More attention should be paid to the treatment of male infertility with drugs—testosterone: to use it or not?

guidelines are not ‘upgraded’ following panel consensus. This statement further confused me. After discussing and analyzing this information with some andrological experts in China and abroad, I decided to express my perspectives on this problem. The estrogen receptor modulator, tamoxifen, when combined with testosterone undecanoate (TU), was shown to be an effective treatment choice for male infertility patients with idiopathic oligozoospermia.2 Therefore, this approach was recommended as a first‐line option for empirical therapy of male infertility and was also the only option that was recommended by the EAU for drug treatment of male infertility.3,4 It would appear that a large discrepancy exists between the suggestions for the application of testosterone in the treatment of male infertility that were provided by the above‐mentioned guidelines and the evidence from previous studies. Regarding the treatment of idiopathic infertility, the 2012 EAU guidelines on male infertility stated ‘treatment by anti‐oestrogens combined with testosterone may be effective for part of the patients’ and provided related references as evidence.4 However, this description was not present in the corresponding section of the 2013 EAU guidelines on male infertility, and the related references were absent. Considering that evidence‐based facts such as ‘treatment by anti‐oestrogens combined with testosterone may be effective for part of the patients’ had been previously recognized, I could not understand why the group compiling the guidelines made such a significant adjustment. Based on the reasons listed below, I believe the conclusion that ‘testosterone replacement is strictly contraindicated for the treatment of male infertility’ was poorly conceived. T replacement is strictly contraindicated for the treatment of male infertility was the advanced view from the ‘2013 European Association of Urology (EAU) guidelines on male infertility’, and this view brings extensive concern and questions. Although sufficient numbers of well‐performed and controlled clinical trials that provide evidence supporting drug treatment of male infertility are not available at present, the opportunity to prove that these drugs are effective should not be prevented, and rigorous examination of drug therapy should be encouraged and strengthened. Therefore, I believe the above conclusion in the EAU guidelines is poorly conceived. While reading the ‘2013 European Association of Urology (EAU) guidelines on male infertility’, I found some information that was difficult to interpret and acknowledge. According to the guidelines, ‘Testosterone replacement is strictly contraindicated for the treatment of male infertility. Grade of Recommendation is A’.1 I was confused by the presentation of the new EAU guidelines for male infertility. Although the related references were listed in the 2013 EAU guidelines on male infertility, I propose that the objective facts that are described in the references should not serve as evidence for a class A (the highest level) recommendation and that the notes on the recommendation level that are given in the OPINION