Management Of Male Factor Infertility Research Articles

Partial Epididymal Obstruction as a Cause of Idiopathic Oligozoospermia: A Reproductive Urologist's Perspective following 35 Years of Surgical and Clinical Experience.

The role of partial epididymal obstruction as contributing to the development of oligozoospermia has been neglected for decades. In the early 1970s, however, Robert Schoysman, a gynecological surgeon devoted to the surgical and medical management of male factor infertility, dedicated many efforts to study such a pathology and its possible effects on male fertility. Following the studies of this pioneer in the field, we concentrated our attention to the patterns of partial and complete epididymal obstruction during surgical scrotal exploration, once made possible even in oligozoospermic men by diagnostic and therapeutic interventions, such as vasovesciculography or seminal tract washout test, at present considered obsolete and no longer feasible in light of the current guidelines. Interestingly, we found signs of partial epididymal obstruction in about 30% of oligozoospermic men with normal testicular volume and serum FSH level as well as normal spermatogenesis at testis biopsy. We, then, compared the findings of scrotal ultrasound with those of scrotal exploration and found that the ultrasound abnormalities of the epididymis were highly predictive of anatomic alteration of the gland. In the present study, we report our experience, together with a historical review of the literature, on this topic.

Male factor infertility: A contemporary overview of investigation, diagnosis and management

Infertility, defined as the failure to achieve a clinical pregnancy after 1 year of regular, unprotected sexual intercourse, is a public health issue of global concern. It affects up to 12% of couples worldwide. While traditionally, research and treatment have focused on female causes of infertility, male factors contribute to up to 70% of cases and therefore deserve appropriate recognition. The purpose of this comprehensive review is to detail the diagnostic work-up, investigations and management of male factor infertility. We discuss much-debated pathologies, such as varicocele, and novel investigations, including sperm DNA fragmentation and reactive oxygen species. Level of evidence: Not applicable

Severe Oligospermia Treatment with Testicular Sperm Using “ICSI”

Introduction: Assisted reproductive technology has been developed significantly throughout the past few years, particularly diagnosing and treating male infertility. Many studies have been performed showing that Intracytoplasmic Sperm Injection (ICSI) is a successful method to attain clinical pregnancy and live birth through impaired spermatozoa characteristics or low sperm count, such as severe oligospermia. Severe oligospermia indicates low sperm count, which in some cases leads to azoospermia. Severe oligospermia can be caused by several factors such as genetics or medication. In search of efficient treatment for couples with Severe oligospermia, numerous retrospective and prospective researches have reported high pregnancy and live birth rates through testicular sperm for men with severe oligospermia and cryptozoospermia with or without high sperm DNA damage. The research showed that the use of testicular sperm in combination with ICSI yielded a high pregnancy rate and live births over another source of sperm, such as ejaculated sperms. Moreover, the use of ICSI in severe oligospermia has shown successful fertilization and pregnancy.
 Methods: In search for effective treatment for couples with severe male factor, a number of small retrospective and prospective studies have reported high pregnancy and live birth rates using testicular sperm for men with necrozoospermia, cryptozoospermia and oligozoospermia with or without elevated sperm DNA damage. Although the data suggest that there may be some benefit in performing testicular sperm retrieval (TSR)-ICSI in select groups of non-azoospermic infertile men, there are potential risks involved with TSR. Clinicians should balance these risks prior to the recommendation of TSR-ICSI on the result of a semen analysis or sperm DNA test alone. Careful evaluation and management of male factor infertility is important. The use of TSR-ICSI in the absence of specific sperm DNA defects is still experimental.
 Discussion: In 1992 and subsequently, several reports indicated that ICSI was a successful technique to achieve clinical pregnancy and live birth using spermatozoa with severely impaired characteristics. The initial optimism over the ability of ICSI to overcome significant sperm abnormalities was later tempered by the findings of more recent publications suggesting that some sperm deficits may not be as effectively treated with ICSI.
 Conclusion: Severe oligospermia indicates low sperm count, which can lead to male infertility; severe oligospermia which can be overcome through ICSI. Genetic factors like microdeletions of the Y chromosome (Yq) can cause severe oligospermia or chemotherapy molecules, affecting the sperm count directly.

