A novel sorting method for the enrichment of early human spermatocytes from clinical biopsies

OBJECTIVE

To determine if early spermatocytes can be enriched from a human testis biopsy using fluorescence-activated cell sorting (FACS).

DESIGN

Potential surface markers for early spermatocytes were identified using bioinformatics analysis of single-cell RNA-sequenced human testis tissue. Testicular sperm extraction samples from three participants with normal spermatogenesis were digested into single-cell suspensions and cryopreserved. Two to four million cells were obtained from each and sorted by FACS as separate biologic replicates using antibodies for the identified surface markers. A portion from each biopsy remained unsorted to serve as controls. The sorted cells were then characterized for enrichment of early spermatocytes.

SETTING

A laboratory study.

PATIENTS

Three men with a diagnosis of obstructive azoospermia (age range, 30-40 years).

INTERVENTION

None.

MAIN OUTCOME MEASURES

Sorted cells were characterized for RNA expression of markers encompassing the stages of spermatogenesis. Sorting markers were validated by their reactivity on human testis formalin-fixed paraffin-embedded tissue.

RESULTS

Serine protease 50 (TSP50) and SWI5-dependent homologous recombination repair protein 1 were identified as potential surface proteins specific for early spermatocytes. After FACS sorting, the TSP50-sorted populations accounted for 1.6%-8.9% of total populations and exhibited the greatest average-fold increases in RNA expression for the premeiotic marker stimulated by retinoic acid (STRA8), by 23-fold. Immunohistochemistry showed the staining pattern for TSP50 to be strong in premeiotic undifferentiated embryonic cell transcription factor 1-/doublesex and Mab-3 related transcription factor 1-/STRA8+ spermatogonia as well as SYCP3+/protamine 2- spermatocytes.

CONCLUSION

This work shows that TSP50 can be used to enrich early STRA8-expressing spermatocytes from human testicular biopsies, providing a means for targeted single-cell RNA sequencing analysis and in vitro functional interrogation of germ cells during the onset of meiosis. This could enable investigation into details of the regulatory pathways underlying this critical stage of spermatogenesis, previously difficult to enrich from whole tissue samples.

Preservation of male fertility in patients undergoing pelvic irradiation

As the number of cancer survivors increases, so does the demand for preserving male fertility after radiation. It is important for healthcare providers to understand the pathophysiology of radiation-induced testicular injury, the techniques of fertility preservation both before and during radiation, and their role in counseling patients on the risks to their fertility and the means of mitigating these risks. Impaired spermatogenesis is a known testicular toxicity of radiation in both the acute and the late settings, as rapidly dividing spermatogonial germ cells are exquisitely sensitive to irradiation. The threshold for spermatogonial injury and subsequent impairment in spermatogenesis is ~ 0.1 Gy and the severity of gonadal injury is highly dose-dependent. Total doses < 4 Gy may allow for recovery of spermatogenesis and fertility potential, but with larger doses, recovery may be protracted or impossible. All patients undergoing gonadotoxic radiation therapy should be counseled on the possibility of future infertility, offered the opportunity for semen cryopreservation, and offered referral to a fertility specialist. In addition to this, every effort should be made to shield the testes (if not expected to contain tumor) during therapy.

TKSM: highly modular, user-customizable, and scalable transcriptomic sequencing long-read simulator

MOTIVATION

Transcriptomic long-read (LR) sequencing is an increasingly cost-effective technology for probing various RNA features. Numerous tools have been developed to tackle various transcriptomic sequencing tasks (e.g. isoform and gene fusion detection). However, the lack of abundant gold-standard datasets hinders the benchmarking of such tools. Therefore, the simulation of LR sequencing is an important and practical alternative. While the existing LR simulators aim to imitate the sequencing machine noise and to target specific library protocols, they lack some important library preparation steps (e.g. PCR) and are difficult to modify to new and changing library preparation techniques (e.g. single-cell LRs).

RESULTS

We present TKSM, a modular and scalable LR simulator, designed so that each RNA modification step is targeted explicitly by a specific module. This allows the user to assemble a simulation pipeline as a combination of TKSM modules to emulate a specific sequencing design. Additionally, the input/output of all the core modules of TKSM follows the same simple format (Molecule Description Format) allowing the user to easily extend TKSM with new modules targeting new library preparation steps.

AVAILABILITY AND IMPLEMENTATION

TKSM is available as an open source software at https://github.com/vpc-ccg/tksm.

Molecular mechanisms of cellular dysfunction in testes from men with non-obstructive azoospermia

Male factor infertility affects 50% of infertile couples worldwide; the most severe form, non-obstructive azoospermia (NOA), affects 10-15% of infertile males. Treatment for individuals with NOA is limited to microsurgical sperm extraction paired with in vitro fertilization intracytoplasmic sperm injection. Unfortunately, spermatozoa are only retrieved in ~50% of patients, resulting in live birth rates of 21-46%. Regenerative therapies could provide a solution; however, understanding the cell-type-specific mechanisms of cellular dysfunction is a fundamental necessity to develop precision medicine strategies that could overcome these abnormalities and promote regeneration of spermatogenesis. A number of mechanisms of cellular dysfunction have been elucidated in NOA testicular cells. These mechanisms include abnormalities in both somatic cells and germ cells in NOA testes, such as somatic cell immaturity, aberrant growth factor signalling, increased inflammation, increased apoptosis and abnormal extracellular matrix regulation. Future cell-type-specific investigations in identifying modulators of cellular transcription and translation will be key to understanding upstream dysregulation, and these studies will require development of in vitro models to functionally interrogate spermatogenic niche dysfunction in both somatic and germ cells.

