The '-ics' of male reproduction: genomics, epigenetics, proteomics, metabolomics, and microbiomics.

PURPOSE OF REVIEW: To review the most current findings, from the past 2 years, in various '-ics' fields in male infertility, with a specific focus on nonobstructive azoospermia, the most severe form, and varicocele, the most common correctable cause of male infertility. RECENT FINDINGS: Recent studies confirm previously identified causes and identify previously unknown genetic mutations as causes for nonobstructive azoospermia and varicocele. SUMMARY: Infertility is a common problem for couples with approximately half of cases attributable to male factor infertility. Although advances in assisted reproductive technology have permitted many more men with infertility to father biological children, the majority of infertile men continue to have unknown causes. The recent explosion of the '-ics' fields, including genomics, epigenetics, proteomics, metabolomics, and microbiomics, has shed light on previously unknown causes for various diseases. New information in these fields will not only shed light on the pathogenesis of these conditions but also may shift the paradigm in clinical testing that may allow clinicians to provide more precise counseling and prognostic information for men with infertility.

Algorithms for Predicting the Probability of Azoospermia from Follicle Stimulating Hormone: Design and Multi-Institutional External Validation.

PURPOSE: To predict the probability of azoospermia without a semen analysis in men presenting with infertility by developing an azoospermia prediction model. MATERIALS AND METHODS: Two predictive algorithms were generated, one with follicle stimulating hormone (FSH) as the only input and another logistic regression (LR) model with additional clinical inputs of age, luteinizing hormone, total testosterone, and bilateral testis volume. Men presenting between 01/2016 and 03/2020 with semen analyses, testicular ochiodemetry, and serum gonadotropin measurements collected within 120 days were included. An azoospermia prediction model was developed with multi-institutional two-fold external validation from tertiary urologic infertility clinics in Chicago, Miami, and Milan. RESULTS: Total 3,497 participants were included (n=Miami 946, Milan 1,955, Chicago 596). Incidence of azoospermia in Miami, Milan, and Chicago was 13.8%, 23.8%, and 32.0%, respectively. Predictive algorithms were generated with Miami data. On Milan external validation, the LR and quadratic FSH models both demonstrated good discrimination with areas under the receiver-operating-characteristic (ROC) curve (AUC) of 0.79 and 0.78, respectively. Data from Chicago performed with AUCs of 0.71 for the FSH only model and 0.72 for LR. Correlation between the quadratic FSH model and LR model was 0.95 with Milan and 0.92 with Chicago data. CONCLUSIONS: We present and validate algorithms to predict the probability of azoospermia. The ability to predict the probability of azoospermia without a semen analysis is useful when there are logistical hurdles in obtaining a semen analysis or for reevaluation prior to surgical sperm extraction.

Vasectomy: a guidelines-based approach to male surgical contraception.

Except for condom use, vasectomy is the only approved form of male contraception. The American Urological Association published guidelines on vasectomy in 2012, which clearly outlined patient counseling, vasectomy techniques to maximize successful occlusion, and postvasectomy care. However, there are certainly areas of further improvement to be addressed. Vasectomy is severely underutilized compared with tubal ligation for sterilization, likely due to lack of patient awareness. Although the majority of vasectomies are performed in the office with local anesthesia, some patients are still routinely prescribed narcotics for postprocedural pain, despite the well-described opioid pandemic. Finally, although patients are counseled on the necessity of a postvasectomy semen analysis to confirm sterility prior to the discontinuation of alternative contraceptives, more than 50% of men do not complete this test. Therefore, alternative strategies must be pursued to improve patient compliance.

Diagnostic Properties of Total and Free Prostate-Specific Antigen to Predict Overall and Clinically Significant Prostate Cancer Among Men With Low Testosterone and Prior Negative Biopsy.

