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Die Diagnostik peniler Hautveranderungen stellt eine urologische und dermatologische Herausforderung dar. Das Spektrum der Differentialdiagnosen erstreckt sich von gutartigen Hautveranderungen ohne Krankheitswert uber Infektionen, blasenbildende Erkrankungen und Neoplasien hin zu akuten Krankheitsbildern mit sofortigem Interventionsbedarf. Evidenzbasierte Therapiekonzepte sind nicht fur alle der besprochenen Krankheitsbilder verfugbar, ob ihrer Seltenheit ist hier die interdisziplinare Zusammenarbeit zielfuhrend und Erfolg versprechend.

A semen allergy is a type I reaction. Reliable figures about incidence/prevalence are not available. Symptoms can be characterized as local and systemic. After exposure to ejaculate, the patient may experience itching and swelling at points of contact, while systemically it may also lead to generalized urticaria with angioedema or higher grade anaphylaxis. As triggering allergens, substances in seminal plasma (SP) have been identified, which can be SP typical or SP atypical. Reactions against spermatozoa have not yet been clearly proven. With regard to SP-typical allergens, prostate-specific antigen (PSA) has been identified, while for SP-atypical allergens, medications or food allergens have been reported, which apparently accumulate in the SP and can then trigger symptoms in women with existing sensitization. The main criteria for the diagnosis of sperm allergy is freedom from symptoms when condoms are used during intercourse. In addition, skin prick tests and determination of allergen-specific IgE are used. In patients with a desire for children, washed, SP-free spermatozoa can be used for insemination. In addition, desensitization may be considered.

On the basis of microscopical examination and further differentiation by special stain techniques, a new classification of defects of midpieces and tails of spermatozoa will be presented: First degree disorders i.e. abnormalities of the staining behaviour and minor structural defects, second degree disorders revealing breakes and coiling of spermatozoa tail, and finally severe third degree disorders only exhibiting a rudimentary anlage of the terminal segment of spermatozoa. The staining abnormalities of the first degree disorders are characterized by nonreactivity to the Polychrome stain of the Papanicolaou technique as well as to scarlet red stain of the Shorr technique. Although the majority of these spermatozoa do not exhibit morphological aberrations, they have to be regarded completely immotile. Considering this classification, we have observed a highly significant correlation between morphological findings of midpieces and tails and the total motility as well as the progressive motility of spermatozoa.

Als einzige kausale medikamentose Therapie ist nur die hormonelle Substitutionsbehandlung bei hypogonadotropem Hypogonadismus bei unterschiedlichen Ursachen allgemein akzeptiert. Effektive Behandlungsverfahren stehen daneben fur die retrograde Ejakulation zur Verfugung. Die Wirksamkeit einer antientzundlichen und immunsuppressiven Therapie sowie einer Behandlung mit Antioxidanzien beim Nachweis von reaktiven Sauerstoffspezies wurde in kontrollierten Studien noch nicht ausreichend bewiesen. Umstritten ist die Behandlung der sog. idiopathischen Infertilitat. Medikamentose, empirische Behandlungsversuche mit Antiostrogenen,Androgenen, Aromatasehemmern, hochgereinigtem und rekombinantem FSH, Mastzellblockern, Zink, Kallikrein, Pentoxifyllin, α-Blockern oder L-Carnitin haben hierbei unterschiedliche Ergebnisse gezeigt. Bei moderatem idiopathischem OAT-Syndrom wird gegenwartig allenfalls ein Versuch mit Antiostrogenen befurwortet, ansonsten werden Masnahmen der kunstlichen Befruchtung empfohlen.

