38 CLINICAL FOCUS
38 CLINICAL FOCUS
10 MAY 2024 ausdoc . com . au
Therapy Update
Male factor infertility
Reproductive medicine
Dr Hossam Elzeiny is a reproductive endocrinologist and infertility specialist and is clinical director of reproductive services at the Royal Women ’ s Hospital ; and clinical director of Melbourne IVF , Melbourne , Victoria .
Male reproductive health is an evolving landscape , with cutting-edge assisted reproductive techniques and AI promising a brighter future .
MALE infertility is common , affecting one in 20 Australian men of reproductive age . 1 It manifests as the inability to achieve conception despite regular unprotected intercourse over an extended period . This condition is multifaceted , involving genetic , hormonal , environmental and lifestyle factors that influence sperm production , motility and morphology . 2
This article aims to review male infertility , including recent advances in research and diagnostic and therapeutic approaches . It also aims to shed light on potential future prospects for improved patient care .
Historical perspectives and current landscape
Recent data suggest that sperm counts have declined significantly worldwide in the past 50 years . One systematic review estimated that between 1973 and 2011 a 50-60 % drop in sperm counts occurred among men from Europe , the US , Australia and New Zealand . 3 However , it is unclear whether there has been an associated decline in sperm quality , and the exact causes and implications of dropping sperm counts are as yet unproven .
In a normal semen analysis , a minimum of 16 million sperm per mL is considered within the normal range ( see
Home testing will likely become an alternative to attending andrology laboratories for semen analysis in coming years . table 1 ). 4 Crucially , despite the concerns that arise from statistics about dropping sperm counts , it only takes one viable sperm to successfully fertilise an egg , emphasising the vital importance of sperm quality over quantity .
Severe male factor infertility presents a major challenge . This is characterised by significantly reduced semen parameters , such as a sperm concentration less than 5 million / mL , very poor sperm motility or morphology , or a combination of these parameters . At the extreme end of the spectrum are cases of azoospermia , where no sperm is found in the ejaculate after two consecutive semen analyses are performed .
Intracytoplasmic sperm injection ( ICSI ) has emerged as the primary therapeutic approach to cases of severe sperm abnormalities . ICSI involves the direct injection of a single sperm into an egg , bypassing natural barriers to fertilisation . 5 This technique has revolutionised the treatment of male factor infertility .
Semen analysis and WHO guidelines
Semen analysis remains a crucial tool in assessing male fertility . However , distinguishing between fertile and subfertile men based on semen characteristics alone can be challenging because of notable overlaps in the profile of fertile men with abnormal semen characteristics and subfertile men with normal results . It is important to remember that variations in semen
Sperm counts have declined significantly worldwide in the past 50 years .
results can be attributed to a wide range of factors , such as cultural , environmental and genetic influences , alongside differences in laboratory methodologies . 6
To address this , the WHO has provided a manual detailing standardised laboratory procedures for semen analysis in its various editions ( see table 1 ). In the fifth edition , published in 2010 , the data utilised encompassed values from nearly 1800 men who had achieved natural conception within a year of trying . In this dataset , the lower fifth percentile was established as a definitive threshold to distinguish between
NEED TO KNOW
When considering semen analysis results , remember the importance of sperm quality , rather than just quantity , in successful conception .
A wide range of factors can influence semen analysis results . To address this , the WHO publishes standardised laboratory procedures — which are revised roughly every decade — to improve and widen the applicability of the datasets .
At-home testing will likely become more widely available for assessment of sperm health .
Recent developments in the field of male infertility include refined testicular biopsy techniques , AI for sperm analysis and the use of antioxidants in IVF .
In the future , precision medicine and stem cell therapy may offer improved outcomes for treatment of male factor infertility .
normal and abnormal semen parameters . In the most recent , sixth , edition , published in 2021 , insights gained from the fifth edition were meticulously scrutinised . Moreover , additional data from approximately 3500 men across 12 countries were incorporated for a more comprehensive analysis . 4 It is important to highlight there were minor variations observed in the reference values , particularly in the lower fifth percentile , when compared with the preceding edition ( see table 1 ).
Innovations
Diagnostics The widespread adoption of telehealth for clinical consultations has paved the way for the development of home-based assays for a diverse range of diagnostic tests . This transition is driven by recent technological advancements , and the field of andrology has been an early adopter of at-home testing methodologies .
In recent times , new tests evaluating sperm motility and concentration have been introduced . 7 However , it is important to note that many commercially available kits have not yet undergone rigorous evaluation , including thorough comparisons with standardised laboratory techniques .
Owing to the swift evolution of technology , the foreseeable future is optimistic , with these assays expected to undergo substantial improvements . It is probable that , within the next five years , self-evaluated samples will offer robust and reliable diagnostic insights . Moreover , these tests may present a cost-effective and convenient alternative to attending andrology laboratories for semen analysis .
Beyond individual diagnostics ,