Citations

Abstract Introduction Over 500,000 men undergo vasectomy in the U.S. annually. Although found to be 99.7% successful, the cost of vasectomy failure that results in an unplanned pregnancy far outweighs the cost of follow up semen analysis to ensure success. Despite the cost-benefits of post-vasectomy semen analysis (PVSA), compliance ranges only 30%-87%. Challenges include access to care, cost, and inconvenience of time4. Mail-in PVSA may help address these challenges and improve compliance, particularly in socially vulnerable and rural communities. Objective To examine geographic and socioeconomic community-level factors linked to mail-in PVSA completion in Texas. Methods We prospectively analyzed data from Texas men after undergoing vasectomy who received a Fellow mail-in PVSA kit between 2021–2024. Home ZIP codes were linked to the Distressed Community Index (DCI), a measure of economic well-being across US communities. The primary outcome-mail in PVSA completion within 40 weeks of being provided a test kit-was evaluated against region, DCI, and kit ordering setting. Chi-square tests and multivariable logistic regression were used, and statistical significance was assessed at the 0.05 level. Results Of 4,744 men included, 81.1% (3,849) completed mail-in PVSA testing. Compliance rates were lower among individuals living in urban areas, in the North Texas region, those residing in communities “at-risk” of socio-economic distress, and those who received their kit in a clinic (Table 1). On multivariate analysis, residence in a rural area was associated with higher completion rates (OR 1.50, 95% CI 1.12–2.04), and men who ordered their kits direct-to-consumer where significantly more likely to be compliant than those receiving their kits in a clinic (OR 10.33, 95% CI 5.01–26.26). Conclusions Men in rural areas of Texas were 74% more likely to complete mail-in PVSA, even after adjusting for social determinants of health. Direct-to-consumer users were also more likely to complete testing than clinic-ordered users. Mail-in PVSA shows higher adherence than historical clinic-affiliated methods (30–50%). Further research is needed to explore regional factors influencing completion, such as cultural attitudes, access to postal services, health literacy around male infertility, and insurance policy. In summary, mail-in PVSA testing may dramatically improve compliance for men in rural areas, and potentially decrease the risk of unplanned pregnancies. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Fellow

Abstract Introduction Infertility insurance benefits remain a key concern for individuals pursuing medical training during peak reproductive years. While urologists play a central role in managing male infertility, the availability and visibility of fertility benefits during urology residency remain poorly characterized. Delays in family building are common among male trainees, often paralleling those of their partners. By the time individuals pursue fertility care, partners may already be within or approaching advanced reproductive age. Additionally, male infertility is increasingly recognized as a marker of systemic health conditions, underscoring the importance of adequate evaluation and support. Objective To assess the prevalence, scope, and accessibility of infertility treatment coverage across U.S. urology residency programs. Methods A total of 148 accredited U.S. urology residency programs were identified and evaluated from the American Urologic Association that participated in last year’s match. Each program's public-facing urology department website, affiliated graduate medical education (GME) website (with linked benefits booklet if applicable), and program details were reviewed. Programs were assessed for the availability of information regarding infertility treatment benefits, gender-specific coverage (male, female, or unspecified), institutional details describing benefit access, and available data such as lifetime coverage limits and cycle caps. Data were descriptively analyzed. Results Out of 148 programs, 40 (27%) provided available information regarding infertility treatment benefits while 140 programs (95%) provided information on general medical benefits. Among these 40 programs, 22 (55%) specified coverage for female fertility services, 16 (40%) included male-specific benefits, and 18 (45%) referenced fertility coverage without specifying sex. Six programs (15%) included information on female-only benefits, whereas none exclusively listed male-specific benefits. (Table 1) Male fertility services were variably represented among the 40 programs with fertility benefit information. There were 6 programs (15%) specified sperm cryopreservation, 4 programs (10%) that included sperm extraction, and 1 program (2.5%) mentioned covering vasectomy reversal. Among programs that disclosed cost-related information, the average lifetime medical fertility benefit was $17,500 (n=8), with an additional $7,800 for pharmacy benefits (n=10). The average of total lifetime fertility coverage maximum was $28,375 (n=20). Only 4 programs (10%) specified a cycle limit, averaging 