Barriers to use of semen analysis in the adolescent with a varicocele: Survey of patient, parental, and practitioner attitudes

Fine, Ronnie; Gitlin, Jordan; Reda, Edward F.; Palmer, Lane S.

doi:10.1016/j.jpurol.2015.06.015

Cited by 33 publications

(25 citation statements)

References 17 publications

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“…Broaching the topic of SA collection can be uncomfortable for the patient and parents 49 . Additionally, a surprising fraction of practitioners are also uncomfortable or unfamiliar with the topic as multiple practitioner surveys demonstrate that only 31–47% obtain a SA during varicocele evaluation 49–51 and only 22% obtain SAs longitudinally 49 .…”

Section: Clinical Evaluation and Outcomementioning

confidence: 99%

The Dilemma of Adolescent Varicoceles: Do They Really Have to Be Repaired?

2017

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The primary indication for varicocele repair in adults, that of failed paternity, must be substituted in the adolescent population with surrogate parameters of testicular size differential and semen analysis. Making recommendations based on these two parameters is incredibly difficult because studies often have contradictory findings, different patient populations, and lack of long term follow up of the key endpoint, paternity. Therefore, it is not a surprise that recommendations for adolescent varicocele repair are general (with some exceptions) and necessarily so because of limitations in quality of evidence. Apart from pain, all indications for varicocele repair in adolescence remain controversial. This highlights the most important task for future studies: to prevent pediatric urologists from allowing a potentially damaging process to go untreated, while at the same time avoiding unnecessary intervention on a highly prevalent condition.

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Section: Clinical Evaluation and Outcomementioning

confidence: 99%

The Dilemma of Adolescent Varicoceles: Do They Really Have to Be Repaired?

2017

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“…Semen analysis (SA) is possibly the most accurate predictor of future fertility [7–9], although for some physicians ethics concerns have arisen for obtaining the sample [10]. Testicular volumetrics offer a non-invasive method of gauging future fertility potential [11–15], but it may not be an accurate predictor of SA results [12,14].…”

Section: Introductionmentioning

confidence: 99%

The natural history of semen parameters in untreated asymptomatic adolescent varicocele patients: A retrospective cohort study

Chu

Zderic

Shukla

et al. 2017

Journal of Pediatric Urology

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Summary Introduction Adolescent males with varicoceles present a dilemma for surveillance and treatment. Testicular volumetrics have not been shown to predict SA outcomes. Serial SAs are thus recommended in asymptomatic adolescent males with varicoceles and normal testicular development, but the natural history of semen parameters is unknown. Objective To explore the natural history of semen parameters in adolescent boys with a left varicocele under active surveillance. Study design Adolescents with an asymptomatic unilateral left varicocele, Tanner V development, normal testicular volumes, and an initial SA were retrospectively reviewed in a single-institution prospectively followed cohort. Total motile count (TMC) was calculated. A cutoff of TMC Z 20 million was used to dichotomize SA results into “normal” or “poor.” Those with poor SA were offered repeat SA. Cumulative probabilities of normal TMC over successive rounds of SA were calculated. Bivariate models were used to explore associations of a second consecutive poor TMC with age and varicocele grade. Results A total of 216 patients provided an initial SA between 1992 and 2015. We excluded 17 for a history of cryptorchidism or incomplete SA data for a final cohort of 199 patients with median follow-up of 3.3 years (interquartile range 1.5–5.6 years). The mean age at initial SA was 17.9 years (range 14.8–21.8 years). One hundred and nine out of 199 had an initial normal TMC. Of the 90 out of 199 with an initially poor TMC, 51 had repeat SA and 24 of the 51 patients improved to normal TMC. Of the 27 patients with two consecutive poor TMCs, 15 had a third SA and five out of 15 improved to normal TMC. Thus, cumulatively, 55%, 67%, and 69% of all patients had a normal TMC after an initial, second, and third SA, respectively. However, fewer patients in each round of SA normalized their TMC (Figure). Neither age nor varicocele grade was associated with a second consecutive poor TMC. Discussion Two-thirds of Tanner V boys with an uncorrected varicocele and normal testicular volumes achieve a normal TMC regardless of varicocele grade or age. Despite Tanner V development, 47% with an initial “poor” SA will improve to normal status without surgery. However, a small subgroup of patients will have persistently poor TMC and thus should be targeted in future research for timely intervention. Conclusion Semen parameters improve over time. SA should be followed and repeated at least once in symptomatic Tanner V boys with varicoceles.

