Financial and Business Literacy Among Urology Residents: Is this a Problem and How Can We Better Prepare Residents for their Careers?

PURPOSE OF REVIEW: Although financial wellness is a predictor of physician burnout, we are yet to optimize financial education or wellness of Urology trainees. We assessed existing studies, compared them to those of other specialties, and discussed resources and methods to address this deficiency. RECENT FINDINGS: Urology residents tend to be less fiscally savvy (carry significant debt, and lack retirement savings or disability insurance), and 90% of trainees and young Urologists do not feel comfortable with the business of practice, including skills like coding and billing, contract negotiation, and self-value assessment. Financial and business literacy are deficiencies of Urology training, as in other specialties. Eventually, the goal should be universal adoption of a formal curriculum that is graded in nature. In the interim, we need to propose and endorse adoption of a formal curriculum, and we should support trainees by promoting a space for easily accessible and transparent information regarding best practices in personal finance and the business of healthcare.

Is Time Spent on Prior Authorizations Associated With Approval?

Advanced practice providers increasingly assume responsibility for prior authorizations (PAs). We hypothesized that the time burden of PAs will be correlated with increased approval. We collected several variables (ie, type, method, time spent, use of peer to peer, and outcome) for all PAs completed by a departmental nurse practitioner in 1 region. Chi-square tests and 2 sample t tests were used to assess significance. There was no significant association between the method of request, the number of attempts, and the time spent to approved PA. Further research is needed to determine ways to decrease the time and opportunity cost associated with PAs.

Trends in outpatient versus inpatient urologic surgery at a university academic medical center.

PURPOSE OF REVIEW: To analyze trends in outpatient and inpatient urologic surgeries at a large university academic medical center and test the hypothesis that the proportion of outpatient surgeries has been increasing as compared to inpatient surgeries in urology. RECENT FINDINGS: We analyzed a total of 33,054 claims for urologic surgeries at a large university academic medical center from 2010 to 2020, of which 23.2% met inpatient criteria (n = 7695), whereas 76.7% were outpatient (n = 25,359). Although outpatient claims increased yearly by an average of 24%, inpatient claims increased yearly by an average of only 1%. Over the same period, Medicare-specific outpatient claims mirrored these trends, and Medicare-specific inpatient claims decreased. SUMMARY: Outcomes of inpatient surgeries are used as a metric for quality by the Centers for Medicare and Medicaid Services (CMS) as well as US News and World Report (USNWR) rankings. However, with increasing numbers of minimally invasive operations, a large proportion of urologic surgeries are performed on an outpatient basis. As this trend continues, it will be important for organizations like CMS and USNWR to incorporate methods of measuring quality that better reflect outpatient surgical outcomes for the urologic subspecialty.

Varicocele is underdiagnosed in men evaluated for infertility: Examination of multi-center large-scale electronic health record data.

Varicocele is the most common reversible cause of male infertility, affecting up to 20% of healthy men and 40% of men with primary infertility. The objective of this study was to investigate the prevalence of varicocele in men evaluated for infertility, and to determine rates of subsequent varicocele repair. Since reproductive endocrinologists are the first specialists seen for male infertility care in North America, we hypothesized that varicocele would be underdiagnosed when compared to its reported prevalence among men with infertility. TriNetX, a large, multicenter electronic health record (EHR) database was queried to establish a cohort of all men (above 18 years of age) with a diagnosis of male infertility. This cohort was used to identify those with ensuing varicocele diagnosis. Men who received varicocelectomy or venous embolization after a diagnosis of varicocele were then identified. Out of 101,309 men with a diagnosis of male infertility in the network, only 9768 (9.6%) had a diagnosis of varicocele. Mean age of men with varicocele was 34. Varicocelectomy or venous embolization was performed in 1699 (20.2%) and 69 (0.76%) of men with varicocele, respectively. In this cross-sectional EHR study, varicocele was underdiagnosed in men evaluated for infertility when compared with prior epidemiological studies.

