Faculty Bibliography

Gender dysphoria, or the incongruence between gender identification and sex assigned at birth with associated discomfort or distress, manifests in transgender patients, whose multifaceted care includes puberty suppression, cross-sex hormonal therapy, and gender-affirming surgery. Discussion of fertility preservation (FP) is paramount because many treatments compromise future fertility, and although transgender patients demonstrate desire for children, use of FP remains low for a plethora of reasons. In transgender women, established FP options include ejaculated sperm cryopreservation, electroejaculation, or testicular sperm extraction. Further research is needed regarding reproductive health and FP in transgender patients.

Objective: Epidemiologic studies have found that a greater degree of comorbidity is associated with worse fertility potential. However, these findings are largely based on retrospective studies of men interacting with the health care system. Our objective was to evaluate the association of fertility and health status in men in the United States using a nationally representative survey.
Design(s): We compared the demographics, healthcare utilization, and overall health status of fertile and infertile men in the National Survey for Family Growth (NSFG).
Material(s) and Method(s): We performed an analysis of the male 2011-2017 cycles of the NSFG, a nationally representative survey of family planning. Infertile men were defined as men who had ever used infertility services or men who self-reported as non-surgically sterile. Men who reported completed pregnancies were considered fertile.
Result(s): Of the 13,861 men surveyed, 1,071 men were infertile, and 5,661 men were known to be fertile. Projecting to the national population, this translates to 5,205,771 infertile men and a 26,577,702 fertile men. Of the total population of sexually active men aged 15-49, roughly 8.5% (95%CI: 7.8-9.3) of men were infertile. Compared to known fertile men, infertile men had significant demographic and healthcare utilization differences (Table). Infertile men were wealthier, better educated, more likely to be white, more likely to be married, and more likely to have private insurance. Importantly, infertile men and fertile men had similar overall health status. On multivariate analysis, differences in income, marital status, and usual healthcare place remained significant.
Conclusion(s): While infertile men do have significant demographic and healthcare utilization differences compared to fertile men, the overall health status of both infertile and fertile men appear similar. [Figure presented]
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OBJECTIVE: Epidemiologic studies have found that a greater degree of comorbidity is associated with worse fertility potential. However, these findings are largely based on retrospective studies of men interacting with the health care system. Our objective was to evaluate the association of fertility and health status in men in the United States using a nationally representative survey. DESIGN: We compared the demographics, healthcare utilization, and overall health status of fertile and infertile men in the National Survey for Family Growth (NSFG). MATERIALS AND METHODS: We performed an analysis of the male 2011-2017 cycles of the NSFG, a nationally representative survey of family planning. Infertile men were defined as men who had ever used infertility services or men who self-reported as non-surgically sterile. Men who reported completed pregnancies were considered fertile.
RESULT(S): Of the 13,861 men surveyed, 1,071 men were infertile, and 5,661 men were known to be fertile. Projecting to the national population, this translates to 5,205,771 infertile men and a 26,577,702 fertile men. Of the total population of sexually active men aged 15-49, roughly 8.5% (95%CI: 7.8-9.3) of men were infertile. Compared to known fertile men, infertile men had significant demographic and healthcare utilization differences (Table). Infertile men were wealthier, better educated, more likely to be white, more likely to be married, and more likely to have private insurance. Importantly, infertile men and fertile men had similar overall health status. On multivariate analysis, differences in income, marital status, and usual healthcare place remained significant.
CONCLUSION(S): While infertile men do have significant demographic and healthcare utilization differences compared to fertile men, the overall health status of both infertile and fertile men appear similar