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“…The ethical dilemma, and potentially key barrier, in using TMC as an outcome is that this requires obtaining SA from adolescents. This dilemma has both severely limited the utilization rate of SA and impaired discussion of obtaining SA among practitioners, parents, and patients [17]. In a survey study with 168 respondents out of 315 pediatric urologists, only 13% routinely used SA for management of adolescent varicoceles, with 53% of respondents never asking for an SA [17].…”

Section: Discussionmentioning

confidence: 99%

“…This dilemma has both severely limited the utilization rate of SA and impaired discussion of obtaining SA among practitioners, parents, and patients [17]. In a survey study with 168 respondents out of 315 pediatric urologists, only 13% routinely used SA for management of adolescent varicoceles, with 53% of respondents never asking for an SA [17]. Indeed, the AUA/ASRM best-practice policy for adolescent males with varicoceles currently considers SA optional, with the recommendation to perform annual surveillance with “objective measurements of testis size and/or semen analyses” [16].…”

Section: Discussionmentioning

confidence: 99%

Does varicocelectomy improve semen analysis outcomes in adolescents without testicular asymmetry?

Chu

Zderic

Shukla

et al. 2017

Journal of Pediatric Urology

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Summary Purpose The main indications for adolescent varicocelectomy are testicular hypotrophy or pain. However, we have previously shown that both serial total testicular volume and volume differential are weakly associated with semen quality. The ultimate patient goal is paternity, but semen analysis is critical to appropriate management of varicocele. We hypothesize that varicocelectomy improves total motile count (TMC) among patients who only have abnormal semen analysis (SA) parameters, but not among those with potential hormonal dysfunction such as Klinefelter syndrome or cryptorchidism. Methods We retrospectively reviewed our registry of adolescent males followed with a clinical left varicocele. For this study, subjects without sustained testicular asymmetry, who were Tanner V, and gave at least one preoperative SA were included. Subjects were excluded if they had embolization for their varicocele or no postoperative SA. Primary outcome was change in TMC before and after surgery, compared using the Wilcoxon signed rank test after stratifying by surgical indication. Secondary outcomes included rates of improved TMC and normalized TMC (> 20 million) after surgery, compared across covariates using the Fisher exact test. Results Seventeen patients met the eligibility criteria, 11 of whom underwent repair for only abnormal preoperative TMC. Overall, median age (interquartile range [IQR]) at first preoperative SA was 17.6 (15.9–17.9) years. The median preoperative TMC across all SA was 2.8 (0.7–7.4) million. The median age at surgery was 18.2 (16.8–18.9) years. Postoperatively, the median TMC across all SA increased to 18.2 (3.6–18.2) million (Wilcoxon signed rank test, p < 0.01; see figure). The improvement in TMC occurred primarily in the group who only had abnormal preoperative TMC (82% improved, 55% normalized); lack of improvement was seen in patients who had a history of Klinefelter or orchiopexy for cryptorchidism. Conclusions Adolescent varicocele patients should undergo SA after development of Tanner V. Varicocelectomy has a high success rate for improving TMC in adolescent or young adult males who only have abnormal TMC and no history of cryptorchidism.

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Barriers to use of semen analysis in the adolescent with a varicocele: Survey of patient, parental, and practitioner attitudes

Cited by 33 publications

References 17 publications

The Dilemma of Adolescent Varicoceles: Do They Really Have to Be Repaired?

The Dilemma of Adolescent Varicoceles: Do They Really Have to Be Repaired?

The natural history of semen parameters in untreated asymptomatic adolescent varicocele patients: A retrospective cohort study

Does varicocelectomy improve semen analysis outcomes in adolescents without testicular asymmetry?

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