Rising vasectomy volume following reversal of federal protections for abortion rights in the United States

In June 2022 the United States Supreme Court issued a ruling in the case Dobbs v. Jackson that overturned Roe v. Wade, the 1973 ruling establishing a federally protected right to abortion in the United States. Anecdotal reports suggested increased vasectomy volume following this event; however, no published data exist. We sought to describe trends in vasectomy consultation before and after the Dobbs v. Jackson ruling (referred to as pre- and post-Dobbs herein). Following IRB approval, we reviewed charts of all adults seeking vasectomy consultation in July-August 2021 and July-August 2022 at a large healthcare organization. We then aggregated vasectomy procedural billing data from 2018 to present. The primary outcome was volume of vasectomy consultation appointments and the secondary outcome was number of vasectomies performed. In July-August 2021 (Pre-Dobbs), 116 men attended vasectomy consultation versus 142 men in July-August 2022 (Post-Dobbs). Median age Post-Dobbs was significantly younger than Pre-Dobbs (35 vs 38 years, respectively, p = 0.01) with a significant increase in Post-Dobbs men under 30 seeking vasectomy (p = 0.005). A total of 16.9% (24/142) of Post-Dobbs men were childless, compared to 8.6% (10/116) of Pre-Dobbs men (p = 0.05). Of those with children, median number of offspring was unchanged at 2. Billing data showed a significant increase in vasectomy procedural volumes Post-Dobbs. While overturning Roe v Wade directly impacted female reproductive rights, number of vasectomy consultations and procedures increased significantly following this decision. Younger men, especially those under 30, as well as childless men were significantly more likely to seek consultation Post-Dobbs compared to the prior reproductive legal climate. While longer-term data are needed, findings indicate that men are invested in maintaining reproductive autonomy for themselves and their partners.

The Evolving Landscape of Male Varicocele Pathophysiology in the Era of Multi-Omics: A Narrative Review of the Current Literature

Male-factor infertility is implicated in over half of the millions of cases of infertility worldwide, and varicoceles are the most common correctable cause of male-factor infertility. The pathophysiologic mechanism for varicoceles is complex and next-generation technologies offer promising insights into the molecular underpinnings of this condition. In this narrative review, we highlight historical and contemporary paradigms associated with varicoceles, with an emphasis on the biological underpinnings of this disease. Specifically, we review the literature describing the underlying causes of varicoceles, discuss the molecular and cellular mechanisms causing pathological changes in some (but not all) men, and highlight key articles regarding the next-generation analyses (e.g., transcriptome, epigenome, proteome, and microbiome) being applied to better understand the condition and its treatment. These data demonstrate an ongoing evolution of the knowledge of varicoceles and the potential for improved personalized care in the future for men with this condition.

The effect of red blood cell disorders on male fertility and reproductive health

Male infertility is defined as a failure to conceive after 12 months of unprotected intercourse owing to suspected male reproductive factors. Non-malignant red blood cell disorders are systemic conditions that have been associated with male infertility with varying severity and strength of evidence. Hereditary haemoglobinopathies and bone marrow failure syndromes have been associated with hypothalamic-pituitary-gonadal axis dysfunction, hypogonadism, and abnormal sperm parameters. Bone marrow transplantation is a potential cure for these conditions, but exposes patients to potentially gonadotoxic chemotherapy and/or radiation that could further impair fertility. Iron imbalance might also reduce male fertility. Thus, disorders of hereditary iron overload can cause iron deposition in tissues that might result in hypogonadism and impaired spermatogenesis, whereas severe iron deficiency can propagate anaemias that decrease gonadotropin release and sperm counts. Reproductive urologists should be included in the comprehensive care of patients with red blood cell disorders, especially when gonadotoxic treatments are being considered, to ensure fertility concerns are appropriately evaluated and managed.

Deafening Silence of Male Infertility

Think about 6 loved ones of reproductive age in your life. Now imagine that 1 of these 6 individuals is suffering from infertility. Perhaps they feel alone and isolated, unable to discuss their heartbreak with their closest friends, family, and support network. Suffering in silence. In this editorial, we discuss the infertility journey through the lens of the patients, the providers, and the scientists who struggle with infertility each and every day. Our goal is to open a dialogue surrounding infertility, with an emphasis on dismantling the longstanding societal barriers to acknowledging male infertility as a disease. Through education, communication, compassion, and advocacy, together we can all begin to break the deafening silence of male infertility.

Penile prostheses harbor biofilms driven by individual variability and manufacturer even in the absence of clinical infection

BACKGROUND

Culture-based studies have shown that penile prostheses harbor biofilms in the presence and absence of infection, but these findings have not been adequately validated using contemporary microbiome analytic techniques.

AIM

The study sought to characterize microbial biofilms of indwelling penile prosthesis devices according to patient factors, device components, manufacturer, and infection status.

METHODS

Upon penile prostheses surgical explantation, device biofilms were extracted, sonicated, and characterized using shotgun metagenomics and culture-based approaches. Device components were also analyzed using scanning electron microscopy.

OUTCOMES

Outcomes included the presence or absence of biofilms, alpha and beta diversity, specific microbes identified and the presence of biofilm, and antibiotic resistance genes on each prosthesis component.

