Engaging practicing gynecologists in the management of infertile men

Abstract

In the modern era, contemporary management of male infertility has undergone groundbreaking changes with the introduction of new concepts, advanced testing, and therapeutic interventions. As practicing gynecologists are often the first physicians who encounter an infertile couple, it is essential that these clinicians are continuously updated about the new pearls and pitfalls of male infertility management. Semen analysis is commonly ordered by gynecologists. In 2010, the WHO released new cutoff reference values for the semen parameters adopting novel methodology, which has incited much debate. Reference values have been lowered in comparison with previous standards, with a direct clinical implication in decision-making strategies. Specialized sperm-function tests, such as sperm oxidative stress and sperm chromatin integrity assessments, became clinically available, thus offering an opportunity to better understand sperm dysfunctions concealed during routine semen analysis. Furthermore, the initial counseling of azoospermic men by an andrologically well educated gynecologist may alleviate the misconception and distress surrounding the false belief of sterility, and will clarify the available options of percutaneous and microsurgical sperm-retrieval techniques and assisted conception outcome. Regarding varicocele, which is commonly seen in infertile males, it is now clear that the best treatment option for infertile men with clinical varicocele is the microsurgical vein ligation. Natural conception is significantly improved after varicocelectomy, and recent data suggest that such treatment optimizes reproductive outcome of couples undergoing ICSI or micro-TESE sperm retrieval. Lastly, new therapeutic interventions, including oral antioxidant therapy and lifestyle modifications, have gained increasing attention, as they aid in alleviating male infertility.

Keywords: Assisted reproductive technique; Azoospermia; Gynecologist; Male infertility; Semen analysis; Sperm function; Varicocele.

Fig. 1

Image of Y chromosome. Reprinted with permission from: O’Flynn O’Brien KL Varghese AC, Agarwal A. The genetic causes of male factor infertility: a review. Fertil Steril. 2010 Jan;93 [1]:1–12

Fig. 2

Image of grade III varicocele. Reprinted with permission from Clinics (São Paulo) 2011, Esteves, Miyaoka, Agarwal. An update on the clinical assessment of the infertile male, vol. 66, issue 4, pages 691–700