Zusammenfassung: Obwohl die modernen Techniken der assistierten Reproduktion einen hohen Stellenwert in der Behandlung schwerer andrologischer Storungen besitzen, konnen diese Methoden nicht bei jedem infertilen Paar eingesetzt werden. Die Aufgabe des Andrologen ist es, durch sorgfaltige diagnostische Masnahmen die Fertilitatsprognose des Mannes herauszuarbeiten und ggf. geeignete therapeutische Schritte in die Wege zu leiten. Dabei beschrankt sich die Diagnostik keinesfalls nur auf die Durchfuhrung eines Spermiogramms, sondern umfasst neben der dezidierten Spermaanalyse die klinische Untersuchung, Hormonbestimmungen, sowie den gezielten Einsatz z.T. sehr aufwendiger Spermatozoenfunktionstests. Unter Zugrundelegung einer abgestuften exakten Diagnostik, die eine bessere Selektion der Patienten fur eine andrologische Behandlung ermoglicht, konnen haufig konventionelle Therapieverfahren eingeleitet werden. Zu diesen gehoren operative Verfahren, die intrauterine Insemination sowie die medikamentose Behandlung. Als einzige kausale medikamentose Therapie ist nur die hormonelle Substitutionsbehandlung bei hypogonadotropem Hypogonadismus bei unterschiedlichen Ursachen allgemein akzeptiert. Effektive Behandlungsverfahren stehen daneben fur die retrograde Ejakulation zur Verfugung. Die Wirksamkeit einer antientzundlichen und immunsuppressiven Therapie sowie einer Behandlung mit Antioxidantien beim Nachweis von reaktiven Sauerstoffspezies wurde in kontrollierten Studien noch nicht ausreichend bewiesen. Umstritten ist die Behandlung der sog. idiopathischen Infertilitat. Medikamentose, empirische Behandlungsversuche mit Antiostrogenen, Androgenen, Aromatasehemmern, Mastzellblockern, Zink, Kallikrein und Pentoxifyllin haben hierbei unterschiedliche Ergebnisse gezeigt. Die Kombination von Antiostrogenen mit Androgenen sowie die Verabreichung von gereinigtem und rekombinantem FSH sind moglicherweise erfolgversprechende neue Entwicklungen. Die andrologische Behandlung zielt neben dem Eintritt einer Schwangerschaft auf naturlichem Weg auch darauf ab, moglichst einfache Verfahren der kunstlichen Befruchtung zu erlauben, was sich nach der Zahl der motilen Spermatozoen nach Spermapraparation richtet. Summary: Although the modern assisted reproduction techniques contribute a lot to overcome severe male factor infertility, application of these methods in every infertile couple is not possible. Andrological diagnosis aims at determination of the fertility prognosis and introduction of adequate treatment. The diagnostic measures are not confined to semen analysis alone but comprise physical examination, determination of hormones and performance of partly very time consuming sperm function tests in addition to detailed investigation of the ejaculate. Based on such diagnostic procedures which allows better selection of patients for andrological treatment, conventional treatment modalities can be introduced. Apart from IUI (intrauterine insemination) these include surgical procedures and administration of drugs. Causal treatment regimens of proven effectiveness are only available for cases of male infertility resulting from hypogonadotrophic hypogonadism of any cause. Drug treatment of retrograde ejaculation is also effective. The effects of antiinflammatory and immunosuppressive therapy as well as treatment with antioxidants in the presence of reactive oxygen species has not yet been demonstrated to be effective by controlled studies. Controversially discussed is the treatment of the so-called idiopathic male infertility. Inconsistent results have been obtained with empirical treatment including antiestrogens, androgens, aromatase-inhibitors, mast cell blockers, zinc, kallikrein and pentoxifylline. The combination of tamoxifen with androgens and administration of purified and recombinant FSH may be promising new developments. Apart from the induction of a pregnancy by the natural way andrological treatment should allow as simple procedures of artificial reproduction as possible, which depends on the number of motile sperm after semen preparation.

Ascomycin and FK 506 are converted into the 9-ketal isomers in high yields by simple treatment with Lewis acids. The structure of the 9-ketal isomer was confirmed by oxidative cleavage.

Classification of male fertility disorders should take into account the cause and severity of a disturbance as well as its effect on the fertilizing capacity of spermatozoa. A reasonable approach is the analysis of sperm morphology according to the Düsseldorf classification, which is based on defects of spermatid differentiation. The kind and frequency of malformed spermatozoa allow conclusions about basic testicular and epididymal disorders, which will facilitate the detection of epididymal sperm motility disturbances and, therefore, initiation of causal treatment. The effect of inflammatory processes on fertility depends on the site of inflammation. In addition, the necessity for varicocele treatment can be determined more exactly under consideration of sperm morphology and hormonal tests. So far, irregular chromatin condensation as a cause of disturbed male fertility has not been attributed to genetic reasons, whereas microdeletions of the Y chromosome are increasingly being discussed. Both the role of oxygen radicals and the significance of environmental factors need to be investigated in the future.

