Citations

Abstract Introduction Women in healthcare are faced with unique challenges that may increase the risk of infertility including irregular work hours, occupational hazards due to radiation or chemicals, and advanced maternal age. Objective We therefore sought to investigate live birth rates of female healthcare workers presenting with infertility compared to their non-healthcare counterparts. Methods After obtaining IRB approval, a retrospective review of hospital employees and partners presenting for a fertility evaluation between 2013-2019 was conducted. Patient age, BMI, history of previous live birth, occupation, use of assisted reproductive technology and female fertility factor were recorded. Couples with at least 12 months of follow up from initial presentation as well as a documented semen analysis were included in the study. Normal semen parameters were defined by the World Health Organization 2010 criteria. Logistic regression analysis was conducted to identify factors associated with increased likelihood of live birth. Results Of the 934 female partners identified, 445 were healthcare workers and 489 non-healthcare workers. Female age, BMI, smoking status, and history of previous live birth were not statistically significant between groups. No differences in male partner age, BMI, semen parameters and presence of male factor were noted. As an overall group, female age, male age, and abnormal concentration were noted to impact live birth rates (p<0.016). Live birth rates were higher in female health care workers compared to non-healthcare workers, 76.1 vs. 69.6%, respectively, p=0.042. The cohort was then further analyzed to determine if there was a difference in between females holding a Doctor of Medicine (MD) and other medical occupations (91 MDs vs 357 other occupations). Live birth rates, pregnancy complications, and preterm labor were not statistically significant, however MDs were found to have higher rates of use of assisted reproductive technologies (IUI or IVF) and were more likely to be older at time of evaluation (p=0.0015). After controlling for age at delivery, female physicians were still more likely to utilize ARTs, but this was no longer statistically significant (p=0.0806). Conclusions In this cohort of hospital employees, female healthcare workers had a higher live birth rate despite no differences in age, BMI, female factor infertility, use of assisted reproductive technology, or male partner factors. However, when the subgroup of female hospital employees was further analyzed, MDs were noted to have higher use of assisted reproductive technologies and older age. This indicates increased difficulty achieving pregnancy, likely a reflection of advanced maternal age. Further research is needed to identify subgroups within the healthcare population that may be at greater risk for infertility. Disclosure No

Abstract Introduction Physicians may be subjected to grueling work hours, sleep deprivation, and a stressful work environment during their prime reproductive years. While attention to fertility among female physicians has garnered interest in recent years, little is known about the fertility of their male colleagues. Objective In this study we sought to compare semen parameters of male physicians presenting for a fertility evaluation compared to their non-physician counterparts. Methods Upon IRB approval, a retrospective review of all hospital employed individuals (or their partners) who underwent a semen analysis between 2013-2019 was performed. Post-vasectomy semen analysis patients were excluded. Baseline patient demographics including age, comorbidities, occupation, and BMI were recorded. Normal semen parameters were defined by the World Health Organization 2010 criteria. A comparison analysis of semen analysis parameters, baseline characteristics, and comorbidities was conducted with a significant p-value defined as <0.05. Results Of the 169 physicians and 438 non-physicians identified, physicians were more likely to have a lower BMI (median 25.8 vs. 28.0, p<0.0001) when compared to their non-physician counterparts. Physicians were less likely to have ADHD, depression, obstructive sleep apnea, malignancy, alcohol abuse, and history of smoking (p<0.05). Physicians had better semen parameters including pH, concentration, motility, volume, and morphology (p<0.05), with a greater sperm concentration (68.4 vs. 52.2 million/mL, p<0.0001) and higher total motile sperm count (125 vs. 86.4 million, p<0.0001) compared to non-physicians. However, male physicians were more likely to be older at time of semen analysis (33.8 versus 32.7 years, p<0.05), more likely to utilize assisted reproductive technology (IVF and IUI, p=0.0277), have older female partners (p=0.0053), and have older female partners at time of delivery (p=0.0124). Conclusions In this study we report, for the first time, semen parameters of physicians compared to non-physicians. Physicians had a significantly higher total motile sperm count and sperm concentration; however, they were older at time of semen analysis, more likely to utilize ART, and more likely to have older female partners. While physicians may be healthier, this may indicate increased difficulty achieving pregnancy. Patient care is directly impacted by the health and safety provided to their physicians. As the paradigm in the medical field shifts from caring only for our patients to caring for ourselves, fertility amongst male physicians warrants further investigation. Disclosure No