PD09-09 PREDICTORS OF MALE FACTOR INFERTILITY MANAGEMENT BY REPRODUCTIVE ENDOCRINOLOGIST VERSUS REFERRAL TO A NEARBY UROLOGIST

You have accessJournal of UrologyCME1 May 2022PD09-09 PREDICTORS OF MALE FACTOR INFERTILITY MANAGEMENT BY REPRODUCTIVE ENDOCRINOLOGIST VERSUS REFERRAL TO A NEARBY UROLOGIST Julie Shabto, Dattatraya Patil, Katherine Poulose, Mackenzie Bennett, Angel Xiao, Heather Hipp, Jennifer Kawwass, and Akanksha Mehta Julie ShabtoJulie Shabto More articles by this author , Dattatraya PatilDattatraya Patil More articles by this author , Katherine PouloseKatherine Poulose More articles by this author , Mackenzie BennettMackenzie Bennett More articles by this author , Angel XiaoAngel Xiao More articles by this author , Heather HippHeather Hipp More articles by this author , Jennifer KawwassJennifer Kawwass More articles by this author , and Akanksha MehtaAkanksha Mehta More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002535.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The AUA/ASRM male infertility guideline recommends urologic evaluation for all subfertile men. Our study evaluates fertility clinic management of male factor infertility, including referral for urologic care. METHODS: Using 2015-2018 CDC Fertility Clinic Success Rates Reports, we identified 480 operative U.S. fertility clinics. We systematically reviewed clinic websites for content regarding male infertility and performed structured phone interviews of clinic staff to determine clinic-specific practices in managing male infertility. Multivariable logistic regression was used to investigate factors that predicted primary management of male factor infertility by the REI, as compared to referral to an outside urologist for medical and/or surgical management of male infertility. Factors considered included: geographic region, practice size, practice setting, in-state andrology fellowship, state-mandated fertility coverage, annual in vitro fertilization (IVF) cycles, and percentage of IVF cycles for male factor infertility. RESULTS: The analysis included data collected from 477 fertility clinics. Ninety-two clinics had REIs manage male partner’s treatment with medication (n=89) or surgical sperm retrieval (n=30). Clinics that were academically affiliated, had embryo laboratory accreditation and those that referred patients to a urologist were less likely to have REIs manage male infertility (Table 1). Larger practice size, academic affiliation and website discussion of surgical sperm retrieval predicted referral to a urologist within 5 miles (Table 2). CONCLUSIONS: Private practice setting, lack of embryo laboratory accreditation and lack of urologic referral predicted REI management of male infertility. Academic affiliation, larger practice, and website educational content predicted referral to a nearby urologist. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e180 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Julie Shabto More articles by this author Dattatraya Patil More articles by this author Katherine Poulose More articles by this author Mackenzie Bennett More articles by this author Angel Xiao More articles by this author Heather Hipp More articles by this author Jennifer Kawwass More articles by this author Akanksha Mehta More articles by this author Expand All Advertisement PDF DownloadLoading ...

Referral Patterns for Infertile Men: Predictors of Continued Treatment by Reproductive Endocrinologist versus Referral to a Nearby Urologist.

We evaluated fertility clinic management of male factor infertility, including patient education and referral for urological evaluation and care. Using 2015-2018 Centers for Disease Control and Prevention Fertility Clinic Success Rates Reports, 480 operative fertility clinics in the United States were identified. Clinic websites were systematically reviewed for content regarding male infertility. Structured telephone interviews of clinic representatives were performed to determine clinic-specific practices for management of male factor infertility. Multivariable logistic regression models were used to predict how clinic characteristics (geographic region, practice size, practice setting, in-state andrology fellowship, state-mandated fertility coverage, annual in vitro fertilization cycles and percentage of in vitro fertilization cycles for male factor infertility) were associated with reproductive endocrinologist physician management of male infertility and/or referral to a urologist. We interviewed 477 fertility clinics and analyzed available websites (474). The majority of websites (77%) discussed male infertility evaluation, while 46% discussed treatment. Clinics that were academically affiliated, had an accredited embryo laboratory and referred patients to a urologist were less likely to have the reproductive endocrinologist manage male infertility (all p <0.05). Practice affiliation, practice size and website discussion of surgical sperm retrieval were the strongest predictors of nearby urological referral (all p <0.05). Variability in patient-facing education, and fertility clinic setting and size influence fertility clinics' management of male factor infertility.

