Testosterone therapy: where do the latest guidelines agree and differ?

PURPOSE OF REVIEW

The incidence of testosterone deficiency and number of men on testosterone therapy (TTh) has increased significantly over the past 3 decades. This rise has been accompanied by controversies surrounding the indications and possible adverse effects of therapy. To better inform prescribing habits among providers, many major medical associations have devised guidelines regarding the diagnosis and management of testosterone deficiency. While these guidelines agree in many areas, there are some key differences that should be identified. This review will explore the similarities, differences, and rationale for these guidelines.

RECENT FINDINGS

Over the past 7 years, much attention has been devoted to the implications of TTh on cardiac health. All reviewed guidelines include dedicated sections discussing these implications and the society's position on prescribing testosterone considering recent findings, however, differ on specific contraindications to TTh and when to initiate therapy after a cardiovascular event. In addition, the American College of Physicians released its first guideline earlier this year which may impact prescribing habits among primary care physicians.

SUMMARY

The differences between testosterone deficiency guidelines may indicate gaps in our knowledge of testosterone deficiency and focuses of future research efforts. Prescribers should be aware of these differences and discuss all treatment options with their patients.

SARS-CoV-2 infection, male fertility and sperm cryopreservation: a position statement of the Italian Society of Andrology and Sexual Medicine (SIAMS) (Società Italiana di Andrologia e Medicina della Sessualità)

PURPOSE

The recent pandemic of severe acute respiratory syndrome (SARS) due to coronavirus (CoV) 2 (SARS-CoV-2) has raised several concerns in reproductive medicine. The aim of this review is to summarize available evidence providing an official position statement of the Italian Society of Andrology and Sexual Medicine (SIAMS) METHODS: A comprehensive Pubmed, Web of Science, Embase, Medline and Cochrane library search was performed. Due to the limited evidence and the lack of studies, it was not possible to formulate recommendations according to the Oxford 2011 Levels of Evidence criteria.

RESULTS

Several molecular characteristics of the SARS-CoV-2 can justify the presence of virus within the testis and possible alterations of spermatogenesis and endocrine function. Orchitis has been reported as a possible complication of SARS-CoV infection, but similar findings have not been reported for SARS-CoV-2. Alternatively, the orchitis could be the result of a vasculitis as COVID-19 has been associated with abnormalities in coagulation and the segmental vascularization of the testis could account for an orchitis-like syndrome. Finally, available data do not support the presence of SARS-CoV-2 in plasma seminal fluid of infected subjects.

CONCLUSION

Data derived from other SARS-CoV infections suggest that in patients recovered from COVID-19, especially for those in reproductive age, andrological consultation and evaluation of gonadal function including semen analysis should be suggested. Studies in larger cohorts of currently infected subjects are warranted to confirm (or exclude) the presence of risks for male gametes that are destined either for cryopreservation in liquid nitrogen or for assisted reproduction techniques.

Quality assurance and quality control in the laboratory andrology

Quality assurance (QA) and quality control (QC) are fundamental aspects of any laboratory measurement. However, in comparison with other medical disciplines, the need for QA and QC in laboratory andrology has been recognized only recently. Furthermore, there is evidence that the effort required to undertake QA and QC has not been wholly welcomed by some clinicians. Nevertheless, accrediting bodies and regulatory authorities increasingly require evidence that laboratories have effective QA and QC measures in place because both are central to the quality management processes. Following the publication of the 5th edition of the World Health Organization Laboratory Manual, existing QA and QC systems will need to be updated to take into account some of the methodological changes recommended by the manual. Three of these are discussed in this commentary; they relate to: (i) the move to infer semen volume from its weight; (ii) the re-classification of sperm motility grades from four to three; and (iii) the publication of a lower reference limit for morphology of 4% (with a corresponding 95% confidence interval of 3%-4%). The importance of QA and QC in all laboratory tests, including up and coming new tests to assess sperm DNA integrity, is discussed. The need for adequate initial training and continuing professional development programmes to support laboratory scientists performing andrology is also described.

Computer-aided evaluation of assessment of “grade a” spermatozoa by experienced technicians

OBJECTIVE

To determine how well technicians assess progressively motile spermatozoa.

DESIGN

Comparison of computerized and technician assessments of "grade a" spermatozoa.

SETTING

University fertility clinic.

PATIENT(S)

Infertile men of barren marriages.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Threshold velocities of spermatozoa categorized as "grade a."

RESULT(S)

The ability of andrology technicians to distinguish "grade a" from "grade b" spermatozoa was examined monthly. Computer-aided sperm analysis (CASA) provided the threshold velocities used by technicians to categorize "grade a" spermatozoa. The mean cutoff value for grades a/b (25.5 microm/s) was close to the designated velocity, but the cutoff for grades b/c sperm (9.9 microm/s) was higher. Cutoff values for "grade a" spermatozoa were significantly, positively, and linearly related with the mean velocity of spermatozoa obtained by CASA, and deviated from it in a systematic way. The percentage of "grade a" spermatozoa judged by technicians was poorly correlated with the percentage "grade a" indicated by CASA and the cutoff velocity of "grade a" spermatozoa depending on the overall sperm quality of the semen sample.

