kunej et al., 2003).

Figure 5.1 Anatomical syndromes of male infertility: (a) right vas deferens absent, left testis non-palpable; (b) epididymis on right shows spermatocele, left vas deferens absent; (c) both epididymides absent, left vas absent; (d) failure of union of epididymis-testis, epididymis separated by vascular mesentery; (e) failure of union of body-tail of epididymis; (f) failure of development of body-lower pole of epididymis; (g) no connection between lower pole of epididymis and vas

Figure 5.2 Testicular feminization syndrome: (a) female habitus with significant breast development; (b) female external genitals without pubic hair. Male hermaphrodite: (c) male legal sex, male psychosexual orientation, female habitus; (d) external genitals

Hydrocele

The description, symptoms, causes, risk factors, diagnosis and surgical approaches to hydrocele are summarized in Table 5.2.

Varicocele

Varicocele, a dilatation of the pampiniform plexus of the spermatic cord, is a treatable cause of male infertility (Figures 5.3-5.7). While the incidence of varicocele in the general population is estimated to be 15%, the incidence in men with subfertility increases to approximately 30%. With the advent of new microsurgical techniques for varicocele ligation, it is assumed that the complication rate following this procedure will be diminished compared to historic norms. In particular, since magnification allows identification and preservation of lymphatic vessels, it is thought that microsurgical varicocele ligation will lead to a lower rate of hydrocele formation than non-microsurgical techniques.

Varicoceles are associated with a time-dependent decline in testicular function in animals and man. Approximately 15% of all adult men have a varicocele. One-third of all males evaluated for infertility have a varicocele, demonstrating the negative impact of varicoceles on testicular function. Significant volume loss occurs in 77% of adolescent boys with a varicocele, with 10% having a left testis one-quarter the size of the right testis. The loss of testicular volume in adolescents with left testicular varicocele is accompanied by a decrease in sperm count. The growth arrest associated with the adolescent varicocele is reversible in most patients.

Varicocele may be associated with poor semen and hormonal parameters, with increased follicle stimulating hormone (FSH) levels indicating damage to the germinal epithelium and a poor prognosis. Studies have reported a lower mean serum testosterone level in patients with varicocele and sexual dysfunction. Varicocele is also associated with decreased testicular size and impaired sex accessory gland secretion with lower semen quality. Thus, varicocele repair should be performed to prevent infertility and subsequent testosterone deficiency. Successful venous occlusion will relieve pain, if present, and will reduce the size of large varicoceles. Surgical treatment of varicocele produces a significant improvement in semen analysis in 60-80% of patients affected by testicular dysfunction, with pregnancy rates of 35% after varicocelectomy. In patients who have undergone varicocele repair, there is a preoperative correlation between semen analysis and varicocele size. Postoperatively, all semen parameters improve with increased left testicular volume varicocele repair, leading to an increase in pregnancy rate.

Peyronie’s disease

Peyronie’s disease is a connective tissue disorder affecting the tunica albuginea and adjacent corpus cavernous tissue. There are two phases of the disease. The early phase consists of a vascular inflammatory reaction. This period usually lasts 2-10 months and symptoms consist primarily of pain during erection. The disease either regresses or continues to the second phase.

In the second or late phase of the disease, the initial inflammatory reaction progresses to form a fibrotic calcified and palpable plaque. Consequences of this plaque include symptoms associated with late-phase disease, which consist of penile deviation when the penis is erect and erectile dysfunction.

Figure 5.3 Laparoscopic Palomo varicocelectomy by transabdominal approach

Figure 5.5 RigiScan^TM portable monitoring device for at- home or in-office assessment of penile tumescence/rigidity changes. It comprises a microcomputer, loops placed around base/tip of shaft of penis and a logging unit (courtesy Archives of Andrology)

Figure 5.6 Scrotal sonography performed with a 7.5-MHz sector scanner of (a) normal and inhomogeneous parenchyma with numerous small hyperechogenic areas, and (b) inhomogeneous parenchyma carcinoma in situ. From Kamischke and Nieschlag (2002), with permission

