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Diagnosis and Treatment of Infertility in Men: AUA/ASRM Guideline Part II Peter N

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Diagnosis and Treatment of Infertility in Men: AUA/ASRM Guideline Part II Peter N Diagnosis and treatment of infertility in men: AUA/ASRM guideline part II Peter N. Schlegel, M.D.,a Mark Sigman, M.D.,b Barbara Collura,c Christopher J. De Jonge, Ph.D, H.C.L.D.(A.B.B.),d Michael L. Eisenberg, M.D.,e Dolores J. Lamb, Ph.D., H.C.L.D.(A.B.B.),f John P. Mulhall, M.D.,g Craig Niederberger, M.D., F.A.C.S.,h Jay I. Sandlow, M.D.,i Rebecca Z. Sokol, M.D., M.P.H.,j Steven D. Spandorfer, M.D.,f Cigdem Tanrikut, M.D., F.A.C.S.,k Jonathan R. Treadwell, Ph.D.,l Jeffrey T. Oristaglio, Ph.D.,l and Armand Zini, M.D.m a New York Presbyterian Hospital-Weill Cornell Medical College; b Brown University; c RESOLVE; d University of Minnesota School of Medicine; e Stanford University School of Medicine; f Weill Cornell Medical College; g Memorial-Sloan Kettering Cancer Center; h Weill Cornell Medicine, University of Illinois-Chicago School of Medicine; i Medical College of Wisconsin; j University of Southern California School of Medicine; k Georgetown University School of Medicine; l ECRI; and m McGill University School of Medicine Purpose: The summary presented herein represents Part II of the two-part series dedicated to the Diagnosis and Treatment of Infertility in Men: AUA/ASRM Guideline. Part II outlines the appropriate management of the male in an infertile couple. Medical therapies, surgical techniques, as well as use of intrauterine insemination (IUI)/in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) are covered to allow for optimal patient management. Please refer to Part I for discussion on evaluation of the infertile male and discussion of relevant health conditions that are associated with male infertility. Materials/Methods: The Emergency Care Research Institute Evidence-based Practice Center team searched PubMedÒ, EmbaseÒ, and Medline from January 2000 through May 2019. When sufficient evidence existed, the body of evidence was assigned a strength rating of A (high), B (moderate), or C (low) for support of Strong, Moderate, or Conditional Recommendations. In the absence of sufficient evidence, additional information is provided as Clinical Principles and Expert Opinions. (Table 1) This summary is being simultaneously published in Fertility and Sterility and The Journal of Urology. Results: This Guideline provides updated, evidence-based recommendations regarding management of male infertility. Such recommendations are summarized in the associated algorithm. (Figure 1) Conclusion: Male contributions to infertility are prevalent, and specific treatment as well as assisted reproductive techniques are effec- tive at managing male infertility. This document will undergo additional literature reviews and updating as the knowledge regarding current treatments and future treatment options continues to expand. (Fertil SterilÒ 2020;-:-–-. Ó2020 by American Urological Association Education and Research, Inc. and American Society for Reproductive Medicine.) Keywords: Male infertility, evaluation, chemotherapy, surgery, health BACKGROUND others may only be managed with 26. Clinicians should not recommend Failure to conceive within 12 months of donor sperm or adoption. varicocelectomy for men with non- ‘‘ ’’ attempted conception is due in whole or In this guideline, the term male or palpable varicoceles detected solely ‘‘ ’’ in part to the male in approximately men is used to refer to biological or by imaging. (Strong Recommenda- one-half of all infertile couples. genetic men. tion; Evidence Level: Grade C) 27. For men with clinical varicocele Although many couples can achieve a Treatment pregnancy with assisted reproductive and non-obstructive azoospermia technologies (ART), evaluation of the Varicocele Repair/Varicocelectomy. (NOA), couples should be fi male is important to identify conditions 25. Surgical varicocelectomy should informed of the absence of de n- that may be medically important, be considered in men attempting itive evidence supporting varico- counsel men regarding future health to conceive, who have palpable cele repair prior to ART. (Expert considerations and to most appropri- varicocele(s), infertility, and Opinion) ately direct therapy. Most male factor abnormal semen parameters, Varicoceles have long been recog- conditions are specifically treatable except for azoospermic men. nized as a condition that can affect with medical or surgical therapy, while (Moderate Recommendation; Evi- male fertility, where correction of a dence Level: Grade B) clinical varicocele can result in sub- stantial improvements in semen pa- The complete unabridged version of the guideline is available at https://www.asrm.org/news-and- publications/practice-committee-documents/. rameters and the chance of