madman
Super Moderator
INTRODUCTION
Infertility is a complex condition that has challenging medical, psychological, economic, and social implications for both patients and clinicians. Based on the International Classification of Diseases (ICD-11), the World Health Organization (WHO) defines infertility as the failure to achieve a pregnancy after 12 months or more of regular unprotected sexual intercourse.’ For women > 35 years, failure to achieve pregnancy after 6 months or more of regular unprotected sexual intercourse warrants infertility evaluation.” Approximately 15% of couples with unknown fertility status are infertile after 1 year of unprotected intercourse, with male factor infertility solely responsible in ~30% of such couples and combined male and female factors presenting an additional 20%.%“ A Global Burden of Disease survey reported in 2019 that infertility is on the rise, with the age-standardized prevalence of infertility in men increasing by 0.3% per year between 1990 and 2017.° Therefore, it is necessary for obstetrics and gynecology (OB/GYN) practitioners to be familiar with the standard evaluation and treatment available for male factor infertility given its implication in couple infertility.
Male factor infertility has a variety of identifiable and reversible causes, including but not limited to varicoceles, vas deferens obstruction, ejaculatory duct obstruction, and hypogonadotropic hypogonadism. Other causes of male infertility can be identified by abnormal semen analysis (SA). When abnormal SA is present without a clear etiology, male factor infertility is termed idiopathic. When female partner evaluation and SA do not explain infertility, the condition is termed unexplained.
Based on the WHO's ICD-11 definition of infertility, failure to achieve pregnancy after 12 months or more of unprotected intercourse (or 6 months if the female partner is more than age 35 years) should trigger comprehensive infertility evaluation and testing. However, several factors might suggest an earlier evaluation of a couple’s fertility status is prudent. These factors include (1) risk factors for male infertility such as if a history of bilateral cryptorchidism and advanced paternal age (>40 years) are present; (2) risk factors for female infertility such as advanced female age (>35 years) are present; and/or (3) the couple questions the male partner’s fertility potential. Providers should recognize that men with a history of previous fertility (ie, a male patient who has successfully conceived before) can acquire a new, secondary, male infertility factor. Therefore, a history of previous fertility should not preclude a male with concerns or risk factors for infertility from evaluation, and men with possible secondary infertility should be evaluated in the same way as men who have never initiated a pregnancy and are being evaluated for primary male factor infertility.”
In this comprehensive review, the authors discuss strategies OB/GYN providers can use to evaluate male factor infertility with the goals of identifying and differentiating between reversible etiologic conditions, irreversible conditions amenable to ART using the male partner’s sperm, irreversible conditions for which donor insemination or adoption is more advisable, and other pathologies or etiologies with implications for the patient and their family.
Background
*Epidemiology of Male Infertility
*Relationship Between Male Infertility and Overall Men’s Health
*Access to Infertility Care
EVALUATION OF MALE INFERTILITY
*Medical History
*Physical Examination
*Endocrine Hormonal Laboratory Testing
*Semen Analysis
Specific Semen Abnormalities
*Azoospermia
*Oligospermia
*Obstructive azoospermia
*Nonobstructive azoospermia
*Asthenospermia
*Teratozoospermia
*Pyospermia
*Genetic Testing
*Specialized Testing
*AntispermAntibodies
*Hyperviscosity Testing
*Testis Mapping and Biopsy
*Imaging Tests
*Treatment
*Role of Supplements
SUMMARY
Fertility evaluation should proceed in parallel for both male and female members of a couple to optimize fertility outcomes. Male factor infertility can be due to several causes and should be initially evaluated with a thorough history, physical examination, adequate SA, and when indicated, endocrine profile analysis. Abnormal SA findings include azoospermia (which warrants further workup to differentiate between obstructive and nonobstructive etiologies), asthenospermia, oligospermia, and teratozoospermia. Depending on the etiology of the male patient's etiology, assisted reproductive techniques may be offered to support the couple in their family planning goals. Given the complexity of managing patients with male infertility, OB/GYN providers should also leverage the expertise of reproductive urologists in evaluating and managing male factor infertility.
