Fertility after cryptorchidism: epidemiology and other outcome studies

Assessment of diagnostic accuracy for cryptorchidism and risk factors for delayed orchidopexy

OBJECTIVES

Cryptorchidism (CO) diagnosis by palpation is challenging. Patients with suspected CO are primarily referred to pediatric urologists by general pediatricians and urologists. Currently, surgical treatment for CO is recommended earlier than in previous guidelines. In this study, we evaluated factors that lead to diagnosis discordance and delayed orchidopexy in patients referred with suspected CO in addition to timing of initial screening.

METHODS

In total, 731 patients (1052 testes) with suspected CO were included. Risk factors for diagnostic discrepancy in CO diagnosis by pediatric urologists and risk of delayed orchiopexy were evaluated.

RESULTS

Herein, 659 (90%) patients were diagnosed during routine public health checkups for infants and young children, and 419 (57%) patients were referred by pediatric practitioners. Of 1052 testes, 374 (36%) were diagnosed with CO by pediatric urologists. In multivariate analysis, risk factors of diagnostic discrepancy for CO diagnosis by pediatric urologists were bilateral testis (odds ratio [OR] = 9.17, p < 0.0001), >6 months old at initial diagnosis (OR = 1.036, p < 0.0001), and pediatric referral (OR = 4.60, p < 0.0001). In total, 296 patients underwent orchiopexy for CO. In multivariate analysis, risk factors for delayed orchiopexy were presence of comorbidities (OR = 3.43, p = 0.003) and >10 months old at referral (OR = 12.62, p < 0.0001).

CONCLUSIONS

Pediatric referral is a risk factor for discordant CO diagnostics, and late age at referral brings a risk of delayed orchiopexy. It is necessary to enlighten pediatricians, who are mainly responsible for routine health checkups, in teaching CO diagnostic techniques to ensure early referral.

Microdissection testicular sperm extraction outcomes in azoospermic patients with bilateral orchidopexy

BACKGROUND

Cryptorchidism is considered to be one of the most common causes of non-obstructive azoospermia. There are several surgical techniques to retrieve sperm in these patients. Microdissection testicular sperm extraction (m-TESE) is a recent sperm retrieval technique which is considered to be a safe, non-blind, and feasible method.

OBJECTIVES

This study aimed to investigate sperm retrieval rate (SRR) by the mTESE method in patients who have undergone orchidopexy due to bilateral cryptorchidism.

MATERIALS AND METHODS

In this retrospective study, 56 ex-cryptorchid patients, who underwent mTESE due to post orchidopexy azoospermia, were included. Patients with hypogonadotropic hypogonadism, Klinefelter syndrome, azoospermia factors (AZF) microdeletion, or chromosomal translocation were excluded from the study. Data were obtained from medical files.

RESULTS

SRR in this study was 46%. Patients were divided into two groups of negative (n = 30) and positive (n = 26) based on the sperm extraction outcomes. There was no statistically significant difference between two groups regarding the mean age at mTESE, mean age at orchidopexy, testicular size, and serum testosterone concentration. However, testicular location, histological patterns, FSH, and LH level showed to have statistically significant relation with sperm retrieval results. But, according to our logistic regression, none of the included variable in the model including FSH, LH, histopathology, and testis location have a significant effect on the presence of the sperm.

DISCUSSION

In the present study, SRR was significantly higher in patients with scrotal testis and low level of FSH and LH.

CONCLUSIONS

Performing mTESE could be recommended in ex-cryptorchid patients with post orchidopexy NOA. Preoperative testicular biopsy seems to be unnecessary while clinical criteria can perfectly define NOA.

Diagnosis, Classification, and Contemporary Management of Undescended Testicles

This article provides a comprehensive review regarding undescended testicles and other related conditions. We have included background information summarizing variable clinical presentations, epidemiology, and the implications of undescended testis (UDT) on fertility and malignancy risk. This article has an emphasis on the approach to diagnosis and surgical management for the UDT. The purpose of this review is to provide readers with useful clinical tools for assessing and treating patients with cryptorchidism.

Reproductive Markers of Testicular Function and Size During Puberty in Boys With and Without a History of Cryptorchidism

CONTEXT

Longitudinal data on levels of hypothalamic-pituitary-gonadal axis hormones and insulin-like growth factor I (IGF-I) during puberty in boys with a history of cryptorchidism are largely missing.

OBJECTIVE

We aimed to compare pubertal hormone levels between boys with a history of congenital cryptorchidism who experienced spontaneous testicular descent or underwent orchiopexy and boys without a history of cryptorchidism.

METHODS

This was a nested case-control study within a population-based birth cohort, with a prospective, longitudinal pubertal follow-up every 6 months (2005 to 2019). Participants were 109 Finnish boys, including boys with a history of unilateral cryptorchidism who underwent orchiopexy (n = 15), unilateral cryptorchidism who had spontaneous testicular descent (n = 15), bilateral cryptorchidism who underwent orchiopexy (n = 9), bilateral cryptorchidism who had spontaneous testicular descent (n = 7), and controls (n = 63). Serum reproductive hormone levels and testicular volumes were measured.

RESULTS

From around onset of puberty, boys with bilateral cryptorchidism who underwent orchiopexy had significantly higher follicle-stimulating hormone (FSH) and lower inhibin B levels than controls. Boys with unilateral cryptorchidism who underwent orchiopexy had significantly higher FSH than controls, whereas inhibin B levels were similar. Testosterone, luteinizing hormone, insulin-like factor 3, and IGF-I were generally similar between groups. Testicular volume of boys with unilateral or bilateral cryptorchidism who underwent orchiopexy was smaller than that of the controls from 1 year after pubertal onset (P < 0.05).

