Use of testosterone replacement therapy (TRT) and anabolic–androgenic steroids (AAS) has increased over the last 20 years, coinciding with an increase in men presenting with infertility and hypogonadism. Both agents have a detrimental effect on spermatogenesis and pose a clinical challenge in the setting of hypogonadism and infertility. Adding to this challenge is the paucity of data describing recovery of spermatogenesis on stopping such agents. The unwanted systemic side effects of these agents have driven the development of novel agents such as selective androgen receptor modulators (SARMs). Data showing natural recovery of spermatogenesis following cessation of TRT are limited to observational studies. Largely, these have shown spontaneous recovery of spermatogenesis after cessation. Contemporary literature suggests the time frame for this recovery is highly variable and dependent on several factors including baseline testicular function, duration of drug use and age at cessation. In some men, drug cessation alone may not achieve spontaneous recovery, necessitating hormonal stimulation with selective oestrogen receptor modulators (SERMs)/gonadotropin therapy or even the need for assisted reproductive techniques. However, there are limited prospective randomized data on the role of hormonal stimulation in this clinical setting. The use of hormonal stimulation with agents such as gonadotropins, SERMs, aromatase inhibitors and assisted reproductive techniques should form part of the counselling process in this cohort of hypogonadal infertile men. Moreover, counselling men regarding the detrimental effects of TRT/AAS on fertility is very important, as is the need for robust randomized studies assessing the long-term effects of novel agents such as SARMs and the true efficacy of gonadotropins in promoting recovery of spermatogenesis.

Diabetes mellitus is a rapidly rising metabolic disorder with important sys-This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

Methods We examined the factors that might potentially influence patient satisfaction with their colonoscopic procedure using a pre test questionnaire [self reported apprehension, the reason for any concerns, expectations of pain (represented as a visual analogue scale of 0e10, 0¼no pain and 10¼maximum pain) and previous experience of colonoscopy]. Data collected during the test itself (patient self reported pain scores collected immediately post procedure and sedation doses used) were compared with a post test questionnaire of overall satisfaction and willingness to undergo the test again in the future if required. Results 448 patients participated (287 females and 201 males). Age range 18e88 years and mean age was 58 years. The mean anticipation of pain on the visual analogue scale was 2.61. The most common causes of anxiety were "fear of cancer?" (n¼70) followed by "pain" (n¼35), "tear/perforation" (n¼14) and "previous adverse endoscopic experiences" (n¼9). The mean actual patient reported pain scores were 3.14. 63 patients (43 females and 19 males) was very worried before test and their average anticipated pain score (AtPS) was 4.19 (total average 2.61) and the actual pain score (AcPS) 3.48 (average 3.14). 225 patients were worried before test and their AtPS 2.95 and AcPS 3.37. The patients who were not worried, their AtPS were 1.74 and AcPS 2.8. Patients (n¼32) whose expected pre test pain scores were between 7 and 10 on visual analogue scale expressed higher levels of satisfaction with their procedures than those with lower anticipated pain scores (0e6) [93.7% vs 73.8%]. Patients who had a pre test apprehension score >7 were more agreeable to undergo the test again than those with score <6. Conclusion Patient satisfaction is strongly correlated with patient comfort. Patients' appreciating that colonoscopy is a potentially painful procedure report a higher level of satisfaction and acceptance of the sedation offered. The importance appropriate preparation of the patient should not be underestimated.