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Öğe Consensus and diversity in the management of varicocele for male infertility: Results of a global practice survey and comparison with guidelines and recommendations(Korean Society for Sexual Medicine and Andrology, 2023) Shah, Rupin; Agarwal, Ashok; Kavoussi, Parviz; Rambhatla, Amarnath; Saleh, Ramadan; Söğütdelen, EmrullahPurpose: Varicocele is a common problem among infertile men. Varicocele repair (VR) is frequently performed to improve semen parameters and the chances of pregnancy. However, there is a lack of consensus about the diagnosis, indications for VR and its outcomes. The aim of this study was to explore global practice patterns on the management of varicocele in the context of male infertility. Materials and Methods: Sixty practicing urologists/andrologists from 23 countries contributed 382 multiple-choice-questions pertaining to varicocele management. These were condensed into an online questionnaire that was forwarded to clinicians involved in male infertility management through direct invitation. The results were analyzed for disagreement and agreement in practice patterns and, compared with the latest guidelines of international professional societies (American Urological As-sociation [AUA], American Society for Reproductive Medicine [ASRM], and European Association of Urology [EAU]), and with evidence emerging from recent systematic reviews and meta-analyses. Additionally, an expert opinion on each topic was provided based on the consensus of 16 experts in the field. Results: The questionnaire was answered by 574 clinicians from 59 countries. The majority of respondents were urologists/ uro-andrologists. A wide diversity of opinion was seen in every aspect of varicocele diagnosis, indications for repair, choice of technique, management of sub-clinical varicocele and the role of VR in azoospermia. A significant proportion of the re-sponses were at odds with the recommendations of AUA, ASRM, and EAU. A large number of clinical situations were identi-fied where no guidelines are available. Conclusions: This study is the largest global survey performed to date on the clinical management of varicocele for male in-fertility. It demonstrates: 1) a wide disagreement in the approach to varicocele management, 2) large gaps in the clinical prac-tice guidelines from professional societies, and 3) the need for further studies on several aspects of varicocele management in infertile men.Öğe Controversy and consensus on indications for sperm DNA fragmentation testing in male infertility: A global survey, current guidelines, and expert recommendations(Korean Society for Sexual Medicine and Andrology, 2023) Agarwal, Ashok; Farkouh, Ala'a; Saleh, Ramadan; Hamoda, Taha Abo-Almagd Abdel-Meguid; Harraz, Ahmed M.; Söğütdelen, EmrullahPurpose: 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 associ-ated 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 pro-fessional 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 clini-cal 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 indi-cations 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. Recur-rent 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 demon-strates diverse practices. Furthermore, it highlights the paucity of professional society guideline recommendations. Expert recommendations are proposed to help guide clinicians.Öğe Controversy and consensus on the management of elevated sperm DNA fragmentation in male infertility: A global survey, current guidelines, and expert recommendations(Korean Society for Sexual Medicine and Andrology, 2023) Farkouh, Ala'a; Agarwal, Ashok; Hamoda, Taha Abo-Almagd Abdel-Meguid; Kavoussi, Parviz; Saleh, Ramadan; Söğütdelen, EmrullahPurpose: Sperm DNA fragmentation (SDF) has been associated with male infertility and poor outcomes of assisted reproduc-tive technology (ART). The purpose of this study was to investigate global practices related to the management of elevated SDF in infertile men, summarize the relevant professional society recommendations, and provide expert recommendations for managing this condition. Materials and Methods: An online global survey on clinical practices related to SDF was disseminated to reproductive clini-cians, according to the CHERRIES checklist criteria. Management protocols for various conditions associated with SDF were captured and compared to the relevant recommendations in professional society guidelines and the appropriate available evidence. Expert recommendations and consensus on the management of infertile men with elevated SDF were then formu-lated and adapted using the Delphi method.Results: A total of 436 experts from 55 different countries submitted responses. As an initial approach, 79.1% of reproductive experts recommend lifestyle modifications for infertile men with elevated SDF, and 76.9% prescribe empiric antioxidants. Regarding antioxidant duration, 39.3% recommend 4-6 months and 38.1% recommend 3 months. For men with unex-plained or idiopathic infertility, and couples experiencing recurrent miscarriages associated with elevated SDF, most respon-dents refer to ART 6 months after failure of conservative and empiric medical management. Infertile men with clinical vari-cocele, normal conventional semen parameters, and elevated SDF are offered varicocele repair immediately after diagnosis by 31.4%, and after failure of antioxidants and conservative measures by 40.9%. Sperm selection techniques and testicular sperm extraction are also management options for couples undergoing ART. For most questions, heterogenous practices were demonstrated.Conclusions: This paper presents the results of a large global survey on the management of infertile men with elevated SDF and reveals a lack of consensus among clinicians. Furthermore, it demonstrates the scarcity of professional society guidelines in this regard and attempts to highlight the relevant evidence. Expert recommendations are proposed to help guide clinicians.