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

PURPOSE

Varicocele is a common problem among infertile men. Varicocele repair (VR) is frequently performed to improve semen parameters and the chances of pregnancy. However, there is a lack of consensus about the diagnosis, indications for VR and its outcomes. The aim of this study was to explore global practice patterns on the management of varicocele in the context of male infertility.

MATERIALS AND METHODS

Sixty practicing urologists/andrologists from 23 countries contributed 382 multiple-choice-questions pertaining to varicocele management. These were condensed into an online questionnaire that was forwarded to clinicians involved in male infertility management through direct invitation. The results were analyzed for disagreement and agreement in practice patterns and, compared with the latest guidelines of international professional societies (American Urological Association [AUA], American Society for Reproductive Medicine [ASRM], and European Association of Urology [EAU]), and with evidence emerging from recent systematic reviews and meta-analyses. Additionally, an expert opinion on each topic was provided based on the consensus of 16 experts in the field.

RESULTS

The questionnaire was answered by 574 clinicians from 59 countries. The majority of respondents were urologists/uro-andrologists. A wide diversity of opinion was seen in every aspect of varicocele diagnosis, indications for repair, choice of technique, management of sub-clinical varicocele and the role of VR in azoospermia. A significant proportion of the responses were at odds with the recommendations of AUA, ASRM, and EAU. A large number of clinical situations were identified where no guidelines are available.

CONCLUSIONS

This study is the largest global survey performed to date on the clinical management of varicocele for male infertility. It demonstrates: 1) a wide disagreement in the approach to varicocele management, 2) large gaps in the clinical practice guidelines from professional societies, and 3) the need for further studies on several aspects of varicocele management in infertile men.

Antisperm Antibody Testing: A Comprehensive Review of Its Role in the Management of Immunological Male Infertility and Results of a Global Survey of Clinical Practices

Antisperm antibodies (ASA), as a cause of male infertility, have been detected in infertile males as early as 1954. Multiple causes of ASA production have been identified, and they are due to an abnormal exposure of mature germ cells to the immune system. ASA testing (with mixed anti-globulin reaction, and immunobead binding test) was described in the WHO manual 5th edition and is most recently listed among the extended semen tests in the WHO manual 6th edition. The relationship between ASA and infertility is somewhat complex. The presence of sperm agglutination, while insufficient to diagnose immunological infertility, may indicate the presence of ASA. However, ASA can also be present in the absence of any sperm agglutination. The andrological management of ASA depends on the etiology and individual practices of clinicians. In this article, we provide a comprehensive review of the causes of ASA production, its role in immunological male infertility, clinical indications of ASA testing, and the available therapeutic options. We also provide the details of laboratory procedures for assessment of ASA together with important measures for quality control. Additionally, laboratory and clinical scenarios are presented to guide the reader in the management of ASA and immunological male infertility. Furthermore, we report the results of a recent worldwide survey, conducted to gather information about clinical practices in the management of immunological male infertility.

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.

Relevance of Leukocytospermia and Semen Culture and Its True Place in Diagnosing and Treating Male Infertility

The current WHO 2010 manual for human semen analysis defines leukocytospermia as the presence of peroxidase-positive leukocytes at a concentration >1×106/mL of semen. Granular leukocytes when activated are capable of generating high levels of reactive oxygen species in semen resulting in oxidative stress. Oxidative stress has been correlated with poor sperm quality, increased level of sperm DNA fragmentation and low fertility potential. The presence of leukocytes and pathogens in the semen may be a sign of infection and/or localized inflammatory response in the male genital tract and the accessory glands. Common uro-pathogens including Chlamydia trachomatis, Ureaplasma urealyticum, Neisseria gonorrhoeae, Mycoplasma hominis, and Escherichia coli can cause epididymitis, epididymo-orchitis, or prostatitis. The relationship between leukocytospermia and infection is unclear. Therefore, we describe the pathogens responsible for male genital tract infections and their association with leukocytospermia. The review also examines the diagnostic tests available to identify seminal leukocytes. The role of leukocytospermia in male infertility and its management is also discussed.

A Comprehensive Guide to Sperm Recovery in Infertile Men with Retrograde Ejaculation

Retrograde ejaculation (RE) is a condition defined as the backward flow of the semen during ejaculation, and when present can result in male infertility. RE may be partial or complete, resulting in either low seminal volume or complete absence of the ejaculate (dry ejaculate). RE can result from anatomic, neurological or pharmacological conditions. The treatment approaches outlined are determined by the cause. Alkalinizing urinary pH with oral medications or by adding sperm wash media into the bladder prior to ejaculation may preserve the viability of the sperm. This article provides a step-by-step guide to diagnose RE and the optimal techniques to retrieve sperm.

