Male Infertility 2020 Flashcards
What should clinicians initiate during the initial infertility evaluation?
Concurrent assessment of both male and female partners.
Expert Opinion
What should be included in the initial evaluation of the male for fertility?
A reproductive history and one or more semen analyses (SAs).
Clinical Principle; Strong Recommendation; Evidence Level: Grade B
When should male reproductive experts perform a complete history and physical examination?
When there are one or more abnormal semen parameters or presumed male infertility.
Expert Opinion
In which situations should clinicians evaluate the male partner?
In couples with failed assisted reproductive technology cycles or recurrent pregnancy losses (two or more).
Moderate Recommendation; Evidence Level: Grade C
What counseling should be provided to infertile males or those with abnormal semen parameters?
They should be informed about the health risks associated with abnormal sperm production.
Moderate Recommendation; Evidence Level: Grade B
What should clinicians inform infertile males with specific, identifiable causes of male infertility?
Relevant associated health conditions.
Moderate Recommendation; Evidence Level: Grade B
What advice should be given to couples with advanced paternal age (≥40)?
There is an increased risk of adverse health outcomes for their offspring.
Expert Opinion
What discussions may clinicians have regarding risk factors associated with male infertility?
Lifestyle, medication usage, environmental exposures, and occupational exposures, noting that current data on many risk factors are limited.
Conditional Recommendation; Evidence Level: Grade C
How should clinicians use semen analysis results in managing male infertility?
To guide patient management, especially when multiple abnormalities are present.
Expert Opinion
When is hormonal evaluation (eg FSH, T) recommended for infertile males?
In cases of impaired libido, erectile dysfunction, oligozoospermia or azoospermia, atrophic testes, or evidence of hormonal abnormalities on physical examination.
Expert Opinion
What initial evaluations are recommended for azoospermic males?
Physical exam, semen volume, semen pH, and serum follicle-stimulating hormone levels to differentiate between genital tract obstruction and impaired sperm production.
Expert Opinion
When should karyotype testing be recommended?
For males with primary infertility and azoospermia or sperm concentration <5 million/mL, accompanied by elevated FSH, testicular atrophy, or impaired sperm production.
Expert Opinion
In which cases is Y-chromosome microdeletion analysis recommended?
For males with primary infertility and azoospermia or sperm concentration ≤1 million/mL, with elevated FSH, testicular atrophy, or impaired sperm production.
Moderate Recommendation; Evidence Level: Grade B
Who should undergo CFTR mutation carrier testing?
Males with vasal agenesis or idiopathic obstructive azoospermia.
Expert Opinion
What is recommended for males harboring a CFTR mutation or with absence of the vas deferens?
Genetic evaluation of the female partner.
Expert Opinion
Is sperm DNA fragmentation analysis recommended in the initial evaluation of infertile couples?
No, it is not recommended.
Moderate Recommendation; Evidence Level: Grade C
What should clinicians do if increased round cells are observed on semen analysis (>1 million/mL)?
Further evaluation to differentiate white blood cells (pyospermia) from germ cells.
Expert Opinion
How should patients with pyospermia be managed?
Evaluate for the presence of infection.
Clinical Principle
Is antisperm antibody testing recommended in the initial evaluation of male infertility?
No, it is not recommended.
Expert Opinion
What evaluations are recommended for couples with recurrent pregnancy loss?
Karyotype analysis and sperm DNA fragmentation assessment of the male partner.
Expert Opinion; Moderate Recommendation; Evidence Level: Grade C
Should diagnostic testicular biopsy be routinely performed to differentiate between obstructive and non-obstructive azoospermia?
No, it should not be routinely performed.
Expert Opinion
Should scrotal ultrasound be routinely performed in the initial evaluation of an infertile male?
No, clinicians should not routinely perform scrotal ultrasound in the initial evaluation of the infertile male.
Expert Opinion
When should clinicians consider transrectal ultrasonography (TRUS) or pelvic magnetic resonance imaging (MRI) in the evaluation of male infertility?
TRUS or pelvic MRI may be recommended in males with semen analysis suggestive of ejaculatory duct obstruction (EDO), characterized by acidic, azoospermic semen with volume <1.4mL, normal serum testosterone, and palpable vas deferens.
Expert Opinion
Is routine abdominal imaging recommended for isolated small or moderate right varicocele?
No, clinicians should not routinely perform abdominal imaging for the sole indication of an isolated small or moderate right varicocele.
Expert Opinion
What imaging is recommended for patients with vasal agenesis?
Clinicians should recommend renal ultrasonography to evaluate for renal abnormalities in patients with vasal agenesis.
Expert Opinion
When should surgical varicocelectomy be considered in males attempting to conceive?
In males with palpable varicocele(s), infertility, and abnormal semen parameters, except for those who are azoospermic.
Moderate Recommendation; Evidence Level: Grade B
Should varicocelectomy be recommended for males with non-palpable varicoceles detected solely by imaging?
No, clinicians should not recommend varicocelectomy in such cases.
Strong Recommendation; Evidence Level: Grade C
What should clinicians inform couples about regarding varicocele repair in males with clinical varicocele and non-obstructive azoospermia?
Couples should be informed about the absence of definitive evidence supporting varicocele repair prior to surgical sperm retrieval with assisted reproductive technologies.
