Real-life users of hormonal or thermal male contraception: An analysis of female partners' motivation, experience, and satisfaction

BACKGROUND

Two male contraceptive methods that inhibit spermatogenesis currently exist: thermal male contraception and hormonal male contraception. Only five studies have been conducted on the acceptability of these methods among men; among women, only the hypothetical acceptability of such a male contraceptive approach as the sole contraception method used by a couple has been evaluated.

OBJECTIVES

To evaluate the motivation, experience, and satisfaction of female partners in couples using hormonal male contraception or thermal male contraception as the sole contraception.

MATERIALS AND METHODS

In this cross-sectional study, 123 male users of hormonal male contraception or thermal male contraception as the couple's sole contraception method were asked to invite their female partner to participate in an anonymous online survey. The questionnaire included 95 questions exploring population characteristics, contraceptive and pregnancy history, motivations for choosing hormonal male contraception or thermal male contraception, the experience of the women in the successive phase of use, relationships with their partner, and satisfaction with the contraception method.

RESULTS

The response rate among participating women was 69% (59/86). The two main reasons for choosing male contraceptive were the desire to share the contraception role in the couple (65%) and the desire of the man to take charge of the contraception (61%). The sexual satisfaction score increased significantly between the contraceptive methods used before hormonal male contraception or thermal male contraception and the phase of contraceptive use (p < 0.01). The overall satisfaction level with thermal male contraception or hormonal male contraception was rated at 3.7 ± 0.6 out of 4. Women mostly recommended hormonal male contraception or thermal male contraception because of the share of contraceptive responsibility and mental load (n = 23/54, 43%).

DISCUSSION

This population of women seemed to have struggled to find a contraceptive method that suited them, but most took advantage of thermal male contraception or hormonal male contraception and trusted their male partner to take charge of contraception use.

CONCLUSION

The positive evaluation from women in partnerships using thermal male contraception and hormonal male contraception should encourage the development of these methods.

Thermal male contraception: A study of users' motivation, experience, and satisfaction

PURPOSE

The aim of this study is to evaluate the motivations, experience, and acceptability of thermal male contraception (TMC) in male partners of couples requesting the use of TMC as the only couple contraceptive.

MATERIALS AND METHODS

To the 72 men of couples seeking male contraception and using TMC between 2011 and 2019, we suggested an anonymous online survey (93 questions) exploring population characteristics, contraceptive histories, motivations for choosing TMC, patient experience at the successive phases of use, relations with partner and environment, and satisfaction with this method.

RESULTS

Sixty-seven men agreed to participate (93% response rate); 63 responses were complete and were analyzed (94% participation rate). The main motivations for choosing TMC were "not using hormones" (n = 59/63, 94%) and using a method regarded as "natural" (n = 49/63, 78%). Most of the men surveyed (68%) adopted the method in less than 2 weeks. During the contraception use phase (n = 59 men), they described significantly improved sexual satisfaction, compared to that experienced with their previous contraceptive methods, and they reported high confidence (100% rather/totally confident partner) and support (88% rather/totally supporting partner) from their partner. Most men (n = 35/59, 59%) also reported improved self-esteem. The main negative point was discomfort, reported by 24% of the men. The overall satisfaction score of using this method was 3.78 ± 0.46/4, and 100% of the men reported that they would recommend the method to other men.

DISCUSSION AND CONCLUSION

Men using TMC successfully assumed the responsibility for and performed a daily task to provide couple contraception. This positive evaluation, together with the already published contraceptive efficacy and reversibility of TMC, should encourage the development of this method.

Knowledge, professional attitudes, and training among health professionals regarding male contraceptive methods

OBJECTIVES

Health professionals are at the forefront of information and acceptability regarding contraceptive methods, however only one study evaluated their knowledge of male contraception (MC) including hormonal MC (HMC) and thermal MC (TMC). Our objective was to evaluate the knowledge, professional attitudes, and training of French practitioners regarding the management of couple contraception by male contraception (MC).

STUDY DESIGN

We designed a descriptive, cross-sectional, multicentre study in 2,396 French practitioners belonging to national or regional institutions involved in contraception. We solicited practitioners by e-mail to complete an anonymous questionnaire; we analysed their knowledge, professional attitudes, and training regarding the management of couple contraception by MC.

RESULTS

The overall participation rate was 18% (427/2,396). Condoms, withdrawal, and vasectomy were known by 98%, 89%, and 76% of the population, respectively. Hormonal MC and Thermal (TMC) were known by 10% and 24% of the population, respectively. Fifty-five percent of the population never or infrequently offered MC during a couple's contraceptive request consultation. Only 14% of the population had ever participated in training on MC; 96% wanted to be better trained on MC, and 87% expressed a willingness to participate in training on the subject.

CONCLUSIONS

Health professionals involved in contraception have unsatisfactory knowledge about MC methods based on spermatogenesis inhibition and are eager to have more information about them. To advance the acceptability and dissemination of MC methods, it seems imperative to enhance research in the field and to provide health professionals with an adapted training programme.

P-014 Thermal Male Contraception: A Study Of Users’ Motivation, Experience And Satisfaction

Study question

What are the motivations, experience, and acceptability of thermal male contraception (TMC) in men using TMC as the only couple contraceptive ?

Summary answer

Men wished to share the role of providing contraception in a couple and to avoid the use of hormones. Sexual satisfaction was significantly improved.

