Garolla, A., Pizzol, D., Carosso, A. R., Borini, A., Ubaldi, F. M., Calogero, A. E., Ferlin, A., Lanzone, A., Tomei, F., Engl, B., Rienzi, L., De Santis, L., Coticchio, G., Smith, L., Cannarella, R., Anastasi, A., Menegazzo, M., Stuppia, L., Corsini, C., & Foresta, C. (2020). Practical Clinical and Diagnostic Pathway for the Investigation of the Infertile Couple. Front Endocrinol (Lausanne). https://doi.org/10.3389/fendo.2020.591837
Garolla A, Pizzol D, Carosso AR, Borini A, Ubaldi FM, Calogero AE, Ferlin A, Lanzone A, Tomei F, Engl B, Rienzi L, De Santis L, Coticchio G, Smith L, Cannarella R, Anastasi A, Menegazzo M, Stuppia L, Corsini C, Foresta C. Practical Clinical and Diagnostic Pathway for the Investigation of the Infertile Couple. Front Endocrinol (Lausanne). 2020. doi:10.3389/fendo.2020.591837
Garolla, A., et al. "Practical Clinical and Diagnostic Pathway for the Investigation of the Infertile Couple." Front Endocrinol (Lausanne), 2020.
This expert opinion summarizes current knowledge on risk factors for infertility and identifies a practical clinical and diagnostic approach for the male and female partners of an infertile couple aimed to improve the investigation and management of fertility problems.
Background
Infertility represents an important and growing health problem affecting up to 16% of couples worldwide. In most cases, male, female, or combined factor can be identified, and different causes or risk factors have been related to this condition. However, there are no standardized guidelines on the clinical-diagnostic approach of infertile couples and the recommendations concerning infertility are sometimes lacking, incomplete, or problematic to apply.
Objective
The aim of this work is to provide an appropriate clinical and diagnostic pathway for infertile couples designed by a multidisciplinary-team of experts. The rationale is based on the history and physical examination and then oriented on the basis of initial investigations. This approach could be applied in order to reduce variation in practice and to improve the investigation and management of fertility problems.
Methods
Prominent Italian experts of the main specialties committed in the ART procedures, including gynecologists, andrologists, embryologists, biologists, geneticists, oncologists, and microbiologists, called "InfertilItaly group", used available evidence to develop this expert position.
Outcomes
Starting from the individuation of the principal risk factors that may influence the fertility of females and males and both genders, the work group identified most appropriate procedures using a gradual approach to both partners aimed to obtain a precise diagnosis and the most effective therapeutic option, reducing invasive and occasionally redundant procedures.
Conclusions
This expert position provides current knowledge on risk factors and suggests a diagnostic workflow of infertile couples. By using this step-by-step approach, health care workers involved in ART, may individuate a practical clinical management of infertile couples shared by experts.
Mazzilli R et al., 2026·Journal of endocrinological investigation
Male factor could contribute, alone or in combination with female factor, to the inability to conceive in a couple in more than half of cases. The effect of male factor infertility (MFI) on embryological assisted reproductive technology (ART) outcomes remains an ongoing discussion.
to evaluate the impact of MFI on embryo aneuploidy rates, to better understand the role and possible indication for Preimplantation genetic testing for aneuploidies (PGT-A), considering the role of sperm characteristics, paternal age, sperm DNA fragmentation and sperm aneuploidies.
this narrative review included all available articles, published up to January 2026.
Available evidence, often based on heterogeneous and old-fashioned methodologies, suggests that MFI may impair embryonic development, particularly in terms of fertilization rate and blastulation rate, more than embryo euploidy; however, a comprehensive evaluation of MFI should be integrated into clinical practice in the context of couple infertility, to also optimize the efficiency and outcomes of ART. Promising results emerged from sperm DNA fragmentation as a tool to predict embryo euploidy, but further investigations involving larger sample sizes and improved standardization are required.
Grande G et al., 2026·The Journal of clinical endocrinology and metabolism·Free to read
Male factor infertility (MFI) is frequently labelled idiopathic when evaluation relies primarily on semen analysis, potentially overlooking endocrine and pathophysiological mechanisms relevant for targeted management.
To phenotypically define MFI and develop a pathophysiology-based classification aimed at reducing idiopathic infertility following comprehensive evaluation.
Prospective monocentric cohort study conducted at a tertiary referral academic centre.
Eight hundred male partners of infertile couples evaluated between October 2024 and January 2026 after exclusion of isolated female factor infertility.
