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Increasing reports suggest that clomiphene citrate (Clomid) is useful in the treatment of idiopathic hypofertile males. Recent studies have advocated low-dose, cyclic therapy (25mg daily for 25days, 5days’ rest) and, although significant clinical responses have been reported, the hormone response has been erratic. This study of 53 patients, given high-dose, alternate-day therapy (100mg three times/week), shows an over-all positive response rate of 66% and a pregnancy rate of 26%. Significant gonadotropin and testosterone surges were seen in the responders, but a selective lack of a follicle-stimulating hormone surge was noted in a small group of nonresponders. Clomiphene given in this dosage seems to be safe for periods of up to 15months and appears to be a rational and useful agent for the treatment of this patient group.

Sophisticated diagnostic techniques have made the isolation of renal lesions more accurate. However, it must be remembered that simultaneous bilateral kidney pathology can exist in any patient. The most obvious lesion may not be the most important. Four cases are presented to illustrate this point.

Sperm were collected over a period of months from a human alloplastic spermatocele implanted at the corpus/caudal epididymal junction and were evaluated for their maturity, motility, and ability to capacitate and acrosome react, as assessed by the hamster zona-free oocyte sperm penetration assay (SPA). A mean of 11×106sperm were obtained with each aspiration, with 34% to 40% being mature, normal forms. Motility was poor; 15%±5% showing nonprogressive movement. SPA results were 22%±3% oocyte penetration. Addition of 7.5mM caffeine markedly enhanced motility and improved the SPA results. After 30 minutes’ exposure, the motility was 45%±5%, with all spermatozoa exhibiting progressive movement. This stimulation was maintained over a 24-hour period. When caffeine was present during the 2-hour preincubation for the SPA, penetration rates increased to 50%±10% (P<0.05). These results demonstrate that the poor-quality sperm retrieved from a human alloplastic spermatocele can be improved with exogenous stimulation and suggest that their fertilizing capacity may be enhanced by this treatment.

Improved methods of urological microsurgery and of various assisted reproductive technologies have resulted in the ability to achieve pregnancies with sperm aspirated microsurgically from men with bilateral congenital absence of the vasa deferentia or with ductal obstructions that cannot be surgically reconstructed. A survey was conducted of the results of such procedures performed in the United States during approximately 2 years. Female partner ovarian stimulation was initiated in 219 instances at 22 centers. Of the 219 procedures 23 (11%) were terminated without attempting any form of gamete fertilization or insemination of the wife for various reasons (no sperm or too few sperm retrieved, poor to absent sperm motility or poor quality eggs). The etiology of azoospermia in the 219 procedures was congenital absence of the vasa deferentia in 115 cases (52%), other congenital conditions in 15 (7%), failed vasectomy reversal in 37 (17%), infection in 4 (2%), other conditions (mainly ejaculatory dysfunctions that did not respond to electroejaculation and complex ductal obstructions) in 26 (12%) and not specified in 22 (10%). When only patient sperm was used pregnancy was achieved in 12 of 115 wives (10%) of those men who had congenital absence of the vasa deferentia and in 0 to 14% of the wives of men whose azoospermia was caused by other conditions. Of the 219 menstrual cycles in which ovarian stimulation was initiated pregnancy occurred in 24 (11%) with patient sperm and in 9 (4%) with donor sperm. Of these 33 pregnancies a full-term, live delivery occurred in 17 (52%), while 8 (24%) were ongoing at the time of reporting, 2 (6%) miscarried, 3 (9%) were chemical pregnancies, 1 (3%) resulted in a stillborn child and the outcome was unknown in 2 (6%). This new therapy offers only a modest chance of pregnancy. However, it affords men with azoospermia the opportunity to achieve paternity with their own sperm when other therapies are not available or applicable.