Andrology subspecialty: Training opportunities for Indian urologists

Andrology is a medical specialty derived from the Greek word “Andros.” It deals with male reproduction and is the male equivalent of gynecology. Over the years, men’s sexual health was also included in andrology. PROBLEMS AND IDENTITY CRISIS Globally, most urology residents get limited exposure to andrology during their residency. A majority (80%) of Indian Urology residents have little exposure to andrology (<10% of the overall work).[1] Andrology laboratory technicians who report semen analysis also self-designate themselves as andrologists just because they “handle” sperms. Hence, it has become a norm to designate a urologist specialized in andrology as a “Uro-andrologist” and not just an “Andrologist” in reproductive medicine forums. Although the male factor is implicated as the case for infertility in nearly 50% of infertile couples, the role of clinical andrologists in the era of assisted reproductive techniques is underestimated.[2] Evaluation of males is limited to just a basic semen analysis when various andrological treatment options such as hormonal management, management of sexual dysfunction, microscopic varicocelectomy, microscopic vasovasostomy, and vasoepididymostomy may result in spontaneous pregnancy if the female partner is normal.[3] Furthermore, there is intense competition between urologists and plastic surgeons in doing penile implant surgery. Urologists are better experienced in managing intraoperative surgical complications such as urethral injuries, corporal perforations, and reservoir placement injuries such as bladder or iliac vessel injuries, and plastic surgeons have experience in neophallus penile implant placement. CLINICAL ANDROLOGY: GLOBAL TRAINING OPPORTUNITIES USA and Canada The American Urological Association (AUA), in collaboration with the Society for the Study of Male Reproduction, conducts the AUA Andrology Fellowship match program annually. Parallelly, the Sexual Medicine Society of North America (SMSNA) conducts a fellowship match process. Overall, there are 33 andrology fellowship centers in the USA (as of July 2024), and only applicants who have completed urology residency are eligible to apply through the AUA and SMSNA websites.[4,5] A total of 324 andrology fellows had completed fellowship between 1982 and 2020; female residents comprised 16.4%.[6] The Canadian Urological Association lists three Canadian centers offering andrology fellowships of 1–2 years’ duration. The American Society of Andrology was founded in 1975 but mainly offers educational programs related to male reproduction and does not offer clinical fellowship training. Europe Unlike in the USA, where fellowship-trained urologists predominantly practice andrology, andrology practice in Europe is varied. The “Andrologist” designation in Europe is used by urologists, gynecologists, endocrinologists, and dermatologists. Non-urologists practicing andrology in Europe restrict themselves to male infertility care, hormonal treatments, and genital infections. They are unlikely to venture into surgical andrology such as penile implant surgeries and Peyronie’s plaque surgeries. The European Academy of Andrology (EAA) has an 18–24-month training program in clinical andrology in association with the European Association of Urology (EAU).[7] The candidate has to clear an exit examination in clinical andrology (seminology, endocrinology, microbiology, imaging, morphology, urology, gynecology, immunology, and psychology) after completion of 18 months of training and is awarded a certificate from EAA. The EAU offers scholarships, such as short visits (2–3 weeks), 1-year scholarships, and clinical visits (6–12 weeks). The applicant must first contact the host center where he/she wishes to do his/her andrology training and obtain a letter from the host institute to apply for scholarships.[8] The European Society for Sexual Medicine (ESSM) started the ESSM Penile Implant Fellowship in 2018, which was discontinued after a few years. Currently (2024), the ESSM Surgical Academy offers a surgical training program for urologists on a 3-level training process: level 1 (live webinars), level 2 (books and videos), and level 3 (2-month hands-on training) at selected centers of excellence in Europe.[9] Asia Registered societies/organizations in urology and sexual medicine from Asia have not listed any andrology fellowship programs. One Australian center has been offering a one-year andrology fellowship for the last few years. A few South Korean, Singaporean, Chinese, and Indian centers offer observership opportunities, but there are no dedicated structured andrology fellowship programs for urologists. AUTHORS SUGGESTIONS Urologists who want to get fully trained in andrology may choose either of the two tracks: Do short-term clinical visits at two-to-three high-volume centers (each 3-month duration) over 1–2 years, preferably with some hands-on training/assistance. One center may offer high-volume prosthetic urology (penile implants and artificial urinary sphincter), another may offer advanced penile reconstructions, and the third may offer exclusive male infertility services and microsurgeries, or Do long-term (1–2 years) andrology fellowship at a single center that does both male infertility and men’s sexual health interventions. The best societies to look forward to for andrology training opportunities/funding/grants for urologists are the AUA, SMSNA, EAU, International Society for Sexual Medicine, and ESSM. All these societies expect the applicant to be a member of their society for some time (1–2 years) before applying for fellowships. The ideal time to start applying for fellowships is at the end of the second year of urology residency so that the fellowship starts immediately after urology residency. Applicants with a good number of PubMed-indexed publications and H-index are highly considered. Attending cadaveric hands-on workshops and live operative workshops may improve surgical confidence levels.[10] The applicants should preferably have a “return plan” about where they will establish their andrology practice after returning home with their completed fellowships. Initially, along with the andrology work, the andrology fellowship-trained andrologist/urologist could continue doing general urology work, such as stones and prostate, which continue to be the breadwinners for any young urologist in India. Once the andrology patient load reaches good numbers, one can relinquish the general urology work based on personal preferences. It is an added luxury if the hospital also has an IVF laboratory so that male infertility work, such as surgical sperm retrievals and sperm cryopreservation, is better coordinated with the in-house reproductive gynecologists and embryologists for better patient outcomes. Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.

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