Consensus and Diversity in the Management of Varicocele for Male Infertility: Results of a Global Practice Survey and Comparison with Guidelines and Recommendations

Predictability of varicocele repair success: preliminary results of a machine learning-based approach

ABSTRACT

Varicocele is a prevalent condition in the infertile male population. However, to date, which patients may benefit most from varicocele repair is still a matter of debate. The purpose of this study was to evaluate whether certain preintervention sperm parameters are predictive of successful varicocele repair, defined as an improvement in total motile sperm count (TMSC). We performed a retrospective study on 111 patients with varicocele who had undergone varicocele repair, collected from the Department of Endocrinology, Metabolic Diseases and Nutrition, University of Catania (Catania, Italy), and the Unit of Urology at the Selcuk University School of Medicine (Konya, Türkiye). The predictive analysis was conducted through the use of the Brain Project, an innovative tool that allows a complete and totally unbiased search of mathematical expressions that relate the object of study to the various parameters available. Varicocele repair was considered successful when TMSC increased by at least 50% of the preintervention value. For patients with preintervention TMSC below 5 × 10 6 , improvement was considered clinically relevant when the increase exceeded 50% and the absolute TMSC value was >5 × 10 6 . From the preintervention TMSC alone, we found a model that predicts patients who appear to benefit little from varicocele repair with a sensitivity of 50.0% and a specificity of 81.8%. Varicocele grade and serum follicle-stimulating hormone (FSH) levels did not play a predictive role, but it should be noted that all patients enrolled in this study were selected with intermediate- or high-grade varicocele and normal FSH levels. In conclusion, preintervention TMSC is predictive of the success of varicocele repair in terms of TMSC improvement in patients with intermediate- or high-grade varicoceles and normal FSH levels.

The epigenetic approach of varicocele: a focus on sperm DNA and m6A-RNA methylation

BACKGROUND

Varicocele is an abnormal dilation and torsion of the pampiniform venous plexus in the scrotum due to venous reflux, primarily affecting the left side. It affects 15% of men and is a prevalent contributor to male infertility. Varicocele is a complex disorder influenced by genetic, epigenetic, and environmental factors. Epigenetic modifications, which regulate genome activity independently of DNA or RNA sequences, may contribute to the development and severity of varicocele. These include DNA methylation, histone modifications, and RNA modifications like N6-methyladenosine (m6A). Irregularities in DNA and m6A-RNA methylation during spermatogenesis can cause gene expression abnormalities, DNA damage, and decreased fertility in varicocele patients.

OBJECTIVE AND RATIONALE

The review aims to comprehensively understand the underlying mechanisms of varicocele, a condition that can significantly impact male fertility. By exploring the role of methylation modifications, specifically DNA and m6A-RNA methylation, the review aims to synthesize evidence from basic, preclinical, and clinical research to expand the existing knowledge on this subject. The ultimate goal is to identify potential avenues for developing targeted treatments that can effectively improve varicocele and ultimately increase sperm quality in affected individuals.

SEARCH METHODS

A thorough investigation of the scientific literature was conducted through searches in PubMed, Google Scholar, and Science Direct databases until May 2024. All studies investigating the relationship between DNA and m6A-RNA methylation and male infertility, particularly varicocele were reviewed, and the most pertinent reports were included. Keywords such as varicocele, epigenetics, DNA methylation, m6A-RNA methylation, hypermethylation, hypomethylation, spermatozoa, semen parameters, spermatogenesis, and male infertility were used during the literature search, either individually or in combination.

OUTCOMES

The sperm has a specialized morphology essential for successful fertilization, and its epigenome is unique, potentially playing a key role in embryogenesis. Sperm DNA and RNA methylation, major epigenetic marks, regulate the expression of testicular genes crucial for normal spermatogenesis. This review explores the role of DNA and m6A-RNA methylation, in responding to oxidative stress and how various nutrients influence their function in varicocele condition. Evidence suggests a potential link between varicocele and aberrant DNA/m6A-RNA methylation patterns, especially hypomethylation, but the body of evidence is still limited. Further studies are needed to understand how abnormal expression of DNA/m6A-RNA methylation regulators affects testicular gene expression. Thus, analyzing sperm DNA 5mC/5hmC levels and m6A-RNA methylation regulators may reveal spermatogenesis defects and predict reproductive outcomes.