Why should we screen for male fertility?

An increasing number of studies show declining sperm counts; however, semen analyses are uncommon until the evaluation for infertility. Semen analysis is a safe, reliable and relatively inexpensive screening test, assessing male fertility and directing further work-up. In young men, the use of semen analysis may identify disease prior to attempted conception and result in improved fertility potential when combined with lifestyle changes, medical or surgical therapy. Furthermore, if sperm counts are significantly low, evaluation and management for genetic causes can be initiated. Our commentary outlines why screening for male infertility in young adult men may be beneficial. We discuss options for early intervention, including sperm cryopreservation, if defects in sperm parameters are identified.

Serum 17-Hydroxyprogesterone is a Potential Biomarker for Evaluating Intratesticular Testosterone.

PURPOSE: Intratesticular testosterone is essential for spermatogenesis and can only be reliably measured with invasive testicular sampling. Previous studies have demonstrated good correlation between intratesticular testosterone and serum 17-hydroxyprogesterone (17-OHP) in men treated with human chorionic gonadotropin. Based on this observation we hypothesized that we can use serum 17-OHP as a serum biomarker for evaluating intratesticular testosterone in men receiving medications that alter serum testosterone. MATERIALS AND METHODS: Initially, we conducted a cross-sectional analysis of men with a single serum 17-OHP evaluation from July 2018 to March 2019. We followed this with a prospective analysis from July 2018 to October 2019 with evaluation of 140 men including fertile controls, and those receiving treatments that alter serum testosterone at baseline and after 3 months of therapy. According to the data distribution, we reported the median and interquartile ranges, and used the Mann Whitney U or Wilcoxon tests. RESULTS: In the initial cross-sectional analysis of 93 men, a total of 30 men received treatments that increase or maintain intratesticular testosterone concentrations, such as clomiphene citrate and/or human chorionic gonadotropin; 21 men received treatments that suppress intratesticular testosterone concentrations (various exogenous testosterone replacement therapy formulations) and 42 fertile men with normal serum testosterone (greater than 300 ng/dl) were used as control. We demonstrated that serum testosterone levels were within normal range among men receiving the various therapies. In contrast, we found that serum 17-OHP was undetectable in men who received exogenous testosterone replacement therapy, as opposed to men receiving human chorionic gonadotropin and/or clomiphene citrate or fertile controls (p <0.05). In the prospective evaluation that ensued, 17-OHP values decreased in the 21 men who received testosterone replacement therapy (47.5 [21-70] to 13.5 [10-23] ng/dl, p <0.05). Conversely, 17-OHP increased in the 55 men who received human chorionic gonadotropin and/or clomiphene citrate when compared to their baseline levels (42 [24-72] to 88 [61-135] ng/dl, p <0.05). CONCLUSIONS: Serum 17-OHP appears to be a reliable serum marker for intratesticular testosterone levels and could potentially be used to titrate or change medications that alter intratesticular testosterone.

Prospective Evaluation of Focal High Intensity Focused Ultrasound for Localized Prostate Cancer.

