The pediatric patient and future fertility: optimizing long-term male reproductive health outcomes

Long-term impact of commonly performed operations in pediatric urology on reproductive and sexual health

Introduction

Sexual dysfunction is highly prevalent among men of reproductive age. Clinical practice guidelines have been established to assist providers in identification and education of patients who are at increased risk for infertility and sexual dysfunction with certain congenital and acquired urogenital disorders. The authors sought to review the reproductive and sexual health implications of treating common childhood urological conditions with commonly performed surgical procedures.

Methods

To ensure the inclusion of influential and highly regarded research, we prioritized citations from the most-frequently cited articles on our respective review topics. Our inclusion criteria considered studies with substantial sample sizes and rigorously designed methodologies. Several topics were reviewed, including penile chordee, hypospadias, posterior urethral valves, varicoceles, undescended testicles, and testicular torsion.

Results

For chordee, surgical plication or corporal grafting may be employed. Erectile function remains unaltered post-surgery, while penile length may decrease after repair, which may be avoided using dermal grafts. Hypospadias repair hinges on severity and availability of the urethral plate. Those who underwent hypospadias repair report decreased penile length, but sexual satisfaction, libido, and semen quality are comparable to controls. Posterior urethral valves are usually treated with valve ablation. While valve ablation and bladder neck incision have not been found to affect ejaculatory function, high degree of concurrent renal dysfunction related to nephrogenic and bladder dysfunction may impact semen parameters and erectile function. Regarding varicocele, earlier management has been associated with better long-term fertility outcomes, and surgical intervention is advisable if there is observable testicular atrophy. Earlier repair of undescended testicle with orchiopexy has been found to improve fertility rates as well as decrease malignancy rates. Unilateral orchiectomy for testicular torsion without the ability for salvage has been shown to have decreased semen parameters but unaffected fertility rates.

Conclusion

Infertility and sexual dysfunction are multivariable entities, with etiologies both congenital and acquired. At the same time, many common pediatric urology surgeries are performed to correct anatomic pathology that may lead to reproductive dysfunction in adulthood. This review highlights the need for diagnosis and management of pediatric urologic conditions as these conditions may impact long-term sexual function post-operatively.

Fertility Preservation in Pediatric Age: Future Perspective among Andrological Diseases

Male infertility is a condition that has always been less studied and known than female infertility. Male infertility is increasingly present and increasingly diagnosed. Although several causes are known, to date about 40% of the causes are considered idiopathic. The worldwide denasality can only be slowed if awareness campaigns are implemented on all the diseases that can alter fertile potential, especially in young adolescents. Male infertility is, in addition, associated with several medical conditions. In particular, the association between infertility and testicular cancer, cardiovascular disease, autoimmune diseases, and genetic diseases is well known. For this reason, fertility preservation should not be proposed or be only oncological in nature, as there are several diagnosable pediatric pathologies that are associated with altered fertile potential to whose patients we could offer a gamete preservation pathway. In this paper we propose our experience on fertility preservation in pediatric andrological diseases.

Pregnancy Outcomes of Assisted Reproductive Technology (ART) Cycle Complicated by Ovarian Hyperstimulation Syndrome (OHSS): Case Series Study

BACKGROUND

Ovarian hyperstimulation syndrome (OHSS) is a frequent, potentially lethal side effect of assisted reproductive technology (ART), distinguished by symptoms such as ovarian enlargement, ascites, and pleural effusion.

OBJECTIVE

This study is designed to study the effect of assisted reproductive technology (ART) cycle complicated by OHSS on pregnancy outcomes.

METHOD

A case series study at King Abdulaziz Medical City (KAMC) in Riyadh, Saudi Arabia, was executed to examine the pregnancy outcomes in in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) cycles. Fifteen patients were admitted to the IVF unit between January 2015 and December 2021. Data were retrieved from patients' medical records, and descriptive statistical methods were employed to analyze participants' data.

RESULTS

The study assessed pregnancy outcomes for 15 female participants (mean age=31.1 years, SD=3.46) with a BMI range of 20-40 (mean BMI=29.6, SD=6.4), of whom 33.3% were classified as obese. The primary factor of infertility was anovulation (66.7%), followed by male factors (20%). About 26.7% of those affected by OHSS had moderate OHSS, and 73.3% had severe OHSS, with 100% of those with severe OHSS having undergone three embryo transfers. None of the participants developed gestational diabetes mellitus (DM), but one participant had high blood sugar levels (6.67% of total participants), with a mean glucose of 6.3±2.0. There were no instances of preeclampsia, gestational hypertension, abnormal placentas, or congenital abnormalities in newborns among the participants. Preterm deliveries were common, with 33.3% delivering between 32 and 37 weeks, 6.7% before 28 weeks, and 33.3% within 28-32 weeks. Overall, 73.3% of the participants experienced pregnancy, and the birth mode was almost evenly split between vaginal and cesarean birth.