Access to Care for Infertile Men: Referral Patterns of Fertility Clinics in the United States

ObjectiveTo evaluate fertility clinic management of male factor infertility, including website educational content as well as factors associated with referral for urologic evaluation and care. Materials and MethodsUsing 2015-2018 Centers for Disease Control and Prevention Fertility Clinic Success Rates Reports, 480 operative fertility clinics in the United States were identified. Clinic websites were systematically reviewed for content regarding male infertility. Structured telephone interviews of clinic representatives were performed to determine clinic-specific practices for management of male factor infertility. Multivariable logistic regression models were used to predict how clinic characteristics (geographic region, practice size, practice setting, proximity to urologist, in-state andrology fellowship, state-mandated fertility coverage, annual in vitro fertilization cycles, and percentage of in vitro fertilization cycles for male factor infertility) were associated with patient referral to a urologist for male infertility care. ResultsWe interviewed 477 fertility clinics and analyzed available websites (n = 474). The majority of websites (77%) discussed male infertility evaluation while 46% discussed treatment. Fifty clinics (11%) had an on-site urologist. Clinics with on-site urologists were more likely to be larger practices, academically affiliated, and discuss male infertility treatment on their website (all P ≤ .05). For clinics without an on-site urologist, practice size and presence of an in-state andrology fellowship program were the strongest predictors of urologic referral (P <.02). ConclusionVariability in patient-facing education and infertility practice setting and size influence access to urologic care for couples with male factor infertility.

Management of male factor infertility: position statement from the Italian Society of Andrology and Sexual Medicine (SIAMS) : Endorsing Organization: Italian Society of Embryology, Reproduction, and Research (SIERR).

Infertility affects 15-20% of couples and male factors are present in about half of the cases. For many aspects related to the diagnostic and therapeutic approach of male factor infertility, there is no general consensus, and the clinical approach is not uniform. In the present document by the Italian Society of Andrology and Sexual Medicine (SIAMS), endorsed by the Italian Society of Embryology, Reproduction, and Research (SIERR), we propose evidence-based recommendations for the diagnosis, treatment, and management of male factor infertility to improve patient and couple care. Components of the initial evaluation should include at minimum medical history, physical examination, and semen analysis. Semen microbiological examination, endocrine assessment, and imaging are suggested in most men and recommended when specific risk factors for infertility exist or first-step analyses showed abnormalities. Full examination including genetic tests, testicular cytology/histology, or additional tests on sperm is clinically oriented and based on the results of previous investigations. For treatment purposes, the identification of the specific cause and the pathogenetic mechanism is advisable. At least, distinguishing pre-testicular, testicular, and post-testicular forms is essential. Treatment should be couple-oriented, including lifestyle modifications, etiologic therapies, empirical treatments, and ART on the basis of best evidence and with a gradual approach. These Guidelines are based on two principal aspects: they are couple-oriented and place high value in assessing, preventing, and treating risk factors for infertility. These Guidelines also highlighted that male infertility and in particular testicular function might be a mirror of general health of a man.

Diagnostic and therapeutic workup of male infertility: results from a Delphi consensus panel.

Male factor infertility (MFI) is a rising issue worldwide with significant socioeconomic costs and negative psychological consequences for the couple. Current guidelines provide recommendations for its diagnosis and treatment but several gaps in the management of MFI are encountered in clinical practice due to the lack of available evidence in published literature. Uncertainty in the management of MFI cases leads to a high degree of variability in therapeutic approaches. We planned a Delphi consensus method to provide insights and help bridge the gaps that separate clinical guidelines from real-world practice. The Advisory Board collected 41 statements on debated topics in the management of MFI, each including multiple items designed as a 5-point Likert scale. The questionnaire was sent by e-mail to a panel of Italian experts for a first round of voting; members of the panel were later invited to a second round of voting, preceded by discussion of the "hot topics" identified in the first round. At both rounds of the Delphi consensus 68 experts participated to the voting process. After the first round 25 statements were identified as hot topics, and these underwent the second round of voting. Consensus was reached on many, but not all cases, leaving vagueness on few debated topics where decisions are unsupported by clinical studies or driven by controversial results. In conclusion, indications emerging from this large panel of experts may help guide the management of male factor infertility in clinical practice. Studies are needed to address unanswered questions left by cases for whom no consensus was reached.

Telomere Signaling and Maintenance Pathways in Spermatozoa of Infertile Men Treated With Antioxidants: An in silico Approach Using Bioinformatic Analysis.

