Couples After Renal Transplantation: Impact of Sex and Relationship Quality on Adherence in a Prospective Study

BackgroundIn patients after kidney transplantation, nonadherence to immunosuppressant medication is a common problem. Identifying factors that influence adherence could optimize medical care and prevent nonadherence. Kidney transplantation is a stressful situation for the patient and also for the relatives. The recipients of renal transplants as well as the family system have to be taken into account as potential impact factors.MethodsFifty-six couples with a renal transplant recipient were investigated regarding adherence, relationship satisfaction, social support, and quality of life. Moreover, sex and role differences (patient vs partner) as well as differences within the couple were analyzed. Impact factors on adherence were identified.ResultsFemale recipients of renal transplant reported higher relationship satisfaction than male recipients, female spouses, and male spouses. Physical quality of life was lower in renal transplant recipients compared with caregivers. For male renal transplant recipients, significant predictors of adherence, such as social support, relationship quality, and quality of life emerged, whereas for female renal transplant recipients mental quality of life and education level were found to influence adherence.ConclusionsThe study reveals the importance of relationship functioning of couples after kidney transplantation, as well as considering sex and role differences. There is a need to examine the posttransplantation nonadherence risk profile of women and men separately.     

Pregnancy following intracytoplasmic sperm injection of immotile spermatozoa selected by the hypo-osmotic swelling-test: a case report

Summary.  The success of intracytoplasmic sperm injection (ICSI) is poor when only immotile spermatozoa can be retrieved. In a couple with complete male asthenozoospermia the possible use of the hypo-osmotic swelling test to select spermatozoa for microinjection was examined. Following incubation in hypo-osmotic medium (Hypo 10, IVF Science, Göteborg, Sweden), 26% of immotile spermatozoa showed signs of sperm swelling (HOS-positive). After injection of HOS-positive spermatozoa, 5 out of 12 oocytes fertilized (41%) and after transfer of three embryos a healthy singleton pregnancy was achieved. In a previous ICSI cycle of this couple without preselection of spermatozoa by the HOS test, only 1 out of 10 oocytes fertilized. It is concluded that selection of spermatozoa by hypo-osmotic swelling-test prior to sperm microinjection seems to be a valuable tool to increase the fertilization rate in cases with complete asthenozoospermia.     

Chromosomal abnormalities in couples undergoing intracytoplasmic sperm injection. A study of 370 couples and review of the literature

Intracytoplasmic sperm injection (ICSI) is now widely acknowledged as the most effective therapeutic approach to severe male infertility or unsuccessful in vitro fertilization. Cytogenetic investigations were performed in 370 females and 335 males prior to ICSI between January 1997 and April 2003. Nine men (2.7%) and 48 women (13%) had an abnormal karyotype, 44 females having some degree of numerical sex chromosome mosaicism. A review of the literature showed the prevalence of all types of chromosomal abnormalities to be much higher among male and female partners of couples examined prior to ICSI than among newborns. As most ICSIs are performed with ejaculated spermatozoa from oligospermic men, the distribution and the prevalence of the several types of chromosomal abnormalities are closer to those of oligospermic rather than azoospermic males. Our results combined with those of the literature stress the importance of karyotyping both male and female partners before ICSI is started. Adequate genetic counselling, possibly followed by prenatal diagnosis, should be offered if a chromosomal anomaly is detected.     

Extracorporeal shock wave lithotripsy for renal calculi in children.

Fifteen children (8 male and 7 female) with an age range of 18 months to 15 years were treated with extracorporeal shock wave lithotripsy (ESWL) using the Siemens Lithostar. Two children had a history of metabolic stone disease and 1 child had previously undergone open stone surgery. Four children were treated with a ureteric stent in place and 1 nephrostomy was inserted before treatment. All children were treated under general anaesthesia and all of the stones treated were confined to the kidney and ranged in size from 5 mm to a complete staghorn. The number of treatments ranged from 1 to 6 and generator voltage ranged from 16 to 19 kV with a maximum number of 30,000 shocks to a complete staghorn. Complications were minimal, with 3 children presenting with colic, 1 child requiring a stent and none requiring a nephrostomy after treatment. The overall stone clearance rate at 3 months was 65%. ESWL provides an effective treatment for selected calculi in children. In the short term, complications are minimal but the long-term effects on children need to be monitored.     

