Male infertility's key topics are obesity, health reform

Key Points

Like any subspecialist, the urologist who treats male infertility cannot practice in a vacuum. General trends in medicine-clinical and otherwise-will inevitably impact his or her practice, often as much as specific advances in diagnosis and treatment.

On the obesity question, Dr. Niederberger cites forthcoming research into the effects of gastric bypass surgery on sperm quality. Early results show no improvement in reproductive capacity among men who undergo the procedure.

The other issue raised by such research, Dr. Niederberger noted, is a chicken-and-egg type of question.

"Is the endocrine problem in these patients causing their obesity and subsequent sperm problems? Or is the obesity causing the endocrine problem? That's another issue to examine," he said.

Reform's effect on costs unclear

It's unclear at this point how the recently enacted health care reform legislation will affect the practice of andrology. A team of researchers is soon expected to present results of a study analyzing the amount patients are paying for fertility treatment after insurance coverage.

"It's uncertain how the federal government will deal with fertility in light of health care reform," Dr. Niederberger said. "Right now, there are only 11 states in which insurers are obligated to pay for fertility care. Since the federal mechanism for health care utilization has previously been Medicare-and fertility obviously isn't a big part of that-the move to more universal care means the government must start paying attention to fertility."

A great deal of fertility care happens outside of the current insurer-based system in the U.S. The above-mentioned researchers will likely report variations in cost depending on treatments and the type of infertility diagnosed.

Morphology and IVF outcomes

If a man has severe teratospermia, does that mean his chances of initiating a pregnancy through in vitro fertilization are low? Not necessarily, according to ongoing studies.

As it turns out, most men's sperm are teratospermatic whether the analysis is conducted using World Health Organization criteria or Krueger strict morphology. The consensus seems to be that isolated teratospermia is not necessarily associated with a significantly lower chance of pregnancy using assisted reproductive technologies-something that should comfort both the urologist and the patient, says Dr. Niederberger.

"You might have a patient come in and the only thing wrong is that his sperm looks funny," he said. "If that's the case, you can often assure him that it's not a problem. And in those cases when a man has been told that his IVF failure was because of abnormal-looking sperm, we can tell him that his DNA is probably as good as anyone else's."

Can mTESE be repeated?

There's no doubt that microdissection testicular sperm extraction (mTESE) is one of the great technological advances in fertility treatment in recent decades. Together with intracytoplasmic sperm injection, it is a widely used procedure for men with nonobstructive azoospermia.

Research in the last few years has analyzed the success of mTESE in specific patient populations, such as those with high levels of follicle-stimulating hormone or those who have biopsies revealing no sperm. Recently, the question has been raised whether men who have previously undergone mTESE can anticipate success with a repeat procedure.

The answer, it seems, is yes.

"We're finding that if you've already had an mTESE, you can have another," Dr. Niederberger said.

Surveillance for small testicular masses

Increasingly, clinicians are using scrotal ultrasound as a tool in evaluating male infertility. One side effect is the incidental detection of small testicular masses. In the past, urologists have generally opted for surgical removal, but a Canadian group is set to present data on the natural history of these masses if they're allowed to remain.

More often than not, these non-palpable masses do not show any significant growth, suggesting ongoing surveillance as an effective alternative to surgery.

"The jury is still out on this, but I don't think anyone would fault a clinician for being overly cautious and resecting the lesion. But waiting and watching can be offered as well," Dr. Niederberger said.