WIDER IMPLICATIONS

Nutri-epigenomics is an emerging field that could enhance the knowledge and management of diseases with unpredictable risks and consequences, even among individuals with similar lifestyles, by elucidating the influence of nutrition on DNA/m6A-RNA methylation through one-carbon metabolism. However, the importance of one-carbon metabolism to varicocele is not well-recognized. Health status and diet influence one-carbon metabolism and its associated DNA/m6A-RNA methylation modification. Future research should identify optimal methylation patterns that promote health and investigate modulating one-carbon metabolism to achieve this. Furthermore, additional studies are necessary to develop personalized dietary strategies through clinical and longitudinal research. However, a research gap exists on dietary interventions utilizing epigenetics as a therapeutic method for treating varicocele.

REGISTRATION NUMBER

Not applicable.

Enhancing Male Fertility Through AI-Based Management of Varicoceles

REVIEW PURPOSE

The clinical management of subclinical and symptomatic varicoceles in male infertility remains challenging. Current guidelines focus on treating men with abnormal semen analyses, but a more precise approach to identify, stratify, and prognosticate men with varicoceles and fertility issues is essential.

RECENT FINDINGS

Multiple studies have utilized Artificial Intelligence (AI) to analyze clinical-demographic characteristics, semen analyses, pre-operative imaging findings, and intra-operative clinical data. These AI-driven approaches aim to discover novel biomarkers that can assess, stratify, and prognosticate men with subclinical and symptomatic varicoceles requiring early intervention. These sophisticated methodologies offer new insights and strategies for understanding normal spermatogenesis and the pathophysiology of varicocele-related male infertility. The application of AI strategies is expected to revolutionize varicocele management, enhancing male fertility and optimizing reproductive outcomes.

Testicular arterial blood flow volume in predicting semen improvement following microscopic subinguinal varicocelectomy

Background

Varicocele is a significant but treatable contributor to male infertility. The efficacy of varicocelectomy in improving sperm quality is not consistent, with only 60-80% of patients experiencing improved semen quality. This prospective cohort study aimed to evaluate the effect of microscopic subinguinal varicocelectomy (MSV) on testicular arterial blood flow volume (TABFV) and to determine the value of preoperative TABFV in predicting the outcome of MSV.

Methods

Patients with varicocele who underwent MSV at the same clinical center between July 2020 and April 2023 were enrolled. All patients underwent ultrasound assessment and at least one semen analysis before and after MSV. Both univariate and multivariate logistic regression analyses were performed to assess the association between pre-MSV variables and semen improvement after MSV. Subsequently, a diagnostic model was developed.

Results

This study enrolled 96 patients with varicocele, including 31 who showed semen improvement after MSV and 65 who did not. The postoperative semen-improved group demonstrated a significant increase in TABFV of the right testis (TABFV-R) and left testis (TABFV-L) (P<0.001). Notably, the postoperative TABFV-L was more than twice the preoperative TABFV-L. Preoperative TABFV-R and a combination of subclinical right-sided varicocele were found to be associated with semen improvement after MSV, and a diagnostic model was developed using these two variables. The diagnostic model exhibited satisfactory performance, with an area under the curve (AUC) of 0.824 [95% confidence interval (CI): 0.735-0.913], which was further validated internally yielding an AUC of 0.824 (95% CI: 0.726-0.900). Additionally, calibration analysis confirmed that the diagnostic model was well calibrated, and the Hosmer-Lemeshow test resulted in a P value of 0.794. The decision curve demonstrated that using this proposed nomogram would yield a net benefit if the threshold probability for semen improvement after MSV exceeded 10%.

