Guidelines On Male Infertility

Guidelines on
Male
Infertility
A. Jungwirth (chair), T. Diemer, G.R. Dohle, A. Giwercman,
Z. Kopa, C. Krausz, H. Tournaye
© European Association of Urology 2014

TABLE OF CONTENTS PAGE
1. METHODOLOGY 6
1.1 Introduction 6
1.2 Data identification 6
1.3 Level of evidence and grade of recommendation 6
1.4 Publication history 7
1.5 Potential conflict of interest statement 7
1.6 Definition 7
1.7 Epidemiology and aetiology 7
1.8 Prognostic factors 8
1.9 Recommendations on epidemiology and aetiology 8
1.10 References 9
2. INVESTIGATIONS 9
2.1 Semen analysis 9
2.1.1 Frequency of semen analysis 10
2.2 Recommendations for investigations in male infertility 10
2.3 References 10
3. TESTICULAR DEFICIENCY (PRIMARY SPERMATOGENIC FAILURE) 11

3.1 Definition 11
3.2 Aetiology 11
3.3 Medical history and physical examination 11
3.4 Investigations 11
3.4.1 Semen analysis 11
3.4.2 Hormonal determinations 11
3.4.3 Testicular biopsy 12
3.5 Conclusions and recommendations for testicular deficiency 12
3.6 References 12
4. GENETIC DISORDERS IN INFERTILITY 14

4.1 Introduction 14
4.2 Chromosomal abnormalities 14
4.2.1 Sex chromosome abnormalities (Klinefelter’s syndrome and variants [47,XXY;
46,XY/47, XXY mosaicism]) 15
4.2.2 Autosomal abnormalities 15
4.2.3 Sperm chromosomal abnormalities 15
4.3 Genetic defects 15
4.3.1 X-linked genetic disorders and male fertility 15
4.3.2 Kallmann syndrome 16
4.3.3 Mild androgen insensitivity syndrome 16
4.3.4 Other X-disorders 16
4.4 Y-chromosome and male infertility 16
4.4.1 Introduction 16
4.4.2 Clinical implications of Y microdeletions 16
4.4.2.1 Testing for Y microdeletions 17
4.4.2.2 Genetic counselling for AZF deletions 17
4.4.2.3 Y-chromosome: ‘gr/gr’ deletion 17
4.4.2.4 Conclusions and recommendations on clinical implications of
Y microdeletions 18
4.4.3 Autosomal defects with severe phenotypic abnormalities and infertility 18
4.5 Cystic fibrosis mutations and male infertility 18
4.6 Unilateral or bilateral absence/abnormality of the vas and renal anomalies 19
4.7 Unknown genetic disorders 19
4.8 DNA fragmentation in spermatozoa 19
4.9 Genetic counselling and ICSI 19
4.10 Conclusions and recommendations for genetic disorders in male infertility 20
4.11 References 20
2 MALE INFERTILITY - UPDATE MARCH 2013

5. OBSTRUCTIVE AZOOSPERMIA 24
5.1 Definition 24
5.2 Classification 25
5.2.1 Intratesticular obstruction 25
5.2.2 Epididymal obstruction 25
5.2.3 Vas deferens obstruction 25
5.2.4 Ejaculatory duct obstruction 25
5.2.5 Functional obstruction of the distal seminal ducts 25
5.3 Diagnosis 25
5.3.1 Clinical history 25
5.3.2 Clinical examination 26
5.3.3 Semen analysis 26
5.3.4 Hormone levels 26
5.3.5 Ultrasonography 26
5.3.6 Testicular biopsy 26
5.4 Treatment 26
5.4.1 Intratesticular obstruction 26
5.4.2 Epididymal obstruction 27
5.4.3 Proximal vas obstruction 27
5.4.4 Distal vas deferens obstruction 27
5.4.5 Ejaculatory duct obstruction 27
5.5 Conclusions and recommendation for obstructive azoospermia 28
5.6 References 28
6. VARICOCELE 30
6.1 Introduction 30
6.2 Classification 30
6.3 Diagnosis 30
6.4 Basic considerations 30
6.4.1 Varicocele and fertility 30
6.4.2 Varicocelectomy 30
6.5 Treatment 31
6.6 Conclusions and recommendations for varicocele 31
6.7 References 32
7. HYPOGONADISM 33
7.1 Introduction 33
7.2 Hypogonadotrophic hypogonadism: aetiology, diagnosis and therapeutic management 34
7.3 Hypergonadotrophic hypogonadism: aetiology, diagnosis and therapeutic management 35
7.4 Conclusion and recommendation for hypogonadism 35
7.5 References 36
8. CRYPTORCHIDISM 36
8.1 Introduction 36
8.2 Incidence of cryptorchidism 37
8.3 Testicular descent and maldescent 37
8.4 Hormonal control of testicular descent 37
8.5 Pathophysiological effects in maldescended testes 37
8.5.1 Degeneration of germ cells 37
8.5.2 Relationship with fertility 37
8.5.3 Germ cell tumours 37
8.6 Treatment of undescended testes 38
8.6.1 Hormonal treatment 38
8.6.2 Surgical treatment 38
8.7 Conclusions and recommendations for cryptorchidism 38
8.8 References 38
9. IDIOPATHIC MALE INFERTILITY 40

9.1 Introduction 40
9.2 Empirical treatments 40
MALE INFERTILITY - UPDATE MARCH 2013 3

9.3 References 40
10. MALE CONTRACEPTION 40

10.1 Introduction 40
10.2 Vasectomy 41
10.2.1 Surgical techniques 41
10.2.2 Complications 41
10.2.3 Vasectomy failure 41
10.2.4 Counselling 41
10.3 Vasectomy reversal 42
10.3.1 Length of time since vasectomy 42
10.3.2 Tubulovasostomy 42
10.3.3 Microsurgical vasectomy reversal versus epididymal or testicular sperm
retrieval and ICSI 42
10.4 Conclusions and recommendations for male contraception 42
10.5 References 42
11. MALE ACCESSORY GLAND INFECTIONS AND INFERTILITY 44

11.2. Ejaculate analysis 44
11.2.2 Microbiological findings 44
11.2.3 White blood cells 44
11.2.4 Sperm quality 44
11.2.5 Seminal plasma alterations 44
11.2.6 Glandular secretory dysfunction 45
11.2.7 Sperm antibodies 45
11.2.8 Reactive oxygen species 45
11.2.9 Therapy 45
11.3 Epididymitis 45
11.3.2 Ejaculate analysis 45
11.3.3 Treatment 46
11.4 Conclusions and recommendations for male accessory gland infections 46
11.5 References 46
12. GERM CELL MALIGNANCY AND TESTICULAR MICROCALCIFICATION 49

12.1 Germ cell malignancy and male infertility 49
12.2 Testicular germ cell cancer and reproductive function 49
12.3 Testicular microlithiasis 49
12.4 Recommendations for germ cell malignancy and testicular microcalcification 50
12.5 References 50
13. DISORDERS OF EJACULATION 51

13.1 Definition 51
13.2 Classification and aetiology 51
13.2.1 Anejaculation 51
13.2.2 Anorgasmia 51
13.2.3 Delayed ejaculation 51
13.2.4 Retrograde ejaculation 52
13.2.5 Asthenic ejaculation 52
13.2.6 Premature ejaculation 52
13.2.7 Painful ejaculation 52
13.3 Diagnosis 52
13.3.1 Clinical history 52
13.3.2 Physical examination 53
13.3.3 Post-ejaculatory urinalysis 53
13.3.4 Microbiological examination 53
13.3.5 Optional diagnostic work-up 53
13.4 Treatment 53

13.5 Aetiological treatment 53
13.6 Symptomatic treatment 53
13.6.1 Premature ejaculation 53
13.6.2 Retrograde ejaculation 53
13.6.3 Anejaculation 54
13.7 Conclusion and recommendations for disorders of ejaculation 54
13.8 References 55
14. SEMEN CRYOPRESERVATION 56

14.1 Definition 56
14.3 Indications for storage 56
14.4 Precautions and techniques 56
14.4.1 Freezing and thawing process 56
14.4.2 Cryopreservation of small numbers of sperm 57
14.4.3 Testing for infections and preventing cross-contamination 57
14.4.4 Fail-safe precautions to prevent loss of stored materials 57
14.4.5 Orphan samples 57
14.5 Biological aspects 57
14.6 Cryopreservation of testicular stem cells 58
14.7 Conclusions and recommendations for semen cryopreservation 58
14.8 References 58
15. ABBREVIATIONS USED IN THE TEXT 60

1. METHODOLOGY
1.1 Introduction
The European Association of Urology (EAU) Guidelines Panel on Male Infertility has prepared these guidelines
to assist urologists and healthcare professionals from related specialties in the treatment of male infertility.
Urologists are usually the specialists who are initially responsible for assessing the male partner when
male infertility is suspected. However, infertility can be a multifactorial condition requiring multidisciplinary
involvement. The Male Infertility Guidelines Panel consists of urologists, endocrinologists and gynaecologists
with special training in andrology and experience in the diagnosis and treatment of male infertility.
1.2 Data identification

The recommendations provided in the current guidelines are based on a systemic literature search
performed by the panel members. MedLine, Embase, and Cochrane databases were searched to identify
original and review articles. The controlled vocabulary of the MeSH database was used alongside a free-
text protocol, combining “male infertility” with the terms “diagnosis”, “epidemiology”, “investigations”,
“treatment”, “spermatogenic failure”, “genetic abnormalities”, “obstruction”, “hypogonadism”, “varicocele”,
“cryptorchidism”, “testicular cancer”, “male accessory gland infection”, “idiopathic”, “contraception”,
“ejaculatory dysfunction”, and “cryopreservation”.
All articles published between January 2011 (previous update) and October 2012 were considered for
review. The expert panel reviewed these records and selected articles with the highest evidence.
1.3 Level of evidence and grade of recommendation

References in the text have been assessed according to their level of scientific evidence (Table 1), and guideline
recommendations have been graded (Table 2) according to the Oxford Centre for Evidence-based Medicine
Levels of Evidence (1). Grading aims to provide transparency between the underlying evidence and the
recommendation given.
Table 1: Level of evidence*
Level Type of evidence

1a Evidence obtained from meta-analysis of randomised trials.
1b Evidence obtained from at least one randomised trial.
2a Evidence obtained from one well-designed controlled study without randomisation.
2b Evidence obtained from at least one other type of well-designed quasi-experimental study.
3 Evidence obtained from well-designed non-experimental studies, such as comparative studies,
correlation studies and case reports.
4 Evidence obtained from expert committee reports or opinions or clinical experience of respected
authorities.
*Modified from (1).
It should be noted that when recommendations are graded, the link between the level of evidence (LE) and
grade of recommendation (GR) is not directly linear. Availability of randomised controlled trials (RCTs) may not
necessarily translate into a grade A recommendation where there are methodological limitations or disparity in
published results.
Alternatively, absence of high level of evidence does not necessarily preclude a grade A
recommendation, if there is overwhelming clinical experience and consensus. There may be exceptional
situations where corroborating studies cannot be performed, perhaps for ethical or other reasons and in this
case unequivocal recommendations are considered helpful. Whenever this occurs, it is indicated in the text
as “upgraded based on panel consensus”. The quality of the underlying scientific evidence - although a very
important factor - has to be balanced against benefits and burdens, values and preferences, and costs when a
grade is assigned (2-4).
The EAU Guidelines Office does not perform structured cost assessments, nor can they address
local/national preferences in a systematic fashion. But whenever these data are available, the expert panel will
include the information.

Table 2: Grade of recommendation*
Grade Nature of recommendations

A Based on clinical studies of good quality and consistency that addressed the specific
recommendations, including at least one randomised trial.
B Based on well-conducted clinical studies, but without randomised clinical trials.
C Made despite the absence of directly applicable clinical studies of good quality.
*Modified from (1).
1.4 Publication history

The EAU Male Infertility Guidelines were first published in 2001, followed by full-text updates in 2004, 2007,
2010 and 2013. For this 2014 print a scoping search was done covering 2012 and 2013, with a cut off date of
September 2013. Embase, Medline and the Cochrane Central Register of Controlled Trails were searched, with
a limitation to reviews, meta-analysis or meta-analysis of RCTs. After de-duplication 447 unique records were
identified, of which 5 publications were selected for inclusion. A quick reference guide presenting the main
findings of the Male Infertility Guidelines is also available (Pocket Guidelines), as well as a number of scientific
publications in the EAU journal European Urology (5-7). The Male Infertility panel published a separate scientific
paper on Vasectomy in 2012 (7). All texts can be viewed and downloaded for personal use at the society
website: http://www.uroweb.org/guidelines/online-guidelines/.
1.5 Potential conflict of interest statement

The expert panel have submitted potential conflict of interest statements which can be viewed on the EAU
website: http://www.uroweb.org/guidelines/.
1.6 Definition
“Infertility is the inability of a sexually active, non-contracepting couple to achieve spontaneous pregnancy in
one year”, World Health Organization (WHO) (8).
1.7 Epidemiology and aetiology

About 15% of couples do not achieve pregnancy within one year and seek medical treatment for infertility. One
in eight couples encounter problems when attempting to conceive a first child and one in six when attempting
to conceive a subsequent child. Three percent of women remain involuntarily childless, while 6% of parous
women are not able to have as many children as they would wish (9). Infertility affects both men and women.
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 (8). Male fertility can be reduced as a result
of (8):
• congenital or acquired urogenital abnormalities;
• malignancies;
• urogenital tract infections;
• increased scrotal temperature (e.g. as a consequence of varicocele);
• endocrine disturbances;
• genetic abnormalities;
• immunological factors.
In 30-40% of cases, no male-infertility-associated factor is found (idiopathic male infertility). These men
present with no previous history of diseases affecting fertility and have normal findings on physical examination
and endocrine laboratory testing. However, semen analysis reveals a decreased number of spermatozoa
(oligozoospermia), decreased sperm motility (asthenozoospermia), and many abnormal forms of sperm
(teratozoospermia). These sperm abnormalities usually occur together and are called oligo-astheno-
teratozoospermia (OAT) syndrome.
Table 3 summarises the main male-infertility-associated factors. Idiopathic male infertility is assumed
to be caused by several factors, including endocrine disruption as a result of environmental pollution, reactive
oxygen species, or genetic and epigenetic abnormalities.