Abstract Introduction Obstructive azoospermia accounts for up to 14% of patients presenting for fertility evaluation. Fine-needle vasography (FNV) is a diagnostic procedure that can be performed to identify an obstruction proximal to the ejaculatory duct. Compared to traditional vasography, FNV utilizes a less-invasive method to perform imaging of the vas deferens and distal ejaculatory structures. Herein we report our experience performing FNV in a series of patients with suspected complete or near-complete obstruction. Objective To report our experience using FNV to identify a site of obstruction and determine candidacy for reconstructive procedures in patients presenting with suspected obstructive azoospermia or cryptozoospermia. Methods We report a multi-Institutional case series of patients with suspected complete or partial obstructive azoospermia. Patients that were included had azoospermia or severe oligoasthenospermia, presence of palpable vasa, testicles ≥12 ml, and FSH <7.6 IU/L. All patients underwent testicular biopsy prior to or at the time of FNV to confirm spermatogenesis. Fine-needle vasography was performed using a 25F angiocatheter, with radio-opaque dye visualized under fluoroscopy. Descriptive statistics are reported as median and interquartile range (IQR). Results A total of 16 patients underwent vasography between 2014 and 2022 with three surgeons. Twelve patients presented with azoospermia, and four with severe oligoasthenospermia. Median age at vasography was 35.0 (IQR 17) years. Median pre-vasography semen parameters were sperm concentration 0 million/mL (IQR 0.3), sperm motility 0% (IQR 1), semen volume 2.5 mL (IQR 2.5), and semen pH 8.0 (0.7). Median total testosterone was 445 ng/dL (IQR 433), and FSH 4.5 IU/L (IQR 3.6). Half of patients had a history of inguinal hernia repair, unilateral in two and bilateral in six cases. History of genitourinary infection was present in six (35.3%) patients. A total of 7 (44%) men were found to have distal obstruction on FNV, while 8 (50%) were offered epididymovasal reconstruction. Of the seven patients diagnosed with obstruction/atresia of the vas deferens within the inguinal canal and/or pelvis, only two were related to prior inguinal hernia repair. Of the eight men with prior inguinal hernia repairs, two were confirmed to have an obstruction at the level of the inguinal canal. Of the six patients with a history of genitourinary infection, four had an obstruction at the level of the epididymis (with normal FNV), while two had atresia of the vas deferens in the pelvis. Conclusions Fine-needle vasography is an effective, minimally-invasive way to identify the site of complete or partial obstruction in patients presenting with suspected obstructive azoospermia or severe oligoasthenospermia. It additionally permits identification of men who are candidates for epididymovasostomy reconstruction and helps to differentiate between ejaculatory duct obstruction and other causes of blockage. Disclosure No

Abstract Introduction Sexual therapy for male sexual dysfunction has been used to help patients address a variety of sexual dysfunction-related conditions. While this intervention is frequently recommended for patients by male sexual health experts, the rate of adherence to the recommended therapy and associated factors is unknown. Objective To understand factors leading to completion of sex therapy consultations and barriers that prevent it. Methods A survey was developed by experts in the management of male sexual dysfunction and sex therapy at our institution. The survey included questions focusing on the decision to pursue sex therapy (or not), barriers or facilitating factors, patient perceptions regarding the referral, and treatment success. A retrospective chart review was performed to identify those patients who were referred for sexual therapy after undergoing evaluation for male sexual dysfunction at an academic Men’s Health urology clinic from 2017 - present. The survey was mailed out to these patients, and respondent survey data was compiled to evaluate survey responses. Results To date, 23 patients completed the survey (20% response rate). Sixty-five percent of survey respondents were ≥ 50 years of age, 87% were straight, and 71% were married. Reasons for sex therapy referral were frequently multi-factorial and included erectile dysfunction (65%, n=15), low libido (43%, n=10), ejaculatory dysfunction (39%, n=9), performance anxiety (30%, n=7), relationship problems (30%, n-7), and genital pain (14%, n=3). Seventy-eight percent of patients (n=18) felt that sex therapy consultation was a reasonable part of their treatment plans. Six (26%) patients did not attend their recommended sex therapy consultations. Reported barriers included sense of shame (n=2), embarrassment (n=2), scheduling conflicts (n=1), lack of anticipated benefits (n=1), and feeling dismissed by the referring provider (n=2). Those who attended sex therapy frequently reported the perception that referral made sense based on their symptoms (n=10, 59%) and/or a feeling of desperation to “do anything do get better” (n=11, 65%). Seventy-eight percent of patients who attended sex therapy found it helpful and would recommend it to a friend with a similar concern. Conclusions The majority of male patients who are referred to sexual therapy feel it is beneficial. However, one in four men choose not to pursue this line of treatment despite recommendations from their treating physicians. Future work is needed to address barriers to pursuing sex therapy. Disclosure No