What is known already

Two male contraceptive methods inducing spermatogenesis suppression have achieved contraceptive efficacy, on a large population for hormonal contraception and a smaller one for thermal contraception (TC). The suppression of sperm counts to below 1 million/mL results in fertility rates commensurate with female pills. TC is obtained by wearing 15 hours/day a contraceptive underwear (CU) inducing a 2°C increase in testicular temperature (Mieusset & Bujan 1994). As no commercially available male thermal contraceptive exists, little information regarding the acceptability of this approach to men has been reported and only one publication analysed the hypothetical acceptability of TMC (Amouroux et al. 2018).

Study design, size, duration

We contacted 72 men who had started the CU testing phase between June 2011 and September 2019. The participants completed an anonymous online survey of 93 questions exploring population characteristics, contraceptive histories, motivations for choosing TC, patient experience at the successive phases of use, relations with partner and environment, and satisfaction with TC. Sexual life was evaluated by rating (1 to 4): frequency and pleasure of sexual intercourse, sexual desire, morning and intercourse erections.

Participants/materials, setting, methods

Among men who had reached the contraception use phase, the quality ratings of sexual life were compared over time, from the contraceptive method used before TC (“N-1” method) to the 2 previous methods (“N-2” and “N-3”)): “N-3” versus “contraception use phase”, “N-3” versus “CU testing phase,” and “CU testing phase” versus “contraception use phase.” These comparisons were made for all 5 sexual life parameters by a paired samples Wilcoxon signed rank test.

Main results and the role of chance

Sixty-seven men responded (93% response rate);63 participated in the survey (94% participation rate). The median age was 31 [21-52], 30 men (48%) had a Master’s degree or more, 49 (78%) had no child and 24 (38%) no parental project. Among the men whose couple's contraception method immediately before TC (N-1) was a female method (n = 36/63, 57%), the 2 main reasons for switching to a male method were the wish to share the role of providing contraception in a couple (n = 31/36, 86%) and the willingness to take responsibility for contraception (n = 21/36, 58%). The main motivations for choosing TC were “not using hormones” (n = 59/63, 94%) and using a method regarded as “natural” (n = 49/63, 78%). Most of men (68%) adopted the method in less than 2 weeks. During the contraception use phase (n = 59 men), they described: i) significantly improved sexual satisfaction (3,49±0,29/4) compared to that experienced with previous contraceptive methods (3,27±0,58/4;p&lt;0,01); ii) high female partner confidence (100% rather/totally confident partner) and support (88% rather/totally supporting partner); iii) improved self-esteem (n = 35/59, 59%). The main negative point was discomfort, reported by 24% of the men.

The overall satisfaction score of using TC was 3.78±0.46/4, and 100% would recommend TC to other men.

Limitations, reasons for caution

The study population may seem small (63 men). However, it is not different from that of the previously pubished studies on men using hormonal contraception, which included 20, 38, 79 and 57 men, respectively. Our study also lacked a similar questionnaire for the female partners.

Wider implications of the findings

Men using TC successfully assumed the responsibility for and performed a daily task to provide couple contraception. This positive evaluation of TC together with its previously published contraceptive efficacy and reversibility on a small population, should encourage the development of this method.

Trial registration number

IRB No. 2020-09-10-005

Development of a multivariable prediction model for congenital unilateral absence of the vas deferens in male partners of infertile couples

BACKGROUND

Congenital unilateral absence of vas deferens has been diagnosed in fertile and normozoospermic males and is associated with the risk of unilateral renal absence or cystic fibrosis transmembrane conductance regulator mutations; but no prediction model currently exists to diagnose this condition.

OBJECTIVES

The study aims to identify clinical and biological variables that may have a predictive value for the diagnosis of congenital unilateral absence of vas deferens in male partners of infertile couples MATERIALS AND METHODS: We designed a retrospective, cross-sectional, case-control study on electronic health records of a single tertiary-care andrological centre collected between 1998 and 2018. We included all subjects diagnosed with congenital unilateral absence of vas deferens using combined scrotal and transrectal ultrasounds. Controls were confirmed free of congenital unilateral absence of vas deferens by the same way. Both groups received standardised exploration procedures. Multivariable logistic regression model was built in a backward stepwise manner. Model performance and calibration were assessed. The study is reported according to TRIPOD statement.

RESULTS

We included 69 congenital unilateral absence of vas deferens cases and 78 controls. Cases had a lower semen volume than controls. The congenital unilateral absence of vas deferens risk was associated with history of cryptorchidism and both levels of semen fructose and α-glucosidase. These predictors were confirmed by a random forest algorithm. The area under the curve was 0.886 (95% interval: 0.81-0.92). Calibration was performed with the Hosmer-Lemeshow test (p = 0.88).

DISCUSSION AND CONCLUSION

History of cryptorchidism, semen fructose and α-glucosidase were identified as relevant and independent predictors for the diagnosis of congenital unilateral absence of vas deferens. The model enables to identify male patients with a high risk of congenital unilateral absence of vas deferens to whom a transrectal ultrasounds would be proposed to confirm the diagnosis, whatever their semen parameters. It will also help to address the risks of unilateral renal absence and of cystic fibrosis transmembrane conductance regulator mutations carrying during the management of infertile couples.

P–047 Knowledge, professional attitudes and training of health professionals on male contraceptive methods

Study question

Among health professionals involved in contraceptive prescribing, what are the knowledge, professional attitudes and training on male contraceptive methods?

Summary answer

The health professionals involved in prescribing contraception are not sufficiently trained in male contraception and almost all of them want more.

What is known already

The most recent large-scale studies show that 70% of couple contraception is provided by women and that the majority of men and women would be willing to adopt male contraception as couple contraception. The medicalization of contraception places the medical profession at the forefront of the acceptability of and information regarding a contraceptive method. However, only one study have evaluated health professionals’ knowledge of the various methods of male contraception (MC), including male hormonal contraception (MHC) and male thermal contraception (MTC).

