Varicocele repair for low testosterone.

PURPOSE OF REVIEW: Several recent clinical studies have added to the existing literature on the impact of varicocelectomy on serum testosterone levels. These studies were not included in the most recent previous review of this topic and strengthen considerably the evidence base supporting the claim that varicocele repair can reliably restore below-normal testosterone levels. RECENT FINDINGS: Three studies were published in 2011 on the effect of varicocele repair on testosterone levels. These studies were all adequately powered to detect statistically significant changes in testosterone preprocedure and postprocedure, and all demonstrated significant increases in testosterone levels in patients who had low preprocedure testosterone levels. SUMMARY: Varicocele repair can restore testosterone to the eugonadal range in hypogonadal patients with either unilateral or bilateral varicocele.

Review of current varicocelectomy techniques and their outcomes.

OBJECTIVES: • To review all the various techniques and their results and efficiencies to provide practicing urologists with some guidance for choice of technique • To discuss improvements of varicocelectomy techniques in the last 15 years and their impact on results of surgery. PATIENTS AND METHODS: • A PubMed English literature review of literature from 1995 to present. RESULTS: • Pregnancy rates were highest with microsurgical subinguinal technique • Varicocele recurrence rates were lowest with microsurgical subinguinal technique • Hydrocele formation rates were lowest with microsurgical inguinal technique • Surgical complications were highest in the laparoscopic technique • Varicocelectomy by itself or in conjunction with IVF is cost effective CONCLUSIONS: • Microsurgical subinguinal or microsurgical inguinal techniques offer best outcomes • Varicocelectomy is a cost effective treatment modality for infertility • Further research is needed to explore new developments in varicocelectomy.

Ejaculatory duct dysfunction and lower urinary tract symptoms: chronic prostatitis.

Chronic pelvic pain syndrome (CPPS) is the most prevalent form of prostatitis. It is characterized by pelvic pain, voiding symptoms, and ejaculatory symptoms in the absence of bacterial infection. This can be a difficult condition to treat. Many etiologies for CPPS have been proposed including immunologic, neurologic, endocrine, and psychological factors. This article examines a potentially correctable condition that may lead to CPPS, ejaculatory duct obstruction (EDO). EDO is easily correctable with minor surgery. In patients with symptoms of CPPS with associated ejaculatory pain, the diagnosis of EDO should strongly be considered.

Rising hypospadias rates: disproving a myth.

Hypospadias is one of the most common congenital abnormalities occurring in males. In recent years, the prevalence of hypospadias and whether that prevalence is rising or stable has become part of a larger debate over the potential effects of so-called 'endocrine disruptors', such as phthalates and bisphenol-A, on male reproductive health. This commentary critically examines allegations suggesting a worldwide increase in hypospadias rates. Despite the lack of scientific support for this hypothesis and for related claims that the disorders of male reproductive health are related to endocrine disruptors, these constructs remain firmly entrenched in popular literature, and are being used in part to justify litigation banning suspected endocrine disruptors such as phthalates and bisphenol-A. A review of the epidemiologic data on this issue amassed to date clearly demonstrates that the bulk of evidence refutes claims for an increase in hypospadias rates. This suggests that two of the three components of alleged testicular dysfunction syndrome, i.e. decline in sperm counts and rise in urogenital anomalies, lack clinical support. It further suggests that extrapolations from data derived in laboratory animal studies about alleged occult risks to humans of various candidate compounds are unwarranted at this time.

Female sexual dysfunction in urological patients: findings from a major metropolitan area in the USA.

OBJECTIVE: To determine the prevalence of and risk factors for female sexual dysfunction (FSD) in a practice focused mainly on female urology. PATIENTS AND METHODS: A modified version of the Female Sexual Function Index (FSFI) was used to assess the prevalence of FSD in 587 patients who completed the questionnaire. Logistic regression was used to identify risk factors. RESULTS: The prevalence of FSD was 63%; age, menopausal status and usage of selective serotonin reuptake inhibitors were statistically significant risk factors for FSD. CONCLUSIONS: FSD is highly prevalent in this population of patients and screening female urological patients for FSD should be considered.

Hypospadias rates in new york state are not increasing.