CONCLUSION

Cryptorchid boys, particularly those with bilateral cryptorchidism who underwent orchiopexy, had altered levels of serum biomarkers of Sertoli cells and germ cells and smaller testicular volumes compared with controls.

The undescended testis in children and adolescents. Part 1: pathophysiology, classification, and fertility- and cancer-related controversies

Undescended testis (UDT) is defined as failure of a testis to descend into the scrotum. It is one of the most common reasons for consultation in pediatric surgery and urology with an incidence of 3% in live-born male infants. Decades ago, classical studies established that the failure of a testis to descend alters the development of its germ cells increasing the risk of infertility and testicular cancer in adulthood. More recent publications have rebutted some of the myths and raised controversies regarding the management of these patients, which, far from being limited to surgical treatment, should include pathophysiological and prognostic aspects for a comprehensive approach to the condition. Therefore, here we present an updated review divided into two parts: the first assessing the pathophysiological aspects and risks of these patients focused on fertility and cancer, and the second addressing the different treatment options for UDT.

A prediction model for risk factors of testicular atrophy after orchiopexy in children with undescended testis

BACKGROUND

There have been limited studies with small sample sizes about risk factors of testicular atrophy. Thus, we aimed to investigate the risk factors for testicular atrophy after orchiopexy in male children with undescended testes and develop a prediction model based on clinical variables.

METHODS

We performed a retrospective review of data on children who underwent orchiopexy for undescended testes from 2013 to 2017. The variables assessed included age, laterality, testicular location, preoperative testicular volume ratio, deferens and epididymis anomaly, hormonal treatment, comorbidities, type of surgical procedure, operating time, and complications as the outcome of testicular atrophy. A nomogram was constructed to predict the probability of testicular atrophy. We also validated our model based on a prospective cohort of patients who underwent orchiopexy from January 2018 to December 2018.

RESULTS

A total of 1,608 patients undergoing orchiopexy were included in the training cohort. The median age was 2.8 years (range, 0.5-11.3 years). After follow-up for 12 to 18 months (median, 14 months), 228 (14.2%) cases of atrophic testes were recorded. The independent predictors of testicular atrophy were preoperative testicular volume ratio [odds ratio (OR) 0.001, P=0.001], testicular location (OR 1.903, P=0.001), deferens and epididymis anomaly (OR 6.470, P=0.001), and two-stage Fowler-Stephens orchiopexy (OR 2.613, P=0.04). Successful validation was achieved, and a receiver operating characteristic (ROC) curve was constructed. The sensitivity and specificity of the prediction model were 78.1% and 77.5%, respectively. The area under the ROC curve was 0.851.

CONCLUSIONS

In patients with undescended testes, excluding those with chromosomal abnormalities and testicular nubbin, the incidence of testicular atrophy after orchiopexy is higher in patients with a lower testicular volume ratio, higher testicular location, deferens and epididymis anomaly, and in two-stage Fowler-Stephens orchiopexy. Therefore, this prediction model provides useful evidence for surgeons to choose an appropriate surgical procedure for undescended testes and predict the probability of testicular atrophy.

The impact of early and successful orchidopexy on hormonal follow-up for 208 boys with bilateral non-syndromic cryptorchidism

PURPOSE

Inhibin-B is produced by Sertoli cells and decreased values might be associated with impaired fertility potential. The aim of the study was to evaluate the impact of bilateral orchidopexy on serum inhibin-B and follicle-stimulating hormone (FSH).

METHODS

A cohort study including 208 bilateral cryptorchid boys (median age: 1.7 year) was evaluated with serum inhibin-B and FSH in relation to histological parameters. Based on the fertility potential, the boys were divided into three subgroups. At follow-up (median age: 2.7 years) the boys were evaluated with FSH and in case of inhibin-B using multiple of the median (MoM).

RESULTS

Inhibin-B MoM improved significantly at follow-up. In 32 boys with high FSH at orchidopexy 63% normalized FSH and 59% increased MoM inhibin-B, but 31% had impaired inhibin-B at follow-up. In 105 boys with transient hypogonadotropic hypogonadism, 52% increased inhibin-B MoM but 31% had impaired inhibin-B at follow-up. In 71 boys with normal FSH, inhibin-B, and G/T, 54% increased inhibin-B MoM and 15% had impaired inhibin-B at follow-up. The effect of the surgery was best in patients younger than 1 year.

CONCLUSION

Orchidopexy, especially before 1 year of age, improves the fertility potential in bilateral cryptorchidism. At follow-up, 26% (54/208) had a risk of infertility based on inhibin-B.

Apparent diffusion coefficient values of cryptorchid testes and malignant transformation of cryptorchidism (MTC) (seminoma) in postpubertal patients

OBJECTIVES

Diffusion-weighted imaging signal contrast can be quantified by apparent diffusion coefficient (ADC) maps, which reflect the diffusion properties of the examined tissue and are helpful for identifying pathology. To determine ADC values of cryptorchid testes in post-pubertal patients and assess performance for characterizing cryptorchid testes.

METHODS

The medical records from 35 patients with unilateral scrotal vacuity were retrospectively reviewed. Data were analyzed in three groups: Group A, normal testes (i.e. the contralateral testes of the patients with cryptorchidism or MTC); Group B, cryptorchid testes; and Group C, malignant transformation of cryptorchidism (MTC) (seminoma). DWI used b-values of 0 and 800 s/mm². Mean ADC values were compared using the independent samples t-test. The ability of ADC values was assessed using receiver operating characteristic curve analysis. The sensitivity, specificity, and accuracy were calculated.

