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1. Global Practice Patterns in the Evaluation of Non-Obstructive Azoospermia: Results of a World-Wide Survey and Expert Recommendations

Author

Rupin Shah, Amarnath Rambhatla, Widi Atmoko, Marlon Martinez, Imad Ziouziou, Priyank Kothari, Nicholas Tadros, Nguyen Ho Vinh Phuoc, Parviz Kavoussi, Ahmed Harraz, Gianmaria Salvio, Murat Gul, Taha Hamoda, Tuncay Toprak, Ponco Birowo, Edmund Ko, Mohamed Arafa, Ramy Abou Ghayda, Vilvapathy Senguttuvan Karthikeyan, Ramadan Saleh, Giorgio Ivan Russo, Germar-Michael Pinggera, Eric Chung, Missy Savira, Giovanni M. Colpi, Wael Zohdy, Edoardo Pescatori, Hyun Jun Park, Shinichiro Fukuhara, Akira Tsujimura, Cesar Rojas-Cruz, Angelo Marino, Siu King Mak, Edouard Amar, Wael Ibrahim, Puneet Sindhwani, Naif Alhathal, Gian Maria Busetto, Manaf Al Hashimi, Ahmed El-Sakka, Asci Ramazan, Fotios Dimitriadis, Massimiliano Timpano, Davor Jezek, Baris Altay, Daniel Suslik Zylbersztejn, Michael YC Wong, Du Geon Moon, Christine Wyns, Safar Gamidov, Hamed Akhavizadegan, Alessandro Franceschelli, Kaan Aydos, Vinh Nguyen Quang, Shedeed Ashour, Adel Al Dayel, Mohamed S. Al-Marhoon, Sava Micic, Saleh Binsaleh, Alayman Hussein, Haitham Elbardisi, Taymour Mostafa, Emad Taha, Jonathan Ramsay, Athanasios Zachariou, Islam Fathy Soliman Abdelrahman, Osvaldo Rajmil, Arif Kalkanli, Juan Manuel Corral Molina, Kadir Bocu, Gede Wirya Kusuma Duarsa, Gokhan Ceker, Ege Can Serefoglu, Fahmi Bahar, Nazim Gherabi, Shinnosuke Kuroda, Abderrazak Bouzouita, Ahmet Gudeloglu, Erman Ceyhan, Mohamed Saeed Mohamed Hasan, Muhammad Ujudud Musa, Ahmad Motawi, Cho Chak-Lam, Hisanori Taniguchi, Christopher Chee Kong Ho, Jesus Fernando Solorzano Vazquez, Shingai Mutambirwa, Nur Dokuzeylul Gungor, Marion Bendayan, Carlo Giulioni, Aykut Baser, Marco Falcone, Luca Boeri, Gideon Blecher, Alireza Kheradmand, Tamilselvi Sethupathy, Ricky Adriansjah, Nima Narimani, Charalampos Konstantinidis, Tuan Thanh Nguyen, Andrian Japari, Parisa Dolati, Keerti Singh, Cevahir Ozer, Selcuk Sarikaya, Nadia Sheibak, Ndagijimana Jean Bosco, Mehmet Serkan Özkent, Sang Thanh Le, Ioannis Sokolakis, Darren Katz, Ryan Smith, Manh Nguyen Truong, Tan V. Le, Zhongwei Huang, Muslim Dogan Deger, Umut Arslan, Gokhan Calik, Giorgio Franco, Ayman Rashed, Oguzhan Kahraman, Sotiris Andreadakis, Rosadi Putra, Giancarlo Balercia, Kareim Khalafalla, Rossella Cannarella, Anh