Prevalence of MFI categories, hormonal patterns across phenotypes, and proportion of idiopathic infertility after comprehensive work-up.
All patients underwent standardized clinical evaluation, hormonal assessment (total testosterone, FSH, LH), testicular ultrasound, and complete semen analysis. Microbiological testing, transrectal ultrasound, and genetic analyses were performed according to guidelines.
Primary spermatogenic failure was the most prevalent category (56.0%), followed by infection/inflammation (22.4%) and hypogonadotropic hypogonadism (8.5%). Idiopathic infertility was identified in only 5.3% of cases. Distinct endocrine profiles were observed, with high-FSH spermatogenic failure representing the dominant phenotype.
Comprehensive phenotyping markedly reduces the proportion of patients classified as having idiopathic infertility and identifies clinically relevant subgroups. This prospective study provides validation of a pathophysiology-based classification and supports a shift toward endocrine-integrated diagnostic strategies in male infertility, with potential implications for targeted management.
Rocca MS et al., 2026·Journal of translational medicine·Free to read
Standard semen analysis has little prognostic value in distinguishing fertile from infertile men. Furthermore, in men with semen parameters within the reference ranges, it cannot distinguish fertile men from infertile men, i.e. partners of couples with idiopathic infertility. Oxidative stress, mitochondrial dysfunction, sperm telomere shortening, and DNA fragmentation have been proposed as contributors to impaired male fertility. However, these biomarkers have not been evaluated as a whole in subjects with normal semen parameters, partners of fertile and infertile couples.
To characterise a multidimensional panel of sperm biomarkers-including sperm telomere length (STL), mitochondrial DNA copy number (mtDNAcn), reactive oxygen species (ROS), lipid peroxidation (LP), sperm chromatin dispersion (SCD), and respiratory control ratio (RCR)-and to identify whether these parameters might discriminate, in men with normal semen parameters, infertile men from fertile controls.
A total of 150 men with semen parameters within the normal ranges were enrolled: 47 male partners of couples with idiopathic infertility and 103 fertile controls. STL and mtDNAcn were quantified by qPCR; ROS were assessed using OxiSperm®II with semiquantitative imaging; LP was measured spectrophotometrically in seminal plasma; SCD was used to determine DNA fragmentation; and mitochondrial function was evaluated by oxygen consumption and RCR. Correlations between biomarkers and semen parameters were analysed using Pearson or Spearman coefficients, and intergroup comparisons were adjusted for age.
Semen parameters did not differ significantly between male partners of fertile and infertile couples. compared to men of fertile couples, men of infertile couples exhibited significantly shorter STL (0.57 ± 0.59 vs 1.21 ± 1.13, p_adj = 0.001) and higher oxidative stress, with both ROS (8300.9 ± 4214.8 vs 6555.3 ± 3394.3, p_adj = 0.027) and LP (88.33 ± 55.50 vs 40.29 ± 46.98, p_adj < 0.001) markedly elevated. mtDNAcn, SCD, and RCR showed no difference between the groups. Across the entire cohort, STL correlated negatively with ROS and LP and positively with RCR. ROS correlated negatively with total sperm count, motility and RCR, and positively with LP. LP displayed the strongest pattern of associations, correlating negatively with concentration, total count, motility, STL and RCR, and positively with age and volume.
Among men with normal semen analysis, partners of couples with idiopathic infertility exhibit a distinct sperm molecular profile characterised by telomere shortening and oxidative imbalance. STL, ROS and LP emerged as age-independent biomarkers associated with infertility status and showed promising discriminatory ability in this cohort, supporting their integration as second-level tests to complement routine semen analysis in cases of normozoospermia.
Ponce MR et al., 2026·Andrology·Free full text on PubMed Central
Transgender individuals assigned male at birth (AMAB) may choose to preserve their fertility prior to starting gender-affirming hormone therapy (GAHT). However, limited data exist regarding the baseline reproductive and hormonal characteristics of this population before and after GAHT.
To characterize semen quality and hormonal profiles in transgender AMAB individuals prior to GAHT and compare findings with cisgender men and with transgender individuals who discontinued GAHT for at least 3 months.
This retrospective study included transgender AMAB individuals from two tertiary andrology centers who underwent sperm cryopreservation before GAHT initiation (treatment-naïve group). Clinical evaluation included anthropometric measures, testicular volume assessment, varicocele detection, and sex hormone measures. Semen parameters were analyzed according to WHO criteria and compared with those of cisgender men and previously treated transgender individuals.