Figure 5.4 (a) Patient being examined with Doppler ultrasonic stethoscopy. (b) Recordings of varicoceles using the Doppler stethoscope. Courtesy Professor L. Lipschultz

Peyronie’s disease affects 1-3% of the male population. Some 10% of men with erectile dysfunction have Peyronie’s disease. The disease most commonly affects men older than 40 years and more than 75% of patients are between 45 and 65 years. The disease was first described in correspondence between Fallopius and Vesalius, but was later named after Francois de la Peyronie, who reported it in the medical literature in 1743. Although Peyronie’s disease was described several centuries ago, the pathophysiology of the disease remains elusive.

While surgery is the main therapy for Peyronie’s disease requiring correction of angulation, interest has grown in the application of extracorporeal shockwave therapy (ESWT) as a minimally invasive approach.

Figure 5.7 (a) Fasciomuscular tube (FMT) and the related venous plexuses.The FMT is divided into anterior pampiniform and posterior vasal compartment by a transverse septum. It acts as an ‘autoelastic’ stocking supporting cord veins and as a ‘pump’ pushing blood up the spermatic cord. It has ‘sphincter’ action, which prevents blood regurgitation. (b) Cremasteric ‘externus’ patterns. The muscle has thermoregulatory function. In cold weather its contraction ‘internus’ helps ductus deferens draining. (c) The scrotal ligament binds dartos muscle to lower testicular pole. It serves two functions: first, a thermoregulatory function, harmonizing testicular movement with dartos; and second, a synchronizing effect on the action of both dartos and cremasteric muscles throughout testicle. Absent ligament or aligomentous testicle syndrome leads to infertility. Courtesy Shafik and Olfat

Traditional therapy

Several modalities have been applied including oral, topical, injection and surgery therapy. Oral regimens employed include vitamin E, colchicines and tamoxifen. In addition to oral medication several intrale- sional injection therapies have been used, including steroids, verapamil and interferons. Unfortunately, the localized side-effects of steroids can be quite severe and have included tissue atrophy and skin thinning. These side-effects can make surgery, if required, technically difficult to perform. Furthermore, interferon and the calcium channel blocker verapamil have only moderate success. Iontophoresis has been used to deliver both verapamil and dexamethasone. Surgical treatment is used primarily in cases refractory to conservative management. There are three categories of surgery for penile curvature. They include tunical shortening and lengthening procedures, as well as placement of prostheses. The Nesbit and modified Nesbit techniques are shortening procedures and have met with positive results. However, complications of both procedures have included erectile dysfunction, penile hematoma, penile narrowing, urethral injury, herniation, glans numbness and phimosis.

Extracorporeal shockwave therapy

ESWT has been the gold standard in treating urolithiasis, and has also been used as an efficient method to treat calcification of connective tissue in orthopedics; furthermore, ESWT of salivary stones may be viable.

Figure 5.8 (a) Severe oligozoospermia ‘Sertoli cell only’, few tubules with inhibited spermatogenesis (150x). (b) Severe oligozoospermia,‘Sertoli cell only’ (150x). (c) Spermatogenic arrest of spermatocyte stage (450x). (d) Spermatogenic arrest at primary spermatocyte stage (150x). (e) Spermatogenic arrest at spermatid stage (180x). (f) Spermatogenic arrest at late spermatid stage (400x)

Testicular torsion

Testicular torsion is a form of ischemia-reperfusion (I/R) injury, which requires early diagnosis and surgical intervention. Testicular torsion causes testicular injury and subfertility (Table 5.3). The pathophysiology of testicular torsion is associated with two types of cell death: necrosis and apoptosis.

Figure 5.9 Comparison between normal testis (a) and altered testis with ‘diffuse’ abnormalities (b) obtained from rat rollowing unilateral vasectomy and stained with hematoxylin and eosin. From Chehval et al., 2002, with permission

Unilaterial testicular torsion (UTT) increases the biochemical changes due to tissue hypoxia and the level of noradrenalin; also, chemical sympathectomy prevents the hypoxic changes after UTT in the contralateral testis. Testicular torsion can provoke contralateral hypoxia due to reduced blood flow through an autonomic nerve reflex. Nitric oxide (NO), derived from vascular endothelium, relaxes vascular smooth muscle. Basal NO release regulates vasodilatation and focal blood flow. NO also plays an important role in the induction of apoptosis, whereas NO protects the heart during I/R through protein kinase C (PKC) activation.