OBJECTIVE: To evaluate whether total serum PSA, free-PSA ratio and PSA density have similar diagnostic properties for detecting prostate cancer (PCa) and clinically-significant (cs) PCa in men with normal testosterone compared to men with low testosterone with a prior negative biopsy. METHODS: We conducted a retrospective analysis of 3295 men undergoing a 2-year prostate biopsy following a negative prestudy biopsy in the placebo arm of the Reduction by Dutasteride of PCa Events (REDUCE) study. Men were divided in 2 groups based on testosterone level < or ≥300 ng/dL. Diagnostic properties of total serum PSA, free-PSA ratio, and PSA density to predict PCa and csPCa, defined as Gleason score ≥7, were determined for several thresholds and plotted as receiver operator characteristic curves. RESULTS: A total of 603 men (18.3%) had low testosterone. The prevalence of PCa and csPCa was 92 (15.3%) and 27 (4.5%), respectively, for low testosterone men compared to 458 (17.0%) and 138 (5.1%), correspondingly, for normal testosterone men. Total PSA, free-PSA ratio and PSA density showed similar sensitivity, specificity, and accuracy to predict PCa and csPCa among low testosterone men compared to normal testosterone men. CONCLUSION: Among subjects in a clinical trial with a prior negative biopsy, total PSA, free-PSA ratio and PSA density have comparable diagnostic characteristics for PCa screening in low and normal testosterone men.

Proposed Key Characteristics of Male Reproductive Toxicants as an Approach for Organizing and Evaluating Mechanistic Evidence in Human Health Hazard Assessments.

BACKGROUND: Assessing chemicals for their potential to cause male reproductive toxicity involves the evaluation of evidence obtained from experimental, epidemiological, and mechanistic studies. Although mechanistic evidence plays an important role in hazard identification and evidence integration, the process of identifying, screening and analyzing mechanistic studies and outcomes is a challenging exercise due to the diversity of research models and methods and the variety of known and proposed pathways for chemical-induced toxicity. Ten key characteristics of carcinogens provide a valuable tool for organizing and assessing chemical-specific data by potential mechanisms for cancer-causing agents. However, such an approach has not yet been developed for noncancer adverse outcomes. OBJECTIVES: The objective in this study was to identify a set of key characteristics that are frequently exhibited by exogenous agents that cause male reproductive toxicity and that could be applied for identifying, organizing, and summarizing mechanistic evidence related to this outcome. DISCUSSION: The identification of eight key characteristics of male reproductive toxicants was based on a survey of known male reproductive toxicants and established mechanisms and pathways of toxicity. The eight key characteristics can provide a basis for the systematic, transparent, and objective organization of mechanistic evidence relevant to chemical-induced effects on the male reproductive system. https://doi.org/10.1289/EHP5045.

Microsurgical varicocele ligation: surgical methodology and associated outcomes.

The impact of clinical varicoceles on semen parameters and male infertility has long been established. In the era of assisted reproduction, clinical discussion has questioned the role of varicocelectomy, offering the potential to bypass, rather than treat, varicocele-associated male infertility. However, current literature supports improved semen parameters and reproductive outcomes following repair. This article presents the stepwise operative approaches to microsurgical varicocelectomy and discusses the recent publications on outcomes.

The epidemiology and etiology of azoospermia.

The misconception that infertility is typically associated with the female is commonly faced in the management of infertile men. It is uncommon for a patient to present for an infertility evaluation with an abnormal semen analysis report before an extensive female partner workup has been performed. Additionally, a man is usually considered fertile based only on seminal parameters without a physical exam. This behavior may lead to a delay in both the exact diagnosis and in possible specific infertility treatment. Moreover, male factor infertility can result from an underlying medical condition that is often treatable but could possibly be life-threatening. The responsibility of male factor in couple's infertility has been exponentially rising in recent years due to a comprehensive evaluation of reproductive male function and improved diagnostic tools. Despite this improvement in diagnosis, azoospermia is always the most challenging topic associated with infertility treatment. Several conditions that interfere with spermatogenesis and reduce sperm production and quality can lead to azoospermia. Azoospermia may also occur because of a reproductive tract obstruction. Optimal management of patients with azoospermia requires a full understanding of the disease etiology. This review will discuss in detail the epidemiology and etiology of azoospermia. A thorough literature survey was performed using the Medline, EMBASE, BIOSIS, and Cochrane databases. We restricted the survey to clinical publications that were relevant to male infertility and azoospermia. Many of the recommendations included are not based on controlled studies.

