Controversy and Consensus on Indications for Sperm DNA Fragmentation Testing in Male Infertility: A Global Survey, Current Guidelines, and Expert Recommendations.

PURPOSE: Sperm DNA fragmentation (SDF) testing was recently added to the sixth edition of the World Health Organization laboratory manual for the examination and processing of human semen. Many conditions and risk factors have been associated with elevated SDF; therefore, it is important to identify the population of infertile men who might benefit from this test. The purpose of this study was to investigate global practices related to indications for SDF testing, compare the relevant professional society guideline recommendations, and provide expert recommendations. MATERIALS AND METHODS: Clinicians managing male infertility were invited to take part in a global online survey on SDF clinical practices. This was conducted following the CHERRIES checklist criteria. The responses were compared to professional society guideline recommendations related to SDF and the appropriate available evidence. Expert recommendations on indications for SDF testing were then formulated, and the Delphi method was used to reach consensus. RESULTS: The survey was completed by 436 experts from 55 countries. Almost 75% of respondents test for SDF in all or some men with unexplained or idiopathic infertility, 39% order it routinely in the work-up of recurrent pregnancy loss (RPL), and 62.2% investigate SDF in smokers. While 47% of reproductive urologists test SDF to support the decision for varicocele repair surgery when conventional semen parameters are normal, significantly fewer general urologists (23%; p=0.008) do the same. Nearly 70% would assess SDF before assisted reproductive technologies (ART), either always or for certain conditions. Recurrent ART failure is a common indication for SDF testing. Very few society recommendations were found regarding SDF testing. CONCLUSIONS: This article presents the largest global survey on the indications for SDF testing in infertile men, and demonstrates diverse practices. Furthermore, it highlights the paucity of professional society guideline recommendations. Expert recommendations are proposed to help guide clinicians.

The Effect of Renal Transplant on Hypogonadism and Erectile Dysfunction due to End-stage Renal Disease.

Hypogonadism is common in patients with chronic kidney disease especially for end-stage renal disease (ESRD), which is referred to as uremic hypogonadism. Men with ESRD are prone to reproductive and sexual disorders such as sexual desire loss, abnormalities in orgasm, sexual dysfunction, and erectile dysfunction (ED). The mechanism of this complex disorder is not well known. Considering the above, we decided to study the effect of renal transplantation on hypogonadism and sexual activity in patients with ESRD. This study was performed on 45 patients with ESRD undergoing renal transplantation. Patients were included into two groups of live donor (24) and cadaveric (21), according to the type of kidney donors. The International Index of Erectile Function-5 (IIEF5) questionnaire was filled out for evaluation of erectile and sexual status. Laboratory parameters were assessed before the renal transplant in a single and valid laboratory including blood urea nitrogen, creatinine, thyroid function tests, luteinizing hormone, follicle-stimulating hormone, testosterone, and prolactin. We refilled the ED questionnaire and checked the laboratory tests again three and six months after transplantation. The mean age of the patients was 51.7 ± 8.0. The mean blood testosterone level in the live group was 347.1 ± 64.9 before transplantation, which reached 413.1 ± 25.9 in six months after transplantation. The same variable for the cadaveric group was 306 ± 56.2 and 355.3 ± 56.9, respectively. The IIEF5 scores before and six months after transplantation were 17.2 ± 4.5 and 24.6 ± 3.3 respectively for the live group and 10.8 ± 2.4 and 13.9% ± 4.1% for the cadaveric one, all of which were statistically significant. Renal transplantation significantly improves the condition of hypogonadism and ED in patients with ESRD. This improvement is not related to the type of donation.

Successful cadaveric transplantation of a splitted crossed fused disc type ectopic kidney to two patients with end-stage renal disease.

Cadaveric donors with congenital renal anomalies are often refused because of technical difficulties. As the waiting periods for kidney transplants continue to increase, transplant centers need to consider them also as potential donors. This paper describes transplantation of a crossed fused disc type ectopic kidney to two patients with end-stage renal disease, after parenchymal transection. The transplants were successful with minimal complications, and the recipients had immediate graft function. It is now one year from transplantation, with excellent renal functions.

The effect of acupuncture on relieving pain after inguinal surgeries.

BACKGROUND: Postoperative pain is one of the most prevalent and bothersome issues found in the surgical department. Nowadays, there are various methods of acupuncture used for relieving pain without the complications found in some routine postoperative analgesics. These methods could be especially useful for high risk patients prone to complications from analgesics, such as transplantation recipients. The aim of this study was to evaluate the efficacy of electro-acupuncture on postoperative pain control after inguinal surgeries. METHODS: Ninety male patients, who were referred to our department with indications of inguinal surgery, were included in the study and randomly divided into two groups, such as acupuncture and control. We used electro-acupuncture for the acupuncture group and no actual acupuncture (but placed needle electrodes similar to the acupuncture group) for the control group. Postoperative pain was quantified by a blind observer in both groups using a visual analogue scale (VAS) standard score before being compared. RESULTS: Pain intensity and analgesic use were significantly higher in the control group (P < 0.05). In the acupuncture group, the VAS pain scores were significantly lower than the control group at 0.5, 1 and 2 hours post operation. When the opioid related side effects were compared for each group, the results showed that the number of subjects who experienced dizziness in the acupuncture group was significantly lower than the control group (P < 0.05). CONCLUSIONS: Acupuncture in patients, after inguinal surgery, can reduce the need of analgesics, which also directly reduces the complications that may occur when analgesics are used in relieving pain postoperatively.

Salvage repair of vesicovaginal fistula.

PURPOSE: To present the long-term results of failed vesicovaginal fistula repair using flap splitting techniques. MATERIALS AND METHODS: Nine women with a previous failed vesicovaginal fistula repair, aged 18 to 69 years, underwent salvage vaginal reconstruction for damaged urethra or bladder, at a five-year interval lasting from 2003 to 2007. Fistulas were repaired using an interposed pediculated vaginal wall flap. RESULTS: The repair was successful in all the patients, even in those with rectovesicovaginal fistula or a large vesicovaginal fistula with sphincter damage. CONCLUSION: Pediculated vaginal wall flap is an easily-prepared, well-vascularized tissue, which provides long-term favorable outcomes.