A Prior History of Cryptozoospermia Is Associated with a Significantly Higher Chance of a Successful Microdissection Testicular Sperm Extraction Compared to Non-Obstructive Azoospermia.

BACKGROUND: Our study sought to evaluate the rates of successful sperm retrieval following microdissection testicular sperm extraction (mTESE) in patients with a prior history of cryptozoospermia, compared to patients with non-obstructive azoospermia (NOA). METHODS: A retrospective chart analysis evaluating all mTESE procedures was performed from January 2004 to August 2018. Inclusion criteria involved all males >18 years of age with a diagnosis of cryptozoospermia and/or NOA that underwent a mTESE. The patient's genetic profile, hormonal profile, semen analysis, testicular volumes, pathology and comorbidities were analyzed. RESULTS: We identified 40 patients with cryptozoospermia and 221 patients with NOA. Successful mTESE occurred in 34/40 (85%) cryptozoospermic males compared to 104/221 (48%) NOA males (p < 0.001). In univariate and multivariate analyses, patients with cryptozoospermia were more likely to undergo a successful mTESE than patients with NOA (OR 5.56 [1.79-17.29], p = 0.003; OR 5.41 [1.94-15.08], p = 0.0013), respectively. Factors that were associated with a statistically significant lower chance of successful mTESE included Sertoli-cell only pathology, pre-operative testosterone < 300 ng/dL and FSH > 7.6 mIU/mL. CONCLUSION: Despite patients with a history of cryptozoospermia having a significantly higher chance of a successful sperm retrieval than patients with NOA, couples should be counselled on the possibility of an unsuccessful sperm extraction, in order to optimize the pre-operative IVF planning and to manage operative expectations.

Prevalence of Hyperprolactinemia and Clinically Apparent Prolactinomas in Men Undergoing Fertility Evaluation.

OBJECTIVE: To determine prevalence of hyperprolactinemia and prolactinoma among men presenting for initial fertility evaluation. METHODS: We performed a retrospective review of men presenting for initial fertility evaluation at a tertiary care, academic health system between 1999 and 2018. Men with measured prolactin levels were analyzed to determine prevalence of hyperprolactinemia and prolactinoma. We compared clinical characteristics of men with and without hyperprolactinemia. Univariable and multivariable analysis were used to determine factors associated with hyperprolactinemia. We assessed effects of hyperprolactinemia and prolactinoma on testosterone levels, semen parameters and pregnancy outcomes after treatment. RESULTS: A total of 3101 men had serum prolactin level measured. 65 (2.1%) had hyperprolactinemia. Patients with hyperprolactinemia had lower testosterone (median 280 ng/dL vs 313 ng/dL, P = 0.038) and lower total motile sperm count (median 7.0 million vs 34.7 million, P = 0.001) compared to men without hyperprolactinemia. 43.1% of men with hyperprolactinemia had oligospermia vs 21.5% of men without hyperprolactinemia (P<0.001). Univariable analysis demonstrated that men with elevated luteinizing hormone (LH) (OR 1.077, P = 0.001) and follicle-stimulating hormone (FSH) (OR 1.032, P = 0.002) were more likely to have hyperprolactinemia. Men with oligospermia were more likely to have hyperprolactinemia (OR 2.334, P = 0.004). On multivariable analysis, neither hormone parameters nor oligospermia were associated with elevated prolactin (P>0.05). Of the 65 men with hyperprolactinemia, 11 (17%) were diagnosed with a prolactinoma, resulting in an overall prevalence of 11 in 3101 (0.35%). CONCLUSION: The overall prevalence of prolactinoma in our cohort of men undergoing fertility evaluation was 35-fold higher than the prevalence in the general male population.

Acute anejaculation, hypogonadism, and fertility preservation in the setting of neurosarcoidosis: case report and literature review.