2.75 cycles. Regional variation in the availability of fertility benefit information was observed, with the Western, North Central, and South Central regions demonstrating the highest proportions of programs providing infertility treatment benefit information (56%, 31%, and 29%, respectively), and the New York region the lowest (5.9%). However, these differences did not reach statistical significance (p = 0.092). Conclusions Fewer than one-third of U.S. urology residency programs provide accessible information regarding infertility treatment coverage. Male-specific services, despite the specialty’s clinical focus and the growing recognition of infertility as a systemic health concern, remain underrepresented. The limited transparency of fertility benefits, almost always requiring indirect access through GME resources, may hinder informed reproductive planning. As many male trainees delay childbearing alongside their partners, timely and visible support for infertility coverage is essential. Improving the availability and clarity of these benefits may help address both reproductive and broader health needs for future urologists. Disclosure No

Abstract Introduction While microdeletions in the azoospermia factor (AZF) regions of the Y chromosome are a well-recognized cause of genetic male infertility, reproductive outcomes and broader health profiles among affected men remain poorly characterized. Objective We explore the distribution of AZF deletion subtypes and evaluate comorbidities and fertility management patterns in this unique population. Methods We performed a multi-institutional retrospective cohort study of men diagnosed with AZF deletions following evaluation by a reproductive urologist and genetic testing. The primary exposure variable was the AZF subtype (AZFa, AZFb, AZFc, or multilocus [e.g., AZFabc]).Clinical data were extracted to assess the presence of comorbidities, including hypertension, diabetes mellitus, hyperlipidemia, liver disease, and cardiac disease. Descriptive statistics were used to characterize the distribution of AZF subtypes, comorbidity profile, and outcomes of sperm retrieval procedures within our cohort. Results Among 40 men with confirmed AZF microdeletions across three academic centers, four patients with SRY translocations were excluded. Of the remaining 36, AZFc was the most common subtype (75%), followed by multilocus (16.6%), AZFa (5.5%), and AZFb (2.7%). The median age was 32.8 years (IQR: 29.2–33.6) and median BMI was 28.6 kg/m2 (IQR: 25.6–32.8). Comorbid conditions were identified in 8% of the cohort, with hyperlipidemia (13.9%), hypertension (11%), and diabetes (11%) most commonly reported. Sperm retrieval was attempted in 31% (n=11) of patients, exclusively among those with AZFc (n=10) andAZFb (n=1) deletions. Microscopic testicular sperm extraction (mTESE) was the predominant technique (91%). Sperm was successfully retrieved in 46% of these cases, all within the AZFc subgroup. Conclusions This study advances limited literature on AZF microdeletions by characterizing systemic health profiles and post-diagnosis infertility management. Our results support a broad phenotype associated with genetic causes of male infertility. In this cohort of men with YCMD, AZFc was the most prevalent subtype. Compared to national estimates for similarly aged men, our findings suggest that men with YCMD may have a distinct comorbidity profile compared to the general population, with an elevated prevalence of metabolic disease. Our findings reinforce male infertility as a heterogeneous condition that may serve as an early marker for broader metabolic disease. In addition, nearly all patients who underwent sperm retrieval were within the AZFc group. Fertility management trends favored mTESE, with moderate success rates in sperm retrieval, particularly among AZFc patients. Our results highlight provider preferences in surgical fertility management in patients withYCMD. Our findings underscore the need for a holistic approach to men with YCMD, addressing both surgical fertility management and systemic health risks. Clear patient counseling on sperm retrieval success rates and early identification of comorbidities may redefine outcomes for this unique population. Our results support a broad phenotype associated with genetic causes of male infertility. Disclosure No

Abstract Introduction Fertility preservation is an essential component to cancer survivorship. One third of male survivors experience infertility following gonadotoxic treatments, and expeditious preservation prior to therapy is recommended by oncology guidelines. However, this can be challenging given time constraints, lab expertise, and financial considerations. Objective We describe national practice patterns and identify barriers and facilitators regarding inpatient male fertility preservation. Methods An anonymous 34-item Qualtrics survey was sent to reproductive Urologists in the United States. Email addresses were obtained from public membership databases. Respondents were queried across several domains, including provider demographics, specific inpatient cryopreservation