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PURPOSE: Sperm DNA fragmentation (SDF) has been associated with male infertility and poor outcomes of assisted reproductive technology (ART). The purpose of this study was to investigate global practices related to the management of elevated SDF in infertile men, summarize the relevant professional society recommendations, and provide expert recommendations for managing this condition. MATERIALS AND METHODS: An online global survey on clinical practices related to SDF was disseminated to reproductive clinicians, according to the CHERRIES checklist criteria. Management protocols for various conditions associated with SDF were captured and compared to the relevant recommendations in professional society guidelines and the appropriate available evidence. Expert recommendations and consensus on the management of infertile men with elevated SDF were then formulated and adapted using the Delphi method. RESULTS: A total of 436 experts from 55 different countries submitted responses. As an initial approach, 79.1% of reproductive experts recommend lifestyle modifications for infertile men with elevated SDF, and 76.9% prescribe empiric antioxidants. Regarding antioxidant duration, 39.3% recommend 4-6 months and 38.1% recommend 3 months. For men with unexplained or idiopathic infertility, and couples experiencing recurrent miscarriages associated with elevated SDF, most respondents refer to ART 6 months after failure of conservative and empiric medical management. Infertile men with clinical varicocele, normal conventional semen parameters, and elevated SDF are offered varicocele repair immediately after diagnosis by 31.4%, and after failure of antioxidants and conservative measures by 40.9%. Sperm selection techniques and testicular sperm extraction are also management options for couples undergoing ART. For most questions, heterogenous practices were demonstrated. CONCLUSIONS: This paper presents the results of a large global survey on the management of infertile men with elevated SDF and reveals a lack of consensus among clinicians. Furthermore, it demonstrates the scarcity of professional society guidelines in this regard and attempts to highlight the relevant evidence. Expert recommendations are proposed to help guide clinicians.

Purpose:We present final 5-year outcomes of the multicenter randomized sham-controlled trial of a water vapor therapy (Rezūm™) for treatment of moderate to severe lower urinary tract symptoms due t...

It is widely accepted that oxidative stress plays an important role in the pathophysiology of male infertility and that antioxidants could have a significant role in the treatment of male infertility. The main objectives of this study are: 1) to systematically review the current evidence for the utility of antioxidants in the treatment of male infertility; and 2) propose evidence-based clinical guidelines for the use of antioxidants in the treatment of male infertility. A systematic review of the available clinical evidence was performed, with articles published on Scopus being manually screened. Data extracted included the type of antioxidant used, the clinical conditions under investigation, the evaluation of semen parameters and reproductive outcomes. The adherence to the Cambridge Quality Checklist, Cochrane Risk of Bias for randomized controlled trials (RCTs), CONSORT guidelines and JADAD score were analyzed for each included study. Further, we provided a Strength Weakness Opportunity Threat (SWOT) analysis to analyze the current and future value of antioxidants in male infertility. Of the 1,978 articles identified, 97 articles were included in the study. Of these, 52 (53.6%) were uncontrolled (open label), 12 (12.4%) unblinded RCTs, and 33 (34.0%) blinded RCTs, whereas 44 (45.4%) articles tested individual antioxidants, 31 (32.0%) a combination of several products in variable dosages, and 22 (22.6%) registered antioxidant products. Based on the published evidence, we 1) critically examined the necessity of additional double-blind, randomized, placebo-controlled trials, and 2) proposed updated evidence-based clinical guidelines for antioxidant therapy in male infertility. The current systematic review on antioxidants and male infertility clearly shows that antioxidant supplementation improves semen parameters. In addition, it provides the indications for antioxidant treatment in specific clinical conditions, including varicocele, unexplained and idiopathic male infertility, as well as in cases of altered semen quality.

Purpose: The use of antioxidants is common practice in the management of infertile patients. However, there are no estab-lished guidelines by professional societies on antioxidant use for male infertility. Materials and Materials and Methods: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: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?? 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?셲 age, geographic origin, experience or training in male infertility. Conclusions:Conclusions: This study is the largest online survey performed to date on this topic and demonstrates 1) a worldwide under-standing 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.