Acceptability, reliability, and validity of a vaginal insert for the self-assessment of endometriosis-associated deep dyspareunia: a cross-sectional study

BACKGROUND

Approximately half of people with endometriosis experience deep dyspareunia; however, there is no means of objective self-testing of endometriosis-associated deep dyspareunia.

AIM

The aim of this study was to assess the acceptability, test-retest reliability, and validity of a vaginal insert for a self-assessment of endometriosis-associated deep dyspareunia.

METHODS

Participants were recruited from a tertiary endometriosis center. Inclusion criteria were: 19 to 49 years of age, self-reported deep dyspareunia of ≥4 of 10, and surgically confirmed endometriosis. Participants completed 2 self-assessments using the vaginal insert to self-assess tenderness at the right and left pelvic floor, bladder, cervix-uterus, and posterior cul-de-sac (vaginal fornix). The participants recorded tenderness at each pelvic site and completed a questionnaire regarding the acceptability of the vaginal insert to assess deep dyspareunia. Test-retest reliability was assessed by correlating the tenderness scores between the 2 assessment dates. Over a 4-week period, the participants also recorded deep dyspareunia severity at each penetrative vaginal sex encounter. Validity was assessed by correlating vaginal insert tenderness to deep dyspareunia severity, and also to tenderness reported on a prior gynecologic pelvic examination.

OUTCOMES

The main outcome measures were the acceptability index score, tenderness (0-10) at each pelvic site, and prospective deep dyspareunia scores (0-10) over 4 weeks.

RESULTS

There were 19 participants (mean age 34 ± 7 years) who completed the study. The majority identified as female (94.7%), heterosexual (89.5%), and white (89.5%). The median acceptability index score was 0.72 (interquartile range, 0.66-0.81). For test-retest reliability, the intraclass correlation coefficients were 0.79 (P = .001) for the left pelvic floor, 0.82 (P < .001) for the right pelvic floor, 0.54 (P = .07) for the bladder, 0.89 (P < .001) for the cervix-uterus, and 0.77 (P = .003) for the cul-de-sac. The correlation between the highest self-assessed mean tenderness in each participant and self-reported deep dyspareunia over 4 weeks was r = 0.32, but correlations for each pelvic site varied significantly. Tenderness at each site on prior gynecologist pelvic exam was associated with higher self-assessed mean tenderness with the vaginal insert in each participant (effect sizes = 0.42-0.88).

CLINICAL IMPLICATIONS

The vaginal insert is acceptable and reliable for the objective self-assessment of endometriosis-associated deep dyspareunia, with initial evidence of validity.

STRENGTHS AND LIMITATIONS

A strength was the inclusion of participants who were avoiding sexual activity and a limitation was the small sample size.

CONCLUSION

Future studies with larger sample sizes are required to further establish the validity of the vaginal insert for the self-assessment of endometriosis-associated deep dyspareunia.

The association of medications and supplements with human male reproductive health: a systematic review

Some medications used to treat comorbidities and conditions in reproductive-aged individuals could have a negative impact on fertility. This may occur through hormonal disruption, toxicity to germ cells and spermatozoa, functional impact on the sperm, teratogenicity potential, or ejaculatory abnormalities. Having knowledge of these potential interactions between medications and reproductive potential is important for clinicians to be aware of and guide the patient, along with their treating clinicians, to reproductively favorable alternatives when available. This review aims to summarize the state of the literature regarding medication interactions with human male reproduction using the Anatomical Therapeutic Chemical Classification System of medications.

Insurance approval rates for collagenase clostridium histolyticum prior to discontinuation: a Canada-wide analysis

Collagenase Clostridium histolyticum (CCh), the first approved non-surgical treatment for Peyronie's disease (PD), was withdrawn from the European, Canadian, and Asian markets due to poor demand and lack of government reimbursement options. We sought to assess insurance approval rates and usage of CCh across Canada to understand the factors that led to its withdrawal. Data on patients prescribed CCh for PD or Dupuytren's contracture was obtained through collaboration with BioScript Solutions to assess the association of variables with insurance approval and prescription filling. We identified 3297 insurance coverage applications for Xiaflex® from April 2018 to June 2020. Of all applications for PD, 92.9% applications were approved while 7.1% were rejected. Despite the withdrawal of CCh from Canadian markets, coverage application approval rates for 2018, 2019, and 2020 were 86.5%, 90.1%, and 89.1%, respectively. Of 2921 approved applications, 88.8% prescriptions were filled. For the 376 rejected applications, 66.4% of prescriptions were filled. Overall, 90% of the cost of Xiaflex® was covered in Canada among those with extended health benefits, with an out-of-pocket expense of $210.4. Insurance coverage requests for Xiaflex® were approved at a high rate in Canada with approved patients being very likely to proceed with therapy, despite interprovincial variation.

3D bioprinting for organ and organoid models and disease modeling

INTRODUCTION

3D printing, a versatile additive manufacturing technique, has diverse applications ranging from transportation, rapid prototyping, clean energy, and medical devices.

