Specific Medical Treatments

Infection

Semen cultures, urine cultures, and cultures of expressed prostatic secretions are indicated in the presence of leukospermia. In patients who demonstrate symptoms referable to the genitourinary tract or sperm agglutination, cultures are obtained after the penis, scrotum, and perineum have been cleansed with an antibacterial scrub as previously described. If cultures are positive, treatment should employ an agent to which the cultured organism is sensitive and that has no effect on spermatogenesis but good genitourinary penetration. Antibiotics with such a profile include the fluoroquinolones and tetracyclines. In the absence of a positive culture but with a high clinical suspicion of infection we employ empiric fluoroquinolone or tetracycline therapy for 3-6 weeks, treating both partners.

Antisperm Antibodies

Our approach to the management of patients with antisperm antibodies is to identify and treat the underlying problem, ie, repair the obstruction or varicocele. If this is not successful, we initiate treatment with 20 mg of prednisone twice daily days 1-10 of the wives' cycle and 5 mg on days 11 and 12 for 3 months. Following this treatment course we reevaluate -for the presence of antibodies. Aseptic necrosis of the femoral head is the most devastating complication of steroid therapy (1 % incidence), although this is uncommon with short term (< 6 months), intermittent (12 days/month) therapy. We now recommend IVF with ICSI which is very successful for severe antibody problems.

Hypogonadotropic Hypogonadism

This condition is due to the lack of the hypothalamic decapeptide gonadotropin-releasing hormone (GnRH), When associated with midline defects such as anosmia, it is called Kallmann's syndrome. Very low or undetectable serum levels of LH, FSH and T in a prepubertal appearing adult confirms the diagnosis. Treatment for the development of secondary sexual characteristics and maintenance of libido is Depo-Testosterone. For induction of spermatogenesis, the Depo-Testosterone is discontinued. Human chorionic gonadotropin (hCG) 1500 IU 3 times weekly is begun. After 3-6 months of hCG therapy, when serum T,Ievels are in the normal range, human menopausal gonadotropin (hMG) 25-75 IU 3 times weekly is added. Sperm usually begin to appear in the ejaculate 6-18 months after initiation of therapy. Testis size and sperm counts remain lower than normal, but pregnancies occur regularly with sperm densities in the 2-6 million per mL range. Men who fail to respond to gonadotropin replacement may respond to pulsatile administration of GnRH by pump.

Normogonadotropic Hypogonadism

These patients have low sperm counts and normal levels of FSH and LH, but a low serum T. Before treatment, a prolaebou should be obtained to rule out a pituitary tumor. In these men clomiphene citrate 25 mg daily (1/2 tab) blocks the negative feedback inhibition of estrogen to the pituitary increasing LH and FSH release and subsequently increasing serum T and improving sperm densities. Semen parameters improve in 94% of men with 40% pregnancy rate achieved. Serum T, estradiol, and a semen analysis are obtained every 3 months. Failure to respond may be attributable to over- or understimulation. If posttreatment testosterone levels remain low, increase the dose to 50 mg daily. If levels exceed 1000 ng/dL and/or estradiol levels exceed 60 ng/L, reduce the dose by 50%. We have observed nonbacterial pyospermia develop in 17% of previously nonpyospermic clomiphene citrate-treated men. As no clomiphene-treated man who has developed pyospermia has contributed to a pregnancy, we serially monitor semen analyses for its development.

Retrograde Ejaculation

Retrograde ejaculation is associated with a diminished volume or complete lack of seminal emission, and is often the first symptom of diabetes mellitus. The diagnosis may be confirmed by microscopic examination of a postejaculation urine specimen. Pseudoephedrine (Sudafed) 120 mg 3 times daily will convert approximately 25% of men to antegrade ejaculation. Ejaculation with a full bladder is sometimes helpful. A full bladder stimulates increased a-adrenergic activity at the bladder neck. If these measures fail, the urine may be alkalinized and the sperm from the postejaculate urine retrieved, processed, and used for IUI or IVF with ICSI.