scenarios, and fertility preservation procedures. Results Thirty-nine (21%, n=39/189) responses were received. The majority of respondents were fellowship-trained reproductive urologists 89.7% (35). The majority (97.4%) of respondents offer microdissection testicular sperm extraction (mTESE) for fertility preservation, and many offer conventional TESE (71.8%), traditional ejaculated sperm cryopreservation (71.8%), or microsurgical epididymal sperm aspiration (59%). Only 30.8% of respondents offer electroejaculation. Respondents rate non-urology provider awareness of male cancer fertility preservation options at 5.05/10 on a Likert scale. Many (65%) respondents provide formal materials or education to nonurology providers to address this deficit. On average, respondents reported 2.6 inpatient oncofertility preservation consults per month (range 0-25, median=1). Most (60%) of respondents reported that <25% of these patients ultimately complete inpatient preservation. Financial burdens (97%), logistical hurdles (97%), limited awareness (97%), and concern for delay of oncologic care (92%) were identified as the most common barriers for patients precluding fertility preservation. In addition, 85% of respondents also listed difficulty coordinating with other specialists as a barrier. On free-text queries, respondents identified facilitators of fertility preservation as automatically triggered consults, use of an urgent cryopreservation pager, formal fertility preservation pathway within the order set, and utilization of an inpatient coordinator as facilitators that aid in achieving timely fertility preservation prior to gonadotoxic therapies. Conclusions Despite all reproductive urologists offering cryopreservation services and education regarding the urgency and priority of inpatient fertility preservation, less than a quarter of patients complete this process during hospitalization prior to initiation of treatment. This remains the consequence of numerous patient, provider, and facility level barriers, even in systems with robust referral processes. Inpatient fertility preservation remains an underutilized and often missed opportunity. Multidisciplinary interventions are needed to address ongoing barriers. Disclosure No

Abstract Introduction Sperm cryopreservation is becoming increasingly accessible and cost-effective. One of the most common indications for cryopreservation remains prior to gonadotoxic therapies and surgeries. However, it may be used by patients undergoing vasectomy as an alternative to potential future more invasive procedures including reversal or sperm retrieval. Objective To characterize demographic and individual factors associated with the utilization of cryopreservation prior to vasectomy. Methods We conducted a retrospective review of all patients from January 2023 to May 2025 at a single academic medical center who underwent a vasectomy. All 186 patients who completed the pre-vasectomy questionnaire were included in our analysis. At the time of vasectomy consultation, patients were informed of the procedure’s permanent nature and, per guidelines, were educated on future fertility options, including vasectomy reversal and sperm retrieval for use with in vitro fertilization. All patients were also separately offered sperm cryopreservation. Demographic and questionnaire data was collected and analyzed. Pre-vasectomy questionnaire information included age, relationship information, familial information, and reason for vasectomy, among other factors. Numerical variables were described as medians with interquartile range and categorical variables were described in counts. Due to violation of the normality assumption, Fisher’s Exact test was used for categorical variables and the Kruskal-Wallis rank sum test was used for numerical variables. Results 186 patients completed the pre-vasectomy questionnaire and were used in our analysis. Of these individuals, 5.4% (n=10) utilized cryopreservation at the time of vasectomy. Individuals utilizing cryopreservation had a median age 5 years younger than those who did not utilize the same service (p = 0.046). Moreover, 40.0% (n=4) of individuals in the cryopreservation group had children compared to 83.5% (n=147) in the no cryopreservation group (p=0.004). Current relationship length was significantly longer for individuals who did not utilize cryopreservation, with a median reported relationship length of 11 years as compared to a median length of 5 years for individuals utilizing cryopreservation (p=0.025). The shorter relationship length is likely related to an additional finding that the percentage of individuals who utilized cryopreservation were married approximately 30% less often than individuals who did not use the same service (p=0.039). Conclusions While only a small proportion of patients undergoing vasectomy choose to pursue cryopreservation despite counselling at their visit, significant differences in demographic and individual characteristics were observed for those who did. These individuals tended to be younger, married at lower rates, without children, and in shorter relationships. With improved access to reproductive services, further work is needed to understand decision choices for men offered sperm cryopreservation prior to permanent sterilization. Disclosure No

