Management of the infertile males is composed of general treatment, medical treatment, surgical treatment, and therapeutic or artificial insemination. A total of 1,842 patients (52%) out of the entire infertile males (3,520 patients) were submitted to various treatments and were followed for more than 1 year.
Medical treatment:
Medical treatment was attempted to the 723 infertile males. They were divided into a normogonadotropic oligozoospermia group consisting of 503 patients with sperm density of less than 20×106/ml, an asthenozoosptropicermia group consisting of 48 patients with sperm motility of less than 30% and a hypogonadism group including 172 patients with 150 hypogonadotropic hypogonadisms and 22 normogonadotropic hypogonadisms (Table 1). Duration of medical treatments ranged from 1 course to 8 courses with the mean of 2 courses. One courses consists of 3 months of continued administration of drugs. Responsiveness to the treatment are evaluated in the following arbitrary manner. That is, improvement represents sperm counts and motility improved more than 20% of the pre-treatment baseline values. Pregnancy represents only the first pregnancy after the treatment in each pregnant woman. Semen quality improved in 28% ranging from 16% (by triiodothyronine) to 31% (by mesterolone and puberogen(HCG) plus amino acids). Pregnancy induced in 14% ranging from 5% (by clomiphene) to 19% (by puberogen(HCG) and peamex(HMG) combinations) (Table 2) in normogonadotropic oligozoospermia group, semen quality improved in 34% and pregnancy occurred in 20% of the patients. In asthenozoospermia group, semen quality improved in 17% and pregnancy occurred in 4% of the patients. Sperm could be found in 6% and pregnancy resulted in 1% of the hypogonadotropic hypogonadism and sperm in 45% and pregnancy in 9% in normogonadotropic hypogonadism with small tests after the long-term combined hormonal treatment of HCG and HMG (Table 1). Similar results were obtained by Sherin´s summary report (1986) that semen improved in 34% and pregnancy resulted in 18% of the 2,307 patients who were treated with 8 different drugs. Nishimura (1979) reported that semen improved in 36% and pregnancy occurred in 7% of the patients after medical treatments (Table 3).
Surgical treatment:
Surgical treatment was applied to the 980 infertile males utilizing various surgical procedures. They were divided into 699 vasovasostomy group, 281 epididymovasostomy group, 57 varicocelectomy group, and 82 andrologic operation group (Table 4).
Vasovasostomy group: In the 699 patients who were operated for reversal of post-vasectomy azoospermias, 329 patients were operated by conventional or macrosurgical technique and the remaining 370 patients were done by microsurgical technique. Duration of obstruction ranged from 1 day to 16 years with the mean of 4.2 years. Reasons for requesting the reversal operation were remarriage in 289 patients, death of children in 250 patients, change of attitute in 119 patients, and psychological problems after vasectomy in 31 patients. A total of 624 patients out of the 699 were followed for more than 1 year. Better results were obtained in shorter duration of obstruction, bilateral straight vas-to-straight vas anastomosis, bilateral leakages of spermatic fluids with sperm from proximal vas end. Results of end-to-end anastomosis technique were similar to the side-to-side technique in macrosurgery and those of two-layer technique were also similar to full-thickness technique in microsurgery. Success rates were 84% for patency and 35% for pregnancy in the 300 macrosurgeries and 90% for patency and 51% for pregnancy in the 324 microsurgeries.
Epididymovasostomy group: One-hundred and 69 patients out of the 281 patients with azoospermia due to inflammatory epididymal obstruction were operated under a surgical microscope and the remaining 112 patients were done by a conventional technique. A total of 255 out of the 281 were followed for more than 1 year. Suspected causes of the obstruction were nontuberculous epididymitis in 179 patients, tuberculous epididymitis in 91 patients, and injury of scrotal contents in 11 patients (33 cases of bilateral agenesis of vas deferens were excluded). Success rates were found to be better in patients with nontuberculous epididymitis than tuberculous epididymitis. There were no significant differences among the anastomosis levels of epididymal window. Consequently, success rates were 31% for patency and 12% for pregnancy in the 97 macrosurgeries, and 37% for patency and 20% for pregnancy in the 158 microsurgeries.
Varicocelectomy group: A total og 57 infertile patients with left-sided varicocele were investigated in our Department. After the varicocelectomy by high ligation of internal spermatic veins, spermiogram improved in 30% and pregnancy occurred in 20% of the 51 patients, but pregnancy resulted in 2 patients out of 6 patients with varicocele without varicocelectomy (33%).
Andrologic operation group: Various operations were performed on 82 patients. Hydrocelectomy for 20 patients with hydrocele, urethroplasty for 5 hypospadias and for 7 patients with urethral injuries, orchidopexy for 17 patients with cryptorchilism, and exploration of scrotal contents for 33 patients with congenital vas agenesis. Results of these plastic surgeries were found to be fairly good.
Alloplastic spermatocele: Patients who are infertile because of congenital absence of the vasa or anejaculation after retroperitoneal operation have been a special problem. Attempts at construction of artificial spermatoceles with grafts of corrugated polytetrafluoroethylene are promising. The graft is sutured to a distal epididymal window and brought laterally into a dartos pouch. Sperm were obtained by aspiration of the spermatocele, and used for artificial insemination. But successful inseminations were very limited.
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