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After a thorough history, physical examination, and diagnostic testing, your physician should be able to recommend treatment options. These have generally been organized into medical and surgical approaches.
MEDICAL THERAPY
Human Chorionic Gonadotropin (hCG), Menotropins (hMG), and GnRH Treatments: These agents are generally used for patients with hypogonadotropic hypogonadism, a condition which results in impaired sperm production due to a deficit in essential hormonal levels, specifically LH and FSH. Human chorionic gonadotropin (hCG) behaves much like LH, stimulating the testicular Leydig cells to produce testosterone, and thus overcome the underlying hormonal defect. Human menopausal gonadotropin (hMG) activity is similar to both LH and FSH stimulation, and it has therapeutic effects similar to hCG. GnRH therapy is also used in men with hypogonadotropic hypogonadism, and its role is to increase production of LH and FSH in the brain, thus correcting their low levels in the circulation. Use of these agents outside of the setting of hypogonadotropic hypogonadism rarely improves semen quality.
Clomiohene Citrate: This synthetic compound works primarily at the level of the brain. It binds to estrogen receptors in the hypothalamus and pituitary gland, thus preventing the inhibitory effects (negative feedback) usually exerted by the estrogens that normally bind to those same sites. Hypothalamic estrogens in the male are formed from aromatization of testosterone. Therefore, in blocking this normal estrogen-negative feedback, clomiphene citrate thus promotes GnRH secretion and, subsequently, also enhanced LH and FSH secretion. As discussed previously, these two hormones result in increased testicular production of testosterone and may improve sperm production as well.
Antioxidants: (Vitamin E and Vitamin C): These medications are used primarily to treat molecules called reactive oxygen species (ROS). ROS are normally present in semen, and at normal concentrations they serve a physiologic function. As previously discussed, they possess an extra electron which is very easily passed onto other molecules. When ROS are present at excessively high levels, their cumulative effects can result in significant damage to the sperm and other genital tract cells. These antioxidants help neutralize ROS, thus preventing their harmful effects.
Dietary Carnitine Supplements: This is an agent currently under study in the United States. Carnifine is a chemical found in high concentrations within the epididymis. Preliminary studies suggest that supplementation with carnitine may improve sperm motility. Rigorous studies are now under way to confirm or refute these findings and to better delineate which groups of patients would best benefit from this treatment.
SURGICAL THERAPY
Varicocele Ligation: The group of blood vessels which collectively provide the primary 
venous drainage from thetestis are called the pampiniform plexus. Varicoceles are dilated veins in the scrotum surrounding the testis, in other words, dilated pampiniform plexus veins. Two separate groups of veins also effectively drain blood away from the testis.
Approximately 15% of all men have varicoceles, and for most men they do not seem to impair testicular function. However, about 40% of all men presenting with fertility problems do have varicoceles, and it is generally believed that their presence, either directly or indirectly, impairs sperm production. Although the precise pathophysiologic mechanism of the varicocele effect has not been delineated, many investigators believe that a secondary increase in testicular temperature causes impaired spermatogenesis.
Whatever the cause, many studies have demonstrated that 40%-70% of men undergoing varicocele repair will have an improvement in semen quality, and about 40% will subsequently initiate a pregnancy.
Many urologists now prefer an operative approach that employs the use of an operating microscope. The use of this higher magnification better ensures preservation of important spermatic cord structures (e.g., artery and lymphatics) with effective ligation of those veins contributing to the varicocele.
Transurethral Resection of the EicculatorLDuct: As described previously, the ejaculatory duct is a structure formed after the union of the vas deferens and seminal vesicle. It is a tubular structure that proceeds through the prostate on both the right and the left to the respective prostatic portion of the urethra. It is responsible for sperm and seminal vesicle fluid transport into the prostatic urethra, the final destination of sperm prior to ejaculation.
A number of factors can cause obstruction of the ejaculatory duct, and thus block the flow of sperm. These include intrinsic problems, such as congenital narrowing or scarring due to infection, and extrinsic problems, such as compression due to a prostatic cyst or tumor.
Obstructed ejaculatory ducts are usually 
diagnosed by transrectal ultrasound imaging or by special radiographic tests called vasograms. Obstructed ducts are treated by a simple transurethral procedure whereby the obstructed part of the duct is removed, thus leaving normal, unobstructed ductal tissue behind.
Microsuraical Reversal of Vasal or Epididymal Obstruction: Obstruction of the vas deferens 
is usually the result of a prior elective vasectomy procedure. Over time, this obstruction may lead to significant "backpressure" experienced by the fragile epididymal tubules, thus causing a secondary epididymal obstruction, often referred to as a "blowout." Vasal obstruction, and even secondary epididymal obstruction, can usually be corrected operatively using special microsurgical techniques to bypass the obstructiona (Figs. 8-A & 8-B). These microscopic procedures are among the most technically demanding ones performed by urologists, and they are best accomplished by individuals with special training in this area.
Sperm Procurement Techniques: Some couples, either as a result of male or female fertility issues, will need to proceed to assisted reproductive techniques such as in vitro fertilization (IVF). In some male patients, sufficient sperm are not availablein the ejaculate. This deficiency may be due to problems with sperm production, obstruction of the male reproductive tract, or disorders of ejaculation. Therefore, sperm retrieval techniques must be employed to obtain sperm for use in IVF.
The type of procurement technique used depends largely on the nature of the patients problem. If obstruction or ejaculatory disturbance is the primary issue, then epididymal sperm retrieval is the preferred method. This will typically yield motile, mature sperm. If the problem is one of abnormal sperm production, then usually removal of a small amount of testicular tissue with sperm extraction is performed. Sperm obtained by these techniques are injected directly into the egg, a process known as intracytoplasmic sperm injection (ICSI). Only one live sperm is needed for each egg. Often, sperm obtained via procurement techniques (such as above) can be used fresh in IVF procedures or cryopreserved, and used at a later date.
A BRIEF WORD ABOUT ASSISTED REPRODUCTIVE TECHNIQUES
Assisted reproductive techniques (ART) describe several special methods used to help couples achieve a pregnancy. The first of these is called intrauterine insemination (IUI). IUI involves the collection of the male's ejaculate and subsequent processing or "washing." The ejaculate is then inserted into the female's cervix or uterus using a special injection catheter. Among ART, this is generally considered to be the least invasive, but its effectiveness is limited for those patients with severe fertility problems.
IVF occurs when the male's sperm is incubated with the female's eggs in the laboratory. The development of the eggs are medically regulated with hormones, and the conditions in the laboratory dish are meticulously controlled to optimize the chances for fertilization. Those eggs which are fertilized (i.e., "embryos") can then be assessed on the basis of their appearance, allowing for the selection and replacement into the female of the best embryos. These embryos have been shown to be the ones with the highest likelihood of resulting in a successful pregnancy. Those embryos not used can be frozen (cryopreserved) for later use.
 A modification of the IVF procedure is the ICSI procedure. ICSI utilizes the same methods as standard IVF, except instead of simply incubating the sperm and egg together in a Petri dish, the egg is stabilized under a special microscope using a micro-suction instrument while a very fine pipette is used to inject a selected sperm into the egg. This sperm injection technique allows couples to overcome many barriers in sperm count, motility, morphology, and degree of sperm maturity. ICSI has made it possible for couples, who in the past would have been unable to achieve pregnancies, to bear their own biologic children.
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