AREAS COVERED

The authors focus on how 3D printing technology can enhance the drug discovery process through automating tissue production that enables high-throughput screening of potential drug candidates. They also discuss how the 3D bioprinting process works and what considerations to address when using this technology to generate cell laden constructs for drug screening as well as the outputs from such assays necessary for determining the efficacy of potential drug candidates. They focus on how bioprinting how has been used to generate cardiac, neural, and testis tissue models, focusing on bio-printed 3D organoids.

EXPERT OPINION

The next generation of 3D bioprinted organ model holds great promises for the field of medicine. In terms of drug discovery, the incorporation of smart cell culture systems and biosensors into 3D bioprinted models could provide highly detailed and functional organ models for drug screening. By addressing current challenges of vascularization, electrophysiological control, and scalability, researchers can obtain more reliable and accurate data for drug development, reducing the risk of drug failures during clinical trials.

A phase I study of an injectable lidocaine paste for spermatic cord block in men with chronic scrotal content pain

INTRODUCTION

Patients with chronic scrotal content pain (CSCP) lack effective, non-invasive treatment options. We aimed to determine the local and systemic safety, tolerability, pharmacokinetics (PK), and efficacy of a long-lasting local anesthetic in patients with CSCP.

METHODS

This was a prospective, single-center, open-label, single-arm, phase 1 dose-escalating trial completed between October 2019 and March 2021. Twelve patients ≥19 years old with unilateral scrotal pain lasting ≥3 months reporting an average maximum pain score over seven days of ≥4 on a 0-10 numerical rating scale (NRS) were included. Patients underwent a test spermatic cord block and those reporting a decrease of ≥2 points were included. The investigational drug, ST-01 (sustained-release lidocaine polymer solution), is a long-acting injection of lidocaine around the spermatic cord. Subjects were provided a NRS dairy and recorded their NRS score until day 28. The Chronic Epididymitis Symptom Index (CESI) was completed on days 0, 7, 14, and 28. All patients underwent an examination and assessment for adverse events (AE) on days 0, 1, 7, 14, and 28. Exploratory statistical hypothesis testing was planned for this study due to its investigative nature.

RESULTS

There were no serious adverse events (SAEs) reported. All subjects reported at least one treatment-emergent adverse event (TEAE); 83% of related AEs were injection-site reactions consisting of swelling and bruising. NRS was reduced across all cohorts between baseline and end of study.

CONCLUSIONS

This study provides evidence that the novel ST-01 treatment is safe and well-tolerated.

Case series: expanding diagnostic markers in postorgasmic illness syndrome

Introduction

Postorgasmic illness syndrome (POIS) is a rare condition in which individuals develop generalized and flu-like symptoms after ejaculation. Several mechanisms and treatments for this disorder have been proposed but many questions remain.

Aims

We sought to present a summary of literature to date and highlight common symptoms, associated features, comorbidities, and laboratory findings in a clinical sample of patients with POIS.

Methods

We conducted a retrospective chart review of 6 patients with POIS in our clinic and presented compiled results.

Results

We identified newly described non-flu-like presentations, onset of symptoms with high states of arousal without ejaculation, and presence of psychiatric comorbidity in a majority of patients. We did not identify a postorgasm allergic response with bloodwork available.

Conclusion

POIS remains a poorly understood condition that likely comprises a number of different clinical entities. Further research on a larger clinical sample is necessary to better characterize POIS and understand its biological and psychological basis.

A review of the experimental methods and results of testing the mechanical properties of Tunica Albuginea

The present work provides a comprehensive review of the literature on the mechanical properties and existing human tunica albuginea tissue testing methods. Assessments were completed on papers reporting experimental values of Young's modulus, tensile strength, puncture strength, stiffness, toughness, and strain at the ultimate tensile strength (UTS). A high degree of variability in the reported experimental values was found; Young's modulus ranged from 5 MPa to 118 MPa, and tensile strength went from 1.1 MPa to 6.1 MPa. A comparison of the variability of the reported experimental values for puncture strength, stiffness, toughness, and strain at the UTS could not be completed due to a lack of experimental results. This review discusses the pathophysiology and surgical treatment of erectile dysfunction and Peyronie's disease, variability in the existing reported mechanical properties, the impact of the variability of mechanical properties on in silico models and explores the absence of a standardised testing method as a possible reason for the variable in results. Finally, this work attempts to provide suggestions for standardising future mechanical testing of the tunica albuginea through minimising and reporting freeze/thaw cycling, noting the proximal/distal region of the cadaver tunica sample, reporting the orientation (o'clock position) of the cadaver tunica sample, and testing the cadaver tunica samples in bi-axial tension. Ultimately, standardising the testing methodologies of the tunica albuginea will provide higher confidence in reported mechanical property values.

