Mark Stovsky

EFFECTS OF SUBINGUINAL VARICOCELE LIGATION ON SPERM CONCENTRATION, MOTILITY AND KRUGER MORPHOLOGY

PURPOSE We examined the effects of varicocelectomy on semen parameters in 30 subfertile men, with emphasis on potential changes in sperm count, motility and morphology as measured by Krugers strict morphologic criteria. MATERIALS AND METHODS A total of 30 patients underwent subinguinal varicocelectomy (25 bilateral and 5 unilateral). Preoperative and postoperative sperm density, motility and morphology were analyzed. Preoperative follicle-stimulating hormone, luteinizing hormone and testosterone levels were measured and compared to those of fertile volunteers enrolled in our sperm donation program. Pregnancy rates after varicocelectomy were also examined: The Wilcoxon signed rank test was used to measure levels of statistical significance in all analyses. RESULTS We found that sperm density and motility improved significantly (p < 0.05) without concomitant changes in strict morphology (p > 0.05) only in men with clinical bilateral varicoceles. No differences were observed in values among testosterone, follicle-stimulating hormone and luteinizing hormone levels of the fertile control group and preoperative varicocele patients. Of 30 patients 12 (40%) had successful, full-term pregnancies, including 6 via natural cycle intercourse, 5 (43%) by in vitro fertilization embryo transfer and 1 by intracytoplasmic sperm injection. CONCLUSIONS Although sperm morphology as measured by strict morphologic criteria does not improve after varicocelectomy, there were highly significant changes in motility and concentration. Hormonal differences are not likely to have a role in or be reflective of pathophysiology of varicocele induced male infertility. The recent observation that sperm motility may be an independent or additive predictive factor for fertilization and pregnancy supports the need for continued varicocele repair independent of the lack of varicocelectomy effect on Kruger morphology.

BPH Procedural Treatment: The Case for Value-Based Pay for Performance

The concept of “pay for performance” (P4P) applied to the practice of medicine has become a major foundation in current public and private payer reimbursement strategies for both institutional and individual physician providers. “Pay for performance” programs represent a substantial shift from traditional service-based reimbursement to a system of performance-based provider payment using financial incentives to drive improvements in the quality of care. P4P strategies currently embody rudimentary structure and process (as opposed to outcomes) metrics which set relatively low-performance thresholds. P4P strategies that align reimbursement allocation with “free market” type shifts in cognitive and procedural care using evidence-based data and positive reinforcement are more likely to produce large-scale improvements in quality and cost efficiency with respect to clinical urologic care. This paper reviews current paradigms and, using BPH procedural therapy outcomes, cost, and reimbursement data, makes the case for a fundamental change in perspective to value-based pay for performance as a reimbursement system with the potential to align the interests of patients, physicians, and payers and to improve global clinical outcomes while preserving free choice of clinically efficacious treatments.