CONCLUSION(S)

Consideration should be given to replacing the subdivision of progressing spermatozoa into two categories with one of progressive spermatozoa, or the use of CASA to distinguish "grade a" sperm reliably should be insisted upon.

Lack of compliance by UK andrology laboratories with World Health Organization recommendations for sperm morphology assessment

BACKGROUND

Sperm morphology is known to correlate with the probability of conception both in vitro and in vivo, but the assessment of sperm morphology in the laboratory remains problematic. The 4th edition (1999) of the World Health Organization (WHO) Laboratory Manual has attempted to improve matters by giving rigorous recommendations regarding sperm morphology assessment. However, it is unknown how well these recommendations have been implemented in practice.

METHODS

A survey of the methods used to undertake the assessment of sperm morphology during semen analysis was undertaken in 37 laboratories in the UK.

RESULTS

In total, only two laboratories (5%) were compliant with all current WHO guidelines regarding morphology assessment, including methods of staining and observation, classifying and sampling methods, and the participation in internal and external quality control programmes.

CONCLUSION

These results illustrate an urgent need for education and training initiatives to encourage laboratories to become compliant with current WHO guidelines for sperm morphology assessment.

Is quality assurance in semen analysis still really necessary? A spermatologist's viewpoint

In a provocative article to this Journal, Anne Jecquier, an eminent andrologist who, more than 20 years ago, was a prime mover in suggesting the need for quality assurance (QA) in andrology laboratories, has now proposed that the QA schemes may no longer be needed. Here I reply to that proposition, largely by agreeing that, since the QA schemes have brought about higher technical standards in laboratories, Anne Jecquier's assertion is possibly true. However, vigilance is still needed in discriminating between unproductive investment of time and energy in the refinement of tests that may offer little information about fertility, and maintaining technical standards such that where necessary they provide the requisite information. Thus, although it may not matter in practice whether a sperm concentration is estimated as 100 or 200 x 10(6)/ml, distinguishing between 25 and 100 x 10(6)/ml would probably influence a clinician's treatment decisions. Anne Jecquier also suggested that sperm function tests have limited predictive value in terms of fertility assessment. While I agree that this is largely true at present, I also argue that these tests are probably not developed to their full potential. I am optimistic that tests to distinguish and quantify the population of fertilization-competent sperm within an ejaculate will eventually become available.

Quality specifications for seminal parameters based on the state of the art

BACKGROUND

The aim of this study was to calculate the analytical goal for seminal parameters based on the state of the art, and then to compare these specifications with those previously obtained by our group based on biological variation.

METHODS

All data used for analysis were derived from the Spanish programme of external quality control on semen analysis. Over 90 laboratories participated from 1999 to 2003. Using graphs of the state of the art, we also determined the numbers of laboratories that achieved quality specifications.

RESULTS

The total allowable error calculated using state of the art graphs is similar to that calculated using biological variation for concentration and total motility. However, it is much higher for morphology and rapidly progressive motility. Over 80% of the laboratories achieved the minimum quality specification based on biological variation for concentration, total and progressive motility. However, only approximately 30% of the laboratories achieved the minimum quality specification based on biological variation for morphology and rapidly progressive motility.

CONCLUSIONS

The study enabled us to identify the state of the art of analytical performance for seminal parameters, and revealed the difficulty inherent in meeting the quality specifications based on biological variation.

Does the potential for selection bias in semen quality studies depend on study design? Experience from a study conducted within an infertility clinic

BACKGROUND

The low participation rates in human semen quality studies raises concern for the potential of differential participation based on semen quality (or a surrogate). To explore the potential for differential participation, we compared semen analysis results from study subjects with those of non-study subjects.

METHODS

We obtained semen analysis results from 235 study subjects and retrospectively obtained results from a subset of 235 infertility clinic patients that were not study subjects but met the same eligibility criteria. The study was conducted at the Massachusetts General Hospital Infertility Clinic. All semen samples (study subjects and non-study subjects) were analysed for sperm concentration and motility by computer-aided semen analysis (CASA), and morphology was assessed using strict criteria. Semen analysis parameters for the non-study subjects were compared with the semen analysis results from study subjects.

RESULTS

For all semen characteristics (sperm concentration, total sperm count, sperm motility and morphology), there were only marginal (non-significant) differences between study subjects and non-study subjects.

CONCLUSIONS

Among men from an infertility clinic, we found no strong evidence of differential participation based on semen quality. This is reassuring since the potential for selection bias is of concern in semen quality studies. However, the potential for selection bias in other study designs remains unclear.

Is quality assurance in semen analysis still really necessary? A clinician's viewpoint

Quality assurance in semen analysis is now a standard procedure in most andrology laboratories. This communication is now questioning its value in any clinical situation and as a consequence asks whether the effort and the expense of such a process is really worthwhile. It concludes that semen analysis needs only to be performed competently without the need for costly and time-consuming forms of quality assurance.

Practice Committee of the American Society for Reproductive Medicine. Treatment of androgen deficiency in the aging male

Although guidelines for androgen replacement therapy for older men have been developed by several groups, the data to support treatment are based on the results of only a small number of clinical trials. It has not been definitively established that the decline in testosterone seen in most aging men results in an androgen deficient state with health-related outcomes that can be improved by androgen therapy.