Diagnosis and Treatment of Infertility in Men

Publication Date: August 15, 2024
Last Updated: August 15, 2024

Guideline Statements

Assessment

1. For initial infertility evaluation, both male and female partners should undergo concurrent assessment. (Expert Opinion)
6731
2. Initial evaluation of the male for fertility should include a reproductive history. (Clinical Principle) Initial
evaluation of the male should also include one or more semen analyses (SAs). (Strong Recommendation; Evidence Level: Grade B)
6731
3. Men with one or more abnormal semen parameters or presumed male infertility should be evaluated by a male reproductive expert for complete history and physical examination as well as other directed tests when indicated. (Expert Opinion)
6731
4. In couples with failed assisted reproductive technology cycles or recurrent pregnancy losses (two or more), clinicians should evaluate the male partner. (Moderate Recommendation; Evidence Level: Grade C)
6731

Lifestyle Factors and Relationships Between Infertility and General Health

5. Clinicians should counsel infertile men or men with abnormal semen parameters of the health risks associated with abnormal sperm production. (Moderate Recommendation; Evidence Level: Grade B)
6731
6. Infertile men with specific, identifiable causes of male infertility should be informed of relevant, associated health conditions. (Moderate Recommendation; Evidence Level: Grade B)
6731
7. Clinicians should advise couples with advanced paternal age (≥40) that there is an increased risk of adverse health outcomes for their offspring. (Expert Opinion)
6731
8. Clinicians may discuss risk factors (ie, lifestyle, medication usage, environmental exposures, occupational exposures) associated with male infertility, and counsel the patients that the current data on the majority of risk factors are limited. (Conditional Recommendation; Evidence Level: Grade C)
6731

Diagnosis/Assessment/Evaluation

9. The results from the SA should be used to guide management of the patient. In general, results are of greatest clinical significance when multiple abnormalities are present. (Expert Opinion)
6731
10. Clinicians should obtain hormonal evaluation including follicle-stimulating hormone (FSH) and testosterone for infertile men with impaired libido, erectile dysfunction, oligozoospermia or azoospermia, atrophic testes, or evidence of hormonal abnormality on physical evaluation. (Expert Opinion)
6731
11. Clinicians should initially evaluate azoospermic males with physical exam, semen volume, semen pH, and serum follicle-stimulating hormone (FSH) levels to differentiate genital tract obstruction from impaired sperm production. (Expert Opinion)
6731
12. Clinicians should recommend karyotype testing for males with primary infertility and azoospermia or sperm concentration < 5 million sperm/mL when accompanied by elevated FSH, testicular atrophy, or a diagnosis of impaired sperm production. (Expert Opinion)
6731

Clinicians should recommend Y-chromosome microdeletion analysis for males with primary infertility and azoospermia or sperm concentration ≤ 1 million sperm/mL when accompanied by elevated FSH, testicular atrophy, or a diagnosis of impaired sperm production. (Moderate Recommendation; Evidence Level: Grade B)

6731
13. Clinicians should recommend Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) mutation carrier testing (including assessment of the 5T allele) in men with vasal agenesis or idiopathic obstructive azoospermia. (Expert Opinion)
6731
14. For men who harbor a CFTR mutation, genetic evaluation of the female partner should be recommended. (Expert Opinion)
6731
15. Sperm DNA fragmentation analysis is not recommended in the initial evaluation of the infertile couple. (Moderate Recommendation; Evidence Level: Grade C)
6731
16. Men with increased round cells on SA (>1million/mL) should be evaluated further to differentiate white blood cells (pyospermia) from germ cells. (Expert Opinion)
6731
17. Patients with pyospermia should be evaluated for the presence of infection. (Clinical Principle)
6731
18. Antisperm antibody (ASA) testing should not be done in the initial evaluation of male infertility. (Expert Opinion)
6731
19. For couples with RPL, men should be evaluated with karyotype (Expert Opinion) and sperm DNA fragmentation. (Moderate Recommendation; Evidence Level: Grade C)
6731
20. Diagnostic testicular biopsy should not routinely be performed to differentiate between obstructive azoospermia and non-obstructive azoospermia (NOA). (Expert Opinion)
6731