PURPOSE: We report short-term outcomes of focal high intensity focused ultrasound use for primary treatment of localized prostate cancer. MATERIALS AND METHODS: Single-center prospectively collected data on patients with prostate cancer who underwent primary focal high intensity focused ultrasound from January 2016 to July 2018 were included. All patients underwent a 12-core biopsy with magnetic resonance imaging-ultrasound fusion biopsy depending on the presence of targetable lesions. Any Grade Group was allowed, however only patients with localized disease were included. The primary outcome was oncologic control, defined as negative followup in-field biopsy of treated cancer. Prostate specific antigen, Sexual Health Inventory for Men, International Prostate Symptom Score and Expanded Prostate Cancer Index Composite domain scores were assessed 3-monthly till 12 months. Biopsy was performed at 6 or 12 months for high or low/intermediate risk cancer, respectively. RESULTS: Fifty-two patients with minimum followup of 12 months were included in the study. The majority of patients (67%) had cancer Grade Group 2 or greater. Fifteen patients (28.8%) underwent complete transurethral prostate resection/holmium laser enucleation of prostate procedure for debulking large prostates to avoid postoperative urinary retention. Among 30 (58%) patients who underwent followup biopsies, 25 (83%) had negative in-field biopsy results and 4 (13%) had de-novo positive out-of-field biopsy. Only 5 major complications (all grade III) in 4 patients were noted. Urinary symptoms returned to near baseline questionnaire scores within 3-6 months. Sexual function returned to baseline at 12 months. CONCLUSIONS: Focal high intensity focused ultrasound is a safe and effective treatment for patients with localized clinically significant prostate cancer with acceptable short-term oncologic and functional outcomes. The complications are minimal and patient selection is essential. Short-term oncologic outcomes are promising but longer followup is required to establish long-term oncologic outcomes.

Impact of Abnormal Sperm Morphology on Live Birth Rates Following Intrauterine Insemination.

PURPOSE: We evaluated the live birth rate and the prevalence of congenital anomalies in couples undergoing intrauterine insemination with abnormal sperm morphology (less than 4% normal forms). MATERIALS AND METHODS: We retrospectively reviewed intrauterine insemination outcomes from January 2012 to March 2015. Patients who were found to have an ultrasound confirmed clinical pregnancy were contacted to determine the live birth rate and the prevalence of congenital abnormalities. We used chi-square analysis to assess categorical variables and the Student t-test to assess continuous variables. Logistic regression was done to assess the odds of achieving pregnancy and the risk of spontaneous abortion while assessing female age, the total motile count and sperm morphology. RESULTS: In 984 intrauterine insemination procedures performed in a total of 501 couples we found no difference in the ultrasound clinical pregnancy rate in couples with sperm morphology less than 4% vs 4% or greater (12.3% vs 13.6%, p=0.59). We collected live birth and birth abnormality data on 95 of the 130 couples with ultrasound confirmed clinical pregnancy for a 73% response rate. We found no difference in the live birth rate or the spontaneous abortion rate after an ultrasound confirmed clinical pregnancy in couples with abnormal sperm morphology (less than 4% normal forms). There was also no increased risk of birth abnormalities for patients with abnormal sperm morphology. CONCLUSIONS: Abnormal sperm morphology impacted neither the pregnancy rate nor the live birth rate in couples undergoing intrauterine insemination. These results can be used to reassure couples who undergo intrauterine insemination that there is a minimal impact of abnormal sperm morphology on the live birth rate and the prevalence of birth abnormalities.

A Surgeon's Guide to the Various Antibiotic Dips Available During Penile Prosthesis Implantation.

PURPOSE OF REVIEW: Inflatable penile prosthesis (IPP) is a treatment for erectile dysfunction. IPPs have undergone improvements; however, post-surgical infections still occur. Furthermore, the type of pathogens infecting the implants has changed recently from Gram-positive to Gram-negative bacteria and fungi due to advances in antibiotic dips targeting the skin flora. To protect against infection, the AMS 700 is pre-coated with InhibiZone (mixture of Rifampin/Minocycline) and the Coloplast Titan, with several antibiotic dip options of differing efficacies. This review discusses strategies to decrease the infection rates in implant surgery, focusing on antibiotic dips. RECENT FINDINGS: Current research endorses the use of rifampin/gentamicin as the most studied combination; however, some studies have utilized different dips for additional coverage including the InhibiZone on the AMS 700. With the increasing prevalence of diabetes and Gram-negative organisms, there is a need to develop strategies for increased coverage against infections. Controlled studies with different antibiotic combinations are needed to identify the ideal cocktail to decrease infection.

Artificial Intelligence in Reproductive Urology.