Đặng Tuấn, Amr El Meliegy, Birute Zilaitiene, Marlene Lizbeth Zamora Ramirez, Filippo Giacone, Aldo E. Calogero, Konstantinos Makarounis, Sunil Jindal, Bac Nguyen Hoai, Ravi Banthia, Marcelo Rodriguez Peña, Dharani Moorthy, Aram Adamyan, Deniz Kulaksiz, Hussein Kandil, Nikolaos Sofikitis, Ciro Salzano, Andreas Jungwirth, Surendra Reddy Banka, Tiago Cesar Mierzwa, Tahsin Turunç, Divyanu Jain, Armen Avoyan, Pietro Salacone, Ateş Kadıoğlu, Chirag Gupta, Haocheng Lin, Iman Shamohammadi, Nasser Mogharabian, Trenton Barrett, Yavuz Onur Danacıoğlu, Andrea Crafa, Salima Daoud, Vineet Malhotra, Abdulmalik Almardawi, Osama Mohamed Selim, Mohamad Moussa, Saeid Haghdani, Mesut Berkan Duran, Yannic Kunz, Mirko Preto, Elena Eugeni, Thang Nguyen, Ahmed Rashad Elshahid, Seso Sulijaya Suyono, Dyandra Parikesit, Essam Nada, Eduardo Gutiérrez Orozco, Florence Boitrelle, Nguyen Thi Minh Trang, Mounir Jamali, Raju Nair, Mikhail Ruzaev, Franco Gadda, Charalampos Thomas, Raphael Henrique Ferreira, Umit Gul, Serena Maruccia, Ajay Kanbur, Ella Kinzikeeva, Saad Abumelha, Nguyen Quang, Raghavender Kosgi, Fatih Gokalp, Mohammad Ayodhia Soebadi, Gustavo Marquesine Paul, Hesamoddin Sajadi, Deepak Gupte, Rafael F. Ambar, Emrullah Sogutdelen, Karun Singla, Ari Basurkano, Shannon Hee Kyung Kim, Mohammad Ali Sadighi Gilani, Koichi Nagao, Sakti Ronggowardhana Brodjonegoro, Andri Rezano, Mohamed Elkhouly, Rossella Mazzilli, Hasan M. A. Farsi, Hung Nguyen Ba, Hamed Alali, Dimitrios Kafetzis, Tran Quang Tien Long, Sami Alsaid, Hoang Bao Ngoc Cuong, Knigavko Oleksandr, Akhmad Mustafa, Herik Acosta, Hrishikesh Pai, Bahadır Şahin, Eko Arianto, Colin Teo, Sanjay Prakash Jayaprakash, Rinaldo Indra Rachman, Mustafa Gurkan Yenice, Omar Sefrioui, Smit Paghdar, Shivam Priyadarshi, Marko Tanic, Noor Kareem Alfatlawy, Fikri Rizaldi, Ranjit B. Vishwakarma, George Kanakis, Dinesh Thomas Cherian, Joe Lee, Raisa Galstyan, Hakan Keskin, Jana Wurzacher, Doddy Hami Seno, Bambang S. Noegroho, Ria Margiana, Qaisar Javed, Fabrizio Castiglioni, Raman Tanwar, Ana Puigvert, Coşkun Kaya, Medianto Purnomo, Chadi Yazbeck, Azwar Amir, Edson Borges, Marina Bellavia, Isaac Ardianson Deswanto, Vinod K V, Giovanni Liguori, Dang Hoang Minh, Kashif Siddiqi, Fulvio Colombo, Armand Zini, Niket Patel, Selahittin Çayan, Ula Al-Kawaz, Maged Ragab, Guadalupe Hernández Hebrard, Ivan Hoffmann, Ozan Efesoy, Barış Saylam, and Ashok Agarwal

