Unmet needs in male reproductive health care.

Abstract

Women came first when medicine turned its head towards fertility. Perhaps this was simply because babies appeared from women, and so it was sensible to assume that the woman was at fault if a couple could not conceive. Perhaps it was that in the male-dominated doctoring days at the genesis of reproductive health care, men found it difficult to imagine that they themselves could be the problem in making babies. But whatever the reason, in the current era while epidemiology and physiology point to a very credible ‘about half male and about half female’ approach when assigning reasons for inability to conceive, care for the man lags far behind in the number of practitioners available, the understanding of the science involved and the therapeutic instruments available. So what can move the field of male reproductive medicine forward? The first is in the diagnosis. Historically, sperm in the ejaculate was an obvious place to start when discerning problems with male fertility. Azoospermia, the lack of sperm in the ejaculate, is plainly a reason for male infertility. Sadly, it's also the only pattern of information derived from microscopic observation of the male gamete that clearly prognosticates male reproductive potential. From the beginnings of analysing semen, the substantial overlap between bulk seminal parameters in fertile and infertile populations has been recognised (MacLeod. Fertil Steril 1950;1(4):347–61). We need better ways to prognosticate, which likely includes genomics, epigenetics, proteomics and metabolomics of both the man and his sperm. Likewise, as reproduction is less concerned with the average sperm and more about the exceptional one, we require better ways of characterising the ultimately successful swimmer, and as assisted reproductive technology seeks the best sperm, we need non-destructive means of identifying the single best sperm to choose for in vitro fertilisation. But the diagnosis is always a prequel to treatment. One of the clearest advances in male reproductive medicine in the past half-century was the development of a surgical technique of testicular sperm extraction to identify sperm in men with azoospermia due to spermatogenic dysfunction, thus allowing biological fatherhood in the most severely afflicted infertile men (Schlegel. Hum Reprod 1999;14(1):131–5.) But this technique had an extraordinary consequence, which was to provide a binary outcome – sperm retrieved or not. And this binary outcome could be tested against therapeutic endocrine protocols, which previously had only the terribly inaccurate and variable semen analysis as a possible endpoint. Suddenly, endocrine stimulation protocols for the man could be studied and demonstrated effective (Hussein et al. BJU Int 2013;111:E110–4). And these medical interventions may also be effective in non-azoospermic men, especially when diagnoses are improved and more directed at the individual infertile man. Of course, all of these opportunities are only realised if the studies demonstrating their utility and efficacy are rigorously performed and as incontrovertible as possible. We must insist on clear outcomes for the male gamete, especially in the context of how it functions in embryogenesis and the later stages of development. But the opportunities are nonetheless promising and alluring. CN reports personal fees from Ferring Investigator, Educator Scientific Study, CME Activity Support, personal fees from Merck Educator CME Activity Support, personal fees from NexHand Co-Founder Medical Device Company, during the conduct of the study; and ASRM Journal Editor Medical Communications AUA Journal Section Editor Medical Communications Co-Editor in Chief, Fertility and Sterility. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.