Sperm Vitality and Necrozoospermia: Diagnosis, Management, and Results of a Global Survey of Clinical Practice

Sperm vitality testing is a basic semen examination that has been described in the World Health Organization (WHO) Laboratory Manual for the Examination and Processing of Human Semen from its primary edition, 40 years ago. Several methods can be used to test sperm vitality, such as the eosin-nigrosin (E-N) stain or the hypoosmotic swelling (HOS) test. In the 6th (2021) edition of the WHO Laboratory Manual, sperm vitality assessment is mainly recommended if the total motility is less than 40%. Hence, a motile spermatozoon is considered alive, however, in certain conditions an immotile spermatozoon can also be alive. Therefore, the differentiation between asthenozoospermia (pathological decrease in sperm motility) and necrozoospermia (pathological decrease in sperm vitality) is important in directing further investigation and management of infertile patients. The causes leading to necrozoospermia are diverse and can either be local or general, testicular or extra-testicular. The andrological management of necrozoospermia depends on its etiology. However, there is no standardized treatment available presently and practice varies among clinicians. In this study, we report the results of a global survey to understand current practices regarding the physician order of sperm vitality tests as well as the management practices for necrozoospermia. Laboratory and clinical scenarios are presented to guide the reader in the management of necrozoospermia with the overall objective of establishing a benchmark ranging from the diagnosis of necrozoospermia by sperm vitality testing to its clinical management.

Sperm DNA Fragmentation: A Critical Assessment of Clinical Practice Guidelines

Sperm DNA fragmentation (SDF) is implicated in male infertility and adverse reproductive outcomes. With the publication of many studies regarding the etiologies and contributors to SDF, as well as the effects of SDF, guidelines are necessary to aid clinicians in the application of SDF for male fertility evaluation. Two recent clinical practice guidelines were published by Agarwal et al and Esteves et al. In this article, we have evaluated and compared both guidelines. We have found fairly similar recommendations between the two guidelines and have also highlighted the differences between them. Finally, we have summarized and combined the best practice recommendations from both guidelines.

A Global Survey of Reproductive Specialists to Determine the Clinical Utility of Oxidative Stress Testing and Antioxidant Use in Male Infertility

Purpose

The use of antioxidants is common practice in the management of infertile patients. However, there are no established guidelines by professional societies on antioxidant use for male infertility.

Materials and Methods

Using an online survey, this study aimed to evaluate the practice pattern of reproductive specialists to determine the clinical utility of oxidative stress (OS) testing and antioxidant prescriptions to treat male infertility.

Results

Responses from 1,327 participants representing 6 continents, showed the largest participant representation being from Asia (46.8%). The majority of participants were attending physicians (59.6%), with 61.3% having more than 10 years of experience in the field of male infertility. Approximately two-thirds of clinicians (65.7%) participated in this survey did not order any diagnostic tests for OS. Sperm DNA fragmentation was the most common infertility test beyond a semen analysis that was prescribed to study oxidative stress-related dysfunctions (53.4%). OS was mainly tested in the presence of lifestyle risk factors (24.6%) or sperm abnormalities (16.3%). Interestingly, antioxidants were prescribed by 85.6% of clinicians, for a duration of 3 (43.7%) or 3–6 months (38.6%). A large variety of antioxidants and dietary supplements were prescribed, and scientific evidence were mostly considered to be modest to support their clinical use. Results were not influenced by the physician's age, geographic origin, experience or training in male infertility.

Conclusions

This study is the largest online survey performed to date on this topic and demonstrates 1) a worldwide understanding of the importance of this therapeutic option, and 2) a widely prevalent use of antioxidants to treat male infertility. Finally, the necessity of evidence-based clinical practice guidelines from professional societies is highlighted.

SARS-CoV-2 pandemic and repercussions for male infertility patients: A proposal for the individualized provision of andrological services

The prolonged lockdown of health facilities providing non‐urgent gamete cryopreservation—as currently recommended by many reproductive medicine entities and regulatory authorities due to the SARS‐CoV‐2 pandemic will be detrimental for subgroups of male infertility patients. We believe the existing recommendations should be promptly modified and propose that the same permissive approach for sperm banking granted for men with cancer is expanded to other groups of vulnerable patients. These groups include infertility patients (eg, azoospermic and cryptozoospermic) undergoing medical or surgical treatment to improve sperm quantity and quality, as well as males of reproductive age affected by inflammatory and systemic auto‐immune diseases who are about to start treatment with gonadotoxic drugs or who are under remission. In both scenarios, the “fertility window” may be transitory; postponing diagnostic semen analysis and sperm banking in these men could compromise the prospects of biological parenthood. Moreover, we provide recommendations on how to continue the provision of andrological services in a considered manner and a safe environment. Our opinion is timely and relevant given the fact that fertility services are currently rated as of low priority in most countries.