Erectile dysfunction (ED) is a prevalent and pertinent condition in the chronic kidney disease (CKD) population. It has a multifactorial etiology, including disruptions of the hypothalamic-pituitary-gonadal axis, the endothelial paracrine signaling system, calcium and vitamin D homeostasis, along with several other factors. Efficacy of treatment of ED in the CKD population is comparable to non-CKD patients across multiple modalities, including PDE5 inhibitors, vacuum erectile devices, intracavernosal injections and penile prostheses. Renal transplant improves the contributing comorbid conditions that lead to ED in CKD patients; thus rates of ED are improved post-transplant. It is important to note that there is a small percentage of patients with persistent ED after renal transplantation.

International audience; 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. Copyright

INTRODUCTION The advent of ureteroscopy has revolutionized the treatment many urologic diseases, including benign essential hematuria. This systematic review examines the treatment of benign essential hematuria (BEH) with ureteroscopic interventions.We performed a systematic review of the literature from 1977 to May 2020. We included studies that evaluated the use of ureteroscopy to diagnose or treat BEH. Demographics, follow up, findings, treatment method and success rate were extracted from each identified paper. Quality analysis was performed independently by both authors.Our search resulted in 587 articles. Fifteen of these studies met inclusion criteria and were included in the final analysis. No randomized controlled trials were found. All 15 studies were case series. Nine studies were graded as good, five as fair, and one as poor. Follow up ranged from 2 to 108 months. A total of 307 patients underwent ureteroscopy for suspected BEH; 223 (73%) were diagnosed with a discrete lesion, 33 (11%) with a diffuse lesion, and 44 (14%) had no lesions seen on ureteroscopy. Of those diagnosed with discrete lesions, the most common was minute venous ruptures (35%), followed by hemangiomas (26%). Ureteroscopic treatment successfully relieved the hematuria and symptoms in most patients, and was more successful in those treated for discrete lesion (115/120, 96%) than diffuse (10/19, 53%).Ureteroscopic treatment of BEH yields excellent outcomes. In this systematic review, 96% of patients with discrete lesions and 53% of patients with diffuse lesions had resolution of their hematuria after ureteroscopic interventions.

Men who have undergone hematopoietic cell transplantation (HCT) will typically follow up with their oncologist/hematologist for many years, often times without evaluation by other medical providers for their nontransplant-related health care needs. As such, it is important to have a basic understanding of health issues that affect men post-HCT and in particular, the impact of chemotherapy and transplantation on erectile dysfunction, infertility, hypogonadism, benign prostatic hyperplasia, and male-organ-specific neoplasms of prostate and testicular cancer. This chapter addresses appropriate evaluation and management of these issues at the level of primary care and the potential diagnoses and treatments that may require referral to a urologist.

International audience; 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.

International audience; 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.

INTRODUCTION Erectile dysfunction is common after radical cystectomy; however, research on sexual dysfunction after this procedure is relatively scarce. Our goal was to evaluate the incidence of penile prosthesis implantation after radical cystectomy, with a focus on rural/urban disparity.We used the SEER-Medicare database to identify patients with bladder cancer diagnosed between 1991-2009 who had a radical cystectomy (ICD-9 codes 57.7, 57.71, 57.79). The outcome was placement of a penile implant (ICD-9 codes 64.95 and 64.97). Covariates extracted included rural county status, age, race, ethnicity, marital status, geographic region, socioeconomic status, Charlson comorbidity, pathologic cancer stage, and type of urinary diversion.A total of 95 penile implants were performed in the 11,477 cystectomy patients (0.83%). Patients who had a penile implant were mostly from urban counties (85.1%) and in the Western region of the United States (83.9%). After controlling for covariates, rural patients who underwent an ileal conduit for urinary diversion were less likely to have a penile prosthesis procedure after radical cystectomy.Penile prosthetic procedures are uncommon in bladder cancer patients who have undergone radical cystectomy; therefore, sexual health should be considered and discussed with patients after radical cystectomy.