Abstract Introduction Medical policy bulletins (also known as clinical policy bulletins) are insurance company guidelines for administering plan benefits. These documents purport to summarize current research, evidence-based guidelines, regulatory status, and physician opinion to determine whether insurers consider procedures and services to be medically necessary. These bulletins, along with member benefit plans, determine which services are covered. We have previously explored the lack of uniformity that exists for insurance payer coverage for penile prostheses. Here, we sought to expand this investigation to determine insurance coverage criteria for medical and surgical management of common men’s health conditions. Objective To determine covered benefits for sexual medicine conditions among the top United States healthcare insurers. Methods A list of common sexual medicine conditions was generated, including Peyronie’s disease, hypogonadism, erectile dysfunction, premature ejaculation, incontinence, and buried penis. The most common treatment modalities for each condition were identified (see Table I). Securities and Exchange Commission (SEC) filings were used to identify the top ten largest private insurers in the United States by member enrollment. This list was cross-referenced with the National Association of Insurance Commissioners (NAIC) 2020 Market Share Report (ref 1). The following list of the largest private US health insurers was thus developed: United, Anthem, Centene, Kaiser, Humana, CVS, Healthcare Service Corporation (HCSC), Cigna, Molina, and Independence Health Group (IBX). Kaiser and Centene were excluded due to lack of nationwide medical policy bulletins. We reviewed medical policy bulletins from the remaining 8 insurers to determine whether the specific treatments were identified as medically necessary, experimental/investigational, or cosmetic. Services and procedures deemed medically necessary were coded as “covered,” and those listed as investigational, or cosmetic were coded as “not covered.” If information about a specific condition or treatment modality was not found in a company’s policy bulletin, it was coded as “unknown.” Results In total, we recorded 143 data points, across the 8 insurance providers. Our review of medical policy bulletins yielded 60 (41.9%) instances where services were considered medically necessary and/or “covered”, 18 (12.6%) non-covered or investigational/cosmetic services, and 65 (45.5%) services with unknown coverage (Table I; covered=1, non-covered=0, unknown=2). Conclusions We encountered substantial difficulty in navigating and interpreting insurance coverage for various sexual medicine treatments and conditions based on review of policy bulletins from the topic insurance providers in the US. There was no readily identifiable coverage information for >45% of the data points that we collected, and instances of “unknown” coverage exceeded covered services across the collective of the largest private insurers. While 76.9% of conditions for which there was available data were covered, we are unable to draw generalizable conclusions for most conditions as there are significant deficits in the availability of policy information from online insurance sources. Further challenges in determining coverage include the additional layers of limitations in member plan benefits (i.e. plan exclusions), which could compound confusion for both physicians and patients. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast.

Abstract Introduction Penile dysmorphophobia is common, with up to 20% of men reporting dissatisfaction with their genital size. The global market for Sexual Enhancement Supplements is estimated at $300 Million in the year 2020 and is projected to reach $608 Million by 2027 in the US alone. Evidence for efficacy is minimal, and purported claims are hyperbolic. Objective We sought to assess penile elongation internet offerings, quantify cost, ingredients, and risk and investigate scientific literature of product ingredients when available. Methods Three online marketplaces (Amazon, Google market, and Walmart) were queried for dietary supplements available without a prescription to improve penile size. Product labels were reviewed to compile penile size-related claims and active ingredients. The one-course (60-day) cost of treatment and consumer star rating were assessed. MEDLINE, Web of Science, and Google Scholar were queried with labeled ingredients to assess the scientific evidence from published and lay sources. Results A total of 84 dietary supplements claimed either increased penile length, girth, enhanced sexual performance, or a combination thereof. Of these 84 products, 90 ingredients were listed. The Mean 60-day cost was $52 (range of $12–$222). The median score by consumers in the markets with a possibility of star rating was 3.5 (range 2.4-4.2) with obvious repetitive and self-promotional tactics. Unsurprisingly, no scientific evidence supporting change in penile size was found for any products in our search. Actual described physiologic activity from active ingredients included were described as antidepressant, lipid and glucose lowering/metabolizing, blood pressure effecting, anti-inflammatory, renally protective, cognitive function effecting, antioxidant, and several ingredients weakly enhancing erectile activity. Renal failure, warnings against long-term use, heart problems, neuropathy, blood pressure effects, fertility toxicity, bleeding, liver disease, and numerous interactions with diabetes, blood thinning, immunosuppressant, and PDE5 medications were found for the ingredients. Conclusions Dietary supplements claiming to enhance penile size contained ingredients with conflicting or no scientific evidence to support their claims. Several ingredients were dangerous. Clinician awareness of these sham “solutions” and their continued mass consumption highlight the magnitude of misinformation, unrealistic expectations, shame, and enhancement desperation regarding penile size in the male public psyche. Disclosure No

