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Purpose: Non-obstructive azoospermia (NOA) is a common, but complex problem, with multiple therapeutic options and a lack of clear guidelines. Hence, there is considerable controversy and marked variation in the management of NOA. This survey evaluates contemporary global practices related to medical and surgical management for patients with NOA., Materials and Methods: A 56-question online survey covering various aspects of the evaluation and management of NOA was sent to specialists around the globe. This paper analyzes the results of the second half of the survey dealing with the management of NOA. Results have been compared to current guidelines, and expert recommendations have been provided using a Delphi process., Results: Participants from 49 countries submitted 336 valid responses. Hormonal therapy for 3 to 6 months was suggested before surgical sperm retrieval (SSR) by 29.6% and 23.6% of participants for normogonadotropic hypogonadism and hypergonadotropic hypogonadism respectively. The SSR rate was reported as 50.0% by 26.0% to 50.0% of participants. Interestingly, 46.0% reported successful SSR in <10% of men with Klinefelter syndrome and 41.3% routinely recommended preimplantation genetic testing. Varicocele repair prior to SSR is recommended by 57.7%. Half of the respondents (57.4%) reported using ultrasound to identify the most vascularized areas in the testis for SSR. One-third proceed directly to microdissection testicular sperm extraction (mTESE) in every case of NOA while others use a staged approach. After a failed conventional TESE, 23.8% wait for 3 months, while 33.1% wait for 6 months before proceeding to mTESE. The cut-off of follicle-stimulating hormone for positive SSR was reported to be 12-19 IU/mL by 22.5% of participants and 20-40 IU/mL by 27.8%, while 31.8% reported no upper limit., Conclusions: This is the largest survey to date on the real-world medical and surgical management of NOA by reproductive experts. It demonstrates a diverse practice pattern and highlights the need for evidence-based international consensus guidelines., Competing Interests: The authors have nothing to disclose., (Copyright © 2025 Korean Society for Sexual Medicine and Andrology.)

Purpose: Non-obstructive azoospermia (NOA) represents the persistent absence of sperm in ejaculate without obstruction, stemming from diverse disease processes. This survey explores global practices in NOA diagnosis, comparing them with guidelines and offering expert recommendations., Materials and Methods: A 56-item questionnaire survey on NOA diagnosis and management was conducted globally from July to September 2022. This paper focuses on part 1, evaluating NOA diagnosis. Data from 367 participants across 49 countries were analyzed descriptively, with a Delphi process used for expert recommendations., Results: Of 336 eligible responses, most participants were experienced attending physicians (70.93%). To diagnose azoospermia definitively, 81.7% requested two semen samples. Commonly ordered hormone tests included serum follicle-stimulating hormone (FSH) (97.0%), total testosterone (92.9%), and luteinizing hormone (86.9%). Genetic testing was requested by 66.6%, with karyotype analysis (86.2%) and Y chromosome microdeletions (88.3%) prevalent. Diagnostic testicular biopsy, distinguishing obstructive azoospermia (OA) from NOA, was not performed by 45.1%, while 34.6% did it selectively. Differentiation relied on physical examination (76.1%), serum hormone profiles (69.6%), and semen tests (68.1%). Expectations of finding sperm surgically were higher in men with normal FSH, larger testes, and a history of sperm in ejaculate., Conclusions: This expert survey, encompassing 367 participants from 49 countries, unveils congruence with recommended guidelines in NOA diagnosis. However, noteworthy disparities in practices suggest a need for evidence-based, international consensus guidelines to standardize NOA evaluation, addressing existing gaps in professional recommendations., Competing Interests: The authors have nothing to disclose., (Copyright © 2024 Korean Society for Sexual Medicine and Andrology.)

The prevalence of isthmocele or caesarean scar niche is increasing nowadays. This is largely attributed to the increasing rate of caesarean deliveries globally, although the growing awareness among gynaecologists and assisted reproductive technology specialists may contribute to the more frequent diagnosis of isthmocele. Although the presenting complaints, diagnosis, and management of isthmocele are discussed extensively in the literature, this case of large isthmocele with a large degenerated false broad ligament myoma, which caused diagnostic dilemma both preoperatively and postoperatively, needs a special mention. This is one such case of large isthmocele rarely reported in perimenopausal women obscured by concomitant uterine pathology like degenerating large broad ligament fibroid. This also stresses the need for awareness and application of various techniques, such as the Halloween sign, for the proper diagnosis of the emerging but treatable complication of the most common surgery performed worldwide., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Sethupathy et al.)

Uterine leiomyoma is a common benign uterine tumor of women in the reproductive age group. Although the common symptoms of leiomyoma are menorrhagia and dysmenorrhoea, this patient presenting as a near collapse is a rare finding. The patient presented with abdominal pain and worsening anemia within a span of hours and hypotension, tachycardia, and tachypnoea needing urgent surgical intervention and blood transfusion and intensive care support is relatively rare. Though every effort to know the exact cause of intraperitoneal hemorrhage in this patient was taken, the rarer diagnosis of capsular venous rupture was not identified prior to surgical intervention. Initially, laparoscopy was introduced first to identify the cause of massive hemorrhage; the approach was changed to open myomectomy keeping in mind the general condition of the patient. Hence, for any patient with a prior diagnosis of myoma with hemodynamic instability, the rarer diagnosis of leiomyomatous capsular venous erosion should be a differential diagnosis to aid in the appropriate management of the women. The team of interdisciplinary expertise will definitely improve the outcomes in such cases., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2022 Tamilselvi Sethupathy et al.)