Telomere shortening is considered as a marker of cellular senescence and it is regulated by various signaling pathways. Sperm telomere appears to play important role in its longevity and function. Antioxidant intake has been known to prevent the shortening of telomere. In the management of male infertility, antioxidants are commonly used to counterbalance the seminal oxidative stress. It is important to understand how antioxidants treatment may modulate telomere signaling in sperm. In the current study, we have identified 377 sperm proteins regulated by antioxidants based on data mining of published literature. Bioinformatic analysis revealed involvement of 399 upstream regulators and 806 master regulators associated with differentially expressed sperm proteins. Furthermore, upstream regulator analysis indicated activation of kinases (EGFR and MAPK3) and transcription factors (CCNE1, H2AX, MYC, RB1, and TP53). Hence, it is evident that antioxidant supplementation activates molecules associated with telomere function in sperm. The outcome of this in silico study suggests that antioxidant therapy has beneficial effects on certain transcription factors and kinases associated with sperm telomere maintenance and associated signaling pathways that may play an important role in the management of male factor infertility.

PD29-04 ACCESS TO CARE FOR INFERTILE MEN: FACTORS INFLUENCING REFERRAL FROM THE REPRODUCTIVE ENDOCRINOLOGIST TO THE UROLOGIST

You have accessJournal of UrologyInfertility: Epidemiology & Evaluation II (PD29)1 Sep 2021PD29-04 ACCESS TO CARE FOR INFERTILE MEN: FACTORS INFLUENCING REFERRAL FROM THE REPRODUCTIVE ENDOCRINOLOGIST TO THE UROLOGIST Julie Shabto, Katherine Poulose, Mackenzie Bennett, Angel Xiao, Heather Hipp, Jennifer Kawwass, and Akanksha Mehta Julie ShabtoJulie Shabto More articles by this author , Katherine PouloseKatherine Poulose More articles by this author , Mackenzie BennettMackenzie Bennett More articles by this author , Angel XiaoAngel Xiao More articles by this author , Heather HippHeather Hipp More articles by this author , Jennifer KawwassJennifer Kawwass More articles by this author , and Akanksha MehtaAkanksha Mehta More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002030.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Men at risk for subfertility should undergo further evaluation by a urologist, ideally with specialization in male reproduction. We investigated patient access to reproductive urologists by analyzing referral practices of United States (US) assisted reproductive technology (ART) clinics. METHODS: Using 2018 Centers for Disease Control Fertility Clinic Success Rates Reports, we identified 537 ART clinics in the US. We excluded 57 clinics due to permanent closure. We conducted a telephone interview of each clinic using a standard template to determine clinic practices in the management of male factor infertility, including referral to a urologist. Differences in variables were evaluated with respect to clinic location; number of ART clinics located within 50 miles (proxy for population density); practice affiliation; presence of urology fertility fellowship in state; state mandated fertility coverage; number of physicians in practice; total in vitro fertilization (IVF) cycles completed; and percentage of IVF cycles completed for male factor infertility. RESULTS: We interviewed 477 clinics (Table 1). Fifty clinics (10.5%) had an onsite urologist for male fertility treatment, 42 of whom were fellowship-trained in male fertility. An additional 33 clinics (6.9%) had a urologist onsite for surgical procedures, 18 of whom were fellowship-trained in male fertility. Among the 427 clinics without an onsite urologist, 30 did not refer male patients to a urologist. Ninety-two clinics had the reproductive endocrinologists manage male partner’s treatment, including with medication (89, 18.7%) and surgical sperm retrieval (30, 6.3%). Clinics located in urban areas (>7 ART clinics within 50 miles), in states with male fertility fellowship program, larger practices (≥5 physicians or ≥1,000 IVF cycles), those with SART membership, and those with academic affiliation were more likely to refer male partners to a reproductive urologist. CONCLUSIONS: Access to reproductive urologists by referral from reproductive endocrinologists was associated with: urban clinic location, presence of fertility fellowship program in-state, affiliation with an academic center, and higher number of IVF cycles. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e527-e528 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Julie Shabto More articles by this author Katherine Poulose More articles by this author Mackenzie Bennett More articles by this author Angel Xiao More articles by this author Heather Hipp More articles by this author Jennifer Kawwass More articles by this author Akanksha Mehta More articles by this author Expand All Advertisement Loading ...

Semen evaluation: methodological advancements in sperm quality-specific fertility assessment - A review.

