Pharmacological therapies for male infertility.

Male factor infertility is a multifaceted problem that affects approximately 50% of couples suffering from infertility. Causes of male infertility include endocrine disturbances, gonadotoxins, genetic abnormalities, varicocele, malignancies, infections, congenital or acquired urogenital abnormalities, iatrogenic factors, immunological factors, and idiopathic reasons. There are a variety of treatment options for male infertility, depending on the underlying cause(s). These can include surgical treatments, medical/hormonal therapies, and assisted reproductive techniques (ART), which can be combined with surgical sperm retrieval (SSR) if necessary. In this review article, the pharmacological therapies for male infertility are grouped by their underlying causes. Some of these therapies are targeted and specific, while others are used empirically to treat idiopathic male infertility. This will include treatments to optimize infertility in patients who have hypogonadism, ejaculatory dysfunction, infections, or idiopathic male infertility. Finally, we will provide an overview of the future directions of pharmacological therapies for male infertility. Significance Statement Male infertility is a significant worldwide problem. Detailed knowledge of the pharmacological therapies available will ensure the prescription of appropriate therapy and avoid the use of unnecessary or harmful treatments.

TIMP2 and IGFBP-7 as Biomarkers For The Diagnosis of Acute Kidney Injury (AKI) in Post-operative Patients: An Evidence-Based Case Report.

BACKGROUND: Acute kidney injury (AKI) is defined as a sudden reduction in kidney function which commonly occurs as a complication of major surgeries. It is traditionally diagnosed using serum creatinine elevation. AKI has relatively slow kinetics that makes it unable to diagnose at an earlier more reversible stage. Furthermore, previous research has shown that TIMP-2 and IGFBP7 were urinary biomarkers to use as a diagnostic tool for AKI. We aimed to compare the accuracy of TIMP2 and IGFBP-7 to the gold standard (serum creatinine) in diagnosing AKI in postoperative patients. METHODS: A thorough search was performed using a search strategy on EMBASE, PubMed, and Medline (Ovid) using keywords according to the objective. The collected articles were critically appraised using CEEBM critical appraisal tool. RESULTS: 5 studies that fulfilled the inclusion criteria were selected and evaluated. They all stated that the use of TIMP2 and IGFBP7 could not detect AKI better than the gold standard as shown in the sensitivity and specificity of the biomarkers. Furthermore, the examination of AKI using both biomarkers showed a sensitivity of 60-100% and specificity of 58-91%. CONCLUSION: TIMP2 and IGFBP7 are promising diagnostic tools for AKI. However, due to the wide variation in results amongst the different studies, further research is required to ensure the credibility of this result.

Technologies to improve sperm retrieval in men undergoing micro-TESE for NOA.

Nonobstructive azoospermia (NOA) is considered the most challenging clinical scenario for infertile men and current treatments leave many men unsuccessful at being able to achieve a pregnancy with their partner using their own sperm. Microdissection testicular sperm extraction (micro-TESE) is the choice for men with NOA desiring to father children with their own gametes. Micro-TESE results in the highest numbers of sperm cells retrieved for use with in vitro fertilization/intracytoplasmic sperm injection. With suboptimal micro-TESE success rates of sperm retrieval and then pregnancy and live birth using the retrieved sperm with in vitro fertilization/intracytoplasmic sperm injection, advances to improve outcomes are necessary. This article comprehensively reviews the technologies investigated to date to improve the outcomes for men undergoing micro-TESE.

Sixth edition of the World Health Organization laboratory manual of semen analysis: Updates and essential take away for busy clinicians.

Background: Semen analysis is the cornerstone for male fertility evaluation. In 2021, the World Health Organization (WHO) released its 6th edition of semen analysis manual. Methods: We highlight the main changes in the latest 6th edition of the WHO manual of semen analysis and their possible interpretations. Results: The manual is highly comprehensive, offering detailed information, and is widely regarded as an excellent technical reference for laboratory staff. Nevertheless, several aspects of the manual require further elucidation for infertility practitioners. Conclusion: The recently published 6th edition of the WHO manual provides a strong framework for the assessment and processing of human semen. Grasping the modifications introduced in this updated edition and their clinical significance can enhance the quality of patient care.

