Future Infertility Not an Absolute For Pediatric Patients

Infertility should not be assumed for all male pediatric patients with urologic problems, suggested a panel of speakers at the 2001 annual meeting of American Urological Association (AUA) in Anaheim, California.

Dr. James Mandell moderated a plenary discussion panel that included Dr. Peter Lee, Dr. R. Lawrence Kroovand, Dr. Barry A. Kogan, and Dr. Stuart B. Bauer, all specialists in the field of pediatric urologic disorders.

Kroovand discussed varicocele, a common problem that occurs in about 10% of all males. To date, there has been little follow-up on varicocele treatment in children and fertility of these patients later in life.

“Most adult studies have been retrospective, looking at patients who are infertile, studying how many of them had varicocele, and then making comparative assumptions to normal findings,” Mandell stated.

There is a lot of difficulty in diagnosing varicocele in pediatric patients, said Kroovand. “You can’t ask them about their sexual and paternal history because they do not have one. There are also complications in obtaining semen samples from this population.”

Studies have demonstrated that varicocele repair can improve outcomes in adult patients. Kroovand suggested that if varicocele is diagnosed in adolescent patients, surgical repair should be offered, but he thinks, overall, more research is needed in this area.

Kogan discussed fertility in patients with Prune Belly Syndrome, a condition in which the abdominal muscle is deficient, the testes are undescended, the bladder is large, hypotonic, and dilated, and tortuous ureters. Although no natural paternity has been reported in a patient with Prune Belly Syndrome, the potential does exist for these patients to father children.

His research has shown that germ cells are present in the testicular tissue of fetuses with Prune Bell Syndrome. The data were obtained from pregnancies that had been terminated. He noted that viable sperm have been obtained from adult patients with this syndrome.

“Fertility is possible for these patients with modern fertility techniques,” concluded Kogan. “We should try to help these children early on so that they have the potential later in life.”

Lee discussed the relationship between long-term paternity with regard to patients with undescended testes (cryptorchism), the manner in which these patients were treated for their condition, and their age at treatment. His data showed that unilateral cryptorchid patients had fertility potential similar to normal controls. Bilateral cryptorchid patients showed reduced fertility, but fertility was possible in approximately two-thirds of them.

There were no significant differences in levels of fertility in patients that were treated at different ages, Lee reported. Orchiopexy did improve outcomes in patients, he said.

Bauer discussed infertility in males with a history of post-urethral valves (PUV). “Very little is known about post-urethral valves and subsequent fertility today,” he said in an interview with NewsRx. “Most of the work that has been done today results from patients that were evaluated and diagnosed before the prenatal ultrasound era. In these cases, most cases of PUV were not detected until well after birth and these patients generally had more severe forms of PUV obstruction.”

More severe PUV obstruction leads to problems with bladder function, incontinence, and infertility, he reported. Fortunately, most males today with PUV are diagnosed prenatally because of the widespread use of prenatal ultrasound. Prenatal ultrasound is capable of diagnosing even the minor forms of valve obstruction, leading to earlier treatment and less pronounced long-term effects of this disorder on the lower urinary tract.

“There are numerous causes of infertility in males with PUV. They stem from problems with undescended testicles, chronic renal failure because of the pronounced affects of these valves, structural abnormalities of the urinary tract, and injury to the genital organs during the time of ablation of the valves,” Bauer continued. “There is about a 25% incidence of end-stage renal disease in males with PUV that have been followed long-term. Most of the cases of end-stage renal disease occur after the onset of puberty.”

Bauer concluded: “The most important aspect of my talk today is that there should be early recognition and treatment of boys with PUV. If a general practitioner, obstetrician, or pediatrician learns of a fetus with a dilated urinary tract and/or bilateral swelling of both kidneys, that infant should be immediately referred to a pediatric urologic specialist. If I could drive home one message, it would be that if we diagnose these babies early, we can help preserve their future fertility capabilities, prevent urinary incontinence, and help maintain their renal function as they reach adulthood.

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