Infection and inflammation of the male reproductive tract are thought to be a primary aetiological factor of male infertility. Furthermore, several studies suggest that T lymphocytes are critically involved as regulator in the pathogenesis of male infertility under these conditions and are thought to induce autoimmune orchitis. In this context of autoimmunity the recently described T helper (Th) 17 subset has been suggested to play an essential role so that the aim of this study was to investigate the expression and characteristics of Th17 cells as well as the presence of Th17 inducing antigen presenting cells (APCs) in azoospermic testis with chronic inflammation (ATCI) compared with normal spermatogenesis. By stereological analysis, we detected base line expression of Th17 cells in Con. However, increased expression intensity and number of Th17 cells and their cytokines [interleukin (IL)-17A, IL-21, IL-22] and a decreased level of Foxp3(+) and interferon-γ(+) cells could be demonstrated in ATCI. Moreover, along with these data, increased numbers of Th17-inducing IL-23 producing CD11c(+) and CD68(+) APCs could be detected in ATCI. From these data, a picture emerges that Th17 cells orchestrated by IL-23 producing APCs are critically involved in chronic inflammation in ATCI.

Sperm morphology was assessed in 78 fertile men according to the Düsseldorf classification. There were 30% normal forms on average, which conforms with the new World Health Organization guidelines. This differs from the strict criteria of the Tygerberg group [9] probably due to the fact that these criteria were established under in vitro conditions.

Infections and inflammations of the genital tract are considered the most frequent causes of reduced male fertility, but conclusive epidemiological data are not available. In view of the exposure of germ cells to pathogenic components as well as the cells and mediators involved in the inflammatory processes, irreversible damage to spermatogenesis and corresponding decline of ejaculate quality are to be expected, particularly in cases of chronic orchitis. While the consequences of orchitis and epididymo-orchitis that exhibit clinical symptoms due to systemic or local infections are well known, including testicular atrophy and complete loss of fertility, those cases of inflammatory reactions of the testicles that manifest an asymptomatic or subclinical course, or are not even due to an infection, have received little attention until now. However, systematic histopathological analyses have shown a high prevalence of asymptomatic inflammatory reactions in testicular biopsies from infertile men. The mostly focal lymphocytic infiltrates correlate with the degree of damage to spermatogenesis and corresponding clinical and endocrinological parameters of testicular function. Noninvasive diagnostic techniques are not yet available so that chronic asymptomatic inflammations of the testicles as the primary cause or cofactor of male fertility disorders are underestimated. Except for administration of pathogen-specific antibiotics, treatment recommendations are to a large extent still lacking.

In patients with complaints of chronic prostatitis, analysis of prostatic secretions for leukocytes and the use of the four-specimen technique allow a distinct classification of chronic bacterial (CBP), nonbacterial prostatitis (NBP), and prostatodynia (Pd). In this study, 32 men with CBP, 102 men with NBP, 142 men with Pd, and 42 volunteers, classified as mentioned above, underwent a two-fold ejaculate analysis using WHO criteria. Sperm count, progressive motility, range of abnormal spermatozoa, increased numbers of common bacteria, and peroxidase-positive leukocytes were analyzed. Additionally, antibody-coated bacteria (ACB), numbers of ureaplasmas in semen, and urethral colonization by chlamydia were investigated. Mean values of sperm density, motility, and morphology revealed no differences between the groups. Significant bacteriospermia (greater than or equal to 10(3) bacterial/ml) was evident in only 47% of the CBP group versus 6.8% (NBP), 16% (Pd), and 4.2% (controls). ACB was positive in 31 of 32 men with CBP versus 3 of 102 with NBP, 9 of 142 with Pd, and none of the controls. Increased numbers of leukocytes were evident in CBP and NBP patients compared to the controls (p less than or equal to 0.001) but were also present in patients of the NBP and Pd groups with chlamydial infections.