Isolated teratozoospermia: revisiting its relevance in male infertility: a narrative review.

Background and Objective: Basic semen analysis is the first step in the evaluation of male infertility. It includes an assessment of sperm morphology which is believed to reflect on overall spermatogenesis and sperm function. Teratozoospermia, defined as abnormal sperm morphology, is frequently present in association with severe oligoasthenozoospermia, but isolated teratozoospermia (in the presence of normal counts and motility) is a poorly understood clinical entity with conflicting implications in terms of fertility potential and treatment strategies. The following paper aims to: (I) discuss the classification of sperm morphology, causes, and molecular mechanism of teratozoospermia; (II) analyze the clinical significance and potential treatment options of isolated teratozoospermia as a cause of male infertility and a predictor of fertility outcome; and (III) provide a SWOT (strengths, weaknesses, opportunities, and threats) analysis based on the existing literature on this topic. Methods: A comprehensive search from database inception to 25 April 2023 was conducted in PubMed for relevant papers relating to isolated teratozoospermia in male infertility. Finally, seven systematic reviews/reviews/meta-analyses and 81 original articles were synthesized into the current narrative review. Key Content and Findings: Classification of sperm morphology has evolved significantly since the first edition of the World Health Organization (WHO) Manual of Human Semen Analysis. Kruger's strict criteria are the most used classification and have been shown to correlate with fertility outcomes. There are many causes of teratozoospermia including genetic and environmental factors and physical conditions like varicocele. Teratozoospermia correlates with sperm DNA damage, elevated oxidative stress, low antioxidant function, and apoptotic alterations, which can result in impaired spermatozoa function and lower pregnancy rates. However, the clinical correlation between teratozoospermia and assisted reproductive technology (ART) outcome shows conflicting data with recent meta-analyses suggesting that isolated teratozoospermia was not associated with poor fertility outcomes from ART and that intrauterine insemination (IUI) can be an effective option even in the presence of teratozoospermia. There is very limited data on effective therapeutic options to treat idiopathic isolated teratozoospermia. The opportunity for future research is huge to fill the gap in the medical literature on this topic. Conclusions: Contemporary literature on isolated teratozoospermia shows conflicting results in terms of its actual clinical implication in male infertility and the utility of available treatment options. Further research is warranted on this clinical entity to improve sperm function and future paternity.

The Global Andrology Forum (GAF): Structure, Roles, Functioning and Outcomes: An Online Model for Collaborative Research.

PURPOSE: There are no published examples of a global online research collaborative in andrology. We describe the development, profile and member characteristics of the first consortium of this type, the Global Andrology Forum (GAF). MATERIALS AND METHODS: An online survey sent to all GAF members collected demographic information (sex, age, experience, academic title, degrees, country, specialty, profession). It also tapped data on members' characteristics e.g., skills in research, software and statistics; preferred activities; time commitments; expected roles; and interest in participating in research, in GAF's scientific activities and collaborative online research. The findings were analyzed and tabulated. We outline members' demographic and professional characteristics and scientific achievements to date. A narrative approach outlined GAF's structure and functioning. RESULTS: A total of 418 out of 540 members completed the survey and were included in the analysis (77.4% response rate). The sample comprised mainly urologists (34.2%) and a third of the respondents had practiced for >15 years (33.3%). Up to 86.1% of the members expressed interest in being actively engaged in writing scientific articles. A third of the sample (37.1%) could dedicate 4 to 6 hours/week. Few respondents reported skills in statistics and artwork (2.6% and 1.9% respectively). Members were assigned to specific roles based on their expertise and experiences. Collaborative working ensured the timely completion of projects while maintaining quality. For outcomes, GAF published 29 original articles within one year of its creation, with authors from 48 countries spanning topics that included varicocele, sperm DNA damage, oxidative stress, semen analysis and male infertility, oocyte/embryo, and laboratory issues of assisted reproductive technique (ART) and male infertility evaluation. CONCLUSIONS: GAF is a successful global online andrology research model. A healthy number of scientific articles have been published. Given such effectiveness, adopting the GAF model could be useful for other disciplines that wish to create and coordinate successful international online research groups.