Thirty-two treatment-naïve transgender AMAB individuals were included. Hormonal parameters were generally within reference ranges. Only 46.9% of treatment-naïve individuals met WHO criteria for normozoospermia, compared with 75.5% of cisgender controls. Compared with nine previously treated individuals, estradiol levels were higher and seminal volume lower. A higher frequency of seminal abnormalities was observed, although not statistically significant.
A substantial proportion of treatment-naïve transgender AMAB individuals exhibited impaired semen parameters prior to GAHT initiation. Prior GAHT exposure showed a trend toward poorer semen quality. These findings support early fertility counseling and preservation in transgender individuals prior to GAHT initiation.
Ferlin A et al., 2020·Journal of clinical medicine·Free full text on PubMed Central
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.
Guidelines by Clinical Area · Fertility and Infertility Guidelines
Foresta C et al., 2002·European journal of human genetics : EJHG
Research on genetic causes of male and female infertility rapidly expanded in the last years, following the development of in vitro fertilising techniques. Genetic tests are now available to explore the cause of the infertility and assess the risk of a given couple to transmit its genetic characteristics. This allows at-risk couples to take an informed decision when electing for a medically assisted reproduction. It also allows the professionals to offer a prenatal diagnosis when appropriate. Thus, the genetic work-up of the infertile couple has become good practice for an appropriate diagnosis, treatment and prognostic assessment. The lack of national or international rules for the genetic approach to the infertile couple, prompted the Italian community of professionals in the field of reproductive medicine to join and set up guidelines for the genetic diagnosis of male and female infertility. The group of clinical and research experts is representative of 12 national scientific societies and was supported by external experts from four international societies. We examine the clinically relevant genetic causes of male and female infertility and suggest the category of patients for which each genetic test is recommended or optional, both for an accurate diagnosis and prior to ART.
Grande G et al., 2025·Andrology·Free full text on PubMed Central
In infertile couples whose male partner has alterations in semen parameters frequently, a comprehensive andrological approach is lacking and approximately 30-50% are classified as idiopathic infertility. These couples are often directly addressed to assisted reproduction techniques (ARTs). However, several clinical conditions may benefit from medical treatment. By acting on etiology and/or risk factors, this aims at improving seminal parameters and restoring natural fertility. To verify the impact of a comprehensive andrological assessment on the management of infertility (in particular, in couples with isolated male factor infertility) using as the primary outcome the natural pregnancy rate. A multicenter retrospective study was conducted between 2015 and 2022 in 1014 couples with primary infertility seeking natural conception (including 266 couples with previous ART failure). Each couple underwent a multidisciplinary evaluation. This involved: a gynecologist and an andrologist both with expertise in infertility, a psychologist when requested, and a fertility awareness practitioner according to a unique diagnostic and therapeutic multidisciplinary protocol. An isolated male factor was found in 23% of couples. In 45%, it was associated with female factors also. The comprehensive diagnostic approach reduced the proportion of idiopathic infertility to 8% of the couples. Targeted treatment, based on diagnostic categories, was associated with spontaneous pregnancy in 40.9% of the couples. In the 233 cases without female factors, normal semen parameters were observed only in 13% of patients. Male genital tract inflammation was observed in 48.8% of the patients, genital tract infection in 43.1%, and hypospermatogenesis in 16.7%. Patients with infections were treated with antibiotics and probiotics. If further inflammation was documented, this was followed by low-dose corticosteroids and antioxidants. Follicle stimulating hormone (FSH) treatment was used in patients with hypospermatogenesis, and varicocele repair surgery was performed in four patients. Our data underline the efficacy of a comprehensive approach to the diagnostic process of male factor infertility, both in reducing the percentage of idiopathic infertility and in restoring natural fertility based on a targeted treatment.