Table 3: M
ale infertility causes and associated factors and percentage of distribution in 10,469 patients
(10)
Diagnosis Unselected patients Azoospermic patients

(n = 12,945) (n = 1,446)
All 100% 11.2%
Infertility of known (possible) cause 42.6% 42.6%
Maldescended testes 8.4 17.2
Varicocele 14.8 10.9
Sperm autoantibodies 3.9 -
Testicular tumour 1.2 2.8
Others 5.0 1.2
Idiopathic infertility 30.0 13.3
Hypogonadism 10.1 16.4
Klinefelter syndrome (47, XXY) 2.6 13.7
XX male 0.1 0.6
Primary hypogonadism of unknown cause 2.3 0.8
Secondary (hypogonadotropic) hypogonadism 1.6 1.9
Kallmann syndrome 0.3 0.5
Idiopathic hypogonadotrophic hypogonadism 0.4 0.4
Residual after pituitary surgery <0.1 0.3
Others 0.8 0.8
Late-onset hypogonadism 2.2 -
Constitutional delay of puberty 1.4 -
General/systemic disease 2.2 0.5
Cryopreservation due to malignant disease 7.8 12.5
Testicular tumour 5.0 4.3
Lymphoma 1.5 4.6
Leukaemia 0.7 2.2
Sarcoma 0.6 0.9
Disturbance of erection/ejaculation 2.4 -
Obstruction 2.2 10.3
Vasectomy 0.9 5.3
Cystic fibrosis (CBAVD) 0.5 3.1
Others 0.8 1.9
1.8 Prognostic factors

Prognostic factors for male infertility are:
• duration of infertility;
• primary or secondary infertility;
• results of semen analysis and
• age and fertility status of female partner.
The cumulative pregnancy rate is 27% in infertile couples with 2 years of follow-up and oligozoospermia as
the primary cause of infertility (11). Female age is the most important single variable influencing outcome in
assisted reproduction (12). Compared to a woman aged 25 years, the fertility potential of a woman aged 35
years is reduced to 50%, to 25% at 38 years, and less than 5% at over 40 years. In many Western countries,
women postpone their first pregnancy until after their education and starting a career.
1.9 Recommendations on epidemiology and aetiology
Recommendations GR
To categorise infertility, both partners should be investigated simultaneously. C
In the diagnosis and management of male subfertility, the fertility status of the female partner must B
also be considered, because this might determine the final outcome (9).
The urologist/andrologist should examine any man with fertility problems for urogenital abnormalities. C
This applies to all men diagnosed with reduced semen quality. A diagnosis is mandatory to start
appropriate therapy (drugs, surgery, or assisted reproduction).

1.10 References
1. Oxford Centre for Evidence-based Medicine Levels of Evidence (May 2001). Produced by Bob
Phillips, Chris Ball, Dave Sackett, Doug Badenoch, Sharon Straus, Brian Haynes, Martin Dawes since
November 1998. Updated by Jeremy Howick March 2009.
http://www.cebm.net/index.aspx?o=1025 [Access date February 2014]
2. Atkins D, Best D, Briss PA, et al; GRADE Working Group. Grading quality of evidence and strength of
recommendations. BMJ 2004 Jun;328(7454):1490.
http://www.ncbi.nlm.nih.gov/pubmed/15205295
3. Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging consensus on rating quality of evidence
and strength of recommendations. BMJ 2008 Apr;336(7650):924-6.
4. Guyatt GH, Oxman AD, Kunz R, et al; GRADE Working Group. Going from evidence to
recommendations. BMJ 2008 May;336(7652):1049-51.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2376019/?tool=pubmed
5. Dohle GR, Colpi GM, Hargreave TB, et al; EAU Working Group on Male Infertility. EAU guidelines on
male infertility. Eur Urol 2005 Nov;48(5):703-11.
6. Dohle GR, Diemer T, Kopa Z, et al. European Association of Urology Working Group on Male Infertility.
European Association of Urology guidelines on vasectomy. Eur Urol 2012 Jan;61(1):159-63.
7. Jungwirth A, Giwercman A, Tournaye H, et al; European Association of Urology Working Group on
Male Infertility. European Association of Urology guidelines on Male Infertility: the 2012 update. Eur
Urol 2012 Aug;62(2):324-32.
8. World Health Organization. WHO Manual for the Standardized Investigation and Diagnosis of the
Infertile Couple. Cambridge: Cambridge University Press, 2000.
http://www.who.int/reproductivehealth/publications/infertility/9780521431361/en/
9. Greenhall E, Vessey M. The prevalence of subfertility: a review of the current confusion and a report of
two new studies. Fertil Steril 1990;54:978-83.
10. Andrology. In: Nieschlag E, Behre HM and Nieschlag S (eds). Male reproductive health and
dysfunction. 3rd edn. Berlin: Springer Verlag, 2010, Chapter 5, pp. 83-7.
11. Snick HK, Snick TS, Evers JL, et al. The spontaneous pregnancy prognosis in untreated subfertile
couples: the Walcheren primary care study. Hum Reprod 1997 Jul;12(7):1582-8.
12. Rowe T. Fertility and a woman’s age. J Reprod Med 2006 Mar;51(3):157-63.
2. INVESTIGATIONS
2.1 Semen analysis
A medical history and physical examination are standard assessments in all men, including semen analysis.
A comprehensive andrological examination is indicated if semen analysis shows abnormalities compared with
reference values (Table 4). Important treatment decisions are based on the results of semen analysis, therefore,
it is essential that the complete laboratory work-up is standardised. Ejaculate analysis has been standardised
by the WHO and disseminated by publication of the WHO Laboratory Manual for the Examination and
Processing of Human Semen (5th edn.) (1). It is the consensus that modern spermatology must follow these
guidelines.

Table 4: Lower reference limits (5th centiles and their 95% CIs) for semen characteristics
Parameter Lower reference limit (range)

Semen volume (mL) 1.5 (1.4-1.7)
Total sperm number (106/ejaculate) 39 (33-46)
Sperm concentration (106/mL) 15 (12-16)
Total motility (PR + NP) 40 (38-42)
Progressive motility (PR, %) 32 (31-34)
Vitality (live spermatozoa, %) 58 (55-63)
Sperm morphology (normal forms, %) 4 (3.0-4.0)
Other consensus threshold values
pH > 7.2
Peroxidase-positive leukocytes (106/mL) < 1.0
Optional investigations
MAR test (motile spermatozoa with bound particles, %) < 50
Immunobead test (motile spermatozoa with bound beads, %) < 50
Seminal zinc (μmol/ejaculate) > 2.4
Seminal fructose (μmol/ejaculate) > 13
Seminal neutral glucosidase (mU/ejaculate) < 20
CIs = confidence intervals; MAR = mixed antiglobulin reaction NP = non-progressive; PR = progressive.
2.1.1 Frequency of semen analysis

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 investigation is indicated. It is important to differentiate
between the following:
• oligozoospermia: spermatozoa < 15 million/mL;
• asthenozoospermia: < 32% motile spermatozoa;
• teratozoospermia: < 4% normal forms.
Often, all three anomalies occur simultaneously, which is defined as OAT syndrome. As in azoospermia, in
extreme cases of oligozoospermia (spermatozoa < 1 million/mL), there is an increased incidence of obstruction
of the male genital tract and genetic abnormalities.
2.2 Recommendations for investigations in male infertility
Recommendations GR
According to WHO criteria, andrological investigations are indicated if semen analysis is abnormal in A
at least two tests.
Assessment of andrological status must consider the suggestions made by WHO for the standardised C
investigation, diagnosis, and management of the infertile couple; this will result in implementation of
evidence-based medicine in this interdisciplinary field of reproductive medicine (2).
Semen analysis must follow the guidelines of the WHO Laboratory Manual for the Examination and A*
Processing of Human Semen (5th edn.) (1).
*Upgraded following panel consensus
2.3 References
1. World Health Organization. WHO Laboratory Manual for the Examination and Processing of Human
Semen. 5th edn. WHO, 2010.
http://www.who.int/reproductivehealth/publications/infertility/9789241547789/en/index.html
2. World Health Organization. WHO Manual for the Standardised Investigation and Diagnosis of the
Infertile Male. Cambridge: Cambridge University Press, 2000.

3. TESTICULAR DEFICIENCY
(PRIMARY SPERMATOGENIC FAILURE)
3.1 Definition
Testicular deficiency as a consequence of primary spermatogenic failure is caused by conditions other than
hypothalamic-pituitary disease and obstruction of the male genital tract. It is the commonest form of reduced
male fertility. Testicular deficiency may have different aetiologies and present clinically as severe OAT or non-
obstructive azoospermia (NOA) (1).
3.2 Aetiology
The causes of testicular deficiency are summarised in Table 5.
Table 5: Causes of testicular deficiency
Factors Causes
Congenital Anorchia
Testicular dysgenesis/cryptorchidism
Genetic abnormalities (karyotype, Y-chromosome deletions)
Acquired Trauma
Testicular torsion
Post-inflammatory forms, particularly mumps orchitis
Exogenous factors (medications, cytotoxic or anabolic drugs, irradiation, heat)
Systemic diseases (liver cirrhosis, renal failure)
Testicular tumour
Varicocele
Surgery that may compromise vascularisation of the testes and lead to testicular atrophy
Idiopathic Unknown aetiology
Unknown pathogenesis
3.3 Medical history and physical examination

Typical findings from the history and physical examination of a patient with testicular deficiency are:
• cryptorchidism;
• testicular torsion;
• genitourinary infection;
• testicular trauma;
• exposure to environmental toxins;
• gonadotoxic medication including anabolic drugs;
• exposure to radiation or cytotoxic agents ;
• testicular cancer;
• absence of testes;
• abnormal secondary sexual characteristics;
• gynaecomastia;
• abnormal testicular volume and/or consistency;
• varicocele.
3.4 Investigations
Routine investigations include semen analysis and hormonal determinations. Other investigations may be
required depending on the individual situation.
3.4.1 Semen analysis

In NOA, semen analysis shows normal ejaculate volume and azoospermia after centrifugation. A recommended
method is semen centrifugation at 3000 g for 15 min and a thorough microscopic examination by phase
contrast optics at ×200 magnification of the pellet. All samples can be stained and re-examined microscopically
(2).
3.4.2 Hormonal determinations

In men with testicular deficiency, hypergonadotrophic hypogonadism is usually present, with high levels of
follicle-stimulating hormone (FSH) and luteinising hormone (LH), and sometimes low levels of testosterone.

Generally, the levels of FSH correlate with the number of spermatogonia:
• when spermatogonia are absent or markedly diminished, FSH values are usually elevated;
• when the number of spermatogonia is normal, but maturation arrest exists at the spermatocyte or
spermatid level, FSH values are within the normal range.
However, for an individual patient, FSH levels do not accurately predict the spermatogenesis status (3-5).
3.4.3 Testicular biopsy

Testicular biopsy can be part of intracytoplasmic sperm injection (ICSI) treatment in patients with clinical
evidence of NOA. Testicular sperm extraction (TESE) is the technique of choice and shows excellent
repeatability (6-8). Spermatogenesis may be focal, which means that in about 50% of men with NOA,
spermatozoa can be found and used for ICSI. Most authors therefore recommend taking several testicular
samples (9,10). There is a good correlation between the histology found upon diagnostic biopsy and the
likelihood of finding mature sperm cells during testicular sperm retrieval and ICSI (7,11,12). However no
threshold value has been found for FSH, inhibin B, or testicular volume and successful sperm harvesting. When
there are complete AZFa and AZFb microdeletions, the likelihood of sperm retrieval is almost zero.
Microsurgical TESE increases retrieval rates versus conventional TESE, and should be preferred in
severe cases of of non-obstructive azoospermia (13-16). After opening the testis, an enlarged tubule is excised
using micro-scissors or forceps. Then, tubules are minced using mechanical or enzymatic digestion to facilitate
sperm search (16). Positive retrievals are reported even in conditions such as Sertoli cell only syndrome type II
(1). Percutaneous epididymal sperm aspiration (PESA) results in lower retrieval rates than microsurgical TESE
and does not allow histological examination to detect carcinoma in situ (CIS) and testicular malignancies
(17,18). PESA may also result in more tubular and vascular damage than TESE (19).
The results of ICSI are worse when using sperm retrieved from men with NOA compared to sperm from
ejaculated semen and from men with obstructive azoospermia (OA) (20-24). Birth rates are lower in NOA versus
OA (19% vs 28%) (25).
• ICSI results in significantly lower fertilisation and implantation rates (26).
• Miscarriage rates are higher in NOA versus OA (11.5% vs 2.5%) (27).
• Neonatal health in terms of birth parameters, major anomalies and chromosomal aberrations in a large
cohort of children born after use of non-ejaculated sperm are comparable to the outcome of children
born after use of ejaculated sperm (28).
In OA, there were no significant differences in ICSI results between testicular and epididymal sperm (23). Also,
no significant differences have been reported in ICSI results between the use of fresh and frozen-thawed sperm
(23,25,26).
3.5 Conclusions and recommendations for testicular deficiency
Conclusions LE
Impaired spermatogenesis is often associated with elevated FSH concentration. 3
Spermatozoa are found in about 50% of patients with NOA. 2a
Pregnancies and live births are eventually obtained in 30-50% of couples with NOA, when 3
spermatozoa have been found in the testicular biopsy.
Recommendations GR
Men who are candidates for sperm retrieval must receive appropriate genetic counselling. A
Testicular biopsy is the best procedure to define the histological diagnosis and possibility of finding A
sperm. Spermatozoa should be cryopreserved for use in ICSI.
For patients with NOA who have spermatozoa in their testicular biopsy, ICSI with fresh or A
cryopreserved spermatozoa is the only therapeutic option.
Men with NOA can be offered TESE with cryopreservation of the spermatozoa to be used for ICSI (28). A
To increase the chances of positive sperm retrieval in men with NOA, TESE (microsurgical or multiple) A
should be used.
3.6 References
1. World Health Organization. WHO Manual for the Standardized Investigation, Diagnosis and
Management of the Infertile Male. Cambridge: Cambridge University Press, 2000.

2. World Health Organization. WHO Laboratory Manual for the Examination and Processing of Human
Semen. 5th edn. WHO, 2010.
http://www.who.int/reproductivehealth/publications/infertility/9789241547789/en/index.html
3. Hauser R, Temple-Smith PD, Southwick GJ, et al. Fertility in cases of hypergonadotropic azoospermia.
Fertil Steril 1995 Mar;63(3):631-6.
4. Martin-du Pan RC, Bischof P. Increased follicle stimulating hormone in infertile men. Is increased
plasma FSH always due to damaged germinal epithelium? Hum Reprod 1995 Aug;10(8):1940-5.
5. De Kretser DM, Burger HG, Hudson B. The relationship between germinal cells and serum FSH in
males with infertility. J Clin Endocrinol Metab 1974 May;38(5):787-93.
6. Amer M, Haggar SE, Moustafa T, et al. Testicular sperm extraction: impact to testicular histology on
outcome, number of biopsies to be performed and optional time for repetition. Hum Reprod 1999
Dec;14(12):3030-4.
7. Colpi GM, Piediferro G, Nerva F, et al. Sperm retrieval for intra-cytoplasmic sperm injection in
nonobstructive azoospermia. Minerva Urol Nefrol 2005 Jun;57(2):99-107.
8. Vernaeve V, Verheyen G, Goossens A, et al. How successful is repeat testicular sperm extraction in
patients with azoospermia? Hum Reprod 2006 Jun;21(6):1551-4.
9. Gottschalk-Sabag S, Weiss DB, Folb-Zacharow N, et al. Is one testicular specimen sufficient for
quantitative evaluation of spermatogenesis? Fertil Steril 1995 Aug;64(2):399-402.
10. Turek PJ, Cha I, Ljung BM. Systematic fine-needle aspiration of the testis: correlation to biopsy and
results of organ ‘mapping’ for mature sperm in azoospermic men. Urology 1997 May;49(5):743-8.
11. Abdel-Meguid TA. Predictors of sperm recovery and azoospermia relapse in men with nonobstructive
azoospermia after varicocele repair. J Urol 2012 Jan;187(1):222-6.
12. Kim ED, Gilbaugh JH 3rd, Patel VR, et al. Testis biopsies frequently demonstrate sperm in men with
azoospermia and significantly elevated follicle-stimulating hormone levels. J Urol 1997 Jan;157(1):
144-6.
13. Schlegel PN. Testicular sperm extraction: microdissection improves sperm yield with minimal tissue
excision. Hum Reprod 1999 Jan:14(1):131-5.
14. Deruyver Y, Vanderschueren D, Van der Aa F. Outcome of microdissection TESE compared with
conventional TESE in non- obstructive azoospermia: a systematic review. Andrology 2014 Jan;2(1):
20-4.
15. Marconi M, Keudel A, Diemer T, et al. Combined trifocal and microsurgical testicular sperm extraction
is the best technique for testicular sperm retrieval in “low-chance” nonobstructive azoospermia. Eur
Urol 2012 Oct;62(4):713-9.
16. Schwarzer JU, Steinfatt H, Schleyer M, et al. No relationship between biopsy sites near the main
testicular vessels or rete testis and successful sperm retrieval using conventional or microdissection
biopsies in 220 non-obstructive azoospermic men. Asian J Androl 2013 Nov;15(6):795-8.
17. Monzo A, Kondylis F, Lynch D, et al. Outcome of intracytoplasmic sperm injection in azoospermic
patients: stressing the liaison between the urologist and reproductive medicine specialist. Urology
2001 Jul;58(1):69-75.
18. Vernaeve V, Tournaye H, Osmanagaoglu K, et al. Intracytoplasmic sperm injection with esticular
spermatozoa is less successful in men with nonobstructive azoospermia than in men with obstructive
azoospermia. Fertil Steril 2003 Mar;79(3):529-33.
19. Silber S, Munne S. Chromosomal abnormalities in embryos derived from testicular sperm extraction
(tese) in men with non-obstructive azoospermia. In: Proceedings of EAA International Symposium.
Genetics of male infertility: from research to clinic. October 2-4, 2003, Florence, Italy.