Sperm DNA integrity is crucial for fertilization and development of healthy offspring. The spermatozoon undergoes extensive molecular remodeling of its nucleus during later phases of spermatogenesis, which imparts compaction and protects the genetic content. Testicular (defective maturation and abortive apoptosis) and post-testicular (oxidative stress) mechanisms are implicated in the etiology of sperm DNA fragmentation (SDF), which affects both natural and assisted reproduction. Several clinical and environmental factors are known to negatively impact sperm DNA integrity. An increasing number of reports emphasizes the direct relationship between sperm DNA damage and male infertility. Currently, several assays are available to assess sperm DNA damage, however, routine assessment of SDF in clinical practice is not recommended by professional organizations. This article provides an overview of SDF types, origin and comparative analysis of various SDF assays while primarily focusing on the clinical indications of SDF testing. Importantly, we report four clinical cases where SDF testing had played a significant role in improving fertility outcome. In light of these clinical case reports and recent scientific evidence, this review provides expert recommendations on SDF testing and examines the advantages and drawbacks of the clinical utility of SDF testing using Strength-Weaknesses-Opportunities-Threats (SWOT) analysis.

Nearly 15% of all couples will struggle with infertility. The role of the clinician is to not only evaluate and treat potentially correctable etiologies of infertility but also to discover and educate the couple on any potential genetic factors at play. After completion of the human genome sequencing (International Human Genome Sequencing Consortium, 2001), the genetic basis of human reproduction began to take shape. The process of spermatogenesis relies on a complex hormonal interplay between the hypothalamus, pituitary, and testis to influence testicular function. Due to these complex interactions, there can be numerous problems in the hormonal support of male fertility due to genetic defects. These defects may lead to alterations in the hormonal milieu necessary for successful spermatogenesis by disrupting upstream signaling hormones such as gonadotropin releasing hormone (GNRH), luteinizing hormone (LH), and/or follicle-stimulating hormone (FSH). Alternatively, chromosomal defects may affect the testicular microenvironment, thereby impeding testicular function.

Anti-Mullerian hormone (AMH), also known as Mullerian-inhibiting substance, is produced by Sertoli cells of the fetal testis and normally causes regression of the Mullerian structures that would otherwise persist in the pathway of normal female development. AMH acts on anti-Mullerian hormone receptor, type II (AMHR2), causing regression of Mullerian ducts. In PMDS, failure to either secrete AMH or act on AMHR2 causes persistence of Mullerian structures in the male.

In this article, we review the most recent articles examining the use of testosterone for the treatment of erectile dysfunction, reduced sexual desire, and ejaculatory dysfunction. The treatment of erectile dysfunction with testosterone therapy has long been investigated as a cure for sexual dysfunction. Men who are testosterone deficient can expect to benefit from testosterone therapy to address erectile dysfunction and libido, while ejaculatory function is unlikely to improve. The literature supports the use of testosterone therapy in testosterone-deficient men with sexual dysfunction. We recommend advising patients about the benefits of testosterone therapy while ensuring that it will address their individual concerns, without delaying adjunct treatments for sexual dysfunction.

Introduction: Excess prescribing of opioid pain medication increases medical costs and the potential for abuse by patients and others. We sought to improve our understanding of postoperative pain and opioid use after scrotal and subinguinal urological surgery to develop a protocol for pain management.Methods: We retrospectively analyzed opioid prescribing and usage in 20 patients undergoing scrotal or subinguinal surgery. Collected data were used to develop a standardized postoperative protocol. This protocol included enhanced pain management education and limiting outpatient opioid prescriptions. Outcomes analysis was then performed for 60 consecutive patients via questionnaire. Statistical analysis was performed using the Wilcoxon rank sum test and ANOVA. Linear regression was performed comparing age and narcotic use.Results: Comparison of preprotocol and postprotocol implementation opioid prescriptions and consumption showed a statistically significant decrease in the number of tablets prescrib...