Conclusions

TABFV-L demonstrated potential utility in clinical practice for assessing outcomes of MSV, and the diagnostic model incorporating TABFV-R and a combination of right-side varicocele performed well in predicting improvements in semen parameters following MSV.

Impact of Varicocele Repair on Assisted Reproductive Technique Outcomes in Infertile Men: A Systematic Review and Meta-Analysis

PURPOSE

In this systematic review and meta-analysis, we investigated assisted reproductive technology (ART) success in infertile men with clinical varicocele and abnormal semen parameters who underwent varicocele repair (VR) before the ART procedure as compared to those who did not.

MATERIALS AND METHODS

A comprehensive search of the Scopus, PubMed, Embase, and Cochrane Library databases was conducted using a specific query string to identify studies examining the impact of VR on ART outcomes, including fertilization rate, clinical pregnancy, pregnancy loss, and live-birth rate, until October 2023. Outcomes were analyzed based on the type of ART. Studies on VR in infertile men with non-obstructive azoospermia and those who underwent ART only due to female factor infertility were excluded from the study.

RESULTS

Out of 1,554 articles reviewed, only 9 met the inclusion criteria for the study. All the included articles were observational studies. The variability in study quality in the included literature resulted in a moderate overall risk of bias. Data analysis showed that for intrauterine insemination, there was no difference in the clinical pregnancy rate (odds ratio [OR] 1.01, 95% confidence interval [CI]: 0.42, 2.45; p=0.97). However, for intracytoplasmic sperm injection (ICSI), men with VR showed a significant improvement in fertilization rate (mean difference 10.9, 95% CI: 5.94, 15.89; p<0.01), clinical pregnancy rate (OR 1.38, 95% CI: 1.07, 1.78; p=0.01) and live-birth rate (OR 2.07, 95% CI: 1.45, 2.97; p<0.01), compared to men who did not undergo VR.

CONCLUSIONS

The findings of this systematic review and meta-analysis suggest that VR has a positive impact on pregnancy and live birth rates after ICSI. However, biases like small sample sizes and heterogeneous populations highlight the need for larger, well-designed prospective studies to validate these findings.

Therapeutic Effects of Mesenchymal Stem Cell Conditioned Medium in Rat Varicocele Model

PURPOSE

This study aimed to examine the therapeutic effects of injection of conditioned medium of adipose-derived mesenchymal stem cells (ADMSC-CM) in a surgically created varicocele model in comparison with varicocelectomy.

MATERIALS AND METHODS

Twenty-eight male Wistar Albino rats were randomly divided into four groups: sham group, varicocele group, varicocelectomy group, and ADMSC-CM injection group. Sperm parameters were analyzed in samples taken from the epididymis after treatment. Malondialdehyde and superoxide dismutase (SOD) levels in blood samples were examined by biochemical analysis. The testicular tissues were stained with hematoxylin-eosin for histological examination (Johnsen's Score). Additionally, Western Blot analyzes were performed to detect Claudin-11 levels, the functional protein of the blood-testis barrier, in testicular tissues.

RESULTS

Varicocelectomy and ADMSC-CM treatments significantly improved mean sperm parameters (concentration, progressive motility, motility, normal sperm morphology) (p≤0.05 for all). Both treatment groups had increased SOD levels along with a decrease in malondialdehyde levels (p≤0.05 for all). No significant difference was observed between the ADMSC-CM group and the varicocelectomy group in preserving normal testicular histology according to Johnsen's Score (p=0.114). Levels of Claudin-11 were significantly higher in the varicocelectomy and ADMSC-CM groups compared to the varicocele group (p≤0.05 for all).

CONCLUSIONS

The therapeutic effects of ADMSC-CM in varicocele model may involve secretion of anti-inflammatory and regenerative factors from ADMSC. ADMSC-CM injection appears to be a promising new strategy in the treatment of varicocele.

