Disturbances in Male Fertility

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Table of Contents

Anatomical and Functional Aspects of the Male Reproductive Organs.- A. Testis.- I. Development.- II. General Anatomy.- III. Cytological Features.- 1. Seminiferous Tubules.- a) Replication of Stem Cells.- b) Meiosis.- c) Spermiogenesis.-—) Formation of the Acrosome.- ß) Development of the Flagellum.-—) Nuclear Changes.-—) Reorganization of Cell Organelles and Cytoplasm.-—) Spermiation.- d) Sertoli Cells.- e) Seminiferous Cycle.- 2. Intertubular Tissue.- a) Lamina Propria of the Seminiferous Tubules.- b) Interstitial Cells.- c) Vasculature.- IV. Function.- 1. Control of Testicular Function.- 2. Spermatogenic Function.- 3. Steroidogenic Function.- B. Anatomy of the Male Reproductive Tract and Accessory Glands.- I. Introduction.- II. Embryogenesis of the Male Reproductive Tract.- III. Intratesticular Ducts.- 1. Transitional Distal Segment of Seminiferous Tubule.- 2. Rete Testis.- a) Septal Rete.- b) Mediastinal Rete.- c) Extratesticular Rete.- d) Cytological Features.- IV. Epididymis.- 1. Derivation and Development.- 2. General Anatomy.- a) Anatomical Relationships.- b) Vasculature.-—) Arterial.- ß) Venous.-—) Lymphatics.- c) Innervation.- 3. Cytological Features.- a) Ductuli efferentes.-—) Epithelium.- ß) Lamina Propria and Muscularis.- b) Ductus Epididymidis.-—) Epithelium.- ß) Lamina Propria.-—) Muscularis.- 4. Function.- a) Absorption.- b) Secretion.- c) Androgen Dependence.- V. Ductus Deferens.- 1. Development.- 2. General Anatomy.- a) Anatomical Relationships.- b) Vasculature.- c) Innervation.- 3. Cytological Features.- a) Epithelium.- b) Lamina Propria.- c) Muscularis.- VI. Seminal Vesicles.- 1. Development.- 2. General Anatomy.- a) Anatomical Relationships.- b) Vasculature.- c) Innervation.- 3. Cytological Features.- a) Epithelium.- b) Lamina Propria.- c) Muscularis.- VII. Prostate.- 1. Development.- 2. General Anatomy.- a) Anatomical Relationships.- b) Vasculature.- c) Innervation.- 3. Cytological Features.- a) Epithelium.- b) Lamina Propria.- c) Muscularis.- VIII. Bulbo-urethral and Urethral Glands.- 1. Derivation and Development.- 2. General Anatomy.- 3. Cytological Features.- References.- Quantitative Morphology of the Prostate and Epididymis.- A. Introduction.- B. Theoretical Basis of Stereology.- I. Symbols and Definitions.- II. Basic Stereological Equations.- 1. Volume Density.- 2. Surface Density.- 3. Numerical Density.- III. Preconditions for Stereological Analysis.- IV. Stereological Procedure.- 1. General Stereological Model.- 2. Morphological Criteria.- 3. Sampling.- 4. Multistage Sampling.- 5. Test Systems (Point and/or Line Sets).- 6. Stereological Model of the Prostatic Gland.- V. Stereological Calculations.- 1. Level I.- 2. Level II.- 3. Level III.- 4. Absolute Values.- C. Ventral Prostatic Lobe of the Rat.- I. Light-Microscopic Analysis.- II. Ultrastructural Findings.- III. Stereological Data.- IV. Experimental Applications on the Ventral Prostatic Lobe.- V. Discussion of the Experimental Applications.- D. Dog Prostate (Normal and Spontaneous Hyperplasia).- I. Light-Microscopic Analysis.- II. Electron Microscopy.- III. Stereological Analysis.- E. Human Prostate.- I. Materials.- 1. Normal Human Prostate.- 2. Benign Prostatic Hyperplasia.- II. Results.- 1. Light-Microscopic Analysis.- 2. Ultrastructural Findings.- 3. Ultrastructural-Microscopic Analysis.- F. Epididymis.- I. Stereological Model.- II. Epididymal Head of the Rat.- III. Experimental Applications.- IV. Discussion of the Experimental Applications.- G. Conclusion and Outlook.- References.- Etiology of Fertility Disturbances in Man.