Evidence-based drug therapy for male infertility is often difficult because 30% of all cases of male infertility are classified as idiopathic, and another 30% need surgical treatment. Without knowledge of the underlying pathology, there is no foundation for a specific and causal treatment. Most of the currently used drug therapies are empirical at best; moreover, many of the studies on drug treatment for male infertility do not fulfill the required standards of evidence-based medicine (randomized, prospective, placebo-controlled), and the statistical endpoints used (sperm quality, pregnancy rate, baby take-home rate) are not uniform. This article, which is based on a literature survey and the current guidelines concerning drug therapy for male infertility, covers the most common treatment options. Regarding the currently insufficient scientific data for drug therapy and dietary supplements on male infertility, there is a demand for critical indications that take into consideration the possible side effects and the treatment costs. In the case of insufficient drug therapy for male infertility, reproductive medicine seems to be promising.

Andrology was included as a further subject for continuing education in the Model Ordinance on Continuing Education at the 106th German Physicians Meeting in Cologne in 2003. In addition to fertility disorders, this discipline comprises medical care for men with fertility disorders, erectile dysfunction, disorders of libido, ejaculation and coitus, various forms of hypogonadism, and delayed puberty. Furthermore, this field also covers questions concerning male contraception, gynecomastia, and male senescence. Diagnostic procedures in andrology require close interdisciplinary cooperation between gynecologists, human geneticists, and specialists in psychosomatic medicine. They include medical history, clinical examination, and laboratory analyses. Except for confirming azoospermia, it is not possible to make a definitive prognosis of fertility based on semen analysis. Functional tests allow a better assessment of the spermatozoa's fertility since 25-30% of men desiring a child exhibit reduced spermatozoan functions which cannot be verified on routine semen analysis.

Cytomorphological semen analysis is an essential part of the diagnostic work-up for male infertility. Apart from the assessment of sperm morphology, it should include the qualitative evaluation of cellular elements other than spermatozoa. Appropriate staining of routine semen smears allows one to differentiate “round cells” (which need to be differentiated with regard to their type and cytomorphological abnormalities) from the completely distinct population of leukocytes, such as neutrophils and macrophages. Moreover, erythrocytes, epithelial cells as well as agglutination of spermatozoa can be identified.

Determinations of the serum concentrations of specific hormones are a prerequisite for the evaluation of infertility and sexual dysfunction. These are easy to perform and can shorten the diagnostic and therapeutic procedures. The most important hormones are FSH, LH and testosterone. Depending on the symptomatic findings, prolactin and thyroxine should also be determined. Knowledge of endocrine regulation and the variables affecting this is important for the interpretation of the hormone concentrations.

Inhibin, a dimeric gonadal glycoprotein, inhibits the production and/or secretion of follicle stimulating hormone (FSH). The major species currently recognized are inhibin A (alphabeta A subunit) and inhibin B (alphabeta B subunit). In men, inhibin B seems to be the physiologically important form of inhibin. Therefore we measured serum inhibin B using a new two-site immunoenzymatic assay in 14 men (mean +/- SEM age, 34.5 +/- 0.7 years) with sperm counts >20 x 10(6)/ ml, in 35 men (mean +/- SEM age, 36.4 +/- 1.3 years) with oligozoospermia (sperm count

A 38-year-old patient with a grade 3 testicular varicocele was treated by antegrade scrotal sclerotherapy. Although performed technically accurate, antegrade sclerotherapy led to a haemorrhagic infarction of the testis by complete occlusion of venous drainage. The testis had to be removed. This complication has not been described yet and patients should be informed about this rare event.

In a previous study, we found a higher degree of alexithymia and somatization in infertile men (Hum Reprod 2001 Vol.16(3),587-592). This study was designed to confirm the findings of the former study88 infertile men (48 idiopathic infertility, 40 somatic infertility) were consecutively enrolled in the study. The control group consisted of 44 healthy men. Alexithymia was measured by the 20-item-Toronto-Alexithymia-Scale;somatization was measured by the Symptom Checklist-90-R.There were no differences between the subgroups of infertile men. The study group showed a significantly higher sum score in the TAS-20 (p0.01) and a higher score on the scale somatization in the Symptom Checklist-90-R (p0.05) compared to the control group.Our study replicated the findings of the previous investigation. Alexithymia and somatization are discussed as consequences of coping with male infertility.

