title: Male infertility after endoscopic Totally Extraperitoneal (Tep) hernia repair (Main): rationale and design of a prospective observational cohort study.
abstract: BACKGROUND
  To describe the rationale and design of an observational cohort study analyzing the effects of endoscopic Totally Extraperitoneal (TEP) hernia repair on male fertility (MAIN study).
  
  
  METHODS
  The MAIN study is an observational cohort study designed to assess fertility after endoscopic TEP hernia repair. The setting is a high-volume single center hospital, specialized in TEP hernia repair. Male patients of 18-60 years of age, with primary, reducible, bilateral inguinal hernias and no contraindications for endoscopic TEP repair are eligible for inclusion in this study. Patients with an ASA-classification≥III and patients with recurrent and/or scrotal hernias and/or a medical history of pelvic surgery and/or radiotherapy, known fertility problems, diabetes and/or other diseases associated with a risk of fertility problems, will be excluded. The primary outcome is the testicular perfusion before and 6 months after TEP hernia repair (assessed by means of a scrotal ultrasonography). Secondary endpoints are the testicular volume (Ultrasound), semen quality and quantity and the endocrinological status, based on serum levels of the sexual hormones follicle-stimulating hormone (FSH), luteinizing hormone (LSH), testosterone and inhibin B before and 6 months after TEP hernia repair.
  
  
  CONCLUSIONS
  The use of polypropylene mesh is associated with a strong foreign body reaction which could play a role in chronic groin pain development. Since the mesh in (endoscopic) inguinal hernia repair is placed in close contact to the vas deferens and spermatic vessels, the mesh-induced inflammatory reaction could lead to a dysfunction of these structures. Relevant large and prospective clinical studies on the problem are limited. This study will provide a complete assessment of fertility in male patients who undergo simultaneous bilateral endoscopic TEP hernia repair, by analyzing testicular perfusion and volume, semen quantity and quality and endocrinological status before and 6 months after TEP repair.
  
  
  BACKGROUND
  The MAIN study is registered in the Dutch Trial Register (NTR2208).
authors.affiliation: Department of Surgery/Hernia Clinic, Diakonessenhuis Utrecht/Zeist, Utrecht, The Netherlands. nelleke.schouten@gmail.com
authors.forename: Nelleke
authors.initials: N
authors.lastname: Schouten
authors.forename: Thijs
authors.initials: T
authors.lastname: van Dalen
authors.forename: Niels
authors.initials: N
authors.lastname: Smakman
authors.forename: Sjoerd G
authors.initials: SG
authors.lastname: Elias
authors.forename: Cees
authors.initials: C
authors.lastname: van de Water
authors.forename: Roan J
authors.initials: RJ
authors.lastname: Spermon
authors.forename: Laurens Sibinga
authors.initials: LS
authors.lastname: Mulder
authors.forename: Ine P J
authors.initials: IP
authors.lastname: Burgmans
mesh_terms: D000293:Adolescent; D000328:Adult; D004724:Endoscopy; D006552:Hernia, Inguinal / Q000601:surgery*; D059685:Herniorrhaphy / Q000009:adverse effects* / Q000379:methods; D006801:Humans; D007248:Infertility, Male / Q000209:etiology*; D008297:Male; D008875:Middle Aged; D013526:Surgical Mesh; D055815:Young Adult