Post-Vasectomy Semen Analysis: What's All the Fuss about?

Vasectomy is a reliable male contraceptive method with a success rate exceeding 98%. Despite its efficacy, vasectomy is not foolproof, with potential early and late failures requiring careful postoperative monitoring via post-vasectomy semen analysis (PVSA). Published guidelines emphasize the necessity of conducting PVSA to ensure clinical sterility. Despite these clear guidelines, discrepancies in adherence and interpretation persist, with significant mismatches between guidelines and actual practice. Recent shifts in societal attitudes toward reproductive autonomy, spurred by significant political events and socioeconomic factors, have increased vasectomy rates, particularly among younger, childless men. This demographic change calls for enhanced PVSA compliance and clear communication about the non-immediate contraceptive effect of vasectomy. Home test kits have emerged as a convenient, though not always reliable, method for conducting PVSAs, which may require reevaluation in clinical practice. Given the variations across clinical guidelines and the challenges in achieving consistent PVSA outcomes, further research is needed to harmonize PVSA protocols across different health systems. PVSA is typically conducted between 8 and 16 weeks post-vasectomy, depending on the surgeon's preference. Success is confirmed when a fresh, uncentrifuged sample exhibits either azoospermia, rare non-motile sperm (RNMS), or fewer than 100,000 non-motile sperm per milliliter. This effort will ensure that both patients and practitioners can rely on vasectomy as a safe and effective form of contraception. Effective patient counseling and strategic follow-up are crucial when it comes to managing expectations and ensuring compliance with post-vasectomy protocols, thereby minimizing the risk of unintended pregnancies post-procedure.

Impact of Shorter Abstinence Periods on Semen Parameters: A Systematic Review and Meta-Analysis.

PURPOSE: The success of assisted reproductive technology (ART) relies heavily on semen parameters, and it is influenced by the length of the abstinence period. The World Health Organization (WHO) recommends a 2- to 7-day abstinence period. Even so, efficacy is still suboptimal. Thus, this study aims to determine whether shorter abstinence periods (<2 days) can improve semen parameters. MATERIALS AND METHODS: This study is a systematic review and meta-analysis. A literature search was performed across five databases: PubMed, Embase, ProQuest, Scopus, and Wiley Online Library using the PICO format. Retrieved articles were assessed according to eligibility criteria and the PRISMA flow diagram. Those eligible for quantitative analysis were assessed using forest plots. Risks of bias were tested using the Newcastle-Ottawa Scale. RESULTS: A total of 22 studies and 31,640 samples were included. Studies showed that short abstinence periods significantly reduced semen volume (mean difference [MD] -0.83, p<0.01), sperm concentration (MD -8.39, p<0.01), and DNA fragmentation (MD -3.82, p<0.01). No differences in sperm morphology were identified. Meanwhile, the overall effect for total (MD 2.30, p<0.05) and progressive motile sperm (MD 2.18, p<0.01) was significantly increased. Subgroup analysis on oligospermia patients revealed a significant increase in normal sperm morphology (MD 1.64, p<0.01) along with reduced DNA fragmentation (MD -3.30, p<0.05). However, no significant changes were seen among other sperm parameters. CONCLUSIONS: In conclusion, our findings suggest a shorter abstinence period could be beneficial due to its effect on sperm motility and DNA fragmentation. Additionally, oligospermia patients will benefit from improved sperm morphology. These findings can provide insight for future guidelines to promote a shorter abstinence period for improving ART outcomes.

Impact of Varicocele Repair on Assisted Reproductive Technique Outcomes in Infertile Men: A Systematic Review and Meta-Analysis.