20. Schwarzer J, Fiedler K, Hertwig I, et al. Sperm retrieval procedures and intracytoplasmatic
spermatozoa injection with epididymal and testicular sperms. Urol Int 2003;70(2):119-23.
21. Ghanem M, Bakr NI, Elgayaar MA, et al. Comparison of the outcome of intracytoplasmic sperm
injection in obstructive and non-obstructive azoospermia in the first cycle: a report of case series and
meta-analysis. Int J Androl 2005 Feb;28(1):16-21.
22. Borges E Jr, Rossi-Ferragut LM, Pasqualotto FF, et al. Testicular sperm results in elevated miscarriage
rates compared to epididymal sperm in azoospermic patients. Sao Paulo Med J 2002 Jul;120(4):
122-6.
23. Gil Salom M. [Spermatic recovery techniques for intracytoplasmic spermatozoid injection (ICSI) in
male infertility.] Arch Esp Urol 2004 Nov;57(9):1035-46. [Article in Spanish]
24. Ben-Yosef D, Yogev L, Hauser R, et al. Testicular sperm retrieval and cryopreservation prior to initiating
ovarian stimulation as the first line approach in patients with non-obstructive azoospermia. Hum
Reprod 1999 Jul;14(7):1794-801.
25. Vernaeve V, Tournaye H, Osmanagaoglu K, et al. Intracytoplasmic sperm injection with testicular
spermatozoa is less successful in men with nonobstructive azoospermia than in men with obstructive
azoospermia. Fertil Steril. 2003 Mar;79(3):529-33.
26. Gil-Salom M, Romero J, Rubio C, et al. Intracytoplasmic sperm injection with cryopreserved testicular
spermatozoa. Mol Cell Endocrinol 2000 Nov;169(1-2):15-9.
27. Sousa M, Cremades N, Silva J, et al. Predictive value of testicular histology in secretory azoospermic
subgroups and clinical outcomes after microinjection of fresh and frozen-thawed sperm and
spermatids. Hum Reprod 2002 Jul;17(7):1800-10.
28. Hauser R, Yogev L, Amit A, et al. Severe hypospermatogenesis in cases of nonobstructive
azoospermia: should we use fresh or frozen testicular spermatozoa? J Androl 2005 Nov-
Dec;26(6):772-8.
29. Belva F, De Schrijver F, Tournaye H, et al. Neonatal outcome of 724 children born after ICSI using non-
ejaculated sperm. Hum Reprod. 2011 Jul;26(7):1752-8.
4. GENETIC DISORDERS IN INFERTILITY

4.1 Introduction
All urologists working in andrology must have an understanding of genetic abnormalities associated with
infertility, so that they can provide correct advice to couples seeking fertility treatment. Men with very low
sperm counts can be offered a reasonable chance of paternity, using in vitro fertilisation (IVF), ICSI, and sperm
harvesting from the epididymis or the testes in case of azoospermia. However, the spermatozoa of infertile men
show an increased rate of aneuploidy, structural chromosomal abnormalities, and DNA damage, carrying the
risk of passing genetic abnormalities to the next generation. Current routine clinical practice is based on the
screening of genomic DNA from peripheral blood samples, however, screening of chromosomal anomalies in
spermatozoa is also feasible and can be performed in selected cases (1,2).
4.2 Chromosomal abnormalities

Chromosome abnormalities can be numerical (e.g. trisomy) or structural (e.g. inversions or translocations) (3).
In a survey of pooled data from 11 publications, including 9,766 infertile men, the incidence of chromosomal
abnormalities was 5.8% (3). Of these, sex chromosome abnormalities accounted for 4.2% and autosomal
abnormalities for 1.5%. In comparison, the incidence of abnormalities was 0.38% in pooled data from three
series, with a total of 94,465 newborn male infants, of which 131 (0.14%) were sex chromosome abnormalities
and 232 (0.25%) autosomal abnormalities (3). The frequency of chromosomal abnormalities increases as
testicular deficiency becomes more severe. Patients with a spermatozoa count < 5 million/mL already show

a 10-fold higher incidence (4%) of mainly autosomal structural abnormalities compared with the general
population (5). Men with NOA are at highest risk (6).
Based on the frequencies of chromosomal aberrations in patients with different sperm concentration,
karyotype analysis is indicated in men with azoospermia or oligozoospermia (spermatozoa < 10 million/mL)
(5,7). If there is a family history of recurrent spontaneous abortions, malformations or mental retardation,
karyotype analysis should be requested, regardless of the sperm concentration.
4.2.1 ex chromosome abnormalities (Klinefelter’s syndrome and variants [47,XXY; 46,XY/47, XXY
S
mosaicism])
Klinefelter’s syndrome is the most common sex chromosome abnormality (3,8). Adult men with Klinefelter’s
syndrome have small firm testicles, devoid of germ cells. The phenotype varies from a normally virilised man to
one with the stigmata of androgen deficiency, including female hair distribution, scant body hair, and long arms
and legs due to late epiphyseal closure. Leydig cell function is commonly impaired in men with Klinefelter’s
syndrome (9). Testosterone levels may be normal or low, oestradiol levels normal or elevated, and FSH levels
increased. Libido is often normal despite low testosterone levels, but androgen replacement may be needed as
the patient ages.
Germ cell presence and sperm production are variable in men with Klinefelter’s mosaicism,
46,XY/47,XXY. There is one case report of declining spermatogenesis in a man with Klinefelter’s syndrome, with
the recommendation that early sperm retrieval should be considered (10). Based on sperm fluorescence in situ
hybridisation (FISH) studies showing an increased frequency of sex chromosomal abnormalities and increased
incidence of autosomal aneuploidy (disomy for chromosomes 13, 18 and 21), concerns have been raised about
the chromosomal normality of the embryos generated through ICSI (11).
The production of 24,XY sperm has been reported in 0.9% and 7.0% of men with Klinefelter’s
mosaicism (12,13) and in 1.36-25% of men with somatic karyotype 47,XXY (14-17). In patients with
azoospermia, TESE or (micro-TESE) can be proposed as a therapeutic option since spermatozoa can
be recovered in about 30% of cases. To date, 49 healthy children have been born using ICSI without
preimplantation genetic diagnosis (PGD) and the conception of one 47,XXY foetus has been reported (8).
However, a study of ICSI combined with PGD in 113 embryos reported a significant fall in the rate of normal
embryos for couples with Klinefelter’s syndrome with respect to controls (54% vs 77.2%) (15). Due to the
significant increase of sex chromosomal and autosomal abnormalities in the embryos of Klinefelter’s patients,
PGD or amniocentesis analysis should be considered.
Follow-up (possibly every year) of men with Klinefelter’s syndrome is required and androgen
replacement therapy should be started when testosterone level is in the range of hypoandrogenism.
4.2.2 Autosomal abnormalities

Genetic counselling should be offered to all couples seeking fertility treatment (including IVF/ICSI) when the
male partner is known or found to have an autosomal karyotype abnormality.
The most common autosomal karyotype abnormalities are Robertsonian translocations, reciprocal
translocations, paracentric inversions, and marker chromosomes. It is important to look for these structural
chromosomal anomalies because there is an increased associated risk of aneuploidy or unbalanced
chromosomal complements in the foetus. As with Klinefelter’s syndrome, sperm FISH analysis provide a more
accurate risk estimation of affected offspring, however, the diffusion of this genetic test is largely limited by the
availability of laboratories able to perform this analysis.
When IVF/ICSI is carried out for men with translocations, PGD or amniocentesis should be performed.
Embryos with known unbalanced translocation should not be implanted.
4.2.3 Sperm chromosomal abnormalities

Sperm can be examined for their chromosomal constitution using multicolour FISH both in men with normal
karyotype and with anomalies. Aneuploidy in sperm, particularly sex chromosome aneuploidy, is associated
with severe damage to spermatogenesis (3,18-20) and with translocations (21).
Florescence in situ hybridisation analysis of spermatozoa remains a research investigation, although it
has been proposed for clinical use to assess spermatozoa from men with defined andrological conditions (18).
Techniques are needed to separate populations of genetically abnormal sperm from normal sperm or to safely
screen individual spermatozoa before IVF and ICSI.
4.3 Genetic defects

4.3.1 X-linked genetic disorders and male fertility
Each man has only one X-chromosome. An X-linked recessive disorder manifests in males. The defect will be
transmitted to daughters, but not to sons.

4.3.2 Kallmann syndrome
The most common X-linked disorder in infertility practice is Kallmann syndrome due to mutation in the KALIG-1
gene on Xp22.3 (22). Several newly identified autosomal gene mutations can also cause Kallmann syndrome
(23). Patients with Kallmann syndrome have hypogonadotrophic hypogonadism and anosmia, but may also
have other clinical features, including facial asymmetry, cleft palate, colour blindness, deafness, maldescended
testes, and unilateral renal aplasia.
Spermatogenesis can be relatively easily induced by hormonal treatment (24), therefore, genetic
screening prior to therapy is advisable although it is limited by the rarity of specialised genetic laboratories that
can offer this genetic test. Treatment with gonadotropins allows natural conception in most cases, even for
men with a relatively low sperm count. Thus, identification of the involved gene (X-linked, autosomal dominant
or recessive) can help to provide more accurate genetic counselling, that is, risk estimation for transmission to
the offspring.
4.3.3 Mild androgen insensitivity syndrome

The AR gene is located on the long arm of the X-chromosome. Mutations in the AR gene may result in
mild to complete androgen insensitivity (25). The phenotypic features of complete androgen insensitivity
syndrome are female external genitalia and absence of pubic hair (Morris syndrome). In partial androgen
insensitivity syndrome, several different phenotypes are evident, ranging from predominantly female phenotype
through ambiguous genitalia, to predominantly male phenotype with micropenis, perineal hypospadias, and
cryptorchidism. The latter phenotype is also termed Reifenstein syndrome. In the above-mentioned severe
forms of androgen resistance, there is no risk of transmission because affected men cannot generate their own
biological children using the current technologies. Patients with mild androgen insensitivity syndrome have
male infertility as their primary or even sole symptom. Disorders of the androgen receptor causing infertility in
the absence of any genital abnormality are rare, and only a few mutations have been reported in infertile (26-29)
or fertile (30) men.
4.3.4 Other X-disorders

An unexpectedly high number of genes with a testis-specific or enriched expression pattern have
been identified on the X-chromosome, and in particular, premeiotic genes are over-represented on the
X-chromosome compared with autosomal chromosomes (31,32). Nevertheless, to date only a few genes have
been screened in relatively small populations and none of them appear relevant for male infertility (33,34). Two
recent independent studies showed a significantly higher deletion load on the X-chromosome in men with
spermatogenic failure with respect to normozoospermic controls (35,36).
4.4 Y-chromosome and male infertility

4.4.1 Introduction
The first association between azoospermia and microscopically detectable deletions of the long arm of the
Y-chromosome was demonstrated in 1976 (37). With the advent of molecular genetic tools, microdeletions
have been defined in three non-overlapping regions termed AZFa, AZFb and AZFc (38). With knowledge of
the precise structure of the Y-chromosome in Yq11, it subsequently became clear that the AZFb and AZFc
regions overlap and that there is no AZFd region (39). Clinically relevant deletions remove partially, or in
most cases completely, one or more of the AZF regions, and are the most frequent molecular genetic cause
of severe oligozoospermia and azoospermia (40). In each AFZ region, there are several spermatogenesis
candidate genes (41). Deletions occur en bloc (i.e. removing more than one gene), thus, it is not possible to
determine the role of a single AZF gene from the AZF deletion phenotype and it is unclear if they all participate
in spermatogenesis. Gene-specific deletions, which remove a single gene, have been reported only in the AZFa
region and concern the USP9Y gene. These studies have suggested that USP9Y is most likely to be a “fine
tuner” of sperm production, and its specific screening is not advised (42).
4.4.2 Clinical implications of Y microdeletions

The clinical significance of Yq microdeletions can be summarised as follows:
• They are not found in normozoospermic men, proving there is a clear cut cause-and-effect relationship
between Y-deletions and spermatogenic failure (43).
• The highest frequency of Y-deletions is found in azoospermic men (8-12%), followed by
oligozoospermic (3-7%) men.
• Deletions are extremely rare with a sperm concentration > 5 million/mL (~0.7%).
• AZFc deletions are most common (65-70%), followed bY-deletions of the AZFb and AZFb+c or
AZFa+b+c regions (25-30%). AZFa region deletions are rare (5%).
• Complete removal of the AZFa region is associated with severe testicular phenotype (Sertoli cell
only syndrome), while complete removal of the AZFb region is associated with spermatogenic rest.

