Best of AUA 2014: Infertility/Andrology


Tobias S. Köhler, MD, MPH, presents the take home messages on infertility/andrology from the AUA annual meeting in Orlando, FL.

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• A study showing a high rate of disagreement between physicians in varicocele grade classification speaks to the need for a more accurate method of evaluation to avoid unnecessary surgery.

• A study including 109 men highlighted intra-individual variation in serum testosterone levels; the testosterone level on repeat exam differed by >100 ng/dL in >20% of patients.

• Men seen in a cardiology clinic were sixfold more likely to have low testosterone compared to the general population.

• Obesity predicted response to transdermal testosterone in hypogonadal men; free and total testosterone levels normalized in 80% of non-obese men versus approximately 50% of obese patients.

• Studies of hypogonadal men receiving injectable testosterone showed no increased risk of prostate cancer, but improvements in voiding, erectile function, quality of life, body mass index, waist circumference, and other parameters of the metabolic syndrome were observed.

• In a study of 231 men treated with subcutaneous testosterone pellets, the 2-year polycythemia development rate was 33%; no predictive factor was identified, although the majority of affected patients were obese.

• Hypogonadal men treated with testosterone benefit with an improved response if they also begin to exercise, and their response to testosterone is maintained better when they continue to exercise after stopping testosterone.

• Risks to the offspring associated with older paternal age are low, and so there is no need to change genetic screening protocols for older fathers or to dissuade them from trying to conceive. Semen quality does not appear to be associated with risk of birth defects.

• The best time to evaluate and preserve fertility in oncology patients is prior to cancer treatment, but there are significant knowledge gaps on this issue among pediatric oncology providers.

• Half of nearly 200 men with newly diagnosed cancer presenting for fertility preservation consultation were hypogonadal.

• Klinefelter’s syndrome is being underdiagnosed; in a study including 1.1 million males, the prevalence of KS was just 1 in 28,200 rather than the expected 1 in 500.

• A study of 67 men with <1% abnormal strict morphology found that 31.3% of the men achieved a pregnancy without in vitro fertilization, suggesting that these men do not need to be immediately referred to IVF/intracytoplasmic sperm injection (ICSI).

• Aberrant expression of discoidin domain receptor 1 is associated with non-obstructive azoospermia (NOA), suggesting the first potential target to modulate gene expression for NOA.

• Patients who remain azoospermic despite varicocele repair still benefit from the operation if they proceed with sperm extraction.

• In a cohort of 445 infertile men with clinical varicocele and abnormal semen parameters by World Health Organization 1999 standards, 13% were considered normal by WHO 2010 standards. In this 13% group, postoperative sperm concentration was 19 mil/mL higher, indicating that a biologic problem cannot be treated solely based on numeric cut-points.

• Microdissection testicular sperm extraction in men with maturation arrest yielded a 56% success rate. Low follicle-stimulating hormone and normal testis size predicted the worst outcomes, a counterintuitive finding.

• Fertilization rates were higher using ejaculated sperm compared with testicular sperm, although the latter was associated with higher pregnancy rates.

• ICSI using organelle morphology examination did not aid in pregnancy outcomes with assisted reproductive techniques.UT

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