Male circumcision and HIV in Zambia

Background: Over the last 10 years considerable interest has developed in male circumcision as a possible tool in reducing HIV transmission in high prevalence countries of sub-Saharan Africa. Statements from normative agencies, though cautious, have encouraged the introduction of safe hospital based circumcision practice where the demand for these services exists1. The anecdotal evidence has now been followed by one randomized control trial. The results of two further trials are awaited. In the interim , interest has grown in the question of how male circumcision can be operationalised in a real clinical setting should the two ongoing trials confirm the efficacy of male circumcision.Methods: The University Teaching Hospital Lusaka has been running an integrated dedicated male circumcision service for the last 2years. This site is, as far as we know, the only dedicated public service male circumcision service site in the region.Results: The site has performed 900 male circumcisions. The lessons learnt in relation to administration, cost, techniques, key operator and outcomes are reviewed. Comparison is drawn with the three research sites and public health strategies to reduce HIV transmission. Some conclusions are drawn about possible paths and pitfalls for future sites in the region

A Controlled Trial of Three Methods for Neonatal Circumcision in Lusaka, Zambia

Neonatal male circumcision (NMC) is not routinely practiced in Zambia, but it promising long-term HIV prevention strategy. We studied the feasibility and safety of three different NMC method

Post-vasectomy semen analysis: Optimizing laboratory procedures and test interpretation through a clinical audit and global survey of practices

Purpose: The success of vasectomy is determined by the outcome of a post-vasectomy semen analysis (PVSA). This article describes a step-by-step procedure to perform PVSA accurately, report data from patients who underwent post vasectomy semen analysis between 2015 and 2021 experience, along with results from an international online survey on clinical practice. Materials and Methods: We present a detailed step-by-step protocol for performing and interpretating PVSA testing, along with recommendations for proficiency testing, competency assessment for performing PVSA, and clinical and laboratory scenarios. Moreover, we conducted an analysis of 1,114 PVSA performed at the Cleveland Clinic’s Andrology Laboratory and an online survey to understand clinician responses to the PVSA results in various countries. Results: Results from our clinical experience showed that 92.1% of patients passed PVSA, with 7.9% being further tested. A total of 78 experts from 19 countries participated in the survey, and the majority reported to use time from vasectomy rather than the number of ejaculations as criterion to request PVSA. A high percentage of responders reported permitting unprotected intercourse only if PVSA samples show azoospermia while, in the presence of few non-motile sperm, the majority of responders suggested using alternative contraception, followed by another PVSA. In the presence of motile sperm, the majority of participants asked for further PVSA testing. Repeat vasectomy was mainly recommended if motile sperm were observed after multiple PVSA’s. A large percentage reported to recommend a second PVSA due to the possibility of legal actions. Conclusions: Our results highlighted varying clinical practices around the globe, with controversy over the significance of non-motile sperm in the PVSA sample. Our data suggest that less stringent AUA guidelines would help improve test compliance. A large longitudinal multi-center study would clarify various doubts related to timing and interpretation of PVSA and would also help us to understand, and perhaps predict, recanalization and the potential for future failure of a vasectomy.American Center for Reproductive Medicin

Controversy and Consensus on Indications for Sperm DNA Fragmentation Testing in Male Infertility: A Global Survey, Current Guidelines, and Expert Recommendations

Purpose: Sperm DNA fragmentation (SDF) testing was recently added to the sixth edition of the World Health Organization laboratory manual for the examination and processing of human semen. Many conditions and risk factors have been associated with elevated SDF; therefore, it is important to identify the population of infertile men who might benefit from this test. The purpose of this study was to investigate global practices related to indications for SDF testing, compare the relevant professional society guideline recommendations, and provide expert recommendations. Materials and Methods: Clinicians managing male infertility were invited to take part in a global online survey on SDF clinical practices. This was conducted following the CHERRIES checklist criteria. The responses were compared to professional society guideline recommendations related to SDF and the appropriate available evidence. Expert recommendations on indications for SDF testing were then formulated, and the Delphi method was used to reach consensus. Results: The survey was completed by 436 experts from 55 countries. Almost 75% of respondents test for SDF in all or some men with unexplained or idiopathic infertility, 39% order it routinely in the work-up of recurrent pregnancy loss (RPL), and 62.2% investigate SDF in smokers. While 47% of reproductive urologists test SDF to support the decision for varicocele repair surgery when conventional semen parameters are normal, significantly fewer general urologists (23%; p=0.008) do the same. Nearly 70% would assess SDF before assisted reproductive technologies (ART), either always or for certain conditions. Recurrent ART failure is a common indication for SDF testing. Very few society recommendations were found regarding SDF testing. Conclusions: This article presents the largest global survey on the indications for SDF testing in infertile men, and demonstrates diverse practices. Furthermore, it highlights the paucity of professional society guideline recommendations. Expert recommendations are proposed to help guide clinicians

Controversy and consensus on the management of elevated sperm DNA fragmentation in male infertility: A global survey, current guidelines, and expert recommendations

Purpose Sperm DNA fragmentation (SDF) has been associated with male infertility and poor outcomes of assisted reproductive technology (ART). The purpose of this study was to investigate global practices related to the management of elevated SDF in infertile men, summarize the relevant professional society recommendations, and provide expert recommendations for managing this condition. Materials and Methods An online global survey on clinical practices related to SDF was disseminated to reproductive clinicians, according to the CHERRIES checklist criteria. Management protocols for various conditions associated with SDF were captured and compared to the relevant recommendations in professional society guidelines and the appropriate available evidence. Expert recommendations and consensus on the management of infertile men with elevated SDF were then formulated and adapted using the Delphi method. Results A total of 436 experts from 55 different countries submitted responses. As an initial approach, 79.1% of reproductive experts recommend lifestyle modifications for infertile men with elevated SDF, and 76.9% prescribe empiric antioxidants. Regarding antioxidant duration, 39.3% recommend 4–6 months and 38.1% recommend 3 months. For men with unexplained or idiopathic infertility, and couples experiencing recurrent miscarriages associated with elevated SDF, most respondents refer to ART 6 months after failure of conservative and empiric medical management. Infertile men with clinical varicocele, normal conventional semen parameters, and elevated SDF are offered varicocele repair immediately after diagnosis by 31.4%, and after failure of antioxidants and conservative measures by 40.9%. Sperm selection techniques and testicular sperm extraction are also management options for couples undergoing ART. For most questions, heterogenous practices were demonstrated. Conclusions This paper presents the results of a large global survey on the management of infertile men with elevated SDF and reveals a lack of consensus among clinicians. Furthermore, it demonstrates the scarcity of professional society guidelines in this regard and attempts to highlight the relevant evidence. Expert recommendations are proposed to help guide clinicians

Iatrogenic penile amputation ananatomy lesson

A case report is presented of a young male patient seen at the University Teaching Hospital Lusaka Zambia with a right scrotal mass. During orchidectomy which was performed through a low inguinal incision iatrogenic complete penile amputation occurred. Subsequent direct replantation was done without microsurgical repair. The excellent outcome achieved with complete sexual function but no sensory or skin loss leads the authors to a discussion on the blood supply to the penis and the possible clinical significance in the management of penile disease. It is well known that the blood supply to the skin of the penis is from the superficial external pudendal artery and distinct from the dorsal artery to the penis which supplies the erectile cylinders. The dorsal artery to the penis is considered an end artery. The case report suggests good anastomosis between these two arteries probably through the prepuce. Microsurgical vascular repair services are not readily available in many parts of the developing world

An overview of the diagnosis and management of prostate cancer in Nigeria: Experience from a north-central state of Nigeria

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