Assessment of male fertility is based on the evaluation of sperm. Semen evaluation measures various sperm quality parameters as fertility indicators. However, semen evaluation has limitations, and it requires the advancement and application of strict quality control methods to interpret the results. This article reviews the recent advances in evaluating various sperm-specific quality characteristics and methodologies, with the help of different assays to assess sperm-fertility status. Sperm evaluation methods that include conventional microscopic methods, computer-assisted sperm analyzers (CASA), and flow cytometric analysis, provide precise information related to sperm morphology and function. Moreover, profiling fertility-related biomarkers in sperm or seminal plasma can be helpful in predicting fertility. Identification of different sperm proteins and diagnosis of DNA damage has positively contributed to the existing pool of knowledge about sperm physiology and molecular anomalies associated with different infertility issues in males. Advances in methods and sperm-specific evaluation has subsequently resulted in a better understanding of sperm biology that has improved the diagnosis and clinical management of male factor infertility. Accurate sperm evaluation is of paramount importance in the application of artificial insemination and assisted reproductive technology. However, no single test can precisely determine fertility; the selection of an appropriate test or a set of tests and parameters is required to accurately determine the fertility of specific animal species. Therefore, a need to further calibrate the CASA and advance the gene expression tests is recommended for faster and field-level applications.

Clinical Andrologists: Do We Really Need Them in the Era of ART?

Infertility is on a rise, and so is the availability of assisted reproductive technique (ART) centres. The sole aim of these centers is to help these unfortunate couples achieve pregnancy. Hence, the concentration of the treatment is on the female partner, while the male is relegated to just being a source for sperm. In the era of intracytoplasmic sperm injection, when pregnancy is possible even with a single mature sperm, evaluation and management of male factor infertility (MFI) is often neglected. MFI and poor semen parameters are markers of male health. He could be suffering from erectile or ejaculatory issues or with correctable obstructive azoospermia. A simple timely varicocele correction may help resolve the issue. It is important to understand that MFI is not a disease but may be a symptom of major underlying clinical condition like testicular or brain tumors. Infertility treatment could be the only occasion when a male seeks health-care evaluation. India has a large pool of qualified urologists trained in andrological care. In contrast, gynecologists may not be trained in the management of male patients, hence there is an important place for andrological services to be an integral part of ART centers. Andrologists would offer minimal andrological evaluation and condition-specific treatment. This could avoid or reduce the need for invasive and expensive ART. Andrologists could also choose the most appropriate mode of sperm retrieval. Undoubtedly, availability of andrological services would improve the overall quality of care, reduce the costs and complications, and would also be medicolegally safe.

Sperm Retrieval in the Obstructive, Nonobstructive Azoospermic and Aspermic Patients

Sperm retrieval includes essential procedures in the treatment and management of male factor infertility. Appropriate diagnostic investigation is necessary to correctly identify the etiology of azoospermia among obstructive, nonobstructive (defective spermatogenesis), and aspermia. In this chapter, we discuss the necessary work-up of an individual presenting with azoospermia along with the relevant medical and surgical management to optimize success with surgical sperm retrieval. This review contains 7 figures, 2 tables, and 68 references. Key Words: anejaculation, azoospermia, MESA, microTESE, nonobstructive azoospermia, obstructive azoospermia, PESA, TESE, testicular biopsy

Sildenafil's impact on male infertility: what has changed in 20 years?

Sildenafil has had a dramatic influence on the field of sexual medicine over the past 20 years. Not only have phosphodiesterase-5 (PDE5) inhibitors improved the treatment of erectile dysfunction (ED), they have indirectly contributed to the treatment of male factor infertility. A review of the literature between 1998 - 2018 was performed using PubMed with regards to sildenafil and male infertility. Numerous studies have demonstrated sildenafil's safety and efficacy for treating ED. Sildenafil does not alter semen parameters, and, in fact, may positively affect semen parameters. Sildenafil is helpful for treating ED caused by the psychological stress of infertility treatments. Sildenafil has improved the treatment of ED and may have a benefit on semen parameters. This has aided in the management of male factor infertility, and has contributed to hundreds of thousands of pregnancies that would have been more difficult, as it was before its advent.