CONCLUSION

 In conclusion, this research provides an exploration into the outcomes of pregnancies in women undergoing assisted reproductive technology treatments complicated by ovarian hyperstimulation syndrome. It shows anovulation as a prevalent cause of infertility and a noteworthy incidence of severe OHSS. Despite these challenges, a significant number of women were able to experience pregnancy, although preterm deliveries and abortions were common. The delivery methods were fairly balanced between vaginal birth and cesarean section. These findings underscore the necessity for more effective strategies to manage OHSS and improve pregnancy outcomes in ART procedures.

Utility of evaluating semen samples from adolescents with Klinefelter Syndrome for cryopreservation: A multi-institution evaluation

INTRODUCTION

Klinefelter Syndrome (KS) is the most common genetic condition cause of non-obstructive azoospermia (NOA). KS also often results in decreased testicular growth and testosterone production. Because of this, exogenous testosterone therapy is commonly prescribed for KS patients to treat hypogonadism, but this may have additional impacts to future fertility potential. KS adolescent patients may be asked to provide multiple semen samples to identify potential sperm for early cryopreservation.

OBJECTIVE

To develop a multi-institutional database to evaluate the prevalence of sperm in the ejaculate of adolescent KS patients.

METHODS

A retrospective study was performed of all adolescent KS patients seen at two high-volume tertiary male infertility clinics between 2015 and 2020. Adolescence was defined as individuals aged 12-19 years, as per the World Health Organization. Demographic information data including weight, height, medical comorbidities, and concurrent medications were collected. Serum hormone levels including FSH, LH, and testosterone were collected, as well as any available semen analysis data.

RESULTS

A total of 116 patients were identified and included in the database. A total of 100 (86.2%) had hormone data available and 48 (41.3%) had semen analysis data. Of the 48 patients with semen analyses, only 4 (8.3%) patients had rare sperm in the ejaculate while the remaining had azoospermia (91.7%). None of the specimens were suitable for cryopreservation. The average serum total testosterone level of adolescent KS patients was 181 ± 216 ng/dL. FSH levels were 14.3 ± 18.8 IU/L (normal 0.3-10.0 IU/L) and LH levels were 7.8 ± 12.4 IU/L (normal 1.2-7.8 IU/L). A total of 17 patients repeated a semen analysis, and in no instance did this result in sperm where there was none previously.

CONCLUSION

The findings from a large multicenter retrospective cohort of adolescent KS patients suggest that a single semen analysis is sufficient for attempted cryopreservation purposes, and that multiple semen analyses is not needed.

Testicular Tissue Banking for Fertility Preservation in Young Boys: Which Patients Should Be Included?

Due to the growing number of young patients at risk of germ cell loss, there is a need to preserve spermatogonial stem cells for patients who are not able to bank spermatozoa. Worldwide, more and more clinics are implementing testicular tissue (TT) banking programs, making it a novel, yet indispensable, discipline in the field of fertility preservation. Previously, TT cryopreservation was predominantly offered to young cancer patients before starting gonadotoxic chemo- or radiotherapy. Nowadays, most centers also bank TT from patients with non-malignant conditions who need gonadotoxic conditioning therapy prior to hematopoietic stem cell (HSCT) or bone marrow transplantation (BMT). Additionally, some centers include patients who suffer from genetic or developmental disorders associated with prepubertal germ cell loss or patients who already had a previous round of chemo- or radiotherapy. It is important to note that the surgical removal of TT is an invasive procedure. Moreover, TT cryopreservation is still considered experimental as restoration methods are not yet clinically available. For this reason, TT banking should preferably only be offered to patients who are at significant risk of becoming infertile. In our view, TT cryopreservation is recommended for young cancer patients in need of high-risk chemo- and/or radiotherapy, regardless of previous low-risk treatment. Likewise, TT banking is advised for patients with non-malignant disorders such as sickle cell disease, beta-thalassemia, and bone marrow failure, who need high-risk conditioning therapy before HSCT/BMT. TT retrieval during orchidopexy is also proposed for patients with bilateral cryptorchidism. Since patients with a medium- to low-risk treatment generally maintain their fertility, TT banking is not advised for this group. Also for Klinefelter patients, TT banking is not recommended as it does not give better outcomes than a testicular sperm extraction later in life.