RESULTS

The average age of participants from whom devices were explanted was 61 ± 11 years, and 9 (45%) of 20 had a diagnosis of diabetes mellitus. Seventeen devices were noninfected, and 3 were associated with clinical infection. Mean device indwelling time prior to explant was 5.1 ± 5.1 years. All analyzed components from 20 devices had detectable microbial biofilms, both in the presence and absence of infection. Scanning electron microscopy corroborated the presence of biofilms across device components. Significant differences between viruses, prokaryotes, and metabolic pathways were identified between individual patients, device manufacturers, and infection status. Mobiluncus curtisii was enriched in manufacturer A device biofilms relative to manufacturer B device biofilms. Bordetella bronchialis, Methylomicrobium alcaliphilum, Pseudoxanthomonas suwonensis, and Porphyrobacter sp. were enriched in manufacturer B devices relative to manufacturer A devices. The most abundant bacterial phyla were the Proteobacteria, Actinobacteria, and Firmicutes. Glycogenesis, the process of glycogen synthesis, was among the predominant metabolic pathways detected across device components. Beta diversity of bacteria, viruses, protozoa, and pathways did not differ among device components.

CLINICAL IMPLICATIONS

All components of all penile prostheses removed from infected and noninfected patients have biofilms. The significance of biofilms on noninfected devices remains unknown and merits further investigation.

STRENGTHS AND LIMITATIONS

Strengths include the multipronged approach to characterize biofilms and being the first study to include all components of penile prostheses in tandem. Limitations include the relatively few number of infected devices in the series, a relatively small subset of devices included in shotgun metagenomics analysis, and the lack of anaerobic and other expanded conditions for culture.

CONCLUSION

Penile prosthesis biofilms are apparent in the presence and absence of infection, and the composition of biofilms was driven primarily by device manufacturer, individual variability, and infection, while being less impacted by device component.

Novel sperm chromatin dispersion test with artificial intelligence-aided halo evaluation: A comparison study with existing modalities

BACKGROUND

Sperm chromatin dispersion test is a common and inexpensive technique to assess sperm DNA fragmentation, but its subjectivity in assessing a small number of spermatozoa is a disadvantage.

OBJECTIVES

To study the efficacy of a new sperm chromatin dispersion test kit (R10) combined with an artificial intelligence-aided halo-evaluation platform (X12) and compare the results to those of existing sperm DNA fragmentation testing methods.

MATERIALS AND METHODS

Semen samples from normozoospermic donors (n = 10) and infertile men with abnormal semen parameters (n = 10) were enrolled. DNA fragmentation indices were examined by multiple assays, including R10, Halosperm G2 (G2), sperm chromatin structure assay, and terminal deoxynucleotidyl transferase deoxynucleotidyl transferase nick end labeling. In R10 assay, the DNA fragmentation indices were obtained both manually (manual R10) and by X12 (AI-R10). The obtained DNA fragmentation indices were analyzed by agreement analyses.

RESULTS

The DNA fragmentation indices obtained by manual R10 and those obtained by AI-R10 showed a strong significant correlation (r = 0.97, p < 0.001) and agreement. The number of spermatozoa evaluated by AI-R10 was 2078 (680-5831). The DNA fragmentation indices obtained by manual R10 and AI-R10 both correlated with those of G2 (r = 0.90, p < 0.001; r = 0.88, p < 0.001). Between the AI-R10 and G2 results, Passing-Bablok regression showed no systematic or proportional difference, and Bland-Altman plots revealed overall agreement and a mean bias of 6.3% with an SD of 6.9% (95% limit of agreement: -7.2% to 19.9%). AI-R10 and sperm chromatin structure assays showed systematic differences with a mean bias of -1.9%, while AI-R10 and terminal deoxynucleotidyl transferase deoxynucleotidyl transferase nick end labeling revealed proportional differences with a mean bias of -10.7%.

CONCLUSIONS

The novel sperm chromatin dispersion kit and artificial intelligence-aided platform demonstrated significant correlation and agreement with existing sperm chromatin dispersion methods by assessing greater number of spermatozoa. This technique has the potential to provide a rapid and accurate assessment of sperm DNA fragmentation without technical expertise or flow cytometry.

Testosterone and luteinizing hormone predict semen parameter improvement in infertile men treated with anastrozole

OBJECTIVE

To identify patient factors associated with a clinically significant improvement in semen parameters among infertile men treated with the aromatase inhibitor anastrozole.

DESIGN

Multi-institutional retrospective cohort study.

SETTING

Two Tertiary Academic Medical Centers.

PATIENTS

A total of 90 infertile men treated at 2 tertiary academic medical centers who met inclusion criteria and obtained pretreatment and posttreatment semen analyses.

INTERVENTION

Prescription of anastrozole (median 3 mg/wk).

MAIN OUTCOME MEASURES

Upgrade in the World Health Organization sperm concentration category (WHO-SCC). Univariate logistic regression, multivariable logistic regression, and partitioning analyses were performed to identify statistically significant patient factors capable of predicting treatment response.

RESULTS

With anastrozole treatment, 46% (n = 41/90) of men responded favorably with a WHO-SCC upgrade, and 12% (n = 11/90) experienced a downgrade. Responders exhibited lower pretreatment levels of luteinizing hormone (LH, 4.7 vs. 8.3 IU/L) and follicle-stimulating hormone (4.7 vs. 6.7 IU/mL), higher pretreatment levels of testosterone (T, 356 vs. 265 ng/dL), and similar baseline level of estradiol (E2, 73% vs. 70% with detectible level). Baseline semen parameters differed, with anastrozole responders demonstrating higher baseline semen concentration (3.6 vs. 0.3 M/mL) and higher total motile sperm counts (3.7 vs. 0.1 M). Anastrozole therapy converted 29% (n = 26/90) of the cohort to normozoospermia and enabled intrauterine insemination access in 31% (n = 20/64) of previously ineligible patients. Interestingly, neither body mass index nor the baseline E2 level or E2-T ratio was associated with WHO-SCC upgrade. Multivariable logistic regression revealed the T-LH ratio (odds ratio: 1.02, 95% confidence interval: 1.00-1.03) and baseline nonazoospermia (odds ratio: 9.4, 95% confidence interval: 1.1-78.9) to be statistically significant predictors of WHO-SCC upgrade (area under receiver operating characteristic curve: 0.77). The final user-friendly partitioning model consisting of the T-LH ratio ≥100 and baseline non-azoospermia was 98% sensitive and 33% specific for WHO-SCC upgrades (area under the curve: 0.77).

