Male Infertility Guideline Amendments Released

The American Urological Association and the American Society of Reproductive Medicine have released updated guidelines on male infertility.

Here are some of the highlights:

1. Previously, genetic testing for abnormalities on the Y chromosome were recommended for patients with sperm counts less than 5 million. Since the incidence of finding a Y chromosome abnormality between 1 and 5 million sperm is low, the guidelines now recommend testing ONLY if the sperm count is less than 1 million. This is done through a simple blood test. The Y chromosome is the “male” chromosome and if there is a genetic defect in a certain region, this may explain why the patient is sub fertile. It’s important to note these patients can still father children, but it may require a procedure called a Testis Microdissection or “micro-TESE” to find sperm.
2. In some patients, checking the DNA fragmentation or “abnormalities of the building blocks of the sperm” is recommended. This may occur in cases where in vitro fertilization has failed due to poor fertilization of eggs, poor development of embryos, or in cases of recurrent miscarriages (at least two). In any of these situations, if there is a high amount of DNA fragmentation, the new guidelines recommend using testis sperm as opposed to ejaculated sperm to improve chances of pregnancy. These sperm may be obtained through a minimally invasive office procedure. At Yale Medicine Urology, we have been following these recommendations for years, but now it is formally in the nationally recognized Male Infertility Guidelines.
3. In patients with low ejaculate volume (less than 1.4 cc), the new guidelines recommend doing a pelvic MRI to rule out any signs of blockage. This replaces a more invasive procedure called a transrectal ultrasound. If a blockage is identified, a minor procedure may be helpful to allow sperm to enter the ejaculate and initiate a pregnancy through natural intercourse.

The following are not new guidelines, but it is important to mention again:

Azoospermia

In patients with non-obstructive azoospermia or no sperm in the ejaculate due to a problem with production, a Testis microdissection or “micro-TESE” is recommended. At Yale Medicine Urology, we have years of surgical expertise in this procedure to help achieve pregnancies, despite the complexity of the case.

Associated Health Conditions

Infertile men with specific, identifiable causes of male infertility should be informed of relevant, associated health conditions (Moderate Recommendation; Evidence Level: Grade B). Every patient with a “male factor” should be evaluated by a reproductive urologist to make sure there are no significant health conditions causing the problem. These health conditions include testis cancer, a brain lesion that can affect hormone levels, genetic concerns and problems that result in ejaculation issues. It’s important to remember, many patients will have treatable and reversible causes of male infertility that allow for a natural pregnancy. Yale Urology’s Stanton Honig, MD, wrote the first paper identifying this.

Testosterone's Impact on Fertility

For the male interested in current or future fertility, testosterone should not be prescribed. Men of reproductive age should NOT take testosterone. It will lower the sperm count in many cases to zero or close to zero. At Yale Medicine Urology, we watch for this and offer other medical treatments that can increase testosterone without have a negative effect on sperm.

Early Evaluation

If you are a couple trying to achieve a pregnancy, early evaluation with a sperm test is important. IVF is not your only option. At Yale Medicine Urology we have the expertise to identify a treatable or reversible cause of male infertility.