achieving a pregnancy. The largest most recent Fertility and Sterility® Vol. -, No. -, - 2020 0015-0282/$36.00 meta-analysis by Wang et al. reported Copyright ©2020 by American Urological Association Education and Research, Inc. and American So- fi ciety for Reproductive Medicine. Published by Elsevier Inc. signi cantly higher pregnancy rates https://doi.org/10.1016/j.fertnstert.2020.11.016 VOL. - NO. - / - 2020 1 for men treated with clinical varicocele repair compared to no TESE) was observed to result in successful extraction 1.5 times treatment (1). Pregnancy rates without treatment were more often than non-microsurgical testis sperm extraction, assumed to be 17%, while rates were calculated to be 42% and testis sperm extraction was 2 times more likely to succeed (95% CI 26% to 61%) with subinguinal microsurgical varico- when compared to testicular aspiration (4). Less effect on celectomy, 35% (95% CI 21% to 54%) with inguinal microvar- testosterone levels is seen after micro-TESE than with icocelectomy, 37% (95% CI 22% to 58%) with inguinal open conventional TESE, but testosterone deficiency requiring (non-microsurgical) surgery, and 37% (95% CI 19% to 61%) testosterone replacement remains a risk, even after micro- with laparoscopic surgery (1). Such findings must be inter- TESE (5). preted with caution given that this meta-analysis included For men with obstructive azoospermia, there are no sub- studies with non-randomized designs and selective outcome stantial differences in ICSI success rates when either cryo- reporting. A systematic review and meta-analysis of varico- preserved or fresh sperm are used, so sperm retrieval and celectomy for subclinical varicocele reported no demon- cryopreservation may be done prior to ART. For men with strable benefit of varicocele repair in pregnancy or bulk NOA, some centers perform simultaneous sperm retrieval seminal parameters with the exception of a possible small nu- with ART because the numbers of sperm obtained may be merical effect on progressive sperm motility that is unlikely to limited and sperm may not survive cryopreservation. No dif- be clinically important (2). These observations support the ferences in outcomes were observed between fresh and importance of identifying clinical varicoceles in men with frozen sperm in most series, as long as there were sperm of male infertility and evidence of abnormal sperm production adequate number that survived cryopreservation and thaw- or quality. ing (6). Case series of men with NOA and clinical varicoceles that Limited data exist comparing outcomes for the various have undergone varicocele repair have been reported. Of note, procedures available to obtain sperm from men with ejacula- a study of NOA men reported return of adequate motile sperm tory dysfunction. Penile vibratory stimulation, electroejacu- to the ejaculate sufficient to avoid surgical sperm retrieval lation, surgical sperm retrieval, or sympathomimetic agents only occurred in 9.6% of men after clinical varicocele repair may be utilized depending on the cause of the ejaculatory (3). These data have to be compared to results of re-analysis dysfunction, the patient’s condition, and the surgeon’s and of sperm in the ejaculate without any intervention beyond IVF laboratory experience. repeat semen analysis (SA) using extended sperm search in men who previously were thought to be azoospermic, where Obstructive Azoospermia, Including Post-Vasectomy Infer- up to 35% of men thought to be azoospermic had at least tility. rare sperm detectable with a more detailed search of the 33. Couples desiring conception after vasectomy should be centrifuged/concentrated semen pellet. Since the above- counseled that surgical reconstruction, surgical sperm mentioned studies did not have a control group, there are retrieval, or both reconstruction and simultaneous sperm no high-quality data to support repair of varicoceles in men retrieval for cryopreservation are viable options. (Moder- with NOA. In addition, varicocele repair defers treatment ate Recommendation; Evidence Level: Grade C) with ART for at least six months. 34. Clinicians should counsel men with vasal or epididymal Sperm Retrieval. obstructive azoospermia that microsurgical reconstruc- 28. For men with NOA undergoing sperm retrieval, micro- tion may be successful in returning sperm to the ejacu- dissection testicular sperm extraction (TESE) should be late. (Expert Opinion) performed. (Moderate Recommendation; Evidence 35. For infertile men with azoospermia and Ejaculatory Duct Level: Grade C) Obstruction (EDO), the clinician may consider transure- 29. In men undergoing surgical sperm retrieval, either fresh thral resection of ejaculatory ducts (TURED) or surgical or cryopreserved sperm may be used for ICSI. (Moderate sperm extraction. (Expert Opinion) Recommendation; Evidence Level: Grade C) Fertility restoration treatment
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