Abstract Introduction The EROS (Erectile Restoration Outcomes and Satisfaction) registry provides prospective questionnaire-based follow-up after IPP was founded in 2020 at the Mayo Clinic, Rochester. Objective We sought to assess general trends in the open-ended responses portion of the questionnaire. Methods Data were collected from 2020 to 2025, with a total of 568 responses. The survey included six open-ended questions pertaining to lifestyle change since IPP, reasons not to repeat the procedure, impediments to use, dissatisfaction, what patients wish they had known more about the procedure, and other recommendations. Evaluable data included 6-month responses from Rochester, Jacksonville, and Phoenix. Results Open-ended feedback was given by 66% of patients on what they wished they had known, 54% gave other recommendations, 38% gave lifestyle feedback, 7% elaborated upon reasons not using, 3% on reasons for dissatisfaction, and 2% on reasons they would not repeat IPP. There was an overall very positive response (“Significant Improvement”, n=74.3%) from those who underwent the IPP placement, with some patients reporting that it was far more convenient than other forms of treatment, and even increased spontaneity in their sexual lives, leading to improved relationships. Among the reported responses are increased confidence (n=39.4%), increased sexual activity (n=13.3%), and improved health and exercise levels (n=6.6%). When questioning patients on why they would not repeat the procedure and what their sources of dissatisfaction were, of those who responded to each question (n=12, n=16), the most report complaint was exaggeration of pre-existing curves (n=41.7%, n=25.0%), particularly due to Peyronie’s disease. When questioned about what prevents use, the main response was partner-related or due to personal problems (n=45.2%). The patients did not have many recommendations but hoped for a better way to deflate and inflate the device (n=20.4%) and reported adequate pre-operative education and use of the pump. The table below outlines the categories of responses and the percentage of each keyword reported per question type. Conclusions In addition to standard pre-operative IPP counseling, providers should provide additional focus on potential difficulty with device inflation/deflation, length loss (IPP not in glans), pain/ recovery expectations, potential of new or worsened curve (erect or flaccid), and potential change in sensation. IPP satisfaction is high, as only 2% of patients gave responses on why they would not repeat the IPP, with many men expressing an increased level of overall confidence. Disclosure No

Abstract Introduction Glans ischemia and subsequent necrosis is a rare but devastating complication of inflatable penile prosthesis (IPP) placement. Differentiating true glans ischemia from severe ecchymosis can be difficult but is critical, particularly in light of the adage, “when in doubt, take it out.” However, post-operative glans discoloration can be misleading and result in premature device explantation. Objective To present clinical cases and identify distinguishing features between true glans ischemia and pronounced post-operative ecchymosis, with emphasis on risk factors and evaluation techniques. Methods A retrospective case series was conducted on four IPP patients in 2025 who presented with significant glans discoloration concerning for ischemia. Key operative variables, physical exam findings, and postoperative images were reviewed. Additionally, a prospective database of 298 implants placed under local anesthesia since 2024 was analyzed for glans bruising severity on postoperative day (POD) 3, using a 0–4 scale. Results Common ischemia risk factors included tight circumferential wrap (e.g., Coban), vasculopathy (e.g., prior arterial bypass), prolonged catheterization, and concomitant procedures. Case 1: History of pelvic radiation with ecchymotic meatus and glans. Improved after wrap removal and better lighting. Case 2: Extensive ecchymosis and discoloration of glans and scrotum noted on POD1 after uneventful IPP under local. Case 3: Patchy glans discoloration after multiple Keith needle passes. Skin tone complicated assessment. Case 4: Severe glans bruising immediately post-op following multiple needle passes due to suture breakage. In all cases, the glans was warm, well-perfused, and not painful out of proportion to appearance. No patients required explantation. Glans bruising rates in 298 implants under local anesthesia were: 0 (3.7%), 1 (48.7%), 2 (25.5%), 3 (21.1%), 4 (0.3%), notably higher than with general anesthesia. Key Clinical Indicators: Favors Hematoma: • Vascular corpora • Small/no catheter • Bruising elsewhere • Wrap excluded glans • No blistering • No paresthesias • Glans warm to touch Favors Ischemia: • Avascular corpora • Large indwelling catheter • Minimal bruising elsewhere • Coban wrap on shaft • Blistering present • Pain or paresthesias • Glans cold to touch Conclusions Significant glans bruising can mimic ischemia, particularly in IPPs placed under local anesthesia. Factors such as multiple Keith needle passes, tight wrapping, and poor photographic lighting may contribute to this diagnostic confusion. Warm, non-painful glans with widespread ecchymosis are reassuring. Avoiding premature explantation requires thorough clinical assessment, device unwrapping, and close patient monitoring. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: UroFill, Coloplast, Boston Scientific, Rigicon