Complete removal of the AZFc region causes a variable phenotype ranging from azoospermia to
oligozoospermia.
• Classical (complete) AZF deletions do not confer a risk for cryptorchidism or testicular cancer (40).
The specificity and genotype/phenotype correlation reported above means that Y deletion analysis has both a
diagnostic and prognostic value for testicular sperm retrieval (40).
4.4.2.1 Testing for Y microdeletions

Indications for AZF deletion screening are based on sperm count and include azoospermia and severe
oligozoospermia (spermatozoa count < 5 million/mL). Thanks to the European Academy of Andrology (EAA)
guidelines (44) and EAA/EMQN (European Molecular Genetics Quality Network) external quality control
programme (http://www.emqn.org/emqn/), Yq testing has become more homogeneous and reliable in different
routine genetic laboratories. The EAA guidelines provide a set of primers capable of detecting > 95% of
clinically relevant deletions (44). The primers consist of two markers for each region and control markers from
the Yp and X-chromosomes. The initial reports of large variability of deletion frequencies are more likely to
have been caused by technical problems and unreliable markers rather than be an expression of true ethnic
differences.
4.4.2.2 Genetic counselling for AZF deletions

After conception, any Y-deletions are transmitted obligatorily to the male offspring, and genetic counselling
is therefore mandatory. In most cases, father and son have the same microdeletion (45-48), but occasionally
the son has a larger one (49). The extent of spermatogenic failure (still in the range of azoo-/oligozoospermia)
cannot be predicted entirely in the son, due to the different genetic background and the presence or
absence of environmental factors with potential toxicity for reproductive function. A significant proportion of
spermatozoa from men with complete AZFc deletion are nullisomic for sex chromosomes (50,51), indicating
a potential risk for any offspring to develop 45,X0 Turner’s syndrome and other phenotypic anomalies
associated with sex chromosome mosaicism, including ambiguous genitalia. The screening for Y-chromosome
microdeletions in patients bearing a mosaic 46,XY/45,X0 karyotype with sexual ambiguity and/or Turner
stigmata has shown a relatively high incidence of AZFc deletions (33%) (52). There are data to support the
association of Yq microdeletions with an overall Y-chromosomal instability, which leads to the formation of
45,X0 cell lines (53,54). Despite this theoretical risk, babies born from fathers affected by Yq microdeletions
are phenotypically normal (40,44). This could be due to the reduced implantation rate and a likely higher risk of
spontaneous abortion of embryos bearing a 45,X0 karyotype.
When ICSI is used in the presence of a Y microdeletion, long-term follow up of any male children
is needed with respect to their fertility status and cryopreservation of spermatozoa at a young age can be
considered.
4.4.2.3 Y-chromosome: ‘gr/gr’ deletion

A new type of Yq deletion, known as the gr/gr deletion, has been described in the AZFc region (55). This
deletion removes half of the gene content of the AZFc region, affecting the dosage of multicopy genes mapping
inside this region. There was an almost eightfold higher risk of developing oligozoospermia [odds ratio (OR)
= 7.9, 95% confidence interval (CI): 1.8-33.8; P < 0.001] in gr/gr deletion carriers in the largest Caucasian
study population published to date (56). The frequency of gr/gr deletion in oligozoospermic patients is ~4%.
According to four meta-analyses, gr/gr deletion is a significant risk factor for impaired sperm production
(57,58).
However, it is worth noticing that both the frequency of gr/gr deletion and its phenotypic expression
vary between different ethnic groups, depending on the Y-chromosome background. For example, in some Y
haplogroups, the deletion is fixed and appears to have no negative effect on spermatogenesis. Consequently,
the routine screening for gr/gr deletion is a still a debated issue, especially in those laboratories serving diverse
ethnic and geographic populations. A large multicentre study has shown that gr/gr deletion is a potential risk
factor for testicular germ cell tumours (59). However, these data need further confirmation in an ethnically and
geographically matched case-control study setting. For genetic counselling it is worth noticing that partial AZFc
deletions (gr/gr and b2/b3) may predispose to complete AZFc deletion in the next generation (60).

4.4.2.4 Conclusions and recommendations on clinical implications of Y microdeletions
Conclusions LE
gr/gr deletion has been confirmed as a significant risk factor for impaired sperm production, whereas 2b
further evidence of the prognostic significance of gr/gr and development of a testicular germ cell
tumour is needed.
A son who inherits a complete AZF deletion will have abnormal spermatogenesis because these 2a
deletions have not been reported in normozoospermic men.
Recommendations GR
Testing for microdeletions is not necessary in men with OA (with normal FSH) when ICSI is used A
because spermatogenesis should be normal.
Men with severely damaged spermatogenesis (spermatozoa < 5 million/mL) should be advised to A
undergo Yq microdeletion testing for both diagnostic and prognostic purposes. Yq microdeletion also
has important implications for genetic counselling (see below).
If complete AZFa or AZFb microdeletions are detected, micro-TESE is not necessary because it is A
extremely unlikely that any sperm will be found.
If a man with Yq microdeletion and his partner wish to proceed with ICSI, they should be advised that A
microdeletions will be passed to sons, but not to daughters.
4.4.3 Autosomal defects with severe phenotypic abnormalities and infertility

Several inherited disorders are associated with severe or considerable generalised abnormalities and infertility
(Table 6). Patients with these defects will be well known to doctors, often from childhood. A fertility problem
must be managed in the context of the care of the man as a whole and considering the couple’s ability to care
for a child.
Table 6: Less common inherited disorders associated with infertility and other alterations to phenotype
Disorder Phenotype Genetic basis

Prader-Willi syndrome Obesity, mental retardation Deletion of 15q12 on paternally
inherited chromosome
Bardet-Biedle syndrome Obesity, mental retardation, retinitis Autosomal recessive 16q21
pigmentosa, polydactyly
Cerebellar ataxia and Eunuchoidism, disturbances of gait Autosomal recessive
hyogonadotrophic hypogonadism and speech
Noonan’s syndrome Short stature, webbed neck, Autosomal dominant
cardiac and pulmonary
abnormalities, cryptorchidism
Myotonic dystrophy Muscle wasting, cataract, testicular Autosomal dominant 19q13.3
atrophy
Dominant polycystic kidney Renal cysts, obstruction from Autosomal dominant 16p13.3 and
disease epididymal cysts 4q
5-α reductase deficiency Perineal or scrotal hypospadias, Autosomal recessive
vaginal pouch, immature female
phenotype
4.5 Cystic fibrosis mutations and male infertility

Cystic fibrosis (CF) is a fatal autosomal-recessive disorder. It is the most common genetic disease of
Caucasians; 4% are carriers of gene mutations involving the CF transmembrane conductance regulator
(CFTR) gene located on chromosome 7p. It encodes a membrane protein that functions as an ion channel
and influences the formation of the ejaculatory duct, seminal vesicle, vas deferens and distal two-thirds of the
epididymis.
Congenital bilateral absence of the vas deferens (CBAVD) is associated with CFTR gene mutations
and was found in ~2% of men with OA attending a clinic in Edinburgh, UK (61). The incidence in men with
OA varies between different countries. The clinical diagnosis of absent vasa is easy to miss and all men with
azoospermia should be very carefully examined to exclude CBAVD; particularly those with a semen volume
< 1.5 mL and pH < 7.0.Approximately 1,500 mutations are listed on the CFTR database (http://www.genet.
sickkids.on.ca/cftr/). Many studies have been published of men with CBAVD tested for varying numbers of

mutations. The most frequently found mutations are the ΔF508, R117H and W1282X but their frequency and
the presence of other mutations largely depend on the ethnicity of the patient (62,63). Given the functional
relevance of a DNA variant (the 5T allele) in a non-coding region of CFTR (63), it is now considered a mild CFTR
mutation rather than a polymorphism and it should be analysed in each CAVD patient.
As more mutations are defined and tested for, almost all men with CBAVD will probably be found to
have mutations. It is not practical to test for all known mutations, because many have a very low prevalence
in a particular population. Routine testing is usually restricted to the most common mutations in a particular
community.
Given that this is a recessive disease, mutations should be found on both alleles of the CFTR gene;
however, with the routine panel, in most men with CBAVD, mutation is found in only one copy. In these cases
a second step analysis is advised which comprises the direct sequencing of the entire gene. Men with CBAVD
often have mild clinical stigmata of CF (e.g., history of chest infections).
When a man has CBAVD, it is important to test him and his partner for CF mutations. If the female
partner is found to be a carrier of CFTR mutations, the couple must consider very carefully whether to proceed
with ICSI using the husband’s sperm, as the risk of a having a child with CF or CBAVD will be 50%, depending
on the type of mutations carried by the parents. If the female partner is negative for known mutations, the risk
of being a carrier of unknown mutations is ~0.4%.
4.6 Unilateral or bilateral absence/abnormality of the vas and renal anomalies

Unilateral absence of the vas deferens is usually associated with ipsilateral absence of the kidney and
probably has a different genetic causation (64). Consequently, in these subjects CFTR mutation screening is
not indicated. Men with unilateral absence of the vas deferens are usually fertile, and the condition is most
commonly encountered as an incidental finding in the vasectomy clinic. CFTR gene mutation screening is
indicated in men with unilateral absence of the vas deferens with normal kidneys.
An abdominal ultrasound should be undertaken both in unilateral and bilateral absence of vas
deferens. Findings may range from unilateral absence of the vas with ipsilateral absence of the kidney, to
bilateral vessel abnormalities and renal abnormalities, such as pelvic kidney (65).
4.7 Unknown genetic disorders

Considering the high predicted number of genes involved in male gametogenesis, it is likely that
most idiopathic forms of spermatogenic disturbances are caused by mutations or polymorphisms in
spermatogenesis candidate genes (34). However, despite an intensive search for new genetic factors, no
clinically relevant gene mutations or polymorphisms (except those related to the Y-chromosome) have so far
been identified (34, 66, 67, and references therein). The introduction of new analytical approaches is likely to
provide major advances in this field (68,69).
Intracytoplasmic sperm injection is used to enable men with severely damaged spermatogenesis to
father children in situations formerly considered hopeless and where very few spermatozoa can be obtained.
This has led to concern that children may be born with a foetal abnormality, because ICSI may enable defective
sperm to bypass the selective processes of the female genital tract and egg covering. Alternatively, eggs may
be fertilised that would otherwise not be.
Intracytoplasmic sperm injection babies have a higher risk of de novo sex chromosomal aberrations
(about a threefold increase compared with natural conceptions) and paternally inherited structural
abnormalities. Treatment with assisted reproductive technology was associated with increased risks of
cardiovascular, musculoskeletal, urogenital, and gastrointestinal defects and cerebral palsy (70-72).
4.8 DNA fragmentation in spermatozoa

There is increased DNA damage in spermatozoa from men with oligozoospermia. This increase is associated
with reduced chances of natural conception and an increase of early pregnancy loss (73,74). DNA damage may
improve after varicocele ligation (75,76).
4.9 Genetic counselling and ICSI

The best management is to agree treatment with the couple and provide them with full information on the
genetic risks. Initially, the couple should be given full information about the risks to the child to help them
decide whether to proceed with ICSI. Where there is conflict between the wishes of the couple and the
interests of the future child, it may be ethically correct to withhold therapy.
When both partners are known to carry defects (e.g., CFTR mutations), there is up to a 50% chance
of the child developing a clinical condition. Many clinicians and infertility clinic personnel may consider it
is unethical to proceed because their duty of care to the future child and the interests of society outweigh
the wishes of the individual couple. If there is a conflict that cannot be resolved by agreement, the interests
of a future child probably take precedence over the interests of a couple. The couple also need to give

consideration to preimplantation diagnosis and replacement only of normal embryos.
4.10 Conclusions and recommendations for genetic disorders in male infertility
Conclusions LE
New insights into the genetic basis of infertility and the advent of ICSI require a good understanding of 3
genetics by clinicians and the general public.
Diagnostic advances will allow us to identify the genetic basis of more disorders and diagnose known 2a
disorders at a lower cost. For some of these disorders, gene therapy might be practical in the future.
Recommendations GR
Standard karyotype analysis should be offered to all men with damaged spermatogenesis B
(spermatozoa < 10 million/mL) who are seeking fertility treatment by IVF.
Genetic counselling is mandatory in couples with a genetic abnormality found in clinical or genetic A
investigation and in patients who carry a (potential) inheritable disease.
All men with Klinefelter’s syndrome need long-term endocrine follow-up and may require androgen A
replacement therapy.
For men with severely damaged spermatogenesis (spermatozoa < 5 million/mL), testing for Yq A
microdeletions is strongly advised.
When a man has structural abnormalities of the vas deferens (unilateral or bilateral absence), he and A
his partner should be tested for CF gene mutations.
4.11 References
1. Griffin DK, Finch KA. The genetic and cytogenetic basis of male infertility. Human Fertil Mar 2005
Mar;8(1);19-26.
2. Carrell DT. The clinical implementation of sperm chromosome aneuploidy testing: pitfalls and
promises. J Androl 2008 Mar-Apr;29(2):124-33.
3. Johnson MD. Genetic risks of intracytoplasmic sperm injection in the treatment of male infertility:
recommendations for genetic counseling and screening. Fertil Steril 1998 Sep;70(3):397-411.
4. Clementini E, Palka C, Iezzi I, et al. Prevalence of chromosomal abnormalities in 2078 infertile couples
referred for assisted reproduction techniques. Hum Reprod 2005 Feb;20(2):437-42.
5. Vincent MC, Daudin M, De MP, et al. Cytogenetic investigations of infertile men with low sperm
counts: a 25-year experience. J Androl 2002 Jan-Feb;23(1):18-22.
6. Foresta C, Ferlin A, Gianaroli L, et al. Guidelines for the appropriate use of genetic tests in infertile
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5. OBSTRUCTIVE AZOOSPERMIA
5.1 Definition
Obstructive azoospermia OA is the absence of spermatozoa and spermatogenetic cells in semen and post-
ejaculate urine due to bilateral obstruction of the seminal ducts. OA is less common than NOA and occurs in
15-20% of men with azoospermia. Common causes of OA are summarised in Table 7.
Men with OA present with normal FSH, normal size testes, and epididymal enlargement. Sometimes,
the vas deferens is absent due to congenital factors or previous inguinal or scrotal surgery. Obstruction in
primary infertile men is often present at the epididymal level; other sites of obstruction are the ejaculatory
ducts and the vas deferens. In 25% of men with a suspected obstruction, no spermatozoa are found in the
epididymis during scrotal exploration, indicating an intratesticular obstruction or non-obstructive cause.
Table 7: Classification of OA, on the basis of ductal obstruction due to congenital and acquired causes
Conditions Congenital Acquired

Epididymal obstruction Idiopathic epididymal obstruction Post-infective (epididymitis)
Epididymis detached from the Post-surgical (epididymal cysts)
testis (e.g., in some maldescended
testes)
Vas deferens obstruction Congenital absence of vas Post-vasectomy
deferens Post-surgical (hernia, scrotal
surgery)
Ejaculatory duct obstruction Prostatic cysts (Mullerian cysts) Post-surgical (bladder neck
surgery)
Post-infective

5.2 Classification
5.2.1 Intratesticular obstruction
Intratesticular obstruction occurs in 15% of men with OA (1). Congenital forms (dysjunction between rete testis
and efferent ductules) are less common than acquired forms, that is, post-inflammatory or post-traumatic
obstructions. Acquired forms are often associated with an obstruction of the epididymis and vas deferens.
5.2.2 Epididymal obstruction

Epididymal obstruction or disjunction is the most common cause of OA, affecting 30-67% of azoospermic men
with serum FSH level less than twice the upper limit of normal (1-4).
Congenital epididymal obstruction usually manifests as CBAVD, which is associated with at least one
mutation of the CF gene in 82% of cases (5). This form is often accompanied by absence of the distal part of
the epididymis and seminal vesicle agenesis (see Chapter 4). Other congenital forms of obstruction are rare, for
example, disjunction between efferent ductules and the corpus epididymis; agenesis/atresia of a short part of
the epididymis.
Congenital forms of epididymal obstruction include chronic sinopulmonary infections (Young’s
syndrome) (6), in which obstruction results from a mechanical blockage due to debris within the proximal
epididymal lumen.
Acquired forms secondary to acute (e.g., gonococcal) and subclinical (e.g., chlamydial) epididymitis
are most common (7,8) (see Chapter 11). Acute or chronic traumas can result in epididymal damage (9).
Azoospermia caused by surgery may occur after epididymal surgery, for example, cyst removal.
Epididymal obstruction secondary to long-lasting distal obstruction must be considered when repairing seminal
ducts (10).
5.2.3 Vas deferens obstruction