PURPOSE: The testicular dysgenesis syndrome describes urogenital abnormalities associated with exposure to environmental endocrine disruptors such as phthalates, specifically decreased semen quality, and increased rates of testis cancer and hypospadias. Recently there has been concern that these abnormalities described in animal studies may also be present in humans. To determine if hypospadias rates are increasing, we retrospectively reviewed the total prevalence of hypospadias in New York State from 1992 to 2005, categorized by maternal age younger than 35 years and 35 years or older. MATERIALS AND METHODS: Hypospadias rates were obtained from the New York State Congenital Malformations Registry from 1992 to 2005. An analysis was also performed on the rates of children with hypospadias who had mothers younger than 35 years and mothers 35 years or older. This investigation was approved by the Columbia University internal review board. RESULTS: There was no statistical change in hypospadias rates in New York State from 1992 to 2005 (r = 0.127, p = 0.6). Overall the mean +/- SE prevalence rate was 34.9 +/- 0.36 per 10,000 live births. However, mean +/- SE hypospadias rates in children of mothers 35 years old or older (38.7 +/- 0.7) were significantly greater than those in children of mothers younger than 35 years (34.1 +/- 0.386, t test p <0.01). CONCLUSIONS: Hypospadias rates have not changed in New York State from 1992 to 2005. Additionally advanced maternal age continues to be a risk factor for hypospadias. Combined with previous studies that demonstrate sperm counts are not declining, these data suggest that the testicular dysgenesis syndrome described in animal models may not be evident in humans.

Older men are having children, but the reality of a male biological clock makes this trend worrisome.

Couples are waiting longer to have children, and advances in reproductive technology are allowing older men and women to consider having children. The lack of appreciation among both medical professionals and the lay public for the reality of a male biological clock makes these trends worrisome. The age-related changes associated with the male biological clock affect sperm quality, fertility, hormone levels, libido, erectile function, and a host of non-reproductive physiological issues. This article focuses on the potentially adverse effects of the male biological clock on fertility in older men. Advanced paternal age increases the risk for spontaneous abortion as well as genetic abnormalities in offspring due to multiple factors, including DNA damage from abnormal apoptosis and reactive oxygen species. Increased paternal age is also associated with a decrease in semen volume, percentage of normal sperm, and sperm motility. Older men considering parenthood should have a thorough history and physical examination focused on their sexual and reproductive capacity. Such examination should entail disclosure of any sexual dysfunction and the use of medications, drugs, or lifestyle factors that might impair fertility or sexual response. Older men should also be counseled regarding the effects of paternal age on spermatogenesis and pregnancy.

Declining worldwide sperm counts: disproving a myth.

This article explores in detail the issue of the alleged decline in semen quality. The impetus for a comprehensive re-evaluation at this time is threefold: (1) the potential impact of a real decline in semen quality and subsequent human fertility is a priori critical to human welfare; (2) governments have begun to enact "anti-endocrine disruptor" legislation that is based, in part, on selected portions of the published data about semen quality; and (3) confusion and misinformation about semen quality remain widespread in lay and professional circles.

Pathologic effects of testosterone deprivation.

PURPOSE OF REVIEW: Androgen deprivation therapy remains the cornerstone of treatment for advanced prostate cancer. There are significant adverse effects associated with prolonged androgen deprivation therapy, with recent findings associating it with the metabolic syndrome and its associated health risks. RECENT FINDINGS: A review of the adverse pathologic effects of testosterone deprivation is performed. Recent findings associate androgen deprivation therapy with endocrine and metabolic disarray, specifically the metabolic syndrome, resulting in increased rates of diabetes and myocardial infarction in patients on testosterone deprivation. SUMMARY: The increased incidence of the metabolic syndrome in patients receiving androgen deprivation therapy and the associated morbidity and possibly mortality require significant investigation into alternatives to complete testosterone deprivation and ways to counteract these adverse effects.

Infertility and testis cancer.

Testicular cancer is the most common solid organ tumor in young men and affects men during their reproductive years. Current therapeutic regimens have significantly improved survival but often adversely impact fertility. Understanding the effects of testicular cancer, the systemic effects of neoplasia, and the effects of treatment protocols, such as radiotherapy, chemotherapy, and retroperitoneal lymph node dissection, is essential to restoring and maintaining fertility in men who have germ cell neoplasms.

Management of ejaculatory duct obstruction: etiology, diagnosis, and treatment.

Abnormalities of the distal ejaculatory ducts related to infertility have been well-documented. Although there are no specific findings associated with ejaculatory duct obstruction, several clinical findings are highly suggestive. A diagnosis of ejaculatory duct obstruction is suggested in an infertile male with oligospermia or azoospermia with low ejaculate volume, normal secondary sex characteristics, testes, and hormonal profile, and dilated seminal vesicles, midline cyst, or calcifications on TRUS. Other causes of infertility may be concomitantly present and need to be evaluated and treated. Trans urethral resection of ejaculatory ducts (TURED) has resulted in marked improvement in semen parameters, and pregnancies have been achieved. Proper patient selection and surgical experience are necessary to obtain optimal results. In case of testicular dysfunction, chances of success are minimal. Extended follow-up periods are needed after TURED to examine the long-term effects of this procedure. Better understanding of the anatomy and pathology of the ejaculatory ducts will continue to refine diagnostic and therapeutic procedures for this disorder.