Differentiation of Peritubular Myoid-Like Cells from Human Induced Pluripotent Stem Cells

Infertility affects 10-15% of couples, with half attributed to male factors. An improved understanding of the cell-type-specific dysfunction contributing to male infertility is needed to improve available therapies; however, human testicular tissues are difficult to obtain for research purposes. To overcome this, researchers have begun to use human induced pluripotent stem cells (hiPSCs) to generate various testis-specific cell types in vitro. Peritubular myoid cells (PTMs) are one such testicular cell type that serves a critical role in the human testis niche but, to date, have not been derived from hiPSCs. This study set forth to generate a molecular-based differentiation method for deriving PTMs from hiPSCs, mirroring in vivo patterning factors. Whole transcriptome profiling and quantitative polymerase chain reaction (qPCR) show that this differentiation method is sufficient to derive cells with PTM-like transcriptomes, including upregulation of hallmark PTM functional genes, secreted growth and matrix factors, smooth muscle, integrins, receptors, and antioxidants. Hierarchical clustering shows that they acquire transcriptomes similar to primary isolated PTMs, and immunostaining shows the acquisition of a smooth muscle phenotype. Overall, these hiPSC-PTMs will allow in vitro study of patient-specific PTM development and function in spermatogenesis and infertility.

A randomized comparison of group mindfulness and group cognitive behavioral therapy vs control for couples after prostate cancer with sexual dysfunction

BACKGROUND

Sexual dysfunction is the most common and most distressing consequence of prostate cancer (PCa) treatment and has been shown to directly affect the sexual function and quality of life of survivors' partners. There are currently no established therapies to treat the emotional and psychological burden that sexual issues impose on the couple after PCa.

AIM

Our study examined the impact of 2 therapies-cognitive behavioral therapy (CBT) and mindfulness therapy-on sexual, relational, and psychological outcomes of PCa survivor and partner couples.

METHODS

PCa survivors (n = 68) who self-reported current sexual problems after PCa treatments and their partners were randomized to 4 consecutive weeks of couples' mindfulness therapy, couples' CBT, or no treatment (control).

OUTCOMES

Couples' sexual distress, survivors' sexual satisfaction, and couples' relationship satisfaction, quality of life, psychological symptoms (anxiety and depression), and trait mindfulness were measured at baseline, 6 weeks after treatment, and 6 months after treatment.

RESULTS

Sexual distress and sexual satisfaction were significantly improved 6 weeks after the CBT and mindfulness interventions as compared with the control group, but only sexual distress remained significantly improved at 6 months. Relationship satisfaction decreased and more so for partners than survivors. There were increases in domains of quality of life for survivors vs their partners 6 months after treatments and an overall increase in general quality of life for couples 6 weeks after mindfulness. There were no significant changes in psychological symptoms and trait mindfulness. Qualitative analysis showed that the mindfulness intervention led to greater personal impact on couple intimacy after the study had ended.

CLINICAL IMPLICATIONS

CBT and mindfulness can be effective treatments for helping couples adapt to and cope with changes to their sexual function after PCa treatments and could help improve the most common concern for PCa survivors-that is, couples' sexual intimacy-after cancer, if added to routine clinical care.

STRENGTHS AND LIMITATIONS

We used established standardized treatment manuals and highly sensitive statistical methodology and accounted for covariable factors and moderators of primary outcomes. Due to difficulty in recruitment, we had a smaller control group than treatment, reducing our power to detect between-group differences. Our sample was mostly White, heterosexual, and affluent, thereby limiting the generalizability.

CONCLUSION

This is the first randomized clinical trial to test and demonstrate benefits among PCa survivors and partners' sexual outcomes after CBT and mindfulness as compared with a nontreatment control group.

Spermatogonial Stem Cells and In Vitro Spermatogenesis: How Far Are We from a Human Testis on a Chip?

An in vitro testis model will provide a superior platform for studying the testis microenvironment and molecular mechanisms that affect male fertility. The ultimate aim is to provide reproductive hope for children diagnosed with cancer who were sterilized by aggressive gonadotoxic therapies.

Fast and accurate matching of cellular barcodes across short-reads and long-reads of single-cell RNA-seq experiments

Single-cell RNA sequencing allows for characterizing the gene expression landscape at the cell type level. However, because of its use of short-reads, it is severely limited at detecting full-length features of transcripts such as alternative splicing. New library preparation techniques attempt to extend single-cell sequencing by utilizing both long-reads and short-reads. These techniques split the library material, after it is tagged with cellular barcodes, into two pools: one for short-read sequencing and one for long-read sequencing. However, the challenge of utilizing these techniques is that they require matching the cellular barcodes sequenced by the erroneous long-reads to the cellular barcodes detected by the short-reads. To overcome this challenge, we introduce scTagger, a computational method to match cellular barcodes data from long-reads and short-reads. We tested scTagger against another state-of-the-art tool on both real and simulated datasets, and we demonstrate that scTagger has both significantly better accuracy and time efficiency.

Automated rare sperm identification from low-magnification microscopy images of dissociated microsurgical testicular sperm extraction samples using deep learning

OBJECTIVE

To develop a machine learning algorithm to detect rare human sperm in semen and microsurgical testicular sperm extraction (microTESE) samples using bright-field (BF) microscopy for nonobstructive azoospermia patients.

DESIGN

Spermatozoa were collected from fertile men. Testis biopsies were collected from microTESE samples determined to be clinically negative for sperm. A convolutional neural network based on the U-Net architecture was trained using 35,761 BF image patches with fluorescent ground truth image pairs to segment sperm. The algorithm was validated using 7,663 image patches. The algorithm was tested using 7,663 image patches containing abundant sperm, as well as 7,985 image patches containing rare sperm.

SETTING

In vitro fertilization center and university laboratories.

PATIENT(S)

Normospermic and nonobstructive azoospermia patients.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Precision (positive predictive value [PPV]), recall (sensitivity), and F1-score of detected sperm locations.