Subjects
azoospermia, diagnosis, guideline, infertility, male, surveys and questionnaires, Medicine, Diseases of the genitourinary system. Urology, RC870-923
Abstract

Purpose: Non-obstructive azoospermia (NOA) represents the persistent absence of sperm in ejaculate without obstruction, stemming from diverse disease processes. This survey explores global practices in NOA diagnosis, comparing them with guidelines and offering expert recommendations. Materials and Methods:Materials and Methods: A 56-item questionnaire survey on NOA diagnosis and management was conducted globally from July to September 2022. This paper focuses on part 1, evaluating NOA diagnosis. Data from 367 participants across 49 coun-tries were analyzed descriptively, with a Delphi process used for expert recommendations. Results:Results: Of 336 eligible responses, most participants were experienced attending physicians (70.93%). To diagnose azoosper-mia definitively, 81.7% requested two semen samples. Commonly ordered hormone tests included serum follicle-stimulating hormone (FSH) (97.0%), total testosterone (92.9%), and luteinizing hormone (86.9%). Genetic testing was requested by 66.6%, with karyotype analysis (86.2%) and Y chromosome microdeletions (88.3%) prevalent. Diagnostic testicular biopsy, distinguishing obstructive azoospermia (OA) from NOA, was not performed by 45.1%, while 34.6% did it selectively. Differ-entiation relied on physical examination (76.1%), serum hormone profiles (69.6%), and semen tests (68.1%). Expectations of finding sperm surgically were higher in men with normal FSH, larger testes, and a history of sperm in ejaculate. Conclusions:Conclusions: This expert survey, encompassing 367 participants from 49 countries, unveils congruence with recommended guidelines in NOA diagnosis. However, noteworthy disparities in practices suggest a need for evidence-based, international consensus guidelines to standardize NOA evaluation, addressing existing gaps in professional recommendations.

Published
2024
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2. Does Varicocele Repair Improve Conventional Semen Parameters? A Meta-Analytic Study of Before-After Data

Author

Rossella Cannarella, Rupin Shah, Taha Abo-Almagd Abdel-Meguid Hamoda, Florence Boitrelle, Ramadan Saleh, Murat Gul, Amarnath Rambhatla, Parviz Kavoussi, Tuncay Toprak, Ahmed M. Harraz, Edmund Ko, Gökhan Çeker, Damayanthi Durairajanayagam, Noora Alkahidi, Shinnosuke Kuroda, Andrea Crafa, Ralf Henkel, Gianmaria Salvio, Berk Hazir, Mahsa Darbandi, Marion Bendayan, Sara Darbandi, Marco Falcone, Raghavender Kosgi, Raneen Sawaid Kaiyal, Keshab Karna, Nguyen Ho Vinh Phuoc, Ponco Birowo, Giovanni M. Colpi, Jean de la Rosette, Germar-Michael Pinggera, Quang Nguyen, Armand Zini, Wael Zohdy, Rajender Singh, Pallavi Saini, Sidney Glina, Haocheng Lin, Taymour Mostafa, Cesar Rojas-Cruz, Mohamed Arafa, Aldo E. Calogero, Fotios Dimitriadis, Priyank Kothari, Vilvapathy Senguttuvan Karthikeyan, Keisuke Okada, Koji Chiba, Ates Kadıoglu, Baris Altay, Tahsin Turunc, Birute Zilaitiene, Fatih Gokalp, Aram Adamyan, Darren Katz, Eric Chung, Tiago Cesar Mierzwa, Daniel Suslik Zylbersztejn, Gustavo Marquesine Paul, Nikolaos Sofikitis, Ioannis Sokolakis, Vineet Malhotra, Sakti Ronggowardhana Brodjonegoro, Ricky Adriansjah, Akira Tsujimura, Toshiyasu Amano, Giancarlo Balercia, Imad Ziouziou, Isaac Ardianson Deswanto, Marlon Martinez, Hyun Jun Park, Mustafa Emre Bakırcıoglu, Erman Ceyhan, Kaan Aydos, Jonathan Ramsay, Suks Minhas, Manaf Al Hashimi, Ramy Abou Ghayda, Nicholas Tadros, Puneet Sindhwani, Christopher C.K. Ho, Rinaldo Indra Rachman, Marcelo Rodriguez Pena, Ahmad Motawi, Arun Karthik Ponnusamy, Satish Dipankar, Azwar Amir, Saleh Binsaleh, Ege Can Serefoglu, Ravi Banthia, Kareim Khalafalla, Ari Basukarno, Nguyen Hoai Bac, Karun Singla, Rafael F. Ambar, Konstantinos Makarounis, Shivam Priyadarshi, Gede Wirya Kusuma Duarsa, Widi Atmoko, Sunil Jindal, Eko Arianto, Hamed Akhavizadegan, Haitham El Bardisi, Ohad Shoshany, Gian Maria Busetto, Mohamad Moussa, Mounir Jamali, Mohamed S. Al-Marhoon, Mikhail Ruzaev, Hasan M. A. Farsi, Shingai Mutambirwa, Dong Sup Lee, Deniz Kulaksiz, Yu-Sheng Cheng, Abderrazak Bouzouita, Selcuk Sarikaya, Hussein Kandil, Georgios Tsampoukas, Ala’a Farkouh, Kasonde Bowa, Missy Savira, Nasser Mogharabian, Tan V. Le, Maruto Harjanggi, Dang Tuan Anh, Tran Quang Tien Long, Mohammad Ayodhia Soebadi, Lukman Hakim, Marko Tanic, Umut Cagin Ari, Firuza R. Parikh, Gokhan Calik, Vinod KV, Gyem Dorji, Andri Rezano, Osvaldo Rajmil, Dung Mai Ba Tien, Yiming Yuan, Juan Francisco Lizarraga-Salas, Balantine Eze, Kay Seong Ngoo, Joe Lee, Umut Arslan, and Ashok Agarwal