CONCLUSION

Anastrozole therapy decreases serum E2 levels, increases serum gonadotropins, and clinically improves semen parameters in half of men with idiopathic infertility. Nonazoospermic infertile men with T-LH ratios ≥100 are likely to benefit from anastrozole treatment irrespective of baseline E2 level or E2-T ratio. Men with azoospermia rarely respond to anastrozole and should be counseled on alternative treatments.

Discordant Bilateral Testicular Pathology Does not Affect Sperm Retrieval Rate in Bilateral Microdissection Testicular Sperm Extraction (mTESE)

OBJECTIVE

To assess the incidence of discordant testicular pathology in men undergoing bilateral microdissection testicular sperm extraction (mTESE) and association with sperm retrieval rate.

METHODS

We performed a retrospective single-institutional review of all patients undergoing mTESE from 2007 to 2021 and aggregated clinical history, physical exam, semen analysis, and operative findings. Specimens with discordant pathology were re-reviewed by an experienced genitourinary.ßpathologist and categorized in a standardized fashion. Data were analyzed using SPSS.

RESULTS

One hundred fourteen non-obstructive azoospermia.ßmen undergoing 132 mTESEs were identified within the study period. Eighty-five percent (112/132) of cases had pathology specimens available, and within this specific cohort the success rate was 41.9% (47/112). A total of 206 pathological reports resulted including 52.4% Sertoli cell only, 4.9% Leydig cell hyperplasia, 8.7% fibrosis, 16.5% maturation arrest, and 17.5% hypospermatogenesis. Twelve percent of testicles had more than 1 pathologic diagnosis. Sixty-six men had synchronous bilateral testicular pathology, and 11/66 (16.6%) had at least partially discordant pathology on initial review. Focused re-review by a genitourinary pathologist confirmed exclusively discordant pathology in 7/66 (10.6%) cases, with a sperm retrieval rate of 57% (4/7). The sperm retrieval rate.ßin men with discordant pathology was not significantly different from those with concordant pathology.

CONCLUSION

Over 1 in 10 men undergoing mTESE may have discordant pathology between testicles, though this may not affect sperm retrieval rate.ßat the time of procedure. Clinicians should consider submitting bilateral testicular specimens for pathology to (1) clarify their outcomes data, and (2) assist with clinical decision-making and surgical planning if a repeat mTESE is indicated.

Post-Vasectomy Semen Analysis: Optimizing Laboratory Procedures and Test Interpretation through a Clinical Audit and Global Survey of Practices

PURPOSE

The success of vasectomy is determined by the outcome of a post-vasectomy semen analysis (PVSA). This article describes a step-by-step procedure to perform PVSA accurately, report data from patients who underwent post vasectomy semen analysis between 2015 and 2021 experience, along with results from an international online survey on clinical practice.

MATERIALS AND METHODS

We present a detailed step-by-step protocol for performing and interpretating PVSA testing, along with recommendations for proficiency testing, competency assessment for performing PVSA, and clinical and laboratory scenarios. Moreover, we conducted an analysis of 1,114 PVSA performed at the Cleveland Clinic's Andrology Laboratory and an online survey to understand clinician responses to the PVSA results in various countries.

RESULTS

Results from our clinical experience showed that 92.1% of patients passed PVSA, with 7.9% being further tested. A total of 78 experts from 19 countries participated in the survey, and the majority reported to use time from vasectomy rather than the number of ejaculations as criterion to request PVSA. A high percentage of responders reported permitting unprotected intercourse only if PVSA samples show azoospermia while, in the presence of few non-motile sperm, the majority of responders suggested using alternative contraception, followed by another PVSA. In the presence of motile sperm, the majority of participants asked for further PVSA testing. Repeat vasectomy was mainly recommended if motile sperm were observed after multiple PVSA's. A large percentage reported to recommend a second PVSA due to the possibility of legal actions.

CONCLUSIONS

Our results highlighted varying clinical practices around the globe, with controversy over the significance of non-motile sperm in the PVSA sample. Our data suggest that less stringent AUA guidelines would help improve test compliance. A large longitudinal multi-center study would clarify various doubts related to timing and interpretation of PVSA and would also help us to understand, and perhaps predict, recanalization and the potential for future failure of a vasectomy.

The Omission of Genitourinary Physical Exam in Telehealth Pre-Vasectomy Consults Does Not Reduce Rates of Office Procedure Completion

OBJECTIVE

To determine whether the omission of pre-procedure genitourinary exam for vasectomy inherent to a virtual consultation reduces the likelihood of successfully completing in-office vasectomy. Currently, the AUA Vasectomy guidelines encourage in-person examination when possible, though COVID-19 has catalyzed the uptake of virtual consultations at many institutions. We hypothesized that rates of completed in-office vasectomy do not significantly differ between patients examined during consultation in the office and those seen virtually with no exam.

METHODS

Virtual vasectomy consults from April to December 2020 were retrospectively reviewed and compared to a size-matched, randomly-selected control group who underwent in-office vasectomy consultation. The primary outcome was completion of in-office bilateral vasectomy. Baseline demographic characteristics were compared. Fisher's exact test and Student's t-test were performed on categorical and continuous variables, respectively.

RESULTS

Of 211 patients who underwent virtual vasectomy consultation during the study period, 153 presented for in-office vasectomy. They were compared to 153 vasectomies from the in-person consult cohort. No demographic differences were observed between virtual and in-office consult groups. No statistical difference was observed in completion rates of in-office vasectomy, which was 97.4% (149/153) in the virtual consult cohort and 98.7% (151/153) in the in-office consultation cohort (p = 0.68).