Predictive parameters of the efficacy of varicocele repair: a review

ABSTRACT

Varicocele has a prevalence of 15% in the population and represents a primary cause of infertility in 40% of cases and a secondary cause in approximately 80% of cases. It is considered the major correctable cause of male infertility. Despite its high prevalence in the infertile population, a large number of patients with varicocele do not experience reproductive difficulties. For this reason, it is still highly debated which parameters could be used to predict which patients with varicocele will be most likely to benefit from its repair. The main international and European guidelines state that treatment should only be considered in infertile patients with abnormal sperm quality. However, these guidelines do not help physicians to identify which of these patients may benefit from the treatment. Therefore, this narrative review collects the evidence in the literature on the usefulness of some factors as predictors of improvement, highlighting how some of them may be effective in an initial selection of patients to be treated, while others are promising but further studies are needed. Finally, a brief consideration on the possible role of artificial intelligence is proposed.

Varicocele and nonobstructive azoospermia

Approximately 15% of men in the general population have varicoceles, and varicoceles are diagnosed in 40% of men presenting for fertility evaluations. One percent of men in the general population are azoospermic, and 15% of men presenting for fertility evaluations are diagnosed with azoospermia. This article aims to review the impact of varicoceles on testicular function in men with azoospermia, the impact of varicocele repair on the semen parameters of azoospermic men, and the impact of varicocele repair on sperm retrieval and pregnancy outcomes when the male partner remains azoospermic after varicocele repair.

Impact of Varicocele on Testicular Oxidative Stress and Sperm Parameters in Experimental Animals: A Systematic Review and Meta-Analysis

PURPOSE

Varicocele has been associated with high seminal oxidative stress (OS), impaired semen quality, and reduced male fertility potential. However, the exact mechanism(s) underlying the development of varicocele-mediated infertility and the cause-effect relationship between varicocele and testicular dysfunction are not fully understood. The aim of this systematic review and meta-analysis (SRMA) is to investigate the impact of varicocele on testicular OS markers and sperm parameters in experimental animals with varicocele as compared to animals without varicocele.

MATERIALS AND METHODS

A literature search was performed using the Scopus and PubMed databases on studies that investigated testicular OS markers and sperm parameters in animals with varicocele. The primary outcomes included malondialdehyde (MDA) (nmol/mg) levels whereas the secondary outcomes included total sperm count (×106), sperm vitality (%), total sperm motility (%), and sperm DNA fragmentation (SDF) (%). Standardized mean difference (SMD) (95% confidence interval [CI]) was chosen to express the effect size. The quality of the included studies was evaluated using the Cambridge Quality Checklist.

RESULTS

Out of 76 identified articles, 6 studies on rats were included in the meta-analysis. The analysis showed a significant increase of MDA (SMD: 15.61 [1.93, 29.29]; p=0.03) in rats with varicocele vs. controls. We also observed a significant decrease in total sperm count (SMD: -17.45 [-28.97, -5.93]; p<0.01), sperm vitality (SMD: -16.41 [-26.30, -6.52]; p<0.01), total sperm motility (SMD: -17.67 [-24.90, -10.44]; p<0.01), and a significant increase of SDF (SMD: 7.41 [1.23, 13.59]; p=0.02), in rats with varicocele vs. controls. The quality of the included studies was ranked as high.

CONCLUSIONS

This SRMA indicates a significant increase in levels of testicular MDA and SDF and a reduction of sperm quality in experimental animals with varicocele. These findings support the potential role of testicular OS in the development of varicocele-induced testicular damage.

Impact of varicocele repair on semen parameters and spontaneous pregnancy: An endless debate put to rest

There has been much controversy about the true value of varicocele repair for improving fertility and the chances of natural conception. This review summarizes the latest research findings, current professional societies' recommendations, and the conclusions of recent systematic reviews and meta-analyses. The current evidence suggests a positive role for varicocele repair in improving basic sperm parameters and increasing the likelihood of natural pregnancy.