Validation of the Chronic Orchialgia Symptom Index for Men With Chronic Orchialgia/Chronic Scrotal Contents Pain

OBJECTIVE

To prospectively validate the chronic orchialgia symptom index (COSI), a newly created instrument with 12 questions in 3 domains (pain, sexual symptoms and quality of life).

METHODS

The COSI was given to 170 men with chronic orchialgia at 2 institutions. Seventy-eight men repeated the COSI before therapy and 42 repeated it after surgical therapy. Data was analyzed for test/retest internal reliability, internal consistency, floor and ceiling effects, construct validity, responsiveness and linear regression of all questions including age, duration, and prior surgeries.

RESULTS

The 170 men had a mean age of 44.3 (range 18-82) and median symptom duration of 24 months (3-420). About 22.4% had prior vasectomy, 12.4% had hernia repair, and 12.9% had other prior surgery. Mean total COSI was 20.0±7.7 (range 1-37) with subscores of pain 9.1±3.5 (0-17), sexual symptoms 1.82±1.5 (0-5) and quality of life 9.0±4.0 (0-15). Test/retest reliability was high with mean retest total score of 21.2±7.9 and intraclass correlation coefficient of 0.82. Internal consistency by Cronbach's alpha was 0.86. There were no floor or ceiling effects for total score. Construct validity showed all items contributed to a good fit model (P = .001). Patient age, duration, and prior surgeries did not influence COSI. Finally, the COSI was responsive to improvement after therapy (mean after treatment 13.5±9.8, P = .00001).

CONCLUSION

COSI is a valid and clinically relevant symptom index to assess severity of orchialgia symptoms and response to therapy in this challenging patient population.

Development of a clinically relevant symptom index to assess patients with chronic orchialgia/chronic scrotal content pain

Background

The purpose of this study was to develop a candidate symptom index for men with an established diagnosis of chronic orchialgia.

Methods

Based on interviews with patients and providers, we developed a 70-item questionnaire that focused on seven areas of orchialgia symptoms: pain, location, urinary symptoms, sexual dysfunction, medical history and quality of life (QOL) impact. The questionnaire was completed by patients at two medical centers. Cluster analysis was performed with the software package R (3.2.1).

Results

A total of 113 men completed the survey. Median symptom duration was 12 months (range, 3-336 months). Outside the testicle, pain was felt in the spermatic cord (66%), groin (66%), penis (24%), suprapubic region (38%), flank (31%), thigh (32%), abdomen (36%) and perineum (35%). Bother scores were high only for testicle and spermatic cord pain. Urinary frequency was common (54%) but not bothersome. Sexual dysfunction was common: 55% had erectile dysfunction, 56% had decreased libido and 39% had painful ejaculation with high bother for all. By cluster analysis, QOL parameters clustered tightly with minimal pain level, pain at night, burning pain, distribution to spermatic cord and groin, erectile dysfunction and premature ejaculation.

Conclusions

Men with chronic orchialgia have a high incidence of associated symptoms. Most bothersome symptoms with highest QOL impact include burning pain, pain at night, radiation to groin and spermatic cord, erectile dysfunction and low libido. Based on these findings, we have created a candidate orchialgia symptom index with domains of pain, sexual symptoms and QOL that will undergo prospective validation.

Targeted Robotic Assisted Microsurgical Denervation of the Spermatic Cord for the Treatment of Chronic Orchialgia or Groin Pain: A Single Center, Large Series Review

PURPOSE

Microsurgical denervation of the spermatic cord is a treatment option for chronic orchialgia refractory to conservative treatment. A recent study showed specific nerve fibers as the possible cause of chronic orchialgia. Our goal was to present the outcomes of ligation of these nerves using a technique of targeted robotic assisted microsurgical denervation of the spermatic cord.