Phospholipids and sterols are known to have multiple functions in reproductive tissue of mammals. High concentrations of the cholesterol precursor desmosterol have been described in testis, epididymis, and spermatozoa of various species. These findings and the recent discovery of some cholesterol precursors as meiosis-activating sterols suggest important functions of cholesterol precursors in fertility. Many sterol intermediates appear from the 19-step conversion of lanosterol, the first sterol synthesized in the cascade of cholesterol synthesis, to cholesterol. The biochemical basis of the genetically inherited Smith-Lemli-Opitz syndrome has been described as a defective conversion of 7-dehydrocholesterol to cholesterol. Since this discovery, interest has focused on this special cholesterol precursor. Here, we report high concentrations of 7- and 8-dehydrocholesterol in caput epididymidis and spermatozoa derived from caput epididymidis of Sprague-Dawley and Wistar rats, which comprised up to 30% of total sterols. In contrast to caput epididymidis, 7- and 8-dehydrocholesterol were barely detected in cauda epididymidis or testis. Desmosterol increased several times from caput to cauda epididymidis. This is the first report of the natural appearance of high concentrations of dehydrocholesterols in mammalian tissue, and it underlines the putative importance of cholesterol precursors in reproductive tissue.

Drug treatment remains an active domain in the therapy of male fertility disorders. Although there are only a few conditions that allow causal treatment, rational approaches are possible in many cases. Best results are obtained in cases requiring an anti-inflammatory treatment and in patients with an impaired sperm transport. High-dosage administration of FSH is a promising new development, aimed particularly at improving the disturbed sperm structures. A careful diagnostic work-up with elucidation of the underlying disease is essential to achieve a successful therapy.

There is empirical evidence that sterility causes a considerable amount of distress and affects correspondingly the partnership. Empirical results concerning male infertility show increased somatic complaints and reduced self-esteem of the men as well as a dominance of the accompanying partners. Which couple conflicts arise after the diagnosis of male infertility?84 infertile men were examined with a partnership diagnostic questionnaire. The questionnaire was evaluated with regard to quantity and quality of unsolved couple conflicts.The results show that infertile men do not mention more unsolved conflict areas in their partnership than healthy men. If one looks qualitatively at the mentioned conflict areas, striking differences in comparison to the control group can be seen.In comparison to the control group of healthy men, the specificity of conflict areas in infertile couples can be best understood on the basis of exchange-theoretical considerations.

Nach den Zahlen des Deutschen IVF-Registers wurden 1997 in Deutschland uber 15000 ICSI-Zyklen vorgenommen, wobei in mehr als 80 % eine andrologische Indikation gestellt wurde. Da jedoch keine einheitlichen Richtlinien existieren, in welchen Fallen die ICSI-Methode angezeigt ist und die ICSI-Behandlung nach wie vor als Kassenleistung nicht anerkannt ist, stellt sich aus andrologischer Sicht die Frage, inwieweit diese Behandlungen wirklich notwendig waren, oder ob nicht doch auch alternative Moglichkeiten zur Verwirklichung des Kinderwunsches existierten. ?Schlechte? Spermawerte sind nicht von vornherein eine Indikation zur ICSI-Behandlung. Diese mussen zunachst durch eine zweite Untersuchung bestatigt werden, daruber hinaus mus im Hinblick auf eine eventuelle alternative Behandelbarkeit abgeklart werden, ob die Storung testikularen oder extratestikularen — meist epididymalen — Ursprungs ist, auch museine Spermatozoentransportstorung ausgeschlossen sein. Dazu sind Anamnese, klinische Untersuchung, Hormonanalysen — unter anderem Inhibin B — und die Spermaanalyse erforderlich.

Several relevant sociodemographic and psychological variables were assessed in addition to clinical and andrological examinations in order to find predictors for sexual satisfaction and somatisation in 68 infertile men of involuntarily childless couples. Subjects reported relatively high average levels of both sexual satisfaction and somatisation, with considerable variance between subjects. Multiple regression analyses revealed that neither age, attitudes towards sexuality, nor andrological findings had an influence on sexual satisfaction. However, an inverse relationship between sexual satisfaction and somatisation was found. Furthermore, a short-lasting partnership and high sexual dissatisfaction prior to the diagnosis of infertility could be unveiled as risk factors for somatisation in infertile men. These results propose state and trait characteristics of sexual satisfaction and suggest a buffering role of longer lasting and sexually satisfying partnerships with respect to the distress of infertility. The promising results need confirmation by repeated investigation. Other possible influences, e.g. styles of coping, should be included in future studies.