Research progress on the role of autophagy in the development of varicocele

Varicocele (VC) is a common cause of infertility in men. Pathophysiological changes caused by VC, such as testicular hypoxia, high temperatures, oxidative stress, abnormal reproductive hormones, and Cd accumulation, can induce autophagy, thus affecting the reproductive function in patients with this condition. Autophagy regulators can be classified as activators or inhibitors. Autophagy activators upregulate autophagy, reduce the damage to the testis and epididymis, inhibit spermatogenic cell apoptosis, and protect fertility. In contrast, autophagy inhibitors block autophagy and aggravate the damage to the reproductive functions. Therefore, elucidating the role of autophagy in the occurrence, development, and regulation of VC may provide additional therapeutic options for men with infertility and VC. In this review, we briefly describe the progress made in autophagy research in the context of VC.

The Global Andrology Forum (GAF): Structure, Roles, Functioning and Outcomes: An Online Model for Collaborative Research

PURPOSE

There are no published examples of a global online research collaborative in andrology. We describe the development, profile and member characteristics of the first consortium of this type, the Global Andrology Forum (GAF).

MATERIALS AND METHODS

An online survey sent to all GAF members collected demographic information (sex, age, experience, academic title, degrees, country, specialty, profession). It also tapped data on members' characteristics e.g., skills in research, software and statistics; preferred activities; time commitments; expected roles; and interest in participating in research, in GAF's scientific activities and collaborative online research. The findings were analyzed and tabulated. We outline members' demographic and professional characteristics and scientific achievements to date. A narrative approach outlined GAF's structure and functioning.

RESULTS

A total of 418 out of 540 members completed the survey and were included in the analysis (77.4% response rate). The sample comprised mainly urologists (34.2%) and a third of the respondents had practiced for >15 years (33.3%). Up to 86.1% of the members expressed interest in being actively engaged in writing scientific articles. A third of the sample (37.1%) could dedicate 4 to 6 hours/week. Few respondents reported skills in statistics and artwork (2.6% and 1.9% respectively). Members were assigned to specific roles based on their expertise and experiences. Collaborative working ensured the timely completion of projects while maintaining quality. For outcomes, GAF published 29 original articles within one year of its creation, with authors from 48 countries spanning topics that included varicocele, sperm DNA damage, oxidative stress, semen analysis and male infertility, oocyte/embryo, and laboratory issues of assisted reproductive technique (ART) and male infertility evaluation.

CONCLUSIONS

GAF is a successful global online andrology research model. A healthy number of scientific articles have been published. Given such effectiveness, adopting the GAF model could be useful for other disciplines that wish to create and coordinate successful international online research groups.

Varicocele and male infertility conundrum: Making sense of a never-ending story for the busy clinician

Background

Varicocele is a common occurrence, particularly among men with primary and secondary infertility. There has been extensive research into the management of varicocele in the context of male infertility.

Methods

This article aims to explore the variations in clinical practice in diagnosing and managing varicoceles in infertile men. A summary of the current recommendations on varicocele management from professional societies is included.

Results

Substantial gaps in knowledge persist regarding varicoceles and male infertility, with significant variation in clinical approaches, despite the wealth of existing data in the medical literature.

Conclusion

The existing literature leaves many questions surrounding varicocele management in infertile men unanswered. This lack of clarity contributes to the ongoing controversy among clinicians in the field. New research is essential to address these contentious points and areas of debate.

A review of the pathophysiology and evidence-based management of varicoceles and pelvic congestion syndrome

Pelvic congestion syndrome (PCS) in females and varicoceles in males may be regarded as closely related conditions since the main pathophysiological cause for both processes is pelvic venous insufficiency. Varicoceles are more prevalent amongst sub-fertile males, with an approximate incidence of 15% in the general male population. PCS is commonly diagnosed amongst premenopausal multiparous women, representing one of the leading causes of chronic pelvic pain. Both conditions appear to be predominantly left-sided and are associated with oxidative stress and pro-inflammatory cascades with subsequent effects on fertility. Clinical examination and pelvic ultrasonography play an essential role in the assessment of varicoceles, PCS and chronic pelvic pain. Venography is generally considered as a gold-standard procedure for both conditions. There is still much debate on how these conditions should be managed. This review article provides a comparative analysis of the underlying pathophysiological mechanisms of both PCS and varicoceles, their impact on fertility, as well as their clinical management.

