RESUMO
A 40-year-old man with a four-year history of infertility was referred to our department. The semen analysis revealed low motility, and the blood test showed low luteinizing hormone levels. Gonadotropin therapy was initiated upon the diagnosis of hypogonadotropic hypogonadism. During treatment, serum prostate-specific antigen (PSA) was consistently low (1.4-1.9 ng/mL). Fourteen years after the start of treatment, at 54 years old, PSA was abruptly elevated (3.5 ng/mL), and gonadotropin therapy was discontinued due to possible prostate cancer. After cessation, PSA decreased temporarily but then gradually increased to 7.6 ng/mL, but the patient requested PSA follow-up. Twenty years after discontinuation of gonadotropin therapy, PSA increased sharply to 65.9 ng/mL. A prostate biopsy revealed adenocarcinoma with a Gleason score of 4+5. A bone scan showed multiple bone metastases, leading to an advanced prostate cancer (cT4N0M1b) diagnosis. Six months after androgen deprivation therapy, PSA increased again. Under castration-resistant prostate cancer diagnosis, enzalutamide and radium-223 chloride were administered. After treatment, bone metastases were significantly reduced, and PSA decreased. Although gonadotropin and testosterone replacement therapy may not increase prostate cancer risk, patients with low testosterone levels may develop high-grade advanced prostate cancer. Therefore, PSA should be monitored regularly; if PSA levels are continuously elevated, even below 4 ng/mL, a close examination of cancer may be warranted.
RESUMO
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.