Study design, size, duration

Between April 2020 and June 2020, we carried out a descriptive prospective multicentre study in a medical population of 2243 prescribers of couple contraception in France.

Participants/materials, setting, methods

The participants were obstetrician-gynaecologists, medical gynaecologists, general practitioners or midwives. They completed a three-part numerical questionnaire, including i) sociodemographic characteristics and personal experiences with contraception, ii) knowledge and professional attitudes about male contraception and iii) training on male contraception.

Main results and the role of chance

The overall participation rate was 19% (340/2243). Condoms and withdrawal were known by 98% and 89% of the population, respectively. Vasectomy was known by 75% of the population and significantly better known by obstetrician-gynaecologists than by medical gynaecologists and general practitioners (p = 0.026). Male hormonal contraception (MHC) and male thermal contraception (MTC) were known by 10% and 23% of the population, respectively, and were significantly better known by medical gynaecologists and general practitioners than by other specialties (p &lt; 0.001). More than half (55%) of the population never or infrequently offered MC during a couple’s contraceptive request consultation. Female practitioners offered MC significantly more often than male practitioners (48% vs. 26%; p = 0.033). Only 14% of the population had ever participated in training on MC, 96% wished to be better trained on MC, and 86% expressed a willingness to participate in such a training.

Limitations, reasons for caution

The population was mainly representative of medical health practitioners of southeastern France. There was an over-representation of women in all medical specialties, except for midwives.

Wider implications of the findings: Our study shows that health professionals involved in contraception have limited knowledge about MC and are eager to have more information about it. To advance the acceptability and dissemination of such contraceptive methods, it seems imperative to provide health professionals with an adapted training program on male contraception.

Trial registration number

2020–01–23–03

[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.

Genetics of the congenital absence of the vas deferens

Congenital absence of the vas deferens (CAVD) may have various clinical presentations depending on whether it is bilateral (CBAVD) or unilateral (CUAVD), complete or partial, and associated or not with other abnormalities of the male urogenital tract. CBAVD is usually discovered in adult men either during the systematic assessment of cystic fibrosis or other CFTR-related conditions, or during the exploration of isolated infertility with obstructive azoospermia. The prevalence of CAVDs in men is reported to be approximately 0.1%. However, this figure is probably underestimated, because unilateral forms of CAVD in asymptomatic fertile men are not usually diagnosed. The diagnosis of CAVDs is based on clinical, ultrasound, and sperm examinations. The majority of subjects with CAVD carry at least one cystic fibrosis-causing mutation that warrants CFTR testing and in case of a positive result, genetic counseling prior to conception. Approximately 2% of the cases of CAVD are hemizygous for a loss-of-function mutation in the ADGRG2 gene that may cause a familial form of X-linked infertility. However, despite this recent finding, 10–20% of CBAVDs and 60–70% of CUAVDs remain without a genetic diagnosis. An important proportion of these unexplained CAVDs coexist with a solitary kidney suggesting an early organogenesis disorder (Wolffian duct), unlike CAVDs related to CFTR or ADGRG2 mutations, which might be the result of progressive degeneration that begins later in fetal life and probably continues after birth. How the dysfunction of CFTR, ADGRG2, or other genes such as SLC29A3 leads to this involution is the subject of various pathophysiological hypotheses that are discussed in this review.

Male partners of infertile couples with congenital unilateral absence of the vas deferens are mainly non-azoospermic

BACKGROUND

Men with congenital unilateral absence of vas deferens were reported to be mainly azoospermic, with both unilateral renal absence and mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) but some have neither.

OBJECTIVES

To assess whether in infertile couples the male partners with congenital unilateral absence of vas deferens are mainly azoospermic men.

MATERIAL AND METHODS

Retrospective study in a unique university hospital; reproductive, clinical, CFTR analysis and seminal data of male partners of infertile couples (from 1998 to 2018) were analysed. Diagnosis of congenital unilateral absence of vas deferens was based on transrectal ultrasounds (TRUS): complete or partial absence of one vas deferens with complete contralateral vas deferens confirmed in 63 men. Distribution of sperm count in three classes: azoospermia, oligozoospermia or normozoospermia. Ultrasound determination of renal status; seminal biomarkers assays; and search for CFTR mutations.

RESULTS

Among the 63 men, 39.7% displayed azoospermia, 27% oligozoospermia and 33.3% normozoospermia; 42% of the non-azoospermic men (16/38) had previously obtained a natural pregnancy. We found unilateral renal absence in 17/59 patients (29%). Among 50 men with CFTR testing, five carried an allele associated with cystic fibrosis belonging to the 29 men without renal anomalies, indicating a high allelic frequency (8.6%). The 63 patients displayed high rates of surgical histories for undescended testicles or inguinal hernia, low values of semen volume and of total seminal glycerophosphocholine.

CONCLUSIONS

Our results indicate that men with congenital unilateral absence of vas deferens mainly display oligozoospermia or normozoospermia and that they were previously fertile. They clearly confirm, first, that CFTR testing is recommended in congenital unilateral absence of vas deferens men and it should be mandatory for those with normal kidneys; and, second, that TRUS is needed for the diagnosis of congenital unilateral absence of vas deferens. As congenital unilateral absence of vas deferens may be present whatever the sperm count, biological warnings are represented by semen volume and seminal epididymal markers and clinical warnings by surgical histories of undescended testes or inguinal hernia.