RESULTS

Mean ADC values for normal testes, cryptorchid testes, and MTC were 1.18 ± 0.18×10^-3 mm²/s, 1.82 ± 0.40×10^-3 mm²/s, and 0.80 ± 0.06×10^-3 mm²/s, respectively. There were statistically significant differences in mean ADC values between normal testes and cryptorchid testes or MTC (p < 0.001). The cut-off ADC value for differentiating normal testes from cryptorchid testes was 1.47 × 10^-3 mm²/s. The sensitivity, specificity, and accuracy were 88%, 91%, and 90%, respectively. The cut-off ADC value for differentiating normal testes from MTC was 1.22 × 10^-3 mm²/s. The sensitivity, specificity, and accuracy were 100%, 31%, and 43%, respectively.

CONCLUSION

ADC values of cryptorchid testes may be used to inform clinical decision-making and also monitor testicular function in patients who retain undescended testicles or post-operatively.

ADVANCES IN KNOWLEDGE

Mean ADC values of cryptorchidism and MTC (seminoma) were used to reflect their pathological features.

[AFU and SALF recommendations for the evaluation of male infertility]

BACKGROUND

The aim of these Association Française d'Urologie (AFU) and Société d'Andrologie de Langue Française (SALF) common recommendations are to provide practice guidelines for the French Urological and Andrological community regarding the evaluation of infertile men.

MATERIAL AND METHODS

Literature search in PubMed using the keywords "male infertility", "diagnosis", "management" and "evaluation" limited to clinical articles in English and French prior to 1/01/2020. To inform the level of evidence, the HAS grading system (2013) was applied.

RESULTS

Concerning the evaluation of infertile men, the AFU and the SALF recommend : (1) a systematic interview exploring the family history, the fertility history of the man outside the couple, the patient's personal history that may have an impact on his fertility, lifestyle habits, treatments, symptoms and possible sexual difficulties of the couple; (2) a general physical examination to assess signs of hypogonadism and secondary sexual characters; (3) a scrotal physical examination performed by an urologist or andrologist to assess (i) the testes for volume and consistency, (ii) vas deferens and epididymes for total or partial absence or nodules, and (iii) presence of varicoceles; (4) Performing two semen analyses, according to World Health Organization guidelines, if the first one has at least one abnormaly; (5) a scrotal ultrasound as part of routine investigation, that can be completed with an endorectal pelvic ultrasound according to the clinic; (6) an endocrine evaluation with at least a Testosterone and FSH serum determination; (7) Karyotype analysis in infertile men with a sperm concentration ≤10 10⁶/mL; (8) assessment of Yq microdeletions in infertile men with a sperm concentration ≤1 10⁶/mL; (9) Cystic fibrosis transmembrane conductance regulator gene evaluation in case of suspicion for bilateral or unilateral congenital agenesis of vas deferens and seminal vesicles. The interest of tests analyzing DNA fragmentation (TUNEL, SCSA) is still under investigation.

CONCLUSION

These guidelines can be applied in routine clinical practice in all infertile men.

Comparison of diagnostic and treatment guidelines for undescended testis

Cryptorchidism or undescended testis is the single most common genitourinary disease in male neonates. In most cases, the testes will descend spontaneously by 3 months of age. If the testes do not descend by 6 months of age, the probability of spontaneous descent thereafter is low. About 1%-2% of boys older than 6 months have undescended testes after their early postnatal descent. In some cases, a testis vanishes in the abdomen or reascends after birth which was present in the scrotum at birth. An inguinal undescended testis is sometimes mistaken for an inguinal hernia. A surgical specialist referral is recommended if descent does not occur by 6 months, undescended testis is newly diagnosed after 6 months of age, or testicular torsion is suspected. International guidelines do not recommend ultrasonography or other diagnostic imaging because they cannot add diagnostic accuracy or change treatment. Routine hormonal therapy is not recommended for undescended testis due to a lack of evidence. Orchiopexy is recommended between 6 and 18 months at the latest to protect the fertility potential and decrease the risk of malignant changes. Patients with unilateral undescended testis have an infertility rate of up to 10%. This rate is even higher in patients with bilateral undescended testes, with intra-abdominal undescended testis, or who underwent delayed orchiopexy. Patients with undescended testis have a threefold increased risk of testicular cancer later in life compared to the general population. Self-examination after puberty is recommended to facilitate early cancer detection. A timely referral to a surgical specialist and timely surgical correction are the most important factors for decreasing infertility and testicular cancer rates.

Diagnosis and treatment of the intra-abdominal gonad in the pediatric population: Testes, ovaries, dysgenetic gonads, streaks, and ovotestes

BACKGROUND/PURPOSE

Pediatric surgical specialists are often confronted with the difficult task of identifying, diagnosing and managing intra-abdominal gonads in children. Ranging from the intra-abdominal cryptorchid testis to normal or pathologic ovaries and gonads in disorders of sexual development, all intra-abdominal gonads in the pediatric population pose different diagnosis and management challenges. Understanding the hormonal and fertility potential of the gonad and knowing its potential cancer risk is essential when deciding how to manage these patients. In addition, the ideal surgical management for each one of these patients is often debated.

METHODS

Descriptive literature review.

RESULTS/CONCLUSION

Herein, we reviewed gonadal formation, common etiologies, diagnosis and management of intra-abdominal testes, pathologic ovaries and gonads in disorders of sexual development. Fertility potential and cancer risk for each were also reviewed and how both affect surgical management of the gonad.

TYPE OF STUDY/LEVEL OF EVIDENCE

Review Article, Level V.