PURPOSE: In this systematic review and meta-analysis, we investigated assisted reproductive technology (ART) success in infertile men with clinical varicocele and abnormal semen parameters who underwent varicocele repair (VR) before the ART procedure as compared to those who did not. MATERIALS AND METHODS: A comprehensive search of the Scopus, PubMed, Embase, and Cochrane Library databases was conducted using a specific query string to identify studies examining the impact of VR on ART outcomes, including fertilization rate, clinical pregnancy, pregnancy loss, and live-birth rate, until October 2023. Outcomes were analyzed based on the type of ART. Studies on VR in infertile men with non-obstructive azoospermia and those who underwent ART only due to female factor infertility were excluded from the study. RESULTS: Out of 1,554 articles reviewed, only 9 met the inclusion criteria for the study. All the included articles were observational studies. The variability in study quality in the included literature resulted in a moderate overall risk of bias. Data analysis showed that for intrauterine insemination, there was no difference in the clinical pregnancy rate (odds ratio [OR] 1.01, 95% confidence interval [CI]: 0.42, 2.45; p=0.97). However, for intracytoplasmic sperm injection (ICSI), men with VR showed a significant improvement in fertilization rate (mean difference 10.9, 95% CI: 5.94, 15.89; p<0.01), clinical pregnancy rate (OR 1.38, 95% CI: 1.07, 1.78; p=0.01) and live-birth rate (OR 2.07, 95% CI: 1.45, 2.97; p<0.01), compared to men who did not undergo VR. CONCLUSIONS: The findings of this systematic review and meta-analysis suggest that VR has a positive impact on pregnancy and live birth rates after ICSI. However, biases like small sample sizes and heterogeneous populations highlight the need for larger, well-designed prospective studies to validate these findings.

Changes in Testosterone Levels Following Surgical Sperm Retrieval in Men with Non-Obstructive Azoospermia: Systematic Review and Meta-Analysis.

PURPOSE: Surgical sperm retrieval (SSR) is used to extract spermatozoa for use with intracytoplasmic sperm injection in men with obstructive and non-obstructive azoospermia (NOA). The procedure may lead to segmental devascularization, postoperative fibrosis, and atrophy with a subsequent decrease in testosterone. The aim of the study is to investigate the impact of SSR on serum levels of total testosterone (TT), follicle-stimulating hormone (FSH), luteinizing hormone (LH) testicular volume, and sexual function in infertile azoospermic men. MATERIALS AND METHODS: In this systematic review and meta-analysis (SRMA), we searched articles in "PubMed" and "Scopus" exploring the impact of SSR on TT, FSH, LH, and testicular volume. The full-text articles were screened to assess eligibility before data extraction, quality assessment, and meta-analysis. RESULTS: Seventeen studies meeting the inclusion criteria were finally analyzed and included 1,685 infertile, azoospermic men. Patients underwent SSR and were followed in the postoperative period (one week to 32 months). The analysis showed a significant reduction in TT (mean difference [MD] 3.81 nmol/L, 95% confidence interval [CI] 0.55:7.06; p=0.02) compared to pre-SSR values. We also observed insignificant differences in serum FSH (MD 5.08 IU/L, 95% CI -5.6:15.8; p=0.35), LH (MD -2.96 IU/L, 95% CI -6.31:0.39; p=0.08), and no change in testicular volume (MD 0.07 mL, 95% CI -1.92:2.07; p=0.94) after SSR. Sexual dysfunction was associated with hypogonadism, depression, and anxiety, especially in men with unsuccessful SSR and Klinefelter syndrome. CONCLUSIONS: The results of this SRMA indicate a significant reduction in TT after SSR. Sexual dysfunction after testicular sperm extraction and the potential negative impact of future SSR repeat should be considered during preoperative counseling.

Impact of Varicocele on Testicular Oxidative Stress and Sperm Parameters in Experimental Animals: A Systematic Review and Meta-Analysis.