Effects of hazelnut supplemented diet on doxorubicin-induced damage of reproductive system in male rats

The present study was objected to investigate the effect of hazelnut supplemented diet on the levels of oxidative stress and fertility parameters against doxorubicin-induced testicular and epididymal tissue damage of male rats. Rats were randomly divided into four groups (each n = 8), namely control group (CG), doxorubicin group (DG), doxorubicin + hazelnut group (DHG), and doxorubicin + vitamin E group (DEG). This is the first study designed using DHG. Doxorubicin was intraperitoneally injected into all diet groups except CG at a dose of 3 mg/kg body weight on days 1, 7, 14, 21, and 28. In addition, DHG was supplemented with a hazelnut diet at a dose of 3 g/kg body weight/day and vitamin E was added to the drinking water of DEG at a dose of 50 mg/kg body weight/day. DHG reversed the side effects of doxorubicin and positively improved the epididymis sperm quality, testicular and epididymal tissue injury, testosterone level, epididymis oxidative stress index, and lipid peroxidation in male rats. These findings suggest that hazelnut has positive effects against doxorubicin dependent damage on male rats and it may be a promising supplement for amelioration of testicular toxicity. PRACTICAL APPLICATIONS: Hazelnut has numerous positive health effects due to its macronutrients, micronutrients, lipid-soluble compounds and bioactive phenolics. Studies have shown that regular consumption of hazelnut may have a positive effect on lipid parameters, oxidative stress, inflammation markers, and endothelial dysfunction in both healthy people and patients with chronic diseases. Although doxorubicin (Adriamycin, DOX) is an antibiotic that has been widely used in cancer treatment for nearly 30 years, it causes organ toxicity including testicular tissue. Hazelnut may have positive effects on the damage caused by DOX in the reproductive system. However, studies on the effect of hazelnut on male reproductive health are scarce. Therefore, this study provided a basis for the clinical evaluation of the effects of hazelnut on the reproductive system.

AKT3 and related molecules as potential biomarkers responsible for cryptorchidism and cryptorchidism-induced azoospermia

BACKGROUND

Cryptorchidism is a common congenital malformation strongly related to future oligospermia and male infertility. Normally functioning early-stage spermatogonia are vital to ensure fertility. The present study aimed to identify new differentially expressed genes (DEGs) associated with signaling pathways related to spermatogonial stem cell (SSC) maintenance during early spermatogenesis.

METHODS

GEO2R was used to screen for genes differentially regulated in cryptorchidism using mRNA expression profiling data in the GEO database. DAVID was used to perform GO and KEGG enrichment analysis of DEGs to analyze their functions. A protein-protein interaction (PPI) network of DEGs was constructed using the STRING database. The hub genes in the PPI networks were identified using Maximal Clique Centrality (MCC) in Cytohubba, and the top 50 genes were displayed as hub genes using Cytoscape software. Then, the miRNAs targeting hub genes were predicted using miRWalk and an mRNA-miRNA interaction network was constructed using Cytoscape. We took the intersection of these target miRNAs and the differentially expressed miRNAs identified from a non-coding RNA sequencing dataset, GSE149084. Furthermore, the intersected miRNAs and their predicted target genes were validated in the testicular tissue of rats with cryptorchidism.

RESULTS

A total of 474 DEGs were identified, most of which were annotated to the PI3K-AKT-mTOR signaling pathway. Hub genes related to the pathway were predicted to be targeted by 27 miRNAs. Further miRNA mining revealed that miRNA-7-5p and miRNA-519d-3p were both dysregulated in cryptorchidism patients. Further, we found that these two miRNAs were predicted with high confidence to share a common target gene, AKT3. In the testicular tissue of rats with cryptorchidism, miRNA-519d-3p was upregulated while miRNA-7-5p and AKT3 were downregulated. We also found that AKT3 plays an essential role in regulating SSC state through the PI3K-AKT-mTOR signaling pathway and that AKT3 is one of the key genes related to SSC self-renewal, proliferation, and differentiation.

CONCLUSIONS

The PI3K-AKT-mTOR signaling pathway functions in SSC maintenance, and alterations in this pathway may explain defects in spermatogenesis. AKT3-related miRNAs, including hsa-miR-7-5p and hsa-miR-519d-3p, might be responsible for cryptorchidism and cryptorchidism-induced azoospermia and serve as potential biomarkers.