Abstract Introduction Sexual Health Curriculum (SHC) in medical schools has been insufficiently training medical students for many years. While most medical schools report teaching a SHC, many medical students and residents report being inadequately trained in sexual health. This has led to infrequent physician screening for sexual problems due to insufficient knowledge and a lack of training about sexual function and dysfunction. Objective To investigate the current body of literature for changes in SHC in medicals schools in the last 20 years, and to identify any discrepancies between SHC taught in medical school and resident and medical student comfort in treating Sexual Health Dysfunction. Methods A literature review was conducted in PubMed on “sexual health education in medical school”, and of 16,962 results 37 relevant papers published in the U.S. and Europe were identified and analyzed. Results In 2003 86% of medical schools reported teaching over 3 hours of SHC, but by 2021 only 65% of students and 50% of PGY 4/5 Urology residents recalled a dedicated SHC in medical school. Consistently 50% of medical students are unsatisfied with their SHC, 52% are rarely or never evaluated on their sexual history taking skills, and 7% report not learning about human sexuality at all. Most German medical students believe that sexual health courses should be mandatory. Medical students have overall positive attitudes towards sexual and gender minority populations but lack adequate knowledge, especially about transgender and intersex health. Only 55% of 3rd/4th year OBGYN residents reported feeling comfortable in performing a targeted sexual dysfunction exam, and 66% of residents in Family Med, IM, OBGYN, and Psych had no previous educational experience in sexual problem management. Conclusions Sexual health curriculum in medical schools has not significantly improved in the last 20 years, leading to students and residents inadequately prepared to treat sexual health dysfunctions. The adoption of previously proposed SHC competencies for medical schools should be strongly considered. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast

Abstract Introduction Collagenase Clostridium Histolyticum (CCH) is an FDA-approved treatment for Peyronie’s Disease (PD). Based on phase-3 trials, the recommended treatment course consists of 8-injections over the course of roughly 18-20 weeks. While its efficacy has been established, less is known about patient-specific reasons for electing to discontinue CCH injection therapy. Objective To evaluate patient-reported factors associated with premature CCH discontinuation. Methods We queried a database of all patients (n=406) who underwent CCH at a single institution from 2014-2021. Patients who did not complete the recommended 8 injections were identified, and a detailed review was undertaken to determine causes of discontinuation. Patients were excluded from our analysis for the following reasons: deceased at the time of chart review, declined to participate, or could not be reached in 3 phone calls. Results Out of 406 patients who underwent Xiaflex treatment at our single institution, 133 did not complete 8 injections (32.8%). The mean number of CCH injections was 4.42 (SD 1.65). The most common reasons for discontinuing Xiaflex were satisfactory curve reduction (27%), unsatisfactory curve reduction (21%), bothersome side effect (15%), and decision to pursue surgery (12%) [Figure 1]. Other less common reasons included other health concerns, pausing treatments due to the Covid-19 pandemic, high treatment cost, transferring care elsewhere, and lack of awareness that more injections were indicated. Conclusions In our single institution study, we find that nearly 1/3 of patients who begin Xiaflex injections will not complete the full recommended treatment course. Understanding the reasons for discontinuation can help providers better stratify patients for Xiaflex treatment versus other modalities. In addition, given previous studies that indicate that 2/3 of men who fail to achieve a 20% curve reduction after their first 4 injections will go on to achieve this curve reduction after their final 4 injections, our data points to the potential impact of improved patient education for the 21% of individuals who discontinue due to unsatisfactory curve reduction (Alom et al 2021). Disclosure No