From Diagnosis to Treatment: Comprehensive Care by Reproductive Urologists in Assisted Reproductive Technology

Infertility is a global health concern, with male factors playing an especially large role. Unfortunately, however, the contributions made by reproductive urologists in managing male infertility under assisted reproductive technology (ART) often go undervalued. This narrative review highlights the important role played by reproductive urologists in diagnosing and treating male infertility as well as any barriers they face when providing services. This manuscript presents a comprehensive review of reproductive urologists' role in managing male infertility, outlining their expertise in diagnosing and managing male infertility as well as reversible causes and performing surgical techniques such as sperm retrieval. This manuscript investigates the barriers limiting urologist involvement such as limited availability, awareness among healthcare professionals, and financial constraints. This study highlights a decrease in male fertility due to lifestyle factors like sedentary behavior, obesity, and substance abuse. It stresses the significance of conducting an evaluation process involving both male and female partners to identify any underlying factors contributing to infertility and to identify patients who do not require any interventions beyond ART. We conclude that engaging urologists more effectively in infertility management is key to optimizing fertility outcomes among couples undergoing assisted reproductive technology treatments and requires greater education among healthcare providers regarding the role urologists and lifestyle factors that could have an effect on male fertility.

Varicocele: To Treat or Not to Treat?

Varicocele treatment in infertility still remains controversial. It is clear, in fact, that in many patients, varicocele has no impact on fertility. Recent scientific evidence demonstrated that varicocele treatment is beneficial in improving semen parameters and pregnancy rate when an appropriate selection of patients is made. The purpose of treating varicocele in adults is mainly to improve current fertility status. On the other hand, the goal of treatment in adolescents is to prevent testicular injury and maintain testicular function for future fertility. Hence, the key to the success of varicocele treatment seems to be a correct indication. The aim of this study is to review and summarize current evidence in managing varicocele treatment focusing on the controversies regarding surgical indications in adolescent and adult patients, and in other specific situations such as azoospermia, bilateral or subclinical varicocele, and prior to ART.

Productivity Index in Clinical Andrology: Research Directions on High-Impact Topics and in Particular on Male Infertility

PURPOSE

Andrological diseases have an important social and economic impact as they cause a serious impairment of the quality of life of the affected patient. Epidemiologically, the impact of these disorders is progressively increasing, as demonstrated by the ever-growing prevalence of male infertility. This evidence justifies the rapid development of research in andrology that the scientific community has undertaken in recent decades. This study aims to evaluate the productivity index of the main andrological topics studied and reported in the literature.

METHODS

The total number of published articles was extracted from the Scopus database by entering the following keywords and mesh terms: "Male Infertility", "Erectile Dysfunction", "Premature Ejaculation", "Male Hypogonadism", "Testicular Tumors", "Prostate Cancer", "Prostatic hyperplasia", "Prostate hyperplasia", "Prostatitis", "Prostate inflammation", and "Male Accessory Gland Infections". Furthermore, a list of the top 50 researchers sorted by productivity was created for each topic. For male infertility, a further search was performed by combining the search term "male infertility" with the above-mentioned terms. Thus, a list of the top 30 authors in order of productivity was also extracted. The graphs were created using Excel.

RESULTS AND CONCLUSIONS

As could be expected, we observed that prostate cancer and male infertility were the two most investigated topics, followed by benign prostatic hyperplasia and erectile dysfunction, whose prevalence is set to increase given the progressive aging of the population. Less investigated is the inflammation of the accessory sexual glands. In conclusion, this study provides a ranking of the main andrological topics investigated in the literature, also presenting the top list of the most productive authors for each one.