ANOMALIES OF SPERMATOGENESIS

There are different degrees of anomalies of spermatogenesis; spermatogenesis arrest may occur at different stages of spermiation (Figures 5.8-5.12; Table 5.4).

Azoospermia and aspermia

‘Azoospermia’ is the absence of sperm in a centrifuged semen sample, while ‘aspermia’ is an absent ejaculate. Azoospermia occurs in 5-20% of infertile men. Azoospermia can be obstructive or non-obstructive.

Testicular biopsy of obstructive azoospermia shows sufficient spermatogenesis associated with physical occlusion of the reproductive tract distal to the testis that prevents sperm from entering the semen. The location of obstruction can be at one of several sites: caput epididymis, cauda epididymis, ejaculatory duct or congenital or non-congenital obstruction of the vas deferens. All forms of obstructive azoospermia can be circumvented with sperm retrieval and intracytoplasmic sperm injection (ICSI). Non-obstructive azoospermia (NOA) is caused by severely reduced sperm production. Several drugs affect sperm production and/or function: alcohol, alkylating agents, allopurinol, anabolic steroids, cimetidine, cocaine, colchicine, cyclosporin, erythromycin, gentamicin, marijuana, neomycin, nitrofurantoin, spironolactone, sulfasalazine and tetracyclines.

Figure 5.10 Diagrammatic illustration of the metabolic/molecular interactions of sex homone-binding globulin (SHBG) within the Sertoli cell.The following remain to be determined: (1) if human testis expresses both the secreted and the alternative form of SHBG/androgen-binding protein (ABP); (2) the proportional amount of each; (3) the cellular type responsible for the expression of each; (4) the steroid affinity of each; (5) the binding capacity of the alternative form of SHBG/ABP; (6) their mechanism of action (the existence and nature of the SHBG/ABP receptor and/or other interacting proteins); (7) the role of the alternative, cytoplasm form; and (8) the epididymal epithelium. From Munell et al., 2002, with permission. ES, engulfing sperm; RS, spermatocyte; SG, spermatogonium; SC, Sertoli cell

Further research is needed to evaluate the inheritance of chromosomal and genetic abnormalities in spermatogenesis that are transmitted only by ICSI. Chromosomal analysis of the male partner should be performed before ICSI treatment is initiated. There is an increased rate of chromosomal aberrations in ICSI patients with poor reproductive outcome. Chromosomal analysis is recommended not only for the male partner but also for the female partner in ICSI. In some cases of chromosomal inversion, recombination of chromosomes can occur during spermatogenesis, and eggs injected with such sperm cannot develop. Sperm chromosomal analysis should also be performed for couples with chromosomal aberrations diagnosed by peripheral cells. Chromosomal analyses of oligozoospermic men have usually been performed using heterologous ICSI of hamster eggs with human sperm, and metaphase chromosomes have been analyzed. However, this technique is not simple and more relevant and straightforward techniques for sperm chromosomal analysis should be developed. Preimplantation genetic diagnosis can be a powerful tool to exclude embryos that cannot develop due to the presence of such recombinant chromosomes.

Testicular hypoplasia

Hypoplasia of the testes is a congenital defect in which the potential for development of the spermatogenic epithelium is lacking. Inherited testicular hypoplasia is best known in Swedish Highland cattle and is caused by a recessive autonomic gene with incomplete (about 50%) penetrance.