Vas deferens obstruction is the most common cause of acquired obstruction following vasectomy for
sterilisation, with possible subsequent germ cell impairment and fibrosis (11,12). Approximately 2-6% of these
men request vasectomy reversal. Of those undergoing vasovasostomy, 5-10% have epididymal blockage as
a result of tubule rupture, making epididymovasostomy mandatory (see Chapter 10). Vasal obstruction may
also occur after herniotomy (13). Polypropylene mesh herniorrhaphy appears to be able to induce a fibroblastic
response that can entrap or obliterate the vas deferens (14).
The most common congenital vasal obstruction is CBAVD, often accompanied by CF. Unilateral
agenesis or a partial defect is associated with contralateral seminal duct anomalies or renal agenesis in 80%
and 26% of cases, respectively (15) (see Chapter 4). Distal vas deferens obstruction includes CBAVD and
accidental injury to the vas deferens during hernia surgery (16).
5.2.4 Ejaculatory duct obstruction

Ejaculatory duct obstruction is found in 1-3% of cases of OA (1) and is classified as either cystic or post-
inflammatory.
Cystic obstructions are usually congenital (i.e., Mullerian duct cyst or urogenital sinus/ejaculatory duct
cysts) and are medially located in the prostate between the ejaculatory ducts. In urogenital sinus abnormalities,
one or both ejaculatory ducts empty into the cyst (17), while in Mullerian duct anomalies, the ejaculatory ducts
are laterally displaced and compressed by the cyst (18).
Paramedian or lateral intraprostatic cysts are Wolffian in origin and rare in clinical practice (19).
Post-inflammatory obstructions of the ejaculatory duct are usually secondary to acute, non-acute, or chronic
urethroprostatitis (20).
Congenital or acquired complete obstructions of the ejaculatory ducts are commonly associated
with low semen volume, decreased or absent seminal fructose, and acid pH. The seminal vesicles are usually
dilated (anterior-posterior diameter > 15 mm) (20,21).
5.2.5 Functional obstruction of the distal seminal ducts

Functional obstruction of the distal seminal ducts might be attributed to local neuropathy (22). This abnormality
is often associated with urodynamic dysfunction because of the vasographic patterns of ampullo-vesicular
atony or ejaculatory duct hypertony. Functional obstruction of the distal seminal ducts has been reported in
juvenile diabetes and polycystic kidney disease (23); however, no relevant pathology has been found in most
cases. Results of semen analysis vary between azoospermia, cryptozoospermia and severe OAT syndrome.
5.3 Diagnosis
5.3.1 Clinical history
Clinical history taking should follow the suggestions for investigation of infertile men (see Chapter 2).

Patients should be asked about:
• haematospermia;
• post-ejaculatory pain;
• previous or present urethritis or prostatitis;
• obstructive or irritative urinary symptoms;
• previous scrotal enlargement or pain or surgery;
• previous inguinal herniorrhaphy or trauma;
• chronic sinopulmonary infection.
5.3.2 Clinical examination

Clinical examination should follow suggestions for investigation of infertile men. The following findings indicate
OA:
• at least one testis with a volume > 15 mL, although a smaller volume may be found in some patients
with OA and concomitant partial testicular failure;
• enlarged and hardened epididymis;
• nodules in the epididymis or vas deferens;
• absence or partial atresia of the vas;
• signs of urethritis;
• prostatic abnormalities.
5.3.3 Semen analysis

At least two examinations must be carried out at an interval of 2-3 months, according to the WHO (see Chapter
2). Azoospermia means the inability to detect spermatozoa after centrifugation at ×400 magnification. Careful
repeat observation of several smears after semen liquefaction is needed. If no spermatozoa are found in a wet
preparation, then aliquots or the whole semen sample should be centrifuged at 3,000 g for 15 min. The pellet
must be examined for spermatozoa.
Ejaculatory duct obstruction or CBAVD is suggested by a semen volume < 1.5 mL, acid pH, and low
fructose level. When semen volume is low, a search must be made for spermatozoa in urine after ejaculation,
because their presence confirms an ejaculatory disorder. Absence of spermatozoa and immature germ cells in
semen smears suggest complete proximal or distal seminal duct obstruction.
5.3.4 Hormone levels

Serum FSH levels may be normal, but do not exclude a testicular cause of azoospermia (e.g., spermatogenic
arrest). FSH level is normal in 40% of men with primary spermatogenic failure. Inhibin B seems to have a higher
predictive value for normal spermatogenesis (4).
5.3.5 Ultrasonography
Scrotal ultrasound is helpful in finding signs of obstruction (e.g., dilatation of rete testis, enlarged epididymis
with cystic lesions, or absent vas deferens) and may demonstrate signs of testicular dysgenesis (e.g., non-
homogeneous testicular architecture and microcalcifications) and associated CIS of the testis. For patients with
a low seminal volume and in whom distal obstruction is suspected, transrectal ultrasound (TRUS) is essential. If
possible, TRUS should be performed at high resolution and with high-frequency (> 7 MHz) biplane transducers.
Seminal vesicle enlargement (anterior-posterior diameter 15 mm) (21) and round, anechoic areas in the seminal
vesicle (24) are TRUS anomalies more often associated with ejaculatory duct obstruction; especially when
semen volume is < 1.5 mL. Mullerian duct or urogenital sinus/ejaculatory duct cysts (20) and ejaculatory duct
calcifications (25) are other known anomalies in OA. TRUS may also be used to aspirate seminal vesicle fluid
(26).
Invasive diagnosis, including testicular biopsy, scrotal exploration, and distal seminal duct evaluation,
are indicated in patients with OA in whom an acquired obstruction of the seminal ducts is suspected.
Explorative and recanalisation surgery should be carried out simultaneously.
5.3.6 Testicular biopsy

In selected cases, testicular biopsy may be indicated to exclude spermatogenic failure. Testicular biopsy
should be combined with extraction of testicular spermatozoa (i.e., TESE) for cryopreservation and subsequent
ICSI, when surgical recanalisation cannot be carried out or has failed. A scoring system for testicular biopsies is
provided (e.g., Johnsen Score) (27).
5.4 Treatment
5.4.1 Intratesticular obstruction
Intratesticularly, seminal duct recanalisation is impossible. TESE allows sperm retrieval in nearly all OA patients

and is therefore recommended. The spermatozoa retrieved may be used immediately for ICSI or should be
cryopreserved.
5.4.2 Epididymal obstruction

Microsurgical epididymal sperm aspiration (MESA) (28) is indicated in men with CBAVD. TESE and PESA are
also viable options for retrieving epididymal sperm from men with OA (29). Retrieved spermatozoa are used for
ICSI. Usually, one MESA procedure provides sufficient material for several ICSI cycles (30) and it produces high
pregnancy and fertilisation rates (31). In patients with azoospermia due to acquired epididymal obstruction,
end-to-end or end-to-side microsurgical epididymovasostomy is recommended, with the preferred technique
being microsurgical intussusception epididymovasostomy (32).
Reconstruction may be carried out unilaterally or bilaterally; patency and pregnancy rates are usually
higher with bilateral reconstruction. Before microsurgery, it is important to check for full patency downstream
of the epididymis. Anatomical recanalisation following surgery may require 3-18 months. Before microsurgery
(and in all cases where recanalisation is impossible), epididymal spermatozoa should be aspirated and
cryopreserved for use in ICSI in case of surgical failure (30).
Patency rates range between 60% and 87% (33-35) and cumulative pregnancy rates between 10%
and 43%. Recanalisation success rates may be adversely affected by preoperative and intra-operative findings
(e.g., concomitant abnormal testicular histology, absence of sperm in the spermatic fluid on sectioning the
small epididymal tubules, or extensive fibrosis of the epididymis).
5.4.3 Proximal vas obstruction

Proximal vas obstruction after vasectomy requires microsurgical vasectomy reversal (see Chapter 10).
Vasovasostomy is also required in rare cases of proximal vasal obstructions (e.g., iatrogenic, post-traumatic,
or post-inflammatory). The absence of spermatozoa in the intraoperative vas deferens fluid suggests the
presence of a secondary epididymal obstruction; especially if the seminal fluid of the proximal vas has a thick
“toothpaste” appearance. Microsurgical tubulovasostomy is then indicated.
5.4.4 Distal vas deferens obstruction

It is usually impossible to correct large bilateral vas deferens defects, resulting from involuntary excision of the
vasa deferentia during hernia surgery in early childhood or previous orchidopexy (16). In these cases, proximal
vas deferens sperm aspiration (37) or TESE/MESA can be used for cryopreservation for future ICSI. In large
unilateral vas deferens defects associated with contralateral testicular atrophy, the vas deferens of the atrophic
testis can be used for a crossover vasovasostomy or tubulovasostomy.
5.4.5 Ejaculatory duct obstruction

The treatment of ejaculatory duct obstruction depends on its aetiology. Transurethral resection of the
ejaculatory ducts (TURED) (20,38) can be used in large post-inflammatory obstruction and when one or both
ejaculatory ducts empty into an intraprostatic midline cyst. Resection may remove part of the verumontanum.
In cases of obstruction due to a midline intraprostatic cyst, incision or unroofing of the cyst is required
(20). Intraoperative TRUS makes this procedure safer. If distal seminal tract evaluation is carried out at the time
of the procedure, installation of methylene blue dye into the vas deferens can help to document opening of the
ducts. The limited success rate of surgical treatment of ejaculatory duct obstruction in terms of spontaneous
pregnancies should be weighed against sperm aspiration and ICSI.
Complications following TURED include retrograde ejaculation due to bladder neck injury and urine
reflux into the ejaculatory ducts, seminal vesicles, and vasa (causing poor sperm motility, semen acid pH, and
epididymitis). The alternatives to TURED are MESA, TESE, proximal vas deferens sperm aspiration, seminal
vesicle ultrasonically guided aspiration, and direct cyst aspiration.
In cases of functional obstruction of the distal seminal ducts, TURED often fails to improve sperm
output. Spermatozoa can then be retrieved by antegrade seminal tract washout (38). Spermatozoa retrieved
by any of the aforementioned surgical techniques should always be cryopreserved for assisted reproductive
procedures.

5.5 Conclusions and recommendation for obstructive azoospermia
Conclusions LE
Obstructive lesions of the seminal tract should be suspected in azoospermic or severely 3
oligozoospermic patients with normal-sized testes and normal endocrine parameters.
Recommendation GR
In azoospermia caused by epididymal obstruction, standard procedures include vasovasostomy and B
tubulovastomy.
Sperm retrieval techniques, such as MESA, TESE, and PESA, can be used additionally. These B
methods should be used only when cryostorage of the material obtained is available
In azoospermia caused by epididymal obstruction, scrotal exploration with microsurgical epididymal B
sperm aspiration and cryopreservation of spermatozoa should be performed. Microsurgical
reconstruction should be performed, if applicable. Results of reconstructive microsurgery depend on
the cause and location of the obstruction, and the surgeon’s expertise.
5.6 References
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Berlin: Springer-Verlag, 1997, pp. 319-36.
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1983 Dec;55(6):785-91.
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4. Pierik FH, Vreeburg JT, Stijnen T, et al. Serum inhibin B as a marker of spermatogenesis. J Clin
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5. Oates RD, Amos JA. The genetic basis of congenital bilateral absence of the vas deferens and cystic
fibrosis. J Androl 1994 Jan-Feb;15(1):1-8.
6. Handelsman DJ, Conway AJ, Boylan LM, et al. Young’s syndrome: obstructive azoospermia and
chronic sinopulmonary infections. New Engl J Med 1984 Jan;310(1):3-9.
7. Silber SJ, Grotjan HE. Microscopic vasectomy reversal 30 years later: a summary of 4010 cases by the
same surgeon. J Androl 2004 Nov-Dec;25(6):845-59.
8. Schoysman R. Vaso-epididymostomy - a survey of techniques and results with considerations of delay
of appearance of spermatozoa after surgery. Acta Eur Fertil 1990 Sep-Oct;21(5):239-45.
9. Matthews GJ, Schlegel PN, Goldstein M. Patency following microsurgical vasoepididymostomy and
vasovasostomy: temporal considerations. J Urol 1995 Dec; 154(6):2070-3.
10. Jarvi K, Zini A, Buckspan MB, et al. Adverse effects on vasoepididymostomy outcomes for men with
concomitant abnormalities in the prostate and seminal vesicle. J Urol 1998 Oct;160(4):1410-2.
11. Raleigh D, O’Donnell L, Southwick GJ, et al. Stereological analysis of the human testis after
vasectomy indicates impairment of spermatogenic efficiency with increasing obstructive interval. Fertil
Steril 2004 Jun;81(6):1595-603.
12. McVicar CM, O’Neill DA, McClure N, et al. Effects of vasectomy on spermatogenesis and fertility
outcome after testicular sperm extraction combined with ICSI. Hum Reprod 2005 Oct;20(10):
2795-800.
13. Sheynkin YR, Hendin BN, Schlegel PN, et al. Microsurgical repair of iatrogenic injury to the vas
deferens. J Urol 1998 Jan;159(1):139-41.
14. Shin D, Lipshultz LI, Goldstein M, et al. Herniorrhaphy with polypropylene mesh causing inguinal
vassal obstruction: a preventable cause of obstructive azoospermia. Ann Surg 2005 Apr;241(4):553-8.