OBJECTIVE: To examine fertility preservation techniques in the setting of neurosarcoidosis, and to review the impact of corticosteroid and methotrexate therapy on fertility. DESIGN: Case report of a patient with infertility secondary to anejaculation associated with spinal neurosarcoidosis, treated with systemic corticosteroids and methotrexate. SETTING: Academic tertiary-care hospital. PATIENTS: A 39-year-old man presented with neurosarcoidosis complicated by acute anejaculation, erectile dysfunction, and hypogonadism. He underwent fertility consultation and sperm cryopreservation before initiating methotrexate therapy. His pretreatment total testosterone was low, at 157 ng/dL. INTERVENTIONS: Unsuccessful pharmacologic therapy and penile vibratory stimulation (PVS) were followed by microdissection testicular sperm extraction (microTESE). Clomiphene was administered for optimization of spermatogenesis before microTESE. MAIN OUTCOME MEASURES: Vials of cryopreserved sperm, testis histopathology, and serum testosterone levels. RESULTS: Eight vials of viable sperm were harvested by means of micro-TESE and cryopreserved. Despite intraoperative appearance of hypospermatogenesis, 90% of seminiferous tubules had active germ cell sloughing. Total testosterone increased to 278 ng/dL 2 months after initiating clomiphene. CONCLUSIONS: Conventional fertility preservation techniques may be effective in the setting of neurosarcoidosis-induced infertility owing to largely intact spermatogenesis. PVS, though not effective for this patient, should be considered along with electroejaculation, given high success rates in other patients with neurogenic anejaculation. Corticosteroid-mediated hypogonadism also must be considered in these patients, because it can negatively affect downstream spermatogenesis. In addition, evidence for the impact of paternal methotrexate exposure on fertility is limited and requires further investigation. As such, fertility consultation before initiating methotrexate is highly recommended.

Online access to male factor infertility care: the challenge of finding a specialist.

OBJECTIVE: To investigate internet search results available to couples searching for a male factor infertility specialist. DESIGN: Cross-sectional. SETTING: Online search engine. PATIENTS: The phrase "male infertility specialist " was searched in Google for 50 states and Washington D.C. The top 10 results (i.e., first page) of each search were evaluated for website content. INTERVENTIONS: None. MAIN OUTCOME MEASURES: The first page of each search was evaluated for provider type (urology vs. obstetrics and gynecology), level of training (fellowship vs. none), male factor fertility information provided, and procedures offered. We compared search position rank (1-10) to determine the likelihood of finding an urologist versus a practitioner in obstetrics and gynecology. RESULTS: A total of 419 results were identified; the majority were obstetrics and gynecology-related (N = 229, 54.7%). Urology-related results appeared higher than obstetrics and gynecology-related results (median, 4 vs. 5). Andrology fellowship-trained urologists were identified in 153 (36.5%) results. Among 229 obstetrics and gynecology results, 152 unique practices were identified. A small portion (N = 38, 16.6%) of these practices had a fellowship-trained urologist identified on the website. Most obstetrics and gynecology websites did not mention vasectomy reversal (N = 116, 76.3%) or varicocele repair (N = 93, 61.2%). A minority of practices offered referral to urologists for sperm extraction (N = 23, 15.1%) or offered sperm retrieval themselves (N = 23, 15.1%). CONCLUSIONS: When searching online for a male factor infertility specialist, most results identified obstetrics and gynecology physicians. A large proportion of obstetrics and gynecology websites lacked information on male factor fertility treatments and did not offer these treatments. These data indicate the need for a more robust online presence of male reproductive urologists to optimize online access.

Renal Papillary Mapping and Quantification of Randall's Plaque in Pediatric Calcium Oxalate Stone Formers.

Introduction: Randall's plaque (RP) with attached stones is recognized as a primary mechanism for stone formation in adult calcium oxalate stone formers (CaOx SFs). The role of RP in pediatric stone pathogenesis is unknown, with no reported studies to date. The purpose of this study is to investigate renal papillary abnormalities and quantify RP in pediatric CaOx SFs. Methods: Eight pediatric CaOx SFs underwent ureteroscopy for symptomatic urolithiasis. The collecting system was mapped using a digital ureteroscope. Video for each patient was then reviewed using a retrograde pyelogram to confirm the location of each papilla. A single investigator (N.L.M.) reviewed the video to quantify RP. Each papilla was graded as having mild, moderate, or severe amount of RP. Patient history was recorded. Results: An average of nine papillae were mapped per patient. RP was present in 100% of patients and in 88.8% (64/72) of all papillae examined. When present, RP was uniformly distributed throughout the kidney without preferential distribution to a region or pole. The amount of RP on the papillae was graded as mild in 60%, moderate in 20.8%, and severe in 8.3%. The mean fractional RP coverage ranged from 0.39% to 9.34%. No correlation was found between the amount of plaque and age at first stone episode or number of prior stone episodes (p = 0.84). Attached stones were rare (1/8 patients). The two patients with severe RP had a small amount of calcium phosphate in their stone analysis. Conclusions: RP is common in pediatric CaOx SFs. Compared with adult CaOx SFs wherein up to 75% of stones are found attached to RP, attached stones were rare. The significance of these findings in the pathogenesis of pediatric stone formation remains unclear and will require longer term follow-up.