Abstract Introduction Chronic scrotal content pain (CSCP), defined as three or more months of scrotal pain interfering with daily life, affects approximately 100,000 men annually in the United States. Historically, the absence of standardized guidelines led to wide variability in diagnosis and treatment. At the time of our study design and data collection, no formal guidance existed for CSCP. In April 2025, after the study’s completion, the American Urological Association (AUA) published its first clinical guidelines for CSCP. Our findings now offer important context regarding real-world practice patterns before guideline publication. Objective To characterize diagnostic and treatment strategies for CSCP among U.S. reproductive urologists. Methods An anonymous 25-question Qualtrics survey was distributed to U.S.-based reproductive urologists. The survey assessed physician demographics, diagnostic evaluations, conservative and surgical treatment strategies, and perceived patient outcomes. Descriptive statistics were calculated, and comparisons were performed using Mann-Whitney U, chi-square, or Fisher’s exact tests, as appropriate. Results Of 183 invited physicians, 41 (22.4%) completed the survey in full. All respondents were fellowship-trained, practicing urologists, with most board-certified (82.9%). Respondents were nearly evenly split between ≤5 years (48.8%) and >5 years (51.2%) in practice. Among ten conservative treatment options, reassurance (41.5%) and NSAIDs (31.7%) were the most frequently selected first-line treatments, with median ranks of 2.5 and 2, respectively (Figure 1). Opioid medications were the least favored (median rank: 10), with 56.1% ranking them last. Pelvic floor physical therapy (PFPT) had a favorable median rank of 3 and was ranked higher by those with ≤5 years in practice compared to those in practice >5 years (median: 3 vs. 4, p = 0.019). GABA analogues and tricyclic antidepressants were assigned median ranks of 6 and 7.5, respectively. The most commonly performed surgical procedure for CSCP was microsurgical denervation of the spermatic cord (MDSC, 95.1%), followed by varicocelectomy (92.7%), vasectomy reversal (78.0%), epididymectomy (73.2%), and orchiectomy (51.2%). For post-vasectomy pain syndrome, MDSC was preferred by 63.4%, followed by vasectomy reversal (22.0%) and epididymectomy (9.8%). Among those performing vasectomy reversals, 80% of patients paid out-of-pocket (IQR: 50.0–93.5%). Respondents perceived surgical management as more effective than conservative treatment, with median complete symptom resolution rates of 70% (IQR: 50–80%) versus 25% (IQR: 10–40%) (p < 0.001). Only 7.3% reported using validated tools like the Chronic Orchialgia Symptom Index (COSI) to evaluate patient outcomes. Conclusions Our study offers a contemporary snapshot of CSCP management among reproductive urologists, revealing substantial variability in practice. Surgery was consistently perceived as more effective than conservative approaches. These findings underscore areas of alignment and divergence with the newly released AUA guidelines and support the need for future comparative trials and implementation studies to guide standardized, evidence-based care. Disclosure No

Abstract Introduction Male-factor infertility contributes to a substantial portion of infertility cases. Genetic factors are believed to play an important role, with Y chromosome microdeletions commonly identified among men with azoospermia. Due to the relatively high prevalence of these deletions, genetic testing for Y chromosome microdeletions has become a routine component of the diagnostic workup for infertile men. While deletions in the AZF (Azoospermia Factor) region are known to impair spermatogenesis, the hormonal profile in this population remains poorly characterized. Hormonal evaluation plays a key role in guiding treatment decisions, including the use of empirical medical therapy (EMT). However, there is limited data on hormonal profiles and EMT usage in men with AZF deletions. Objective We aimed to characterize preoperative hormonal profiles and evaluate the use and outcomes of EMT in men with AZF microdeletions undergoing surgical sperm retrieval. Methods We conducted a multi-institutional retrospective cohort study of men with genetically confirmed AZF micro-deletions, including AZFa, AZFb, AZFc, and combined deletions. Data were collected on preoperative serum gonadotropin levels (follicle-stimulating hormone [FSH] and luteinizing hormone [LH]), total testosterone (TT), and semen analysis parameters. Additionally, we evaluated patterns