RESULT(S)

For sperm-only samples, our algorithm achieved 91% PPV, 95.8% sensitivity, and 93.3% F1-score at ×10 magnification. For dissociated microTESE samples doped with an abundant quantity of sperm, our algorithm achieved 84.0% PPV, 72.7% sensitivity, and 77.9% F1-score. For dissociated microTESE samples doped with rare sperm, our algorithm achieved 84.4% PPV, 86.1% sensitivity, and 85.2% F1-score.

CONCLUSION(S)

Rare sperm can be detected in patients' testis biopsy samples for potential subsequent use in in vitro fertilization-intracytoplasmic sperm injection. A machine learning algorithm can use BF images at ×10 magnification to accurately detect sperm locations using automated imaging.

OHNUT VS WAITLIST CONTROL FOR THE SELF-MANAGEMENT OF ENDOMETRIOSIS-ASSOCIATED DEEP DYSPAREUNIA: A PILOT RANDOMIZED CONTROLLED TRIAL PROTOCOL (Preprint)

BACKGROUND

Endometriosis-associated deep dyspareunia is associated with reduced sexual quality of life, lower self-esteem, and impaired sexual function.

OBJECTIVE

The primary objective is to assess the acceptability of a phallus length reducer (brand name: Ohnut [OhnutCo]), which is a buffer worn over the penis or a penetrating object to reduce endometriosis-associated deep dyspareunia, and the feasibility of a definitive randomized controlled trial (RCT). The secondary objective is to obtain estimates of the effectiveness of the buffer. An embedded substudy will explore the acceptability and the preliminary validity and reliability of a vaginal insert for the self-assessment of deep dyspareunia.

METHODS

Ours is an investigator-initiated, 2-arm RCT. We will recruit 40 patient participants with diagnosed endometriosis between the ages of 19 and 49 years, as well as their sexual partners. The participating couples will be randomized in a 1:1 ratio into the experimental arm or the waitlist control arm. The length of the study period will be 10 weeks, during which time all participants will record deep dyspareunia severity following each episode of sexual intercourse. In weeks 1 to 4, all patient participants will record deep dyspareunia severity at each sexual encounter. In weeks 5 to 10, participants in the experimental arm will use the buffer during vaginal penetration; participants in the waitlist control arm will continue engaging in vaginal penetration as usual. Participants will complete questionnaires for assessing measures of anxiety, depression, and sexual function at baseline, at 4 weeks, and at 10 weeks. In the substudy, patient participants will self-assess dyspareunia by using a vaginal insert on 2 occasions, at least 1 week apart. The primary outcomes-the acceptability and feasibility of the buffer-will be assessed with descriptive statistics, and the secondary outcome-phallus length reducer effectiveness-will be assessed by using an analysis of covariance-based approach. For the vaginal insert, we will assess acceptability, test-retest reliability, and convergent validity via correlation analyses comparing the use of the insert to clinical examination in terms of dyspareunia assessment outcomes.

RESULTS

Our pilot will provide initial data on the acceptability and effectiveness of the buffer and the feasibility of the study methodology. The results from our study are expected to be submitted for publication by the spring of 2023. As of September 2021, we have consented 31 couples into the study.

CONCLUSIONS

Our study will provide preliminary evidence for the self-assessment and management of endometriosis-associated deep dyspareunia. The findings will inform the decision to proceed to a definitive RCT.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04370444; https://clinicaltrials.gov/ct2/show/NCT04370444.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/39834.

Using clinically derived human tissue to 3-dimensionally bioprint personalized testicular tubules for in vitro culturing: first report

OBJECTIVE

To study the feasibility and spermatogenic potential of 3-dimensional (3D) bioprinting personalized human testicular cells derived from a patient with nonobstructive azoospermia (NOA).

DESIGN

A human testicular biopsy from a single donor with NOA was dissociated into single cells, expanded in vitro, and 3D bioprinted into tubular structures akin to the seminiferous tubule using AGC-10 bioink and an RX1 bioprinter with a CENTRA coaxial microfluidic printhead from Aspect Biosystems. Three-dimensional organoid cultures were used as a nonbioprinted in vitro control.

SETTING

Academic medical center.

PATIENT(S)

A 31-year-old man with NOA with testis biopsy demonstrating Sertoli cell-only syndrome.

INTERVENTION(S)

Three-dimensional bioprinting and in vitro culturing of patient-derived testis cells.

MAIN OUTCOME MEASURE(S)

Cellular viability after printing was determined, along with the expression of phenotypic and spermatogenic functional genetic markers after 12 days of in vitro culture.

RESULT(S)

Testicular cultures were expandable in vitro and generated sufficiently large numbers for 3D bioprinting at 35 million cells per mL of bioink. Viability 24 hours after printing was determined to be 93.4% ± 2.4%. Immunofluorescence staining for the phenotype markers SRY-Box transcription factor 9, insulin-like 3, actin alpha 2 smooth muscle, and synaptonemal complex protein 3 after 12 days was positive, confirming the presence of Sertoli, Leydig, peritubular myoid, and meiotic germ cells. Reverse transcription qualitative polymerase chain reaction analysis showed that after 12 days in spermatogenic media, the bioprints substantially up-regulated spermatogenic gene expression on par with nonbioprinted controls and showed a particularly significant improvement in genes involved in spermatogonial stem cell maintenance: inhibitor of deoxyribonucleic acid binding 4 by 365-fold; fibroblast growth factor 3 by 94,152-fold; stem cell growth factor receptor KIT by twofold; stimulated by retinoic acid 8 by 125-fold; deleted in azoospermia-like by 114-fold; synaptonemal complex protein 3 by sevenfold; zona pellucida binding protein by twofold; transition protein 1 by 2,908-fold; and protamine 2 by 11-fold.