The learning curve of bilateral laparoscopic varicocelectomy: a prospective study

Varicocele occurs in 15% of general male population and in 35% of infertile men. Since 1992, surgical correction with laparoscopic varicocelectomy is the gold standard for treatment of symptomatic patients or patients with abnormal seminal analysis. The learning curve for this frequently performed procedure has not yet been described. In the present study, we investigated the learning curve of a single urologist in training performing his first 21 laparoscopic varicocelectomies using qualitative and quantitative tools to evaluate his performance during the process. Our results show that 14 bilateral laparoscopic varicocelectomies are enough to achieve the plateau of the learning curve.

Radiation Exposure and Surgical Outcomes after Antegrade Sclerotherapy for the Treatment of Varicocele in the Paediatric Population: A Single Centre Experience

INTRODUCTION

Antegrade sclerotherapy (Tauber) effectively treats varicocele. However, fluoroscopy exposes young males to ionizing radiation. We aimed to evaluate radiation exposure and surgical outcomes after the Tauber procedure.

MATERIALS AND METHODS

We retrospectively analysed data from 251 patients. Dose area product (DAP) and fluoroscopy time were recorded. The effective dose was calculated with the PCXMC software. Descriptive statistics and linear regression tested the association between clinical predictors and radiation exposure.

RESULTS

Median (IQR) age and body mass index (BMI) were 14 (13-16) years and 20.1 (17.9-21.6) kg/m². Five (2.1%) patients developed clinical recurrence and two (0.81%) developed complications. Median fluoroscopy time and DAP were 38.5 (27.7-54.0) s and 89.6 (62.5-143.9) cGy*cm². The effective dose was 0.19 (0.14-0.31) mSv. Fluoroscopy time was higher in patients with collateral veins (41 (26-49) s vs. 36 (31-61) s, p = 0.02). The median amount of sclerosing agent (SA) used was 3 (3-4) ml. DAP was higher when SA > 3 mL was used (101.4 (65-183) cGy*cm² vs. 80.5 (59-119) cGy*cm²; p < 0.01). At univariable linear regression, age, BMI, operative time and SA > 3 mL were associated with higher DAP (all p < 0.01). At multivariable linear regression, only BMI (beta 12.9, p < 0.001) and operative time (beta 1.9, p < 0.01) emerged as predictors of higher DAP, after accounting for age and SA > 3 mL.

CONCLUSIONS

The Tauber procedure is safe and associated with low effective doses. Operative time and the patient's BMI independently predict a higher radiation dose.

Sperm DNA fragmentation testing in clinical management of reproductive medicine

Background

Approximately 8%-12% of couples worldwide face infertility, with infertility of individuals assigned male at birth (AMAB) contributing to at least 50% of cases. Conventional semen analysis commonly used to detect sperm abnormalities is insufficient, as 30% of AMAB patients experiencing infertility show normal results in this test. From a genetic perspective, the assessment of sperm DNA fragmentation (SDF) is important as a parameter of sperm quality.

Methods

In this narrative study, we review and discuss pathophysiological causes, DNA repair mechanisms, and management of high SDF. We then summarize literature exploring the association between SDF and reproductive outcomes.

Main Findings

Recent systematic reviews and meta-analyses have revealed a significant association between high SDF in AMAB individuals and adverse reproductive outcomes including embryo development, natural conception, intrauterine insemination, and in vitro fertilization. However, the association with live birth rates and pregnancy rates following intracytoplasmic injection remains inconclusive. The disparities among quantitative assays, inconsistent reference range values, absent high-quality prospective clinical trials, and clinical heterogeneity in AMAB patients with elevated SDF represent the main limitations affecting SDF testing.

Conclusion

The evaluation and management of SDF plays an important role in a subset of AMAB infertility, but widespread integration into clinical guidelines will require future high-quality clinical trials and assay standardization.