I-1: The Andrological Counselling of the Infertile Men

Background: Infertility is defined as the inability of a sexually active, non-contracepting couple to achieve spontaneous pregnancy in one year. About 15% of couples do not achieve pregnancy within one year and seek medical treatment for infertility. One out of eight couples encounters problems when attempting to conceive a first child and one in six when attempting to conceive a subsequent child. In 50% of involuntarily childless couples, a male-infertility-associated factor is found together with abnormal semen parameters. A fertile partner may compensate for the fertility problem of the man and thus infertility usually becomes manifest if both partners have reduced fertility. Male fertility can be reduced as a result of many diseases such as congenital or acquired urogenital abnormalities, urogenital tract infections, varicocele, endocrine disturbances, genetic abnormalities and immunological factors. In 30-40% of cases, no male-infertilityassociated factor is found (“idiopathic male infertility”). The purpose of this presentation is to underline the importance of the evaluation of the infertile male in order to predict the spontaneous time-to-pregnancy to couples and to offer them the best chance to achieve a pregnancy, spontaneously or with assisted reproduction techniques. Materials and Methods: We decided to review the literature in order to understand what are the newest advances in the evaluation of the infertile male. Results: In the evaluation of infertile men, medical history, physical examination and semen analysis are standard assessments. If the results of semen analysis are normal according to WHO criteria, one test is sufficient. If the results are abnormal in at least two tests, further andrological investigations are indicated in order to diagnose, if possible, one of the conditions that could decrease male fertility. Sperm DNA fragmentation has emerged as a potential cause of fertility impairment and its assessment has been suggested as a useful adjunct to the laboratory evaluation, especially before the application of assisted reproduction technology (ART). Scrotal ultrasound is needed to detect the presence of varicocele and its characteristics (useful for deciding its surgical correction) and/or signs of seminal pathways obstruction; to demonstrate signs of testicular dysgenesis that are more frequent in infertile men and could lead to testicular malignancies. A low seminal volume can be due to distal seminal tract obstruction, where transrectal ultrasound is mandatory. Microbiological evaluation is useful in detecting infections of the male urogenital tract. Hormonal and genetic determinations are mandatory but only in specific situation (azoospermia, endocrinological diseases). Invasive diagnosis is indicated in patients with obstructive or non-obstructive azoospermia. In these cases, the procedures should be combined with extraction of testicular spermatozoa (i.e., TESE) for cryopreservation and subsequent ICSI and/or recanalisation surgery (in OA patients). Testicular biopsy is also important to detect carcinoma in situ, especially in men with non-obstructive azoospermia. Conclusion: The andrological evaluation of the infertile male is extremely important even in the era of assisted reproduction technology because it could lead to detect and treat diseases that could impair fertility and because the presence of malignancies among infertile patients is not so uncommon.