Imaging

21. Scrotal ultrasound should not be routinely performed in the initial evaluation of the infertile male. (Expert Opinion)
6731
22. Clinicians should not perform transrectal ultrasonography (TRUS) or pelvic magnetic resonance imaging (MRI) as part of the initial evaluation of the infertile male. Clinicians may recommend TRUS or pelvic MRI in males with SA suggestive of ejaculatory duct obstruction (EDO) (ie, acidic, azoospermic semen with volume < 1.4 mL, with normal serum T, palpable vas deferens). (Expert Opinion)
6731
23. Clinicians should not routinely perform abdominal imaging for the sole indication of an isolated small or moderate right varicocele. (Expert Opinion)
6731
24. Clinicians should recommend renal ultrasonography for patients with vasal agenesis to evaluate for renal abnormalities. (Expert Opinion)
6731

Treatment

Varicocele Repair/Varicocelectomy

25. Surgical varicocelectomy should be considered in men attempting to conceive who have palpable varicocele(s), infertility, and abnormal semen parameters, except for azoospermic men. (Moderate Recommendation; Evidence Level: Grade B)
6731
26. Clinicians should not recommend varicocelectomy for men with non-palpable varicoceles detected solely by imaging. (Strong Recommendation; Evidence Level: Grade C)
6731

27. For males with clinical varicocele and non-obstructive azoospermia, clinicians should inform couples of the absence of definitive evidence supporting varicocele repair prior to surgical sperm retrieval with assisted reproductive technologies. (Expert Opinion)

6731

Sperm Retrieval

28. For men with NOA undergoing sperm retrieval, microdissection testicular sperm extraction (TESE) should be performed. (Moderate Recommendation; Evidence Level: Grade C)
6731
29. In men undergoing surgical sperm retrieval, either fresh or cryopreserved sperm may be used for ICSI. (Moderate Recommendation; Evidence Level: Grade C)
6731
30. In men with azoospermia due to obstruction undergoing surgical sperm retrieval, sperm may be extracted from either the testis or the epididymis. (Conditional Recommendation; Evidence Level: Grade C)
6731
31. For men with aspermia, surgical sperm extraction or induced ejaculation (sympathomimetics, vibratory stimulation or electroejaculation) may be performed depending on the patient’s condition and clinician’s experience. (Expert Opinion)
6731

32. Clinicians may treat infertility associated with retrograde ejaculation (RE) with sympathomimetics (with or without alkalinization and/or urethral catheterization), induced ejaculation, or surgical sperm retrieval. (Expert Opinion)

6731
Clinicians may consider the utilization of testicular sperm in nonazoospermic males with an elevated sperm DNA Fragmentation Index. (Clinical Principle)
6731

Obstructive Azoospermia, Including Post-Vasectomy Infertility

33. Couples desiring conception after vasectomy should be counseled that surgical reconstruction, surgical sperm retrieval, or both reconstruction and simultaneous sperm retrieval for cryopreservation are viable options. (Moderate Recommendation; Evidence Level: Grade C)
6731
34. Clinicians should counsel men with vasal or epididymal obstructive azoospermia that microsurgical reconstruction may be successful in returning sperm to the ejaculate. (Expert Opinion)
6731
35. For infertile males with ejaculatory duct obstruction, clinicians may consider transurethral resection of ejaculatory ducts (TURED) and/or surgical sperm extraction. (Expert Opinion)
6731

Medical & Nutraceutical Interventions for fertility

36. Male infertility may be managed with ART. (Expert Opinion)
6731

37. Clinicians may advise an infertile couple with a low total motile sperm count on repeated semen analyses that intrauterine insemination success rates may be reduced, and treatment with assisted reproductive technology (in vitro fertilization/intracytoplasmic sperm injection) may be considered. (Expert Opinion)