CONCLUSIONS

Rates of completed in-office vasectomy did not significantly differ based on consult platform, suggesting that a pre-vasectomy physical exam is not required to predict successful completion of the procedure. Telehealth should be utilized as an additional platform to improve access for male contraceptive procedures in a young and busy population.

Men With Chronic Orchialgia Exhibit Differential Neuroinflammatory Gene Expression Relative to Asymptomatic Controls

OBJECTIVE

To identify differences in neuroinflammatory gene expression in individuals with chronic orchialgia (CO) compared to asymptomatic controls.

METHODS

Vas deferens, spermatic cord fascia, blood, and urine were collected from 9 men with CO at time of microscopic spermatic cord denervation and 7 asymptomatic controls at time of vasectomy. RNA was isolated and analyzed with the NanoString Human Neuroinflammation panel. Data were normalized, gene expression fold changes and enriched pathways relative to asymptomatic controls were determined. Gene expression was considered significantly different if there was a >2-fold change and P-value <.05 relative to controls.

RESULTS

Mean patient age was 51 years and median symptom duration 12 months. There were 26 genes with significantly differential expression in vas deferens. cFos, a marker of nociceptive pain, had the greatest difference (30.2-fold change, P <.000001). Enriched pathways in vas deferens included nerve function, matrix remodeling, and innate immune responses. In fascia, cFos also had the greatest differential expression (38-fold, P = .000002), followed by S100A12 (11-fold, inducer of innate immune response). Enriched pathways in fascia included nerve function and inflammation. In blood, there were no differentially expressed genes, and in urine there were 95 differentially expressed genes.

CONCLUSION

Men with CO have a diverse set of neuroinflammatory genes with differential expression in tissue and urine relative to healthy controls. These findings confirm pathologic changes in tissue targeted by denervation surgery, and suggest molecular changes in neuropathic pain that could lead to biomarker identification and novel treatment.

Male-specific late effects in adult hematopoietic cell transplantation recipients: a systematic review from the Late Effects and Quality of Life Working Committee of the Center for International Blood and Marrow Transplant Research and Transplant Complications Working Party of the European Society of Blood and Marrow Transplantation

Male-specific late effects after hematopoietic cell transplantation (HCT) include genital chronic graft-versus-host disease (GvHD), hypogonadism, sexual dysfunction, infertility, and subsequent malignancies. They may be closely intertwined and cause prolonged morbidity and decreased quality of life after HCT. We provide a systematic review of male-specific late effects in a collaboration between transplant physicians, endocrinologists, urologists, dermatologists, and sexual health professionals through the Late Effects and Quality of Life Working Committee of the Center for International Blood and Marrow Transplant Research, and the Transplant Complications Working Party of the European Society of Blood and Marrow Transplantation. The systematic review summarizes incidence, risk factors, screening, prevention and treatment of these complications and provides consensus evidence-based recommendations for clinical practice and future research.

Follicle-stimulating hormone modestly predicts improvement in semen parameters in men with infertility treated with clomiphene citrate

Clomiphene citrate is a commonly prescribed empiric medical therapy for male infertility, but outcomes data and response rates remain incompletely understood. We retrospectively reviewed our single-institutional experience of infertile men prescribed clomiphene. Clomiphene treatment in the final cohort of 140 men was associated with a modest increase in median sperm concentration from 2.2 to 2.5 million/ml (p < 0.001). A total of 46/140 (33%) of men upgraded according to World Health Organization concentration categories. Clomiphene treatment in 26/113 (23%) of previously ineligible men became eligible for intrauterine insemination. Using both univariate and multivariable regression, pre-treatment follicle-stimulating hormone was inversely associated with change in semen concentration with clomiphene treatment. On binary logistic regression, follicle-stimulating hormone level was inversely related to World Health Organization concentration category upgrade (p = 0.01). Unfortunately, 17/140 (12%) of men paradoxically worsened on clomiphene, but no predictors for this could be identified. In summary, clomiphene citrate confers a clinically relevant but modest benefit in a subset (1/3^rd ) of infertile men, particularly those with lower pre-treatment follicle-stimulating hormone levels. Men with elevated follicle-stimulating hormone over 15 IU/ml are less likely to benefit from treatment and should be counselled on other relevant treatment alternatives.

Neuroinflammatory gene expression analysis reveals potential novel mediators and treatment targets in interstitial cystitis with Hunner lesions

Background

We sought to study differential neuroinflammatory gene expression in men with interstitial cystitis (IC) with Hunner lesions compared with asymptomatic controls using NanoString, which uses barcoded probes to measure hundreds of genes. IC is a heterogenous condition lacking reliable biomarkers, and a subset of patients exhibits Hunner lesions, implicating the bladder as an inflammatory pain generator.

Methods

Blood, urine, and bladder biopsies were collected from 6 men with IC and Hunner lesions. 7 asymptomatic controls had blood and urine collected and 2 benign bladder biopsies were obtained from our tissue bank. RNA was isolated and analyzed with NanoString Human Neuroinflammation panel. Gene expression was considered significant if there was a >1.5-fold change and adjusted P value <0.05 compared with controls.

Results

Mean patient age was 61.5 years with 8 years median symptom duration. In bladder tissue, while many cytokine and chemokine genes had higher expression as expected (e.g., TNF, CXCL10), other significant genes included TRPA1 (1098-fold increased, expressed in pain sensing neurons) and TNFRSF17 (735-fold, B-cell related). In urine, there was 114-fold increase in S1PR4, which mediates pain via TRP-dependent pathways. A patient on cyclosporine had lower inflammatory gene expression levels relative to other IC patients, but no difference in TRPA1.