Objective To study the semen analysis values required to cause a pregnancy after vasectomy reversal (VR). Vasectomy reversal is increasingly performed on men who wish to regain fertility after elective sterilization. Despite a thorough understanding of predictors of vasal patency after surgery, little is known about the patients' semen parameters and pregnancy potential. Design Retrospective case-control study. Setting Tertiary-care hospital. Patient(s) A total of 139 patients who underwent VR at the Cleveland Clinic from 2010 to 2014. Intervention(s) Vasectomy reversal. Main Outcome Measure(s) Pregnancy, semen parameters. Data regarding patient and spouse ages, obstructive interval, intraoperative findings, procedure performed, postoperative semen results, and spontaneous pregnancy outcome were collected. Pearson and t tests were used to analyze categoric and numeric data, respectively. Average semen reference values were developed. Result(s) The mean obstructive interval was 9.5 ± 1.2 years. Spontaneous pregnancy was achieved by 49.6% of patients (69/139) and was directly related to better intraoperative vasal fluid quality and postoperative sperm concentration, motility, and strict morphology. The reference ranges of postoperative semen parameters of patients with spontaneous pregnancy were substantially lower than normal values published by the World Health Organization (WHO) in 2010. Spontaneous pregnancy was reported in 15%, 21.3%, and 14.8% of patients with a sperm concentration of Conclusion(s) Normal ranges of semen parameters as established by the 2010 WHO standards may not adequately predict post–vasectomy reversal fertility. Significantly lower post-reversal semen parameters may be considered to be sufficient in previously fertile patients after reversal compared with the normal population.

Background Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is often associated with pelvic floor muscle spasm. While pelvic floor physical therapy (PFPT) is effective, some men are unable to resolve their symptoms and have residual trigger points (TPs). TP injection has been used for treatment in several neuromuscular pain syndromes. The objective of this study was to examine the efficacy and side effects of TP injection in men with CP/CPPS and pelvic floor spasm refractory to PT. Methods Using an IRB approved Men’s Health Registry we reviewed the records of all men with a diagnosis of CP/CPPS who received at least 1 TP injection. Patients were phenotyped with UPOINT (all had the “T” domain for tenderness of muscle) and symptoms measured with the NIH Chronic Prostatitis Symptom Index (CPSI). Response was measured by a 5-point Global Response Assessment (GRA) and change in CPSI (paired t-test). For pelvic TPs, a pudendal block was done in lithotomy position and then each TP was identified transrectally by palpation. A nerve block needle was passed through the perineum into the TP confirmed by palpation. Between 0.5–1 cc was injected into each TP of a local anesthetic mixture (30:70 of 2% lidocaine and 0.25% bupivacaine). For anterior TPs, an ultrasound guided ilioinguinal block was done first and then each TP injected by direct palpation through the abdominal skin. Men were offered up to three sets of injections separated by 6 weeks each. Results We identified 37 patients who had a total of 68 procedures. Three men had no follow-up after their first injection and were included for side effects but not included for outcome. The indication was failure to progress on PT in 33, recurrent symptoms in 1 and refusal to do PT in 3. Mean age was 43.7 years (range 21–70 years) and median UPOINT domains was 3 (range 1–5). Initial CPSI was pain 13.7±3.4, urinary 5.3±2.2, quality of life 9.8±2.1 and total 28.8±6.0. 16 men had 1 injection, 11 had 2 and 10 had 3. All had pelvic TPs injected and 9 also had anterior TPs. By GRA, 12 had significant improvement (35.3%), 10 had some improvement (29.4%), 11 had no change (32.3%) and 1 was worse (2.9%). Mean CPSI dropped from 28.8±6.0 to 21.8±7.2 (P

