Guideline-based management of male infertility: Why do we need it?

Abstract

The current clinical guidelines for the management of infertility as presented by the American Urologic Association and European Association of Urology represent consensus opinions for the management of male-factor infertility. The goal of the present study is to define the currently available guidelines for male-factor infertility, provide a rationale for why guidelines should be implemented, and review concerns and shortcomings towards their incorporation into clinical practice. Successfully integrating guidelines into clinical practice offers the potential benefit of creating a standardized, efficient, and cost-effective algorithm for the evaluation of infertility and facilitates future research. Despite their availability and ease of use, many clinicians fail to adopt clinical guidelines for numerous reasons including decreased awareness of available guidelines, insufficient time, lack of interest, and personal financial considerations. The current guidelines are limited by the inability to generalize recommendations to a heterogeneous patient sample, the lack of interdisciplinary adoption of guidelines, and the need for additional emphasis on prevention and lifestyle modifications. Future direction for the current guidelines will likely incorporate a multidisciplinary approach with increasing utilization of genetic analysis and novel treatment strategies. As the field of infertility continues to expand, the utility of guidelines combined with physician clinical judgment will remain prominent in the treatment of male-factor infertility.

Keywords: Consensus; semen analysis; standard.

Figure 1

Summary algorithm for initial management of the infertile male as presented in the AUA and EAU guidelines * Earlier evaluation may be warranted if male or female infertility risk factors present or if the male questions his fertility potential. ** EAU guideline recommends second semen analysis if first noted to be abnormal § Except in patients with bilateral vasal agenesis or clinical signs of hypogonadism. §§ Some recommend TRUS for oligospermic patients with low volume ejaculates, palpable vasa and normal testicular size. Ø Ideally treated at less than 1 year of age. ∞ Including azoospermia, impaired sexual function, or clinical findings of possible endocrinopathy

Figure 2

“Summary of management guidelines for infertile males presenting with a palpable varicocele or CBAVD. *Earlier evaluation may be warranted if male or female infertility risk factors present or if the male questions his fertility potential. **EAU guideline recommends second semen analysis if first noted to be abnormal ß If normal ipsilateral testicle size, offer follow-up monitoring with annual objective measurements of testicular size and / or semen analyses. ºFollow-up to include semen analysis at three-month intervals for one year or until pregnancy occurs. † EAU guidelines indicates that varicocele treatment should not be undertaken unless there has been a full discussion with the infertile couple regarding the uncertainties of treatment. Ø Ideally treated at less than 1 year of age.

Figure 3

Summary of management guidelines for infertile males with a prior vasectomy or uncorrected undescended testes. *Earlier evaluation may be warranted if male or female infertility risk factors present or if the male questions his fertility potential. ** EAU guideline recommends second semen analysis if first noted to be abnormal. Sperm retrieval / ICSI is preferred to surgical treatment if (1) advanced female age is present, (2) female factors requiring IVF are present (3) the chance for success with sperm retrieval / ICSI exceeds the chance for success with surgical treatment or (4) sperm retrieval / ICSI is preferred by the couple for financial reasons. Ø Ideally treated at less than 1 year of age.