CONCLUSION(S)

This study demonstrates for the first time the feasibility of 3D bioprinting adult human testicular cells. We show that the bioprinting process is compatible with high testicular cell viability and without loss of the main somatic phenotypes within the testis tissue. We demonstrate an increase in germ cell markers in the 3D bioprinted tubules after 12 days of in vitro culture. This platform may carry future potential for disease modeling and regenerative opportunities in a personalized medicine framework.

Canadian Urological Association guideline: Erectile dysfunction

Erectile dysfunction (ED) impacts the wellness and quality of life of millions of Canadians. An evaluation focused on the identification of reversible and irreversible underlying factors is recommended for patients presenting with ED. Through a shared decision-making model framework, the goal of ED treatment is to improve functional outcomes and enhance sexual satisfaction while minimizing adverse effects associated with treatment. Given that ED is assessed and treated by multiple different types of health practitioners, the purpose of this guideline is to provide the best available evidence to facilitate care delivery through a Canadian lens. After a narrative review of ED assessment and treatment for general readership, five key clinical questions relating to priority areas of ED are assessed using the GRADE and evidence-to-decision-making frameworks.

Impact of duloxetine on male fertility: A randomised controlled clinical trial

This study assessed the impact of duloxetine (serotonin and norepinephrine reuptake inhibitor) on semen parameters, sperm DNA fragmentation and serum hormones. We performed a double-blind, placebo-controlled, randomised clinical trial of duloxetine 60mg or placebo daily for 6 weeks (5 weeks full dose and 1 week taper). The primary outcome was the proportion of men with abnormal DNA fragmentation during and after duloxetine administration. Secondary outcomes were changes in semen parameters and hormones on treatment (2 and 6 weeks) and after discontinuation (8 and 10 weeks). Sixty-eight healthy males aged 18-65 were included. Duloxetine was not associated with an increase in the proportion of participants with abnormal sperm DNA fragmentation terminal deoxynucleotidyl transferase dUTP nick-end labelling scores (>25%) on treatment (p = 0.09) or after treatment (p = 0.56), nor did median sperm DNA fragmentation increase on treatment. Compared with placebo, there were no changes in bulk semen parameters during treatment. Limited changes in hormonal values were detected. This first published human study of a serotonin and norepinephrine reuptake inhibitor on male fertility revealed no clinically meaningful effects on sperm DNA fragmentation, semen parameters or serum hormones. Duloxetine, and possibly other serotonin and norepinephrine reuptake inhibitors, may be considered for men desiring fertility who require antidepressant treatment.

Male factor infertility: Initial workup and diagnosis in primary care

OBJECTIVE

To present a case-based discussion on the workup of male factor infertility and review currently available treatments.

SOURCES OF INFORMATION

This discussion is based on the current Canadian Urological Association and American Urological Association guidelines, with reference to landmark papers as appropriate from 2010 onward. All articles were retrieved through PubMed.

MAIN MESSAGE

Approximately 15% of Canadian couples experience infertility, making it a commonly encountered condition in the primary care setting. Among couples suffering from infertility, male factors can be identified as the sole cause in 30% of cases and as a contributing issue in 20% of cases. Although many of the treatments described aim to improve a couple's chances of naturally conceiving a child via intercourse, many patients ultimately require medical or surgical intervention to achieve pregnancy. This can be a long, protracted course for patients, with important roles for primary care providers and fertility specialists alike.

CONCLUSION

Male fertility assessment and treatment has historically been left in the hands of fertility specialists, creating a bottleneck for patients to receive fertility care. However, with increased understanding of the underlying causes of male factor infertility, the workup and initial management can occur in the primary care setting, helping to streamline care.

Promoting Men's Health With the "Don't Change Much" e-Program

Men's e-health promotion programs can offer end-user anonymity and autonomy that provide avenues for supporting positive health behavior change. The twofold purpose of the current study was to use a benchmark cohort as a reference group to: (1) describe associations between men's usage levels of the e-health program Don't Change Much (DCM) and their recent and intended health behavior changes, and (2) report an exploratory analysis of the moderating effects of demographic variables on the associations between DCM users and their recent and intended health behavior changes. Based on self-report, DCM users were classified into limited (n = 613, 34.7%), low (n = 826, 46.8%), and high (n = 327, 18.5%) exposure groups. Compared with the benchmark cohort, DCM high-exposure respondents had significantly increased odds for eight of the nine recent behavior changes, with the largest effect size observed for "Made an effort to sit less and walk more" (odds ratio [OR] 2.996, 95% CI [2.347, 3.826]). Eight of the nine intended health behavior changes in the DCM high-exposure group had significantly increased odds compared to the benchmark cohort, with "Reduce stress level" (OR 3.428, 95% CI [2.643, 4.447]) having the largest effect size. Significantly greater total numbers of recent (F(12, 2850) = 29.32; p = .001; R² = .086) and intended health behavior changes (F(12, 2850) = 34.59; p = .001; R² = 0.100) were observed among high exposure respondents while adjusting for demographics. Younger age, being employed, and household income <$120,000 had an enhancing moderator effect on DCM users' number of intended behavior changes.