Fertility outcomes and predictors for successful sperm retrieval and pregnancy in 327 azoospermic men with a history of cryptorchidism who underwent microdissection testicular sperm extraction

BACKGROUND

Although few studies have reported fertility outcomes, no study has reported risk factors that might predict sperm retrieval and pregnancy in azoospermic men with a history of cryptorchidism in a large series.

OBJECTIVES

To investigate fertility outcomes and predictors for successful sperm retrieval and pregnancy in azoospermic men with a history of cryptorchidism who underwent microdissection testicular sperm extraction (mTESE).

MATERIALS AND METHODS

This retrospective observational study included 327 azoospermic men with a history of cryptorchidism who underwent mTESE. Fertility outcomes including sperm retrieval, fertilization rate, number of transferred embryos, pregnancy, miscarriage, and live birth rates were recorded.

RESULTS

Sperm retrieval was observed in 172 (52.6%) of the patients. The mean fertilization, pregnancy, and live birth rates were 55.2%±20.5, 53.5%, and 44.8%, respectively. The sperm retrieval rate was significantly higher at the orchidopexy age of ≤ 9.5 years (70.8%) than the orchidopexy age of > 9.5 years (42.1%) (P = .000). Patients with total testicular volume of ≥ 13.75 mL had significantly higher sperm retrieval rate (65.2%) than the patients with total testicular volume of < 13.75 mL (45.5%) (P = .001). Patients with total testosterone level of ≥ 300.5 ng/dL had significantly higher sperm retrieval rate (65.6%) than the patients with total testosterone level of < 300.5 ng/dL (40.3%) (P = .000). Patients with follicle-stimulating hormone (FSH) level of ≤ 17.25 mIU/ml had significantly higher sperm retrieval rate (72.3%) than the patients with FSH level of > 17.25 mIU/mL (44.4%) (P = .000). Younger male and female ages, and higher fertilization rates were the parameters that might predict pregnancy.

CONCLUSIONS

Infertile azoospermic men with a history of cryptorchidism have high sperm retrieval rate with mTESE. Patients who had orchidopexy at the age of ≤ 9.5 years, and having total testicular volumes of ≥ 13.75 mL with total testosterone level of > 300.5 ng/dL and FSH level of ≤ 17.25 mIU/mL have higher success rate for sperm retrieval.

Successful in vitro fertilization in a 30 years old man with bilateral abdominal cryptorchidism

Retention of the testis is one of the most common congenital malformation in male infants. The incidence of this disease is 1-2% at 1 year of age. As nonpalpable are reported around 20% of cases and in up to 30% of neonates may affect both sides. For optimal results, orchidopexy should be performed between the ages of six and eighteen months. We presented a rare case of successful in vitro fertilization after laparoscopic Fowler-Stephens orchidopexy in 30 years old man with bilateral abdominal cryptorchidism.

Factors associated with delay in undescended testis referral

INTRODUCTION

Undescended testis (UDT) is one of the most common congenital disorders and is associated with infertility and testicular cancer. Multiple guidelines internationally have recommended orchiopexy by 18 months. Multiple large retrospective studies published in the last decade have found persistent delay in timing of orchiopexy.

OBJECTIVE

The aim of the study was to determine timing at which UDTs are referred at the tertiary pediatric hospital and assess factors that are associated with delay in UDT referral.

STUDY DESIGN

Based on clinical observations and previous data, a series of clinical and socio-economic variables were constructed to design a prospective database. All patients who underwent orchiopexy for UDT from March 1, 2017, to August 31, 2018, were reviewed for demographic and clinical data. Referral appointments after 18 months were considered delayed. Factors associated with delay in UDT referral were analyzed using univariate and multivariate analysis with logistic regression.

RESULTS

One hundred seventy-eight patients underwent orchiopexy for UDT. The median age was 44 months, and 64% of them had delay in referral. On univariate analysis, normal birth testicular examination, diagnosis of 'retractile testicle,' long gap without seeing pediatrician, diagnosis by a new physician, and primary language non-English were associated with delayed UDT referral. On multivariate analysis, delayed referral was associated with normal testicular examination at birth, history of 'retractile testis,' diagnosis not by the regular primary care provider, and other health or social issues that may have led to delay.

DISCUSSION

This is the first prospective study analyzing timing of referral for boys with cryptorchidism. It was found that timing of treatment of UDT with orchiopexy has not improved over the last decade. Major causes in delay in referral may be due to poor of education of families and lack of routine testicular examinations by referring providers. Secondary ascent may account a significant number of delayed orchiopexy cases.

CONCLUSION

Most patients at Doernbecher had delayed referral of cryptorchidism. Factors associated with delay were determined. To improve treatment of cryptorchidism, quality-based interventions and the importance of education and routine testicular examinations need to be focused on.

Hypogonadism and Cryptorchidism

Congenital cryptorchidism (undescended testis) is one of the most common congenital urogenital malformations in boys. Prevalence of cryptorchidism at birth among boys born with normal birth weight ranges from 1.8 to 8.4%. Cryptorchidism is associated with a risk of low semen quality and an increased risk of testicular germ cell tumors. Testicular hormones, androgens and insulin-like peptide 3 (INSL3), have an essential role in the process of testicular descent from intra-abdominal position into the scrotum in fetal life. This explains the increased prevalence of cryptorchidism among boys with diseases or syndromes associated with congenitally decreased secretion or action of androgens, such as patients with congenital hypogonadism and partial androgen insensitivity syndrome. There is evidence to support that cryptorchidism is associated with decreased testicular hormone production later in life. It has been shown that cryptorchidism impairs long-term Sertoli cell function, but may also affect Leydig cells. Germ cell loss taking place in the cryptorchid testis is proportional to the duration of the condition, and therefore early orchiopexy to bring the testis into the scrotum is the standard treatment. However, the evidence for benefits of early orchiopexy for testicular endocrine function is controversial. The hormonal treatments using human chorionic gonadotropin (hCG) or gonadotropin-releasing hormone (GnRH) to induce testicular descent have low success rates, and therefore they are not recommended by the current guidelines for management of cryptorchidism. However, more research is needed to assess the effects of hormonal treatments during infancy on future male reproductive health.