PURPOSE OF REVIEW: The promise of artificial intelligence (AI) in medicine has been widely theorized over the past couple of decades. It has only been with technological advances over the past few years that physicians and computer scientists have started discovering its true clinical potential. Reproductive urology is a sub-discipline that AI could be of great contribution, as current predictive models and subjectivity within the field have several limitations. We review the literature to summarize recent AI applications in reproductive urology. RECENT FINDINGS: Early AI applications in reproductive urology focused on predicting semen parameters based on questionnaires that identify potential environmental factors and/or lifestyle habits impacting male fertility. AI has shown success in predicting the patient subpopulation most likely to need a genetic workup for azoospermia. With recent advances in image processing, automated sperm detection is a reality. Semen analyses, once a laboratory-only diagnostic test, have moved into health consumer homes with the advent of AI. AI's prospects in medicine are considerable and there is strong potential for AI within reproductive urology. Research in identifying the factors that can affect reproductive success either naturally or with assisted reproduction is of paramount importance to move the field forward.

Human Chorionic Gonadotropin monotherapy for the treatment of hypogonadal symptoms in men with total testosterone > 300 ng/dL.

PURPOSE: The 2018 American Urological Association guidelines on the Evaluation and Management of Testosterone Deficiency recommended that 300 ng/dL be used as the threshold for prescribing testosterone replacement therapy (TRT). However, it is not uncommon for men to present with signs and symptoms of testosterone deficiency, despite having testosterone levels greater than 300 ng/dL. There exists scant literature regarding the use of hCG monotherapy for the treatment of hypogonadism in men not interested in fertility. We sought to evaluate serum testosterone response and duration of therapy of hCG monotherapy for men with symptoms of hypogonadism, but total testosterone levels > 300 ng/dL. MATERIALS AND METHODS: We performed a multi-institutional retrospective case series of men receiving hCG monotherapy for symptomatic hypogonadism. We evaluated patient age, treatment indication, hCG dosage, past medical history, physical exam findings and serum testosterone and gonadotropins before and after therapy. Descriptive analysis was performed and Mann Whitney U Test was utilized for statistical analysis. RESULTS: Of the 20 men included in the study, treatment indications included low libido (45%), lack of energy (50%), and erectile dysfunction (45%). Mean testosterone improved by 49.9% from a baseline of 362 ng/dL (SD 158) to 519.8 ng/dL (SD 265.6), (p=0.006). Median duration of therapy was 8 months (SD 5 months). Fifty percent of patients reported symptom improvement. CONCLUSIONS: Treatment of hypogonadal symptoms with hCG for men who have a baseline testosterone level > 300 ng/dL appears to be safe and effi cacious with no adverse events.

Does time of intraoperative exposure to the aerobiome increase microbial growth on inflatable penile prostheses?

Inflatable penile prosthesis (IPP) implantation is a surgical approach for the management of erectile dysfunction (ED). A feared complication is IPP infection, and increased operative time is a risk factor for infection. Exposure of an IPP implant to ambient air in the operating room (OR aerobiome) is thought to contribute to risk of infection from increased operative time, but this is not well-supported. The objective of this study was to evaluate if exposure to the OR aerobiome increased microbial colonization of IPPs. This was an ex vivo study using an uncoated IPP, observing standard surgical sterility and OR conditions. A sterile swab was collected every 30 min for 3 h from each IPP component. Positive controls consisted of swabs exposed to unprepped scrotal skin during in-office vasectomies. All swabs underwent quantitative polymerase chain reaction (qPCR) and next generation sequencing (NGS). Bioinformatic processing was carried out and taxonomic assignment was performed. No microbial growth was detected on any component of the IPPs at any time point, while positive control swabs all detected various skin flora, including bacterial and fungal growth. These findings suggest that exposure to the OR aerobiome does not increase the risk of IPP microbial colonization, at least within a 3-hour period. Further in vivo studies are needed.

Majority of men with premature ejaculation do not receive pharmacotherapy.

