Ferlin, A., & Foresta, C. (2020). Infertility: Practical Clinical Issues for Routine Investigation of the Male Partner. Journal of clinical medicine. https://doi.org/10.3390/jcm9061644
Ferlin A, Foresta C. Infertility: Practical Clinical Issues for Routine Investigation of the Male Partner. Journal of clinical medicine. 2020. doi:10.3390/jcm9061644
Ferlin, Alberto, and Carlo Foresta. "Infertility: Practical Clinical Issues for Routine Investigation of the Male Partner." Journal of clinical medicine, 2020.
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A review recommends a stepwise medical workup for infertile men
A narrative review recommends evaluating both partners of an infertile couple at the same time. The authors draw on guidelines and their own experience and say a man's workup goes past semen analysis. Men with no known risk factors start with history, exam and semen analysis. Infection, hormone and imaging tests become mandatory if risk factors or abnormal results appear.
Key Findings
About 15–20% of couples in Western countries are infertile, meaning they have not conceived after a year of trying. In roughly half of those couples, a male factor is present.
The authors list medical history, a physical exam and semen analysis as the minimum first evaluation for men with no known risk factors.
Semen results vary naturally, so the authors state that a diagnosis needs two separate semen analyses.
WHO semen criteria are reference values from a study of under 2000 fathers. Men below the fifth percentile are not necessarily infertile. Values inside the reference range do not ensure fertility.
The authors say sperm DNA fragmentation testing could be useful, to date, only for couples with recurrent pregnancy loss and men with unexplained infertility and fully normal semen.
Interpretation
The paper is a narrative review, an expert overview that pools no data. The authors blend international guidelines with decades of their own experience, so the stepwise order reflects their judgment. The review reports no data on pregnancy outcomes after a fuller male workup. Several tests it covers, such as sperm DNA fragmentation, lack standard methods and normal values, and prospective randomized studies of them have not been done. Current guidelines omit many such tests or do not support routine use.
RRM Context
Restorative reproductive medicine looks for the condition behind infertility. The review takes that view for men too. It calls infertility a possible symptom of a broader disease. Evaluating both partners together fits the couple-centered approach of RRM. Unexplained infertility means undiagnosed.
Our editorial summary of this paper, not the article's abstract.
Abstract
About one-fifth of couples has fertility problems in Western countries. Male factors are present in about half of them, either alone or in combination with female causes. Therefore, both partners should be evaluated simultaneously. The fertility status and/or specific conditions of each partner influence the clinical and treatment approach. This article summarizes in a practical way when, how, and why the male partner of an infertile couple should be investigated. The available evidence and international guidelines were used, interpreting, discussing, and expanding them from personal decades-long experience in this field. The aim is to delineate the most appropriate clinical approach for the male partner of infertile couples, considering traditional and emerging technologies and laboratory analyses in the context of their clinical significance. Components of the initial evaluation in men without known risk factors for infertility should include at minimum medical history, physical examination, and semen analysis. Semen microbiological examination, endocrine assessment, scrotal ultrasound, and transrectal ultrasound are suggested in most men and are mandatory when specific risk factors for male infertility are known to be present or when the initial screening demonstrated abnormalities. Full examination, including genetic tests, testicular histology, or additional tests on sperm, is clinically oriented and/or suggested after the results of initial investigations.
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