PURPOSE: Varicocele has been associated with high seminal oxidative stress (OS), impaired semen quality, and reduced male fertility potential. However, the exact mechanism(s) underlying the development of varicocele-mediated infertility and the cause-effect relationship between varicocele and testicular dysfunction are not fully understood. The aim of this systematic review and meta-analysis (SRMA) is to investigate the impact of varicocele on testicular OS markers and sperm parameters in experimental animals with varicocele as compared to animals without varicocele. MATERIALS AND METHODS: A literature search was performed using the Scopus and PubMed databases on studies that investigated testicular OS markers and sperm parameters in animals with varicocele. The primary outcomes included malondialdehyde (MDA) (nmol/mg) levels whereas the secondary outcomes included total sperm count (×106), sperm vitality (%), total sperm motility (%), and sperm DNA fragmentation (SDF) (%). Standardized mean difference (SMD) (95% confidence interval [CI]) was chosen to express the effect size. The quality of the included studies was evaluated using the Cambridge Quality Checklist. RESULTS: Out of 76 identified articles, 6 studies on rats were included in the meta-analysis. The analysis showed a significant increase of MDA (SMD: 15.61 [1.93, 29.29]; p=0.03) in rats with varicocele vs. controls. We also observed a significant decrease in total sperm count (SMD: -17.45 [-28.97, -5.93]; p<0.01), sperm vitality (SMD: -16.41 [-26.30, -6.52]; p<0.01), total sperm motility (SMD: -17.67 [-24.90, -10.44]; p<0.01), and a significant increase of SDF (SMD: 7.41 [1.23, 13.59]; p=0.02), in rats with varicocele vs. controls. The quality of the included studies was ranked as high. CONCLUSIONS: This SRMA indicates a significant increase in levels of testicular MDA and SDF and a reduction of sperm quality in experimental animals with varicocele. These findings support the potential role of testicular OS in the development of varicocele-induced testicular damage.

Effects of Varicocele Repair on Sperm DNA Fragmentation and Seminal Malondialdehyde Levels in Infertile Men with Clinical Varicocele: A Systematic Review and Meta-Analysis.

PURPOSE: Varicoceles can be a source of elevated seminal oxidative stress (OS) and sperm DNA fragmentation (SDF). However, it remains unclear whether varicocele repair (VR) could reduce these parameters. This systematic review and meta-analysis (SRMA) aims to investigate the impact of VR on SDF and seminal malondialdehyde (MDA). MATERIALS AND METHODS: A literature search was performed in Scopus, PubMed, Ovid, Embase, and Cochrane databases. This SRMA included randomized controlled trials and observational studies reporting the pre- and postoperative levels of SDF and seminal OS in infertile men with clinical varicocele that underwent VR. Subgroup analyses included techniques of VR and SDF testing. The effect size was expressed as standardized mean difference (SMD). RESULTS: Out of 1,632 abstracts assessed for eligibility, 29 studies with 1,491 infertile men were included. The analysis showed a significant reduction in SDF after VR, compared to preoperative values (SMD -1.125, 95% confidence interval [CI] -1.410, -0.840; p<0.0001) with high inter-study heterogeneity (I²=90.965%). Reduction in SDF was evident with microsurgical technique and non-microsurgical inguinal approaches (SMD -1.014, 95% CI -1.263, -0.765; p<0.0001, and SMD -1.495, 95% CI -2.116, -0.873; p<0.0001), respectively. Reduction in SDF was significant irrespective of testing was done by sperm chromatin dispersion (SMD -2.197, 95% CI -3.187, -1.207; p<0.0001), sperm chromatin structure assay (SMD -0.857, 95% CI -1.156, -0.559; p<0.0001) or TUNEL (SMD -1.599, 95% CI -2.478, -0.719; p<0.0001). A significant decrease in seminal MDA levels was observed following VR (SMD -2.450, 95% CI -3.903 to -0.997, p=0.001) with high inter-study heterogeneity (I²=93.7%). CONCLUSIONS: Using pre- and post-intervention data, this SRMA indicates a significant reduction in SDF and seminal MDA levels in infertile men with clinical varicocele treated with VR. These findings may have important implications for the future management of this selected group of infertile patients.

