Global Andrology Forum (GAF) Clinical Guidelines on the Management of Non-obstructive Azoospermia:Bridging the Gap between Controversy and Consensus

PURPOSE: Non-obstructive azoospermia (NOA), defined as the absence of sperm in the ejaculate due to testicular failure, is observed in 5% to 15% of infertile men and accounts for two-thirds of azoospermia cases. The management of NOA is marked by significant controversy and global variation in diagnostic and therapeutic approaches, highlighting the crucial need for well-designed and standardized clinical practice guidelines. We present comprehensive graded clinical practice recommendations and statements for diagnosing and treating NOA, aiming to establish standardized strategies that can globally help guide practitioners in their practice.MATERIALS AND METHODS: A comprehensive literature review was conducted to gather evidence on the epidemiological, diagnostic, and therapeutic aspects of NOA. The Global Andrology Forum (GAF) recommendations were developed through the collaboration of a global panel of experts using the Delphi method and surveys to achieve consensus. Statements were graded according to the Oxford Centre for Evidence-Based Medicine "GRADE" classification as either "Strong" or "Weak." Statements receiving at least 80% expert consensus were graded as "Strong," while others were categorized as "Weak."RESULTS: The GAF has formulated a total of 49 recommendations and statements on the diagnosis and treatment of NOA, including 21 for diagnosis and 28 for treatment. The recommendations and statements were evaluated and graded by a panel of 48 GAF experts from 25 countries worldwide. The majority of experts (60.5%) had more than 10 years of clinical experience in managing NOA.CONCLUSIONS: The GAF guidelines address discrepancies in NOA management across diverse clinical settings and provide comprehensive graded recommendations to guide clinicians in its diagnosis and treatment. Developed and graded by a large worldwide panel of experts, the current guidelines present simplified, high-standard strategies that can be seamlessly integrated into the daily global practice, offering practitioners a clear framework for managing NOA.</p

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Management of Renal Malignancies in Von Hippel–Lindau Syndrome: Lessons Learned from a Series of Six Patients from Sri Lanka

Management of renal malignancies in Von Hippel-Lindau (VHL) is challenging. We present six patients [mean age = 35.1 years (range: 24–54), males = 5] with VHL syndrome with multiple bilateral renal malignancies and the lessons learned during their management. The number of tumors at the time of presentation ranged from 1 to 6, while the number of new lesions varied from 1 to 3. Different combinations of radical nephrectomy (n = 2), partial nephrectomy (n = 7), and focal therapy (n = 6) were used appropriately. Median follow-up was 36 months (range: 12–72). Two patients developed new lesions which were managed with focal therapy. Nephron-sparing approaches are successful even in bilateral, multifocal, large, and recurring renal tumors associated with VHL. Awareness about the availability of efficacious surgical and minimally invasive measures would reduce psychosocial problems faced by patients and their families due to the social stigma associated with malignancies running in a family and burden of renal replacement therapy

Dissections or Prosections; Which Method has a Better Impact on Sustainable Gross Anatomy Knowledge?

Abstract Background: Two groups of medical students in their final year were tested on the key concepts of gross anatomy using a question paper that included true false type questions and identification of anatomical line diagrams. These two batches of students followed a dissection based curriculum and a newly introduced prosections based curriculum at the beginning of their medical education respectively. The prosections based curriculum brought with it a significant cut down on the in-class teaching and learning activities when compared to the old curriculum. The objective of the study was to establish which method was more effective at establishing a core of anatomy knowledge that could be recalled after a considerable amount of time. This would in turn reflect how much of anatomy knowledge one would possess when they start to practice medicine as a newly qualified doctor and also embark on a postgraduate training programme.Methods: The two groups were subjected without prior warning to a question paper that comprised six questions, each with five True/False statements and four questions on identification and labelling of anatomical line diagrams.Results: There was no statistically significant difference in the marks obtained for the true false type questions between the two groups (p=0.076), but the prosections group obtained higher marks for the diagram identification questions (p = 0.022).Conclusions: Therefore, it was concluded that a prosection based curriculum when compared to a dissection based curriculum was equally effective at establishing a core of gross anatomy knowledge in a considerably lesser amount of time.</jats:p

High sperm DNA fragmentation u2013 finding a needle in the haystack: tips on selecting the best sperm for ICSI and ART

International audienceHigh levels of sperm DNA fragmentation (SDF) are associated with reduced assisted reproductive technology (ART) outcomes. Currently, SDF is not included in routine clinical assessment of male partners of infertile couples, but the 6th edition of the World Health Organization (WHO) manual for semen analysis included the SDF assessment in the chapter on extended semen examinations. SDF evaluation may be indicated in several clinical conditions that have been shown to affect and increase DNA fragmentation. In cases with high SDF levels, the clinician will attempt to correct any reversible factors and may treat the patients empirically with antioxidants. If high levels of SDF persist despite empirical treatment, intracytoplasmic sperm injection (ICSI) may be indicated. During ICSI, embryologists can employ advanced selection procedures, to reduce the proportion of spermatozoa with DNA fragmentation, although no procedure can ensure that only non-DNA-fragmented will be spermatozoa selected