Conclusions

Men with IC and Hunner lesions have a diverse set of neuroinflammatory genes with differential expression compared to controls. We identified genes linked to neuropathic pain through the TRP pathway and this expression was not reduced by cyclosporine. These findings open a new direction for biomarker and therapeutic discovery.

Factors Influencing the Decision for Fresh vs Cryopreserved Microdissection Testicular Sperm Extraction for Non-Obstructive Azoospermia

OBJECTIVE

To determine reproductive urologists' (RU) practice patterns for microdissection testicular sperm extraction (microTESE) and factors associated with use of fresh vs frozen microTESE for non-obstructive azoospermia.

MATERIALS AND METHODS

We electronically surveyed Society for Study of Male Reproduction members with a 21-item questionnaire. Our primary outcomes were to determine RU preference for fresh or frozen microTESE and to understand barriers to performing microTESE. Pearson's chi-square and Fisher's exact tests were used to analyze categorical outcomes and candidate predictor variables. Firth logistic regression was performed to identify the predictors for preferring and performing fresh vs frozen microTESE.

RESULTS

A total of 208 surveys were sent with 76 responses. Most (63.0%) primarily perform frozen microTESE for non-obstructive azoospermia, while 37.0% primarily perform fresh. However, in an ideal practice, 59.3% prefer fresh microTESE, 22.2% prefer frozen microTESE, and 18.5% had no preference. MicroTESE is performed most often (61.1%) at surgical centers not affiliated with a fertility practice. The most commonly reported barriers for both fresh and frozen microTESE are cost (42.6%), scheduling (33.3%), and andrologist unavailability (16.7%). There are no statistically significant differences between these barriers and performing fresh vs frozen microTESE. On multivariable analysis, reproductive endocrinology and infertility-based surgical center (OR 22.9; 95% CI 1.1-467.2; P = 0.04) and professional fee $2,500-$4,999 (OR 20.7; 95% CI 1.27-337.9; P = 0.03) are significant predictors of performing fresh microTESE.

CONCLUSION

Frozen microTESE is performed more commonly than fresh, despite most RU preferring fresh microTESE in an ideal setting. Both fresh and frozen microTESE have a role in reproductive care. Barriers to performing fresh microTESE include cost, scheduling and andrologist availability.

The Impact of Race and Gender on 30-Day Urologic Surgery Complications

OBJECTIVE

To assess the effect of race and gender on complications after urologic surgeries.

MATERIALS AND METHODS

The American College of Surgeons' National Surgical Quality Improvement Program data was utilized for patients undergoing urologic surgeries. Patient demographics and comorbidities were analyzed. Postoperative complications occurring in a 30-day postoperative period were noted and classified per the Clavien-Dindo classification.

RESULTS

From 2008-2018, 284,050 patients underwent urologic surgery. The majority were men (80%) and identified as non-Hispanic white (80%). Complications occurred in 12%, including 9% minor, 5% major, and mortality in 0.6%. Univariate analysis found female gender, non-Hispanic black and Native American race, and patient comorbidities (hypertension, diabetes, heart failure, lung disease, chronic kidney disease) to be associated with increased risk of complications. Female gender remained a significant predictor on multivariable logistic regression, and Hispanic race was found to be an independent negative predictor of postoperative complications, although these results did not appear clinically significant. On exclusion of gender-specific urologic surgeries, female gender was associated with higher likelihood of minor complications, but male gender was associated with higher likelihood of major complications or mortality.

CONCLUSION

Race was not associated with postoperative complication rate. Patient comorbidities are associated with an increased risk of 30-day postoperative complications. Females were more likely to have minor and males were more likely to major complications. Optimizing patient comorbidities preoperatively is key to improving postoperative outcomes.

Functional and Taxonomic Dysbiosis of the Gut, Urine, and Semen Microbiomes in Male Infertility

BACKGROUND

Little is known about the role of the genitourinary and gastrointestinal microbiota in the pathogenesis of male infertility.

OBJECTIVE

To compare the taxonomic and functional profiles of the gut, semen, and urine microbiomes of infertile and fertile men.

DESIGN, SETTING, AND PARTICIPANTS

We prospectively enrolled 25 men with primary idiopathic infertility and 12 healthy men with proven paternity, and we collected rectal swabs, semen samples, midstream urine specimens, and experimental controls.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

We performed comprehensive semen analysis, 16S rRNA sequencing for quantitative high-resolution taxonomy, and shotgun metagenomics with a median of 140 million reads per sample for functional metabolic pathway profiling.

RESULTS AND LIMITATIONS

We identified a diverse semen microbiome with modest similarity to the urinary microbiome. Infertile men harbored increased seminal α-diversity and distinct β-diversity, increased seminal Aerococcus, and decreased rectal Anaerococcus. Prevotella abundance was inversely associated with sperm concentration, and Pseudomonas was directly associated with total motile sperm count. Vasectomy appeared to alter the seminal microbiome, suggesting a testicular or epididymal contribution. Anaerobes were highly over-represented in the semen of infertile men with a varicocele, but oxidative stress and leukocytospermia were associated with only subtle differences. Metagenomics data identified significant alterations in the S-adenosyl-L-methionine cycle, which may play a multifaceted role in the pathogenesis of infertility via DNA methylation, oxidative stress, and/or polyamine synthesis.

CONCLUSIONS

This pilot study represents the first comprehensive investigation into the microbiome in male infertility. These findings provide the foundation for future investigations to explore causality and identify novel microbiome-based diagnostics and therapeutics for men with this complex and emotionally devastating disease.

PATIENT SUMMARY

We explored the resident populations of bacteria living in the gut, semen, and urine of infertile and fertile men. We found several important bacterial and metabolic pathway differences with the potential to aid in diagnosing and treating male infertility in the future.