Mild experimental increase in testis and epididymis temperature in men: effects on sperm morphology according to spermatogenesis stages

Background

A mild increase in testicular and epididymal temperatures in men, bulls and rams (pendulous scrotum) inhibits spermatogenesis and increases the percentage of sperm with an abnormal morphology. However, the stages of spermatogenesis that are most sensitive to a mild increase in testicular temperature in men are unknown. The aim of the present study was to explore the effects of a mild induced increase in testicular and epididymal temperature (i.e., testicular temperature maintained below the core body temperature) on sperm morphology in humans depending on the physiological time of spermatogenesis and epididymal transit.

Methods

Five healthy volunteers were enrolled in an experimental study in which testicular and epididymal temperatures were increased by maintaining the testes in a supra-scrotal position with a specially designed underwear worn 15±1 h a day for 120 consecutive days. Semen collection was scheduled on specific days depending on spermatogenic stages and epididymal transit.

Results

Sperm morphology and the multiple anomalies index (MAI) were analysed before, during and after heating. This mild induced increase in testicular and epididymal temperatures resulted in a significant rise in the percentage of morphologically abnormal spermatozoa on day 34 of heating, which remained elevated throughout the heating period and persisted until 45 days after cessation of heating. The MAI was significantly increased on day 20 throughout the heating period and persisted 45 days after cessation of heating. An increase in the percentage of anomalies in the sperm head, acrosome or tail occurred on days 34 and/or 45 of heating. Abnormal sperm morphology and MAI reverted to control values 73 days after cessation of heating.

Conclusions

A mild sustained increase in testicular and epididymal temperature in man leads morphological abnormalities in spermatozoa mainly due to an impairment of spermiogenesis and meiosis.

Are men ready to use thermal male contraception? Acceptability in two French populations: New fathers and new providers

Background

Since the 1970s, international research has actively pursued hormonal male contraception (HMC) and, to a lesser extent, thermal male contraception (TMC). Although the efficacy of TMC has been confirmed in limited populations, its acceptability has not been studied in either potential users or potential prescribers.

Methods

A cross-sectional descriptive multicentre study of potential male users of TMC (new fathers) and potential prescribers of TMC (new providers) was conducted between November 2016 and February 2017.The participants completed a 3-part survey, and their responses were evaluated to i) determine their socio-demographic profiles; ii) identify personal experiences with contraception; and iii) gauge the participants’ knowledge, interest and preference for male contraception, particularly TMC. For new providers only, the survey included a fourth part to evaluate professional experience with male contraception.

Results

The participation rate was 51% for new fathers (305 NFs) and 34% for new providers (300 NPs, including 97 men (male new providers, MNPs) and 203 women (female new providers, FNPs)). Only 3% of NFs and 15% of NPs knew about TMC (including 26% of the MNPs and 10% of the FNPs, p<0.01). After reading information on TMC, new fathers were significantly less willing to try TMC (29%) than were new providers (40%) (p<0.01). The 3 main advantages of TMC for the new fathers included the following factors: “natural” (52%), “without side effects” (38%) and “non-hormonal” (36%). The main disadvantages were “lengthy wear time” (56%), “daily undergarment wear” (43%) and “concern about possible discomfort” (39%).

Conclusions

Young male and female providers have limited knowledge of male contraception, are interested in further information and would generally prescribe TMC to their patients. Successful expansion of the use of male contraception, including TMC, would require distribution of better information to potential users and providers.

Altered secretion of Sertoli cells hormones in 2-year-old prepubertal cryptorchid boys: a cross-sectional study

In cryptorchid boys, failures in germ cell development have been clearly established. Some studies reported some abnormalities in Sertoli cells morphology but the results regarding their endocrine secretion remain controversial. To compare testicular hormone levels in young boys with and without cryptorchidism, we performed a cross-sectional hospital-based study. From surgery appointment records, we identified a case group of boys with unilateral or bilateral cryptorchidism and a control group undergoing dental care, minor osteoarticular or dermal surgery. Blood samples were withdrawn during the surgical procedure to perform testosterone, inhibin B and anti-müllerian hormone (AMH) immunoassays. We included 27 cryptorchid boys and 27 controls aged of 26.6 vs. 24.2 months, respectively (p = 0.172) far from the post-natal mini-puberty and the corresponding hormonal surges. Age-adjusted AMH and inhibin B levels were significantly lower in cryptorchid than in control boys (AMH: 87 ng/mL vs. 135 ng/mL; p = 0.009, inhibin B: 97 pg/mL vs. 133 pg/mL; p = 0.019, respectively). Moreover, AMH and inhibin B levels were significantly lower in the bilateral cryptorchid subgroup, being 50% lower than in the controls (p = 0.011 and 0.019, respectively) and while both hormones levels were independent in controls, they became strongly correlated in bilateral cryptorchid boys (R² = 0.75, p = 0.001). In addition, testosterone levels were still detectable in some boys, with significantly lower levels in cryptorchid group than in controls. Overall, 2-year-old cryptorchid patients presented a simultaneous and significant drop in AMH and inhibin B levels, suggesting a functional defect of Sertoli cells. This deficiency appeared more pronounced in bilateral cryptorchidism and thus, regarding the pivotal role of Sertoli cells in germ cell development, it may explain the compromised fertility found later in men born with such a malformation.

Ejaculation and sperm characteristics in men with cauda equina and conus medullaris syndromes

STUDY DESIGN

Retrospective.

OBJECTIVES

The objective of the study was to describe the type of ejaculation in patients with cauda equina (CE) and conus medullaris (CM) lesions, and to analyse sperm quality.

SETTING

France.

