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.

Review of “Sperm-Bank Baby”

I had looked forward to Sperm-Bank Baby, if only to honor the only living legend I have ever come on. He was a research scientist at Aberystwyth, who, intrigued by stories of Russian scientists whose wives conceived after their husbands’ deaths, solemnly presented his wife with a wedding present of a quarter pint of his own semen. They kept it in a fridge in the zoology lab. But those of you with a scientific bent will appreciate the lengths to which this heroic man went. It took him two months and he went down the aisle looking like the moon at mid-day.

But science has advanced since then. The donor in the film – he was known only as Donor 28 Red – looked sprightly enough, or rather his jeans and Cuban heels did, and the hand holding the phone did not shake. That was all we saw, and the cameraman loved it, trickling from wrist to boot and back again. There was an unpleasant archness about the photography. Donor 28 Red had been traced by Des but would not appear. His mother, he said, wouldn’t like it.

The danger of this film was that it nevertheless showed so many kooks that it could have floated away. There was one donor who was filmed and said that it had been a logical progression from donating blood; his name was Bliss. And the man who actually ran the sperm bank travelled round in a windowless van full of pedigree Border collies, and semen.

It was his job to contact the sperm donor, check him into a hotel room, and wait ‘while he goes up and does his bit’; the camera lingered on a plastic cup. Wilcox soft-pedalled on this side of things, so central to the enterprise. What do they think about then? Are there props or just memories? Is it interesting work? What sort of hours do they keep?

But what made the film was the woman herself, a real human being at last. She was nice and sad, and her predicament, of loneliness and middle age, very touching. She even had a sense of humor, as when she confessed to falling in love with Donor 28 Red’s curriculum vitae. Because of her you could even put up with Wilcox. ‘No Daddy for Doran,’ he said heavily. But the worst thing about him is the way he is not prepared to let a sentence go. ‘Do you feel you’re part of a changing pattern in mankind – grandiose though it sounds?’ He loves his purring vowels.

Then the lady spoilt it by inviting Des and the boys in to film the build-up to the act: much chanting and candlesticks. With great tact they withdrew before the water-pistol was brandished, Des allowing himself one close-of-play report: ‘As yet there is no confirmation of Afton’s pregnancy.’
In the New Year he will be back ‘with six months in the life of a young couple from Wales’. Oh God, perhaps it’s Neil and Glenys. Perhaps Wilcox was there that afternoon in the vasectomy clinic. God save us all, said Tiny Tim.

Ten Years On – Hope Fades; Infertility

Infertility remains one of society’s most miserable afflictions. Ten years ago the birth of Louise Brown, the world’s first test-tube baby, brought hope to thousands of previously barren marriages. A tidal wave of subsequent advances reinforced the notion that such problems would soon be a thing of the past.

Yet treatment remains patchy, lengthy, costly, and offers a disappointingly low success rate. And of equal importance to most of those concerned it is rarely available on the National Health Service.

Ten per cent of couples fail to conceive after a year of unprotected intercourse. One half of this group may never conceive. The experience of raising a family continues to be a tantalizing dream.

A recent report by the Greater London Association of Community Health Councils highlights the problem. Its questionnaire to the 476 London hospitals showed that, although there are 22 specialist infertility clinics in the capital, the majority of cases are handled by over-stretched general gynaecology departments. Some couples wait a year even for an initial appointment.

The study showed poor co-ordination between GPs, specialists and patients. The quality of routine services eventually received was often poor. Little attempt was made to monitor either the cost of treatment or its outcome.

In today’s cash-conscious NHS, there is little enthusiasm for investing resources to alleviate a condition from which nobody dies (though it has certainly led to a handful of suicides). “We have many demands on our budget, which is already overstretched. There is virtually nothing left over for the new and non-urgent,” one associate general manager said recently.
One of the most common causes of infertility is blocked fallopian tubes, where an in-vitro (or “test-tube”) fertilization is often the only hope of achieving a pregnancy. Of the 30 centers in this country offering IVF, only one hospital, in Manchester, is fully funded by the NHS.

A promising new technique for tackling unexplained infertility known as gamete intra-fallopian transfer, or GIFT, where the egg and sperm are placed in the tubes together is also being developed. But that too is unlikely to be made available quickly or cheaply.

Advanced technology is little use without expert back-up, and that too is in short supply. One center this year had to discontinue its IVF program completely, partly because the hospital’s overburdened laboratory could not guarantee semen analysis facilities.

For many desperate couples, “going private” offers the only realistic hope. But this inevitably means hardship for all but the seriously rich. And then the chances of success are small. For four out of five couples, the arduous road will end in heartbreak.

The Voluntary Licensing Authority for Human In-Vitro Fertilization and Embryology, set up after the Warnock report in 1984, admits that “treatment continues to be determined largely by a couple’s financial resources”. It is hard to accept that, for the majority, finance should rule out even the slimmest chance of having a child.

One third of fertility problems can be traced to the would-be mother, one third to the father and the final third to both partners combined. The treatment of male infertility is even less satisfactory than the female kind. Although research is progressing rapidly, male-factor deficiency most frequently forces the couple to resort to artificial sperm insemination by donor (AID). Although the resulting pregnancy may well produce the child they long for, it may also initiate psychological problems.

Why are the treatment and research resources so stingily rationed? It can’t simply be because the techniques are new. Coronary artery bypass grafting was revolutionary at its inception. Now it is a widely accepted and safe procedure. Will IVF and the newer procedures be as successful in 10 years? The simple answer is: without increased investment, no.

Some might argue that there are already too many babies being born on our planet. Should we be setting aside scarce cash to create even more? It is easy to stand back and say no. But if there is technology available to give even the smallest chance of a yearned-for baby, what right has anyone to deny it?

The problem is not just financing the technology: there are not enough specialists to administer the treatment, and no generally-accepted formula for establishing how many are needed. The best guess, by the Royal College of Obstetricians & Gynaecologists, is that nearly twice as many consultants as are now available would be needed to meet all the needs that arise in childbirth. The government’s current policy is to fund enough “pump priming” posts to expand the number of consultants by 2% a year. But no such posts have yet been established in obstetrics.

“The government is paying lip service to the concepts of consultant expansion,” says James Drice, senior lecturer in obstetrics and gynaecology at Leicester University Medical School. “What does a 2% expansion rate mean to the two or three consultant gynaecologists in a district general hospital who are struggling to cope with their existing work? Absolutely nothing.”

The Department of Health will publish its white paper on the future of the NHS early next year. A consultant gynaecologist recently observed that the service “is supposed to provide care from the cradle to the grave. At the moment, this excludes the infertile, who cannot even get to the cradle-side”.