Introduction: Infertility affects approximately 15% of all couples, and male factor contribute to up to 50% of cases. Unfortunately, the cause of male infertility is unknown in about 30% of these cases. Infertility of unknown origin is classified as idiopathic male infertility when abnormal semen parameters are present. Despite not having a definable cause, these men may respond to treatment. This review focuses on the use of empiric hormonal therapies for idiopathic male infertility. Methods: A detailed PubMed/MEDLINE search was conducted to identify all publications pertaining to empiric use of hormonal therapies in the treatment of idiopathic male infertility using the keywords “idiopathic,” “male infertility,” “empiric treatment,” “clomiphene,” “SERM,” “gonadotropin,” “aromatase inhibitor,” and “androgen.” These manuscripts were reviewed to identify treatment modalities and results. Results: Gonadotropins, androgens, aromatase inhibitors, and selective estrogen receptor modulators (SERMs) have all been used with varying results. The studies on these treatments are of variable quality. The most well-studied agents are the SERMs which show a modest increase in semen parameters and pregnancy rates. Aromatase inhibitors are most effective in non-idiopathic patients. Gonadotropin treatment is limited by their inconvenience and relative ineffectiveness in this population. Testosterone suppresses spermatogenesis and should not be used to treat infertility. Conclusion: Gonadotropins, SERMs, and aromatase inhibitors may improve semen parameters and hormone levels in men with idiopathic infertility with the best results from SERMs. Testosterone should never be used to treat infertility. Large multicenter randomized controlled studies are needed to better determine the success of empiric use of hormonal therapy on pregnancy rates.

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&ndash, oocyte interaction.

Despite advances in the field of male reproductive health, idiopathic male infertility, in which a man has altered semen characteristics without an identifiable cause and there is no female factor infertility, remains a challenging condition to diagnose and manage. Increasing evidence suggests that oxidative stress (OS) plays an independent role in the etiology of male infertility, with 30% to 80% of infertile men having elevated seminal reactive oxygen species levels. OS can negatively affect fertility via a number of pathways, including interference with capacitation and possible damage to sperm membrane and DNA, which may impair the sperm's potential to fertilize an egg and develop into a healthy embryo. Adequate evaluation of male reproductive potential should therefore include an assessment of sperm OS. We propose the term Male Oxidative Stress Infertility, or MOSI, as a novel descriptor for infertile men with abnormal semen characteristics and OS, including many patients who were previously classified as having idiopathic male infertility. Oxidation-reduction potential (ORP) can be a useful clinical biomarker for the classification of MOSI, as it takes into account the levels of both oxidants and reductants (antioxidants). Current treatment protocols for OS, including the use of antioxidants, are not evidence-based and have the potential for complications and increased healthcare-related expenditures. Utilizing an easy, reproducible, and cost-effective test to measure ORP may provide a more targeted, reliable approach for administering antioxidant therapy while minimizing the risk of antioxidant overdose. With the increasing awareness and understanding of MOSI as a distinct male infertility diagnosis, future research endeavors can facilitate the development of evidence-based treatments that target its underlying cause.

Testosterone has long been touted as the panacea for men wishing to restore their vitality, sexuality, and masculinity to that of their youth. While the benefits of testosterone are not mythical, they are definite. In this article we will review the various benefits of testosterone as it pertains to men's health and male infertility.

Many environmental and genetic variables affect male reproductive health. Some of these factors, however, interfere not only with fertility, but also the non-genomic materials within spermatozoa that can cause phenotypic changes in the offspring, and in some cases, multiple generations. This intergenerational and transgenerational inheritance is due to epigenetic modifications, which is a complex adjunct to traditional Mendelian genetics whose influence on a wide range of human diseases is an active area of research. As the epigenome is a gestalt of individual exposures to the world, ongoing research is evaluating the scope of environmental impacts on the epigenome, as well as its mechanisms for adjusting the phenotypic expression of the organism without changing the code itself. Of particular interest is how these traits are passable to subsequent generations. This article will cover the latest data concerning how the overall quality of nutrition and lifestyle of an individual has been demonstrated to have a significant effect on male reproductive health, and how the accumulation of these modifications are risk factors for the health of their offspring.