Type 1 diabetes in a Nigerian family-occurrence in three out of four siblings: A case report

BACKG ROUND Most occurrences of type 1 diabetes cases in any population are sporadic rather than familial. Hence, type 1 diabetes among siblings is a rare occurrence. Even more rare is for three or more siblings to develop type 1 diabetes. In this report,we describe a case of a Nigerian family in which type 1 diabetes occurred in three siblings among four children with neither parent having diabetes. All three siblings are positive for glutamic acid decarboxylase and anti-islet cell antibodies.CASE SUMMARY There were four siblings(three males and one female) born to a couple without a diagnosis of diabetes. The eldest child(male) was diagnosed with diabetes at the age of 15, the second child(female) was diagnosed at the age of 11 and the fourth child(male) was diagnosed at the age of 9. All the siblings presented with similar osmotic symptoms and were diagnosed of diabetic ketoacidosis. All of them had markedly reduced serum C-peptide levels with high levels of glutamic acid decarboxylase and insulinoma-associated protein-2 antibodies. We could not perform genetic analysis of HLA-DR, DQ and CTLA4 in the siblings as well as the parents; hence haplotypes could not be characterized. Both parents of the probands have no prior history of diabetes, and their blood glucose and glycated hemoglobin levels were within normal ranges. The third child(male) has no history suggestive of diabetes, and his blood glucose and glycated hemoglobin have remained within normal ranges.CONCLUSION Although the occurrence of type 1 diabetes in proband siblings is uncommon,screening for diabetes among siblings especially with islet autoantibodies should be encouraged.     

Sources of HIV incidence among stable couples in sub-Saharan Africa

Introduction

The recent availability of efficacious prevention interventions among stable couples offers new opportunities for reducing HIV incidence in sub-Saharan Africa. Understanding the dynamics of HIV incidence among stable couples is critical to inform HIV prevention strategy across sub-Saharan Africa.

Methods

We quantified the sources of HIV incidence arising among stable couples in sub-Saharan Africa using a cohort-type mathematical model parameterized by nationally representative data. Uncertainty and sensitivity analyses were incorporated.

Results

HIV incidence arising among stable concordant HIV-negative couples contribute each year, on average, 29.4% of total HIV incidence; of those, 22.5% (range: 11.1%–39.8%) are infections acquired by one of the partners from sources external to the couple, less than 1% are infections acquired by both partners from external sources within a year and 6.8% (range: 3.6%–11.6%) are transmissions to the uninfected partner in the couple in less than a year after the other partner acquired the infection from an external source. The mean contribution of stable HIV sero-discordant couples to total HIV incidence is 30.4%, with most of those, 29.7% (range: 9.1%–47.9%), being due to HIV transmissions from the infected to the uninfected partner within the couple. The remaining incidence, 40.2% (range: 23.7%–64.6%), occurs among persons not in stable couples.

Conclusions

Close to two-thirds of total HIV incidence in sub-Saharan Africa occur among stable couples; however, only half of this incidence is attributed to HIV transmissions from the infected to the uninfected partner in the couple. The remaining incidence is acquired through extra-partner sex. Substantial reductions in HIV incidence can be achieved only through a prevention approach that targets all modes of HIV exposure among stable couples and among individuals not in stable couples.     

Malignant presacral teratoma in children.

Malignant presacral teratoma is a rare tumor seen predominantly in young female children. The introduction of planned multidisciplinary treatment has improved the outlook for patients with this once dismal disease. Six female children were seen at Memorial Hospital with the diagnosis of malignant presacral teratoma. Five children were age 17 mo to 3 yr and the sixth child was 13 yr old at diagnosis. Presenting symptoms included masses in the buttock or groin, constipation, difficulty voiding, and local pain. Pathological features were varied and complex but three had predominantly endodermal sinus features. One child had the malignant presacral teratoma develop 18 mo after successful resection of a benign sacrosoccygeal teratoma in the newborn period. Treatment varied in the six cases since all were referred after failure of treatment elsewhere. All children had surgery, irradiation, and multiple drug chemotherapy. Four of the six children are surviving disease-free, 3 more than 24 mo off treatment. Evolution of treatment up to the present protocol management is discussed.     

Chlamydia trachomatis infection among sexual partners of the patients with non-gonococcal urethritis

During the past 3 years, 30 sexual partners including 18 married couples and 12 extramarital sexual pairs whose male partners were diagnosed as having non-gonococcal urethritis were examined for Chlamydia trachomatis infection. Twenty-three of the 30 couples (76.7%) had identical results either positive or negative for Chlamydia trachomatis infection. All 3 male partners of the 3 pairs who had the non-identical results for Chlamydia trachomatis infection, male negative and female positive, had history of urethritis or prostatitis. Fourteen of the 17 female partners (82.4%) who were positive for Chlamydia trachomatis, had no subjective complaints. The above findings suggest the necessity of treating the female sexual partners of the non-gonococcal urethritis patients irrespective of their symptom.     