15. Schlegel PN, Shin D, Goldstein M. Urogenital anomalies in men with congenital absence of the vas
deferens. J Urol 1996 May;155(5):1644-8.
16. Borovikov A. Treatment of large vasal defects. In: Goldstein M (ed). Surgery of Male Infertility.
Philadelphia: WB Saunders, 1995, pp. 77-95.
17. Elder JS, Mostwin JL. Cyst of the ejaculatory duct/urogenital sinus. J Urol 1984 Oct;132(4):768-71.
18. Schuhrke TD, Kaplan GW. Prostatic utricle cysts (müllerian duct cysts). J Urol 1978 Jun;119(6):765-7.
19. Surya BV, Washecka R, Glasser J, et al. Cysts of the seminal vesicles: diagnosis and management. Br
J Urol 1988 Nov;62(5):491-3. [No abstract available]
20. Schroeder-Printzen I, Ludwig M, Kohn F, et al. Surgical therapy in infertile men with ejaculatory
duct obstruction: technique and outcome of a standardized surgical approach. Hum Reprod 2000
Jun;15(6):1364-8.
21. Kuligowska E, Baker CE, Oates RD. Male infertility: role of transrectal US in diagnosis and
management. Radiology 1992 Nov;185(2):353-60.
22. Colpi GM, Casella F, Zanollo A, et al. Functional voiding disturbances of the ampullo-vesicular seminal
tract: a cause of male infertility. Acta Eur Fertil 1987 May-Jun;18(3):165-79.
23. Hendry WF, Rickards D, Pryor JP, et al. Seminal megavesicles with adult polycystic kidney disease.
Hum Reprod 1998 Jun;13(6):1567-9.
24. Colpi GM, Negri L, Nappi RE, et al. Is transrectal ultrasonography a reliable diagnostic approach in
ejaculatory duct sub-obstruction? Hum Reprod 1997 Oct;12(10):2186-91.
25. Meacham RB, Hellerstein DK, Lipshultz LI. Evaluation and treatment of ejaculatory duct obstruction in
the infertile male. Fertil Steril 1993 Feb;59(2):393-7.
26. Jarow JP. Seminal vesicle aspiration of fertile men. J Urol 1996 Sep;156(3):1005-7.
27. Johnsen SG. Testicular biopsy score count-a method for registration of spermatogenesis in human
testes: normal values and results in 335 hypogonadal males. Hormones 1970;1(1):2-25. [No abstract
available]
28. Silber SJ, Balmaceda J, Borrero C, et al. Pregnancy with sperm aspiration from the proximal head
of the epididymis: a new treatment for congenital absence of the vas deferens. Fertil Steril 1988
Sep;50(3):525-8. [No abstract available]
29. Esteves SC, Miyaoka R, Agarwal A. Sperm retrieval techniques for assisted reproduction. Int Braz J
Urol 2011 Sep-Oct;37(5): 570-83
30. Schroeder-Printzen I, Zumbe G, Bispink L, et al. Microsurgical epididymal sperm aspiration: aspirate
analysis and straws available after cryopreservation in patients with non-reconstructable obstructive
azoospermia. MESA/TESE Group Giessen. Hum Reprod 2000 Dec;15(12):2531-5.
31. Van Peperstraten A, Proctor ML, Johnson NP, et al. Techniques for surgical retrieval of sperm prior to
ICSI for azoospermia. Cochrane Database Syst Rev 2006 Jul 19;3:CD002807.
http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD002807/frame.html
32. Chan PT, Brandell RA, Goldstein M. Prospective analysis of outcomes after microsurgical
intussusception vasoepididymostomy. BJU Int 2005 Sep;96(4):598-601.
33. Matthews GJ, Schlegel PN, Goldstein M. Patency following microsurgical vasoepididymostomy and
vasovasostomy: temporal consideration. J Urol 1995 Dec;154(6):2070-3.
34. Mangoli V, Dandekar S, Desai S, et al. The outcome of ART in males with impaired spermatogenesis.
Hum Reprod Sci 2008 Jul;1(2):73-6.

35. Kim ED, Winkel E, Orejuela F, et al. Pathological epididymal obstruction unrelated to vasectomy:
results with microsurgical reconstruction. J Urol 1998 Dec;160(6 Pt 1):2078-80.
36. Kolettis PN, Thomas AJ Jr. Vasoepididymostomy for vasectomy reversal: a critical assessment in the
era of intracytoplasmic sperm injection. J Urol 1997 Aug;158(2):467-70.
37. Ruiz-Romero J, Sarquella J, Pomerol JM. A new device for microsurgical sperm aspiration. Andrologia
1994 Mar-Apr;26(2):119-20. [No abstract available]
38. Fisch H, Lambert SM, Goluboff ET. Management of ejaculatory duct obstruction: etiology, diagnosis,
and treatment. World J Urol 2006 Dec;24(6):604-10.
6. VARICOCELE
6.1 Introduction
Varicocele is a common abnormality (see Chapter 2) with the following andrological implications:
• failure of ipsilateral testicular growth and development;
• symptoms of pain and discomfort;
• male infertility.
6.2 Classification
The following classification of varicocele (1,2) is useful in clinical practice:
• subclinical: not palpable or visible at rest or during Valsava manoeuvre, but can be shown by special
tests (Doppler ultrasound studies) (3);
• grade 1: palpable during Valsava manoeuvre, but not otherwise;
• grade 2: palpable at rest, but not visible;
• grade 3: visible and palpable at rest.
6.3 Diagnosis
The diagnosis of varicocele is made by clinical examination and should be confirmed by colour Doppler
analysis (2). In centres where treatment is carried out by antegrade or retrograde sclerotherapy or embolisation,
diagnosis is additionally confirmed by X-ray.
6.4 Basic considerations

6.4.1 Varicocele and fertility
Varicocele is a physical abnormality present in 11.7% of adult men and in 25.4% of men with abnormal semen
analysis (4). The exact association between reduced male fertility and varicocele is unknown, but a recent
meta-analysis showed that semen improvement is usually observed after surgical correction (5). Current
information fits with the hypothesis that in some men the presence of varicocele is associated with progressive
testicular damage from adolescence onwards due to germ cell dysfunction, testicular hypoxia, retrograde
flow of metabolites, increased temperature and/or decreased secretion of gonadotropins and androgens, and
consequent reduction in fertility. However, the pathophysiology of varicocele still remains unsolved. Varicocele
is associated with increased sperm DNA damage, and this sperm pathology may be secondary to varicocele-
mediated oxidative stress. Varicocelectomy can reverse this sperm DNA damage, as shown in several studies
(6).
6.4.2 Varicocelectomy
Varicocele repair has been a subject of debate for several decades: controversy exists as to whether varicocele
repair results in more spontaneous pregnancies as compared to observation. The 2009 Cochrane Database
review concluded that there is no evidence that treatment of varicocele improves a couples’ chance of
conception (7). This meta-analysis was criticised for including several heterogeneous studies, men with normal
semen analysis, and men with a subclinical varicocele (8). In three RCTs repair of a subclinical varicocele was
found to be ineffective (9-11). Also, studies of men with a varicocele and normal semen analysis have shown no
clear benefit of treatment over observation (12,13).
The duration of infertility also seems to be important. In a recent study it was shown that couples with
infertility of > 2 years duration had a significantly higher pregnancy rate after varicocelectomy compared to

couples with an uncorrected varicocele. In couples with a shorter duration of infertility, such a difference was
not observed (14).
In a recent meta-analysis of four RCTs of varicocelectomy in men with a clinical varicocele,
oligospermia and otherwise unexplained infertility, there was a trend in favour of surgical correction (15).
The combined OR was 2.23 (95% CI, 0.86-5.78; P = 0.091), indicating that varicocelectomy was moderately
superior to observation, but the effect was not statistically significant.
There is a need for a large, properly conducted RCT of varicocele treatment in men with abnormal
semen from couples with otherwise unexplained subfertility (16). Although treatment of varicocele in infertile
men may be effective, in adolescents there is a significant risk of overtreatment: most adolescents with a
varicocele will have no problem achieving pregnancy later in life (17).
6.5 Treatment
Several treatments are available for varicocele (Table 9). The type of intervention chosen depends mainly on
the experience of the therapist. Although laparoscopic varicocelectomy is feasible, it must be justified in terms
of cost-effectiveness. Current evidence indicates that microsurgical varicocelectomy is the most effective and
least morbid method among the varicocelectomy techniques (17).
Table 9: Recurrence and complication rates associated with treatments for varicocele
Treatment Ref. Recurrence/ Complication rates

persistence %
Antegrade sclerotherapy 18 9 Complication rate 0.3-2.2%: testicular atrophy, scrotal
haematoma, epididymitis, left-flank erythema
Retrograde 19 9.8 Adverse reaction to contrast medium, flank pain,
sclerotherapy persistent thrombophlebitis, vascular perforation
Retrograde embolisation 20,21 3.8-10 Pain due to thrombophlebitis, bleeding haematoma,
infection, venous perforation, hydrocele, radiological
complication (e.g., reaction to contrast media),
misplacement or migration of coils, retroperitoneal
haemorrhage, fibrosis, ureteric obstruction
Open operation
Scrotal operation - Testicular atrophy, arterial damage with risk of
devascularisation and testicular gangrene, scrotal
haematoma, postoperative hydrocele
Inguinal approach 22 13.3 Possibility of missing out a branch of testicular vein
High ligation 23 29 5-10% incidence of hydrocele (< 1%)
Microsurgical inguinal or 24,25 0.8-4 Postoperative hydrocele arterial injury, scrotal
subinguinal haematoma
Laparoscopy 26,27 3-7 Injury to testicular artery and lymph vessels; intestinal,
vascular and nerve damage; pulmonary embolism;
peritonitis; bleeding; postoperative pain in right
shoulder (due to diaphragmatic stretching during
pneumoperitoneum); pneumoscrotum: wound infection
6.6 Conclusions and recommendations for varicocele
Conclusions LE
Current information supports the hypothesis that the presence of varicocele in some men is 2a
associated with progressive testicular damage from adolescence onwards and a consequent
reduction in fertility.
Although the treatment of varicocele in adolescents may be effective, there is a significant risk of 3
overtreatment.
Varicocele repair may be effective in men with subnormal semen analysis, a clinical varicocele and 1a
otherwise unexplained infertility.

Recommendations GR
Varicocele treatment is recommended for adolescents with progressive failure of testicular B
development documented by serial clinical examination.
No evidence indicates benefit from varicocele treatment in infertile men who have normal semen A
analysis or in men with subclinical varicocele. In this situation, varicocele treatment cannot be
recommended (15-17).
Varicocele repair should be considered in case of a clinical varicocele, oligospermia, infertility duration A
of > 2 years and otherwise unexplained infertility in the couple.
6.7 References
1. Hudson RW, Perez Marrero RA, Crawford VA, et al. Hormonal parameters in incidental varicoceles and
those causing infertility. Fertil Steril 1986 May;45(5):692-700.
3. Dhabuwala CB, Hamid S, Moghissi KS. Clinical versus subclinical varicocele: improvement in fertility
after varicocelectomy. Fertil Steril 1992 Apr;57(4):854-7.
4. No authors listed. The influence of varicocele on parameters of fertility in a large group of men
presenting to infertility clinics. World Health Organisation. Fertil Steril 1992; 57(6):1289-93.
5. Argawal A, Deepinder F, Cocuzza M, et al. Efficacy of varicocelectomy in improving semen
parqameters: new meta-analytical approach. Urology 2007 Sep;70(3):532-8.
6. Zini A, Dohle G. Are varicoceles associated with increased deoxyribonucleic acid fragmentation? Fertil
Steril 2011 Dec;96(6):1283-7.
7. Evers JH, Collins J, Clarke J. Surgery or embolisation for varicoceles in subfertile men. Cochrane
Database Syst Rev 2009 Jan 21;(1):CD000479.
8. Ficarra V, Cerruto MA, Iguori G, et al. Treatment of varicocele in subfertile men: The Cochrane review -
a contrary opinion. Eur Urol 2006 Feb;49(2):258-63.
9. Grasso M, Lania C, Castelli M, et al. Low-grade left varicocoele in patients over 30 years old: the
effect of spermatic vein ligation on fertility. BJU Int 2000 Feb;85(3):305-7.
10. Yamamoto M, Hibi H, Hirata Y, et al. Effect of varicocoelectomy on sperm parameters and pregnancy
rates in patients with subclinical varicocele: a randomized prospective controlled study. J Urol 1996
May;155(5):1636-8.
11. Unal D, Yeni E, Verit A, et al. Clomiphene citrate versus varicocoelectomy in treatment of subclinical
varicocoele: a prospective randomized study. Int J Urol 2001 May;8(5):227-30.
12. Nilsson S, Edvinsson A, Nilsson B. Improvement of semen and pregnancy rate after ligation and
division of the internal spermatic vein: fact or fiction? Br J Urol 1979 Dec;51(6):591-6.
13. Breznik R, Vlaisavljevic V, Borko E. Treatment of varicocoele and male fertility. Arch Androl 1993 May-
June;30(3):157-60.
14. Giagulli VA, Carbone MD. Varicocele correction for infertility: which patients to treat? Int J Androl 2011
Jun;34(3):236-41.
15. Baazeem A, Belzile E, Ciampi A, et al. Varicocele and male factor infertility treatment: a new
metaanalysis and review of the role of varicocele repair. Eur Urol 2011 Oct;60(4):796-808.
16. Abdel-Meguid, TA, Al-Sayyad A, Tayib A, et al. Does varicocele repair improve male infertility? An
evidence-based perspective from a randomized, controlled trial. Eur Urol 2011 Mar;59(3):455-61.

17. Ding H, Tian J, Du W, et al. Open non-microsurgical, laparoscopic or open microsurgical
varicocelectomy for male infertility: a meta-analysis of randomized controlled trials. BJU Int 2012
Nov;110(10):1536-42.
18. Tauber R, Johnsen N. Antegrade scrotal sclerotherapy for the treatment of varicocele: technique and
late results. J Urol 1994 Feb;151(2):386-90.
19. Sigmund G, Bahren W, Gall H, et al. Idiopathic varicoceles: feasibility of percutaneous sclerotherapy.
Radiology 1987 Jul;164(1):161-8.
20. Seyferth W, Jecht E, Zeitler E. Percutaneous sclerotherapy of varicocele. Radiology 1981
May;139(2):335-40.
21. Lenk S, Fahlenkamp D, Gliech V, et al. Comparison of different methods of treating varicocele.
J Androl 1994 Nov-Dec;15(Suppl):34S-37S.
22. Ivanissevich O. Left varicocele due to reflux; experience with 4,470 operative cases in forty-two years.
J Int Coll Surg 1960 Dec;34:742-755. [No abstract available]
23. Palomo A. Radical cure of varicocele by a new technique; preliminary report. J Urol 1949 Mar;61(3):
604-7. [No abstract available]
24. Goldstein M, Gilbert BR, Dicker AP, et al. Microsurgical inguinal varicocelectomy with delivery of the
testis: an artery and lymphatic sparing technique. J Urol 1992 Dec;148(6):1808-11.
25. Jungwirth A, Gogus C, Hauser G, et al. Clinical outcome of microsurgical subinguinal varicocelectomy
in infertile men. Andrologia 2001 Mar;33(2):71-4.
26. Miersch WD, Schoeneich G, Winter P, et al. Laparoscopic varicocelectomy: indication, technique and
surgical results. Br J Urol 1995 Nov;76(5):636-8.
27. Tan SM, Ng FC, Ravintharan T, et al. Laparoscopic varicocelectomy: technique and results. Br J Urol
1995 Apr;75(4):523-8.
7. HYPOGONADISM
7.1 Introduction
Hypogonadism is characterised by impaired testicular function, which may affect spermatogenesis and/
or testosterone synthesis. The symptoms of hypogonadism depend on the degree of androgen deficiency
and if the condition develops before or after pubertal development of the secondary sex characteristics. The
symptoms and signs of hypoandrogenism presenting before and after completion of puberty are provided in
Table 10.
Table 10: Symptoms and signs of hypogonadism appearing before and after completion of puberty*
Affected organ/function Before completed puberty After completed puberty

Larynx No voice mutation No voice mutation
Hair Horizontal pubic hairline Diminished secondary body hair
Straight frontal hairline
Diminished beard growth
Skin Absent sebum production Decreased sebum production
Lack of acne Lack of acne
Pallor Pallor
Skin wrinkling Skin wrinkling
Bones Eunuchoid tall stature Osteoporosis
Osteoporosis

Bone marrow Mild anaemia Mild anaemia
Muscles Underdeveloped Hypotrophy
Prostate Underdeveloped Hypotrophy
Penis Infantile No change of size
Testes Possibly maldescended testes Decrease of testicular volume
Small volume
Spermatogenesis Not initiated Involuted
Libido and potency Not developed Loss
*Modified from Nieschlag et al. (1).
The aetiological and pathogenetic mechanisms of male hypogonadism can be divided into three main
categories:
1. Primary (hypergonadotrophic) hypogonadism due to testicular failure.
2. Secondary (hypogonadotrophic) hypogonadism caused by insufficient gonadotropin-releasing
hormone (GnRH) and/or gonadotropin (FSH, LH) secretion.
3. Androgen insensitivity (end-organ resistance).
The most common conditions within these three categories are given in Table 11 (see also Chapter 4).
Table 11: Disorders associated with male hypogonadism*
Primary (hypergonadotrophic) hypogonadism (testicular failure)*