Öğe Effect of varicocele repair on conventional sperm parameters in infertile patients with clinical varicocele: A systematic review and metaanalysis(Elseiver Science Inc, 2022) Agarwal, Ashok; Cannarella, Rossella; Saleh, Ramadan; Boitrelle, Florence; Hamoda, Taha Abdel-Meguid; Söğütdelen, EmrullahEffect of varicocele repair on conventional sperm parameters in infertile patients with clinical varicocele: A systematic review and metaanalysisÖğe Impact of varicocele repair on semen parameters in infertile men: A systematic review and meta-analysis(Korean Society for Sexual Medicine and Andrology, 2022) Agarwal, Ashok; Cannarella, Rossella; Saleh, Ramadan; Boitrelle, Florence; Gül, Murat; Söğütdelen, EmrullahPurpose: Despite the significant role of varicocele in the pathogenesis of male infertility, the impact of varicocele repair (VR) on conventional semen parameters remains controversial. Only a few systematic reviews and meta-analyses (SRMAs) have evaluated the impact of VR on sperm concentration, total motility, and progressive motility, mostly using a before-after analytic approach. No SRMA to date has evaluated the change in conventional semen parameters after VR compared to untreated controls. This study aimed to evaluate the effect of VR on conventional semen parameters in infertile patients with clinical varicocele compared to untreated controls.Materials and Methods: A literature search was performed using Scopus, PubMed, Embase, and Cochrane databases following the Population Intervention Comparison Outcome (PICOS) model (Population: infertile patients with clinical varicocele; Intervention: VR [any technique]; Comparison: infertile patients with clinical varicocele that were untreated; Outcome: sperm concentration, sperm total count, progressive sperm motility, total sperm motility, sperm morphology, and semen volume; Study type: randomized controlled trials and observational studies).Results: A total of 1,632 abstracts were initially assessed for eligibility. Sixteen studies were finally included with a total of 2,420 infertile men with clinical varicocele (1,424 patients treated with VR vs. 996 untreated controls). The analysis showed significantly improved post-operative semen parameters in patients compared to controls with regards to sperm concentration (standardized mean difference [SMD] 1.739; 95% CI 1.129 to 2.349; p<0.001; I2=97.6%), total sperm count (SMD 1.894; 95% CI 0.566 to 3.222; p<0.05; I2=97.8%), progressive sperm motility (SMD 3.301; 95% CI 2.164 to 4.437; p<0.01; I2=98.5%), total sperm motility (SMD 0.887; 95% CI 0.036 to 1.738; p=0.04; I2=97.3%) and normal sperm morphology (SMD 1.673; 95% CI 0.876 to 2.470; p<0.05; I2=98.5%). All the outcomes showed a high inter-study heterogeneity, but the sensitivity analysis showed that no study was sensitive enough to change these results. Publication bias was present only in the analysis of the sperm concentration and progressive motility. No significant difference was found for the semen volume (SMD 0.313; 95% CI-0.242 to 0.868; I2=89.7%).Conclusions: This study provides a high level of evidence in favor of a positive effect of VR to improve conventional semen parameters in infertile men with clinical varicocele. To the best of our knowledge, this is the first SRMA to compare changes in conventional semen parameters after VR with changes in parameters of a control group over the same period. This is in contrast to other SRMAs which have compared semen parameters before and after VR, without reference to a control group. Our findings strengthen the available evidence and have a potential to upgrade professional societies' practice recommendations favoring VR to improve conventional semen parameters in infertile men.Öğe The impact of varicocele repairon conventional semen paramaeters in infertile men: A meta-analysis using pre- and post-operative data(Elsevier Science Inc, 2022) Agarwal, Ashok; Cannarella, Rossella; Shah, Rupin; Boitrelle, Florence; Gül, Murat; Söğütdelen, EmrullahThe impact of varicocele repairon conventional semen paramaeters in infertile men: A meta-analysis using pre- and post-operative dataÖğe Technical aspects and clinical limitations of sperm DNA fragmentation testing in male infertility a global survey, current guidelines, and expert recommendations(Korean Soc Sexual Medicine & Andrology, 2024) Söğütdelen, Emrullah; Agarwal, Ashok; Farkouh, Ala'a; Saleh, Ramadan; Hamoda, Taha Abo-Almagd Abdel-Meguid; Salvio, GianmariaPurpose: 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 exami-nation 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 profes-sional 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 deoxyuri-dine 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 in-fluenced 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 respon-dents 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 en-countered by clinicians. Unified global recommendations regarding clinician implementation and standard laboratory inter-pretation of SDF testing are crucial.