Artificial Intelligence in Andrology: From Semen Analysis to Image Diagnostics.

Artificial intelligence (AI) in medicine has gained a lot of momentum in the last decades and has been applied to various fields of medicine. Advances in computer science, medical informatics, robotics, and the need for personalized medicine have facilitated the role of AI in modern healthcare. Similarly, as in other fields, AI applications, such as machine learning, artificial neural networks, and deep learning, have shown great potential in andrology and reproductive medicine. AI-based tools are poised to become valuable assets with abilities to support and aid in diagnosing and treating male infertility, and in improving the accuracy of patient care. These automated, AI-based predictions may offer consistency and efficiency in terms of time and cost in infertility research and clinical management. In andrology and reproductive medicine, AI has been used for objective sperm, oocyte, and embryo selection, prediction of surgical outcomes, cost-effective assessment, development of robotic surgery, and clinical decision-making systems. In the future, better integration and implementation of AI into medicine will undoubtedly lead to pioneering evidence-based breakthroughs and the reshaping of andrology and reproductive medicine.

Global Practice Patterns in the Evaluation of Non-Obstructive Azoospermia: Results of a World-Wide Survey and Expert Recommendations.

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.

Regenerative Therapy in Erectile Dysfunction: A Survey on Current Global Practice Trends and GAF Expert Recommendations.

PURPOSE: This study aimed to examine current global practices in regenerative therapy (RT) for erectile dysfunction (ED) and to establish expert recommendations for its use, addressing the current lack of solid evidence and standardized guidelines. MATERIALS AND METHODS: A 39-question survey was developed by senior Global Andrology Forum (GAF) experts to comprehensively cover clinical aspects of RT. This was distributed globally via a secure online Google Form to ED specialists through the GAF website, international professional societies, and social media, the responses were analyzed and presented for frequencies as percentages. Consensus on expert recommendations for RT use was achieved using the Delphi method. RESULTS: Out of 479 respondents from 62 countries, a third reported using RT for ED. The most popular treatment was low-intensity shock wave therapy (54.6%), followed by platelet-rich plasma (24.5%) and their combination (14.7%), with stem cell therapy being the least used (3.7%). The primary indication for RT was the refractory or adverse effects of PDE5 inhibitors, with the best effectiveness reported in middle-aged and mild-to-moderate ED patients. Respondents were confident about its overall safety, with a significant number expressing interest in RT's future use, despite pending guidelines support. CONCLUSIONS: This inaugural global survey reveals a growing use of RT in ED treatment, showcasing its diverse clinical applications and potential for future widespread adoption. However, the lack of comprehensive evidence and clear guidelines requires further research to standardize RT practices in ED treatment.

Global Practice Patterns and Variations in the Medical and Surgical Management of Non-Obstructive Azoospermia: Results of a World-Wide Survey, Guidelines and Expert Recommendations.

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.

Video exoscope as a cost-effective alternative to surgical microscope in microsurgical subinguinal varicocelectomy in Indonesia: A case report.

Microsurgical subinguinal varicocelectomy (MSV) is considered the preferred treatment for varicocele. However, its adoption among urologists in Indonesia is limited due to the high cost of acquiring a surgical microscope. Therefore, most varicoceles were managed using loupe-assisted MSV, which is considered a less effective approach. This paper presents a case study of a patient with bilateral grade II varicocele who underwent a successful MSV procedure using a video exoscope. The exoscope provided sufficient magnification and image quality for the safe and efficient performance of MSV on a patient.

X-ray free Percutaneous Nephrolithotomy (PCNL) with Alken Telescopic Metal Dilator for large stone in horseshoe kidney: A case report.

Percutaneous Nephrolithotomy (PCNL) has been shown as a safe and effective method for treating nephrolithiasis in horseshoe kidney patients. We report the first X-ray Free PCNL with Alken Telescopic Metal Dilator (ATMD) in horseshoe kidney. A 58-Year-Old female was diagnosed with left large staghorn stone and horseshoe kidney treated with X-ray Free PCNL with ATMD. X-ray Free PCNL with ATMD is safe and effective nephrolithiasis lithotripsy for staghorn stone in Horseshoe Kidney. This technique is the first of its kind and possibly has become an excellent alternative for urological centers without access to fluoroscopy.

