Guidelines for Male Infertility

Newly Released 2020/2021 ASRM/AUA Guidelines for Male Infertility Suggest Greater Role in Evaluation and Treatment of the Male

By Stanton Honig, MD

The American Urological Association (AUA) and the American Society of Reproductive Medicine (ASRM) have combined to release new Guidelines for the evaluation and treatment of male infertility. This updates the guidelines that were last reviewed about eight years ago and gives a much more detailed approach to men who have fertility problems. In this update, we will review some of the important new concepts and why it is important for men to be evaluated.

One of the new guidelines stresses the importance of doctors to review the health risks associated with infertile men with abnormal sperm production. This has been known for years and includes the concept that men with these abnormalities may have some underlying medical conditions such as testicular cancer, genetic abnormalities such as Klinefelter’s syndrome, tumors of the pituitary gland, etc that may be responsible for their low sperm production. This is important because as one of the guidelines says “men with one or more abnormal semen markers should be evaluated by a male reproductive expert with a complete history and physical exam.” In the era of telehealth, discussion is important but physical exam can identify specific abnormalities like a testis mass.

There is also growing evidence that men who have abnormal semen parameters may have a slightly higher mortality rate or “chance of dying earlier.” This is based on preliminary data in one study, is certainly concerning. More studies are necessary to confirm whether this is true or not.

One of the other important new guidelines involves advising couples that “men who are older are at increased risk of adverse health outcomes for their offspring.” This has been noted previously with older women but now there is evidence that this is true for paternal age as well. There is a higher incidence of schizophrenia, autism and chondrodysplasia (genetically caused bony and cartilage disorders). While there is no clear definition for advanced paternal age, this risk starts to increase over the age 40 and increases further above the age of 50.

One of the important new guidelines stresses the importance that doctors discuss risk factors such as lifestyle, medication usage and environmental exposures associated with male infertility. However, the guidelines stress that the current data on the majority of these risk factors is limited. It is clear to most reproductive urologists that a “healthy lifestyle will most likely result in healthier sperm.” So eating healthy, not smoking, not drinking excessively, not using marijuana excessively and generally living a healthy lifestyle is going to portend a better outcome in terms of getting your partner pregnant.

The benefits of supplements such as antioxidants and vitamins in the treatment of male infertility are highlighted in the new guidelines as well. At the present time, existing data is inadequate to provide specific recommendations for men regarding dietary supplements. Supplements that have thought to be valuable for men include vitamin C, vitamin E, carnitine, and Coenzyme Q.

One of the most important guidelines addresses the use of testosterone in men of reproductive years.

Testosterone use will shut off sperm production and is NOT indicated in the treatment of male factor infertility. In patients with low testosterone, these patients may be treated with “off label” use medications such as clomiphene citrate or “clomid,” (a selective estrogen receptor modulator) or human chorionic gonadotropin (hCG) or with a combination of these medicines. These medications will increase testosterone but will not have a negative effect on sperm production.

One of the other new guidelines addresses the use of FSH analogues (Follicle-Stimulating Hormone) with the aim of improving sperm count, pregnancy rate and live birth rates in men with unexplained infertility male infertility. Although these studies are old, there is data to show a benefit to men. Unfortunately, these medications can be expensive and may not covered by insurance plans.

Men who have a clinical or palpable varicocele should be repaired with the hopes of improving abnormal sperm parameters. In this patient population, with normal female partners, a significant # of men will see an improvement in semen quality. In patients who have non-palpable varicoceles detected only by imaging, these should not be repaired as they do not typically result in improvement in semen quality. Seeing a reproductive urologist can be helpful to tell the difference.

In men who have azoospermia as a result of an obstruction, there are two options to achieve a pregnancy. These patients should be counseled regarding the possibility of surgical reconstruction, surgical sperm retrieval and IVF (in vitro fertilization) or a combination. The most common cases are a result of a prior vasectomy or blockages in the epididymis. In the patients who choose surgical sperm retrieval, this can either be performed timed with the ivf cycle or performed prior to an egg retrieval and frozen. The new Guidelines identify that success rates are equivalent.

In patients who have no sperm in ejaculate as a result of low sperm production (non-obstructive azoospermia), a procedure called a microsurgical testicular sperm extraction or “microTESE” should be performed to give the best results in finding sperm. 50% of the time, sperm can be found in these cases and if found, then can be combined with oocytes in vitro to achieve a pregnancy.

It is important for patients and their partners to understand the new guidelines developed by the American Urological Association and the American Society of Reproductive Medicine. Much of this is based on scientific data but it also includes the expert opinions of many reproductive urologists and has been “peer reviewed’ by multiple physicians and scientists from around the country.