Clinico-pathological analysis and re-evaluation of role of testicular biopsy in male factor infertility: A prospective study and review of literature

Context: For many years Testicular biopsy was considered the gold standard for diagnosis in men with unexplained infertility. However recent guidelines have limited the indications for a diagnostic testicular biopsy and there is paradigm shift towards prognostic and therapeutic significance. Aims1. To re-evaluate the role of testicular biopsy in male factor infertility and guide in planning the management protocols.2. To identify potential candidates who would benefit from assisted reproductive techniques.Settings and Design:The present study was conducted at the Department of pathology, Kamineni Institute of Medical Sciences, Narketpally over a period of 3 years, starting from June 2015 to June 2018. This study was a prospective study. Material and Methods:This study involved schematic evaluation of cases with male infertility which included clinical history, physical examination, semen analysis, hormone analysis, radiological evaluation (Scrotal and trans-rectal Ultrasonography) for obstructive etiology and finally testicular biopsy. Histomorphology of Testicular biopsy specimens were analyzed and the results were documented.Statistical analysis used: Simple percentages and Graphical representation of the data.Results: Testicular biopsy done in 71 patients revealed Hypo-spermatogenesis as the most common histological finding. Second most common abnormality reported was Sertoli cell only syndrome/Germ cell aplasia. Majority of cases of Varicocele, inguinal hernia and radiologically documented obstructive cases revealed normal spermatogenesis. And using microsurgical assisted reproduction techniques, sperms were retrieved from all cases of Hypo-spermatogenesis. Sperm retrieval rates were 70% and 31.3% in maturation arrest and Sertoli cell only syndrome respectively.Conclusions: Testicular biopsy in the management of Male factor infertility carries prognostic significance. In patients with obstructive azoospermia, presence of normal spermatogenesis and hypo-spermatogenesis carries good prognosis as surgical repair of the defects recovers fertility in majority of cases. In cases with non-obstructive azoospermia with findings of hypo-spermatogenesis, Sertoli cell only syndrome and maturation arrest, testicular biopsy predicts the chances of sperm retrieval by microsurgical TESE for intracytoplasmic sperm injection (ICSI) and thus carries prognostic and therapeutic significance.

Use of testicular sperm for ICSI in oligozoospermic couples: how far should we go?

In 1992 and subsequently, several reports indicated that ICSI was a successful technique to achieve clinical pregnancy and live birth using spermatozoa with severely impaired characteristics. The initial optimism over the ability of ICSI to overcome significant sperm abnormalities was later tempered by the findings of more recent publications suggesting that some sperm deficits may not be as effectively treated with ICSI. In search for effective treatment for couples with severe male factor, a number of small retrospective and prospective studies have reported high pregnancy and live birth rates using testicular sperm for men with necrozoospermia, cryptozoospermia and oligozoospermia with or without elevated sperm DNA damage. Although the data suggest that there may be some benefit in performing testicular sperm retrieval (TSR)-ICSI in select groups of non-azoospermic infertile men, there are potential risks involved with TSR. Clinicians should balance these risks prior to the recommendation of TSR-ICSI on the result of a semen analysis or sperm DNA test alone. Careful evaluation and management of male factor infertility is important. The use of TSR-ICSI in the absence of specific sperm DNA defects is still experimental.

Novel concepts in male factor infertility: clinical and laboratory perspectives.

In recent years, the management of male factor infertility has undergone important changes with the introduction of novel concepts, advanced testing, and therapeutic interventions. This review highlights some of these changes and discusses their impact to routine clinical practice. First, we discuss the recent changes in the World Health Organization (WHO) laboratory methods and reference values for the examination of human semen. Second, we examine the role of sperm chromatin integrity tests in light of increasing evidence of the detrimental effect of sperm DNA fragmentation on reproductive outcomes. Third, we summarize the main findings of varicocele-related infertility and the outcomes of microsurgical varicocele repair to different case scenarios. Lastly, we critically discuss the current management of men with nonobstructive azoospermia seeking fertility and the new opportunities that emerged to help these men achieve biological fatherhood.