Varicocele, a pathological dilation of the scrotal veins, is thought to be the cause of infertility in up to 41% of male factor infertility and is the most common cause of secondary infertility. Men with clinically significant varicocele are found to have reduced sperm counts, impaired motility, and abnormal morphology when compared to men without varicocele. Studies have found that men treated for varicocele show improvement in semen analysis as well as improvement in pregnancy rate. The pathophysiology of varicocele is multifactorial with resulting hyperthermia of the testis, which is believed to be the greatest contributing factor to infertility. Other theories of how varicoceles cause damage include buildup of metabolic waste and reflux of renal and adrenal metabolites. Varicoceles have been found to cause damage to the Leydig cells of the testicle, resulting in decreased serum testosterone levels. Varicocele is also associated with direct damage to the Sertoli cells and germ cells. The damaging effects to these cell types has been found to be reversed when clinical varicoceles are treated by varicocelectomy. Varicoceles not only damage the testes but also the epididymis, affecting the storage and maturation of newly developed sperm. Damage to the epididymis can be quantified by measurement of alpha-glucosidase, and the effect of such damage is seen by decreased transit time through the epididymis, impaired motility, and decreased sperm storage viability. These effects can be reversed with appropriate treatment.

Introduction Despite the fact that oxidative stress (OS) is involved in several human diseases, treating patients with antioxidants has failed to show a benefit in many diseases. The idea that OS is uniformly bad and that antioxidant administration can minimize OS and improve outcomes is oversimplified at best and dangerous at worst. Materials and Methods An extensive literature search ending June 2017 examining the relationship between reactive oxygen species, antioxidants, infertility, and other disease states was performed using Google Scholar, PubMed, and MEDLINE. The following keywords were used: “oxidant paradox,” “oxidative stress,” “reactive oxygen species,” “infertile men,” “infertility,” “cancer,” and “inflammation.” Results Many studies have examined the role of OS in aging, cancer, infertility, and many other diseases. Antioxidant treatment has not improved outcomes in many studies and has worsened outcomes in others. The correct antioxidant type and dose have yet to be determined. Conclusions The balance between antioxidants and oxidants in the human body is complex and tightly regulated. Dysregulation of this system may contribute to many disease processes including infertility. Existing trials examining treatment with antioxidants at varied doses across several disease states have thus far shown little or nonsignificant improvement and occasionally harm.

The advent of intracytoplasmic sperm injection (ICSI) has changed the human reproduction landscape by overcoming several limitations related to both male and female infertility factors. However, despite the development of new technologies, the live-birth rate with ICSI has not exceeded 30%. In order to improve assisted reproductive technology outcomes, advanced sperm function analysis have gained increased attention and the effects of sperm DNA fragmentation (SDF) on assisted repro-duction success are being extensively studied. Utilizing ejaculated sperm with an elevated SDF has been found to result in poor ICSI outcomes. Furthermore, studies have reported that testicular sperm has lower SDF level, when compared to ejacu-lated sperm. This has led a number of clinicians world-wide to offer testicular sperm retrieval for ICSI in non-azoospermic males with high SDF. This practice has remained controversial due to lack of high quality evidence.

Approximately 15% of couples are unable to conceive after one year of unprotected intercourse and a male factor is solely responsible or contributory in approximately 50% (1). Of these couples up to 30% may have unexplained infertility with a normal semen analysis and no obvious reason for their inability to conceive (2,3). Semen analyses alone are difficult to use in clinical decision making due to their inherent variability (4). This limitation extends into a variety of clinical situations including assistive reproductive technique (ART) failure, unexplained infertility in the setting of normal bulk semen parameters, and patients with low grade clinical varicoceles.

Erectile dysfunction (ED) is a common condition in the aging population that can be broadly classified as organic, psychogenic, or mixed. A thorough evaluation of a patient with ED begins with acknowledging that it is intimately related to a host of medical, neurologic, and psychological conditions. Providers should be confident in their ability to obtain a relevant history, perform a targeted physical exam, and, when indicated, select appropriate diagnostic testing. Patients should also be evaluated for associated urologic conditions, including male hypogonadism and lower urinary tract symptoms, the treatment of which may improve ED symptoms. It is also important that clinicians be aware that ED may be a “sentinel event” for undiagnosed cardiovascular disease as the implications of intervention can potentially be lifesaving. This review contains 7 figures, 10 tables and 138 references Key words: cardiovascular disease, Doppler ultrasonography, erectile dysfunction, hypogonadism, lower urinary tract symptoms, male impotence, metabolic syndrome, penile tumescence, Peyronie disease, premature ejaculation, sexual desire, testosterone