Role of Ozone Therapy in Preventing Testicular Damage in an Experimental Cryptorchid Rat Model

Background

Cryptorchidism is the most common developmental abnormality of the male reproductive system. If left untreated, it results with infertility and testicular cancer. According to current evidence, surgery is the mainstay of treatment, and hormonal therapy approaches are still under investigation. For the protection of testicular functions, antioxidants have emerged as novel options. This study aimed to evaluate the protective properties of ozone, a strong antioxidant, on testicular tissue.

Material/Methods

Thirty-five male Wistar-albino rats, 1-month-old, were used for the study. Groups were formed as follows: 1) control, 2) sham surgery (cryptorchidism), 3) cryptorchidism plus ozone, 4) cryptorchidism plus human chorionic gonadotropin (hCG), and 5) ozone plus hCG. Surgical procedures were performed on all rats except the control group. All rats except the control group were used to create an experimental cryptorchidism model, and left testes of animals were surgically placed into the abdomen. After 1 month of surgery, groups 3, 4, and 5 were given corresponding treatments intraperitoneally for 4 weeks. At the end of the study period, testicular atrophy index (TAI) and testicular sperm motility (TSM) were assessed and biochemical, histopathological, and immunohistochemical tests were performed.

Results

TAI and TSM were higher in the ozone, hCG, and ozone plus hCG groups than in the sham surgery group (p=0.001). TSM in the ozone group was significantly higher than in the hCG and ozone plus hCG groups. In biochemical analyses, the parameters of oxidative stress (GPx1, MDA, CAT, GSH, SOD) indicated increased oxidative activity in cryptorchidism, which was resolved by applying ozone and hCG (p=0.001). In addition, apoptotic markers, Caspase 3 and bcl-2 were significantly decreased by applying ozone and hCG (p=0.001).

Conclusions

Results of this study suggest that ozone therapy, either as a single agent or in combination with hCG, is a promising approach for protection of testicular functions.

Canadian Urological Association-Pediatric Urologists of Canada (CUA-PUC) guideline for the diagnosis, management, and followup of cryptorchidism

Cryptorchidism is one of the most common congenital anomalies in males, characterized by inability to palpate the testicle in the expected normal anatomical position (i.e., within its respective hemi-scrotum). It represents an abnormality of testicular descent and development associated with long-term concerns, including infertility, hypogonadism, and development of neoplasms.

Management of undescended testes: European Association of Urology/European Society for Paediatric Urology Guidelines

CONTEXT

Undescended testis is the most common endocrinological disease in the male newborn period. Incidence varies between 1.0% and 4.6% in full-term neonates, with rates as high as 45% in preterm neonates. Failure or delay of treatment can result in reduced fertility and/or increased testicular cancer risk in adulthood.

OBJECTIVE

To provide recommendations for the diagnosis and treatment of boys with undescended testes which reduce the risk of impaired fertility and testicular cancer in adulthood.

EVIDENCE ACQUISITION

Embase and Pubmed were searched for all relevant publications, from 1990 to 2015 limited to English language. Data were narratively synthesized in light of methodological and clinical heterogeneity. The risk of bias of each included study was assessed.

EVIDENCE SYNTHESIS

There is consensus that early treatment, by 18 months at the latest, for undescended testes is mandatory to avoid possible sequelae regarding fertility potential and cancer risk. The current standard therapy is orchidopexy, while hormonal therapy is still under debate. However, in some individuals the successful scrotal placement of previously undescended testes may not prevent potential negative long-term outcomes regarding fertility and testicular malignancy.

CONCLUSIONS

There is good evidence for early placement of undescended testes in the scrotal position to prevent potential impairment of fertility and reduce the risk of testicular malignancy. No consensus exists on the various forms of hormonal treatment, which are assessed on an individual basis.

Cryptorchidism and Fertility

Cryptorchidism, the failure of one or both testes to descend into the scrotum prenatally, occurs in 2.4%–5% of newborns. Many of these testes will descend spontaneously shortly after birth, but ~23% will remain undescended unless surgery is performed. Bilaterally cryptorchid men have a six times greater risk of being infertile when compared with unilaterally cryptorchid men and the general male population. Approximately 10% of infertile men have a history of cryptorchidism and orchidopexy. The main reasons for infertility in men with a history of cryptorchidism treated by orchidopexy are maldevelopment of the testes and an improper environment for the normal development of the testes, hyperthermia, and antisperm antibodies.

Putting the pieces together: cryptorchidism - do we know everything?

Cryptorchidism is one of the most common birth defects in male children, and it has a potential impact on future health. It is the best-characterized risk factor for reduced fertility and testicular cancer. However, the etiology of cryptorchidism remains largely unknown. In the literature, we find different opinions and theories on this topic. Probably, the etiology is multifactorial, and hormonal, genetic and environmental factors may regulate testicular development and descent from intra-abdominal location into the bottom of the scrotum. The descent of the testis is a complex, two-stage process. A critical role in testicular descent has been attributed to androgens, insulin-like hormone 3 (insl3) and anti-Müllerian hormone. It is believed that interaction between Leydig and Sertoli cells may cause impaired spermatogenesis. Based on recent knowledge of germ cell development, it is believed that the best treatment for undescended testis is orchiopexy between 6th and 12th month of life. Long follow-up studies are needed to focus on the effect of this recommendation.

