Sperm retrieval success and testicular histopathology in idiopathic nonobstructive azoospermia.

Prior studies have investigated sperm retrieval rates in men with nonobstructive azoospermia (NOA) secondary to specific etiologies, yet most cases of NOA are idiopathic. We compared sperm retrieval rates and testicular histopathology in idiopathic NOA (iNOA) and nonidiopathic NOA (niNOA). We performed a retrospective review of men with NOA who underwent microdissection testicular sperm extraction (microTESE) between 2000 and 2016. Men with no history of malignancy or cryptorchidism and negative genetic evaluation were considered idiopathic. Multivariable regression determined the association between idiopathic etiology and primary outcomes of sperm retrieval and active spermatogenesis on histopathology. Among 224 men, 86 (38.4%) were idiopathic, 75 (33.5%) were nonidiopathic, and 63 (28.1%) did not undergo genetic testing. Median age and serum testosterone were higher among iNOA or no testing versus niNOA. Median follicle-stimulating hormone (FSH) was lower among iNOA or no testing versus niNOA. A higher proportion of iNOA or no testing versus niNOA had a clinical varicocele. Sperm retrieval rates were similar between iNOA, niNOA, and no testing (41.8% vs 48.0% vs 55.6%, respectively; P = 0.255). Active spermatogenesis was seen in a higher proportion of iNOA or no testing versus niNOA (31.4% and 27.0% vs 16.0%, P = 0.073). On multivariaile analysis, iNOA was not associated with sperm retrieval or spermatogenesis (P = 0.430 and P = 0.078, respectively). Rates of sperm retrieval and spermatogenesis on testis pathology were similar in men with iNOA and niNOA. These data will be useful to clinicians in preoperative counseling for men with NOA and negative genetic evaluation.

Underutilization of primary medical care among men presenting for fertility evaluation.

OBJECTIVE: To determine the proportion of men presenting for fertility evaluation who reported having an established primary care physician (PCP). DESIGN: Retrospective, observational study. SETTING: Academic health center. PATIENTS: All men presenting for initial male factor infertility consultation with a single reproductive urologist between 2002 and 2018. INTERVENTIONS: Men were asked to provide the name of their PCP at the time of initial visit. MAIN OUTCOME MEASURES: Descriptive statistics characterized the proportion of men with a PCP at the time of evaluation and associations between PCP status and clinical characteristics. RESULTS: Among 4,127 men presenting for initial fertility consultation, 844 (20.5%) reported having an established PCP, 480 (11.6%) reported no PCP, and 2,803 (67.9%) did not have data available. Among 1,302 men who had a prior primary care visit within our healthcare system, 414 (31.8%) had been seen within 1 year before their fertility evaluation. Men with an established PCP were slightly older than those without a PCP, with higher body mass index, and lower systolic blood pressure. Hormonal profiles were similar across groups, but men with an established PCP had a significantly higher total motile sperm count than those without a PCP, median 53 (interquartile range, 11-109) versus 35 (interquartile range, 8-98). CONCLUSIONS: More than one third of men presenting for fertility evaluation did not have an established PCP. Reproductive urologists are uniquely positioned to facilitate the critical relationship between young men and PCPs, which should be a key component of the male fertility treatment paradigm.

The evolution of financial incentives in the U.S. health care system.

The U.S. health care system continues to evolve toward value-based payment, rewarding providers based upon outcomes per dollar spent. To date, payment innovation has largely targeted primary care, with little consideration for the role of surgical specialists. As such, there remains appropriate uncertainty surrounding the optimal role of the urologic oncologist in alternative payment models. This commentary summarizes the context of U.S. health care reform and offers insights into supply-side innovations including accountable care organizations and bundled payments. Additionally, and importantly, we discuss the implications of rising out-of-pocket health care expenditures giving rise to health care consumerism and the implications therein.