OBJECTIVE:To evaluate novel preoperative hormonal predictors of sperm retrieval success in men with idiopathic nonobstructive azoospermia (NOA) undergoing microsurgical testicular sperm extraction (mTESE). DESIGN:Multi-institutional retrospective cohort study conducted between 2014 and 2024. SUBJECTS:A total of 60 men with strictly defined idiopathic NOA from multiple sites participating in the MOBYUS Male Infertility Research Consortium were included, comprising a prediction cohort (n = 30) and an independent multi-institutional validation cohort (n = 30). Idiopathic NOA was defined by azoospermia on two separate semen analyses without prior paternity, evidence of obstruction, prior genitourinary surgery, documented genetic abnormalities, or use of empirical medical therapy within 1 year before surgery. Sensitivity analyses were performed by excluding men with follicle-stimulating hormone (FSH) levels <7.6 IU/L and men with hypospermatogenesis on pathology. EXPOSURE:Preoperative FSH, luteinizing hormone (LH), and total testosterone (T) levels measured within 1 year before mTESE. Hormone-derived ratios, including T/FSH, T/LH, and LH/FSH, were subsequently analyzed. MAIN OUTCOME MEASURES:Successful sperm retrieval at mTESE served as the primary outcome. Predictive performance was evaluated using logistic regression to assess hormonal predictors, area under the receiver operating characteristic curve (AUC), and partition analysis to identify optimal clinical thresholds for sperm retrieval prediction. RESULTS:Men with successful sperm retrieval had significantly lower gonadotropin levels and higher T/FSH ratios. Among all hormonal metrics, T/FSH demonstrated the strongest discriminative ability (AUC = 0.81). The significance remained after excluding men with hypospermatogenesis noted on testicular pathology. In external validation, T/FSH was the only variable that maintained statistical significance (AUC = 0.74). Partition analysis further revealed a two-step model (T/FSH >20 and LH <10) that achieved 93% sensitivity and 81% specificity for predicting sperm retrieval success. CONCLUSION:This multi-institutional study demonstrates that the T/FSH ratio is a reproducible and clinically meaningful predictor of sperm retrieval success in men with idiopathic NOA. Across two independent and diverse cohorts, this ratio consistently outperformed single-hormone predictors and remained the only externally validated preoperative predictor of mTESE success.

Abstract Introduction Despite a prevalence of nearly 1 in 10 men, male infertility remains incompletely understood and half of all diagnoses remain idiopathic despite extensive diagnostic workup. Even at large institutions, the rarity of many subpopulations of infertile men limits sample size and data quality. Objective We initiated an integrated multi-institutional research consortium to better under the pathogenesis of male infertility and improve our ability to conduct diverse, clinically relevant evidence-based research in this area. Methods A standardized 400-point database with advanced branching logic and automated calculation capabilities was generated and iteratively optimized using the HIPAA-compliant REDCap platform. Individual instruments were produced to capture demographic information, medical history, physical examination findings, lab and semen testing results, procedural and surgical data, and fertility outcomes. The database can be rapidly deployed at new institutions following completion of a standard data use agreement and is internally maintained by site investigators and exported at regular intervals for consortium-wide aggregation in a de-identified fashion. Results With the primary goal of pursuing collaborative and democratic research, the IRB-approved MOBYUS (Male Organ Biology Yielding United Science) consortium currently consists of at least twelve large US-based academic medical institutions. Data collection is ongoing with >4000 patients included to date with new projects are identified at regular monthly virtual meetings. The group has successfully published three proof-of-principle manuscripts to date. Conclusions As the field of urology and its subspecialties move towards collaboration and data-driven management, male infertility and its associated rare diseases may benefit from a decentralized network capable of leveraging large data sets. The MOBYUS Consortium aims to accomplish this goal for male infertility patients with an emphasis on generating the best possible clinical data for the patients suffering from this difficult condition. The collaborative approach adopted by the MOBYUS Consortium has the capability of rapidly generating a robust cohort for practice-shaping studies. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Fellow Health (Dr. David Shin, Stockholder); Posterity Health (Dr. Akanksha Mehta, Advisory Board Member); Boston Scientific Corporation (Dr. Marah Hehemann, Consultant); Coloplast Corporation (Dr. Marah Hehemann, Consultant); Endo International (Dr. Marah Hehemann, Speaker).