The influence of anorectal malformations on fertility: a systematic review

PURPOSE

This systematic review aims to give an overview of available evidence concerning the influence of anorectal malformations (ARM) on fertility.

METHODS

We conducted a search in PubMed, EMBASE and Cochrane Library conformed to the PRISMA standards. All studies reporting on fertility and ARM were included.

RESULTS

2,905 studies were identified. Based on title, abstract and full text, nine articles on 429 patients remained to answer the research question. Childbirth rate was the only reported outcome parameter to describe fertility. An overall childbirth rate of 27 % (range 0-57 %) was found. Mean age at time of study ranged from 23 to 35 years. There was no statistical significant difference in childbirth rate between female and male patients, based on seven studies (p = 0.45). Patients with a more complex type of ARM (imperforated anus without fistula, rectourethral bulbar and prostatic fistulas, rectobladderneck fistulas and cloacal malformations) had a lower childbirth rate compared to healthy controls, whereas in patients with a less complex ARM (rectoperineal or rectovestibular fistula) the childbirth rate was similar to healthy controls. Patients with a more complex type of ARM had a significant lower childbirth rate than patients with a less complex type of ARM (18 vs 47 %, respectively) (p = 0.0001). When further dividing these patients by gender, this difference was only seen in female patients (p = 0.04).

CONCLUSION

In patients with a more complex type of ARM a lower childbirth rate was found compared to healthy controls and patients with a less complex type of ARM. The latter was only seen in female patients. However, conclusions concerning fertility in ARM patients have to be taken with caution due to limited quality of the studies. Further investigation is recommended.

Testicular tissue cryopreservation and spermatogonial stem cell transplantation to restore fertility: from bench to bedside

Male infertility management has made significant progress during the past three decades, especially after the introduction of intracytoplasmic sperm injection in 1992. However, many boys and men still suffer from primary testicular failure due to acquired or genetic causes. New and novel treatments are needed to address these issues. Spermatogenesis originates from spermatogonial stem cells (SSCs) that reside in the testis. Many of these men lack SSCs or have lost SSCs over time as a result of specific medical conditions or toxic exposures. Loss of SSCs is critical in prepubertal boys who suffer from cancer and are going through gonadotoxic cancer treatments, as there is no option of sperm cryopresrvation due to sexual immaturity. The development of SSC transplantation in a mouse model to repopulate spermatozoa in depleted testes has opened new avenues of research in other animal models, including non-human primates. Recent advances in cryopreservation and in vitro propagation of human SSCs offer promise for human SSC autotransplantation in the near future. Ongoing research is focusing on safety and technical issues of human SSC autotransplantation. This is the time to counsel parents and boys at risk of infertility on the possibility of cryopreserving and banking a small amount of testis tissue for potential future use in SSC transplantation.

Male infertility: assessment of juvenile testicular dysfunction and risk for malignancy in cryptorchid boys based on resin section evaluation

Infertility is sometimes more a man's problem than a woman's, failure of one or both of the testes to descend (cryptorchidism) being the most frequent genital malformation in boys. Untreated, the undescended testis impairs germ cell development and significantly reduces adult fertility. A-dark spermatogonia are the stem cells for all future spermatozoa, and their depletion can be reliably estimated in resin semithin sections. Additionally, there is an increased risk of testicular preneoplasia in the form of carcinoma in situ (CIS) cells. The authors report how the pathologic biopsy examination of juvenile cryptorchid testes can assess infertility and malignancy risk.

Fertility potential in a cohort of 65 men with previously acquired undescended testes

PURPOSE

To evaluate testicular function in men with previously acquired undescended testes (AUDT) in whom spontaneous descent was awaited until puberty followed by orchiopexy in case of nondescent.

METHODS

Andrological evaluation including paternity, scrotal ultrasound, reproductive hormones, and semen analysis was performed in three groups: men with AUDT, healthy controls, and men with previously congenital undescended testes (CUDT).

RESULTS

In comparison with controls, men with AUDT more often had significantly abnormal testicular consistency, smaller testes, lower sperm concentration, and less motile sperm. Except for more often a normal testicular consistency in men with AUDT, no differences were found between men with AUDT and men with CUDT. Also, no differences were found between men with AUDT which had spontaneously descended and men who underwent orchiopexy.

CONCLUSIONS

Fertility potential in men with AUDT is compromised in comparison with healthy controls, but comparable with men with CUDT. This suggests that congenital and acquired UDT share the same etiology. No significant difference was found between men who had spontaneous descent and men needing orchiopexy. However, fertility potential is unknown for men after immediate surgery at diagnosis, and this should be a subject for future studies.

Management of undescended testis: a decision analysis

BACKGROUND

Undescended testis (UDT) or cryptorchidism is the most common genital anomaly seen in boys and can be treated surgically by orchidopexy. The age at which orchidopexy should be performed is controversial for both congenital and acquired UDT.

METHODS

A decision analysis is performed in which all available knowledge is combined to assess the outcomes of orchidopexy at different ages.

RESULTS

Without surgery, unilateral congenital UDT and bilateral congenital UDT are associated with average losses in quality-adjusted life-years (QALYs) of 1.53 QALYs (3% discounting 0.66 QALYs) and 5.23 QALYs (1.91 QALYs), respectively. Surgery reduces this QALY loss to on average 0.84 QALYs (0.21 QALYs) for unilateral UDT and 1.66 QALYs (0.40 QALYs) for bilateral UDT. Surgery at detection will lead to the lowest QALY loss of 0.91 (0.34) and 1.73 (0.60) QALYs, respectively, for unilateral and bilateral acquired UDT compared with surgery during puberty and no surgery. No sensitivity analysis is able to change the preferences for these strategies.