- A. Introduction.- B. Primary Testicular Failure.- I. Genetic Abnormalities.- 1. Sertoli-Cell-Only Syndrome.- 2. Maturation Arrest.- 3. Structural Defects of Spermatozoa.- II. Chromosomal Abnormalities.- 1. Additional X Chromosomes (Klinefelter’s Syndrome).- 2. Additional Y Chromosomes and Y Chromosome Abnormalities.- 3. Noonan’s Syndrome (Male Turner’s Syndrome).- 4. Autosomal Abnormalities and Translocations.- III. Developmental Abnormalities.- 1. Congenital Anorchism.- 2. Cryptorchidism.- 3. Intersexuality.- IV. Defective Androgenization.- 1. Inadequate Androgen Synthesis.- 2. Inadequate Androgen Utilization (Androgen Insensitivity) 180 V. Acquired “Primary” Testicular Failure.- C. Secondary Testicular Failure.- I. Hypothalamic Failure.- II. Pituitary Failure.- D. Extratesticular Disturbances of Male Fertility.- I. Infections.- 1. Gonorrhea.- 2. Tuberculosis.- 3. Smallpox.- 4. Viral Infections.- 5. T Mycoplasma Infections.- 6. Trichomonas vaginalis.- 7. Candida albicans.- 8. Reiter’s Syndrome.- II. Stress.- III. Radiation.- IV. Drugs.- V. Ejaculatory Problems.- 1. Anorgasmy.- 2. Retrograde Ejaculation.- References.- Male Fertility Disorders — History and Clinical Examination.- A. History.- I. Past History.- II. Sexual History.- III. Drug History.- IV. Urinary Symptoms.- B. Clinical Examination.- I. Genital Tract.- II. General Examination.- 1. Typical Alterations of Physical Habit with Related Disorders of Spermatogenesis.- a) Early (Prepubertal) Castration.- b) Late (Postpubertal) Castration.- c) Congenital Hypogonadism: Werner’s Syndrome.- d) Rothmund’s Syndrome.- e) Lawrence-Moon-Biedel Syndrome.- 0 Prader-Labhardt-Willi Syndrome.- g) Klinefelter’s Syndrome.- h) “Pseudo-”Klinefelter’s Syndrome.- References.- Semen Analysis.- A. Introduction.- B. Collection of the Ejaculate.- C. Sexual Abstinence Before Collection of the Ejaculate.- D. Examination of the Ejaculate.- I. Coagulation and Liquefaction.- II. Volume.- III. Biochemical Analysis.- E. Microscopic Examination.- I. Motility.- II. Count.- III. Morphology.- IV. Supravital Staining.- F. Normal Values.- G. Outlook.- References.- Testicular Biopsy.- A. Introduction.- B. Technique.- C. Histologic Evaluation of the Testicular Biopsy.- References.- Radiologic Investigation of Male Fertility Disorders.- A. Demonstration of Patency in the Spermatic Tract.- I. Indications.- II. Technique.- III. Complications.- B. Imaging of Glandular Structures.- C. Assessment of Urethral Abnormalities.- D. Phlebography of Varicoceles.- References.- Endocrine Evalution of Male Fertility Disorders.- A. Introduction.- B. Hormone Base Levels.- I. Testosterone.- II. Prolactin.- III. Follicle-Stimulating Hormone (FSH).- IV. Luteinizing Hormone (LH).- C. Dynamic Tests.- I. Clomiphene Citrate Test.- II. GNRH Test.- III. Human Chorionic Gonadotropin (HCG) Test.- D. Usefulness of Hormonal Tests for Selection of Patients for Gonadotropin Therapy.- References.- Neurology of Male Fertility Disorders.- A. Anatomic and Physiologic Basis.- I. Spinal Centers Involved in Genital Function.- II. Peripheral Innervation of the Genitalia.- III. Genital Function: Erection, Emission and Ejaculation, Orgasm.- 1. Erection.- 2. Emission.- 3. Ejaculation.- 4. Orgasm.- 5. Synopsis: Sexual Function and Spinal Segments.- IV. Centripetal Spinal Pathways of Genital Function.- V. Centrifugal Spinal Pathways of Genital Function.- VI. Pathways Connecting Spinal Centers.- VII. Genital Function and the Brain.- B. Neurologic Disturbances of Genital Function.- I. Spinal Transections and Their Significance for the Function of the Genital Organs.