In men with impaired semen parameters, empiric medical therapies such as clomiphene citrate, a selective estrogen receptor modulator (SERM), and anastrozole, a selective aromatase inhibitor, are often employed. The effects of jointly administering these agents on semen parameters are not well understood. Here, we describe the findings of our multi-center, retrospective cohort study of men with idiopathic primary or secondary infertility. Twenty-one men were treated with combination therapy (anastrozole and clomiphene) and 69 men were treated with monotherapy (anastrozole). Patients with pre-treatment normozoospermia and recent or current exogenous testosterone therapy were excluded. Baseline and post-treatment semen and sex hormone parameters were compared among groups. The median follow-up duration was 91 days [interquartile range (IQR), 64-117 days]. Following treatment, 43% of men in the combination therapy group demonstrated normozoospermia, compared to 25% in the monotherapy group. Furthermore, men in the combined group demonstrated marked improvements in total motile sperm count (TMSC) [11.3 vs. 2.1 million (M), P=0.03]. There were no significant differences in hormone levels among the two groups following treatment. Combination therapy with clomiphene citrate and anastrozole was associated with modest benefits in post-treatment semen parameters, when compared to anastrozole monotherapy. These benefits may contribute to improvements in pregnancy outcomes with less invasive assisted reproductive technologies, such as intrauterine insemination (IUI). Future investigations with larger sample sizes and prospective study designs are necessary.

Male infertility is defined as a failure to conceive after 12 months of unprotected intercourse owing to suspected male reproductive factors. Non-malignant red blood cell disorders are systemic conditions that have been associated with male infertility with varying severity and strength of evidence. Hereditary haemoglobinopathies and bone marrow failure syndromes have been associated with hypothalamic–pituitary–gonadal axis dysfunction, hypogonadism, and abnormal sperm parameters. Bone marrow transplantation is a potential cure for these conditions, but exposes patients to potentially gonadotoxic chemotherapy and/or radiation that could further impair fertility. Iron imbalance might also reduce male fertility. Thus, disorders of hereditary iron overload can cause iron deposition in tissues that might result in hypogonadism and impaired spermatogenesis, whereas severe iron deficiency can propagate anaemias that decrease gonadotropin release and sperm counts. Reproductive urologists should be included in the comprehensive care of patients with red blood cell disorders, especially when gonadotoxic treatments are being considered, to ensure fertility concerns are appropriately evaluated and managed.

Supplementary Data from Hypoxia-Reoxygenation Couples 3βHSD1 Enzyme and Cofactor Upregulation to Facilitate Androgen Biosynthesis and Hormone Therapy Resistance in Prostate Cancer