Premature ejaculation is the most common male sexual dysfunction, with therapies including selective serotonin reuptake inhibitors, clomipramine, topical anesthetics, dapoxetine and tramadol. However, it is currently unknown how many men are receiving pharmacotherapy for premature ejaculation. Using the TriNetX Research network, a large multicenter database containing over 75 million patient records from hospitals across the United States, we evaluated prescribing patterns for treatment of premature ejaculation and assessed variations in prescription patterns among patients from 2015-2021. In addition, we examined if the prescription patterns for tramadol changed with the establishment of Prescription Drug Monitoring Programs. We found that most men (51.7%) were not receiving any pharmacotherapy for premature ejaculation. However, men with mental health disorders, were more likely (56.0%), to have been treated than those without (44.4%). On further analysis, men with mental health diagnoses were significantly more likely to be treated with Selective Serotonin Reuptake Inhibitors (45.0 vs 32.2%) and Tramadol (5.1% vs 3.5%). While the pharmacotherapy for premature ejaculation has been well researched, our findings revealed that most patients diagnosed with premature ejaculation do not receive pharmacotherapy and that patients are more likely to be prescribed premature ejaculation medications if they have a pre-existing mental health diagnosis.

Artificial Intelligence Based Machine Learning Models Predict Sperm Parameter Upgrading after Varicocele Repair: A Multi-Institutional Analysis.

PURPOSE: Varicocele repair is recommended in the presence of a clinical varicocele together with at least one abnormal semen parameter, and male infertility. Unfortunately, up to 50% of men who meet criteria for repair will not see meaningful benefit in outcomes despite successful treatment. We developed an artificial intelligence (AI) model to predict which men with varicocele will benefit from treatment. MATERIALS AND METHODS: We identified men with infertility, clinical varicocele, and at least one abnormal semen parameter from two large urology centers in North America (Miami and Toronto) between 2006 and 2020. We collected pre and post-operative clinical and hormonal data following treatment. Clinical upgrading was defined as an increase in sperm concentration that would allow a couple to access previously unavailable reproductive options. The tiers used for upgrading were: 1-5 million/mL (ICSI/IVF), 5-15 million/mL (IUI) and >15 million/mL (natural conception). Thus moving from ICSI/IVF to IUI, or from IUI to natural conception, would be considered an upgrade. AI models were trained and tested using R to predict which patients were likely to upgrade after surgery. The model sorted men into categories that defined how likely they were to upgrade after surgery (likely, equivocal, and unlikely). RESULTS: Data from 240 men were included from both centers. A total of 45.6% of men experienced an upgrade in sperm concentration following surgery, 48.1% did not change, and 6.3% downgraded. The data from Miami were used to create a random forest model for predicting upgrade in sperm concentration. On external validation using Toronto data, the model accurately predicted upgrade in 87% of men deemed likely to improve, and in 49% and 36% of men who were equivocal and unlikely to improve, respectively. Overall, the personalized prediction for patients in the validation cohort was accurate (AUC 0.72). CONCLUSIONS: A machine learning model performed well in predicting clinically meaningful post-varicocelectomy sperm parameters using pre-operative hormonal, clinical, and semen analysis data. To our knowledge, this is the first prediction model to show the utility of hormonal data, as well as the first to use machine learning models to predict clinically meaningful upgrading. This model will be published online as a clinical calculator that can be used in the preoperative counseling of patients.

Endourological management of osteitis pubis secondary to a calcified prostate ossifying into the pubic symphysis.

Osteitis pubis is a rare but known complication of multiple urological procedures including transurethral resection of the prostate, prostate cryotherapy, photovaporisation of the prostate, high-intensity focused ultrasound treatment of the prostate, prostatectomy and cystectomy, especially in the context of salvage therapy for prostate cancer. Patients can present with significant often intractable pain secondary to this condition. We report a case of a patient with a history of radiation therapy and salvage cryoablation who presented with osteitis pubis, calcification of the prostatic tissue bed which was inseparable from the pubic symphysis. Treatment with salvage holmium laser enucleation of the prostate and holmium lithotripsy was demonstrated to be effective for palliative management of osteitis pubis from prostatic calcification ossifying into the pubic symphysis.