The epidemiology and etiology of azoospermia

The misconception that infertility is typically associated with the female is commonly faced in the management of infertile men. It is uncommon for a patient to present for an infertility evaluation with an abnormal semen analysis report before an extensive female partner workup has been performed. Additionally, a man is usually considered fertile based only on seminal parameters without a physical exam. This behavior may lead to a delay in both the exact diagnosis and in possible specific infertility treatment. Moreover, male factor infertility can result from an underlying medical condition that is often treatable but could possibly be life-threatening. The responsibility of male factor in couple's infertility has been exponentially rising in recent years due to a comprehensive evaluation of reproductive male function and improved diagnostic tools. Despite this improvement in diagnosis, azoospermia is always the most challenging topic associated with infertility treatment. Several conditions that interfere with spermatogenesis and reduce sperm production and quality can lead to azoospermia. Azoospermia may also occur because of a reproductive tract obstruction. Optimal management of patients with azoospermia requires a full understanding of the disease etiology. This review will discuss in detail the epidemiology and etiology of azoospermia. A thorough literature survey was performed using the Medline, EMBASE, BIOSIS, and Cochrane databases. We restricted the survey to clinical publications that were relevant to male infertility and azoospermia. Many of the recommendations included are not based on controlled studies.

Testicular adrenal rest tumor in infertile man with congenital adrenal hyperplasia: case report and literature review.

CONTEXT: Synthesis of cortisol and aldosterone is impaired in patients with congenital adrenal hyperplasia (CAH) because of 21-hydroxylase deficiency. Men with CAH have low fertility rates compared with the normal population, and this is related to testicular adrenal rest tumors. Findings of azoospermia in combination with a testicular tumor on ultrasound are likely to have a mechanical cause, especially when in the testicular mediastinum. The preferred treatment method consists of intensive corticoid therapy. However, when the tumor is unresponsive to steroid therapy, surgical treatment should be considered. CASE REPORT: We present the case of a male patient with CAH due to 21-hydroxylase deficiency who presented a testicular tumor and azoospermia. Treatment with low daily corticoid doses had previously been started by an endocrinologist, but after 12 months, no significant change in sperm count was found. Although the adrenocorticotrophic hormone and 17-hydroxyprogesterone levels returned to normal values, the follicle-stimulating hormone (FSH), luteinizing hormone and testosterone levels remained unchanged. Ultrasound examination confirmed that the testicles were small and heterogenous bilaterally, and revealed a mosaic area at the projection of the testis network bilaterally. Magnetic resonance imaging confirmed the finding. Testicular biopsy revealed the presence of preserved spermatogenesis and spermiogenesis in 20% of the seminiferous tubules in the right testicle. The patient underwent testis-sparing tumor resection. After 12 months of follow-up, there was no tumor recurrence but the patient still presented azoospermia and joined an intracytoplasmic sperm injection program.

Sclerotherapy of hydroceles and spermatoceles with alcohol: results and effects on the semen analysis.

PURPOSE: To evaluate the success rates of sclerotherapy of the tunica vaginalis with alcohol for the treatment of hydroceles and/or spermatoceles, as well as, evaluation of pain, formation of hematomas, infection and its effects in spermatogenesis. MATERIALS AND METHODS: A total of 69 patients, with offsprings and diagnosis of hydrocele and/or spermatocele, were treated during the period from April 2003 to June 2007. Semen analysis was obtained from patients who were able to provide us with samples. The sclerotherapy with alcohol at 99.5% was undertaken as outpatient procedure. RESULTS: The average volume drained pre-sclerotherapy was 279.82 mL (27 to 1145). The median follow-up was 43 months (9 to 80). A total of 114 procedures were performed on 84 units, with an average of 1.35 procedures/unit and an overall success rate of 97.62%. Of the 69 patients, 7 (10.14%) reported minor pain immediately after the procedure, 3 (4.35%) moderate pain and 2 (2.89%) intense pain. Post-Sclerotherapy spermograms revealed reduction of the parameters regarding: concentration, motility and morphology up to 6 months post procedure, with return to normal parameters 12th months after procedure. CONCLUSIONS: Sclerotherapy of hydroceles and spermatoceles with 99.5% alcohol is an efficient procedure that can be performed without difficulties, cost-effectiveness, with few side effects and which may be performed in patients who wish fertility.