METHODS

One hundred sixty-six patients with CE and CM lesions were included. Diagnosis was based on clinical (no motor responses, sensation or sacral reflexes) and urodynamic assessments (no detrusor activity). Vibromassage (VM) was used to induce ejaculation according to the recommendations for patients with spinal cord injury. If ejaculation did not occur, oral midodrine was administered in progressive doses. Retrograde ejaculation was systematically sought. Sperm parameters were analysed according to World Health Organisation recommendations (2010).

RESULTS

Eighty-nine patients were included. Eleven ejaculated on the first VM trial (four anterograde (AE), six retrograde (RE) and one antero-retrograde (ARE)). Five patients continued trials of VM alone, two of whom ejaculated following a mean 1.9 trials (one RE, one ARE). Twenty-six patients underwent trials of VM+ midodrine, 18 of whom ejaculated following a mean 4.4 trials with a mean dose of 22.5 g of midodrine (2 AE, 13 RE and 5 ARE). Fifty-three ejaculates from 26 patients were analysed. Sperm concentration was low in 90.6% of samples; total necrospermia was found in 65% and asthenospermia in 95% of samples.

CONCLUSION

Ejaculation is difficult to induce using VM in patients with CE and CM lesions, and requires high doses of midodrine. Sperm counts were generally low, and asthenospermia and necrospermia were found in the majority of specimens. Cryopreservation of sperm should be systematic in case of medically assisted procreation.

Diagnosis of Partial Retrograde Ejaculation in Non-Azoospermic Infertile Men with Low Semen Volume

In non-azoospermic patients with low semen volume (LSV), looking for partial retrograde ejaculation (PRE) by searching sperm in the postejaculatory urine (PEU) is required. The use of a retro-ejaculatory index (R-ratio) was suggested to define PRE, but none of the studies indicated a specific threshold above which PRE must be considered. Our objective was to propose a threshold value for the R-ratio as indicative of PRE in patients with LSV selected to be devoid of any known causes or risk factors for retrograde ejaculation or LSV. Among our data base (2000–2009) including 632 patients with PEU, 245 male patients from infertile couples who had had a first semen analysis with LSV (< 2mL) and a second semen analysis associated with PEU, were selected on the previous criteria. A prospective control group was randomly constituted (2007–2008) of 162 first consulting male patients from infertile couples, with a normal semen volume (≥ 2mL) on a first semen analysis and who accepted to collect PEU with their usual second semen analysis, selected on the previous criteria. To define an R-ratio threshold indicative of PRE, we used a ROC curve analysis and a regression tree based on a classification and regression tree (CART) algorithm. Of the 245 LSV patients, 146 still presented low semen volume (< 2 mL) on the second semen analysis. From the use of the CART algorithm, two low (1.5% and 2.8%) and two high R-values (7.1% and 8.3%) were defined, according to the lower reference limit for semen volume of 2.0 mL (WHO 1999) or 1.5 mL (WHO 2010) respectively. As only one or no patient with normal semen volume was observed above the two high R-values, we suggest an R-value higher than the range of [7.1–8.3]% as indicative of PRE until confirmation by a prospective multicenter study.

Truncating Mutations in the Adhesion G Protein-Coupled Receptor G2 Gene ADGRG2 Cause an X-Linked Congenital Bilateral Absence of Vas Deferens

In 80% of infertile men with obstructive azoospermia caused by a congenital bilateral absence of the vas deferens (CBAVD), mutations are identified in the cystic fibrosis transmembrane conductance regulator gene (CFTR). For the remaining 20%, the origin of the CBAVD is unknown. A large cohort of azoospermic men with CBAVD was retrospectively reassessed with more stringent selection criteria based on consistent clinical data, complete description of semen and reproductive excurrent ducts, extensive CFTR testing, and kidney ultrasound examination. To maximize the phenotypic prioritization, men with CBAVD and with unilateral renal agenesis were considered ineligible for the present study. We performed whole-exome sequencing on 12 CFTR-negative men with CBAVD and targeted sequencing on 14 additional individuals. We identified three protein-truncating hemizygous mutations, c.1545dupT (p.Glu516Ter), c.2845delT (p.Cys949AlafsTer81), and c.2002_2006delinsAGA (p.Leu668ArgfsTer21), in ADGRG2, encoding the epididymal- and efferent-ducts-specific adhesion G protein-coupled receptor G2, in four subjects, including two related individuals with X-linked transmission of their infertility. Previous studies have demonstrated that Adgrg2-knockout male mice develop obstructive infertility. Our study confirms the crucial role of ADGRG2 in human male fertility and brings new insight into congenital obstructive azoospermia pathogenesis. In men with CBAVD who are CFTR-negative, ADGRG2 testing could allow for appropriate genetic counseling with regard to the X-linked transmission of the molecular defect.

The human epididymis: its function in sperm maturation

BACKGROUND

Spermatozoa acquire their fertilizing ability and forward motility properties during epididymal transit. Our knowledge of gamete physiology is based on studies conducted in laboratory and domestic species; our knowledge of these processes in humans is limited. Medical indications for assisted reproductive technologies (ART) have progressed to include male infertility. Surgical procedures allow collection of spermatozoa from all along the human excurrent ducts, and the former have been used with some success in reproductive medicine. This has raised questions over the role of the epididymis in human sperm physiology.

OBJECTIVE AND RATIONALE

To reanalyze what we now know about epididymal physiology in humans and to assess the relevance of laboratory animal models for understanding human physiology and the pathophysiology of the epididymis.