Purpose Sperm play an essential role in embryonic genome activation and embryonic progression to blastocyst. In the present work, we focus on development of embryos created as a result of ICSI with testicular or epididymal sperm from azoospermic males and compare this to outcomes from normospermic males. The objective of this study was to determine if sperm origin influences clinical outcomes, the kinetics of embryo development, or the incidence of cleavage anomalies and multinucleation. Methods A total of 93 consecutive intracytoplasmic sperm injection cycles (ICSI) performed for 83 couples were included in this study. Observations were made on 594 fertilized oocytes cultured in the EmbryoScope using time-lapse microscopy (TLM). Epididymal sperm (n = 29) cycles or surgically retrieved sperm from the testis (TESE; n = 37 cycles) of men with either obstructive (OA) or non-obstructive azoospermia (NOA) were used to inject oocytes. A further 27 ICSI cycles were performed using ejaculated sperm from normospermic males, designated as our control sperm (CS) group. Kinetic data and cycle outcomes were retrospectively analyzed. Results The clinical pregnancy rate was not different between the three groups (TESE 51.4%, PESA 57.7%, and CS 59.3%). A non-significant decrease was observed in both implantation (30.9%) and live birth rate (43%) with TESE as compared to PESA (35.3%, 58%, respectively) and CS groups (45.1%, 56%, respectively). Failure to compact was significantly higher amongst TESE-NOA embryos (35.2%; P

To review our institution's experience and success with vasectomy reversal to treat postvasectomy pain syndrome (PVPS) over the last 20 years.A single surgeon (E.F.F.) performed all the vasectomy reversals. We identified 123 procedures done for PVPS treatment and were able to contact 76 patients. We sent surveys or conducted phone interviews inquiring about satisfaction, levels of pain preoperatively and postoperatively, and the need for additional procedures for pain. Thirty-one patients completed phone or written surveys. In addition, we compared the location of vasectomy among patients presenting for pain to that of fertile patients.Thirty-one men had vasectomy reversal for postvasectomy pain, with median age of 38 years (range, 31-55 years), of which 26 underwent vasovasostomy (VV). Seven patients required epididymovasostomy (EV) on at least 1 side based on intraoperative findings. Eighty-two percent of patients reported improvement in their pain at 3.2 months (±3.4 months) after vasectomy reversal. Thirty-four percent patients had complete resolution of all pain. Mean pain score before procedure was 6.4 (±2.4), decreasing to a median of 2.7 (±2.7) afterward. There was a 59% improvement in pain scores (P .001). Two patients required additional procedures for continued pain, one orchiectomy and one epididymectomy. Four patients required an additional reversal procedure, one a repeat VV at 1 year and 3 an EV at 1, 5, and 9 years, respectively. Follow-up ranged from 1 to 19 years, with a mean follow-up of 8.4 years. We found no relationship between vasectomy location and pain.Vasectomy reversal, through the use of both VV and EV, can provide long-term relief from PVPS.

Oxidative stress (OS) is an important contributing factor to male infertility. While previous methods to measure seminal OS are time-consuming and limited to the use of freshly produced semen, oxidation reduction potential (ORP) is easier and quicker to perform and can also be used in frozen semen. Therefore, this study evaluated the clinical utility of ORP as a potential marker of male infertility. ORP was measured in semen samples from 293 patients and 15 fertile controls and categorised according to WHO criteria as normozoospermic, oligozoospermic, asthenozoospermic, teratozoospermic and oligoasthenoteratozoospermic. Receiver operating characteristic (ROC) curves were generated to differentiate these categories. Semen parameters were significantly different when subjects were grouped as control and patients or between the patient and normozoospermic group for concentration and morphology. ORP levels were significantly different between the control and normozoospermic group. When subjects were grouped based on concentration, motility, morphology or a combination of these, the area under the ROC curve, sensitivity, specificity, positive predictive value and cut-off values were significantly different. These differences were significant when combined with ORP and grouped with any two sperm abnormalities. In conclusion, ORP is a quick, easy, cost-effective and reliable marker of semen quality as well as oxidative stress for use in a clinical setting.