Subjects
controlled before-after studies, infertility, male, meta-analysis, varicocele, Medicine, Diseases of the genitourinary system. Urology, RC870-923
Abstract

Purpose: The purpose of this meta-analysis is to study the impact of varicocele repair in the largest cohort of infertile males with clinical varicocele by including all available studies, with no language restrictions, comparing intra-person conventional semen parameters before and after the repair of varicoceles. Materials and Methods: The meta-analysis was performed according to PRISMA-P and MOOSE guidelines. A systematic search was performed in Scopus, PubMed, Cochrane, and Embase databases. Eligible studies were selected according to the PICOS model (Population: infertile male patients with clinical varicocele; Intervention: varicocele repair; Comparison: intraperson before-after varicocele repair; Outcome: conventional semen parameters; Study type: randomized controlled trials [RCTs], observational and case-control studies). Results: Out of 1,632 screened abstracts, 351 articles (23 RCTs, 292 observational, and 36 case-control studies) were included in the quantitative analysis. The before-and-after analysis showed significant improvements in all semen parameters after varicocele repair (except sperm vitality); semen volume: standardized mean difference (SMD) 0.203, 95% CI: 0.129–0.278; p

Published
2024
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3. Technical Aspects and Clinical Limitations of Sperm DNA Fragmentation Testing in Male Infertility: A Global Survey, Current Guidelines, and Expert Recommendations