Infertility is proposed to be a continuing stressor for couples suffering from involuntary childlessness. A long duration of the desire for a child and, correspondingly, a longer period of diagnostic and treatment procedures could have a negative impact on sexual satisfaction, thus leading to an unfavorable psychological circuit. The present evaluation should clarify the state of sexual satisfaction and relationships, with relevant parameters in 68 men with fertility problems, of couples with involuntary childlessness. Subjects reported relatively high average levels of present sexual satisfaction with only nonsignificant lower scores (p = .08) compared to recalled sexual satisfaction prior to diagnosis of infertility. Multiple regression analyses revealed that a positive age difference between men and their spouses (p = .042) and a higher weekly coitus frequency (p = .002) were the only significant parameters associated independently with higher sexual satisfaction. Neither the age of partners, attitudes toward sexuality, treatment duration, duration of the partnership and the duration of the desire for a child, nor andrological findings had an influence on present sexual satisfaction. The results propose that treatment duration and duration of the desire for a child may not necessarily be connected to lowered sexual satisfaction in infertile males and that coitus frequency seems to be an indicator of sexual satisfaction in this patient group.

A 38-year-old patient with a grade 3 testicular varicocele was treated by antegrade scrotal sclerotherapy. Although performed technically accurate, antegrade sclerotherapy led to a haemorrhagic infarction of the testis by complete occlusion of venous drainage. The testis had to be removed. This complication has not been described yet and patients should be informed about this rare event.

Sperm morphology has always been considered an important tool in evaluating a man's fertilizing potential. The objective of this multicentric study was to evaluate intra- and interindividual variability and between-laboratory variation using the same or different criteria of sperm morphology assessment. Semen samples were obtained from 20 males and 32 smears were made of all samples. Eighty coded smears (4 per patient) were sent to 8 laboratories for morphology assessment. The centers applied different classification systems (strict criteria, WHO 1987, Dusseldorf criteria) and participants were asked to analyze the 80 smears twice, with an interval of 1 week between each participant's two analyses. Intraclass correlations between repeats showed that sperm morphology can be assessed with acceptable within observer reproducibility. Expected increases in imprecision were observed up to coefficients of variation of >30% with decreasing morphology scores, regardless of the classification system used. Agreement in correct classification of samples as normal/abnormal was obtained in 80% of cases. Differences in reproducibility between slides may reflect an important source of heterogeneity due to smear preparation. These results emphasize the importance of external quality control systems to improve the value of sperm morphology assessments in the investigation of the male partner in a subfertile couple.

For the diagnosis of male fertility disorders, history-taking, physical examination and the semen analysis continue to be the main pillars of the initial investigative program. The physical examination frequently includes rectal and testicular ultrasonography. For the most part, considerable importance is attached to the accurate examination of sperm morphology. Additional investigations are, however, often required. Of importance here is a careful work-up of any inflammation presenting, the determination of spermatozoa antibodies, and a basic investigation of the hormones. Sperm function tests are increasingly being performed, the most important of which are acrosine activity, the acrosome reaction, chromatin condensation, and spermovum binding. The biochemical determination of specific marker enzymes, testicular biopsy and a detailed microbiological work-up round off the diagnostic program.

The reasons for the discrepancy between 'patency' and 'pregnancy' in the outcome of microsurgical refertilization are partially unknown. The quality of the intra-operative aspirate and of the spermatozoa at the level of the anastomosis are discussed worldwide as important factors influencing the success of fertilization in the case of post-operative patency. In 152 men undergoing microsurgical refertilization (vasovasostomy, tubulovasostomy, microsurgical epididymal sperm aspiration, transurethral resection of the ejaculatory duct), 281 aspirates were classified intra-operatively according to Silber, and post-operatively using the Shorr staining technique. In 62 aspirates a computer-aided sperm analysis (CASA) was performed. The percentage of intact spermatozoa decreased from 94.9% at the caput to 9.4% at the cauda epididymidis. The post-operative classification demonstrated an acceptable correlation (0.71) to all grades of intraoperative classification. There was a good correspondence in Silber 4 and 5 but worse in Silber 1 and 2. In CASA, the percentage of motile spermatozoa was not different between epididymal and post-epididymal aspirates. Furthermore, velocity parameters did not differ significantly, but there was a significantly higher straightness of post-epididymal spermatozoa in comparison to epididymal spermatozoa.