Aide entre conjoints. Dynamiques de genre dans les couples adultes avec handicap

Family care for disabled adults is more often provided by women, but spousal care more often by men. Hands-on care is equally provided by male and female spouses, but care for daily life is provided twice as much by male than by female spouses. The article describes and tries to explain this paradox. Three hypotheses have been explored: gender differences in disability prevalence; gender differences in couple life with equivalent disability; gender differences in spousal care for disabled people living in couples. The study is limited to the adult population, i.e. to disabled people of 18–59 years old. Data come from the French HSM-HAS Health Survey (INSEE, 2008). Results show gender similarities in disability prevalence, in couple life and in hands-on care. Care in daily life, on the contrary, is much more provided by male spouses, even after controlling for disability characteristics. Especially women with few restrictions get more help from their male spouse than men in the same situation. The difference seems to be more related to the initial gender division of activities than to gendered willingness for care when disability arrives. Domestic activities can be taken over by a household member, professional activities cannot. It is not disability but preexisting division of activities that create differences in spousal care.     

Comparative results of urological evaluation of children with initial and recurrent urinary tract infection.

Complete urologic evaluation was done on male and female children having initial or recurrent urinary tract infection. Of 200 girls having recurrent urinary tract infection 43 per cent showed ureterovesical reflux on the cystogram. Of 39 boys with recurrent urinary tract infection 41 per cent had reflux. Thus, the incidence of reflux is comparable in male versus female patients. Of 47 girls studied after only 1 episode of urinary tract infection 36 per cent had reflux and of 20 boys studied after initial infection 45 per cent had reflux. The data indicate that initial or recurrent urinary tract infection in boys or girls is of equal significance. All other factors being equal, failure to evaluate a patient urologically after 1 or more episodes of urinary tract infection solely because of the sex of the child could mean that a potentially severe urinary tract abnormality can be undetected and untreated.     

Vasovasostomy: multiple children and long-term pregnancy rates

PURPOSE: To determine the long-term patency and pregnancy rates after vasovasostomy and to determine the likelihood of having more than 1 child after this procedure. MATERIALS AND METHODS: We performed a retrospective examination of 73 patients that were at least 4 years out from vasovasostomy at our institution. Patients and their partners completed questionnaires that focused on their pre- and post-procedure fertility, vasal obstructive interval, time to pregnancy, and the number of children conceived. All patients were asked to obtain a current semen analysis. RESULTS: From a population of 73 patients with proven prior fertility, 43 could be contacted for data collection. Of the 43 men, 39 (91%) reported that they had actively tried to father children. These 39 men are a mean of 84.8 months (range, 4 to 10 years) out from their surgery, with a mean vasal obstructive interval of 87 months (7.4 years). All men denied using assisted reproduction techniques except the father of the only twins, who reported the use of ICSI for female-factor infertility. He was excluded from further pregnancy calculations. Forty-five percent of couples achieved at least 1 pregnancy, whereas 6 of 17 (35%) conceived 2 children. Mean time to conception was 14.7 months for the first child and 51 months for the second (range, 13 to 108 months). In those that did not conceive (n = 21), the mean obstructive interval was 106 months versus 81 months for those that did conceive. This time interval was not statistically different (P > 0.05). Mean maternal age was significantly less in those that did versus those that did not conceive (32.2 vs 36.6 years) (P < 0.01). We also noted that 10 of 21 were with a different spouse that had never been pregnant. Three of these 10 had known female-factor fertility problems. Semen analyses were obtained in 6 of the 21 patients that did not father children. Only 1 of the 6 was azoospermic. Thirteen (33%) desired more than 1 child at the time of vasectomy reversal. CONCLUSIONS: After vasovasostomy in patients with a vasal obstructive interval of 7 years, up to 45% of couples may achieve pregnancy and up to 35% could go on to conceive a second child. Long-term anastomosis patency after the procedure is estimated to be approximately 60%. Maternal age is a significant factor in predicting a couple's success in conceiving a child. Vasovasostomy remains a highly effective option for restoration of fertility in vasectomy patients, while offering the opportunity for multiple pregnancies with only a single intervention.     