6731
38. The patient presenting with hypogonadotropic hypogonadism (HH) should be evaluated to determine the etiology of the disorder and treated based on diagnosis. (Clinical Principle)
6731
39. Clinicians may use aromatase inhibitors (AIs), hCG, selective estrogen receptor modulators (SERMs), or a combination thereof for infertile men with low serum testosterone. (Conditional Recommendation; Evidence Level: Grade C)
6731
40. For the male interested in current or future fertility, clinicians should not prescribe exogenous testosterone therapy. (Clinical Principle)
6731
41. The infertile male with hyperprolactinemia should be evaluated for the etiology and treated accordingly. (Expert Opinion)
6731
42. Clinicians should inform the male with idiopathic infertility that the use of selective estrogen receptor modulators has limited benefits relative to results of assisted reproductive technology. (Expert Opinion)
6731
43. Clinicians should counsel patients that the benefits of supplements (e.g., antioxidants, vitamins) are of questionable clinical utility in treating male infertility. Existing data are inadequate to provide recommendation for specific agents to use for this purpose. (Moderate Recommendation; Evidence Level: Grade B)
6731
44. For men with idiopathic infertility, a clinician may consider treatment using an FSH analogue with the aim of improving sperm concentration, pregnancy rate, and live birth rate. (Conditional Recommendation; Evidence Level: Grade B)
6731

45. In patients with non-obstructive azoospermia, clinicians may inform the patient of the limited data supporting pharmacologic manipulation with selective estrogen receptor modulators, aromatase inhibitors, and gonadotropins prior to surgical intervention. (Conditional Recommendation; Evidence Level: Grade C)

6731

Gonadotoxic Therapies and Fertility Preservation

46. Clinicians should discuss the effects of gonadotoxic therapies and other cancer treatments on sperm production with patients prior to commencement of therapy. (Moderate Recommendation: Evidence Level: Grade C)
6731
47. Clinicians should inform patients undergoing chemotherapy and/or radiation therapy to avoid initiating a pregnancy for a period of at least 12 months after completion of treatment. (Expert Opinion)
6731
48. Clinicians should encourage men to bank sperm, preferably multiple specimens when possible, prior to commencement of gonadotoxic therapy or other cancer treatment that may affect fertility in men. (Expert Opinion)
6731
49. Clinicians may inform patients that a semen analysis should be performed at least 12 months (and preferably 24 months) after completion of gonadotoxic therapies. (Conditional Recommendation; Evidence Level: Grade C)
6731
50. Clinicians should inform patients undergoing a retroperitoneal lymph node dissection (RPLND) of the risk of aspermia or retrograde ejaculation. (Clinical Principle)
6731

51. Clinicians should obtain a post-orgasmic urinalysis for males with aspermia after retroperitoneal lymph node dissection and reduced volume ejaculate who are interested in fertility. (Clinical Principle)

6731
52. Clinicians should inform men seeking paternity who are persistently azoospermic after gonadotoxic therapies that TESE is a treatment option. (Strong Recommendation; Evidence Level: Grade B)
6731

Recommendation Grading

Overview

Title

Diagnosis and Treatment of Infertility in Men

Authoring Organizations

American Society for Reproductive Medicine

American Urological Association

Publication Month/Year

August 15, 2024

Last Updated Month/Year

September 3, 2024

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Male, Adult

Health Care Settings

Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Diagnosis, Treatment

Diseases/Conditions (MeSH)

D007248 - Infertility, Male

Keywords

infertility, Clinical guildeline

Source Citation

Brannigan RE, Hermanson L, Kaczmarek J, Kim SK, Kirkby E, Tanrikut C. Updates to male infertility: AUA/ASRM guideline (2024). J Urol. Published online August 15, 2024. doi:10.1097/JU.0000000000004180. https://www.auajournals.org/doi/10.1097/JU.0000000000004180

Methodology

Number of Source Documents
356
Literature Search Start Date
January 1, 2000
Literature Search End Date
August 30, 2023