SEARCH METHODS

A systematic bibliographic search of PubMed for articles published in English before May 2015 was carried out using the search terms 'epididymis' and 'sperm maturation'. Literature on the consequences of vasectomy on the epididymis was also searched.

OUTCOMES

Whereas the proximal epididymis is almost exclusively occupied by efferent ducts, the sperm reservoir capacity is poorly developed in humans. At the molecular level, the human transcriptome and proteome show some segment specificity; conflicting results persist with regard to secretome variation along the tubule. The number of genes regulated along the excurrent ducts in men is lower when compared to rodent species, but remains significant. It is challenging to reconcile biochemical and physiological studies with clinical data obtained from men undergoing reanastomosis of the vas deferens at different points along the excurrent duct. We propose that vasectomy/vasovasostomy is a model to understand the consequences of obstruction on epididymis function in humans.

WIDER IMPLICATIONS

Despite the scarcity of biological material available, the interspecies variability of the male reproductive tract urges us to use modern molecular and cellular biology tools to better understand human epididymis physiology in order to apply ART in a more responsible manner.

The spectrum of renal involvement in male patients with infertility related to excretory-system abnormalities: phenotypes, genotypes, and genetic counseling

BACKGROUND

While reproductive technologies are increasingly used worldwide, epidemiologic, clinical and genetic data regarding infertile men with combined genital tract and renal abnormalities remain scarce, preventing adequate genetic counseling.

METHODS

In a cohort-based study, we assessed the prevalence (1995-2014) and the clinical characteristics of renal disorders in infertile males with genital tract malformation. In a subset of 34 patients, we performed a detailed phenotype analysis of renal and genital tract disorders.

RESULTS

Among the 180 patients with congenital uni- or bilateral absence of vas deferens (CU/BAVD), 45 (25 %) had a renal malformation. We also identified 14 infertile men with combined seminal vesicle (SV) and renal malformation but no CU/BAVD. Among the 34 patients with detailed clinical description, renal disease was unknown before the assessment of the infertility in 27 (79.4 %), and 7 (20.6 %) had chronic renal failure. Four main renal phenotypes were observed: solitary kidney (47 %); autosomal-dominant polycystic kidney disease (ADPKD, 0.6 %); uni- or bilateral hypoplastic kidneys (20.6 %); and a complex renal phenotype associated with a mutation of the HNF1B gene (5.8 %). Absence of SV and azoospermia were significantly associated with the presence of a solitary kidney, while dilatation of SV and necroasthenozoospermia were suggestive of ADPKD.

CONCLUSION

A dominantly inherited renal disease (ADPKD or HNF1B-related nephropathy) is frequent in males with infertility and combined renal and genital tract abnormalities (26 %). A systematic renal screening should be proposed in infertile males with CU/BAVD or SV disorders.

Basic and Clinical Andrology reviewer acknowledgement 2015

The editor of Basic and Clinical Andrology would like to thank all of our reviewers who have contributed to the journal in Volume 25 (2015).

Reviewer acknowledgement 2014

The Editors of Basic and Clinical Andrology would like to thank all of our reviewers who have contributed to the journal in Volume 24 (2014) and whose valuable support is fundamental to its success.

Are oxybutynin and trospium efficacious in the treatment of detrusor overactivity in spinal cord injury patients?

OBJECTIVES

To evaluate the efficacy of anticholinergic agents in the treatment of neurogenic overactive bladder (NOAB) and neurogenic detrusor overactivity (NDO) in spinal cord injury (SCI) patients on clean intermittent catheterisation (CIC).

METHODS

Chronic suprasacral SCI patients on CIC presenting with at least one urinary leakage a day were included. Urodynamics and voiding diaries were performed at baseline and 1 month follow-up. In case of NDO at baseline, an anticholinergic drug was prescribed.

RESULTS

The 231 SCI patients presented with one to five urinary leakages per day (mean 2.1). Urodynamics showed NDO in all patients. A new anticholinergic treatment was started in all, either in monotherapy (134 patients) or in association with the existing anticholinergic drug (oxybutynin+trospium bitherapy, 97 patients). The mean maximum bladder capacity significantly increased from 225 to 441 ml, and the mean involuntary detrusor contractions (IDC) significantly decreased from 67 to 41 cm H2O. Only 75 SCI patients (32%) were fully continent. However, 25 out of these 75 patients showed persistent NDO, with amplitudes of IDC above 40 cm H2O in 12 patients. Incontinence was still found in 156 SCI patients (67%), with an average of 1,2 leakages a day. In 100 patients, amplitudes of IDC remained above 40 cm H2O. There was no statistical difference between patients on anticholinergic monotherapy or bitherapy at follow-up.

CONCLUSION

Anticholinergic treatment is not always satisfactory in terms of control of NDO and rarely allows full continence. Urodynamic follow-up is mandatory in all patients, even in those showing clinical continence.

Meeting report: measuring endocrine-sensitive endpoints within the first years of life

An international workshop titled "Assessing Endocrine-Related Endpoints within the First Years of Life" was held 30 April-1 May 2007, in Ottawa, Ontario, Canada. Representatives from a number of pregnancy cohort studies in North America and Europe presented options for measuring various endocrine-sensitive endpoints in early life and discussed issues related to performing and using those measures. The workshop focused on measuring reproductive tract developmental endpoints [e.g., anogenital distance (AGD)], endocrine status, and infant anthropometry. To the extent possible, workshop participants strove to develop or recommend standardized measurements that would allow comparisons and pooling of data across studies. The recommended outcomes include thigh fat fold, breast size, vaginal cytology, AGD, location of the testis, testicular size, and growth of the penis, with most of the discussion focusing on the genital exam. Although a number of outcome measures recommended during the genital exam have been associated with exposure to endocrine-disrupting chemicals, little is known about how predictive these effects are of later reproductive health or other chronic health conditions.