Genetic counselling for infertile men of known and unknown etiology

Of the couples trying to conceive (had frequent, unprotected sexual intercourse for a year or longer) 15% will experience infertility with the annual incidence of infertility estimated at 1.2 couples per 1,000 total in the general population. Male factors contribute to over 50% of the cases with 7% of the male population experiencing infertility. Not being able to conceive a child is emotionally traumatic and frustrating and can affect the person’s self esteem and the couple’s relationship. Major progress has been achieved in identifying the etiology of male infertility and especially the genetic causes. However, in about 40% of the male infertility cases, the etiology remains unknown and both the diagnosis and/or treatment are a challenge. Genetic testing to determine the underlying genetic cause of infertility is not 100% and genes involved are still being discovered. Consequently, negative genetic test results do not rule out a genetic cause. Thus, genetic counselling should include information regarding the genetic etiology, if known, and the treatment options available. Furthermore, when the infertile couple/male is seeking assisted reproductive technology (ART) using intracytoplasmic sperm injection (ICSI), genetic counselling should include information regarding the risk of transmitting the genetic disorder, causing the male infertility, to the offspring. Therefore, the provision of genetic counselling is an integral component in the investigation and treatment of male infertility. This article will discuss the genetic counselling approach in cases with male infertility.     

Sigmoid reconfigured vaginal construction in children

PURPOSE: We present a modified technique of sigmoid neovaginal construction in children that protects the sigmoid pedicle from traction, allows easy adjustment of caliber and reorients the mucosal fold in a longitudinal direction. MATERIALS AND METHODS: From 1997 to 2000, 10 genetically male (46 XY) children 1 to 13 years old underwent construction of a neovagina with sigmoid, incorporating the Yang-Monti concept of intestinal reconfiguration. The diagnosis was androgen insensitivity in 7 patients, congenital adrenal hyperplasia in 2 due to 17 alpha-hydroxylase deficiency and 3 beta-hydroxysteroid dehydrogenase deficiency, respectively, and bladder exstrophy in 1 who required sex reassignment. RESULTS: Eight children had an adequate caliber neovagina after an initial period of systematic dilation. In 1 case a relevant stricture required reoperation using the same technique and the outcome was good. In another child a stricture developed in the middle of the reconfigured sigmoid segment and a regular dilation schedule is still being followed after 23 months of followup. CONCLUSIONS: The new sigmoid reconfiguration technique enables the use of smaller dimension intestinal segments and construction of a long vaginal conduit of adequate caliber. Its optimal adequacy for penetration must be assessed in the future after these patients begin sexual activity.     

Conservative treatment of ureteropelvic junction obstruction in children with antenatal diagnosis of hydronephrosis: lessons learned after 16 years of follow-up

OBJECTIVES: We attempted to define predictive factors for surgery in children with antenatal diagnosis of hydronephrosis that led to postnatal diagnosis of ureteropelvic junction (UPJ) obstruction. METHODS: We retrospectively evaluated our 16-yr experience (1988-2003) with 343 children (260 male and 83 female) with antenatal diagnosis of hydronephrosis that led to postnatal diagnosis of UPJ obstruction and who were followed conservatively. Right-sided hydronephrosis was present in 110 and left-sided in 233 children. According to the Society for Fetal Urology (SFU) classification none had grade 0 of postnatal hydronephrosis, 20 had grade 1, 118 grade 2, 147 grade 3, and the remaining 58 children grade 4 postnatal hydronephrosis. Relative renal function (RRF) on radionuclide scans revealed 235 children with RRF>40%, 68 with RRF between 30% and 40%, and 40 patients with RRF<30%. Renal function deterioration >5% was the main indication for surgery. Commercially available software GraphPad Prism 4.0 (GraphPad prism, Prism 4 for Windows, version 4) using the Fisher exact test was used for statistical evaluation. RESULTS: Surgical correction was needed in 179 children (52.2%) during the course of conservative management. The average age at surgery was 10.6 mo (range, 1 mo to 7 yr). Of those, 50% underwent surgery during the first 2 yr of life and the majority of the remaining patients underwent surgery between the 2 and 4 yr of age; only two patients required surgery later on. Univariate analysis revealed that child sex, side of hydronephrosis, and SFU grade of prenatal hydronephrosis were not significant predictive factors for surgery. However, SFU grade 3-4 of postnatal hydronephrosis (p<0.0001; odds ratio, 0.06281) and RRF<40% (p<0.0001; odds ratio, 0.1022) were significant independent risk factors for surgery. CONCLUSION: In contrast with previous publications by others and by us these data show that >50% of children with antenatal diagnosis of UPJ obstruction in this series required surgical correction while on conservative protocol. SFU grade 3-4 of postnatal hydronephrosis and RRF<40% are significant independent predictive factors for surgery.     

