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

Postoperative varicose recurrence at the junctions. A multicentric study of 1056 patients by the Italian Society of Phlebolymphology. Conclusive considerations

AIM: Since new endovascular procedures and foam sclerotherapy have been developed for the treatment of varicose veins of the lower limbs the recent literature seems to demonstrate that surgery of the saphenofemoral and saphenopopliteal junctions (SFJ, SPJ) is the main responsible for varicose recurrence (VR) owing to neovascularization by neoangiogenesis (NN). Aim of the study was to verify the anatomical causes of postoperative VR at the SFJ and SPJ. METHODS: Fourteen centers belonging to the Italian Society of Phlebolymphology collected the data of 1056 patients (=1081 limbs-25 bilateral) affected with VR. Clinical feature ranged from C2 to C6. Limbs were studied by Duplex ultrasound (DUS) investigation and by surgical revision from 2001 up to now: N. 927 (85.7%) retrospectively, 154 (14.2%), prospectively. Distribution of the limbs was as follows: mean age of patients was 56.6 years; the study enrolled 291 males (27.5%) and 765 females (72.4%); right limbs were 532 (49.2%), left limbs were 549 (50.7%); symptoms from venous insufficiency were found in 1043 subjects (96.4%). Previous surgery data: SFJ+stripping 873 (80.7%), SFJ alone 156 (14.3%), SPJ 52 (4.8%). Only 611 (56.5%), were studied by Duplex ultrasound (DUS), 470 by DUS+introperative observation (43.4%). The surgical revision was performed by direct dissection in 200 limbs and by Li technique in 270. The following elements were investigated: saphenous stump (SS), identified and unidentified tributaries (IT, UT) of the SFJ, tributaries of the SPJ, common tributaries outlet, tributaries outlet into the deep veins, suspected NN. RESULTS: Residual veins detected: saphenous stump+identified tributary (IT) 711 (65.7%), anterior accessory 298 (27.5%), superficial iliac circumflex 127 (11.7%), superficial epigastric 96 (8.8%), residual greater saphenous 95 (8.7%), medial accessory 88 (8.1%), superficial external pudendal 44 (4%), deep external pudendal 4 (0.3%), common outlet into the common femoral 14 (1.3%), independent outlet into the common femoral 7 (0.6%), unidentified tributaries (UT) at the SFJ 290 (26.8%), UT at the SPJ 52 (4.8%), complex varicose collateral circulation (CVC) total 386 (35.7%), CVC+IT 147 (13.5%), CVC+UT 149 (13.7%), CVC without IT/UT (unrecognized-suspected NN) 90 (8.3%). Unrecognized IT/UT at the SFJ (suspected NN) 45 (4.1%); unrecognized IT/UT at the SPJ (suspected NN) 2 (0.1%), surgically assessed NN 5 (0.4%). CONCLUSION: The causes of VR must be investigated by detailed DUS examination. Direct observation by surgical dissection leads to a verify better than by the Li technique. CVC is a consequence of VR and renders more difficult the detection of IT/UT both by DUS and surgical revision. NN plays a minimal role in VR at the groin and at the popliteal region but is not yet sufficiently demonstrated. Residual saphenous stump and IT/UT caused by inadequate surgery appeared to be the main causes of VR at the saphenous junctions

L’attività dei Centri Antifumo italiani tra problematiche e aree da potenziare: i risultati di un’indagine svolta attraverso un questionario on-line

Introduzione. In Italia sono 295 i Servizi per la cessazione dal fumo di tabacco (Centri Antifumo - CA) afferenti al Servizio Sanitario Nazionale (SSN) censiti nel 2011 dall’Osservatorio Fumo, Alcol e Droga (OssFAD) dell’Istituto Superiore di Sanità. La presente indagine, condotta dall’OssFAD in collaborazione con i CA, è stata volta a rilevare alcune delle problematiche con le quali il personale dei CA si confronta per portare avanti la propria attività e le iniziative ritenute utili per migliorarla. Materiali e metodi. L’indagine è stata condotta dal 7 al 21 maggio 2012, mediante un questionario compilabile on-line composto da 5 brevi sezioni di domande con un totale di 38 items da completare. Il link al questionario on-line è stato inviato per e-mail a 322 indirizzi dei CA censiti nel 2011 dall’OssFAD. I dati raccolti sono stati elaborati statisticamente con il programma SPSS 20. Risultati. All’indagine hanno risposto 146 operatori dei CA (45,3%). Sebbene ci siano aspetti ormai consolidati dell’attività dei CA, sono ancora molte le criticità che gli operatori riscontrano nella loro attività. Le principali problematiche che influiscono in modo fondamentale/rilevante per la buona attività del centro sono le “Scarse o nulle risorse economiche” per il 60,7% del personale, “la mancanza di personale dedicato” per il 52,4% del personale; il “riconoscimento/mandato istituzionale del CA” per il 40,9% del personale. Tra le azioni ritenute più efficaci per facilitare l’accesso ai CA sono risultate la sensibilizzazione del personale sanitario (91%), in particolare dei medici di famiglia e l’inserimento delle prestazioni antitabagiche nei LEA (76,8%). Conclusioni. È auspicabile che l’attività dei CA riceva una maggiore attenzione, attraverso la dotazione di strutture, personale e finanziamenti adeguati a svolgere un importante ruolo nella tutela e promozione della salute