What are the treatment options for male infertility?

Treatment Options for Male Infertility

The treatment of male infertility should begin with proper evaluation to identify correctable conditions, followed by targeted interventions ranging from lifestyle modifications to surgical procedures and assisted reproductive technologies, depending on the specific cause identified. 1

Diagnostic Evaluation

Before treatment can be initiated, a comprehensive evaluation is necessary:

• Both male and female partners should undergo concurrent assessment to properly direct therapy 1
• Initial evaluation of the male should include a detailed reproductive history and at least one semen analysis 1
• Men with abnormal semen parameters should be evaluated by a male reproductive expert for complete history, physical examination, and directed tests 1
• Evaluation should be considered in couples with failed assisted reproductive technology cycles or recurrent pregnancy losses 1

Treatment Options Based on Diagnosis

Varicocele Treatment

• Varicocelectomy is indicated for infertile men with clinical varicocele, abnormal semen parameters, and otherwise unexplained infertility when the female partner has good ovarian reserve 1
• Do not treat varicocele in men with normal semen analysis or subclinical varicocele 1
• Varicocelectomy may be considered in men with elevated sperm DNA fragmentation with unexplained infertility or failure of assisted reproductive techniques 1

Obstructive Azoospermia

• For ejaculatory duct obstruction, transurethral resection of ejaculatory ducts (TURED) and/or surgical sperm extraction may be considered 1
• For men with azoospermia due to obstruction, both epididymal and testicular sperm retrieval are viable options with similar fertilization, pregnancy, and live birth rates 1
• Avoid epididymal sperm retrieval if future microsurgical reconstruction might be pursued due to risk of scarring and obstruction 1

Hormonal Treatments

• In patients with hypogonadotropic hypogonadism, evaluate to determine the etiology and treat based on diagnosis 1
• Avoid exogenous testosterone therapy in men seeking fertility as it suppresses spermatogenesis 1
• Consider gonadotropin therapy for specific hormonal deficiencies 2

Sperm DNA Fragmentation

• Testicular sperm may be considered in nonazoospermic males with elevated sperm DNA Fragmentation Index (DFI) 1
• Recent meta-analysis shows improved clinical pregnancy rates, live births, and reduced pregnancy loss rates with testicular sperm in men with elevated DFI 1

Infections

• Treat male accessory-gland infections to improve sperm quality 1
• Refer sexual partners of patients with accessory sex gland infections caused by sexually transmitted diseases for evaluation and treatment 1

Cancer Patients

• All men with cancer must be offered sperm cryopreservation before gonadotoxic treatment or ablative surgery 1
• Preservation of ejaculated semen is the most cost-effective strategy for fertility preservation 1
• In cases of severe oligozoospermia or azoospermia, consider surgical sperm extraction (onco-TESE) 1
• Use contraception during and for at least 6 months after completion of gonadotoxic treatment 1

Assisted Reproductive Technologies

• Intrauterine insemination (IUI) and in vitro fertilization (IVF) with or without intracytoplasmic sperm injection (ICSI) are options for couples unable to achieve natural pregnancy 1, 2
• IVF treatment typically allows for a 37% live delivery rate per initiated cycle, with results closely related to female age 1
• For unexplained infertility, options include another year of unprotected intercourse or proceeding to assisted reproductive technologies 2

Lifestyle Modifications

• Limit alcohol intake, avoid tobacco and illicit drug use 3
• Consider weight loss if obese 3
• Consume a pro-fertility diet 3

Important Considerations

• Male factor conditions may be treatable with medical or surgical therapy, while others may require donor sperm or adoption 1
• Some conditions have health and genetic implications for the patient and potential offspring 1
• Without adequate male evaluation, the female partner may pursue unnecessary costly, time-consuming, and invasive treatment options 1
• The ultimate goal should be to achieve natural pregnancy when possible, with assisted reproductive technologies as a secondary option 4