Primary perineal surgeries for the low and intermediate anorectal anomalies: 5‐year results in a developing country

Aim: The late presentation of clinically unstable children with anorectal anomaly requires the creation of a prior colostomy. The objective of the present study was to examine the feasibility and applicability of primary perineal surgeries for low and intermediate anorectal anomalies without a prior colostomy. Methods: A 5‐year experience with consecutive cases of children that had primary perineal surgeries for low/intermediate anorectal anomaly at the University of Benin Teaching Hospital, Benin City, Nigeria, between January 2003 and December 2007. Results: A total of 29 children aged between 1 day and 3 years (mean 5.4 months ± 2.7), comprising 17 males and 12 females with a male/female ratio of 1.4:1 had primary perineal surgeries for low 19 (65.5%) and intermediate 10 (34.5%) anorectal anomalies. They accounted for 15.6% of children who underwent gastrointestinal operations, and diagnosis was mainly clinical in the majority of them. Transposition anorectoplasty done in 19 (65.5%) children was the commonest procedure, followed by anterior perineal anorectal pullthrough in six (20.7%) and cutback anoplasty in four (13.8%). Anal stenosis which responded to serial dilatation was the main complication and it was statistically significant for the intermediate group compared to the low group (P < 0.0002). More children among the low group had recurrent constipation, although no significant statistical difference was observed when this was compared (P < 0.6451). Overall, 27 (93.1%) children, comprising 18 low and nine intermediate lesions, were successfully managed whereas one (3.4%) child with intermediate lesion had revision surgery with one (3.4%) mortality recorded due to sepsis. Conclusion: Primary perineal surgeries without a prior colostomy in children with low and intermediate anorectal anomaly were feasible, applicable and should be used in our setting.     

Gender Differences in the Associations of PTSD Symptom Clusters With Relationship Distress in U.S. Vietnam Veterans and Their Partners

Research has consistently linked symptoms of posttraumatic stress disorder (PTSD) with relationship distress in combat veterans and their partners. Studies of specific clusters of PTSD symptoms indicate that symptoms of emotional numbing/withdrawal (now referred to as negative alterations in cognition and mood) are more strongly linked with relationship distress than other symptom clusters. These findings, however, are based predominantly on samples of male veterans. Given the increasing numbers of female veterans, research on potential gender differences in these associations is needed. The present study examined gender differences in the multivariate associations of PTSD symptom clusters with relationship distress in 465 opposite‐sex couples (375 with male veterans and 90 with female veterans) from the National Vietnam Veterans Readjustment Study. Comparisons of nested path models revealed that emotional numbing/withdrawal symptoms were associated with relationship distress in both types of couples. The strength of this association, however, was stronger for female veterans (b = .46) and female partners (b = .28), compared to male veterans (b = .38) and male partners (b = .26). Results suggest that couples‐based interventions (e.g., psychoeducation regarding emotional numbing symptoms as part of PTSD) are particularly important for both female partners of male veterans and female veterans themselves.     

10-Year outcome of children born with anorectal malformation, treated by posterior sagittal anorectoplasty, assessed according to the Krickenbeck classification

Background

Anorectal malformations (ARMs) affect 1 in 4000 to 5000 births. The Krickenbeck conference developed a classification based on anatomical and functional criteria to better compare treatment outcome.

Aim

The aim of this study is to evaluate the functional outcome in patients 10 years following standardized surgical treatment of ARM related to the Krickenbeck classification. .

Methods

Anatomical anomalies were classified as above. Children and carers were followed closely in a multidisciplinary clinic. Data were collected using a functional outcome questionnaire for a minimum of 10 years after surgical reconstruction. Outcome measurements were related to the Krickenbeck classification.