Abstract Introduction The COVID-19 pandemic impacted nearly all aspects of life for American families. Urologic care was also disrupted, including access to elective sterilization procedures. In the setting of these social and economic changes, it is unknown how the advent of the COVID-19 pandemic affected the population pursuing vasectomy. Objective We sought to evaluate how the COVID-19 pandemic affected the age, paternity status, and fertility of men undergoing vasectomy. Methods We completed a retrospective cohort study of men undergoing vasectomy a single academic medical center across a ten-year period (11/1/2011-10/31/2021) that overlapped with the COVID-19 pandemic. The pandemic start date was defined as 04/01/2020, which coincided with the implementation of government-enacted restrictions on public activities. Patients undergoing vasectomy were identified via a systematic search of the electronic medical record. Patient age, BMI, paternity status, number of children, and procedure date were abstracted. To obtain a more granular appreciation of demographic changes, vasectomized men were divided into age categories spanning 5-year increments. Fisher’s exact and chi-squared tests were performed to compare age group prevalence and paternity status before and after the pandemic. T-tests were employed to compare the distribution of age, BMI, and number of children. Results 1999 vasectomized men were included in the cohort, 1829 (91.5%) of whom underwent sterilization prior to the start of the COVID-19 pandemic. Patients undergoing vasectomy during the pandemic were approximately one year older than those getting vasectomized before the pandemic (39.6 vs. 38.5 years, p=0.04, Table 1), while BMI was similar (29.0 vs. 29.2 kg/m^2, p=0.51). Paternity data was available for 59% of the cohort (n=1180/1999), the majority of whom attained fatherhood prior to obtaining vasectomy (n=822/1180, 69.7%). Men undergoing vasectomy during the pandemic were more likely to be fathers (89.9% vs. 67.8%, p=0.0001) and had more children, on average, than men being sterilized before the advent of COVID-19 (2.2 vs. 1.7 children, p=0.0004). Interestingly, there was also a statistically significant difference in the age category distribution of vasectomized men before and during the pandemic (p=0.02, Figure 1). Relatively fewer 30-34 year-olds underwent vasectomy after the debut of COVID-19 (12.4% vs. 21.1%, p=0.02), while relatively more 45-49 year-olds were sterilized during the pandemic (17.7% vs. 11.9%, p=0.04). Further illustrating this point, only 19.4% of the pandemic group was younger than 35 years of age compared to 28.5% of the pre-pandemic group (p=0.01). Conclusions Men obtaining vasectomies during the COVID-19 pandemic were older, were more likely to be fathers, and had more children on average than men who pursued sterilization beforehand. These findings imply that men with larger families exhibited greater interest in vasectomy following the advent of the pandemic. Additional investigation is required to validate these findings and better understand the social and economic forces that drove these demographic changes. Disclosure No

Abstract Introduction Clomiphene citrate (CC), a selective estrogen receptor modulator, and anastrozole, a selective aromatase inhibitor, are common empiric medical therapies for men with idiopathic infertility. The effects of jointly administering these agents are not well understood. Objective The objective of this study is to compare semen parameters in men treated with clomiphene citrate and anastrozole (CC-A) combination therapy to those in men taking anastrozole alone. Methods We performed a multi-center, retrospective cohort study of men with idiopathic infertility prescribed anastrozole at two tertiary referral institutions. Demographic, laboratory, and prescription data were captured. The subset of patients taking CC at the time of anastrozole initiation were identified. Patients with pre-treatment normozoospermia, recent or current exogenous testosterone or human chorionic gonadotropin use, previous orchiectomy, and scrotal surgery during the treatment period were excluded. Outcome measures included changes in World Health Organization sperm concentration category (WHO-SCC) following initiation of anastrozole therapy. Linear and logistic regression models were constructed to evaluate the association of combination therapy with these outcomes. Results 72 men were included in the analysis cohort, including 54 men taking anastrozole alone and 18 men on CC therapy who subsequently started taking anastrozole (CC-A). Men on CC-A relative to anastrozole monotherapy were older (40 vs. 35 years, p=0.03) and had a lower BMI (30 vs. 34 kg/m^2, p=0.05), respectively. Pre-treatment LH levels (5.6 vs. 7.6 IU/L, p=0.25) and testosterone (336 vs 263 ng/dL, p=0.32) were similar. Baseline semen parameters including sperm concentration (3.7 vs. 2.3 M/mL, p=0.26) and motility (41 vs. 36%, p= 0.17) were also comparable. However, post-treatment median sperm concentration (6.9 vs. 3.4M/mL, p=0.02) and the change in mean sperm concentration (17.5 vs. 6.2 M/mL, p=0.03) were significantly higher in the CC-A combination group. Univariate linear regression also revealed an association between the use of CCA combination therapy and increase in sperm concentration (p=0.05). Despite these differences, WHO-SCC upgrade rates between groups were comparable (56 vs. 39%, p=0.22) in the setting of similar post-treatment levels of LH (7.4 vs. 8.6 IU/L, p=0.5), FSH (8.6 vs. 9.4 IU/mL, p=0.19), and testosterone (537 vs. 415 ng/dL, p=0.09). Conclusions Combination therapy with clomiphene citrate and anastrozole was associated with modest benefits in post-treatment sperm concentration when compared to anastrozole monotherapy. Combination empiric medical therapy using clomiphene citrate and anastrozole offers a small, but significant, clinical benefit over anastrozole alone for infertile men Disclosure No