To determine the factors used to make the decision between vasovasostomy (VV) and vasoepididymostomy (VE) by leaders performing microsurgical vasectomy reversal using a questionnaire.An online questionnaire was sent to all members of the Society for the Study of Male Reproduction (SSMR), a male reproduction subspecialty society of the AUA, using the SurveyMonkey platform.Sixty-seven surgeons responded to the questionnaire (27% of SSMR members). Of which 72% of members performed less than 50 vasectomy reversals per year. Also, 71% of members stated that less than 20% of their vasectomy reversals are vasoepididymostomies. When evaluating epididymal fluid at the time of reversal, 87% would perform a VE for pasty fluid, 66% with creamy fluid without sperm heads and 55% with no or scant fluid. With respect to banking sperm, 36% take sperm or testicular tissue at the time of VE while 37% sometimes take sperm mostly depending on the couple's preference. The Berger end-to-side with intussusception VE technique is used by the majority of members (78%). The presence of intact sperm or sperm parts determined the location in the epididymis for anastomosis for 55% and 19% of members respectively. Postoperative semen testing after a VE is evaluated first between 6 weeks to 3 months for 64%. The procedure is considered a failure between 6 to 12 months for 34% and 12 to 18 months for another 48% if no sperm is seen on semen analysis.Most members perform a VE with pasty fluid or creamy fluid without sperm heads. Three out of four members are using the Berger end-to-side intussusception technique to perform their VE. More studies are needed to determine the optimal circumstances to perform a VE as there is significant variation in responses even among members of the SSMR.

Male factor infertility is implicated in 50% of couples being evaluated for infertility, and varicoceles are thought to be the most common cause of that infertility. Their pathophysiology is still poorly understood, but multiple studies have been performed regarding varicocele repair and its affects on fertility. With the advances in assisted reproductive techniques (ARTs), some physicians question the need to treat varicoceles at all. We present a review of the evidence for the role and treatment of varicoceles in the infertile male and its effects on the need for assisted reproductive techniques. Treatment of clinically significant varicoceles results in significantly improved semen parameters in 60–80% of men and pregnancy rates of 20–60%, especially when a subinguinal microscopic varicocele ligation is performed. Overall, 30–50% of couples who were felt to require ART due to low semen quality (and even azoospermia) may be able to avoid this after varicocele treatment, while also being more cost-effective than ART alone. Varicocelectomy can increase the chances of successful conception when used in conjunction with ART.

Objectives To present an overview of our surgical experience in the management of growing teratoma syndrome. Methods A retrospective analysis of all patients undergoing post-chemotherapy retroperitoneal lymphadenectomy between November 2005 and February 2012 revealed 15 patients who met the criteria for growing teratoma syndrome. Their clinical data, imaging characteristics, and surgical and oncological outcomes were reviewed. Results The median age at diagnosis was 23 years. Primary testis tumors included non-seminomatous germ cell tumor in 12 of 15 patients, seminoma in two of 15 patients and hemorrhagic mass in one patient. Mature teratoma was present in just six (40%) of the orchiectomy specimens. All patients received preoperative chemotherapy. On imaging, the median size of the largest retroperitoneal mass was 7 cm (range 3.9–24.5 cm). The median rate of linear growth was 0.5 cm/month (range 0.03–2.9), and the increase in volume was 9.2 cm3/month. All tumors were found to have cystic and necrotic components. Median operative time was 6.2 h (range 4.2–15.2 h). Estimated blood loss was 600 mL (range 100–7000 mL), and median length of stay was 5 days (range 3–19 days). Four patients required resection of non-retroperitoneal growing teratoma masses after post-chemotherapy retroperitoneal lymphadenectomy to achieve tumor-free status. There were two minor (Clavien I–II) and two major postoperative complications (Clavien ≥III). All patients are alive and disease free with a median duration of follow-up of 8 months (range 1–64 months). Conclusions Growing teratoma syndrome tumors vary in their growth rate, but they all appear to have cystic features with necrosis elements on radiographic evaluation. Aggressive surgical excision is associated with excellent outcomes.