MATERIALS AND METHODS

We retrospectively reviewed the records of 772 patients who underwent targeted robotic assisted microsurgical denervation of the spermatic cord from October 2007 to July 2016. Selection criteria were chronic testicular pain more than 3 months in duration, failed conservative treatments, negative neurological and urological workup, and temporary resolution of pain with a local anesthetic spermatic cord block. Targeted robotic assisted microsurgical denervation of the spermatic cord was performed. Pain was assessed preoperatively and postoperatively using a subjective visual analog scale and objectively with the standardized and validated PIQ-6 (Pain Impact Questionnaire-6) score.

RESULTS

Followup data were available on 860 cases. During a median followup of 24 months (range 1 to 70) 718 cases (83%) showed a significant reduction in pain and 142 (17%) had no change in pain by subjective visual analog scale scoring. Of cases with a significant reduction in pain 426 (49%) had complete resolution and 292 (34%) had a 50% or greater reduction. Objective PIQ-6 analysis showed a significant reduction in pain in 67% of patients 6 months postoperatively, in 68% at 1 year, in 77% at 2 years, in 86% at 3 years and in 83% at 4 years.

CONCLUSIONS

Targeted robotic assisted microsurgical denervation of the spermatic cord is an effective, minimally invasive approach with potential long-term durability in patients with refractory chronic orchialgia.

Robot-assisted microsurgery for chronic orchialgia

Chronic orchialgia is one of the most common complaints seen in the urologists office and has traditionally been considered a very difficult diagnostic and therapeutic challenge for the clinician. First line management of chronic orchialgia is conservative treatment; however, in men who fail conservative therapy, surgical intervention may be indicated. Microsurgery has been the mainstay for surgical treatment of chronic orchialgia, but the implementation of robotics to microsurgery lends itself particularly to surgical treatment of chronic orchialgia. PubMed was used to perform a current literature search on chronic orchialgia with robotic microsurgery, robotic spermatic cord denervation, robotic varicocelectomy, and robotic vasectomy reversal. Although conservative therapy is considered the first line treatment for chronic orchialgia, reported outcomes are moderate to poor, with the need to proceed to surgical intervention in select cases. Current surgical therapies in which robot assistance have been applied to microsurgery include microsurgical denervation of the spermatic cord, varicocelectomy, and vasectomy reversal. As further studies have assisted in the understanding of surgical treatment of chronic orchialgia, the application of robot assistance to this level of microsurgery has been shown to be feasible and safe with comparable outcomes to traditional microsurgery and may provide potential advantages.

Genital pain: algorithm for management

Chronic testicular pain although becoming very common in our patient population poses a challenge to the physician, the patient and his family. The pathogenesis of chronic orchialgia (CO) is not well understood. The objective of this paper is to review the current literature on chronic testicular pain and its management and to propose an algorithm for its treatment. Abstracts, original papers and review articles were reviewed during a literature search using words such as testicular pain, CO, and microsurgical anatomy of spermatic cord. Chronic scrotal content pain (CSP) is a difficult condition to treat and could be idiopathic or secondary. Conservative therapy is the first line of treatment attempted to allow the patient to return to his routine activities. When conservative treatment fails, patients can now turn toward surgical options such as microsurgical denervation of the spermatic cord (MDSC) which has a success rate published in the 60-85% range and/or minimally invasive therapies such as microcryoablation of the spermatic cord, Botox or Amniofix injection. There is an increase in referrals for CO. The true pathogenesis is still unclear and the road to complete recovery is unsure for certain patients. This paper proposes an algorithm for the management of patients suffering with CO.

Chronic orchialgia: Review of treatments old and new

Introduction:

Chronic orchialgia is historically and currently a challenging disease to treat. It is a diagnostic and therapeutic challenge for physicians. Conservative therapy has served as the first line of treatment. For those who fail conservative therapy, surgical intervention may be required. We aim to provide a review of currently available surgical options and novel surgical treatment options.

Methods:

A review of current literature was performed using PubMed. Literature discussing treatment options for chronic orchialgia were identified. The following search terms were used to identify literature that was relevant to this review: Chronic orchialgia, testicular pain, scrotal content pain, and microsurgical denervation of the spermatic cord (MDSC).

Results:

The incidence of chronic orchialgia has been increasing over time. In the USA, it affects up to 100,000 men per year due to varying etiologies. The etiology of chronic orchialgia can be a confounding problem. Conservative therapy should be viewed as the first line therapy. Studies have reported poor success rates. Current surgical options for those who fail conservative options include varicocelectomy, MDSC, epididymectomy, and orchiectomy. Novel treatment options include microcryoablation of the peri-spermatic cord, botox injection, and amniofix injection.

Conclusion:

Chronic orchialgia has been and will continue to be a challenging disease to treat due to its multiple etiologies and variable treatment outcomes. Further studies are needed to better understand the problem. Treatment options for patients with chronic orchialgia are improving. Additional studies are warranted to better understand the long-term durability of this treatment options.

