Management

Empirical Treatment of Idiopathic Infertility

• Drug therapy for idiopathic infertility
  • Human menopausal gonadotropin (hMG) (Pergonal), essentially FSH; human chorionic gonadotropin (hCG) (APL), essentially LH; or the combination of hMG and hCG
    • Has not resulted in significant improvement in sperm counts in idiopathic infertility
    • Associated with significantly higher pregnancy rates in various studies
    • GnRH therapy, when given in a pulsatile fashion, has the potential to raise LH and FSH levels, but administration is complex and costly
  • Testosterone rebound
    • Complete suppression of spermatogenesis with exogenous testosterone followed by discontinuation of therapy after the patient's sperm counts have been reduced to zero
    • It is hoped that the recovery of spermatogenesis will be greater than it was prior to therapy. However, there is no physiologic basis for this finding and it has been therapeutically abandoned.
  • Clomiphene citrate (antiestrogen)
    • Men with low-normal testosterone and FSH levels may be the best responders to this therapy
  • Tamoxifen (antiestrogen)
    • This agent lacks the estrogenic activities of clomiphene and may provide equal efficacy
  • Kallikreins
    • Presently, the compound is not available in the United States
  • t.-Carnitine
    • Oral L-carnitine is currently being evaluated in a multicenter, randomized study to evaluate its possible beneficial effect on sperm motility
• Assisted reproductive techniques (ART)
  • Sperm processing and insemination of the female or manipulation of the sperm and ova extracorporeally; In vitro or in vivo
  • Intrauterine insemination (IUI) can be used to treat male factor infertility
  • IVF
  • Gamete intrafallopian transfer (GIFT)
    • Zygote intrafallopian transfer (ZIFT)
    • Pronuclear stage tuba] transfer (PROUST)
    • Tubal embryo transfer (TET) or tubal embryo stage transfer (TEST)
    • Given the recent success of IVF and ICSI, the role of adding tubal transfer to IVF has undergone serious reexamination
  • Micromanipulation
    • Sperm and oocyte micromanipulation by intracytoplasmic sperm injection (ICSI)
      • IVF with ICSI should not be performed without karyotype analysis on both partners

References

• Bonduelle M, Wilikens A, Buysse A, et al: Prospective follow-up study of 877 children born after intracytoplasmic sperm injection (ICSI), with ejaculated epididymal and testicular spermatozoa and after replacement of cryopreserved embryos obtained after ICSI. Hum Reprod (suppl) 4:131-155; discussion 156-159, 1996.
• Mulhall 7P, Reijo R, Alagappan R, et al: Azoospermic men with deletion of the DAZ gene cluster are capable of completing spermatogenesis: Fertilization, normal embryonic development and pregnancy occur when retrieved testicular spermatozoa are used for intracytoplasmic sperm injection. Hum Reprod, 12:503-508, 1997.
• Parinaud J, Le Lannou D, Vieitez G, Griveau JF, Milhet P, Richoilley G: Enhancement of motility by treating spermatozoa with an antioxidant solution (Sperm-Fit) following ejaculation. Hum Reprod 12:2434-2436, 1997.
• Reijo R, Alagappan RK, Patrizio P, Page DC: Severe oligospermia resulting from deletions of azoospermia factor gene on Y chromosome. Lancet 347:1290-1293,1996.
• Rolf C, Cooper TG, Yeung CH, Nieschlag E: Antioxidant treatment of patients with asthenozoospermia or moderate oligoasthenozoospermia with highdose vitamin C and vitamin E: A randomized, placebo-controlled, doubleblind study. Hum Reprod 14:1028-1033, 1999.
• Schlegel PN, Chang TSK: Physiology of male reproduction. In: Walsh PC, Retik A, Vaughan ED Jr., Wein A, eds. Campbell's Urology, 7th ed. Philadelphia, Saunders, 1998, pp 1254-1286.
• Sigman M, Howards SS: Male infertility. In: Walsh PC, Retik A, Vaughan ED Jr., Wein A, eds. Campbell's Urology, 7th ed. Philadelphia, Saunders, 1998, pp 1287-1330.
• Sigman M, Jarow JP: Endocrine evaluation of infertile men. Urology 50:659-664, 1997.