The male biological clock.

Do men have biological clocks that affect their hormone levels, fertility, and the genetic quality of their sperm? Women can no longer be viewed as solely responsible for age-related fertility and genetic problems. The effects of andropause and advanced paternal age on fertility and offspring are still under investigation. Further research is needed to fully characterize the associated risks and to treat the underlying abnormalities. A better understanding of the cellular and biochemical mechanisms of "gonadal" aging is important in order to determine safe, effective ways to delay this process and "rewind" the male biological clock. The benefits may include decreasing the potential for adverse genetic consequences in offspring, improvement in the sexual and reproductive health of aging males, and increase a woman's chance of having healthy children by correcting defects in the male reproductive system.

Hypogonadism and metabolic syndrome: implications for testosterone therapy.

PURPOSE: Metabolic syndrome, characterized by central obesity, insulin resistance, dyslipidemia and hypertension, is highly prevalent in the United States. When left untreated, it significantly increases the risk of diabetes mellitus and cardiovascular disease. It has been suggested that hypogonadism may be an additional component of metabolic syndrome. This has potential implications for the treatment of metabolic syndrome with testosterone. We reviewed the available literature on metabolic syndrome and hypogonadism with a particular focus on testosterone therapy. MATERIALS AND METHODS: A comprehensive MEDLINE review of the world literature from 1988 to 2004 on hypogonadism, testosterone and metabolic syndrome was performed. RESULTS: Observational data suggest that metabolic syndrome is strongly associated with hypogonadism in men. Multiple interventional studies have shown that exogenous testosterone has a favorable impact on body mass, insulin secretion and sensitivity, lipid profile and blood pressure, which are the parameters most often disturbed in metabolic syndrome. CONCLUSIONS: Hypogonadism is likely a fundamental component of metabolic syndrome. Testosterone therapy may not only treat hypogonadism, but may also have tremendous potential to slow or halt the progression from metabolic syndrome to overt diabetes or cardiovascular disease via beneficial effects on insulin regulation, lipid profile and blood pressure. Furthermore, the use of testosterone to treat metabolic syndrome may also lead to the prevention of urological complications commonly associated with these chronic disease states, such as neurogenic bladder and erectile dysfunction. Physicians must be mindful to evaluate hypogonadism in all men diagnosed with metabolic syndrome as well as metabolic syndrome in all men diagnosed with hypogonadism. Future research in the form of randomized clinical trials should focus on further defining the role of testosterone for metabolic syndrome.

Transurethral resection of the ejaculatory ducts for treating ejaculatory symptoms.

OBJECTIVES: To report our experience with transurethral resection of the ejaculatory ducts (TURED) in infertile men with symptomatic ejaculatory duct obstruction (EDO). PATIENTS AND METHODS: Before surgery, all patients complained of a decrease in the volume of their ejaculate, 14 of 15 had a non-projectile ejaculation, nine had a genitourinary infection necessitating antibiotic treatment, and five had pain with orgasm. The mean ejaculate volume and total motile sperm count was 1.1 mL and 8.1 million sperm per ejaculate. After surgery, at a mean follow-up of 2 months, 10 men reported having projectile ejaculation, and eight reported a marked improvement in their sensation of orgasm. Overall, 14 men reported a subjective improvement in their ejaculation. The average postoperative ejaculate volume was 2.3 mL and the total motile sperm count was 38.1 million per ejaculate. CONCLUSIONS: Men with symptomatic EDO who underwent TURED showed improvements in their ejaculation, sensation of orgasm, semen analysis values and fertility.

Clomiphene citrate effects on testosterone/estrogen ratio in male hypogonadism.

AIM: Symptomatic late-onset hypogonadism is associated not only with a decline in serum testosterone, but also with a rise in serum estradiol. These endocrine changes negatively affect libido, sexual function, mood, behavior, lean body mass, and bone density. Currently, the most common treatment is exogenous testosterone therapy. This treatment can be associated with skin irritation, gynecomastia, nipple tenderness, testicular atrophy, and decline in sperm counts. In this study we investigated the efficacy of clomiphene citrate in the treatment of hypogonadism with the objectives of raising endogenous serum testosterone (T) and improving the testosterone/estrogen (T/E) ratio. METHODS: Our cohort consisted of 36 Caucasian men with hypogonadism defined as serum testosterone level less than 300 ng/dL. Each patient was treated with a daily dose of 25 mg clomiphene citrate and followed prospectively. Analysis of baseline and follow-up serum levels of testosterone and estradiol levels were performed. RESULTS: The mean age was 39 years, and the mean pretreatment testosterone and estrogen levels were 247.6 +/- 39.8 ng/dL and 32.3 +/- 10.9, respectively. By the first follow-up visit (4-6 weeks), the mean testosterone level rose to 610.0 +/- 178.6 ng/dL (P < 0.00001). Moreover, the T/E ratio improved from 8.7 to 14.2 (P < 0.001). There were no side effects reported by the patients. CONCLUSIONS: Low dose clomiphene citrate is effective in elevating serum testosterone levels and improving the testosterone/estradiol ratio in men with hypogonadism. This therapy represents an alternative to testosterone therapy by stimulating the endogenous androgen production pathway.