Impact of Diagnostic Delay in Testis Cancer: Results of a Large Population-Based Study

OBJECTIVE

Testis cancer is the most common cancer in young men, and its incidence continues to rise. Even if prognosis is considered as good, a group with bad prognosis still remains. Diagnostic delay (DD), defined as the time elapsing from the onset of tumour symptoms to the day of diagnosis, is a way to evaluate the rapidity of diagnosis. We assessed the relationship between DD, disease stage, and survival rate.

METHODS

A series of 542 patients diagnosed with a germ cell tumour between 1983 and 2002 at health facilities in the Midi-Pyrenees region, southwest France, were asked about DD. We analysed DD together with data regarding the disease (histologic type, stage), its treatments, and prognosis (impact on survival).

RESULTS

Mean DD was longer in seminoma (4.9+/-6.1 mo) than in non-seminomatous germ cell tumour (NSGCT; 2.8+/-4.0 mo). DD was correlated with disease stage for the whole population (p=0.014) and for NSGCT (p=0.0009), but not for seminoma. DD had a significant impact on the 5-yr survival rate in the overall population (p=0.001) and in the NSGCT group (p=0.001), but not in the seminoma group. Global trends in mean DD did not change over the 20-yr study period, but we observed a slight decrease during the last decade.

CONCLUSIONS

DD is highly correlated with stage and survival in NSGCT. Urologists should promote programmes to enhance awareness and knowledge of testis cancer, so the diagnosis can be made more rapidly.

Thermal asymmetry of the human scrotum

BACKGROUND

Scrotal temperatures in men have been reported to be either similar on both sides or higher on the left than the right scrotum. We aimed to clarify this discrepancy from new data.

METHODS

Retrospective analyses of scrotal temperatures in men aged 20-52 years measured every 2 min with probes connected to a data collector in three experiments. In Experiment I, eight men have been submitted to four successive body positions for 15 min each, first naked then clothed. Experiment II involved 11 postal employees working in a standing position for 90 min continuously. Experiment III involved 11 bus drivers and a 90 min period of continuous driving. Outcome parameters were left and right scrotal temperatures.

RESULTS

In Experiment I, mean values and kinetics of scrotal temperature differed significantly in the naked and clothed state. In all three experiments, left scrotal temperature in the clothed state was higher than right scrotal temperature in terms of mean values and temperature kinetics.

CONCLUSIONS

Lack of thermal symmetry was seen in the right and left scrotum, whether naked or clothed, and this applied regardless of position or activity when clothed. This thermal difference between right and left scrotum could contribute to the asymmetry in the male external genital organs.

High risk of temporary alteration of semen parameters after recent acute febrile illness

OBJECTIVE

To report parameters in semen samples and sperm deoxyribonucleic acid integrity in a fertile volunteer presenting a 2-day fever of 39 degrees -40 degrees C.

DESIGN

Case report.

SETTING

University-affiliated teaching hospital.

INTERVENTION(S)

None.

PATIENT(S)

Semen samples from a fertile volunteer of proven fertility were obtained and analyzed before the febrile illness episode and at days 15, 37, 58, 79, and >180 after the fever.

MAIN OUTCOME MEASURE(S)

Semen parameters (total sperm count, motility a+b, and vitality), sperm protamination state, measured by sperm chromatin structure assay (SCSA) and apoptotic activities, measured by terminal uridine nick-end labeling (TUNEL) assay.

RESULTS

Total sperm count significantly decreased at days 15, 37, and 58 after the fever and returned to normal by day 79 after the fever. The percentage of motility significantly decreased at days 15 and 37 after the fever and returned to normal by day 58. Vitality score also showed a slight, although not statistically significant, decrease after the fever. The DNA fragmentation index (DFI, a SCSA parameter), which defines abnormal chromatin structure, significantly increased by 24% and 36% at days 15 and 37 after the fever, respectively, and decreased to 15% and 8% when reaching days 58 and 79 after the fever. High DNA stainability (HDS, a SCSA parameter) also significantly increased at day 37 after the fever. On the other hand, sperm DNA fragmentation, as measured by TUNEL assay, increased up to 23% by day 15 after the fever but this was not statistically significant.

CONCLUSION(S)

This report demonstrates that a febrile episode can have marked effects on semen parameters and sperm DNA integrity. These results are particularly important for the counseling of infertile couples and in relation to assisted reproductive techniques (ART).

Contraceptions masculines non déférentielles : revue de la littérature

OBJECTIVES

To review the state of progress of the various male contraceptive methods (with the exception of deferential methods).

MATERIAL AND METHODS

A review of the literature was performed by using the key words: male/contraception, limiting the search to original articles in English and French. Articles on vasectomy and the other deferential methods of contraception are not considered in the present review.

RESULTS

Three methods of male contraception are widely used at the present time: withdrawal, male condom and vasectomy, although other types of male contraception have been shown to be effective, including hormonal contraception, which appears to be the most promising technique and the subject of the majority of research. Other contraceptive methods (immunological, thermal...) could constitute possible alternatives.

CONCLUSION

Male contraception remains under-used, as only male condoms are commonly used (apart from withdrawal and vasectomy). Consequently, new research protocols in the field of male contraception must be strongly encouraged.