Guideline Appraisal · Guideline Variation and Disagreement
Grande G et al., 2024·Human reproduction (Oxford, England)
Sir, We read with interest the guideline about unexplained infertility developed by the Guideline Group (GDG) on Unexplained Infertility of ESHRE (Romualdi et al., 2023). We appreciated the efforts to have clear, evidence-based recommendations on this important topic but would like to point out fundamental problems and misunderstandings on the approach to the male factor. Although we can agree on the definition of unexplained infertility made by the GDG as ‘infertility in couples with apparently normal ovarian function, fallopian tubes, uterus, cervix and pelvis, age ≤40 years and with adequate coital frequency; and apparently normal testicular function, genito-urinary anatomy, and a normal ejaculate’, substantial differences in the diagnostic approach for the female and male partner are then proposed to assess these features. In fact, a comprehensive evaluation of the female partner is recommended considering ovulation, ovarian reserve, tubal factor, uterine factor, and even vaginal microbiota, whereas the approach to the male partner is limited only to semen analysis. The entire following line of reasoning assumes that a normal semen analysis is sufficient to rule out male factor infertility and no further examination is needed. There are several problems with this approach. First of all, it is quite clear that a normal testicular function and genito-urinary anatomy cannot be determined by semen analysis only, but instead require a combination of, at least, history, physical examination, endocrine assessment, and ultrasound examination of the testes and seminal tract. For semen analysis, the GDG correctly refers to the World Health Organization (WHO) manual for semen analysis (6th edition) (World Health Organization, 2021) but misinterpreted it because the GDG does not recommend any other diagnostic procedure when ‘semen analysis according to WHO criteria is normal’. Not only did the GDG neglect to consider a broad approach to understand whether the testicular function and genito-urinary anatomy are normal, but also it made substantial misunderstandings on the role and significance of semen analysis and its relation with fertility. A main point is that the WHO manual does not define normal semen analysis (World Health Organization, 2021), simply because the so-called ‘reference values’, and in particular the fifth percentile reference, do not represent cut-off limits for fertility and infertility. These values represent the distribution of results from around 3500 presumed fertile men and they are ‘not sufficient to establish clinically useful decision limits’ (World Health Organization, 2021). WHO is very clear when stating that ‘reference values cannot be used to distinct limits between fertile and subfertile men’, ‘the lower fifth percentile of data from men in the reference population does not represent a limit between fertile and infertile men’, and ‘for an individual patient, a semen analysis is never prognostic of infertility’. Since, it is well known that natural fertility is possible with semen parameters below the fifth percentile and infertility with semen parameters above the fifth percentile, a ‘normal ejaculate’ cannot be defined. Therefore, there is a ‘problem in applying a dichotomous categorization to fertility that must be considered a continuum. It is also well known that there is a substantial overlap of semen examination results between fertile and infertile men’ (World Health Organization, 2021). Hence, the reference limits cannot be used as a specific limit between infertile and fertile men (Björndahl et al., 2023). Results of semen examination below the WHO reference values do not automatically mean that the problem of the couple resides in the male, and results above the limits do not always mean that the male partner of an infertile couple is undoubtedly fertile (Björndahl et al., 2023). Semen analysis is fundamental in the initial investigation of the male partner of an infertile couple, but its [truncated]
Infertility › Evaluation › Diagnostic Workup · Clinical Guidelines and Standards › Guidelines by Clinical Area › Fertility and Infertility Guidelines · Diagnostics › Hormone Testing › Serum Panels
Andrea Borini, Antonio Lanzone, Laura Rienzi
A Borini, A Lanzone, L Rienzi
PMID 33542705 33542705 DOI 10.3389/fendo.2020.591837 10.3389/fendo.2020.591837 Garolla et al. 2020, Garolla 2020
Cite this article
Garolla, A., Pizzol, D., Carosso, A. R., Borini, A., Ubaldi, F. M., Calogero, A. E., Ferlin, A., Lanzone, A., Tomei, F., Engl, B., Rienzi, L., De Santis, L., Coticchio, G., Smith, L., Cannarella, R., Anastasi, A., Menegazzo, M., Stuppia, L., Corsini, C., & Foresta, C. (2020). Practical Clinical and Diagnostic Pathway for the Investigation of the Infertile Couple. Front Endocrinol (Lausanne). https://doi.org/10.3389/fendo.2020.591837
Garolla A, Pizzol D, Carosso AR, Borini A, Ubaldi FM, Calogero AE, Ferlin A, Lanzone A, Tomei F, Engl B, Rienzi L, De Santis L, Coticchio G, Smith L, Cannarella R, Anastasi A, Menegazzo M, Stuppia L, Corsini C, Foresta C. Practical Clinical and Diagnostic Pathway for the Investigation of the Infertile Couple. Front Endocrinol (Lausanne). 2020. doi:10.3389/fendo.2020.591837
Garolla, A., et al. "Practical Clinical and Diagnostic Pathway for the Investigation of the Infertile Couple." Front Endocrinol (Lausanne), 2020.