Y-microdeletions: a review of the genetic basis for this common cause of male infertility

The human Y-chromosome contains genetic material responsible for normal testis development and spermatogenesis. The long arm (Yq) of the Y-chromosome has been found to be susceptible to self-recombination during spermatogenesis predisposing this area to deletions. The incidence of these deletions is estimated to be 1/4,000 in the general population but has been found to be much higher in infertile men. Currently, Y-microdeletions are the second most commonly identified genetic cause of male infertility after Klinefelter syndrome. This has led to testing for these deletions becoming standard practice in men with azoospermia and severe oligospermia. There are three commonly identified Y-microdeletions in infertile males, termed azoospermia factor (AZF) microdeletions AZFa, AZFb and AZFc. With increased understanding and investigation of this genetic basis for infertility a more comprehensive understanding of these deletions has evolved, with several other deletion subtypes being identified. Understanding the genetic basis and pathology behind these Y-microdeletions is essential for any clinician involved in reproductive medicine. In this review we discuss the genetic basis of Y-microdeletions, the various subtypes of deletions, and current technologies available for testing. Our understanding of this issue is evolving in many areas, and in this review we highlight future testing opportunities that may allow us to stratify men with Y-microdeletion associated infertility more accurately

Histology and sperm retrieval among men with Y chromosome microdeletions

In this review of Y chromosome microdeletions, azoospermia factor (AZF) deletion subtypes, histological features and microTESE sperm retrieval rates are summarized after a systematic literature review. PubMed was searched and papers were identified using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Approximately half of infertile couples have a male factor contributing to their infertility. One of the most common genetic etiologies are Y chromosome microdeletions. Men with Y chromosome microdeletions may have rare sperm available in the ejaculate or undergo surgical sperm retrieval and subsequent intracytoplasmic sperm injection to produce offspring. Azoospermia or severe oligozoospermia are the most common semen analysis findings found in men with Y chromosome microdeletions, associated with impaired spermatogenesis. Men with complete deletions of azoospermia factor a, b, or a combination of any loci have severely impaired spermatogenesis and are nearly always azoospermic with no sperm retrievable from the testis. Deletions of the azoospermia factor c or d often have sperm production and the highest likelihood of a successful sperm retrieval. In men with AZFc deletions, histologically, 46% of men demonstrate Sertoli cell only syndrome on biopsy, whereas 38.2% have maturation arrest and 15.7% have hypospermatogenesis. The microTESE sperm retrieval rates in AZFc-deleted men range from 13-100% based on the 32 studies analyzed, with a mean sperm retrieval rate of 47%.

The effects of Y chromosome microdeletions on in vitro fertilization outcomes, health abnormalities in offspring and recurrent pregnancy loss

Male factor infertility accounts for approximately 50% of all infertility evaluations. A common cause of severe oligozoospermia and azoospermia is Y chromosome microdeletions (YCMs). Men with these genetic microdeletions must typically undergo assisted reproductive technology (ART) procedures to obtain paternity. In this review, we performed a thorough and extensive search of the literature to summarize the effects of YCMs on in vitro fertilization (IVF) outcomes, health abnormalities in offspring and recurrent pregnancy loss (RPL). The PubMed database was searched using specific search terms and papers were identified using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Sperm retrieval amongst men with complete AZFa and/or AZFb deletions is extremely rare and thus data on ARTs is largely unavailable. In AZFc-deleted men undergoing assisted reproduction, the collective fertilization rate (FR) is 59.8%, the clinical pregnancy rate is 28.6% and the live birth rate is 23.4%. When successful, the YCM is always transmitted to the male offspring and the deletion size either remains unchanged or widens. YCMs generally result in decreased fertilization, clinical pregnancy and live birth rates compared to men with intact Y chromosomes during ART interventions. There is a minimal or absent association of YCMs with abnormalities in the offspring or RPL.

Canadian men's health stigma, masculine role norms and lifestyle behaviors

Men are at high risk for both morbidity and premature mortality from several of the most common serious diseases. Although numerous factors have been identified to explain men's risk, this study focused on the relationship between lifestyle behaviors, health-related self-stigma and masculine role norms. An age and location stratified sample of 2000 Canadian men completed measures assessing five lifestyle behaviors (smoking, alcohol use, sleep, diet and exercise), a screen for depression, and measures of self-stigma and masculine role norms. The results showed that elements of both health-related self-stigma and masculine role norms were associated with increased risk for being above the clinical threshold for four of the lifestyle behaviors and depression. The most frequent and largest relationships were associated with exercise and depression. The total number of lifestyle behaviors for which participants were above the clinical cut-points was also associated with self-stigma and masculine role norms. These findings demonstrate the importance of health-related self-stigma and masculine role norms as potential barriers to men's health and well-being.

Regulation of Human Spermatogenesis

Human spermatogenesis (HS) is an intricate network of sequential processes responsible for the production of the male gamete, the spermatozoon. These processes take place in the seminiferous tubules (ST) of the testis, which are small tubular structures considered the functional units of the testes. Each human testicle contains approximately 600-1200 STs [1], and are capable of producing up to 275 million spermatozoa per day [2].