Sclerotherapy of hydroceles and spermatoceles with alcohol: results and effects on the semen analysis

PURPOSE: To evaluate the success rates of sclerotherapy of the tunica vaginalis with alcohol for the treatment of hydroceles and/or spermatoceles, as well as, evaluation of pain, formation of hematomas, infection and its effects in spermatogenesis . MATERIALS AND METHODS: A total of 69 patients, with offsprings and diagnosis of hydrocele and/or spermatocele, were treated during the period from April 2003 to June 2007. Semen analysis was obtained from patients who were able to provide us with samples. The sclerotherapy with alcohol at 99.5 percent was undertaken as outpatient procedure. RESULTS: The average volume drained pre-sclerotherapy was 279.82 mL (27 to 1145). The median follow-up was 43 months (9 to 80). A total of 114 procedures were performed on 84 units, with an average of 1.35 procedures / unit and an overall success rate of 97.62 percent. Of the 69 patients, 7 (10.14 percent) reported minor pain immediately after the procedure, 3 (4.35 percent) moderate pain and 2 (2.89 percent) intense pain. Post-Sclerotherapy spermograms revealed reduction of the parameters regarding: concentration, motility and morphology up to 6 months post procedure , with return to normal parameters 12th months after procedure. CONCLUSIONS: Sclerotherapy of hydroceles and spermatoceles with 99.5 percent alcohol is an efficient procedure that can be perormed without difficulties, cost-effectiveness, with few side effects and which may be performed in patients who wish fertility.

Testicular adrenal rest tumor in infertile man with congenital adrenal hyperplasia: case report and literature review / Tumor testicular de remanescente adrenal em homem infértil com hiperplasia adrenal congênita: relato de caso e revisão de literatura

CONTEXT: Synthesis of cortisol and aldosterone is impaired in patients with congenital adrenal hyperplasia (CAH) because of 21-hydroxylase deficiency. Men with CAH have low fertility rates compared with the normal population, and this is related to testicular adrenal rest tumors. Findings of azoospermia in combination with a testicular tumor on ultrasound are likely to have a mechanical cause, especially when in the testicular mediastinum. The preferred treatment method consists of intensive corticoid therapy. However, when the tumor is unresponsive to steroid therapy, surgical treatment should be considered. CASE REPORT: We present the case of a male patient with CAH due to 21-hydroxylase deficiency who presented a testicular tumor and azoospermia. Treatment with low daily corticoid doses had previously been started by an endocrinologist, but after 12 months, no significant change in sperm count was found. Although the adrenocorticotrophic hormone and 17-hydroxyprogesterone levels returned to normal values, the follicle-stimulating hormone (FSH), luteinizing hormone and testosterone levels remained unchanged. Ultrasound examination confirmed that the testicles were small and heterogenous bilaterally, and revealed a mosaic area at the projection of the testis network bilaterally. Magnetic resonance imaging confirmed the finding. Testicular biopsy revealed the presence of preserved spermatogenesis and spermiogenesis in 20 percent of the seminiferous tubules in the right testicle. The patient underwent testis-sparing tumor resection. After 12 months of follow-up, there was no tumor recurrence but the patient still presented azoospermia and joined an intracytoplasmic sperm injection program.