AB28. Management of male factor infertility: present on the assisted reproductive technology

Infertility is a common yet complex problem affecting approximately 10-15% of couples attempting to conceive a baby. Especially, 40-50% of these factors are known as male-related disorders. Unlike female infertility, the cause of which is often easily identified, diagnosing male factors can be difficult. Male infertility is due to low sperm production, abnormal sperm function or blockages of sperm transport.Classical semen analysis in laboratory, which include sperm concentration, motility and morphology gives an approximate evaluation of the functional competence of spermatozoa, but does not always reflect the quality of sperm DNA. The fertilizing potential of sperm depends not only on the functional competence of spermatozoa but also on sperm DNA integrity. The most commonly used techniques to assess sperm DNA integrity are the TUNEL assay, Comet assay, SCSA assay and hallo sperm assay. Recent studies have highlighted the significance of sperm DNA integrity as an important factor which affects functional competence of the sperm. Sperm DNA damage has been closely associated with numerous indicators of reproductive health including fertilization, embryo quality, implantation, spontaneous abortion, congenital malformations.To overcome male infertility, there are variety of surgical and non-surgical urological procedures and medical-pharmacological interventions, and advanced assisted reproductive technologies (ART). Among the surgically retrieved methods, there are TESE, TFNA, PESA and MESA that is used with ICSI.The ART, augmented with ICSI in moderate to serve cases, efficiently treat a variety of male infertility disorders by constituting validated and successfully treatment methods. Also, this technique is employed because the limited numbers and functional capacity of motile sperm that can be obtained. Especially, there are technologies such as IMSI and PICSI that are used to select healthy sperms.

The role of bacterial infections on male infertility in Al-Anbar province of Iraq

Background: Bacterial infections on male infertility has always been in the field of debate due to scarce analysis tools to examine seminal fluid specimens as a result of which these infectious processes leads to deterioration of spermatogenesis, impairment of sperm function and/or obstruction of the seminal tract. Aims & Objective: In the current study we investigated the role of bacterial infections in male factor infertility in Al-Anbar Province, West of Iraq through detection of abnormal sperms and other factor pertains to male infertility. Material and Methods: Seminal fluid from six hundred volunteer males was investigated for infertility by the detection of abnormal sperms using the WLJY-9000 TYPE WEILI Color Sperm Analysis System and the Neubauer counting chamber. Results: From the six hundreds patients investigated for infertility, it was found that 408 (68%) patients had a positive culture for pathogenic bacteria, of different species. The results indicate that 32.0% had sperm density less than twenty million per millilitre. The oligospermic were 23.0%, severe oligospermic 0.17% and Azoospermia 8.83%. Asthenospermia was reported to be 76.33% and Teratospermia 86.16% respectively. Conclusion: Seminal fluid infection increases with decreasing sperm density, motility and morphology. The prevalence of abnormal sperm indices and bacterial infection is high with Klebsiella spp. infection. Hence, treatment measures should be taken properly in the management of male factor infertility.

Management of male-factor infertility

For many years, the management of male-factor infertility has been empirical rather than evidence-based. In current clinical practice, assisted reproductive techniques are the most successful methods of alleviating male-factor infertility. To date, it remains unclear what adjuvant actions can be taken to improve the outcome of assisted reproductive techniques for male-factor infertility. Evidence shows that smoking adversely affects sperm quality to some extent, and the genetic make-up of sperm to a greater extent; however, because of the scarcity and heterogeneity of studies, its effect on in-vitro fertilisation outcome remains largely unknown. Although smoking cessation should be part of the assisted reproductive techniques treatment plan, the benefit of antioxidant treatment in either smokers or non-smokers undergoing assisted reproductive techniques is still under scrutiny. Other lifestyle modifications in subfertile men, such as refraining from moderate alcohol and caffeine consumption, are even more controversial. When embarking on assisted reproductive techniques to alleviate male-factor infertility, intrauterine insemination may be considered as a first-line treatment for couples in whom the female partner has a normal fertility status, and at least 0.8×10(6) progressively motile spermatozoa are recovered after sperm preparation. If no pregnancy is achieved after three to six cycles of intrauterine insemination, in-vitro fertilisation can be proposed. When too few progressively motile spermatozoa are obtained after sperm processing for in-vitro fertilisation, or when surgically retrieved sperm are to be used, intracytoplasmic sperm injection is preferable. Although the outcome of no other assisted reproductive techniques has been scrutinised so much, and no large-scale 'macro-problems' have yet been observed after intracytoplasmic sperm injection, malformation rates are reported to be higher compared with the general population. Therefore, candidates for intracytoplasmic sperm injection should be rigorously screened before embarking on in-vitro fertilisation or intracytoplasmic sperm injection, and thoroughly informed of the limitations of our knowledge on the hereditary aspects of male infertility and the safety aspects of assisted reproductive techniques.