Male Fertility Evaluation and Treatment

Introduction to Fertility Evaluation

A proper fertility evaluation should be performed in couples who have not conceived after 12 consecutive months of regular, unprotected intercourse, as recommended by the European Association of Urology and the American Urological Association 1, 2
Male factors contribute to approximately 50% of infertility cases, highlighting the importance of evaluating both partners 2

Clinicians should understand that WHO lower limits of semen parameters are based on the lowest fifth centile of values for fertile males, including:
Parameter Normal Value
Volume 1.5-5.0 ml
pH >7.2
Sperm concentration >20 million/ml
Total motile sperm count >5 million
At least two semen analyses are recommended as parameters fluctuate substantially, according to the European Association of Urology and the American Urological Association 2

Lifestyle changes including weight loss, physical exercise, and smoking cessation are strongly recommended as they enhance sperm parameters and improve overall health of men seeking fertility, according to the European Urology guidelines 1
Weight management is crucial as obesity is associated with hormonal imbalances and decreased sperm quality 1
Smoking cessation is essential as tobacco use damages sperm DNA and reduces sperm count 1
Regular physical activity improves sperm parameters but excessive exercise should be avoided 1
Moderate alcohol consumption and avoidance of excessive testicular heat exposure may be beneficial for men with elevated FSH, as suggested by the EAU and the ASRM 1, 2, 4, 3

Antioxidant therapy may be beneficial, with a Cochrane review showing improvement in live birth rates, although evidence quality was low 1
Prebiotic/probiotic supplementation has been shown to increase sperm concentration, motility, normal morphology, and DNA integrity in an RCT 1
hCG therapy with or without FSH is well-established for secondary hypogonadism, resulting in sperm production in 75% of cases 1
Selective estrogen receptor modulators (SERMs) may increase pregnancy rates and improve sperm parameters, but evidence quality is low 1
Treatment of asymptomatic Chlamydia infection may improve sperm parameters 1
Antibiotic therapy is recommended only for chronic bacterial prostatitis (type II) 1
Aromatase inhibitors may increase endogenous testosterone production and improve spermatogenesis by decreasing estrogen production 1
Combined therapy with HCG and FSH is often used for optimal outcomes, especially in cases of complete hypogonadotropic hypogonism, as recommended by the EAU 7, 1

Infertile men are at higher risk of developing cardiometabolic disorders and have higher cardiovascular mortality compared to fertile men, highlighting the importance of overall health evaluation 1
Male infertility may be an early warning sign of other health issues, emphasizing the need for comprehensive evaluation 1

Initial screening for male fertility should include a reproductive history and two semen analyses performed at least one month apart, as recommended by the American Academy of Family Physicians and the American Urological Association 5, 2
Testicular examination should be performed to evaluate size, consistency, and descent, as recommended by the American Urological Association 8
Serum FSH measurement is used to assess underlying reproductive health status, according to the American Urological Association 8
Hormonal evaluation should include FSH, LH, and testosterone (mandatory) 6
Free testosterone is a better indicator of gonadal status than total testosterone, as stated by the Endocrine Society, because total testosterone can be misleading when SHBG is abnormal 9
LH, testosterone, inhibin B, and AMH levels provide additional information about testicular function, with normal FSH levels between 1.5-8 mIU/ml, and elevated FSH often a sign of primary testicular dysfunction 1

Karyotype testing is recommended for patients with severe teratozoospermia (<1% normal forms) 2, 1
Y-chromosome microdeletion analysis should be considered if teratozoospermia is accompanied by oligozoospermia (<5 million/ml) 1
Genetic testing (karyotype, Y-chromosome microdeletion analysis) is recommended for men with non-obstructive azoospermia, as indicated by the European Association of Urology 1
Surgical correction may be considered based on TRUS findings for ejaculatory duct obstruction 6
Microdissection testicular sperm extraction (micro-TESE) has a successful sperm retrieval rate of 55-60%, with lower complication rates and better preservation of testicular tissue and function compared to conventional TESE, as reported by the American Urological Association 1, 3

In vitro fertilization with intracytoplasmic sperm injection (ICSI) is recommended for severe male infertility and negates the negative impact of poor semen quality, as recommended by the American Urological Association 3
Sperm banking before gonadotoxic treatments is crucial for fertility preservation, as recommended by the American Society for Reproductive Medicine 6
Sperm DNA fragmentation testing is recommended for couples with recurrent pregnancy loss or failed ART cycles 6

Regular monitoring of testosterone levels and semen analyses every 3-6 months is recommended to assess treatment response, as recommended by the European Association of Urology and the American Urological Association 7, 5, 2
Biomarkers such as AMH and Inhibin B may help monitor treatment response, although their use is not widely established, as reported by the European Association of Urology 7