The efficacy of antibiotic and alpha-blocker combination therapy versus antibiotic monotherapy in chronic prostatitis/chronic pelvic pain syndrome: A systematic review.

OBJECTIVES: This study attempted to explore the efficacy of a combination of alpha-blockers and antibiotics compared with antibiotic monotherapy in patients with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). METHODS: We searched PubMed/MEDLINE, Cochrane/CENTRAL, EBSCOHost/CINAHL, ProQuest, and Scopus on January 2020. Randomized controlled trials comparing antibiotic monotherapy with combination therapy of antibiotics and alpha-blockers in CP/CPPS patients lasting at least 4 weeks were included. The study eligibility assessment, data extraction, and study quality assessment were carried out by each author independently and in duplication. RESULTS: A total of six low- to high-quality studies with 396 patients were included in the study. Two reviews reported lower National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) total scores in the monotherapy arm at Week 6. Only one study reported otherwise. On Day 90, the NIH-CPSI score was found to be lower in the combination group. In the pain, urinary, and quality-of-life domain, most studies agree that combination therapy is not superior to monotherapy. However, on Day 90, all domains were found to be lower in the combination therapy. Responder rates were found to vary between studies. Only four out of six studies reported a response rate. Responder rates were lower in the combination group at 6 weeks of observation. On Day 90, responder rates were found to be better in the combination group. CONCLUSIONS: The combination therapy of antibiotics and alpha-blockers is not substantially better than antibiotic monotherapy in the first 6 weeks of treatment for CP/CPPS patients. This might not be applicable to a longer duration of treatment.

Clinical parameters as predictors for sperm retrieval success in azoospermia: experience from Indonesia.

Background: Azoospermia is the most severe type of male infertility. This study aimed to identify useful clinical parameters to predict sperm retrieval success. This could assist clinicians in accurately diagnosing and treating patients based on the individual clinical parameters of patients. Methods: A retrospective cohort study was performed involving 517 patients with azoospermia who underwent sperm retrieval in Jakarta, Indonesia, between January 2010 and April 2023. Clinical evaluation and scrotal ultrasound, serum follicle stimulating hormone (FSH), luteinizing hormone (LH), and testosterone levels were evaluated before surgery. Multivariate analyses were conducted to determine clinical parameters that could predict overall sperm retrieval success. Further subgroup analysis was performed to determine the factors that the diagnosis of non-obstructive azoospermia (NOA) diagnosis and sperm retrieval success among patients with NOA. Results: A total of 2,987 infertile men attended our clinic. Men with azoospermia (n=517) who met the inclusion criteria and did not fulfil any exclusion criteria were included in the study. The overall sperm retrieval success was 47.58%. Logistic regression revealed that FSH 7.76 mIU/mL (sensitivity: 60.1%, specificity: 63.3%, p<0.001); longest testicular axis length 3.89 cm (sensitivity: 33.6%, specificity: 41.6%); and varicocele (p<0.001) were independent factors for overall sperm retrieval. The FSH cutoff of 7.45 mIU/mL (sensitivity: 31.3%, specificity: 37.7%, p<0,001); longest testicular axis length 3.85 cm (sensitivity: 76.7%, specificity: 65.4%, p<0.001); and varicocele (p<0.001) were independent factors for NOA diagnosis. Varicocele was the only clinical parameter that significantly predicted the success of sperm retrieval in patients with NOA. Conclusions: FSH, LH, longest testicular axis, and varicocele are among the clinical parameters that are useful for predicting overall sperm retrieval success and NOA diagnosis. However, varicocele is the only clinical parameter that significantly predicts sperm retrieval success in patients with NOA. High-quality studies are required to assess the other predictors of sperm retrieval success.