Diagnosis and Treatment of Infertility in Men

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Diagnosis and Treatment of Infertility in Men: AUA/ASRM Guideline Part I
Peter N. Schlegel, MD, et al

Purpose: The summary presented herein represents Part I of the two-part series dedicated to the Diagnosis and Treatment of Infertility in Men: AUA/ ASRM Guideline. Part I outlines the appropriate evaluation of the male in an infertile couple. Recommendations proceed from obtaining an appropriate history and physical exam (Appendix I), as well as diagnostic testing, where indicated.

Materials/Methods: The Emergency Care Research Institute Evidence-based Practice Center team searched PubMed, Embase, and Medline from January 2000 through May 2019. When sufficient evidence existed, the body of evidence was assigned a strength rating of A (high), B (moderate), or C (low) for support of Strong, Moderate, or Conditional Recommendations. In the absence of sufficient evidence, additional information is provided as Clinical Principles and Expert Opinions (table 1). This summary is being simultaneously published in Fertility and Sterility and The Journal of Urology.

Results: This Guideline provides updated, evidence-based recommendations regarding the evaluation of male infertility as well as the association of male infertility with other important health conditions. The detection of male infertility increases the risk of subsequent development of health problems for men. In addition, specific medical conditions are associated with some causes of male infertility. Evaluation and treatment recommendations are summarized in the associated algorithm (figure).

Conclusion: The presence of male infertility is crucial to the health of patients and its effects must be considered for the welfare of society. This document will undergo updating as the knowledge regarding current treatments and future treatment options continues to expand.




BACKGROUND

The overall goal of the male evaluation is to identify conditions that may affect the management or health of the patient or their offspring. The specific goals of the evaluation of the infertile male are to identify the following:


potentially correctable conditions;

irreversible conditions that are amenable to assisted reproductive technologies (ART) using the sperm of the male partner;

irreversible conditions that are not amenable to the above, and for which donor insemination or adoption are possible options;

life- or health-threatening conditions that may underlie infertility or associated medical comorbidities that require medical attention; and

genetic abnormalities or lifestyle and age factors that may affect the health of the male patient or of offspring particularly if ART are to be employed. In this guideline, the term “male” or “men” is used to refer to biological or genetic men.




GUIDELINE STATEMENTS

Assessment

Lifestyle Factors and Relationships Between Infertility and General Health

Diagnosis/Assessment/Evaluation

Imaging




SUMMARY

Evaluation and management of men in a couple with infertility involve a step-wise process of evaluation and consultation regarding treatment options. An increasing understanding of general health conditions associated with male infertility is valuable for counseling, as well as diagnosis of the underlying cause of fertility. Evaluation should proceed in parallel for both male and female members of a couple to optimize treatment success.




FUTURE DIRECTIONS

The causes of male infertility, including their genetic basis, have only been superficially explained at this time. The interactions of male infertility with other health conditions require a deeper understanding as well. Sperm clearly affect stages of embryo development, implantation, and maintenance of pregnancy via mechanisms that are incompletely defined at this time. However, the use of ART allows a unique insight into the interaction of sperm with egg and the development of the resulting embryo. The potential to recover spermatogenesis for men who have lost germ cells throughout the testis and are azoospermic will require novel interventions with stem cell technology, possibly coupled with additional techniques to support germ cell development. Since men with severely impaired spermatogenesis appear to often have underlying genetic defects responsible for their testicular dysfunction, understanding of the specific cause of spermatogenic dysfunction may be critical for successful interventions. Fortunately, progress continues to be made on each of these fronts.

