EAU Guidelines on Male Infertility
Section snippets
Definition
“Infertility is the inability of a sexually active, non-contracepting couple to achieve pregnancy in one year” [WHO, 2000].
Epidemiology and aetiology
About 25% of couples do not achieve pregnancy within 1 year, 15% of the couples seek medical treatment for infertility and ultimately less than 5% remain childless. Infertility affects both men and women. Male causes for infertility are found in 50% of these couples. In many couples, however, male and female factors are present. In case of a single factor the fertile partner may compensate for the less fertile partner. Infertility then usually becomes manifest if both partners are subfertile.
Prognostic factors
The main factors influencing the prognosis in infertility are:
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Duration of infertility
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Age and fertility status of the female partner
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Primary or secondary infertility
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Results of semen analysis
When the duration of infertility exceeds four years of unprotected intercourse, the conception rate per month is only 1.5%. At present, in many western countries women postpone their first pregnancy until they have finished their education and have started a professional career. However, the fertility of a
Medical history and physical examination
Investigation of the male partner should include full medical history and physical examination according to the standardised scheme published by WHO (1) so that any causative factor can be diagnosed and, if possible, treated. Also this helps implement evidence-based medicine in this interdisciplinary field of reproductive medicine.
Investigations
Semen analysis should follow the guidelines of the World Health Organisation (WHO) Laboratory Manual for Human Semen and Sperm-Cervical Mucus Interaction, which is in its fourth edition [3].
Definition
Primary spermatogenic failure is defined as impaired spermatogenesis originating from causes different than hypothalamic-pituitary diseases. The severe forms of primary spermatogenic failure have a clinical presentation as non-obstructive azoospermia [1] (Table 2).
Aetiology
Typical findings from the physical examination of a patient with spermatogenic failure may be abnormal secondary sexual characteristics, gynaecomastia and low testicular volume (<15 cc per gonad) and/or consistency. FSH may be
Definition
Obstructive azoospermia means the absence of both spermatozoa and spermatogenic cells in semen and post-ejaculate urine due to bilateral obstruction of the seminal ducts.
Classification
Intratesticular obstruction has been reported in 15% of obstructive azoospermia [8] and is usually caused by post-inflammatory obstruction of the rete testis.
Epididymal obstruction is the most common cause of obstructive azoospermia, affecting 30–67% of azoospermic men with a serum FSH less than twice the upper limit of normal
Genetic disorders in infertility
Knowledge of genetic abnormalities in infertility is mandatory for every urologist working in andrology.
Varicocele
Varicocele is a common abnormality with the following andrological implications:
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Failure of ipsilateral testicular growth and development
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Symptoms of pain and discomfort
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Reduced fertility
Hypogonadotrophic hypogonadism
Primary hypogonadotrophic hypogonadism is caused either by hypothalamic or pituitary diseases. The failure of hormonal regulation can easily be determined [29]. Endocrine deficiency leads to a lack of spermatogenesis and testosterone secretion due to decreased secretion patterns of LH and FSH. Standard treatment is human chorionic gonadotrophin (hCG) treatment, with the later addition of human menopausal globulin (hMG), dependent on initial testicular volume. If hypogonadotrophic hypogonadism
Cryptorchidism and testicular tumours
Cryptorchidism is the most frequent congenital abnormality of the male genitalia with a 2–5% incidence at birth. At the age of 3 months the incidence is reduced spontaneously to 1–2%. Approximately 20% of undescended testes are nonpalpable and may be located within the abdominal cavity.
The aetiology of cryptorchidism is multifactorial and both disrupted endocrine regulation and several gene defects may be involved. For a normal descent of the testes, a normal hypothalamo-pituitary-gonadal axis
Male accessory gland infection
Infections of the male accessory glands are potentially correctable causes of male infertility [4], [37]. In this context, urethritis and prostatitis, orchitis and epididymitis have been mentioned as male accessory gland infection by the WHO [1]. However, concrete data are lacking to confirm a negative influence of these diseases on sperm quality.
Urethritis and prostatitis are not always associated with male sub- or infertility [4]. In many cases, basic ejaculate analysis does not reveal a link
Idiopathic male infertility
Many men presenting with infertility are found to have idiopathic oligo-astheno-teratozoospermia (OAT). No demonstrable cause of male infertility, except for OAT, is found in 40–75% of infertile men [1]. The unexplained forms of male infertility may be caused by several factors, such as chronic stress, endocrine disruption due to environmental pollution, reactive oxygen species and genetic abnormalities.
Counselling
Sometimes certain ‘lifestyle’ factors may be responsible for poor semen quality: for example obesity, alcohol abuse, use of anabolic steroids, extreme sports (marathon training, excessive strength sports), and increase in scrotal temperature through thermal underwear, sauna or hot tub use or occupational exposure to heat sources. A considerable number of drugs can affect the spermatogenesis.
Medical (hormonal) treatment
There is no evidence that empiracle hormonal therapies, such as human menopausal gonadotrophin
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