Author

Ashok Agarwal, Ala’a Farkouh, Ramadan Saleh, Taha Abo-Almagd Abdel-Meguid Hamoda, Gianmaria Salvio, Florence Boitrelle, Ahmed M. Harraz, Ramy Abou Ghayda, Parviz Kavoussi, Murat Gül, Tuncay Toprak, Giorgio Ivan Russo, Damayanthi Durairajanayagam, Amarnath Rambhatla, Ponco Birowo, Rossella Cannarella, Nguyen Ho Vinh Phuoc, Armand Zini, Mohamed Arafa, Christine Wyns, Kelton Tremellen, Selçuk Sarıkaya, Sheena Lewis, Donald P. Evenson, Edmund Ko, Aldo E. Calogero, Fahmi Bahar, Marlon Martínez, Rafael F. Ambar, Giovanni M. Colpi, Mustafa Emre Bakircioglu, Ralf Henkel, Hussein Kandil, Ege Can Serefoglu, Abdullah Alfakhri, Akira Tsujimura, Alireza Kheradmand, Angelo Marino, Aram Adamyan, Birute Zilaitiene, Cevahir Ozer, Edoardo Pescatori, Paraskevi Vogiatzi, Gian Maria Busetto, Giancarlo Balercia, Haitham Elbardisi, Hamed Akhavizadegan, Hesamoddin Sajadi, Hisanori Taniguchi, Hyun Jun Park, Israel Maldonado Rosas, Mohamed Al-Marhoon, Mohammad Ali Sadighi Gilani, Naif Alhathal, Nguyen Quang, Germar-Michael Pinggera, Priyank Kothari, Sava Micic, Sheryl Homa, Tran Quang Tien Long, Wael Zohdy, Widi Atmoko, Wael Ibrahim, Marjan Sabbaghian, Saad Mohammed Abumelha, Eric Chung, Muhammet Rasit Ugur, Mehmet Serkan Ozkent, Osama Selim, Mahsa Darbandi, Shinichiro Fukuhara, Mounir Jamali, Jean de la Rosette, Shinnosuke Kuroda, Ryan P. Smith, Aykut Baser, Arif Kalkanli, Nicholas N. Tadros, Kaan Aydos, Tiago Cesar Mierzwa, Kareim Khalafalla, Vineet Malhotra, Mohamad Moussa, Federica Finocchi, Rinaldo Indra Rachman, Carlo Giulioni, Tomer Avidor-Reiss, Oguzhan Kahraman, Gökhan Çeker, Cătălina Zenoaga-Barbăroșie, Trenton L. Barrett, Mehmet Yilmaz, Ates Kadioglu, Sunil Jindal, Huda Omran, Kadir Bocu, Vilvapathy Senguttuvan Karthikeyan, Giorgio Franco, Jesús Fernando Solorzano, Ranjit B. Vishwakarma, Eko Arianto, Nicolas Garrido, Divyanu Jain, Nazim Gherabi, Ioannis Sokolakis, Ayad Palani, Gokhan Calik, Deniz Kulaksiz, Vaida Simanaviciene, Mara Simopoulou, Nur Dokuzeylül Güngör, Gideon Blecher, Marco Falcone, Davor Jezek, Mirko Preto, Edouard Amar, Tan V. Le, Sun Tae Ahn, Andri Rezano, Keerti Singh, Lucia Rocco, Missy Savira, Osvaldo Rajmil, Sara Darbandi, Emrullah Sogutdelen, Luca Boeri, Guadalupe Hernández, Lukman Hakim, Yoshiharu Morimoto, Andrian Japari, Nikolaos Sofikitis, Baris Altay, Asli Metin Mahmutoglu, Manaf Al Hashimi, Imad Ziouziou, Christina Anagnostopoulou, Haocheng Lin, and Rupin Shah

Subjects
delphi method, diagnostic test, dna fragmentation, infertility, male, survey, Medicine, Diseases of the genitourinary system. Urology, RC870-923
Abstract

Purpose: Sperm DNA fragmentation (SDF) is a functional sperm abnormality that can impact reproductive potential, for which four assays have been described in the recently published sixth edition of the WHO laboratory manual for the examination and processing of human semen. The purpose of this study was to examine the global practices related to the use of SDF assays and investigate the barriers and limitations that clinicians face in incorporating these tests into their practice. Materials and Methods: Clinicians managing male infertility were invited to complete an online survey on practices related to SDF diagnostic and treatment approaches. Their responses related to the technical aspects of SDF testing, current professional society guidelines, and the literature were used to generate expert recommendations via the Delphi method. Finally, challenges related to SDF that the clinicians encounter in their daily practice were captured. Results: The survey was completed by 436 reproductive clinicians. Overall, terminal deoxynucleotidyl transferase deoxyuridine triphosphate Nick-End Labeling (TUNEL) is the most commonly used assay chosen by 28.6%, followed by the sperm chromatin structure assay (24.1%), and the sperm chromatin dispersion (19.1%). The choice of the assay was largely influenced by availability (70% of respondents). A threshold of 30% was the most selected cut-off value for elevated SDF by 33.7% of clinicians. Of respondents, 53.6% recommend SDF testing after 3 to 5 days of abstinence. Although 75.3% believe SDF testing can provide an explanation for many unknown causes of infertility, the main limiting factors selected by respondents are a lack of professional society guideline recommendations (62.7%) and an absence of globally accepted references for SDF interpretation (50.3%). Conclusions: This study represents the largest global survey on the technical aspects of SDF testing as well as the barriers encountered by clinicians. Unified global recommendations regarding clinician implementation and standard laboratory interpretation of SDF testing are crucial.