Testicular Torsion and Spermatogenesis

Testicular torsion (TT) is a common urologic emergency that can occur at any age. It is most common in newborns and during puberty. Prompt evaluation and management is required to salvage the testis following an episode of torsion. TT brings about damage to testicular tissue and spermatogenesis through various hypothesized mechanisms; however there is a consensus that the effects of ischemia, ischemia-reperfusion injury, and oxidative stress account for the most destructive effects. Numerous studies have examined the effects of various agents and therapies in limiting the effects of TT on the testis.

Testosterone therapy: Prescribing and monitoring patterns of practice in British Columbia

INTRODUCTION

Guidelines recommend that testosterone therapy (TTh) be restricted to men with a biochemical diagnosis of hypogonadism, and that therapeutic responses be titrated within the normal range.

METHODS

Using four provincial longitudinal databases in British Columbia, we identified men prescribed TTh from 1997-2013. We characterized the prescribing and monitoring practices of TTh in the context of serum testosterone levels drawn prior to and following initiation of TTh in a population-based setting.

RESULTS

In our analysis of 37 741 men who received at least one TTh prescription, 48% received injectable testosterone and the vast majority were treated by general practitioners. The number of prescriptions for men increased annually, particularly after 2008; 40% discontinued their treatment after their first or second prescription, while 27% received more than 10 repeats. The absolute percentage of pre- and post-serum testosterone levels ordered increased by 16% and 31% during the study period, respectively. However, after initiating TTh, only 36% of all the men had a followup serum testosterone level drawn. Of those with low serum testosterone levels prior to TTh, 49% remained biochemically hypogonadal following TTh, suggesting non-compliance or inadequate dosing.

CONCLUSIONS

Many men prescribed TTh did not continue beyond a short trial. While the practice of checking pre-and post-TTh testosterone levels improved over the study period, it is concerning that only one-third had a followup serum testosterone level and half remained biochemically low. Further education is required around TTh prescribing, dose titration, and monitoring to ensure both effective and safe prescribing practice.

Men's health in Canada: A national survey of urologists

N/A 

Vasovasostomy: kinetics and predictors of patency

OBJECTIVE

To assess the timing of patency and late failure (secondary azoospermia) after vasovasostomy (VV) using standardized kinetics definitions.

DESIGN

Retrospective cohort study.

SETTING

University-affiliated hospital.

PATIENT(S)

Patients with obstructive azoospermia.

INTERVENTION(S)

Vasovasostomy.

MAIN OUTCOME MEASURE(S)

Univariate and multivariate logistic regression assessed predictors of patency and late failure. Patency was defined as any sperm return to the ejaculate; and >2 million total motile sperm (TMS) in ejaculate. Late failure after VV was defined as azoospermia; or <2 million TMS in ejaculate.

RESULT(S)

429 men underwent VV, with median follow up of 242 days. Mean time to patency was 3.25 months versus 5.29 months in the "any sperm" versus ">2 million TMS" groups. Finding sperm intraoperatively during VV significantly improved patency rates in multivariable analysis (odds ratio [OR] 4.22). This association was further boosted when sperm was found bilaterally (OR 6.70). Late failure rate (azoospermia) was 10.6% at mean time of 14.1 months and 23% for <2 million, at mean time of 15.7 months. When assessing predictors of late failure, intraoperative motile sperm bilaterally was a statistically significant protective factor on multivariate analysis (hazard ratio 0.22).

CONCLUSION(S)

Vasovasostomy remains highly efficacious in treating obstructive azoospermia. Young patients, shorter obstructive intervals, and sperm identified intraoperatively predict improved outcomes. Clinicians can expect VV patency in 3 months and late failure within the first 2 years after surgery. However, patency rates, late failure rates, and kinetics vary by definition.

Predictors of Unhealthy Alcohol Consumption Behavior in Canadian Men

Aims: Men are more likely to engage in alcohol consumption, which can have long term consequences. The objective of our study was to sample Canadian men to determine predictors of alcohol hazardous consumption as well as predictors for change. Methods: Canadian men were surveyed investigating demographics, medical comorbidities, health behaviors and their willingness to change. Alcohol consumption was classified based on validated Audit-C scoring (>3 was positive for dependency or abuse). Stages of change were classified based on the trans-theoretical model of change (pre-contemplation, contemplation, preparation, action, and maintenance). Multivariate regression was performed to determine demographic factors as predictors for consumption and change. Results: After exclusions and sample stratification, 2000 participants were included. Participants were aged 19-94 (median 48, IQR 34-60). Approximately 773 (38.7%) screened positive based on Audit-C scores. On multivariate analysis, minority status, age, work, income, retirement, living situation, geographic location and level of education were associated with hazardous drinking. Of those with hazardous drinking, the majority were in pre-contemplation or contemplation 488 (63.1%). On multivariate analysis, various demographic factors were associated with the five stages of change.  Conclusion: Our study illustrates that approximately 40% of men screen positive for unhealthy drinking behavior and associated demographic risk factors for those at highest risk. The majority are in the earliest stages in trans-theoretical model for change (>60%), and there exist only few associated demographic risk factors. This warrants awareness of this national problem, insight for patient education and targeted interventions to address hazardous behavior and reduce morbidity and mortality.