Attitudes towards disposition of cryopreserved sperm in the event of death.

INTRODUCTION: To evaluate patient preference for sperm disposition in case of death based on demographic factors and infertility etiology. MATERIALS AND METHODS: This retrospective cohort study was performed at a university hospital-affiliated fertility center. Charts of 550 men undergoing cryopreservation for assisted reproductive technologies (ART) between 2016-2019 were reviewed to create a descriptive dataset. Patients previously signed consent forms stating their preference for sperm transfer to their partner or disposal in the event of their subsequent death. Patients undergoing sperm cryopreservation for the purpose of ART were analyzed to assess associations between demographic characteristics and etiology of infertility and their choice to either transfer sperm to their partner or discard. RESULTS: A total of 84.9% (342/403) of patients included in final analyses elected to transfer their sperm to their partner in the event of their death. Factors associated with a significantly increased likelihood to transfer versus discard included a male-factor infertility diagnosis compared to female-factor infertility diagnosis (transfer rate 89.3% vs. 79.9%; p = .022) and commercial insurance coverage versus non-commercial/no insurance coverage (transfer rate 86.3% vs. 75.0%, p = .029). No significant differences relating to age, race/ethnicity, occupation classification, marital status or duration of marriage, or prior paternity were found. CONCLUSION: A majority of male patients seeking sperm cryopreservation for ART elected to transfer their sperm to their partner if future death should occur. There does not appear to be a clear factor that would impact this decision based on demographic characteristics.

Improving resident learning on vasectomy: a national survey on urology resident vasectomy training.

INTRODUCTION: Resident training in vasectomy, especially in the office setting on the awake patient, may be limited. The aim of this study is to understand resident exposure to vasectomy and to identify barriers to learning. MATERIALS AND METHODS: An anonymous 18-question survey was distributed to urology residents of the 135 ACGME-accredited urology residencies in the United States. Residents were asked to specify the total number of vasectomies they had performed and in what environment (operating room versus office), their comfort performing vasectomy independently, and any barriers to learning the procedure. RESULTS: In total, 119 residents responded to the survey, representing a 10% response rate. Vasectomy case volumes were variable, with 36.7% of residents logging ≤ 20 vasectomies by their final year of training. Total of 23.4% indicated they did not receive training in perioperative counseling for patients considering vasectomy. Only 64.7% of all residents felt comfortable in the office setting versus 89.1% who felt comfortable in the operating room (p < 0.001). This difference persisted throughout training, and 16.7% of residents in their final year of residency were uncomfortable performing office vasectomy. Total of 60.5% of respondents cited one or more barriers to training, with lack of surgical volume (38.7%), lack of vasectomies in the resident clinic (29.4%), and lack of autonomy when performing the procedure (22.7%) being the most common. CONCLUSIONS: Residents are significantly less comfortable performing vasectomy in the office setting versus in the operating room, including in their graduating year. Residents describe low volume and lack of autonomy as barriers to vasectomy training.

Genetic disorders related to male factor infertility and their adverse consequences.

Assisted reproductive techniques have revolutionized the treatment of male reproductive failure, allowing biological fatherhood to be achieved by many men that nature would have never permitted. As we are able to help more and more couples with our therapies, the genetic basis of the man's spermatogenic, anatomical, or spermatozoal dysfunction needs to be determined so as to inform the couple whether there will be adverse consequences to either the patient individually or to any female or male offspring that may result. The goal of all that is done in reproductive medicine should include not just a singular thought process involving the couple and their desires to get pregnant but should take a wider view that encompasses the children we create and their physical, psychological, and genetic well-being. This article will review some of the more common or recognized conditions resulting in male reproductive failure, what is known or hypothesized about their genetic basis, and the adverse consequences that may arise for the patient or any offspring.

Robot-assisted laparoscopic distal ureterectomy and ureteral reimplantation with psoas hitch.

For midureteral and distal-ureteral tumors not amenable to endoscopic resection, distal ureterectomy with ureteral reimplantation is a treatment option. When ureteral length is insufficient for direct reimplantation, additional length can be gained with either a psoas hitch or a Boari flap. We describe our technique for robot-assisted laparoscopic distal ureterectomy and ureteral reimplantation with psoas hitch.

Use of human immunodeficiency virus postexposure prophylaxis in adolescent sexual assault victims.

OBJECTIVES: To describe the use of human immunodeficiency virus (HIV) postexposure prophylaxis (PEP) in adolescent survivors of sexual assault and to explore barriers to PEP completion in this population. DESIGN: Chart review. SETTING: Two academic medical centers in Boston, Mass, between July 1, 2001, and June 30, 2003. PARTICIPANTS: Adolescents presenting to 2 urban pediatric emergency departments within 72 hours of a penetrating sexual assault. Of 177 charts reviewed, adequate documentation of the sexual assault and medical management was available for 145 patients. INTERVENTION: Provision of HIV PEP. MAIN OUTCOME MEASURE: Documented completion of a 28-day course of PEP. RESULTS: Among the 145 patients, 96% were female, 38% were black, and 14% were Hispanic. Many patients were uncertain regarding their exposures: 27% were unsure whether a condom had been used, 54% were unsure whether ejaculation had occurred, and 21% had blacked out during the assault. One hundred ten (76%) received HIV PEP. Of the 97 patients referred for follow-up at the academic centers, 37 returned for at least 1 visit and 13 completed a 28-day course of PEP. Sixteen (46%) of those taking PEP who returned for follow-up developed an adverse reaction to medication. Forty-seven percent of adolescent sexual assault survivors had carried a psychiatric diagnosis before the assault; adherence to PEP was lower among these adolescents. CONCLUSIONS: We observed low rates of PEP completion among adolescent sexual assault survivors. Potential difficulties of using PEP in this population include uncertainties regarding exposure, high rates of psychiatric comorbidity, and low rates of return for follow-up care.