Figure 5.11 In situ detection of germ cell apoptosis in monkeys before (a) and after heat treatment (b). Cellular localization of apoptosis was characterized by terminal deoxynucleotidyl transferase mediated dUTP nick end labeling (TUNEL) assay. Methyl green was used as a counterstain. Many apoptotic germ cells (dark brown in color) were noted in testicular biopsies obtained 3 days after the first heat treatment (b) but not from control animal (a). Bax immunoactivity in the testis before (c) and after heat treatment (d). A portion of seminiferous tubule from a normal adult monkey showing that Bax is localized in the cytoplasm of germ cells, Sertoli cells and a small amount in Leydig cells (c), and from a monkey 3 days after the first heat treatment (d) displaying intense immunoactivity of Bax in apoptotic germ cells (arrows). Scale bar 25 |im. From Lue et al., 2002, with permission. See also color plate

Figure 5.12 (a) and (b) Immunofluorescence of epididymal cell lines cultured for 1 week after approximately 30 passages on a glass slide with supplemented IMDM with 10% fetal calf serum and stained with PEB-like protein antibody (20Hg/ml). (c) and (d) Immunofluorescence of the cell lines cultured for 1-2 weeks after approximately 30 passages on glass slides with supplemented IMDM with 10% fetal calf serum, stained with a cytokeratin antibody (68Hg/ml). Cytokeratin immunofluorescent staining was green and Hoechst 33342-stained nuclei were blue. (a) PCI; (b) DC1; (c) PCI; (d) DC1.Bar 10μm. From Araki et al., 2002, with permission. See also color plate

Table 5.4 Testicular biopsy findings related to semen analysis and secondary sexual characteristics

Testicular biopsy interpr	station	Nature		Semen analysis
Normal	Adult tubular size,thin wall and basement membrane	Obstructive
		Complete		Azoospermia no sperma-togenic cells, pus cells may be present
	Regular and full spermatogenesis up to sperm formation	Incomplete		Severe oligospermia with spermatogenic cells
	Lumen present, interstitium narrow, with adult Leydig cells	Intermittent		Varying between azoo- and oligospermia
Spermatogenic arrest	Adult tubular size, wall thin or may show early thickening	Functional
Spermatogonium	Only basal cell is intact with spermatogonia and Sertoli cells, wide lumen			Azoospermia
Primary spermatocyte	Spermatogenesis up to primary spermatocyte, few or no spermatids, hypo- or hypercellularity			Azoospermia few or no spermatogenic cells
Spermatid complete or partial arrest	Spermatogenesis up to early to late spermatid, often associated with hypercellularity; no or few spermatozoa			Spermatogenic cells few or no sperm
Sertoli cell only	Tubular size small or normal, wall thin or shows early thickening, complete absence of spermato- genic cells, only Sertoli cells, and their cytoplasms Leydig cells normal or show hyperplasia	Congenital		Azoospermia no spermatozoa or spermatogenic cells
Mixed Sertoli cell only	Sertoli cell-only tubules mixed with normal tubules or tubules with disturbed spermatogenesis	Functional		Azoospermia or oligospermia
Prepubertal	Tubules of small diameter, thin wall, no basement membrane, lumen absent or small, only two types of cells: primary spermatogenic cells and undifferentiated cells Leydig cells are absent	Hypogonadotropic hypopituitarism		Azoospermia, very small volume with no spermatozoa 1
Multiple lesions	Appearance is not uniform, with mixed areas of Sertoli cell-only tubules Partially and completely hyalinized tubules Leydig cells often show hyperplasia, which is more pronounced in areas completely hyalinized giving an appearance similar to Klinefelter’s syndrome	Functional		Azoospermia or severe oligospermia
Azoospermatogenesis	Tubules are of normal adult size Thinning of spermatogenic cells, tubular hyalinization	Functional		Severe oligospermia or azoospermia
Early diffuse (TH)	Diffuse early to moderate peritubular thickening Various grades of inhibited spermatogenesis	Functional		Oligospermia
Focal TH	Areas of TH mixed with tubules showing disturbed spermatogenesis	Functional		Severe oligospermia
Progressive	Generalized, moderate to severe peritubular thickening Residual Sertoli cells and few spermatogenic cells Leydig cells commonly show diffuse hyperplasia	Functional		Azoospermia
Testicular biopsy interpretation		Nature	Semen analysis
Klinefelter’s syndrome	Tubules of small diameter, completely hyalinized or show Sertoli cells, hyperplasia of Leydig cells in clumps so that tubules appear relatively empty with few cells and wide lumen	Chromosomal aberration	Azoospermia
Sloughing	Tubules are of normal adult size tubular wall is thin Basal cells layers are intact, the more mature cells are sloughed in lumen so that only few spermatozoa are formed and their passage is blocked by the sloughed cells Leydig cells are normal	Functional	Oligospermia or severe oligospermia many spermatogenic cells
Sloughing and disorganization	As above in addition to disordering arrangement of cells commonly associated with mild to moderate diffuse peritubular thickening Leydig cells are normal or show mild degree of diffuse hyperplasia	Functional	Severe oligospermia or azoospermia with spermatogenic cells, both normal and abnormal

