Timing of the surgical repair of undescended testicules

For many years there has been debate among pediatric urologists regarding the timing of the repair of undescended testicules. A prospective, randomized study by Kollin and colleagues addressed this issue. Patients were randomized to surgery at 9 months (72 patients) or 3 years (83 patients) and testicular volume was measured by ultrasonography at ages 6, 12, 24, 39, and 48 months. The ultrasound volume results demonstrated that surgical treatment at 9 months resulted in partial catch-up of testicular growth until at least age 4 years, indicating that early surgery had a beneficial effect on testicular growth. Although testicular growth per se does not predict ultimate fertility, this study provides at least indirect evidence that earlier orchiopexy may be beneficial.

Cryptorchidism and testicular cancer

Wood and Elder performed a Medline search to provide recommendations concerning the optimum management of cryptochidsm in relation to the development of testicular cancer. They reported that a relative risk of testicular cancer in a cryptorchid case is 2.75 to 8.0. A relative risk of 2 to 3 occurs in patients who undergo orchiopexy by age 12. Patients who undergo orchiopexy after age 12 are 2 to 6 times as likely to have testicular cancer as those who undergo prepubertal orchiopexy. The investigators further reported that a contralateral, normally descended testis in patients with crytorchidsm carries no increased risk of testis cancer.

Cryptorchidism and testicular cancer

Wood and Elder performed a Medline search to provide recommendations concerning the optimum management of cryptochidsm in relation to the development of testicular cancer. They reported that a relative risk of testicular cancer in a cryptorchid case is 2.75 to 8.0. A relative risk of 2 to 3 occurs in patients who undergo orchiopexy by age 12. Patients who undergo orchiopexy after age 12 are 2 to 6 times as likely to have testicular cancer as those who undergo prepubertal orchiopexy. The investigators further reported that a contralateral, normally descended testis in patients with crytorchidsm carries no increased risk of testis cancer.

Cryptorchidism and intracytoplasmic sperm injection

Raman and Schlegel evaluated the results of testicular sperm extraction with intracytoplasmic sperm injection (ICSI) in men with nonobstructive azoospermia associated with cryptorchidism. At their institution, they achieved successful retrieval in 35 of 47 testicular sperm extraction attempts (74%) with fertilization in 214 of 347 metaphase II oocytes (62%). Clinical pregnancies resulted for 16 of 35 cycles (46%) when sperm were retrieved, with ongoing pregnancies or deliveries in 15 of the 35 (43%). The investigators identified testicular volume and age at orchiopexy as independent predictors of sperm retrieval for men with a history of cryptorchidism.

Operative approaches for varicocelectomy

Throughout the years, urologists have debated the relative merits of the various operative approaches for varicocele repair. Al-Said and colleagues conducted a prospective randomized study comparing an open inguinal approach (92 patients), laparoscopic approach (94 patients), and a subinguinal microsurgical approach (112 patients). Operative time was significantly longer in the microscopic group and early postoperative complications were comparable in the 3 groups. There was no significant difference in pregnancy rates at 1 year among the 3 groups. Microsurgical repair was associated with no hydrocele formation, a lower incidence of recurrent varicocele, and better improvement in sperm count and motility.

Varicolectomy and intrauterine insemination success rates

Daitch and colleagues reported on 58 couples who were evaluated for infertility. The women were considered normal and all the men had varicoceles. Twenty-four of the men were left untreated and 34 underwent varicocele repair. Although the semen motility rates were not statistically different between the 2 groups, the pregnancy rate was almost double in the group that underwent varicocele ligation. The investigators speculate that functional factors not measured on routine semen analysis may affect pregnancy rates.

Intracytoplasmic sperm injection in the United States

Jain and Gupta analyzed data on ART reported to the Centers for Disease Control and Prevention to determine trends in the use of ICSI and IVF in the United States. They found that the percentage of IVF cycles with the use of ICSI increased dramatically from 11.0% to 57.5% of IVF cycles from 1995 to 2004. This occurred despite the number of cases of male factor conditions remaining stable during this period, suggesting an increasing use of ICSI for conditions other than male factor infertility.

In a related article, Meacham and colleagues estimated that the total expenditure for treating primary male infertility in 2000 was $17 million. It was anticipated that the cost would continue to escalate because there was increasing use of ARTs. Further discussion regarding the economics of male infertility was provided by Meng and colleagues. They used formal decision analysis to estimate and compare the cost-effectiveness of surgical therapy (varicocele ligation and vasectomy reversal) versus ART. Their data suggested that vasectomy reversal is as cost effective as ART if bilateral vasovasostomy can be performed. If a vasoepididymotomy is required, however, sperm retrieval and injection techniques may be more cost effective due to lower patency rates associated with vasoepididymotomy. Vasectomy reversal is more cost effective if patency rates are greater than 79%. They also found that varicocele repair is more cost effective when the postoperative pregnancy rate is greater than 14% in men with a preoperative total motile sperm count of less than 10 million sperm and greater than 45% in men with greater than 10 million total motile sperm. As health care costs continue to rise, the costs of the treatment of male infertility will come under even closer scrutiny.