The most recent developments in assisted reproduction [subzonal insemination (SUZI), (ICSI)] are used very successfully, especially in the therapy of male factor infertility (Van Steirteghem et al. 1993). By these new techniques, male fertility disturbances can be overcome in patients who previously had no chance of achieving pregnancy, e.g., those with globozoospermia. Moreover, dogmas have been questioned that until recently were generally accepted, e.g., the role of the epididymis in sperm maturation, given that epididymal and even testicular spermatozoa have also been used successfully in the above-mentioned methods. Alternative possiblilites of drug treatment in andrology are very limited; those which were thought to be useful in the past, e.g., kallikrein, are doubted today (Glezerman et al. 1993). Consequently, at present, there is considerable uncertainty in andrology, so that the role of traditional andrology in reproductive medicine is questioned.

Technical advances in microsurgery have produced a calculable success rate for reconstructive surgery in cases of obstructive azoospermia. Nevertheless, in standardized vasovasostomy and tubulovasostomy, the different outcomes for patency and pregnancy indicate that further comprehensive clinical and basic scientific studies are required to improve the results of surgery. The aspiration of epididymal and testicular spermatozoa in combination with intra-cytoplasmic sperm injection (ICSI) is one example of a fruitful integration of microsurgery into new areas of reproductive medicine. Where there is ejaculatory duct obstruction, the continuity with the posterior urethra can be restored by a transurethral operation.

Trotz zahlreicher Verbesserungen der andrologischen Diagnostik durch die Einfuhrung von Spermatozoenfunktionstests hat die Hodenbiopsie nach wie vor ihren Platz in der Abklarung mannlicher Fertilitatsstorungen. Sie ist indiziert bei Diskrepanzen zwischen klinischem, spermatologischem und hormonellem Befund und dient zur Abgrenzung ei-ner normalen Spermatogenese bei Verschlusazoospermie von entzundlichen Hodenveranderungen und anlage- bzw. tumorbedingten Storungen der Spermatogenese. Vor Durchfuhrung einer Hodenbiopsie sollten Spermatozoentransportstorungen ausgeschlossen sein. Kontrovers diskutiert wird der Wert der Sklerosierungstherapie bzw. der operativen Beseitigung einer Varikozele im Hinblick auf eine Verbesserung der mannlichen Fertilitat sowie eine Zunahme der Schwangerschaftsrate. Eine eigene Studie an 48 Patienten mit einoder beidseitiger Varikozele ergab, das bei Patienten mit pathologi-schem GnRH-Test die nachfolgende Behandlung der Varikozele zu einer deutlichen Ver-besserung der Spermaparameter fuhrte, wahrend bei einer Kontrollgruppe mit pathologischem GnRH-Test ohne Varikozelenbehandlung eine weitere Verschlechterung der Spermaparameter zu verzeichnen war. Die verbesserte Spermaqualitat ging vor allem mit einer Abnahme von Ub er streckungsformen der Spermatozoen einher; die Bestimmung des Nebenhoden-Markers Alpha-Glucosidase im Seminalplasma vor und nach Va-rikozelenbehandlung zeigte keine signifikanten Veranderungen.

For the clarification of sperm motility disorders, changes in the flagella must be differentiated from influences exerted by the seminal fluid and extrinsic factors. The disorders of the flagella may be testicular or epididymal in origin. Only by taking account of these aspects of etiology and pathogenesis, will a rational therapeutic approach be possible.

The role of the human epididymis in spermatozoa maturation is demonstrated by means of several sperm function tests, with the aid of which, the various stages in the fertilization process can be mimicked. Accordingly, as they pass through the epididymis, spermatozoa become progressively more motile--which can be enhanced by the addition of phosphatidylcholine--inducibility of the acrosome reaction increases, and chromatin condensation is completed. Capability of fusing with the ovum is observed for spermatozoa from the epididymis, but not for those from the caput epididymis, while the spermatozoa from the latter already have normal acrosine activity. Ability to bind to the zona pellucida has not been adequately clarified. These results demonstrate the significance of the human epididymis for sperm maturation, even though a small percentage seem to reach adequate maturity in the caput epididymis.