- 1. General Considerations on Spinal Transection: the Phase of Spinal Areflexia and the Phase of Increased Reflex Activity.- 2. Destruction of the Lumbar Sympathetic Centers (L2–4).- 3. Destruction of the Sacral Parasympathetic Centers (S2–4).- 4. Cauda Equina Lesions.- 5. Supralumbar Cord Lesions.- II. Peripheral Nerve Lesions and Genital Function.- III. Cerebral Causes of Impotence.- C. Neurologic Assessment.- I. History.- 1. Interpretation of the History.- II. Neurologic Status.- 1. Important Intrinsic Reflexes Bearing on Neurologic Fertility Disorders, According to Segmental Level.- 2. Chief Extrinsic Reflexes of Importance for the Neurologic Aspects of Fertility, According to Spinal Segments.- III. Special Investigations.- D. Synopsis of Neurologic Disturbances of Potency.- I. Synopsis According to Functional Impairment.- 1. Absence of Libido.- 2. Total Impotence.- 3. Impotentia Generandi.- 4. Impotentia Coeundi.- 5. Erection.- 6. Absence of Psychogenic Erection in the Presence of Reflex Erection.- 7. Absence of Psychogenic and Reflex Erections.- 8. Priapism (Semierection).- 9. Ejaculation.- 10. Absence of Ejaculation or Disordered Ejaculation (Dripping) with or without Disturbance of Erection (Pollutio Flaccida).- 11. Absence of Ejaculation in the Presence of Reflex Erection.- 12. Retrograde Ejaculation.- 13. Anorgasmia.- II. Synopsis According to Localization in the Central or Peripheral Nervous Systems.- 1. Cerebral Lesions.- 2. Supralumbar Spinal Transection.- 3. Lumbar Transection Involving the Sympathetic Genital Centers L2–4.- 4. Lesions of the Sacral Automic Center S2–5.- a) Conus Syndrome (S3–5 and Coccygeal Segment Cocc. 1).- b) Epiconus Syndrome (L4–5 and S1–2).- 5. Cauda Equina Syndrome (Below Vertebral Level L1/2).- 6. Peripheral Paralysis.- References.- Immunologic Causes of Male Fertility Disorders.- A. Antigenicity.- I. Blood Group Antigens in Seminal Fluid.- II. Antigenic Fractions of Seminal Fluid.- III. Antigens of Spermatozoa.- IV. Antigenic Properties of the Testes.- V. Allergic Orchitis.- VI. Antigenic Properties of the Seminal Vesicles.- VII. Antigenic Properties of the Prostate.- B. Antibodies in Male Fertility Disorders.- I. Humoral Antibodies.- II. Cellular Antibodies.- C. Diagnosis of Immunologic Fertility Disorders.- I. Sperm Agglutination Tests.- 1. Antisperm Antibodies Assay: Gelatin Agglutination Test (GAT) (Kibrick).- 2. Microscopic Sperm Agglutination Test.- II. Immobilization Tests.- III. Cytotoxin Tests.- IV. Immunofluorescence.- D. Generation of Antibodies.- I. Testes as Portal of Entry for Sperm Autoantigens.- II. Epididymis as Portal of Entry for Sperm Autoantigens.- III. Sperm Autoantigens Entering via the Seminal Vesicles and the Prostate.- E. Vasectomy and Sperm Antibodies.- I. Clinical Significance of Sperm Antibodies for Male Fertility.- F. Treatment of Immunologic Fertility Disorders in Men.- References.- Treatment of Male Infertility.- A. Hormonal Treatment of Male Infertility.- I. Gonadotropin-Releasing Hormone (GnRH).- II. Human Gonadotropins.- 1. Human Chorionic Gonadotropin (HCG).- 2. Human Menopausal Gonadotropin (HMG/HCG Therapy).- III. Prolactin Inhibitors.- IV. Androgens.- 1. Androgen Replacement Therapy.- 2. Androgens as Contraceptive Agents.- 3. Androgens as Spermatogenetic Agents.- V. Antiestrogens.- 1. Clomiphene Citrate.- 2. Tamoxifen.- VI. Various Hormonal Compounds.- B. Nonhormonal Treatment of Male Infertility (Excluding Surgical Interventions).- I. General Measures.- II. Split Ejaculate.- III. In Vitro Treatment of the Ejaculate.- 1. Problem: High Viscosity.- 2. Problem: Nonliquification of the Ejaculate.- 3. Problem: Contamination of the Ejaculate with “Debris”.