Table of contents

Male infertility

What's new

Updated 2023 CUA guidelines for the management of non-obstructive azoospermia.


Key sources

The following summarized guidelines for the evaluation and management of male infertility are prepared by our editorial team based on guidelines from the European Association of Urology (EAU 2024,2023), the American Urological Association (AUA 2023,2014), the Canadian Urological Association (CUA 2023,2017), the European Reference Network on Rare Adult Solid Cancers (EURACAN/ESMO 2022), the American Urological Association (AUA/ASRM 2021), and the ...
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Screening and diagnosis

Indications for evaluation
As per EAU 2023 guidelines:
Evaluate all males seeking medical help for fertility issues, including patients with abnormal semen parameters for urogenital abnormalities.
Evaluate for infertility after 6 months of attempted conception if the female partner is aged > 35 years.
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  • Evaluation of female partner

Diagnostic investigations

History and physical examination: as per EAU 2023 guidelines, elicit a complete medical history and perform a physical examination in the evaluation of male patients with infertility.
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  • SA

  • Hormone testing

  • Diagnostic imaging (scrotal ultrasound)

  • Diagnostic imaging (transrectal ultrasound)

  • Diagnostic imaging (renal and abdominal imaging)

  • Genetic testing (karyotyping)

  • Genetic testing (Y-chromosome microdeletion)

  • Genetic testing (CFTR mutation)

  • Genetic testing (sperm DNA fragmentation)

  • Antisperm antibodies

  • Reactive oxygen species testing

Diagnostic procedures

Testicular biopsy: as per EAU 2023 guidelines, consider obtaining a multidisciplinary team discussion concerning invasive diagnostic modalities (such as ultrasound-guided testicular biopsy with frozen section versus radical orchidectomy versus surveillance) in male patients with infertility with ultrasound-detected indeterminate testicular lesions, especially in the presence of additional risk factors for malignancy.

Medical management

Hormonal therapy, general principles: as per CUA 2023 guidelines, avoid initiating neoadjuvant hormone therapies in patients with testicular failure non-obstructive azoospermia in order to improve IVF-intracytoplasmic sperm injection live birth rates.

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  • Hormonal therapy (FSH analogs)

  • Hormonal therapy (testosterone therapy)

  • Management of ejaculatory dysfunction

  • Management of erectile dysfunction

  • Treatment of active infections

Nonpharmacologic interventions

Lifestyle changes: as per EAU 2023 guidelines, consider advising lifestyle changes, including weight loss, increased physical activity, smoking cessation, and alcohol intake reduction, to improve sperm quality and the chances of conception in male patients with idiopathic oligoasthenoteratozoospermia.

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  • Dietary supplements

Therapeutic procedures

Conservative sperm retrieval: as per ASRM/AUA 2021 guidelines, consider offering induced ejaculation in patients with aspermia, including using sympathomimetics, vibratory stimulations, and electroejaculation depending on the patient's condition and clinician's experience.

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  • Testicular sperm aspiration

  • Assisted reproductive technologies

Surgical interventions

Surgical sperm retrieval
As per CUA 2023 guidelines:
Consider performing cryopreservation of surgically retrieved sperm in most couples with non-obstructive azoospermia and subsequent IVF-intracytoplasmic sperm injection.
Consider offering observation rather than performing varicocelectomy in patients with varicoceles and testicular failure non-obstructive azoospermia considering surgical sperm retrieval and IVF-intracytoplasmic sperm injection.

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  • Microsurgical vasoepididymostomy

  • Transurethral resection of ejaculatory ducts

Specific circumstances

Patients with hypogonadotropic hypogonadism
As per EAU 2023 guidelines:
Initiate combined hCG and FSH (recombinant FSH, highly purified FSH) or pulsed GnRH via pump therapy to stimulate spermatogenesis in patients with hypogonadotropic hypogonadism (secondary hypogonadism), including congenital causes. Induce spermatogenesis by effective medical therapy (hCG, human menopausal gonadotropins, recombinant FSH, highly purified FSH) in patients with hypogonadotropic hypogonadism.
Initiate testosterone therapy in symptomatic patients with primary or secondary hypogonadism not considering parenthood.

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  • Patients with hyperprolactinemia

  • Patients with varicocele

  • Patients with cryptorchidism

  • Patients with testicular microcalcification

  • Patients with testicular cancer

  • Patients with neurological disorders

  • Patients after vasectomy

Patient education

General counseling: as per EAU 2023 guidelines, counsel male patients with infertility or abnormal semen parameters of the associated health risks.

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  • Genetic counseling