Abstract Introduction Peyronie’s disease (PD), estimated to affect around 10% of the male population, is an acquired disorder of penile fibrotic tissue. The only FDA approved medical treatment for PD is Intralesional Collagenase Clostridium Histolyticum (CCh). CCh is a mixture of AUX1 and AUXII, two different forms of collagenase that cleave collage type I and type III, leading to plaque degradation. PD plaques, however, also contain fibrin and calcium which CCh is unable to digest. It is unknown if plaque calcification prevents collagenolysis with CCh. Objective To determine if calcification prevents collageolysis of PD plaques with CCh. Methods Calcified PD plaques were collected from five males undergoing excision and grafting for PD. Control tissue was collected from five males undergoing penile implant surgery for erectile dysfunction, with no known history of PD. Tissue samples were then divided into equal weights and incubated with CCh or PBS for 24 hours. The CCh or PBS was injected into the tissue (control or plaque) to mimic administration of CCH for treatment of PD. Following incubation, the fluid (CCh or PBS) was measured for soluble collagen amount and tissue was subjected to Picrosirius Red and H&E staining. Results There was a higher concentration of soluble collagen in the tissue (control and plaque) incubated in CCh (301ug, SD 21.1) compared to the issue incubated in PBS (32.5ug, SD 3.7) (p=0.02). Additionally, there was less type 1 and 3 collagen present in the CCh condition (mean 0.12, SD=0.08), when compared to the PBS condition (0.44, SD=0.17) (p=0.002). However, when comparing within the CCh condition to look at differences between tissue types (calcified vs. control) no differences were found. There was a similar amount of soluble collagen in the CCh control condition (316ug, SD 35) and the CCh calcified condition (286ug, SD 11) (p=0.06). Similarly, the PBS control condition (30ug, SD17) and the PBS calcified condition (35ug, SD 48) were found to have no significant differences in collagen concentration (p=0.4). Finally, there were no significant differences found in type I/III collagen staining between tissues in the CCh condition, with control (0.08, SD=0.02) and calcified (0.17, SD=0.09) demonstrating no significant difference (p=0.08). Tissues in the PBS condition, control (0.5, SD=0.23) and calcified (0.39, SD=0.39), similarly were not significant (p=0.2) (table 1). Conclusions CCh is capable of breaking down collagen in calcified plaques. Further research into CCh as a treatment option for PD calcified plaques is necessary. Disclosure Yes, this is sponsored by industry/sponsor: Endo Pharmaceuticals Clarification Industry funding only - investigator initiated and executed study Any of the authors act as a consultant, employee or shareholder of an industry for: Acerus Pharmaceuticals, Boston Scientific, Coloplast, Endo Pharmaceuticals, Empower Pharmacy, Nestle Health, Olympus, Hims, Inc.

Abstract Introduction Independently performed procedures by well-trained advanced practice providers (APP) facilitate access to specialized care. We sought to compare outcomes between physicians and APPs with intralesional collagenase clostridium histolyticum (CCH). Objective Compare outcomes of CCH injections based on injection provider. Outcomes included curvature improvement and adverse events. Methods Men receiving CCH between 2014-2021 at our institution by four physicians and four APPs were included in an IRB-approved database. CCH was delivered as a series of 8 injections per protocol. Patient demographics, procedural-related adverse events, and curvature changes were recorded. The “APP-ratio” is defined as percentage of total injections administered by an APP per patient. Results After excluding patients who did not complete the entire CCH course or return for final assessment, 150/406 patients were analyzed. Mean baseline penile curvature was 66.2° (SD 23). Mean absolute and percent improvements in curvature were 21.7° (SD 18) and 33% (SD 27). The mean APP ratio was 69%, and 133 patients (89%) had at least 25% of their injections performed by an APP. There was no significant difference (p=0.65, p=0.39) in absolute or relative curvature improvement based on the APP-ratio [Figure 1]. There was also no difference in adverse events (pain, swelling, and hematoma). Conclusions In our high-volume CCH practice, APPs achieve the same outcomes and safety compared to physicians. Greater training efforts expand access to care for patients with PD. Disclosure No