AbstractAndrogen deprivation therapy suppresses tumor androgen receptor (AR) signaling by depleting circulating testosterone and is a mainstay treatment for advanced prostate cancer. Despite initial treatment response, castration-resistant prostate cancer nearly always develops and remains driven primarily by the androgen axis. Here we investigated how changes in oxygenation affect androgen synthesis. In prostate cancer cells, chronic hypoxia coupled to reoxygenation resulted in efficient metabolism of androgen precursors to produce androgens and activate AR. Hypoxia induced 3βHSD1, the rate-limiting androgen synthesis regulator, and reoxygenation replenished necessary cofactors, suggesting that hypoxia and reoxygenation both facilitate potent androgen synthesis. The EGLN1/VHL/HIF2α pathway induced 3βHSD1 expression through direct binding of HIF2α to the 5′ regulatory region of HSD3B1 to promote transcription. Overexpression of HIF2α facilitated prostate cancer progression, which largely depended on 3βHSD1. Inhibition of HIF2α with the small-molecule PT2399 prevented prostate cancer cell proliferation. These results thus identify HIF2α as a regulator of androgen synthesis and potential therapeutic target in prostate cancer.Significance:Hypoxia followed by reoxygenation in prostate cancer drives androgen deprivation therapy resistance via increasing the rate-limiting enzyme and cofactors for androgen synthesis, revealing HIF2α as a therapeutic target to subvert resistance.

Anastrozole is a selective aromatase inhibitor commonly prescribed as empiric medical therapy for men with idiopathic infertility and elevated estradiol levels. The goal of this study is to identify patient factors associated with a clinically significant improvement in semen parameters on anastrozole.

Androgen deprivation therapy depletes circulating testosterone and is the mainstay treatment for advanced prostate cancer by suppressing tumor androgen receptor signaling. Despite initial treatment response, castration-resistant prostate cancer nearly always develops and remains driven primarily by the androgen axis. We investigated how changes in oxygenation affect androgen synthesis. Our study indicates that when chronic hypoxia is coupled to reoxygenation, prostate cancer cells efficiently metabolize androgen precursors to produce androgens and activate AR. Hypoxia induces 3βHSD1, the rate-limiting androgen synthesis regulator, and reoxygenation replenishes necessary cofactors. Therefore, hypoxia and reoxygenation are both essential for potent androgen synthesis. The EGLN1/VHL/HIF2α pathway promoted transcription of HSD3B1 by directly binding the 5’ regulatory region of HSD3B1. HIF2α overexpression facilitated prostate cancer progression, which largely depends on 3βHSD1. PT2399, a specific HIF2α inhibitor, prevented prostate cancer cell proliferation. Our study indicates HIF2α is a potential therapeutic target in prostate cancer. Citation Format: Liang Qin, Yoon-Mi Chung, Michael Berk, Bryan Naelitz, Eric Klein, Abhishek A Chakraborty, Nima Sharifi. Hypoxia-reoxygenation couples enzyme and cofactor upregulation to quicken prostate cancer androgen biosynthesis and hormone therapy resistance [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 122.