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Hyperprolactinemia

Elevated prolactin levels are sometimes discovered in the workup of the infertile male renal transplant patient. This may be found in association with uremia, a poorly functioning renal graft, or even occasionally a well-functioning graft. These individuals often have coinciding complaints of diminished libido and ED. The testosterone is often low, but testosterone supplementation does not correct the impaired libido nor the ED because elevated prolactin disrupts penile end organ responsiveness. Dopamine is normally produced by the hypothalamus and transported to the pituitary gland where it has an inhibitory effect on prolactin secretion. Bromocriptine and carbergoline are dopamine receptor agonists which have prolactin-lowering effects. These agents have also been shown to be helpful in restoring libido, erectile function, and spermatogenesis to normal.

Anatomic Abnormalities

Transplant patients do not generally appear to be at increased risk for anatomic etiologies for infertility than the general population.5 As such, the incidence of varicoceles is approximately forty-two percent and the incidence of obstruction within the reproductive tract (at the level of the epididymis, vas deferens, or ejaculatory duct) is approximately fifteen percent. These two common as well as other anatomic abnormalities (such as penile deformity, congenital absence of the vas deferens, etc.) should be kept in mind during the evaluation. It is important to consider, however, the possibility of iatrogenic injury to the spermatic cord and vas deferens, especially during the renal transplantation procedure. These structures are close to the renal allograft site and may be inadvertently injured during transplantation.

Urinary Tract Infections/Positive Semen Cultures

Transplant patients are prone to opportunistic infections due to their immunosuppression medical regimen. As a result, they are at increased risk for genitourinary tract infections, including cystourethritis, prostatitis, and epididymitis. Each of these conditions can have a potentially detrimental impact on fertility status. These conditions may lead to a higher likelihood of pyospermia, or white blood cells (WBCs) within the semen. WBCs, when present in excessively high numbers, may release abnormally high levels of molecules called reactive oxygen species (ROS) into the semen.6 These ROS have the ability to pass an extra electron, or "free radical", onto other molecules. This electron transfer can be severely detrimental to the fatty acids of the sperm membrane and thus impair sperm function, including sperm-oocyte binding. The treatment of this condition includes effectively eradicating the infection as well as supplementing the patient with antioxidant therapy, such as Vitamin E. (Dosages should be carefully determined and the patients closely monitored, especially in transplant patients with hepatic failure.)

Retrograde Ejaculation

This condition should be suspected in men with azoospermia/severe oligosper-mia and no or abnormally low ejaculate volume. The abnormality arises from an open bladder neck at the time of ejaculation which permits retrograde passage of semen into the bladder. The diagnosis is made by catheterizing the bladder after ejaculation and finding sperm in the pellet from the centrifuged urine sample. This condition is most often seen in men with autonomic neuropathy, such diabetics and patients who have undergone extensive retroperitoneal surgery. The treatment of choice is sympathomimetic agents such as pseudephedrine, which increases bladder neck tone and thus facilitates antegrade ejaculation.

Dealing With Erectile Dysfunction

Dealing With Erectile Dysfunction

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