Disease of testes and/or accessory glands

Pathological conditions of the testes, epididymis and seminal vesicles may interfere with fertilization by disturbing spermatogenesis of sperm maturation, causing abnormal semen characteristics, or preventing the passage of sperm from the testes to the urethra.

CHROMOSOMAL AND GENETIC ANOMALIES (TABLE 5.5)

Chromosomal arrangements occur during mitosis and meiosis. Normally the ovum (X) is fertilized by sperm bearing an X or a Y chromosome. In abnormal cases of non-disjunction of oogenesis or spermatogenesis, fertilization may occur between an abnormal sperm and/or an abnormal egg, resulting in various chromosomal anomalies. Structural anomalies of the chromosomes include translocations, deletions, rings and inversions of chromosomes during either mitosis or meiosis. Such anomalies affect individual autosomes or sex chromosomes. The human cell comprises a nucleus, protein-manufacturing units and energy-production points. The sequence or layout of the DNA contains all the instructions the cell needs to function. Recent advances in genetic engineering have enabled scientists to uncover, rearrange and make copies, or clones, of genes. For example, each cell contains some 100 000 genes. At least 22 000 of these genes have been isolated, and some of their specific functions have been identified.

Chromosomal defects (Table 5.6)

Male infertility may be caused by a variety of chromosomal abnormalities:

(1) Abnormalities in sex chromosomes or autosomes;

(2) Gain or loss of an entire single chromosome resulting in aneuploidy, whereas a polyploid state occurs when the entire chromosomal content is multiplied (polyploid cells are most commonly associated with malignancies);

(3) Structural abnormalities which include the rearrangement or translocation of fragments of chromosomes, as in Robertsonian translocations, or deletions of single genes or portions of a chromosome (Maduro et al., 2003).

DNA fragmentation in testicular sperm

There is a negative correlation between sperm DNA fragmentation and embryo cleavage and pregnancy rates obtained with ICSI, underlining the importance of sperm DNA quality. Aging affects chromosomal structural abnormalities and generation of reactive oxygen species. Because the sulfhydryl (SH) bonds are not oxidized until transit through the epididymis, testicular sperm DNA packaging is not complete, and their DNA may be more susceptible to assault. DNA integrity is determined by modified alkaline singlecell gel electrophoresis.

Of the structural anomalies of chromosomal aberrations in ICSI fetuses, ten have been reported to be of paternal origin. It is suggested that chromosomal anomalies after ICSI are the result of not only the incidence of cytogenetic anomalies of the male infertility patient but also the ICSI technique itself. There are some differences in the ‘choreography’ of the cell cycle of fertilization between in vitro fertilization (IVF) and ICSI using non-human primates as a model.

Decondensation of sperm nuclei occurs initially in the basal region and the apical region remains condensed, surrounded by the perinuclear theca, a structure typically removed during sperm incorporation into the egg. This unusual nuclear remodeling in the first cell cycle of ICSI may not allow the synchronized decongestion of chromosomes and may introduce a delay of the S-phase entry of the male pronucleus, leading to mitotic errors during the first cleavage. Karyoanalysis is used to elucidate the relationships between various types of congenital disorders and the abnormalities in chromosomes. Although, to date, only light microscopy has been used for this type of study, scanning electron microscopy can be applied to this field and serves to elucidate the changes of chromosomes at the submicroscopic level.