Androgenization in Klinefelter syndrome: Clinical spectrum from infancy through young adulthood

Klinefelter syndrome (KS) is an uncommon chromosomal disorder in males that has a variable clinical appearance. Classic KS involves an extra X chromosome, (47, XXY), although other variations may exist, including a milder mosaic form as well as multiple extra sex chromosomes with more dramatic phenotypes. KS is underdiagnosed, especially pre-pubertally, owing to a paucity of concrete clinical signs; however, diagnostic rates increase during and after puberty, as the consequences of hypergonadotropic hypogonadism begin to manifest. Testicular failure causing decreased circulating testosterone (T) and germ cell depletion, a hallmark feature in KS, commonly begins shortly after the onset of puberty and leads to the most commonly recognized KS traits: small testes, azoospermia, gynecomastia, decreased facial and pubic hair. While many KS men maintain adequate T levels leading up to young adulthood, some may have lower T levels at an earlier age leading to varied levels of androgenization and clinical KS features. At certain critical time points, absent or decreased T may alter the development of normal male reproductive organs, external genitalia, development of secondary sexual characteristics and spermatogenesis. Testicular failure in utero may lead to ambiguous genitalia, cryptorchidism and/or hypospadias, all of which depend on fetal T production. In the neonatal period and childhood, decreased T levels during the mini-puberty of infancy may negatively impact germ cell differentiation and male neuropsychological development. Finally, decreased T during pubertal and young adulthood can lead to decreased virilization during puberty, eunuchoid skeleton and decreased spermatogenesis. Depending on the timing of the testicular failure, a reproductive window of sperm production may exist to achieve paternity for KS men. The presence or absence of clinical characteristics reflecting decreased androgenization provides an insight to the relative testicular function during these developmental time points for those with KS and contributes to variability within the syndrome.

Visualization of Spatial Distribution of Spermatogenesis in Mouse Testes Using Creatine Chemical Exchange Saturation Transfer Imaging

BACKGROUND

When determining treatment strategies for male infertility, it is important to evaluate spermatogenesis and its spatial distribution in the testes.

PURPOSE

To investigate the usefulness of creatine chemical exchange saturation transfer (CrCEST) imaging for evaluating spermatogenesis and its spatial distribution.

STUDY TYPE

Prospective.

ANIMAL MODEL

C57BL/6 control mice (n = 5) and model mice of male infertility induced by whole testis X-ray irradiation (n = 11) or localized X-ray irradiation to lower regions of testes (n = 3).

FIELD STRENGTH/SEQUENCE

A 11.7-T vertical-bore magnetic resonance imaging (MRI)/segmented fast low-angle shot acquisition for CEST.

ASSESSMENT

The magnetization transfer ratio for the CrCEST effect (MTR_Cr* ) was calculated in each testis of the control mice and X-ray irradiation model mice at 10, 15, 20, and 30 days after irradiation. Correlation analysis was performed between MTR_Cr* and Johnsen's score, a histological score for spermatogenesis. In the localized X-ray irradiation model, regional MTR_Cr* and Johnsen's score were calculated for correlation analysis.

STATISTICAL TESTS

Unpaired t-test, one-way analysis of variance with Tukey's HSD test and Pearson's correlation analysis. A P value < 0.05 was considered statistically significant.

RESULTS

In the irradiation model, CrCEST imaging revealed a significant linear decrease of MTR_Cr* after irradiation (control, 8.7 ± 0.6; 10 days, 7.9 ± 0.8; 15 days, 6.5 ± 0.6; 20 days, 5.4 ± 1.0; 30 days, 4.4 ± 0.8). A significant linear correlation was found between MTR_Cr* and Johnsen's score (Pearson's correlation coefficient (r) = 0.79). In the localized irradiation model, CrCEST imaging visualized a significant regional decrease of MTR_Cr* in the unshielded region (shielded, 6.9 ± 0.7; unshielded, 4.9 ± 1.0), and a significant linear correlation was found between regional MTR_Cr* and Johnsen's score (r = 0.78).

DATA CONCLUSION

Testicular CrCEST effects correlated well with spermatogenesis. CrCEST imaging was useful for evaluating spermatogenesis and its spatial distribution.

EVIDENCE LEVEL

2 TECHNICAL EFFICACY: Stage 2.

What does the future hold? Emerging diagnostic and therapeutic strategies for male infertility

The field of reproductive medicine is rapidly evolving, and important advances have the potential to profoundly impact the way we care for our patients. Emerging developments, including the application of big data analytics and informatics, the notion of reciprocal diagnosis, insights into applied genetics, and stem cell biological and transplantation experimental advances all have the potential to markedly change our therapeutic approach to patients. This month's "Views and Reviews" collection provides an informative glimpse at these emerging technologies, which promise to substantially impact our field and the way we provide care for our patients.