Microsurgical denervation of rat spermatic cord: safety and efficacy data

OBJECTIVE

To describe a microsurgical technique for denervation of the spermatic cord and use of multiphoton microscopy (MPM) laser to identify and ablate residual nerves after microsurgical denervation. To evaluate structural and functional changes in the rat testis and vas deferens after denervation.

MATERIALS AND METHODS

Nine Sprague-Dawley rats were divided into three experimental groups: sham, microsurgical denervation of the spermatic cord (MDSC), and MDSC immediately followed by laser ablation with MPM. At 2 months after surgery, we assessed testicular volume, functional circulation of the testicular artery with Doppler, patency of the vas deferens, and histology of the testis and vas deferens.

RESULTS

There was a significant decrease in the median number of nerves remaining around the vas deferens with MDSC alone (3.5 nerves) or MDSC with MPM (1.5 nerves) compared with sham rats (15.5 nerves) (P = 0.003). Although, MDSC with MPM resulted in the fewest remaining nerves, this result was similar to MDSC alone (P = 0.29). No deleterious effects on spermatogenesis or vas patency were seen in the experimental groups when compared with the sham rats.

CONCLUSION

A microsurgical approach can be used to effectively and safely denervate the rat spermatic cord with minimal changes to structure and function of the testis and vas deferens. MPM can be used as an adjunct to identify and ablate residual nerves after MDSC.

Perioperative outcomes of robot-assisted nephroureterectomy for upper urinary tract urothelial carcinoma: a multi-institutional series

OBJECTIVE

To review a multi-institutional series of robot-assisted nephroureterectomy (RANU) for management of upper urinary tract urothelial carcinoma (UUTUC) with respect to technique and perioperative outcomes.

PATIENTS AND METHODS

Between May 2007 and July 2011, 43 RANU were performed at three institutions for UUTUC with review of perioperative outcomes. A three- or four-armed robotic technique was used in all cases based on surgeon preference and the entirety of all procedures was performed using the robot-assisted technique. Single and two robot-docking techniques are described.

RESULTS

The mean (range) operating time was 247 (128-390) min, blood loss was 131 (10-500) mL and the median (range) length of stay was 3 (2-87) days. Pathology was pTa in nine patients, pT1 in 14 patients, pT2 in three patients, pT3 in 15 patients and pT4 in two patients. Lymph node dissection was performed in 22 patients (51%) with a mean (range) lymph node count of 11 (4-23). There were six postoperative complications: bleeding requiring a blood transfusion (grade II), splenic bleeding (grade IV), two cases of pneumonia (grade II) and two cases of rhabdomyolysis (grades II and IV). Nine recurrences (six bladder, two within the retroperitoneum and one in the contralateral collecting system) have been found to date on routine surveillance with a mean follow-up of 9 months.

CONCLUSIONS

RANU is a feasible alternative to laparoscopic and open techniques. Particular steps of the operation including sutured closure of the cystotomy and regional lymphadenectomy are facilitated with the use of robot-assisted surgery. Long-term outcomes are necessary to assess the relative efficacy of these approaches to more established techniques; however, early perioperative outcomes appear promising.

Robot-assisted airway support: a simulated case

Recent advances in telemedicine and robotically assisted telesurgery may offer advanced surgical care for the geographically remote patient. Similar advances in tele-anesthesia will be necessary to optimize perioperative care for these patients. Although many preliminary investigations into tele-anesthesia are underway, none involves remote performance of anesthesia-related procedures. Here we describe simulated robotically assisted fiberoptic intubations using an airway simulation mannequin. Both oral and nasal approaches to fiberoptic intubation were successful, but presented unique opportunities and challenges inherent to the robot's design. Robotically assisted airway management is feasible using multipurpose surgical robotic systems.

Technical communication: robot-assisted regional anesthesia: a simulated demonstration

Recent advances in robotically assisted telesurgery offer expert surgical care for the geographically remote patient. Similar advances in teleanesthesia will be necessary to bring comparable perioperative care to the geographically remote patient. Although many preliminary investigations into teleanesthesia are underway, none involve remote performance of anesthesia-related procedures. Herein, we describe the placement of ultrasound-guided nerve blocks into an ultrasound phantom using the da Vinci multipurpose surgical robotic system (Intuitive Surgical, Sunnyvale, CA). Both single-injection and perineural catheter techniques were successfully performed by an operator who was not physically present at the bedside.