Klinefelter’s syndrome

The most common chromosomal anomaly in infertile men is Klinefelter’s syndrome (KS). In men with non-obstructive azoospermia, such as men with nonmosaic KS, there is no clinical marker to predict the success of sperm recovery with testicular sperm extraction (TESE). Serum inhibin B is a useful predictor of spermatogenesis in men with oligozoosper- mia and azoospermia. Diagnostic TESE has been successfully applied to identify the presence of sperm in men with KS. The application of TESE with subsequent ICSI results in pregnancy. Inhibin B is not predictive of successful surgical sperm recovery in men with non-mosaic Klinefelter’s syndrome. Even a concentration of serum inhibin B below the level of detection does not exclude foci of spermatogenesis. We recommend that all our azoospermic men with Klinefelter’s syndrome have a diagnostic TESE before treatment unless donor sperm backup is available and fully accepted by the couple (Westlander et al., 2003).

Figure 5.13 Mechanism of varicocele formation. Upon venous backflow and hypertension, three pathological stages occur in varicocele: medial hypertrophy - no blood stasis, symptomless (compensated); medial failure - leading to venous stasis but no clinical varicocele (concealed varicocele) leading to infertility; dilatation - prolonged stasis leading to varicosity (manifest varicocele) leading to infertility

BIOCHEMICAL PARAMETERS

Varicocele and antioxidant capacity

The damage inflicted to sperm by reactive oxygen species (ROS) plays a major role in male infertility. Sperm have a high content of polyunsaturated fatty acids within the plasma membrane and a low concentration of scavenging enzymes in the cytoplasm, and they are susceptible to peroxidation in the presence of elevated seminal ROS levels. Seminal plasma and sperm possess a variety of antioxidant systems to counteract the effects of ROS. The seminal plasma is endowed with antioxidant buffer capacity, and the protective system includes chain-breaking antioxidants capable of reducing oxidant radical levels and blunting the propagation of free radical chain reactions. However, sperm possess a small amount of cellular ROS defense system that consists of catalase, superoxide dismutase, glutathione peroxides and vitamin E.

Meucci et al. (2003) evaluated a possible molecular defect linked to infertility, studying total antioxidant capacity (TAC) of seminal plasma in varicocele (VAR) (Figure 5.13). The latency phase, proportional to antioxidant concentration, showed significantly greater values in all VAR patients. VAR patients undergoing surgery may suffer from ejaculatory dysfunction after treatment.

Proacrosin, acrosin and idiopathic infertility

Acrosin (EC 3.4.21.10) is a trypsin-like endprotease localized on the sperm acrosome, that aids in sperm penetration by limited proteolysis of zona pellu- cida (ZP) lipoproteins. Acrosin protease activity is involved in dissolution of the acrosomal matrix, and in a regulated release of acrosomal contents at the time of the acrosome reaction. Independent of its proteolytic activity, acrosin binds lipoproteins from the extracellular egg coat, supporting its participation in secondary sperm binding to the ZP. Acrosin is synthesized and stored as its inactive zymogen, proacrosin. During the acrosome reaction, proacrosin is converted to the mature enzyme B-acrosin and released. Proacrosin activation involves processing the 53-55-kDa proenzyme to 50-40-kDa activation intermediates, the 34-kDa mature enzyme and lower molecular weight forms. The presence of human proacrosin/acrosin in whole sperm can be detected by immunocytochemistry with specific antibodies.

Biochemical and molecular evaluation of the proacrosin-acrosin system in patients undergoing treatment with standard IVF-embryo transfer (ET) has been performed. Male patients diagnosed with unexplained infertility were only included in the study group to avoid other factors that could contribute to abnormal fertilization. The studies involved evaluation of acrosin activity in ejaculated sperm, the proacrosin-acrosin system in whole sperm by immunocytochemistry, proacrosin activation patterns in sperm protein extracts, and nucleotide sequence around the amino acids of the catalytic triad by single-strand conformation polymorphism (SSCP) analysis. In the study group, the mean value of acrosin activity was 53 pIU/million spermatozoa (range 5.8-135). Five of the 27 cases (19%) showed abnormal activity (Hafez, unpublished data).