[Quality evaluation of three different sperm counting chambers].

OBJECTIVE: Semen evaluation is the most important laboratory test for assessing male fertility. However, lack of strict quality control (QC) for semen analyses in hospital andrology laboratories makes it difficult and meaningless to compare semen data between different laboratories. This paper reports a comparative study on the accuracy of the Hemacytometer (Qiujing Inc., Shanghai, China), Makler (Sefi-Medical Instrument, Haifa, Israel), and Cell-VU (Millennium Sciences Inc., New York, USA) chambers for sperm counting. METHODS: Both low [(18 +/- 2.5) x 10(6)/ml] and high [(35 +/- 5) x 10(6)/ml] pre-calibrated standard latex bead solutions (Hamilton Thorne Biosciences, USA) were used as the quality control solution to perform counts on the three different counting chambers. Bead counts for the three different chambers were compared, and variability within the chambers determined for standard solutions at low and high concentrations of latex beads, respectively. RESULTS: Mean bead concentrations for the Cell-VU, Hemacytometer and Makler chambers were (37.63 +/- 4.89), (42.74 +/- 4.98) and (53.52 +/- 6.67) x 10(6)/ml respectively for a standard solution containing (35 +/- 5) x 10(6) beads/ml, and (18.22 +/- 1.77), (20.48 +/- 1.56), (24.97 +/- 4.75) x 10(6)/ml respectively for a standard solution containing (18 +/- 2.5) x 10(6) beads/ml. Mean bead concentrations for the Cell-VU chamber were consistently similar and close to the standard pre-calibrated bead solutions, while those for both the Hemacytometer and the Makler chambers were significantly overestimated (P < 0.001). The average coefficients of variation for the Cell-VU chamber were 7.51% for a higher concentration of the standard solution containing (36 +/- 5) x 10(6) beads/ml and 1.22% for a lower concentration of the standard solution containing (18 +/- 2.5) x 10(6) beads/ml, while the mean variation rates of the Hemacytometer and Makler chambers were 22.11% and 13.78% for a standard solution containing (36 +/- 5) x 10(6) beads/ml, and 52.91% and 38.72% for a standard solution containing (18 +/- 2.5) x 10(6) beads/ ml, respectively. CONCLUSION: Semen analysis is one of the most important tests for male fertility evaluation, but the data obtained from commercially available counting chambers may differ markedly in accuracy and reliability. Results from this comparative study demonstrated that the Cell-VU chamber exhibits significantly more accurate and less variable results than those of the Hemacytometer and Makler chambers. To ensure the best possible evaluations and accurate diagnoses, we therefore recommend that Cell-VU be used as the standard counting chamber for routine semen analyses in andrology laboratories.

A novel surgical approach to subinguinal varicocelectomy: artery and lymphatic isolation technique.

Clinically relevant varicoceles require surgical management through one of several techniques. We introduce an innovative technique for varicocelectomy via a subinguinal approach that allows identification and preservation of the arteries and lymphatics. This method allows the safe excision of the varicocele, while minimizing the risk of complications.

The relationship of long term global temperature change and human fertility.

UNLABELLED: According to the United Nations, global fertility has declined in the last century as reflected by a decline in birth rates. The earth's surface air temperature has increased considerably and is referred to as global warming. Since changes in temperature are well known to influence fertility we sought to determine if a statistical relationship exists between long-term changes in global air temperatures and birth rates. The most complete and reliable birth rate data in the 20th century was available in 19 industrialized countries. Using bivariate and multiple regression analysis, we compared yearly birth rates from these countries to global air temperatures from 1900 to 1994.A common pattern of change in birth rates was noted for the 19 industrialized countries studied. In general, birth rates declined markedly throughout the century except during the baby boom period of approximately 1940 to 1964. An inverse relationship was found between changes in global temperatures and birth rates in all 19 countries. Controlling for the linear yearly decline in birth rates over time, this relationship remained statistically significant for all the 19 countries in aggregate and in seven countries individually (p<0.05). CONCLUSIONS: The results of our analyses are consistent with the underlying premise that temperature change affects fertility and suggests that human fertility may have been influenced by change in environmental temperatures.