CONTEXTO: Pacientes com hiperplasia adrenal congênita (HAC) por deficiência da 21-hidroxilase podem ter a síntese de cortisol e de aldosterona prejudicada. Homens com HAC têm baixas taxas de fertilidade em comparação com a população normal, e isso está relacionado a tumores testiculares de remanescente adrenal. A associação de azoospermia e tumor testicular sugere uma causa mecânica, principalmente quando o tumor é encontrado no mediastino testicular. O método preferencial de tratamento consiste na corticoterapia intensa. No entanto, quando o tumor não é responsivo à terapia com esteroides, o tratamento cirúrgico deve ser considerado. RELATO DE CASO: Apresentamos o caso de um paciente do sexo masculino com HAC por deficiência da 21-hidroxilase, portador de tumor testicular e azoospermia. Em consulta prévia com endocrinologista, o paciente começou tratamento com baixas doses diárias de corticoide, porém, após 12 meses de tratamento, não houve mudança significativa no espermograma. Embora os níveis de hormônio adrenocortitrófico e 17-hidroxiprogesterona tenham se normalizado, os níveis séricos de hormônio folículo-estimulante, hormônio luteinizante e testosterona não se alteraram. Exame ultrassonográfico confirmou testículos bilateralmente diminuídos e heterogêneos, além de área em mosaico na projeção da rede testis bilateralmente. Ressonância nuclear magnética confirmou o achado. Biópsia testicular revelou espermatogênese e espermiogênese preservadas em 20 por cento dos túbulos seminíferos no testículo direito. O paciente foi submetido a cirurgia poupadora testicular, com ressecção tumoral. Após 12 meses de acompanhamento, não houve recorrência tumoral, mas o paciente ainda apresentava azoospermia, sendo integrado no programa de injeção intracitoplasmática de espermatozoides.

The systematic use of intraoperative vascular Doppler ultrasound during microsurgical subinguinal varicocelectomy improves precise identification and preservation of testicular blood supply.

OBJECTIVE: To evaluate the impact of systematic use of intraoperative Doppler ultrasound during microsurgical subinguinal varicocele repair. DESIGN: Prospective clinical study. SETTING: Andrology laboratory and male infertility section of the urology department of a tertiary care hospital. PATIENT(S): Two hundred and thirteen men with clinical varicocele. INTERVENTION(S): Subinguinal microsurgical varicocele ligation using an intraoperative vascular Doppler flow detector. MAIN OUTCOME MEASURE(S): Number of veins ligated, lymphatic spared, arteries identified or accidentally ligated. RESULT(S): A statistically significant greater number of arteries were identified and preserved when intraoperative vascular Doppler was used. In addition, the average number of internal spermatic veins ligated was statistically significantly greater in the same group. Accidental artery ligation occurred in two cases (1.1%) in which the Doppler was not applied. There was no statistically significant difference in number of lymphatics spared between groups. CONCLUSION(S): Our findings showed that concomitant use of intraoperative vascular Doppler during microsurgical varicocelectomy allows more arterial branches to be preserved, and more internal spermatic veins are likely to be ligated. This device should be considered an attractive tool to improve surgical outcomes and safety.

Use of subinguinal incision for microsurgical testicular biopsy during varicocelectomy in men with nonobstructive azoospermia.

OBJECTIVE: To describe a subinguinal technique of microsurgical testicular biopsy performed during subinguinal varicocelectomy in men with nonobstructive azoospermia. DESIGN: Prospective clinical study. SETTING: Andrology laboratory at tertiary care hospital. Male infertility section, department of urology, at tertiary care hospital. PATIENT(S): Ten azoospermic men with clinical varicocele. INTERVENTION(S): Subinguinal microsurgical testicular biopsy and microsurgical varicocele repair. MAIN OUTCOME MEASURE(S): Safety, feasibility, and effectiveness of subinguinal testicular biopsy during varicocele repair. RESULT(S): All testes were easily delivered through the subinguinal incision, and testicular biopsies were successfully performed under microscopic view. After a median follow-up of 9 months, none of the patients had any discomfort, pain, or presented with testicular atrophy. No intraoperative or postoperative complications were observed. There was no incidence of wound infection or scrotal hematoma. CONCLUSION(S): The subinguinal approach is a safe and effective option for testicular biopsy during varicocele repair in men with nonobstructive azoospermia. This technique may be an attractive alternative to traditional biopsy because it obviates scrotal violation.