- 4. Problem: Asthenospermia.- IV. Antibiotic Treatment.- V. Various Compounds.- References.- Operative Therapy of Male Infertility.- A. Varicocele.- I. Methods of Treatment.- 1. The Ivanissevich Technique.- 2. Palomo Technique.- 3. High Ligature of the Vena Spermatica.- II. Complications.- B. Vas-Epididymis Anastomosis.- I. Indications.- II. Etiology.- 1. Congenital Anomalies.- 2. Infections.- 3. Cystic Changes.- 4. Trauma.- III. Diagnosis.- IV. Surgical Technique.- V. Postoperative Care.- C. Artificial Spermaele.- D. Vas-Vas Anastomosis.- I. Problems.- 1. Reversibility.- 2. Frequency of Sperm-Immobilizing and Sperm-Agglutinating Antibodies After Vasectomy.- II. Immunologic Considerations.- III. Technique.- 1. Schoysman Technique (1976).- 2. Schmidt Techniques.- 3. Silber Technique.- 4. Friek Technique.- IV. Complications.- V. Results.- References.- Artificial Insemination and Semen Preservation.- A. Artificial Homologous Insemination.- I. Indications.- 1. Female Indications.- 2. Male Indications.- II. Timing of Insemination.- III. Technique.- IV. Results of Artificial Homologous Insemination.- B. Artificial Donor Insemination.- I. Indications for AID.- II. Selection of Donors.- III. Technique of Insemination.- IV. Results of AID.- V. Legal Aspects of AID.- C. Semen Preservation.- References.- Male Contraception.- A. Introduction.- B. The Need for Fertility Control.- C. Different Methods of Male Fertility Control.- I. Coitus Interruptus.- 1. Side Effects.- 2. Extent of Use.- II. Condom.- 1. Failure Rate.- 2. Side Effects.- III. Vasectomy.- 1. General Comments.- 2. Factors to be Considered Before Vasectomy is Performed.- a) Reversibility.- b) Frequency of Sperm-Immobilizing and Sperm-Agglutinating Antibodies After Vasectomy.- 3. Information to be Given to Patients and Preliminary Examinations.- 4. Surgical Technique.- 5. Complications.- 6. Side Effects.- IV. New Concepts in Vas Occlusion and Vasectomy.- 1. Occlusion by a Filament.- a) Procedure for Insertion.- b) Clinical Studies.- 2. Reversible Intravasal Device (R-IVD).- 3. Plugging of the Vas.- a) Technique.- b) Results.- 4. Reversible Intravasal Occlusive Device (RIOD).- 5. Spermatozoa Controller (SPACER).- 6. Injection of Sclerosing Chemicals.- 7. A Possible Reversible Vasectomy Procedure (Frick).- a) Technique.- b) Results.- V. Pharmacologic Male Contraception.- 1. Steroidal Effects on Spermatogenesis.- a) Orally Administered Steroids.- b) Steroid Implants.- c) Other Pharmacologic Methods of Sperm Suppression.- 2. Side Effects in all Studies of Sperm Suppression Reviewed.- a) Studies with TE only in Different Regimens.- b) Studies with Estrogen and Testosterone in Combination.- c) Studies with Progestins Alone or in Combination with Androgen.- D. New Aspects for the Future.- References.- Impotence.- A. Abnormalities of Erection.- I. Congenital Abnormalities of the Penis Interfering with Erection.- 1. Epispadias.- 2. Phimosis.- II. Acquired Abnormalities of the Penis Associated with Impotence.- 1. Peyronie’s Disease (Induratio Penis Plastica).- 2. Abnormal Erection Following Priapism.- 3. Posttraumatic Change in the Penis.- 4. Impotence Following Pelvic Fracture.- III. Vascular Causes of Impotence.- IV. Diabetes Mellitus and Disorders of Erection.- V. Drugs, Poisons, and Disorders of Erection.- VI. Blood Pressure and Impotence.- B. Abnormalities of Ejaculation.- I. Premature Ejaculation.- II. Failure of Emission.- III. Retrograde Ejaculation.- References.- Functional Sexual Disorders in the Male.- References.- Male Climacteric?.- A. Introduction.- B. Diagnosis and Management.- References.
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