CONCLUSIONS

Based on our decision analytic model using societal valuations of health outcomes, surgery for unilateral UDT (both congenital and acquired) yielded the lowest loss in QALYs. Given the modest differences in outcomes, there is room for patient (or parent) preference with respect to the performance and timing of surgery in case of unilateral UDT. For bilateral UDT (both congenital and acquired), orchidopexy at any age provides considerable benefit, in particular through improved fertility. As there is no strong effect of timing, the age at which orchidopexy is performed should be discussed with the parents and the patient. More clinical evidence on issues related to timing may in the future modify these results and hence this advice.

Fertility potential in men with a history of congenital undescended testes: a long-term follow-up study

Men with a history of congenital undescended testes (UDT) have an increased risk of fertility problems. Despite no definitive proof, current guidelines recommend early surgical intervention because this may have a positive effect on future fertility potential by preventing degenerative changes of the testes in early life. Also surgical intervention facilitates observability of the testes in view of possible malignancy. We evaluated testicular function in adult men with previous UDT treated at different ages before puberty. A long-term follow-up study of men with previous UDT was performed. Andrological evaluation included medical history taking, physical examination, scrotal ultrasound, determination of reproductive hormones, and semen analysis. Findings were compared with those of a control group of men with normal testicular descent. The influence of age at orchiopexy on future fertility parameters was evaluated in a multivariate regression analysis. 62 men were included of whom seven had had bilateral UDT. Twenty-four patients had had their orchiopexy before the age of 24 months of whom eight men had it before 12 months of age. Forty-eight men had had unsuccessful luteinizing-hormone-releasing-hormone (LHRH) nasal spray treatment during childhood, whereas 14 of 24 men operated before 24 months of age had not received LHRH treatment before orchiopexy. Fertility potential in men with a history of UDT is compromised in comparison with controls. We could not detect any influence of age at orchiopexy on fertility parameters. However, the number of patients operated before the age of 12 months is limited. This study does not support the assumption that early orchiopexy results in better fertility potential.

Inguinal and genital anomalies

Problems of the groin and genitalia are a common presenting complaint in both pediatrician's offices and emergency departments. The authors endeavor to provide a comprehensive review of the most common inguinal and genital anomalies encountered by the pediatrician, with a special focus on examination and management.

Pediatric inguinal hernias, hydroceles, and undescended testicles

Pediatric inguinal hernias are extremely common, and can usually be diagnosed by simple history taking and physical examination. Repair is elective, unless there is incarceration or strangulation. Hydroceles are also quite common, and in infancy many will resolve without operative intervention. Undescended testicles harbor an increased risk of infertility and malignancy, and require orchiopexy in early childhood.

Adult care of children from pediatric urology: part 2

PURPOSE

We describe the outcomes of undescended testes and sex development disorders in adolescence and young adulthood. We reviewed the requirements for the long-term care of children born with these and other major congenital anomalies of the genitourinary system.

MATERIALS AND METHODS

The current English language literature was retrieved with a PubMed® search for articles on these subjects. Only articles covering outcomes at ages past puberty were included in analysis. The material was supplemented from the database of the clinic for adults with sex development disorders at University College London Hospitals.

RESULTS

An undescended testis has impaired spermatogenesis. In men in whom a unilateral undescended testis was corrected before puberty the incidence of paternity is normal at around 90% of those who attempt it. The equivalent rate for those with bilateral undescended testes is about 65%. If surgery for bilateral undescended testes is delayed until after puberty, fertility is unlikely. The risk of testicular neoplasms is overestimated and the relative risk is between 2.5 and 8. Children born with a sex development disorder receive multidisciplinary treatment throughout childhood and require the same care as adults. Males who are under virilized likely have a micropenis (greater than 2 SD below the mean stretched length) but they may have normal sexual function. Fertility depends on the underlying condition. Virilized females, who most commonly have congenital adrenal hyperplasia, currently present to adult clinics with an inadequate vagina after infantile surgery. Reconstruction is required to allow intercourse.

CONCLUSIONS

The care of adults born with abnormalities of the genitalia is complex. Early management may define upbringing in childhood but requirements for sexuality and fertility in adult life are different. Multidisciplinary care is essential and a case can be made to establish a subspecialty of urology to coordinate it.

Practice variation and clinical confusion regarding undescended testes and retractile testes among primary care respondents: a multi-regional survey study in the United States

PURPOSE

Although previous studies have looked at referral patterns and indications for orchiopexy, this is the first attempt at quantifying the primary care provider knowledge base of cryptorchidism and its implications in a large multi-state setting in the United States.

METHODS

Primary care providers (PCPs) (n = 3,000) were invited to complete a web-based survey regarding cryptorchidism. We evaluated: practice setting; training; knowledge of cryptorchidism; relationship to pediatric urologists and surgeons; understanding of the relationship between cryptorchidism, infertility and testis cancer.

RESULTS

Seventeen percent (n = 453) of PCPs responded to the survey. Fifty-three percent indicated that they had minimal to no exposure to pediatric urology during training. Two-thirds refer patients with retractile testes to surgical specialists. Practice setting was associated with the type of information families received about the impact of UDT on fertility and malignancy with rural practices being more likely to counsel that unilateral UDT imparted a high risk of malignancy (RR 1.5; 95 % CI 1.2, 1.9) and bilateral UDT resulted in likely infertility (RR 2.1; 95 % CI 1.5, 2.8).

CONCLUSIONS

This study underscores the need for increased evidence-based recommendations, as well as improved training and education of PCPs in the US who deal with disorders of testicular descent.