Infertility is a complex condition that has challenging medical, psychological, economic, and social implications for both patients and clinicians. Based on the International Classification of Diseases (ICD-11), the World Health Organization (WHO) defines infertility as the failure to achieve a pregnancy after 12 months or more of regular unprotected sexual intercourse.’ For women > 35 years, failure to achieve pregnancy after 6 months or more of regular unprotected sexual intercourse warrants infertility evaluation.” Approximately 15% of couples with unknown fertility status are infertile after 1 year of unprotected intercourse, with male factor infertility solely responsible in ~30% of such couples and combined male and female factors presenting an additional 20%.%“ A Global Burden of Disease survey reported in 2019 that infertility is on the rise, with the age-standardized prevalence of infertility in men increasing by 0.3% per year between 1990 and 2017.° Therefore, it is necessary for obstetrics and gynecology (OB/GYN) practitioners to be familiar with the standard evaluation and treatment available for male factor infertility given its implication in couple infertility.
Male factor infertility has a variety of identifiable and reversible causes, including but not limited to varicoceles, vas deferens obstruction, ejaculatory duct obstruction, and hypogonadotropic hypogonadism. Other causes of male infertility can be identified by abnormal semen analysis (SA). When abnormal SA is present without a clear etiology, male factor infertility is termed idiopathic. When female partner evaluation and SA do not explain infertility, the condition is termed unexplained.
Based on the WHO's ICD-11 definition of infertility, failure to achieve pregnancy after 12 months or more of unprotected intercourse (or 6 months if the female partner is more than age 35 years) should trigger comprehensive infertility evaluation and testing. However, several factors might suggest an earlier evaluation of a couple’s fertility status is prudent. These factors include (1) risk factors for male infertility such as if a history of bilateral cryptorchidism and advanced paternal age (>40 years) are present; (2) risk factors for female infertility such as advanced female age (>35 years) are present; and/or (3) the couple questions the male partner’s fertility potential. Providers should recognize that men with a history of previous fertility (ie, a male patient who has successfully conceived before) can acquire a new, secondary, male infertility factor. Therefore, a history of previous fertility should not preclude a male with concerns or risk factors for infertility from evaluation, and men with possible secondary infertility should be evaluated in the same way as men who have never initiated a pregnancy and are being evaluated for primary male factor infertility.”
In this comprehensive review, the authors discuss strategies OB/GYN providers can use to evaluate male factor infertility with the goals of identifying and differentiating between reversible etiologic conditions, irreversible conditions amenable to ART using the male partner’s sperm, irreversible conditions for which donor insemination or adoption is more advisable, and other pathologies or etiologies with implications for the patient and their family.
Background
*Epidemiology of Male Infertility
*Relationship Between Male Infertility and Overall Men’s Health
*Access to Infertility Care
EVALUATION OF MALE INFERTILITY
*Medical History
*Physical Examination
*Endocrine Hormonal Laboratory Testing
*Semen Analysis
Specific Semen Abnormalities
*Azoospermia
*Oligospermia
*Obstructive azoospermia
*Nonobstructive azoospermia
*Asthenospermia
*Teratozoospermia
*Pyospermia
*Genetic Testing
*Specialized Testing
*AntispermAntibodies
*Hyperviscosity Testing
*Testis Mapping and Biopsy
*Imaging Tests
*Treatment
*Role of Supplements
SUMMARY
Fertility evaluation should proceed in parallel for both male and female members of a couple to optimize fertility outcomes. Male factor infertility can be due to several causes and should be initially evaluated with a thorough history, physical examination, adequate SA, and when indicated, endocrine profile analysis. Abnormal SA findings include azoospermia (which warrants further workup to differentiate between obstructive and nonobstructive etiologies), asthenospermia, oligospermia, and teratozoospermia. Depending on the etiology of the male patient's etiology, assisted reproductive techniques may be offered to support the couple in their family planning goals. Given the complexity of managing patients with male infertility, OB/GYN providers should also leverage the expertise of reproductive urologists in evaluating and managing male factor infertility.