Published
2024
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4. Male Oxidative Stress Infertility (MOSI): Proposed Terminology and Clinical Practice Guidelines for Management of Idiopathic Male Infertility

Author

Ashok Agarwal, Neel Parekh, Manesh Kumar Panner Selvam, Ralf Henkel, Rupin Shah, Sheryl T. Homa, Ranjith Ramasamy, Edmund Ko, Kelton Tremellen, Sandro Esteves, Ahmad Majzoub, Juan G. Alvarez, David K. Gardner, Channa N. Jayasena, Jonathan W. Ramsay, Chak-Lam Cho, Ramadan Saleh, Denny Sakkas, James M. Hotaling, Scott D. Lundy, Sarah Vij, Joel Marmar, Jaime Gosalvez, Edmund Sabanegh, Hyun Jun Park, Armand Zini, Parviz Kavoussi, Sava Micic, Ryan Smith, Gian Maria Busetto, Mustafa Emre Bakırcıoğlu, Gerhard Haidl, Giancarlo Balercia, Nicolás Garrido Puchalt, Moncef Ben-Khalifa, Nicholas Tadros, Jackson Kirkman-Browne, Sergey Moskovtsev, Xuefeng Huang, Edson Borges Jr, Daniel Franken, Natan Bar-Chama, Yoshiharu Morimoto, Kazuhisa Tomita, Vasan Satya Srini, Willem Ombelet, Elisabetta Baldi, Monica Muratori, Yasushi Yumura, Sandro La Vignera, Raghavender Kosgi, Marlon P. Martinez, Donald P. Evenson, Daniel Suslik Zylbersztejn, Matheus Roque, Marcello Cocuzza, Marcelo Vieira, Assaf Ben-Meir, Raoul Orvieto, Eliahu Levitas, Amir Wiser, Mohamed Arafa, Vineet Malhotra, Sijo Joseph Parekattil, Haitham Elbardisi, Luiz Carvalho, Rima Dada, Christophe Sifer, Pankaj Talwar, Ahmet Gudeloglu, Ahmed M.A. Mahmoud, Khaled Terras, Chadi Yazbeck, Bojanic Nebojsa, Damayanthi Durairajanayagam, Ajina Mounir, Linda G. Kahn, Saradha Baskaran, Rishma Dhillon Pai, Donatella Paoli, Kristian Leisegang, Mohamed-Reza Moein, Sonia Malik, Onder Yaman, Luna Samanta, Fouad Bayane, Sunil K. Jindal, Muammer Kendirci, Baris Altay, Dragoljub Perovic, and Avi Harlev

Subjects
Infertility, male, MOSI, Oxidation reduction potential, Oxidative stress, Semen, Medicine, Diseases of the genitourinary system. Urology, RC870-923
Abstract

Despite advances in the field of male reproductive health, idiopathic male infertility, in which a man has altered semen characteristics without an identifiable cause and there is no female factor infertility, remains a challenging condition to diagnose and manage. Increasing evidence suggests that oxidative stress (OS) plays an independent role in the etiology of male infertility, with 30% to 80% of infertile men having elevated seminal reactive oxygen species levels. OS can negatively affect fertility via a number of pathways, including interference with capacitation and possible damage to sperm membrane and DNA, which may impair the sperm’s potential to fertilize an egg and develop into a healthy embryo. Adequate evaluation of male reproductive potential should therefore include an assessment of sperm OS. We propose the term Male Oxidative Stress Infertility, or MOSI, as a novel descriptor for infertile men with abnormal semen characteristics and OS, including many patients who were previously classified as having idiopathic male infertility. Oxidation-reduction potential (ORP) can be a useful clinical biomarker for the classification of MOSI, as it takes into account the levels of both oxidants and reductants (antioxidants). Current treatment protocols for OS, including the use of antioxidants, are not evidence-based and have the potential for complications and increased healthcare-related expenditures. Utilizing an easy, reproducible, and cost-effective test to measure ORP may provide a more targeted, reliable approach for administering antioxidant therapy while minimizing the risk of antioxidant overdose. With the increasing awareness and understanding of MOSI as a distinct male infertility diagnosis, future research endeavors can facilitate the development of evidence-based treatments that target its underlying cause.

Published
2019
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