Effect of posture and clothing on scrotal temperature in fertile men

Investigation of the effects of body position and clothing on the temperature of the scrotum has given discordant results. The aim of the present study was to evaluate these effects in 13 fertile male volunteers in successive positions each held for 15 minutes, either Supine, Standing, Seated with legs apart, and Seated with legs crossed (n = 8) or Standing, Seated with legs crossed, and Standing (n = 5), at first naked and then clothed. The Standing naked position was that in which scrotal temperature reached the lowest point. Clothing increased the scrotal temperature compared with the naked state, whatever the position. The Seated with legs crossed position had specific characteristics: in the naked state, it was thermogenic and increased scrotal temperature as much as clothing in the Supine or Standing positions; in the clothed state, the increase in temperature was less than expected, which could indicate that local mechanisms are involved. Moreover, the Seated with legs crossed position had a persisting effect on scrotal temperature in the next position. These results have both pathophysiological and epidemiological implications.

Ten-year variation in semen parameters and sperm deoxyribonucleic acid integrity in a healthy fertile man

OBJECTIVE

To report parameters in semen samples and sperm DNA integrity in a healthy fertile volunteer over a 10-year period.

DESIGN

Case report.

SETTING

University-affiliated teaching hospital.

INTERVENTION(S)

None.

PATIENT(S)

Semen samples from a nonsmoking healthy male volunteer of proven fertility aged from 40 to 50 years were collected and analyzed over a decade.

MAIN OUTCOME MEASURE(S)

Semen parameters (sperm count, total sperm count, percentage of progressive motility grades a+b, morphology, and percentage of living spermatozoa) and sperm DNA integrity, measured by sperm chromatin structure assay (SCSA) and terminal uridine nick-end labeling (TUNEL) assay.

RESULT(S)

Median (min-max) value of total sperm count was 330 (126-511) million. Motility and vitality presented a median of 50% (40%-75%) and 78% (53%-92%), respectively. Among semen parameters, morphology and vitality showed the lowest within-subject coefficient of variation (CV(W)) and the total sperm count the highest (8.1% and 12.0% vs. 34.9%). Median values of DNA fragmentation index (DFI) and high DNA stainability (HDS) were 12.7% (7.9%-16.5%) and 6.5% (5.5%-8.2%), respectively. Sperm DNA fragmentation presented a median value of 8.9%, a minimum value of 1.4% and maximum value of 18.6%. Compared with TUNEL data, SCSA parameters (DFI and HDS) showed less variation over the data collection period (47.4% vs. 22.4% and 13.0%, respectively).

CONCLUSION(S)

Our data show that in this healthy fertile volunteer, semen parameters and sperm DNA integrity remained normal, and no trend was observed over the study period. More interestingly, in this subject aged from 40 to 50 years old, sperm nucleus status presented less than 20% of sperm DNA fragmentation over a decade.

Geographic variations in probability of pregnancy in four cities of France

BACKGROUND

Several studies have described geographic variations in human fecundability, but this phenomenon has almost exclusively been studied at an international level rather than within a given country. Our aim was to describe geographic variations in fecundability, the monthly probability of pregnancy, between four cities of France.

METHODS

We conducted a cross-sectional study in four French maternity units from Toulouse, Rennes, Lyons and Paris, among partners of pregnant women. Women were asked about the time to pregnancy (TTP) of their current pregnancy. TTP was analysed with a discrete Cox model allowing to estimate fecundability ratios (FR).

RESULTS

Time to pregnancy was defined for 894 couples. There was no strong evidence of heterogeneity in fecundability between the four compared cities (p=0.05 without adjustment and p=0.25 after adjustment for behavioural and medical factors). The highest fecundability was observed in Rennes and the lowest in Toulouse (fecundability ratio (FR)=1.28, 95% CI: 1.01-1.63). Differences in fecundability were smaller between the other cities.

CONCLUSION

We highlighted a possibly slightly higher fecundability in Rennes compared to Toulouse. Possible explanations for this finding are discussed. We note that the finding is consistent with previous observations indicating a higher sperm concentration among semen donors in Rennes than in Toulouse.

CONSERVATIVE MANAGEMENT OF SMALL TESTICULAR TUMORS RELATIVE TO CARCINOMA IN SITU PREVALENCE

PURPOSE

We evaluated the prevalence of carcinoma in situ (CIS) in orchiectomy specimens performed for germ cell tumors smaller than 40 mm in diameter to propose an appropriate conservative approach to bilateral tumors or tumor of a solitary testis.

MATERIALS AND METHODS

Of 127 patients treated with orchiectomy between 1990 and 2002, 41 who presented with a tumor of less than 40 mm in diameter were selected for histological analysis of testicular parenchyma. The morphological items assessed were CIS, spermatogenesis and Leydig cell hyperplasia.

RESULTS

CIS was observed in 39 of the 41 patients (95%). CIS was evenly distributed throughout the testicular parenchyma (ie around and beyond the tumor) in all 39 cases. Spermatogenesis was observed in 12 of 41 specimens (29%), spermatogenesis without spermatozoa was noted in 14 (34%) and absent germ cells were found in 15 (37%). Leydig cell hyperplasia was observed in 24 cases (58%).

CONCLUSIONS

Histological analysis of whole orchiectomy specimens showed that CIS is almost always present in testicular parenchyma adjacent to germ cell tumor. In bilateral testis cancer or cancer occurring in a solitary testis tumorectomy plus radiotherapy appears to be the appropriate treatment in patients with a small tumor and no other risk factors. In patients who wish to father a child and have preserved spermatogenesis the natural history of CIS allows the postponement of testicular radiotherapy after orchiectomy, giving the double advantage of preserving testicular endocrine function and maintaining the possibility of natural fatherhood.