A prospective study analyzing both inflation and deflation preference for commonly available inflatable penile prostheses.

Despite popularity, satisfaction rates of inflatable penile prosthesis (IPP) use can be improved by evaluating the ability to operate devices in the preoperative setting. The purpose of this study was to prospectively analyze the preference of three commonly available IPPs. In total, 125 IPP-naïve men 60 years of age or older were prospectively recruited from an outpatient Urology clinic from June 2019 to January 2020. A questionnaire standardized to all encounters was utilized to collect demographics, selected medical information, and key pinch strength. Participants were then asked to rank three models in terms of preference (from 1 to 3, 1 representing most preferred) for each inflation and deflation in a double-blinded manner. Statistical analysis was performed using ANOVA, a Chi-square test and multivariable logistical regression analysis. The results demonstrated preference for Coloplast Titan (44%) for inflation, and preference for AMS 700 (40%) for deflation. Men who preferred the Coloplast Titan inflation had a lower chance of preferring the AMS 700 MS deflation (OR = 0.29; p = 0.010) and Coloplast Titan Touch deflation (OR = 0.27; p = 0.012). Preference for Coloplast Titan was weakly associated with participant history of coronary artery disease (OR = 5.96, p = 0.006) and osteoarthritis (OR = 3.04, p = 0.044). Neither key pinch strength nor age was associated with preference for a particular model. IPP-naïve men over 60 years favor Coloplast Titan for inflation and AMS 700 for deflation, and men who preferred the Coloplast Titan for inflation were less likely to choose the AMS 700 MS or Coloplast Titan Touch for deflation. Further studies should aim to confirm these findings.

Semen parameter improvements after microsurgical subinguinal varicocele repair are durable for more than 12 months.

INTRODUCTION: Varicoceles account for the most common correctable cause of male infertility, with varicocele repair leading to improvements in semen quality. However, there is little evidence to establish the durability of varicocele repair. We analyzed the durability of improvements in postoperative semen parameters following microsurgical subinguinal varicocele repair. METHODS: We evaluated all men who underwent microscopic subinguinal varicocelectomy from 2015-2019. Patients were included if they desired fertility and had a followup of at least 12 months. We assessed the baseline characteristics of these patients, as well as semen volume, total motile sperm count (TMSC), concentration, percent motility, and morphology. Semen parameters were analyzed at baseline (preoperative) and at approximately three months and ≥12 months postoperatively. RESULTS: Of 105 men who underwent varicocelectomy, 18 men had a followup of at least 12 months. These men presented with median age of 34.5 (27-38) years for a median followup duration of 14.5 (13-22.5) months. TMSC levels increased from 6.4 (1.1-24.5) million at baseline to 11.1 (2.4-38.4) million at approximately three months and remained similar at 12.5 (1.6-31.5) million at ≥12 months. The study is limited by its retrospective nature and limited sample size. CONCLUSIONS: Microscopic subinguinal varicocele repairs can result in durable improvements of semen quality beyond one year, as demonstrated by upgrade in median TMSC. Further studies should be performed to confirm our findings.

Preoperative follicle-stimulating hormone: A factor associated with semen parameter improvement after microscopic subinguinal varicocelectomy.

