This paper tries to address the question of identifying the cause of the difficulty in obtaining a semen analysis (SA) in adolescents with a varicocele in order to try to find improved strategies in giving patient advice, treatment and care. Among infertile adults with a varicocele, surgery is indicated in the presence of abnormal semen analysis regardless of testicular atrophy. The authors carried out a survey consisting of 14 multiple choice questions and two open-ended questions regarding the use of SA in practice, barriers to its use, indications for varicocelectomy, and demographics. In addition they surveyed patients presenting for initial evaluation of a varicocele, as well as their parents, regarding their knowledge about SA and their attitude towards obtaining it. Thirty-seven consecutive adolescent male patients referred for a varicocele and their parents (27 mothers, 10 fathers) were offered the survey. In addition, an anonymous electronic survey was emailed to the active membership of the Society for Pediatric Urology. Parents and patients had similar knowledge of the collection of semen for analysis. Fourteen of thirty-one patients (45%), who claimed they knew what a semen analysis was, agreed to the semen analysis versus 16/23 (70%) of their parents. Reasons given by patients for discomfort in providing a semen analysis were: lack of knowledge regarding a semen analysis (nine); not knowing how it is collected (seven); and discomfort in discussing the topic with the parents (seven). Religious / social limitations were not cited as barriers. Amongst urologists 53% (168/315) responded. There was near unanimity (92.3%) in use of testis size / texture discrepancies (using ultrasound and physical examination) as an indication for surgery. Most paediatric urologists (53%) never asked for semen analysis while 13.1% routinely asked for semen analysis in patients meeting their criteria. Some ordered semen analysis if there appeared to be interest of the patient / family (23.8%) or if there was no other indication, such as testis volume discrepancy or symptoms of pain (9.5%). Postoperative semen analyses were routinely ordered by 8% and never by 12% of those ordering preoperative semen analyses; 50% ordered them if performed preoperatively and 30% ordered them if there was an interest by the patient / family. Twenty-five percent of urologists felt uncomfortable asking an adolescent to provide a semen analysis and another 22% felt a sense of discomfort depending on the patient / family. Fifty-three percent of paediatric urologists expressed no discomfort in asking for a semen analysis, regardless of their years in practice, physician gender, or varicocele patient volume. Physicians who felt uncomfortable asking for a semen analysis cited ethical concerns of labelling an adolescent as sub-fertile, religious reasons, and discomfort because of the presence of the parents. Ninety percent of practitioners who cited discomfort never ordered a semen analysis for patients with varicoceles. The authors conclude that paediatric urologists, as well as patients and their families, face significant barriers regarding the ordering of semen analyses in adolescents with a varicocele. They suggest from their own experience that if physicians provide a supportive environment and sound reasoning for the need for a semen sample, patients are willingly compliant. This allows the physician to make an informed decision regarding the need for surveillance versus intervention leading to better patient care. The paper’s weakness is the fact that the patient / carer numbers are small and that only just over 50% of urologists replied; however, it does indicate a significant variation in practice and highlights some of the problems that occur in unifying an approach to treating adolescent varicoceles. 

Barriers to use of semen analysis in the adolescent with a varicocele: survey of patient, parental, and practitioner attitudes.
Fine RG, Gitlin J, Reda EF, Palmer LS.
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Henrik Steinbrecher

Southampton University Hospital NHS Trust

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