 

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Table 1. AUA nomenclature linking statement type to level of certainty, the magnitude of benefit or risk/burden, and body of evidence strength

 

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Male infertility algorithm

 

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Table 2. Summary of evidence on medical comorbidities from a systematic review

 

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Table 3. Hormonal assessment expected in azoospermic men with severely impaired spermatogenesis, obstruction, and hypogonadotropic hypogonadism

 

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Appendix. Male reproductive health physical examination

The goal of the physical examination is to identify potential etiologies of reproductive impairments, health ailments, or factors that can be optimized to improve health or reproductive success

 

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Diagnosis and Treatment of Infertility in Men: AUA/ASRM Guideline PART II
Peter N. Schlegel, MD,* Mark Sigman, MD, Barbara Collura, Christopher J. De Jonge, PhD, HCLD (ABB), Michael L. Eisenberg, MD, Dolores J. Lamb, PhD, HCLD (ABB), John P. Mulhall, MD, Craig Niederberger, MD, FACS, Jay I. Sandlow, MD, Rebecca Z. Sokol, MD, MPH, Steven D. Spandorfer, MD, Cigdem Tanrikut, MD, FACS, Jonathan R. Treadwell, PhD, Jeffrey T. Oristaglio, PhD and Armand Zini, MD




Purpose: The summary presented herein represents Part II of the two-part series dedicated to the Diagnosis and Treatment of Infertility in Men: AUA/ ASRM Guideline. Part II outlines the appropriate management of the male in an infertile couple. Medical therapies, surgical techniques, as well as the use of intrauterine insemination (IUI)/in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) are covered to allow for optimal patient management. Please refer to Part I for discussion on evaluation of the infertile male and discussion of relevant health conditions that are associated with male infertility.

Materials/Methods: The Emergency Care Research Institute Evidence-based Practice Center team searched PubMed, Embase, and Medline from January 2000 through May 2019. When sufficient evidence existed, the body of evidence was assigned a strength rating of A (high), B (moderate), or C (low) for support of Strong, Moderate, or Conditional Recommendations. In the absence of sufficient evidence, additional information is provided as Clinical Principles and Expert Opinions (table). This summary is being simultaneously published in Fertility and Sterility and The Journal of Urology.

Results: This Guideline provides updated, evidence-based recommendations regarding the management of male infertility. Such recommendations are summarized in the associated algorithm (figure).

Conclusion: Male contributions to infertility are prevalent, and specific treatment, as well as assisted reproductive techniques, are effective at managing male infertility. This document will undergo additional literature reviews and updating as the knowledge regarding current treatments and future treatment options continues to expand.






BACKGROUND

Failure to conceive within 12 months of attempted conception is due in whole or in part to the male in approximately one-half of all infertile couples. Although many couples can achieve a pregnancy with assisted reproductive technologies (ART), evaluation of the male is important to identify conditions that may be medically important, counsel men regarding future health considerations, and most appropriately direct therapy. Most male factor conditions are specifically treatable with medical or surgical therapy, while others may only be managed with donor sperm or adoption. In this guideline, the term “male” or “men” is used to refer to biological or genetic men.




Treatment

Varicocele Repair/Varicocelectomy

Sperm Retrieval

Obstructive Azoospermia, Including PostVasectomy Infertility

Medical & Nutraceutical Interventions for Fertility

Gonadotoxic Therapies and Fertility Preservation




SUMMARY

Evaluation and management of men in a couple with infertility involve a step-wise process of evaluation and consultation regarding treatment options. Specific interventions such as varicocele repair, correction of identifiable hormonal abnormalities, microsurgical reconstruction of obstructive conditions, and surgical relief of ejaculatory duct obstruction are effective at increasing fertility for men. This recognition supports a thorough evaluation of a man for correctable conditions that may affect his fertility. The use of ART is an effective intervention for fertility and a critical component for the treatment of some couples, such as men with CBAVD or NOA who also require surgical sperm retrieval. Evaluation should proceed in parallel for both male and female members of a couple to optimize treatment success.




FUTURE DIRECTIONS

The causes of male infertility, including their genetic basis, have only been superficially explained at this time. There is a strong suggestion that most cases of apparently idiopathic severe male infertility, including NOA, have a genetic basis that may underlie the impaired sperm production seen for these men. A greater understanding of the basis for impaired sperm production could also lead to treatments to enhance sperm production and fertility. The interactions of infertility with other health conditions require a deeper understanding as well. Fortunately, progress continues to be made on each of these fronts.