OBJECTIVE:To assess changes in the practice patterns of urologists performing male infertility procedures (vasal reconstruction, sperm retrieval, varicocelectomy) from 2004 to 2015 in the United States. DESIGN/METHODS:Examination of self-reported procedural volumes from urologists undergoing certification and recertification using case log data provided by the American Board of Urology. The study period was stratified into early (2004-2007) and recent (2012-2015) time periods. SETTING/METHODS:Not applicable. PATIENT(S)/METHODS:None. INTERVENTION(S)/METHODS:None. MAIN OUTCOMES MEASURE(S)/METHODS:Temporal variations in male infertility practice patterns among different urologic subspecialties between the early and recent time periods. RESULT(S)/RESULTS:The overall proportion of total male infertility procedures performed by andrologists significantly increased between the early and recent groups (23% to 26%). This growth was driven by a significant increase in the proportion of varicocele repairs being performed by andrologists between the early and recent periods (19% to 25%). Most notably, an assessment of total number of male infertility procedures performed by newly certifying urologists showed that there was a significant increase in the overall proportion of all male infertility procedures being performed by recently trained andrologists (24% to 35%). This significant increase was seen individually among all three types of male infertility procedures. CONCLUSION(S)/CONCLUSIONS:With the increased trend in urologists obtaining fellowship training, male infertility surgical volume is beginning to shift from general urologists to subspecialized andrologists.

OBJECTIVE:To evaluate whether varicocelectomy improves both serum testosterone and sexual function, as assessed by the Male Sexual Health Questionnaire (MSHQ). METHODS:A retrospective chart review of patients who have undergone varicocelectomy and had both pre- and postoperative MSHQ was performed. The MSHQ is a clinically validated questionnaire that assesses erectile function, ejaculatory function, and sexual satisfaction, with higher scores indicating better function. Clinical parameters pre and postvaricocelectomy were compared with paired t test. RESULTS:Thirty-four patients met study criteria. Seventeen patients (50%) presented for infertility, and the remaining 13 had symptomatic varicocele associated with hypogonadism. Average postsurgical follow-up was 20.6 ± 12.5 months. The majority of men in the study had bilateral varicoceles and left grade III varicoceles. Significant improvements in the total MSHQ score (3.9 ± 8.7, P = .027), the MSHQ erectile function (1.2 ± 2.3, P = .007), and the MSHQ ejaculatory function (1.4 ± 3.1, P = .018) domains were seen. Fifteen (44%) men saw improvement in their erectile function and 18 (53%) saw improvement in ejaculatory function. The improvement in serum testosterone was also significant (136.0 ± 201.3 ng/dL, P = .007). CONCLUSION/CONCLUSIONS:Microsurgical repair of varicocele not only improves testosterone, but also improves patient-reported erectile and ejaculatory functions. Patients can confidently be counseled that varicocelectomy has the potential to improve sexual function along with serum testosterone.

PURPOSE: Inguinal herniorrhaphy is the most common general surgical procedure. It is associated with frequent complications such as recurrence (1.9% with mesh), post-operative hematoma (4.5%), reduced sensation (0 - 42.8%), chronic post-operative pain (5.1%), vasal injury (0.1 - 0.53%) and infection (3 - 6%)1-5. Drawing on our experience utilizing the operating microscope for varicocelectomy, vasectomy reversal and repair of iatrogenic vasal obstruction from hernia repair, we employed it for inguinal hernia repair. This paper describes the rationale, technique and outcomes of microsurgically assisted inguinal hernia repair. MATERIALS AND METHODS: 291 microsurgically assisted inguinal hernia repairs were performed on 253 men by the same urologist (MG). Simultaneous microsurgical varicocelectomy or other testicular procedures were performed in 83% of cases. All were open repairs through an inguinal incision with the vas deferens, ilioinguinal nerve, genital branch of the genitofemoral nerve and spermatic vasculature identified and preserved. Median follow up was 8.6 months, and outcomes were assessed through examination, pain reporting and pathology reports. RESULTS: Chronic postoperative pain, sensory loss, infection, hematoma, vasal injury and recurrence were assessed. The incidence of hematoma was 0.85%. No hernia recurrences, chronic postoperative pain, sensory loss, infection or vasal injury was reported. CONCLUSIONS: Using an operating microscope, complications of inguinal hernia repair such as vasal obstruction, testicular atrophy, recurrence, infection, hematoma, chronic postoperative pain and loss of sensation are minimized. Microsurgically assisted hernia repair is a promising technique, especially when employed by a urologist performing simultaneous microsurgical varicocelectomy or procedures involving spermatic cord structures or testis.