SYNDROMES OF MALE INFERTILITY

Idiopathic male infertility

Routine semen analysis using light microscopy is used for the initial evaluation of the male of an infertile couple. However, the diagnosis of defective sperm function by standard semen analysis is difficult because sperm are highly specialized cells that express a diverse array of biological properties to achieve fertilization. Sperm DNA damage is significantly increased in men with idiopathic and male factor infertility, and in men who fail to initiate a pregnancy after assisted reproductive techniques. Such an increase in sperm damage may be related to high levels of seminal oxidative stress (Saleh et al., 2003).

Psychosocial parameters of the infertile couple

Infertile couples are characterized by various psychosocial parameters: anger, grief, guilt, frustration, depression, feelings of isolation and powerlessness, marital problems, separation and divorce. However, sporadic conception is noted in infertile couples after or during romantic holidays, after adoption or after abandoning treatment in an infertility clinic. Spontaneous pregnancy occurs in some 10% of untreated infertile couples with oligozoospermic men, in patients placed for 1-2 years on a waiting list for IVF or ICSI. ‘Psychogenic infertility’ is associated with chronic and acute stress, with transitory azoospermia or oligospermia. De Gennaro et al. (2003) studied normozoospermic and oligozoospermic men for differences in alexithymia (difficulty identifying feelings, difficulty describing feelings, externally oriented thinking), personality traits (extroversion, neuroticism, psychoticism) and coping style toward stressors (task-oriented coping, emotion-oriented coping, avoidance-oriented coping). Significant relationships were noted between these variables and semen characteristics.

Testicular germ cell tumor

Germ cell tumor of the testis (TGCT) is the most common malignancy in 15-35-year-old men. The combination of surgery, radiotherapy and chemotherapy has made TGCT curable in 90% of patients with newly diagnosed disease (Figure 5.14; Tables 5.7- 5.9). Most of the patients have decreased baseline spermatogenesis at the time of diagnosis, a pre-existing defect in spermatogenesis, a history of cryptorchidism, hormone production by the tumor, antisperm antibodies, possible contralateral or intraepithelial germ cell neoplasia, and/or generalized stress associated with illness. Cryptorchidism is associated with both testicular cancer and infertility. Although the majority of patients with testicular cancer have fulfilled their wishes with regard to children, it seems to be more difficult to father a child after treatment compared with the general population. Because it is not possible to predict which patient will have fertility problems after treatment, cryopreservation of sperm should be offered to every testicular cancer patient (Spermon et al., 2003). Deterioration of spermatogenesis occurs after adjuvant radio- or chemotherapeutic treatment in a dosedependent fashion. Some patients remain azoospermic after treatment while others undergoing surgery may suffer from ejaculatory dysfunction after treatment.

Figure 5.14 Seminal parameters after chemotherapy in patients with testicular germ cell tumor: (a) sperm concentration, (b) motility and (c) morphology. Open circles, patients with normal _β-human chorionic gonadotropin (PhCG); closed circles, patients with high PhCG. Courtesy Professor Tomomasa

Table 5.8 Clinical staging of testicular germ-cell tumors according to the Lugano classification

Clinical stage	Description
I	No evidence of metastases
IA	Tumor limited to testis and epididymis
IB	Infiltration of spermatic cord or tumor in cryptorchid testicle
1C	Infiltration of the scrotum, trans-scrotal surgery, tumor developing after trans-scrotal or inguinal surgery
IX	Extent of primary tumor cannot be evaluated
II	Retroperitoneal lymph-node metastases
IIA	All lymph nodes < 2 cm
IIB	More than one lymph node 2-5 cm
IIC	Lymph nodes > 5 cm
IID	Abdominal tumor palpable, fixed inguinal tumor
III	Mediastinal and supraclavicular lymph-node metastases, visceral metastases
IIIA	Mediastinal and supraclavicular lymph-node metastases only
IIIB	Pulmonary metastases only
IIIC	Hematogenous metastases outside the lung
IIID	Persistent elevated markers without evidence of metastases