of empirical medical therapy (EMT) prescriptions and outcomes of surgical sperm retrieval. Results 40 men with confirmed Y-chromosomal micro-deletions across three academic centers was identified. Patients with SRY translocations (n=4) were excluded from the study. The final cohort included 27 patients with AZFc deletions (75%), 2 with AZFa (6%), 1 with AZFb (3%), and 6 with multilocus deletions (17%). FSH (reference: >7.6 mIU/mL) was elevated in 23 patients (64%), with a median of 19.6 IU/L (IQR: 14.4–25.8). LH (reference: >9 mIU/mL) was elevated in 8 patients (22%), with a median of 14.9 IU/L (IQR: 13.7–20.1). Overall median TT was 243.5 (7.7-379.7). TT was below the lower limit of normal (<300 ng/dL) in 13 patients (36%), with a median of 184 ng/dL (IQR: 133–233). Most patients were azoospermic on semen analysis (86%, n=31/36). Of the seven men treated with EMT, the majority (6/7, 86%) received clomiphene citrate. While there were differences in initial levels of TT, FSH, and LH for those treated with EMT compared to those without EMT, these were not statistically significant (Table 1). Among the 13 patients who underwent surgical sperm retrieval, 6 (46%) had successful outcomes; however, only one had received EMT. Conclusions Men with AZF deletions exhibit varying degrees of hormonal imbalance and rates of empirical medical therapy (EMT) use. Despite EMT, sperm retrieval outcomes were poor, with only 1 out of 7 EMT-treated patients achieving successful sperm retrieval. While hormonal differences were observed between those who received EMT and those who did not, these differences did not reach statistical significance. This is likely due to the limited sample size inherent to this rare patient population. Our findings underscore the variability in hormonal profiles and the unclear efficacy of EMT in promoting spermatogenesis in men with AZF deletions, highlighting the need for further research to inform standardized management strategies. Disclosure No

Abstract Introduction Many couples who do not achieve pregnancy with intrauterine insemination (IUI) subsequently pursue in vitro fertilization (IVF). While the impact of semen parameters on IUI outcomes is well established, it remains unclear whether characteristics of sperm following IUI preparation predict future IVF success. Many couples who do not achieve pregnancy with intrauterine insemination (IUI) subsequently pursue in vitro fertilization (IVF). While the impact of semen parameters on IUI outcomes is well established, it remains unclear whether sperm characteristics following IUI preparation predict future IVF success. Here we study a novel, clinically accessible marker of sperm quality – percent change in total motile sperm (TMS) after IUI sperm wash-that may predict fertilization and blastulation outcomes in subsequent IVF cycles. Objective This aims to evaluate the association between changes in total motile sperm (TMS) after IUI sperm wash and fertilization rates in subsequent IVF cycles.This study aims to evaluate the association between changes in TMS after IUI sperm wash and fertilization and blastulation rates in subsequent IVF cycles. Methods In this retrospective study, we identified couples at a single academic center who failed to achieve a live birth following IUI and subsequently underwent IVF with the same partner. To minimize confounding, only couples with a diagnosis of unexplained infertility or male factor infertility were included. In patients who underwent multiple IUIs (median of 2), the cycle with the greatest percent decrease in TMS was selected for analysis. Additional predictive variables of female partner age, male partner age, pre-wash TMS, and insemination method were assessed. A stepwise variable selection method was utilized to identify predictors of fertilization rate and complete blastulation failure, with linear and logistic regression models of selected variables developed, respectively. Results From the cohort of 388 couples, the median fertilization rate during IVF was 56% (IQR 43%–70%). Thirteen percent of couples experienced complete blastulation failure. Change in TMS was selected as a predictor of both fertilization rate and blastulation failure. A 10% greater decline in TMS after IUI sperm wash was associated with a 1.02% lower fertilization rate (p=0.052), after adjustment for insemination method. A 10% greater decrease in TMS was associated with a 1.22-times (95% CI 1.04, 1.48) increased odds of blastulation failure (p=0.023) after adjusting for female partner age. Conclusions A greater percent decrease in TMS following IUI sperm wash is associated with lower fertilization rates and a higher odds of blastulation failure in subsequent IVF cycles. These findings support the hypothesis that significant declines in TMS after sperm preparation may reflect underlying sperm quality defects not detected by routine semen analysis, yet still relevant to fertility outcomes. By identifying sperm quality issues not apparent on standard semen analysis, these findings offer a new tool for risk stratification and counseling of couples transitioning from IUI to IVF. Disclosure No