Anorchia
Maldescended testes
Klinefelter’s syndrome
Y-chromosome microdeletions
Numerical and structural chromosomal anomalies
Trauma, testicular torsion, orchitis
Iatrogenic (surgery, medications, irradiation, or cytostatic drugs)
Exogenous factors (toxins, heat, or occupational hazards)
Systemic diseases (liver cirrhosis, or renal failure)
Testicular tumour
Varicocele
Idiopathic (e.g., late-onset hypogonadism)
Secondary (hypogonadotrophic) hypogonadism (secondary testicular failure)
Congenital
• Idiopathic hypogonadotrophic hypogonadism
• Normosmic
• Hiposmic/anosmic (Kallmann syndrome)
Acquired (tumours in the following regions)
• Diencephalon (craniopharyngioma or meningioma)
• Hypothalamus or pituitary
Empty sella
Granulomatous illnesses
Fractures of the skull base
Ischaemic or haemorrhagic lesions in hypothalamic area
Hyperprolactinaemia
Drugs/anabolic steroids, radiotherapy
Target organ resistance to androgens
Testicular feminisation
Reifenstein syndrome
*Modified from Nieschlag et al. (1).
7.2 Hypogonadotrophic hypogonadism: aetiology, diagnosis and therapeutic management

Idiopathic hypogonadotrophic hypogonadism (IHH) is characterised by low levels of gonadotropins and sex
steroid in the absence of anatomical or functional abnormalities of the hypothalamic-pituitary-gonadal axis (2).
IHH may be an isolated condition or may be associated with anosmia/hyposmia (Kallmann syndrome). Genetic
factors causing a deficit of gonadotropins may act at the hypothalamic or pituitary level.
Mutations in candidate genes (X-linked or autosomal) can be found in ~30% of congenital cases (2)

and should be screened prior to assisted reproduction (3).
Acquired hypogonadotrophic hypogonadism can be caused by some drugs, hormones, anabolic
steroids, or tumours. A suspected tumour requires imaging [computed tomography (CT) or magnetic resonance
imaging (MRI)] of the sella region and a complete endocrine work-up.
Failure of hormonal regulation can easily be determined (4). Endocrine deficiency leads to a lack of
spermatogenesis and testosterone secretion as a result of decreased secretion of FSH and LH. After having
excluded secondary forms (drugs, hormones, or tumours), the therapy of choice depends on whether the goal
is to achieve normal androgen levels or fertility.
Normal androgen levels and subsequent development of secondary sex characteristics (in cases of
onset of hypogonadism before puberty) and a eugonadal state can be achieved by androgen replacement
alone. However, stimulation of sperm production requires treatment with human chorionic gonadotropin (hCG)
combined with recombinant FSH or urinary FSH or human menopausal gonadotropins (HMGs). In the rare
case of “fertile eunuchs”, who have sufficient production of FSH but not LH, treatment with hCG alone may be
sufficient to stimulate sperm production and achieve normal testosterone levels (5).
If hypogonadotrophic hypogonadism is hypothalamic in origin, an alternative to hCG treatment is
pulsatile GnRH (6). In patients who have developed hypogonadism before puberty and have not been treated
with gonadotropins or GnRH, 1-2 years of therapy may be needed to achieve sperm production.
Once pregnancy has been established, patients can return to testosterone substitution.
7.3 Hypergonadotrophic hypogonadism: aetiology, diagnosis and therapeutic

management
Many conditions in men are associated with hypergonadotrophic hypogonadism (Table 11, see also Chapter
4). Most conditions listed in Table 11 only affect the reproductive function of the testes so that only FSH level
is elevated. However, it has been reported that men with infertility are at higher risk for developing impaired
Leydig cell function (7), while men with Klinefelter’s syndrome often show high LH values and develop
hypoandrogenism with ageing (8). A decrease in testosterone blood concentrations after extensive testicular
biopsy in the context of TESE/ICSI has been observed, raising questions about the need for long-term
endocrine follow-up of these patients (9).
Hypogonadism affecting both reproductive and endocrine functions of the testes occurs after
treatment with GnRH analogues or surgical castration for prostatic cancer (10).
Laboratory diagnosis of hypergonadotrophic hypogonadism is based on a high level of FSH,
decreased serum testosterone, and increased LH levels (3). Testosterone levels should be evaluated in view
of the serum concentration of sex hormone binding globulin (SHBG). Based on levels of total testosterone,
albumin and SHBG, free and bioavailable testosterone can be calculated (http://www.issam.ch/freetesto.htm).
Due to diurnal variation, blood samples for testosterone assessment should be taken before 10.00
h. The existing guidelines for androgen replacement are based on presence of symptoms of hypogonadism
and total testosterone levels. There is general agreement that a total testosterone level > 12 nmol/L (350 ng/
dL) does not require substitution. Similarly, based on the data of younger men, there is consensus that patients
with serum total testosterone levels < 8 nmol/L (230 ng/dL) will usually benefit from testosterone treatment. For
the group with serum total testosterone level between 8 and 12 nmol/L (in repeated samples), a 3-6-month trial
period with testosterone supplementation can be considered. Generally, androgen replacement should not be
given to men not presenting with symptoms of hypogonadism.
Testosterone suppresses pituitary production of LH and FSH, therefore, replacement therapy should
not be given for infertility.
In obese men, decision-making may be helped by measuring total testosterone with SHBG to
calculate free testosterone or measurement of free testosterone by equilibrium dialysis (11). Injectable, oral and
transdermal testosterone preparations are available for clinical use (3). The best preparation to use is one that
maintains serum testosterone levels within the physiological concentration (11-13). See also EAU Guidelines on
Hypogonadism (14).
7.4 Conclusion and recommendation for hypogonadism
Conclusion LE
It is generally agreed that patients with primary or secondary hypogonadism associated with 1b
hypoandrogenism should receive testosterone substitution therapy.
Recommendation GR
Effective drug therapy is available to achieve fertility in men with hypogonadotrophic hypogonadism A*
(4).
Testosterone replacement is strictly contraindicated for the treatment of male infertility (13). A*

7.5 References
1. Andrology. In: Nieschlag E, Behre HM (eds). Male Reproductive Health and Dysfunction. Berlin:
Springer Verlag, 1997, Chapter 5, pp. 83-7.
2. Bianco SD, Kaiser UB. The genetic and molecular basis of idiopathic hypogonadotropic
hypogonadism. Nat Rev Endocrinol 2009 Oct;5(10):569-76.
3. Krausz C. Genetic aspects of male infertility. European Urological Review 2009;3(2):93-6.
4. World Health Organization. WHO manual for the Standardized Investigation, Diagnosis and
5. Burris AS, Rodbard HW, Winters SJ, et al. Gonadotropin therapy in men with isolated
hypogonadotropic hypogonadism: the response to human chorionic gonadotropin is predicted by
initial testicular size. J Clin Endocrinol Metab 1988 Jun;66(6):1144-51.
6. Schopohl J, Mehltretter G, von Zumbusch R, et al. Comparison of gonadotropin-releasing hormone
and gonadotropin therapy in male patients with idiopathic hypothalamic hypogonadism. Fertil Steril
1991 Dec;56(6):1143-50.
7. Andersson AM, Jorgensen N, Frydelund-Larsen L, et al. Impaired Leydig cell function in infertile men:
a study of 357 idiopathic infertile men and 318 proven fertile controls. J Clin Endocrinol Metab 2004
Jul;89(7):3161-7.
8. Lanfranco F, Kamischke A, Zitzmann M, et al. Klinefelter’s syndrome. Lancet 2004 Jul;364(9430):
273-83.
http://www.ncbi.nlm.nih.gov/pubmed/15262106.
9. Manning M, Junemann KP, Alken P. Decrease in testosterone blood concentrations after
testicular sperm extraction for intracytoplasmic sperm injection in azoospermic men. Lancet 1998
Jul;352(9121):37. [No abstract available]
10. Daniell HW. Osteoporosis after orchiectomy for prostate cancer. J Urol 1997 Feb;157(2):439-44.
11. Finkelstein JS. Androgens and bone metabolism. In: Nieschlag E, Behre HM (eds). Testosterone:
Action, Deficiency, Substitution. 2nd edn. Berlin: Springer-Verlag, 1998, pp. 187-207.
12. Nieschlag E, Swerdloff R, Behre HM, et al. Investigation, treatment and monitoring of late-onset
hypogonadism in males: ISA, ISSAM, and EAU recommendations. Int J Androl 2005 Jun;28(3):125-7.
13. Nieschlag E, Wang C, Handelsman DJ, et al. Guidelines for the Use of Androgens in Men. Geneva:
WHO, 1992.
http://apps.who.int/iris/handle/10665/60776
14. Dohle G, Arver S, Bettocchi C, et al. Members of the EAU Guidelines Office. Guidelines on Male
Hypogonadism. In: EAU Guidelines, edn. presented on the 27th EAU Annual Congress, Paris 2012.
ISBN: 978-90-79754-83-0.
8. CRYPTORCHIDISM
8.1 Introduction
Cryptorchidism is the most common congenital abnormality of the male genitalia and is found in 2-5% of
newborn boys, depending on gestational age (cryptorchidism occurs more often in premature boys) and age
after birth. At the age of 3 months, the incidence of cryptorchidism falls spontaneously to 1-2%. Approximately
20% of undescended testes are non-palpable and may be located within the abdominal cavity.
The aetiology of cryptorchidism is multifactorial, involving disrupted endocrine regulation and several
gene defects. The normal descent of the testes requires a normal hypothalamic-pituitary-gonadal axis.
Endocrine disruption in early pregnancy can potentially affect gonadal development and normal descent of the
testes; however, most boys with maldescended testes show no endocrine abnormalities after birth. It has been
postulated that cryptorchidism may be a part of the so-called testicular dysgenesis syndrome (TDS), which is a
developmental disorder of the gonads caused by environmental and/or genetic influences early in pregnancy.
Besides cryptorchidism, TDS includes hypospadias, reduced fertility, increased risk of malignancy, and Leydig
cell dysfunction (1).

8.2 Incidence of cryptorchidism
The Caucasian population has a threefold higher incidence of cryptorchidism compared to African-Americans.
Even between Caucasians, there are significant differences in the risk of cryptorchidism, for example, it is
significantly more common among Danish than Finnish newborns (2). Premature babies have a much higher
incidence of cryptorchidism than full-term babies. In a British study, the incidence of cryptorchidism was 2.7%
in > 3,000 boys weighing > 2.5 kg and 21% in premature boys weighing < 2.5 kg. At the age of 3 months,
spontaneous descent occurred in most boys, and the incidence of cryptorchidism fell to 0.9% and 1.7%, in the
> 2.5 kg and < 2.5 kg group, respectively (3).
8.3 Testicular descent and maldescent

The process of testicular descent has two distinct phases: transabdominal and inguinal. During transabdominal
descent, development of the gubernaculum and genitoinguinal ligament plays an important role. The anti-
Mullerian hormone regulates transabdominal descent of the testes. Induction of the gubernaculum depends
on a functional Insl3 gene in mice (4). This gene is expressed in Leydig cells and its targeted deletion causes
bilateral cryptorchidism with free-moving testes and genital ducts (5). Androgens play an important role in both
phases of testicular descent, whereas other gene families, for example, the homeobox (HOX) and GREAT/
RXFP2 genes (G-protein-coupled receptor affecting testis descent), are important in the development of genital
organs and may be associated with testicular maldescent (6,7).
8.4 Hormonal control of testicular descent

Maldescent can be caused by two hormonal factors: hypogonadism and androgen insensitivity. The increasing
incidence of reproductive abnormalities in male humans can be explained by increased oestrogen exposure
during gestation (8). Some pesticides and synthetic chemicals act as hormonal modulators, often possessing
oestrogenic activity (xeno-oestrogens) (9). The oestrogenic and antiandrogenic properties of these chemicals
may cause hypospadias, cryptorchidism, reduced sperm density, and an increased incidence of testicular
tumours in animal models, via receptor-mediated mechanisms or direct toxic effects associated with Leydig
cell dysfunction (10).
8.5 Pathophysiological effects in maldescended testes

8.5.1 Degeneration of germ cells
The degeneration of germ cells in maldescended testes is apparent after the first year of life. Degenerative
changes vary, depending on the position of the testis (11). During the second year, the number of germ cells
declines. In 10-45% of affected patients, the complete loss of germ cells can be detected. Early treatment
is therefore recommended to conserve spermatogenesis; especially in bilateral cases. Surgical treatment is
the most effective and reliable method of bringing testes into the scrotum. Hormone treatment with hCG has
been used widely in the past, but it has now been abolished because of increased germ cell apoptosis after
treatment (12).
8.5.2 Relationship with fertility

Semen parameters are often impaired in men with a history of cryptorchidism (13). Surgical treatment during
the first or second year of life may have a positive effect on subsequent fertility (14). However, there is no
definitive proof of the protective effect of early orchidopexy. In men with a history of unilateral cryptorchidism,
paternity is almost equal (89.7%) to that in men without cryptorchidism (93.7%).
In men with unilateral cryptorchidism, paternity is independent of age at orchidopexy and preoperative
testicular location and size (15). However, a history of unilateral cryptorchidism may result in reduced fertility
potential and therefore a longer time to achieve pregnancy.
In men with bilateral cryptorchidism, oligozoospermia can be found in 31% and azoospermia in 42%.
In cases of bilateral cryptorchidism, the rate of paternity is only 35-53%. In cases of bilateral cryptorchidism
and azoospermia, orchidopexy performed even in adult life might lead to the appearance of spermatozoa in the
ejaculate (16).
8.5.3 Germ cell tumours

Cryptorchidism is a risk factor for testicular cancer and is associated with testicular microcalcification and
intratubular germ cell neoplasia of unclassified type (ITGCNU); formerly CIS of the testes. In 5-10% of testicular
cancers, there is a history of cryptorchidism (17). The risk of a germ cell tumour (GCT) is 3.6-7.4 times higher
than in the general population and 2-6% of men with a history of cryptorchidism will develop a testicular
tumour (17). Orchidopexy performed before the age of puberty has been reported to decrease the risk of
testicular cancer (18). However, this and other similar reports are based on retrospective data and do not
exclude the possibility that boys undergoing early and late orchidopexy represent different pathogenetic groups
of testicular maldescent.

