Male infertility: what on earth is going on? Pilot international questionnaire study regarding clinical evaluation and fertility treatment for men

Abstract

Infertility is a time-consuming and exhaustive process, which disproportionally affects women. Although concerns have been raised about deficiencies in clinical evaluation of infertile men, there is currently little published data documenting this. A SurveyMonkey questionnaire was therefore created to capture current clinical practice of fertility specialists working in IVF clinics. Responses were collected May - July 2021. 112 clinicians completed the pilot survey with respondents from Europe (n=49; 43.8%), Africa (n=39, 34.8%), North America (n=6; 5.4%), Asia (n=16; 14.3%), South America (n=1; 0.9%) and Australasia (n=1;0.9%). 41% fertility specialists (45/110) reported taking only a brief medical history and 24% reported that they never routinely examined infertile male patients. 54% fertility specialists also reported issues getting men to undertake diagnostic semen analysis. Treatment for male infertility spanned Assisted Reproductive Technology (ART), with themes of individualised medicine influencing treatment recommendations. 48.2% clinicians reported using empirical medical therapy (EMT) for unexplained male infertility. Notably, 3.6% respondents recommended testosterone treatment, despite likely negative impact on spermatogenesis. However, high levels of opportunistic general health advice were reported, including discussion of life exposures thought to be important for male reproductive health. This study adds novel evidence and highlights current deficiencies in clinical practice relating to male infertility. Evaluation of the infertile male using simple medical tools (detailed history taking and clinical examination) has the potential to identify treatable or reversible conditions and should be an immediate focus for education and improvement in Reproductive Medicine. Investment in research and development is much needed in the field of andrology, to develop effective non-ART treatment options for male infertility.

Figure 1

World map depicting distribution of respondents. Number of responses from each continent indicated (Europe (blue) n  = 49, Africa (orange) n  = 39, North America (yellow) n  = 6, South America (green) n  = 1, Australasia (dark blue) n  = 1 and Asia (pink) n  = 16).

Figure 2

Reported routine evaluation of men in specialist fertility clinic. Brief medical history and no examination (blue) n  =  11; detailed medical history and no examination (orange) n  = 16; brief medical history and sometimes examination (grey) n  = 29; detailed medical history and sometimes examination (yellow) n  = 30; brief medical history and usually examination (purple) n  = 5; detailed medical history and usually examination (green) n  = 19 and evaluation by urology (red) n  = 2.

Figure 3

Clinicians’ experiences of getting men to undertake diagnostic semen analysis. (A) No issues were experienced by 46% (n = 52) respondents; however, 54% (n = 60) reported issues commonly encountered. (B) Geographical distribution of respondents reporting no issues encountered with getting men to undertake diagnostic semen analysis. (C) Geographical distribution of respondents commonly encountering issues getting men to undertake diagnostic semen analysis. (D) Primary reasons reported for issues getting men to undertake diagnostic semen analysis included an assumption by men that they had no fertility problem because they were sexually active (blue; n  = 20) or because they had previously fathered a pregnancy (orange; n  = 15), that men were not comfortable producing or submitting a sample for testing (grey; n  = 14), an assumption that infertility is a woman’s issue (brown; n  = 10) as well as cost (purple; n  = 1). (E) Geographical distribution of respondents commonly experiencing issues getting men to undertake diagnostic semen analysis because they were uncomfortable producing or submitting a sample for laboratory assessment.

Figure 4

Treatment routinely recommended for unexplained male infertility. (A) ART routinely offered included IVF (blue; n  = 55); ICSI (orange; n  = 28); ICSI and surgical sperm retrieval (SSR) (peach; n  = 11) and donor sperm (grey; n  = 5). Notably, some indicated individualised treatment recommendations according to semen analysis results (pale yellow; n  = 6) or partner/couple characteristics (green; n  = 6). (B) Use of empirical medical therapy (EMT) for unexplained male infertility. EMT used routinely by 48% of clinicians, including clomiphene or tamoxifen (blue; n  = 37), letrozole (orange; n  = 2), combined follicle-stimulating hormone (FSH) and human chorionic gonadotrophin (HCG) injections (grey; n  = 7), testosterone (yellow; n  = 4) and other (red; n  = 4). EMT not routinely used by 52% of respondents (green; n  = 58). (C) Vitamin and dietary supplements (VDS) for unexplained male infertility. Respondents reported recommending VDS never (blue; n  = 14), not routinely (orange; n  = 25), sometimes (grey; n  = 51) or always (yellow; n  = 22).