Fertility

Reviewing the Literature

RIU0288_11-20.qxd 11/20/06 2:50 PM Page 235 Fertility Medical Visits Among Adults With Symptoms Commonly Associated With an Overactive Bladder Kim SH, Boye M, Bhattacharyya SK, et al. BJU Int. 2006;97:551-554. To obtain estimates of the use of health care by adult patients with symptoms of OAB, Kim and associates examined three US databases (the National Ambulatory Medical Care Survey, the National Hospital Ambulatory Medical Care Survey, and the National Hospital Discharge Survey) for the year 2000. During that year, adult Americans made 1.4 million ambulatory visits to non-federal, office-based physicians with International Classification of Disease (ICD-9) coding indicative of OAB symptoms. The prevalence of OAB is estimated to be 34 million adult Americans. When compared with this prevalence, the 1.4 million ambulatory visits reported by Kim and colleagues suggest that as few as 4% of adult Americans with OAB sought medical treatment during the year 2000. These results therefore suggest a large unmet medical need among adult Americans with OAB. However, most patients with OAB also have other medical issues, such as diabetes and hypertension. Could there be significant under-reporting of OAB codes due to doctors deciding to code other conditions for which patients are coming to their offices? At present there is no way to answer this, and the truth might be that both scenarios are correct. After botulinum toxin injection, the volume of the first involuntary detrusor contraction and bladder capacity increased twofold, whereas postvoid residual volume increased fourfold for both patient groups after 1 month, decreasing slightly at 3 months. Complete continence and improvement of incontinence grade, respectively, were achieved in 1 (8.3%) and 5 (41.7%) patients with CVA and in 4 (33.3%) and 7 (58.3%) patients with SCI. However, patients in both groups experienced an increase in voiding difficulty after treatment. The therapeutic effect declined gradually after 3 months, and all patients experienced symptom relapse by 6 months. Dr. Kuo concluded that suburothelial botulinum A toxin at a dose of 200 U increased bladder capacity and improved incontinence in more than 90% of SCI patients but only 50% of the patients with CVA. This is an interesting observation that has not yet been confirmed or refuted at another institution. It is hoped that the US Food and Drug Administration phase III neurogenic bladder botulinum toxin study that began in July 2006 will be able to address whether specific types of neurological conditions are associated with different outcomes from botulinum toxin injection. Fertility Reviewed by Jacob Rajfer, MD Therapeutic Effects of Suburothelial Injection of Botulinum A Toxin for Neurogenic Detrusor Overactivity Due to Chronic Cerebrovascular Accident and Spinal Cord Lesions Department of Urology, The David Geffen School of Medicine at UCLA, Los Angeles, and Division of Urology, Harbor-UCLA Medical Center, Torrance, CA [Rev Urol. 2006;8(4):235-236] © 2006 MedReviews, LLC Kuo HC. Urology. 2006;67:232-236. Carnitine and Male Infertility Dr. Kuo at the Department of Urology, Buddhist Tzu Chi General Hospital, Hualien, Taiwan, is an expert on the use of botulinum toxin in the bladder. In a study of 24 patients, he examined the effects of suburothelial injection of botulinum A toxin for neurogenic detrusor overactivity due to chronic cerebrovascular accident (CVA) (n  12) or spinal cord injury (SCI) (n  12). The patients, whose neurogenic detrusor overactivity was refractory to anticholinergics, were treated with 200 U of botulinum A toxin injected into the suburothelial space. The clinical effects on lower urinary tract symptoms and urodynamic parameters were assessed. ne of the difficult aspects of treating infertile men is that there are no recommended medical therapies for men with idiopathic oligospermia. This applies to the drug clomiphene citrate (CC). Although CC has at times been used empirically to treat men with idiopathic oligospermia, stringent, randomized, blinded, placebocontrolled trials demonstrating the efficacy of CC are lacking. As a result, physicians treating male infertility are always hopeful that some compound, which may have been associated with sperm function, will turn out to be the successful medication they have been searching for. One such compound that has captured the imagination is O VOL. 8 NO. 4 2006 REVIEWS IN UROLOGY 235 RIU0288_11-20.qxd 11/20/06 2:50 PM Page 236 Fertility continued carnitine, which may have a number of different functions associated with sperm function (eg, support of mitochondrial function and serving as an antioxidant within sperm). Some studies have suggested that carnitine may be reduced in the semen of infertile men, and uncontrolled studies added fuel to the fire by demonstrating that oral carnitine seemed to improve sperm motility in men with low sperm motility. deterrent to inducing a pregnancy, contrary to what is known to occur with a woman’s fertility as she ages. But because a man’s ability to impregnate a woman is statistically related to his sperm count, and because sperm counts can and do decline with age, one question that has been raised is whether age itself impacts a man’s ability to impregnate his partner. Carnitine for the Treatment of Idiopathic Asthenospermia: A Randomized, Double-Blind, Placebo-Controlled Trial Effect of Male Age on Fertility: Evidence for the Decline in Male Fertility With Increasing Age Sigman M, Glass S, Campagnone J, Pryor JL. Hassan MAM, Killick SR. Fertil Steril. 2006;85:1409-1414. Fert Steril. 2006;79(suppl):1520-1527. To try to separate fact from fiction, Sigman and colleagues performed a randomized, double-blind, placebo-controlled study on 21 patients with idiopathic oligospermia, whereby 12 patients received oral carnitine and 9 received placebo for a total of 24 weeks. The investigators found that carnitine did not demonstrate any clinical or statistically significant effect on sperm motility or on total motile sperm counts. More interestingly, the carnitine levels in the seminal fluid and in the spermatozoa did not change after 24 weeks of treatment. On the basis of this well done study, it would be difficult to recommend oral carnitine supplementation for improving sperm motility in infertile men with low sperm motility. To answer this question, Hassan and Killick decided not to measure sperm counts but rather the time to achieve a pregnancy (TTP) once the couple began attempting to conceive. Their data clearly showed that men aged 45 years or more had a 5-fold increased TTP (32 months vs 6 months, on average) when compared with men aged less than 30 years. Although sperm counts were not analyzed in this questionnaire study, and the data were adjusted for age of the female partner, coital frequency, and lifestyle effect, as well as other subfertility risk factors, the data clearly suggested that men, like women, have a greater TTP as they age, and this becomes exacerbated at 45 or more years of age. These observations suggest that for men older than 45 years, even if their sperm counts are normal, it may take much longer for them to initiate a pregnancy. Therefore it may be prudent for these men and their partners to attempt conception for at least 3 years (rather than the usually stated 1 year) before a diagnosis of “infertility” is ascribed and a workup is attempted. Older Men Take Longer to Initiate a Pregnancy Than Younger Men Although there are reports attesting to the fact that overall sperm counts are declining from decade to decade, it has always been assumed that in men age alone is not a 236 VOL. 8 NO. 4 2006 REVIEWS IN UROLOGY