INTRODUCTION: Currently, there exists no serum biomarker to predict patients likely to benefit from varicocelectomy. The purpose of this study was to assess the association between baseline follicle-stimulating hormone (FSH) and semen parameter changes after subinguinal microscopic varicocelectomy. METHODS: We retrospectively reviewed all men who underwent microscopic subinguinal varicocelectomy between August 2015 and October 2018. Pre- and postoperative semen analyses were stratified per total motile sperm count (TMSC): TMSC <5, 5-9, and >9 million (based on TMSC required for in vitro fertilization, intrauterine insemination [IUI], and natural conception, respectively). Then, variables were analyzed to determine the correlation with postoperative TMSC values and upgrade in TMSC category. RESULTS: Among the 66 men analyzed, 55 (83.3%) and 11 (16.7%) had a preoperative TMSC of <5 million and 5-9 million, respectively. A total of 33 (50%) patients upgraded in TMSC category, 26 of them achieving levels corresponding to natural conception and seven achieving those of IUI. Additionally, a significant correlation was observed between postoperative TMSC and preoperative TMSC (r=0.528; p<0.001), and preoperative FSH (r=-0.314; p=0.010). A lower preoperative FSH (odds ratio [OR] 0.82; 95% confidence interval [CI] 0.68-0.98; p=0.028) and a higher preoperative TMSC (OR 1.37; 95% CI 1.06-1.76; p=0.015) were associated with upgrade in TMSC category. CONCLUSIONS: Lower preoperative FSH and higher TMSC are associated with improvement in TMSC category after varicocelectomy, although small sample size limited the study. FSH can be useful to identify men who are most likely to benefit from varicocele repair.

Reasons that should prompt a referral to a reproductive urologist: guidelines for the gynecologist and reproductive endocrinologist.

Obstetricians and gynecologists, and in particular reproductive endocrinologists (REIs), are typically the gatekeepers and first-line providers for couples initially seeking an infertility evaluation. A timely referral to a reproductive urologist may improve pregnancy outcomes in certain clinical scenarios. This review examines the evidence behind circumstances requiring referral and delivers practice-based recommendations on commonly encountered scenarios in the clinic. Scenarios that should prompt referral to a reproductive urologist include semen analysis (SA) abnormalities (e.g., asthenozoospermia, azoospermia, globozoospermia, leukocytospermia, necrozoospermia, oligospermia), recurrent intrauterine insemination (IUI)/in vitro fertilization (IVF) failure, and idiopathic recurrent pregnancy loss (RPL). Conversely, deferment is appropriate in the cases of isolated teratozoospermia and subclinical varicocele. Men with infertility are also at higher risk for other comorbid conditions and should have at least a baseline evaluation by a primary care physician. Coordination of care between a REI and reproductive urologist is critical in several clinical scenarios and expedient referral can improve reproductive outcomes.

Human chorionic gonadotropin monotherapy for the treatment of hypogonadal symptoms in men with total testosterone > 300 ng/dL

ABSTRACT Purpose The 2018 American Urological Association guidelines on the Evaluation and Management of Testosterone Deficiency recommended that 300 ng/dL be used as the threshold for prescribing testosterone replacement therapy (TRT). However, it is not uncommon for men to present with signs and symptoms of testosterone deficiency, despite having testosterone levels greater than 300 ng/dL. There exists scant literature regarding the use of hCG monotherapy for the treatment of hypogonadism in men not interested in fertility. We sought to evaluate serum testosterone response and duration of therapy of hCG monotherapy for men with symptoms of hypogonadism, but total testosterone levels > 300 ng/dL. Materials and Methods We performed a multi-institutional retrospective case series of men receiving hCG monotherapy for symptomatic hypogonadism. We evaluated patient age, treatment indication, hCG dosage, past medical history, physical exam findings and serum testosterone and gonadotropins before and after therapy. Descriptive analysis was performed and Mann Whitney U Test was utilized for statistical analysis. Results Of the 20 men included in the study, treatment indications included low libido (45%), lack of energy (50%), and erectile dysfunction (45%). Mean testosterone improved by 49.9% from a baseline of 362 ng/dL (SD 158) to 519.8 ng/dL (SD 265.6), (p=0.006). Median duration of therapy was 8 months (SD 5 months). Fifty percent of patients reported symptom improvement. Conclusions Treatment of hypogonadal symptoms with hCG for men who have a baseline testosterone level > 300 ng/dL appears to be safe and efficacious with no adverse events.