Increased expression of the natural killer cell inhibitory receptor CD85j/ILT2 on antigen-specific effector CD8 T cells and its impact on CD8 T-cell function.

We investigated whether inhibitory natural killer cell receptor (iNKR) expression contributes to impaired antigen-specific cytotoxicity and interferon-gamma (IFN-gamma) production by CD8 T cells during chronic infection. iNKR immunoglobulin-like transcript-2 (ILT2/CD85j) is expressed on 40-55% of cytomegalovirus (CMV)-, Epstein-Barr virus (EBV)- and human immunodeficiency virus (HIV)-specific CD8 T cells in both healthy and HIV-infected donors. Other iNKRs (CD158a, b1, e1/e2, k, CD94/NKG2A) are expressed on only a small minority of CD8 T cells and are not preferentially expressed on tetramer-staining virus-specific cells. In normal donors, ILT2 is expressed largely on perforin(+) CD27(-) effector cells. However, in HIV-infected donors, only a third of ILT2(+) cells are also perforin(+). In both normal and HIV-infected donors, ILT2(+) cells are prone to spontaneous apoptosis. Therefore, ILT2 is normally expressed during effector cytotoxic T-lymphocyte (CTL) differentiation, but can also be expressed when effector maturation is incomplete, as in HIV infection. The effect of ILT2 on CD8 cell function was assessed by preincubating effector cells with ILT2 antibody. While blocking ILT2 engagement has no appreciable effect on cytotoxicity, it increases antiviral IFN-gamma production by approximately threefold in both normal and HIV-infected donors. Thus, ILT2 expression, increased on antiviral CD8 cells in chronic infection, may interfere with protective CD8 T-cell function by suppressing IFN-gamma production.

Proliferation responses to HIVp24 during antiretroviral therapy do not reflect improved immune phenotype or function.

OBJECTIVE: To ascertain whether lymphoproliferation (LP) responses to HIVp24 in chronically infected patients treated with antiretroviral therapy (ART) predict an improved cytolytic T-cell phenotype or better in vivo immune function as measured by immunization responses. METHODS: HIV-infected patients who started ART during chronic infection and who achieved viral suppression (HIV-RNA < 400 copies/ml for > 12 months) were grouped by the presence of strong [stimulation index (SI) > 10; n = 21] or absent (SI < 3; n = 18) LP to HIV-core antigen. The two groups were compared for functional immune responses to vaccination with diphtheria-toxoid, tetanus-toxoid and keyhole-limpet-hemocyanin, frequency of circulating naive and memory CD4+ and CD8+ T lymphocytes, maturation phenotype and expression of cytolytic molecules on total and HIV-specific CD8+ T cells, and frequency of memory CD4+ T cells with intracellular HIV-mRNA. Group comparisons were analyzed by non-parametric Mann-Whitney tests. Proportions were estimated by Pearson's chi analysis. RESULTS: There were no differences between the groups in immune responses to vaccination or in the numbers or phenotype of circulating T cells. In a subgroup of HLA-A2+ or B8+ patients, HIV-reactive CD8+ T cells in both groups had similar expression of perforin, granzyme A and T-cell maturation markers (CD27, CD28, CCR7, CD62L). However, patients with SI > 10 in response to HIVp24 tended to more often have high levels of circulating CD4+ T cells with intracellular HIV-1 mRNA than did patients with SI < 3. CONCLUSION: Following long-standing suppression of viral replication on ART, the presence of HIV-1 specific T-helper proliferation responses does not correlate with improved indices of immune phenotype or function but may reflect relatively higher levels of HIV-expression.

Most antiviral CD8 T cells during chronic viral infection do not express high levels of perforin and are not directly cytotoxic.

Despite the frequency of HIV-specific CD8 T cells, most HIV-infected patients do not control viral replication without antiviral drugs. Although CD8 T cells are important in containing acute HIV and simian immunodeficiency virus (SIV) infection, CD8 T-cell functions are compromised in chronic infection. To investigate whether functional deficits are specific to HIV, the phenotypic and functional properties of HIV, Epstein-Barr virus (EBV), and cytomegalovirus (CMV)-specific CD8 T cells, labeled with HLA A2.1 or B8 tetramers, were compared in 35 HIV-infected and 9 healthy donors. Cytotoxic T lymphocytes express the cytolytic molecules perforin and granzymes, and are thought to be CD45RA(+)CD27(-). Although most HIV- specific cells are antigen experienced and express granzyme A (median, 85%), few express high levels of perforin (median, 10%) or CD45RA (median, 14%) or have down-modulated CD27 (median, 12%). Perforin expression by HIV-specific cells is not significantly different from that of EBV- or CMV-specific cells in the same donors or in healthy donors. EBV- and CMV-specific cells, like HIV-specific cells, are often not cytotoxic when tested directly ex vivo. HIV-specific T-cell expression of other phenotypic markers is similar to that of EBV- and CMV-specific CD8 T cells in healthy donors. However, CMV-specific cells (and, to a lesser extent, EBV-specific cells) in HIV-infected donors are more likely to be CD27(-), CD45RA(+), and GzmA(+). These results suggest that the chance to eradicate an infection by T-cell-mediated lysis may be undermined once an infection becomes chronic. Impaired antiviral cytotoxicity during chronic infection is not specific to HIV but likely represents the immune response to chronic antigenic exposure.