Results

There were 53 children in the study group (29 male, 24 female). Krickenbeck anatomy: perineal fistula, 36%; vestibular fistula, 26%; rectourethral fistula, 36%; rectovesical fistula, 2%.All children were treated by posterior sagittal anorectoplasty.In children with perineal fistula, continence was achieved in 90%. Grade 2 constipation was noted in 21%. One child had a Malone antegrade continence enema (MACE) procedure.In children with vestibular fistula, continence was achieved in 57%. Grade 3 constipation was noted in 28%. One child had grade 1, and one child had grade 2 soiling. Two children had a MACE procedure.In children with rectourethral fistula, continence was achieved in 58%. One child had grade 3 soiling. Grade 3 constipation was found in 42% of children and grade 2 constipation in 1 child. A MACE procedure was performed in 36%.The only child with a bladder neck fistula had a MACE procedure for intractable soiling.

Conclusions

The outcome for patients with ARM is related to the severity of the anomaly. The uniform application of the Krickenbeck classification should allow rational comparison of treatment outcome.     

Treatment of infertility due to anejaculation in the male with electroejaculation and intracytoplasmic sperm injection

PURPOSE: We tested the hypothesis that spinal cord injury and/or anejaculation affects the outcome of intracytoplasmic sperm injection (ICSI). MATERIALS AND METHODS: From November 1993 to October 1998 we obtained and prospectively reviewed data on 34 ICSI cycles using electroejaculated sperm, 620 male factor infertility ICSI cycles using normal ejaculated sperm and 120 cases of obstructive azoospermia, in which microsurgical epididymal aspiration and testicular sperm extraction-ICSI were done in 93 and 27, respectively. RESULTS: A total of 34 ICSI cycles were performed in 17 couples with male infertility due to anejaculation secondary to spinal cord injury in 10 patients and retroperitoneal lymph node dissection in 5, and idiopathic in 2. In all 17 couples at least 3 previous intrauterine insemination cycles had failed. After electroejaculation 11 men had oligozoospermia and 6 normal sperm density. Median sperm retrieval volume plus or minus standard deviation was 1.9 +/- 1.9 ml., median sperm concentration 70.7 +/- 60.2 x 106 sperm per ml., median motility 10.7% +/- 10.8% and median forward progression 2.3 +/- 0.5 (scale 1 to 4). In the anejaculation group ICSI resulted in a median fertilization of 60% +/- 28%, 15% pregnancies per cycle and 29% pregnancies per couple. In the control group of 620 ICSI cycles from ejaculated specimens obtained from male patients with infertility median fertilization was 58% +/- 26%, and there were 39% pregnancies per cycle and 47% pregnancies per couple. The rate of pregnancies per embryo transfer and per couple was higher in the control than in the electroejaculation-ICSI group (p <0.05). However, there was no statistically significant difference in the fertilization rate. CONCLUSIONS: ICSI or in vitro fertilization is a viable alternative for patients with anejaculation in whom intrauterine insemination failed. While the fertilization rate is similar in these couples, the pregnancy rate is significantly lower than that achieved with ejaculated specimens from patients with severe male factor infertility. ICSI is a viable alternative for a patient with anejaculation in whom intrauterine insemination or in vitro fertilization failed.     

Infertility as a marital crisis

For many couples infertility is a major trauma, particularly when the fault occurs in the male. Donor insemination provides a simple means of relieving this stress but may conceal a morass of emotional complexity. Counselling of the couple is essential to ensure their own future and that of the children. The diagnosis of marital infertility can be shattering to a man's self-esteem and indirectly to the woman also. A further problem may arise in deciding what to tell the child in later life. It is encouraging that help is available for those who may be involved in this neglected area of human distress.     

Epidemiologic methods for investigating male fecundity

Fertility is a couple concept that has been measured since the beginning of demography, and male fecundity （his biological capacity to reproduce） is a component of the fertility rate. Unfortunately, we have no way of measuring the male component directly, although several indirect markers can be used. Population registers can be used to monitor the proportion of childless couples, couples who receive donor semen, trends in dizygotic twinning, and infertility diagnoses. Studies using time-to-pregnancy （TTP） may identify couple subfecundity, and TTP data will correlate with sperm quality and quantity as well as sexual activity and a number of other conditions. Having exposure data available for couples with a fecund female partner would make TTP studies of interest in identifying exposures that may affect male fecundity. Biological indicators such as sperm quality and quantity isolate the male component of fertility, and semen data therefore remain an important source of information for research. Unfortunately, often over half of those invited to provide a sperm sample will refuse, and the study is then subject to a selection that may introduce bias. Because the most important time windows for exposures that impair semen production could be early fetal life, puberty, and the time of ejaculation; longitudinal data over decades of time are required. The ongoing monitoring of semen quality and quantity should continue, and surveys monitoring fertility and waiting TTP should also be designed.