Assessing online price transparency of sperm cryopreservation across the United States

Although the lack of information on the costs and pricing of healthcare services prevails throughout the medical industry, empiric observations have demonstrated that pricing information is even more obscured in the sperm cryopreservation market. Thus, the objectives of our study are to assess and compare online price transparency and the price of sperm cryopreservation across various healthcare settings in the United States. This study examined online pricing published by facilities that have an active registration to store spermatozoa with the Food and Drug Administration. Less than one-fifth of registered facilities display any pricing information online. Price transparency also varies among census regions and facility types. Nationally, the median initial bank fee and annual price of storage are $350 and $385 respectively. Although there were no differences in the initial fee by facility type and census region, the annual price of storing spermatozoa is highest in the Northeast, which could be attributed to laboratory techniques, demographic patterns or insurance coverage. Guidelines from professional societies or different legislation and regulatory requirements across different US states can increase price transparency, which can promote consumer decision-making and decrease the barrier for men seeking fertility preservation.

Microscopic spermatic cord denervation for chronic orchialgia/chronic scrotal content pain: operative outcomes and predictors of failure

Background

To describe our institutional outcomes with microscopic spermatic cord denervation (MSCD) for chronic scrotal content paint (CSCP) and identify predictors of treatment failure.

Methods

Retrospective chart review was performed to identify all MSCD performed by two surgeons at a single institution from 2010–2019. Patient demographic data and operative outcomes were collected. Patients were excluded from analysis if no post-operative follow up was available. Success was defined as complete resolution of bothersome pain. Multivariable logistic regression was utilized to identify predictors of treatment failure.

Results

During the study period, 101 patients were identified in which 113 MSCD procedures were performed. Final analysis included 103 procedures across 93 patients. Mean age was 41.8 years (SD 13.2), mean BMI was 29.2 kg/m² (SD 5.96) and median months of pain preceding surgery were 24 (range, 3–300 months). Overall, 75/103 (73%) MSCD were successful. Of the failures, 5 patients had recurrence of pain greater than 6 months after surgery. Only the presence of pelvic floor muscle spasm (PFMS) independently predicted MSCD failure (OR 3.95, P=0.02). 9 of 19 (47%) patients with PFMS experienced treatment failure, while 19 of 84 (23%) without PFMS experienced failure.

Conclusions

MSCD offers a therapeutic option for patients with refractory CSCP. The presence of PFMS is associated with lower surgical success rates. Patients with pre-operatively identified PFMS should be counseled regarding a higher risk of treatment failure.

The effect of trainee involvement on surgical outcomes and complications of male infertility surgical procedures

In this study, we sought to determine the effect of trainee (resident or fellow physician) involvement in male infertility surgical procedures on patient surgical outcomes and complications. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was retrospectively reviewed for fertility surgical procedures from 2006 to 2012. The procedures included were as follows: epididymectomy, spermatocelectomy, varicocelectomy ± hernia repair, ejaculatory duct resection, vasovasostomy, vasoepididymostomy and 'unlisted procedure male genital system' (to capture sperm retrieval procedures). A variety of peri- and post-operative outcomes were examined. Trainee and nontrainee-involved groups were compared by Wilcoxon rank sum tests, followed by logistic regression, univariate and multivariate analyses. 924 cases were included: 309 with trainees and 615 without. The median post-graduate trainee year was 3 (range: 0-10). Patients in the trainee-involved cohort had higher rates of chronic obstructive pulmonary disease, steroid usage and black race. Mean operative time was 42.5% longer in trainee-involved cases, even after controlling for other covariates (76.2 vs. 49.5 min, p = .00). Hospital stay length was also longer in trainee-involved cases (0.41 vs. 0.35 days, p = .02). There were no differences in superficial infections (p = 1.00), deep wound infections (p = 1.00), urinary tract infections (p = .26), or reoperations (p = .23) with or without trainee involvement.

Failure of testosterone replacement therapy to improve symptoms correlates with burden of systemic conditions

Background

The symptoms of hypogonadism are non-specific and restoring testosterone (T) to physiologic levels may not lead to clinical improvement. In men with a high burden of systemic illness, it is difficult to assess whether hypogonadism is a primary contributing factor of their symptoms. Given that testosterone replacement therapy (TRT) is not without risk, it is important to understand which patients will benefit from treatment. Therefore, we hypothesize that men with a higher burden of systemic illness would be less likely to continue with TRT.

Methods

We performed a retrospective review of our men’s health registry for men who started TRT and adhered to follow up labs and visits within the first year. We restricted treatment to Testopel pellets due to reliable early T levels. Men were classified as yes/no for continued TRT based on whether they felt their presenting symptoms improved on therapy and they chose to continue TRT. The previously validated ACTIONS men’s health phenotype was calculated as a composite systemic disease score grading severity [0–2] for each of anxiety, cardiovascular disease, low testosterone, diabetes, obesity, neurologic disease and obstructive sleep apnea (total score 0–14).

Results

Sixty men were identified with a mean age of 59.5 (range, 33–81) years and mean starting total testosterone of 215 [48–332] ng/dL. Thirty-nine men (65%) felt symptomatic benefit and continued therapy for a median of 40.4 (20.5–76.4) months vs. 21 men without benefit treated for a median of 4.1 months (2.9–10.7, P<0.0001). Those who stopped TRT had a higher ACTIONS score than those who continued (8±2.5 vs. 4.1±1.6, P<0.0001). Age weakly correlated with total ACTIONS score (r=0.28, P=0.03) but age had no impact on continuing TRT and the relationship between continuing TRT and ACTIONS score held true regardless of age.