Expert Opinion
What procedure is recommended for sperm retrieval in males with non-obstructive azoospermia?
Clinicians should perform a microdissection testicular sperm extraction (micro-TESE).
Moderate Recommendation; Evidence Level: Grade C
Can intracytoplasmic sperm injection (ICSI) be performed with fresh or cryopreserved sperm?
Yes, in males undergoing surgical sperm retrieval, ICSI may be performed with either fresh or cryopreserved sperm.
Conditional Recommendation; Evidence Level: Grade C
From where can sperm be extracted in males with azoospermia due to obstruction?
Clinicians may extract sperm from either the testis or the epididymis.
Conditional Recommendation; Evidence Level: Grade C
When might testicular sperm be utilized in non-azoospermic males?
Clinicians may consider the utilization of testicular sperm in non-azoospermic males with an elevated sperm DNA Fragmentation Index (DFI).
Clinical Principle
What options are available for males with aspermia?
Clinicians may perform surgical sperm extraction or induced ejaculation (using sympathomimetics, vibratory stimulation, or electroejaculation) depending on the patient’s condition and clinician’s experience.
Expert Opinion
How can infertility associated with retrograde ejaculation be treated?
Clinicians may treat it with sympathomimetics (with or without alkalinization and/or urethral catheterization), induced ejaculation, or surgical sperm retrieval.
Expert Opinion
What should clinicians counsel couples about regarding conception after vasectomy?
That surgical reconstruction, surgical sperm retrieval, or both reconstruction and simultaneous sperm retrieval for cryopreservation are viable options.
Moderate Recommendation; Evidence Level: Grade C
What is the success potential of microsurgical reconstruction in males with vasal or epididymal obstructive azoospermia?
Clinicians should counsel that it may be successful in returning sperm to the ejaculate.
Expert Opinion
What procedure may be considered for infertile males with ejaculatory duct obstruction?
Transurethral resection of ejaculatory ducts (TURED) and/or surgical sperm extraction.
Expert Opinion
How may clinicians manage male infertility?
Clinicians may manage male infertility with assisted reproductive technology.
Expert Opinion
What should clinicians advise couples with a low total motile sperm count on repeated semen analyses?
That intrauterine insemination success rates may be reduced, and treatment with assisted reproductive technology (in vitro fertilization/intracytoplasmic sperm injection) may be considered.
Expert Opinion
What should clinicians do for a patient presenting with hypogonadotropic hypogonadism (HH)?
Evaluate the patient to determine the etiology of the disorder and treat based on diagnosis.
Clinical Principle
What treatments may clinicians consider for infertile males with low serum testosterone?
Aromatase inhibitors (AIs), human chorionic gonadotropin (hCG), selective estrogen receptor modulators (SERMs), or a combination thereof.
Conditional Recommendation; Evidence Level: Grade C
Should exogenous testosterone therapy be prescribed to males interested in current or future fertility?
No, clinicians should not prescribe exogenous testosterone therapy to these patients.
Clinical Principle
How should clinicians manage infertile males with hyperprolactinemia?
Evaluate the patient to determine the etiology and treat accordingly.
Expert Opinion
What should clinicians inform males with idiopathic infertility regarding the use of selective estrogen receptor modulators?
That these agents have limited benefits compared to results achieved with assisted reproductive technology.
Expert Opinion
What counseling should be provided regarding the use of supplements (e.g., antioxidants, vitamins) for treating male infertility?
Clinicians should counsel patients that the benefits of such supplements are of questionable clinical utility due to inadequate supporting data.
Moderate Recommendation; Evidence Level: Grade B
May clinicians consider using follicle-stimulating hormone analogues for males with idiopathic infertility?
Yes, to potentially improve sperm concentration, pregnancy rate, and live birth rate.
Conditional Recommendation; Evidence Level: Grade B
What should clinicians inform patients with non-obstructive azoospermia about pharmacologic treatments prior to surgical intervention?
That there is limited data supporting the use of selective estrogen receptor modulators, aromatase inhibitors, and gonadotropins before surgery.
Conditional Recommendation; Evidence Level: Grade C
What should clinicians discuss with patients prior to commencing gonadotoxic therapies or other cancer treatments?
The potential effects of these treatments on sperm production.
Moderate Recommendation; Evidence Level: Grade C
What advice should be given to patients undergoing chemotherapy and/or radiation therapy regarding conception?
To avoid initiating a pregnancy for at least 12 months after completing treatment.
Expert Opinion
What should clinicians encourage males to do before starting gonadotoxic therapy or other fertility-impacting cancer treatments?
Bank sperm, preferably multiple specimens, prior to beginning treatment.
Expert Opinion
When should a semen analysis be performed after completing gonadotoxic therapies?
At least 12 months (preferably 24 months) post-treatment.
Conditional Recommendation; Evidence Level: Grade C
What risk should clinicians inform patients about regarding retroperitoneal lymph node dissection (RPLND)?
The potential for aspermia or retrograde ejaculation.
Clinical Principle
What evaluation is recommended for males with aspermia after RPLND who are interested in fertility?
A post-orgasmic urinalysis to assess for retrograde ejaculation.
Clinical Principle
What option should be discussed with males who remain azoospermic after gonadotoxic therapies and are seeking paternity?
Microdissection testicular sperm extraction as a treatment option.
Strong Recommendation; Evidence Level: Grade B