Age-related increase of reactive oxygen species in neat semen in healthy fertile men.

OBJECTIVES: The effects of advancing paternal age on the male reproductive system are well known, but its effects on fecundity remain controversial. Although oxidative stress is associated with poor semen quality and function, a relationship with advancing male age has not been established. The objective of this study was to analyze the relationship between male age and seminal reactive oxygen species (ROS) levels in men presenting for voluntary sterilization. METHODS: We prospectively evaluated 98 fertile men who were candidates for vasectomy. These were divided into 2 age groups: less than 40 years (n = 78) and 40 or more years (n = 20). We used 46 infertile patients as positive controls. Standard semen analysis, seminal leukocyte count and ROS levels were measured in all samples. Fertile men with leukocytospermia were excluded. RESULTS: The mean age of the men was 35.1 +/- 5.6 years. Men 40 years and older had significantly higher ROS levels compared with younger men (P <0.001). We observed a positive correlation between seminal ROS levels and age (r = 0.20; P = 0.040). In addition, ROS was negatively correlated with sperm concentration (r = -0.48; P <0.001) and motility (r = -0.21; P = 0.030). CONCLUSIONS: Reactive oxygen species levels are significant higher in seminal ejaculates of healthy fertile men older than 40 years. ROS levels in whole ejaculate are significantly correlated to age among fertile men. Because ROS are clearly implicated in the pathogenesis of male infertility, these data suggest that delayed fatherhood may reduce the chances of pregnancy as men become progressively less fertile with age.

Impact of clinical varicocele and testis size on seminal reactive oxygen species levels in a fertile population: a prospective controlled study.

OBJECTIVE: To investigate: 1) the impact of clinical varicocele on reactive oxygen species (ROS) levels in neat and washed semen in a proven fertile population; and 2) the correlation between ROS levels, testicular volume, and varicocele grade in the same population of fertile men. DESIGN: Prospective controlled clinical study. SETTING: Andrology laboratory at tertiary-care hospital. PATIENT(S): One hundred fourteen healthy fertile men (81 normal fertile and 33 fertile with clinical varicocele) and 30 infertile patients (control subjects). INTERVENTION(S): Standard semen analysis and measurement of sperm ROS production. MAIN OUTCOME MEASURE(S): Seminal parameters, seminal ROS levels, seminal leukocyte levels, clinical varicocele, and testis size. RESULT(S): Thirty-three of the 114 (29%) fertile men had clinical varicocele (grade 1, n = 14; grade 2, n = 11; and grade 3, n = 8), and the remaining 81 (71%) had a normal physical examination. Levels of ROS and semen quality did not differ significantly between the fertile men with or without varicocele. No significant differences in ROS levels in neat and washed semen were observed compared with fertile men with grades 2 and 3 varicocele and with fertile men with varicocele grade 1. The ROS levels in neat and washed semen were not significantly correlated with varicocele grade in fertile men. No significant correlations between ROS levels and testis volume were observed between the fertile groups. CONCLUSION(S): The presence of clinical varicocele in fertile men is not associated with higher seminal ROS levels or abnormal semen parameters. Levels of ROS are not correlated with varicocele grade or testis volume in the same population of fertile men.

Y chromosome genes and male infertility.

Normal spermatogenesis is a complex process that depends on many factors. Genetics plays a major role in many of these factors including providing a normal hormonal milieu, the development of the testis and ductal system, and control of the stepwise maturation of sperm in the testis. The Y chromosome plays a key role in testis determination and control of spermatogenesis. Understanding how these genes work together can elucidate of the exact cause of infertility in some patients once thought to have idiopathic infertility. It is not only important that patients understand the cause of their infertility. Using sperm from these men to attain pregnancies by assisted reproductive techniques will probably result in infertile male offspring. Additional consequences are currently unknown but are the topic of research investigations.