Conclusions

Patients with a greater burden of systemic disease were less likely to have symptomatic improvement with TRT and more likely to stop therapy within a year. As several hypogonadal symptoms are non-specific, it is imperative that patients be counseled on the likelihood of success with TRT, particularly if they have multiple comorbidities. Ideal outcomes may come from multimodal therapy that includes lifestyle modification, and optimization of conditions such as diabetes, cardiovascular disease and sleep apnea.

MON-140 Prolactin to Testosterone Ratio Reduces Pituitary Magnetic Resonance Imaging Expenditures for Hypogonadal Men with Mild Hyperprolactinemia

Background: Hyperprolactinemia is a common laboratory finding in men with symptomatic hypogonadism. Persistent elevations in serum prolactin (PRL) are typically evaluated with pituitary magnetic resonance imaging (pitMRI) to assess for structural pathology. However, this practice pattern may result in overutilization of pitMRI and unnecessary healthcare expenditures.

Objective: We sought to examine the cost savings associated with utilizing combinations of serum PRL and the prolactin to testosterone ratio (PRL/T) to predict positive findings on pitMRI and obviate the need for unnecessary imaging studies.

Methods: A retrospective case-control study was performed. Men <75 presenting with symptomatic hypogonadism and mild hyperprolactinemia (15-55 ng/ml) who obtained pitMRI at a tertiary care center were included. Individuals previously evaluated for pituitary abnormality were excluded, as were those presenting with symptoms strongly concerning for a pituitary abnormality (e.g. visual change, headache). Laboratory studies were abstracted from the electronic medical record and pitMRI results were reviewed. A cost analysis was performed based on the institutional expense of pitMRI and laboratory evaluations. The cost of measuring PRL and T was calculated for all patients. The expense of pitMRI was calculated for those screening positive.

Results: 141 men were included in the study. Pituitary lesions were identified in 40/141 men (28%). The total cost of evaluation was calculated at $458,814.

Ordering pitMRI when PRL/T >0.10 is 80% sensitive (32/40 lesions captured) and 64% specific (65/101 with normal anatomy excluded). 68/141 are indicated for pitMRI, while 73 patients avoid imaging. Employing this threshold reduces expenses by 46% with cost savings calculated at $212,795. The cost of identifying each lesion was estimated at $7,688.

Ordering pitMRI when PRL/T >0.10 or when PRL >25 is 90% sensitive (36/40 lesions captured) and 48% specific (48/101 with normal anatomy excluded). 89/141 are indicated for pitMRI, while 52 patients avoid imaging. Employing this threshold reduces expenses by 33% with cost savings calculated at $151,580. The cost of identifying each lesion was estimated at $8,534.

Ordering pitMRI when PRL/T >0.08 or when PRL >25 is 98% sensitive (39/40 lesions captured) and 32% specific (32/101 with normal anatomy excluded). 108/141 are indicated for pitMRI, while 33 patients avoid imaging. Employing this threshold reduces expenses by 21% with cost savings calculated at $96,195. The cost of identifying each lesion was estimated at $9,011.

Conclusions: Serum PRL and PRL/T correctly predict the vast majority of pituitary lesions in patients with mild hyperprolactinemia, with screening costs increasing as more sensitive thresholds are employed. Future guidelines should establish a reasonable cutoff for pitMRI to minimize the expense of unnecessary imaging.

MON-275 Prolactin to Testosterone Ratio Predicts Pituitary Pathology in Hypogonadal Men with Mild Hyperprolactinemia

Background: Serum prolactin (PRL) and testosterone (T) levels are routinely evaluated in men presenting with clinical symptoms of hypogonadism. Persistent mild elevations in PRL are often benign, but may reflect structural pathology. Though pituitary magnetic resonance imaging (pitMRI) is often obtained to assess for anatomic lesions, it remains unclear how to optimize screening in hypogonadal men with mild hyperprolactinemia.

Objective: We sought to identify risk factors associated with detection of pituitary pathology among hypogonadal men with mild hyperprolactinemia and aimed to improve selection of those indicated for pitMRI.

Methods: A retrospective, case-control study was performed. Men under 75 presenting with clinical hypogonadism and mild hyperprolactinemia (15-50 ng/dL) who underwent pitMRI at a single tertiary care center were included. Individuals presenting with clinical symptoms strongly suggestive of a pituitary mass (e.g. visual change, headache, panhypopituitarism) were excluded, as were patients who had been previously evaluated for hyperprolactinemia. Age, body mass index (BMI), presenting symptoms, prescription history, and pitMRI findings were abstracted from the electronic medical record.

Results: 141 men met inclusion criteria. A minority exhibited pituitary pathology (n=40, 28%) with adenoma being the most common finding (n=35, 88%). Empty sella variants and non-neoplastic cysts comprised the remainder of pathologies (n=5, 12%). Mean PRL was higher in men with pituitary pathology than in controls (27.2 vs. 23.3 ng/mL; p=0.0106), while mean T levels were lower (190 vs 287 ng/dL; p=0.0001). Mean PRL/T ratio values were greater in cases (0.34 vs. 0.08; p<0.0001), as were median values (0.15 vs. 0.09). PRL/T outperformed PRL or T in predicting positive pitMRI findings (AUC: 0.75 vs. 0.64 vs. 0.71, respectively). A PRL/T ratio >0.08 was 90% sensitive, detecting 36/40 lesions, and 42% specific, excluding 42/101 patients with normal anatomy (p=0.0003). If applied to the study cohort, this cutoff would have reduced pitMRI burden by 30%. Ordering pitMRI when the PRL/T ratio >0.08 or when PRL >25 increases sensitivity (98%, 39/40 lesions detected) at the cost of decreased specificity (32%, 32/101 controls excluded). Presenting symptoms including fatigue, decreased libido, erectile dysfunction, and gynecomastia did not vary between cases and controls. Though patients with pituitary lesions were more likely to receive dopamine agonists than controls (40% vs. 23%; p=0.0392), they were not more likely to be prescribed testosterone, antipsychotics, or antidepressants.