Management of cryptorchidism: a survey of clinical practice in Italy

BACKGROUND

An evidence-based Consensus on the treatment of undescended testis (UT) was recently published, recommending to perform orchidopexy between 6 and 12 months of age, or upon diagnosis and to avoid the use of hormones. In Italy, current practices on UT management are little known. Our aim was to describe the current management of UT in a cohort of Italian children in comparison with the Consensus guidelines. As management of retractile testis (RT) differs, RT cases were described separately.

METHODS

Ours is a retrospective, multicenter descriptive study. An online questionnaire was filled in by 140 Italian Family Paediatricians (FP) from Associazione Culturale Pediatri (ACP), a national professional association of FP. The questionnaire requested information on all children with cryptorchidism born between 1/01/2004 and 1/01/2006. Data on 169 children were obtained. Analyses were descriptive.

RESULTS

Overall 24% of children were diagnosed with RT, 76% with UT. Among the latter, cryptorchidism resolved spontaneously in 10% of cases at a mean age of 21.6 months. Overall 70% of UT cases underwent orchidopexy at a mean age of 22.8 months (SD 10.8, range 1.2-56.4), 13% of whom before 1 year. The intervention was performed by a paediatric surgeon in 90% of cases, with a success rate of 91%. Orchidopexy was the first line treatment in 82% of cases, while preceded by hormonal treatment in the remaining 18%. Hormonal treatment was used as first line therapy in 23% of UT cases with a reported success rate of 25%. Overall, 13 children did not undergo any intervention (mean age at last follow up 39.6 months). We analyzed the data from the 5 Italian Regions with the largest number of children enrolled and found a statistically significant regional difference in the use of hormonal therapy, and in the use of and age at orchidopexy.

CONCLUSIONS

Our study showed an important delay in orchidopexy. A quarter of children with cryptorchidism was treated with hormonal therapy. In line with the Consensus guidelines, surgery was carried out by a paediatric surgeon in the majority of cases, with a high success rate.

Testicular biopsy: clinical practice and interpretation

Testicular biopsy was considered the cornerstone of male infertility diagnosis for many years in men with unexplained infertility and azoospermia. Recent guidelines for male infertility have limited the indications for a diagnostic testicular biopsy to the confirmation of obstructive azoospermia in men with normal size testes and normal reproductive hormones. Nowadays, testicular biopsies are mainly performed for sperm harvesting in men with non-obstructive azoospermia, to be used for intracytoplasmic sperm injection. Testicular biopsy is also performed in men with risk factors for testicular malignancy. In a subgroup of infertile men, there is an increased risk for carcinoma in situ of the testis, especially in men with a history of cryptorchidism and testicular malignancy and in men with testicular atrophy. Ultrasonographic abnormalities, such as testicular microlithiasis, inhomogeneous parenchyma and lesions of the testes, further increase the risk of carcinoma in situ (CIS) in these men. For an accurate histological classification, proper tissue handling, fixation, preparation of the specimen and evaluation are needed. A standardized approach to testicular biopsy is recommended. In addition, approaches to the detection of CIS of the testis testicular immunohistochemistry are mandatory. In this mini-review, we describe the current indications for testicular biopsies in the diagnosis and management of male infertility.

Focus issue on male infertility

Male infertility problems can occur when sperms are limited in number or function. In this paper, we describe the clinical evaluation of male infertility. A detailed history, physical examination, and basic semen analysis are required. In addition, ultrasound, karyotyping, and hormonal studies are needed to determine specific causes of infertility. In addition, the World Health Organization (WHO, 2009) has developed a manual to provide guidance in performing a comprehensive semen analysis. Among the possible reasons for male infertility, nonobstructive azoospermia is the least treatable, because few or no mature sperm may be produced. In many cases, men with nonobstructive azoospermia typically have small-volume testes and elevated FSH. Although treatment may not completely restore the quality of semen from men with subnormal fertility, in some cases a successful pregnancy can still be achieved through assisted reproductive technology.

Common scrotal and testicular problems

Scrotal and testicular problems range from the benign and painless to the malignant and debilitating. The primary care physician should be able to triage these problems and know when to give reassurance and when to initiate a targeted workup that may lead to specialist intervention. This article focuses on scrotal pain and palpable abnormalities. Scrotal pain includes well-defined acute causes such as torsion and infection and the less well-defined chronic orchialgia. Palpable abnormalities covered here include cryptorchidism, hydrocele, spermatocele, varicocele, and testicular cancer.

Torsion of Testis in an Infant with Unilateral UDT

Torsion of an undescended testis is uncommon. Torsion of a cryptorchid testicle presents a nonspecific symptomatology. Clinical suspicion indicates emergent surgical exploration, irrespective of Doppler ultrasound with its inherent false negative results. Management of the contralateral testis is controversial. We emphasize the need of a complete physical examination of the child who goes to the emergency room with nonspecific symptoms of abdominal pain and ipsilateral empty hemiscrotum to rule out torsion of a cryptorchid testicle. Herein, we report a one-year-old infant with missed torsion of undescended left testis.

Cryptorchidism: pathogenesis, diagnosis, treatment and prognosis

Cryptorchidism is a common genital anomaly diagnosed at birth or during childhood. Genetic and/or environmental factors that alter expression or function of hormones crucial for testicular descent, insulin-like 3, and testosterone, may contribute to cryptorchidism. When identified at birth, surgical treatment is indicated by 6 months of age if testes fail to descend, or at the time of diagnosis in older children. A laparoscopic approach is preferred for abdominal testes. Early surgical therapy may reduce the risk of subfertility and/or malignancy.