Conclusions: The PRL/T ratio is superior to PRL or T alone in identifying pituitary pathology in hypogonadal men with mild hyperprolactinemia. Ordering pitMRI when the PRL/T >0.08 is sensitive for detecting pituitary lesions and may reduce pitMRI burden in this population by 30%.

Pathophysiology and treatment options of varicocele: An overview

Varicocele is the most common correctable cause for male infertility, but not all men with varicocele are affected equally by this condition. The pathophysiology of varicocele-induced fertility remains ill-defined. While evidence suggests that oxidative stress remains a central factor, other mechanisms likely include scrotal hyperthermia, reflux of metabolites, hypoxia and cadmium accumulation. Microsurgical varicocelectomy remains the gold standard treatment option for infertile men with a clinically palpable varicocele and abnormal semen parameters. Newer evidence suggests a potential role for antioxidant supplementation and a meaningful role of varicocelectomy for patients destined for ART to improve pregnancy outcomes.

Fertility considerations in men with testicular cancer

The modern approach to cancer management has evolved into a multidisciplinary initiative focused not only on cancer specific and overall survival, but also patient quality of life and survivorship. Future fertility is often a major concern for young patients undergoing cancer therapy. Fertility preservation has emerged as a viable but significantly underutilized option. Patients and families should be aware of the varying effects of antineoplastic therapy on their future fertility to allow for an informed decision regarding their fertility preservation options. In this review we discuss the epidemiology, pathophysiology, and management of fertility in the setting of testicular cancer diagnosis and treatment.

Childless Men at the Time of Vasectomy are Unlikely to Seek Fertility Restoration

OBJECTIVE

To examine whether men who were childless at the time of vasectomy sought consultation for fertility restoration.

METHODS

Retrospective chart review was performed to determine if patients without children at the time of vasectomy sought consultation for fertility restoration (defined as vasectomy reversal or sperm retrieval). If the patient had not been seen in our healthcare system within the previous 12 months, he was contacted by phone to determine whether he had sought consultation for fertility restoration.

RESULTS

Of 1656 men, 68 men (4.1%) were childless at the time of vasectomy. Fifteen patients were excluded as they were not followed in our hospital system and were unreachable by phone. Zero patients sought consultation for fertility restoration.

CONCLUSION

Our single institution study demonstrated that no men who were childless at the time of vasectomy sought consultation for fertility restoration. Given that there are no other FDA approved methods for nonbarrier sterilization for males, men with no children at the time of vasectomy should receive the same AUA guideline-recommended counseling that men with children receive.

Sperm granuloma masquerading as a supernumerary testis

Sperm granuloma is a common finding following vasectomy, with majority of the lesions located at the site of the vasectomy defect. Sperm granulomas are typically small and asymptomatic. We describe a case in which the nodule presented similarly to a supernumerary testis by radiographic features.

Effect of Antioxidant Supplementation on the Sperm Proteome of Idiopathic Infertile Men

Antioxidant supplementation in idiopathic male infertility has a beneficial effect on semen parameters. However, the molecular mechanism behind this effect has not been reported. The objective of this study was to evaluate the sperm proteome of idiopathic infertile men pre- and post-antioxidant supplementation. Idiopathic infertile men were provided with oral antioxidant supplementation once daily for a period of 6 months. Of the 379 differentially expressed proteins (DEPs) between pre- and post-antioxidant treatment patients, the majority of the proteins (n = 274) were overexpressed following antioxidant treatment. Bioinformatic analysis revealed the activation of oxidative phosphorylation pathway and upregulation of key proteins involved in spermatogenesis, sperm maturation, binding of sperm, fertilization and normal reproductive function. In addition, the transcriptional factors associated with antioxidant defense system (PPARGC1A) and free radical scavenging (NFE2L2) were predicted to be functionally activated post-treatment. Key DEPs, namely, NDUFS1, CCT3, PRKARA1 and SPA17 validated by Western blot showed significant overexpression post-treatment. Our novel proteomic findings suggest that antioxidant supplementation in idiopathic infertile men improves sperm function at the molecular level by modulating proteins involved in CREM signaling, mitochondrial function and protein oxidation. Further, activation of TRiC complex helped in nuclear compaction, maintenance of telomere length, flagella function, and expression of zona pellucida receptors for sperm-oocyte interaction.

Smartphone-based home screening tests for male infertility

Diagnostic testing for male infertility has traditionally been limited to andrology labs. The advent of home-based semen testing has the potential to allow patients to perform testing in the comfort of their home and screen those who need a formal evaluation. An extensive review of the literature was performed. There are several FDA-approved devices for home semen testing. The mechanism of the test and the results provided differ by test. The existing tests are limited in their diagnostic capabilities but may fill a niche for men who do not have access to andrology lab testing or prefer home testing.

Male infertility in renal failure and transplantation

The global disease burden of end stage renal disease (ESRD) is growing rapidly, and organ transplantation remains the gold standard for improving both the quality and quantity of life particularly in young adults. It is therefore critical to understand the effect of ESRD and renal transplantation on male fertility. Many men in renal failure exhibit subfertility or infertility due to several factors including hypogonadism, erectile dysfunction (ED), and direct impairment of spermatogenesis with spermatotoxicity and late stage maturational arrest causing oligospermia or azoospermia. Kidney transplantation has been shown to rescue some-but not all-of these defects, with normalization of reproductive hormonal parameters, improvement in semen parameters (sperm count, motility, morphology), and partial restoration of erectile function. This improvement in fertility is sufficient for a subset to father children either naturally or with assisted reproduction. In this review, we summarize the literature regarding fertility in men with chronic kidney disease (CKD) and on dialysis, and we describe the changes associated with renal transplantation.