8.6 Treatment of undescended testes
8.6.1 Hormonal treatment
Human chorionic gonadotropin or GnRH has been used widely in the past to treat cryptorchidism. Although
15-20% of retained testes descend during hormonal treatment, one-fifth of these reascend later. Also,
treatment with hCG may be harmful to future spermatogenesis by increasing the apoptosis of germ cells (12),
which is why hormonal treatment is no longer recommended.
8.6.2 Surgical treatment

The success rate of surgical treatment for undescended testes is 70-90% (19). If the spermatic cords or the
spermatic vessels are too short to allow proper mobilisation of the testis into the scrotum, a staged
orchidopexy (Fowler-Stephenson procedure) can be performed, using open surgery, laparoscopy, or
microsurgery.
The optimal age for performing orchidopexy is still debated. Some retrospective studies have
indicated that early treatment (during the first 2 years of life) has a beneficial effect on preserving future fertility
(20), whereas a recent randomised study showed that surgery at 9 months resulted in a partial catch-up of
testicular growth until at least age 4 years versus surgery at 3 years (21). The results clearly indicate that early
surgery has a beneficial effect on testicular growth. Testicular volume is an approximate indirect measure
of spermatogenic activity, therefore, it is possible that orchidopexy at an early age might improve future
spermatogenesis.
A biopsy at the time of orchidopexy (see Section 8.5.3) can reveal (ITGCNU), which can be removed,
thereby preventing development of a malignant tumour. If not corrected by adulthood, an undescended testis
should not be removed because it still produces testosterone. Furthermore, as indicated above, correction of
bilateral cryptorchidism, even in adulthood, can lead to sperm production in previously azoospermic men (16).
Vascular damage is the most severe complication of orchidopexy and can cause testicular atrophy in
1-2% of cases. In men with non-palpable testes, the postoperative atrophy rate was 12% in those cases with
long vascular pedicles that enabled scrotal positioning. Postoperative atrophy in staged orchidopexy has been
reported in up to 40% of patients (19).
8.7 Conclusions and recommendations for cryptorchidism
Conclusions LE
Cryptorchidism is multifactorial in origin and can be caused by genetic factors and endocrine 3
disruption early in pregnancy.
Cryptorchidism is often associated with testicular dysgenesis and is a risk factor for infertility and GCT. 2b
Whether early surgical intervention can prevent germ cell loss is still debatable, but in a randomised
study it improved testicular growth in boys treated at the age of 9 months compared to those aged 3
years at the time of orchidopexy.
Paternity in men with unilateral cryptorchidism is almost equal to that in men without cryptorchidism. 3
Bilateral cryptorchidism significantly reduces the likelihood of paternity. 3
Recommendations GR
Hormonal treatment of cryptorchidism in adults is not recommended. A
Early orchidopexy (6-12 months of age) might be beneficial for testicular development in adulthood. B
If undescended testes are corrected in adulthood, testicular biopsy for detection of ITGCNU (formerly B
CIS) is recommended at the time of orchidopexy.
8.8 References
1. Skakkebaek NS, Rajpert-De Meyts E, Main KM. Testicular dysgenesis syndrome: an ncreasingly
common developmental disorder with environmental aspects. Hum Reprod 2001 May;16(5):972-8.
2. Boisen KA, Kaleva M, Main KM, et al. Difference in prevalence of congenital cryptorchidism in infants
between two Nordic countries. Lancet 2004 Apr;363(9417):1264-9.
3. Heyns CF, Hutson JM. Historical review of theories on testicular descent. J Urol 1995 Mar;153
(3 Pt 1):754-67. [No abstract available]
4. Scorer CG. The descent of the testis. Arch Dis Child 1964 Dec;39:605-9.

5. Nguyen MT, Showalter PR, Timmons CF, et al. Effects of orchiopexy on congenitally cryptorchid
insulin-3 knockout mice. J Urol 2002 Oct;168(4 Pt 2):1779-83.
6. Lewis AG, Pecha BR, Smith EP, et al. Early orchidopexy restores fertility in Hoxa 11 gene knockout
mouse. J Urol 2003 Jul;170(1):302-5.
7. Gorlov IP, Kamat A, Bogatcheva NV, et al. Mutations of the GREAT gene cause cryptorchidism. Hum
Mol Genet 2002 Sep;11(19):2309-18.
8. Hadziselimovic F, Geneto R, Emmons LR. Elevated placental estradiol: a possible etiological factor of
human cryptorchidism. J Urol 2000 Nov;164(5):1694-5.
9. Hosi S, Loff S, Witt K, et al. Is there a correlation between organochlorine compounds and
undescended testes? Eur J Pediatr Surg 2000 Oct;10(5):304-9.
10. Mahood IK, Scott HM, Brown R, et al. In utero exposure to di(n-butyl) phthalate and testicular
dysgenesis: comparison of fetal and adult end points and their dose sensitivity. Environ Health
Perspect 2007 Dec;115 Suppl 1:55-61.
11. Garcia J, Gonzalez N, Gomez ME, et al. Clinical and anatomopathological study of 2000 cryptorchid
testes. Br J Urol 1995 Jun;75(6):697-701.
12. Ritzén EM. Undescended testes: a consensus on management. Eur J Endocrinol 2008 Dec;159 Suppl
1:S87-90.
13. Yavetz H, Harash B, Paz G, et al. Cryptorchidism: incidence and sperm quality in infertile men.
Andrologia 1992 Sep-Oct;24(5):293-7.
14. Wilkerson ML, Bartone FF, Fox L, et al. Fertility potential: a comparison of intra-abdominal and
intracanalicular testes by age groups in children. Horm Res 2001;55(1):18-20.
15. Miller KD, Coughlin MT, Lee PA. Fertility after unilateral cryptorchidism: paternity, time to conception,
pretreatment testicular location and size, hormone and sperm parameters. Horm Res 2001; 55(5):
249-53.
16. Giwercman A, Hansen LL, Skakkebaek NE. Initiation of sperm production after bilateral
orchiopexy:clinical and biological implications. J Urol 2000 Apr;163(4):1255-6. [No abstract available]
17. Giwercman A, Bruun E, Frimodt-Moller C, et al. Prevalence of carcinoma in situ and other
histopathological abnormalities in testes of men with a history of cryptorchidism. J Urol 1989
Oct;142(4):998-1001.
18. Pettersson A, Richiardi L, Nordenskjold A, et al. Age at surgery for undescended testis and risk of
testicular cancer. N Engl J Med 2007 May 3;356(18):1835-41.
19. Jones PF. Approaches to orchidopexy. Br J Urol 1995 Jun;75(6):693-6. [No abstract available]
20. Hadziselimovic F, Hocht B, Herzog B, et al. Infertility in cryptorchidism is linked to the stage of germ
cell development at orchidopexy. Horm Res 2007;68(1):46-52.
21. Kollin C, Stukenborg JB, Nurmio M, et al. Boys with Undescended Testes: Endocrine, Volumetric and
Morphometric Studies on Testicular Function before and after Orchidopexy at Nine Months or Three
Years of Age. J Clin Endocrinol Metab 2012 Dec;97(12):4588-95

9. IDIOPATHIC MALE INFERTILITY
9.1 Introduction
No demonstrable cause of infertility is found in at least 44% of infertile men (1).
9.2 Empirical treatments

A wide variety of empirical drug treatments of idiopathic male infertility have been used; however, there is little
scientific evidence for an empirical approach (2). Clomiphen citrate and tamoxifen have been widely used
in idiopathic OAT but there is no proven evidence for their benefit. A recent meta-analysis reported some
improvement in sperm quality and spontaneous pregnancy rate (3). Androgens, hCG/HMG, bromocriptine,
alpha-blockers, systemic corticosteroids and magnesium supplementation are not effective in the treatment of
OAT syndrome. Follicle-stimulating hormone (3) might be beneficial in a selection of patients (3). A Cochrane
analysis showed that men taking oral antioxidants had an associated significant increase in live birth rate
(pooled OR = 4.85; 95% CI: 1.92-12.24; P = 0.0008; I(2) = 0%) when compared with men taking the control
treatment. No studies have reported harmful side effects from antioxidant therapy. The evidence suggests
that antioxidant supplementation in subfertile men may improve the outcomes of live birth and pregnancy
rate for subfertile couples undergoing assisted reproduction technique (ART) cycles. Further head-to-head
comparisons are necessary to identify the superiority of one antioxidant over another (4).
Recommendation GR
Medical treatment of male infertility is recommended only for cases of hypogonadotrophic A
hypogonadism.
9.3 References
1. Pierik FH, Van Ginneken AM, Dohle GR, et al. The advantages of standardized evaluation of male
infertility. Int J Androl 2000 Dec;23(6):340-6.
2. Foresta C, Bettella A, Spolaore D, et al. Suppression of the high endogenous levels of plasma FSH
in infertile men are associated with improved Sertoli cell function as reflected by elevated levels of
plasma inhibin B. Hum Reprod 2004 Jun;19(6):1431-7.
3. Chua ME, Escusa KG, Luna S, et al. Revisiting oestrogen antagonists (clomiphene or tamoxifen) as
medical empiric therapy for idiopathic male infertility: a meta-analysis. Andrology 2013 Sep;1(5):
749-57.
4. Paradisi R, Busacchi P, Seracchioli R, et al. Effects of high doses of recombinant human follicle
stimulating hormone in the treatment of male factor infertility: results of a pilot study. Fertil Steril 2006
Sep;86(3):728-31.
5. Showell MG, Brown J, Yazdani A, et al. Antioxidants for male subfertility. Cochrane Database Syst Rev
2011 Jan;(1):CD007411.
10. MALE CONTRACEPTION

10.1 Introduction
“Male contribution to contraception” is a more accurate phrase than “male contraception”, because men do
not conceive. Development of male contraceptive methods is important because up to 40% of women have
an unmet need for family planning, with approximately 80 million women every year having unintended or
unwanted pregnancies (1).
Three of the four methods of male contraception have been in use for hundreds of years (i.e.,
condoms, periodic abstinence, and withdrawal). The typical first-year failure rates of traditional male methods
are high (withdrawal 19%, periodic abstinence 20%, and condoms 3-14%) compared to the failure rates of
0.1-3% for modern reversible female methods (2). For men to take more responsibility for family planning, male
contraceptive methods must be acceptable, cheap, reversible, and effective.
Research is attempting to (3):
• Prevent sperm production by using exogenic androgens, progestogen, and GnRH formulations in
various combinations.

• Interfere with the ability of sperm to mature and fertilise, by using an epididymal approach to create a
hostile environment for sperm.
• Produce better barrier methods (e.g., polyurethane condoms can be used by those with latex allergy,
although they have higher breakage rates) (4).
• Produce an antisperm contraceptive vaccine (5).
• Inhibit sperm-egg interactions.
These approaches remain experimental. The method nearest to being generally available clinically is hormonal
male contraception, which is based on the suppression of gonadotropins and testosterone substitution
to maintain male sexual function and bone mineralization, and to prevent muscle wasting (6). Various
contraceptive regimens have been developed and tested, including testosterone monotherapy, androgen/
progestin combinations, testosterone with GnRH analogues, and selective androgen- and progestin-receptor
modulators. There are racial differences in the response to androgens alone. However, a combination of
testosterone with progestin results in complete suppression of spermatogenesis in all races, and provides
contraceptive efficacy equivalent to female hormonal methods (7). Phase III clinical trials of depot preparations
of androgen/progestin combinations are in progress.
10.2 Vasectomy
Vasectomy is an effective method of permanent male surgical sterilisation (8). Extensive guidelines on
vasectomy were published by the EAU in 2012 (9). Before vasectomy, the couple should be fully informed
about the benefits and risks, especially as an Australian telephone survey found that 9.2% of respondents
regretted having a vasectomy (10).
10.2.1 Surgical techniques

Various techniques are available for vasectomy. The least invasive approach is no-scalpel vasectomy (11),
which is also associated with a low rate of complications (12). The most effective occlusion technique is
cauterisation of the lumen of the vas deferens and fascial interposition (13-15). Most techniques can be carried
out safely under local anaesthesia in an outpatient clinic.
10.2.2 Complications
Vasectomy does not significantly alter spermatogenesis and Leydig cell function. The volume of ejaculate
remains unchanged. Potential systemic effects of vasectomy, including atherosclerosis, have not been proven,
and there is no evidence of a significant increase in any systemic disease after vasectomy. An increased rate
of prostate cancer in men who underwent vasectomy has not been detected (16,17). Acute local complications
associated with vasectomy include haematoma, wound infection, and epididymitis in up to 5% of cases (17).
The potential long-term complications (e.g., chronic testicular pain) (18) must be discussed with the patient
before the procedure. Epididymal tubal damage is common, and is associated with consequent development
of sperm granuloma and time-dependent secondary epididymal obstruction, which limits vasectomy reversal.
10.2.3 Vasectomy failure

If an effective occlusion technique is used, the risk of recanalisation after vasectomy should be < 1% (12).
However, patients should be informed preoperatively that, although rare, long-term recanalisation might
occur (19). No motile spermatozoa should be detected 3 months after vasectomy. Persistent motility is a
sign of vasectomy failure, and the procedure will need to be repeated. A “special clearance” with non-motile
spermatozoa < 10,000/mL is still under discussion (20).
10.2.4 Counselling
Counselling with regard to vasectomy must address the following aspects:
• Vasectomy should be considered irreversible.
• Vasectomy is associated with a low complication rate; however, because it is an elective operation,
even small risks must be explained, because men (and their partners) might wish to consider these
before giving consent.
• Vasectomy can fail, although the failure rate is low.
• Couples should be advised to continue with other effective contraception until clearance is confirmed.
• All available data indicate that vasectomy is not associated with any serious, long-term, side effects
(15).
• Vasectomy involving cauterisation and fascial interposition appears to be the most effective technique
(12-14).

10.3 Vasectomy reversal
A wide range of surgical success rates has been published for vasectomy reversal (up to 90%), depending
on the time between vasectomy and re-fertilisation, type of vasectomy (e.g., open-ended or sealed), type of
reversal (vasovasostomy or vasoepididymostomy), and whether reversal was unilateral or bilateral. However,
there have been no RCTs comparing macrosurgery (loops) and microsurgery. Microsurgical techniques with the
help of magnification and smaller suture materials should be used (21).
10.3.1 Length of time since vasectomy

Vasovasostomy results have shown patency rates up to 90%. The longer the interval is from vasectomy to
reversal, the lower is the pregnancy rate. In a study of 1,469 men who had undergone microsurgical vasectomy
reversal, patency and pregnancy rates were 97% and 76%, respectively, for an interval up to 3 years after
vasectomy; 88% and 53% for 3-8 years, 79% and 44% for 9-14 years, and 71% and 30% for > 15 years (22).
10.3.2 Tubulovasostomy
The chance of secondary epididymal obstruction after vasectomy increases with time. After an interval of
10 years, 25% of men appear to have epididymal blockage. If secondary epididymal obstruction occurs,
tubulovasostomy is needed to reverse the vasectomy (see Chapter 5) (23).
10.3.3 Microsurgical vasectomy reversal versus epididymal or testicular sperm retrieval and ICSI
According to the calculations of cost per delivery for vasectomy reversal versus sperm retrieval/ICSI, under a
wide variety of initial assumptions, it is clear that vasectomy reversal is associated with a considerably lower
cost per delivery and higher delivery rates (24,-27). Sperm retrieval and ICSI must yield an 81% pregnancy rate
per cycle to achieve equal costs to vasectomy reversal.
10.4 Conclusions and recommendations for male contraception
Conclusions LE
Vasectomy is considered the gold standard for the male contribution to contraception. 1
All available data indicate that vasectomy is not associated with any serious, long term side effects. 1b
Pregnancy is still achievable after successful vasectomy reversal. 2a
Methods of male contraception other than vasectomy are associated with high failure rates or are still 3
experimental (e.g., hormonal approach).
Recommendations GR
Vasectomy meets best the criteria for the male contribution to contraception, with regard to efficacy, A
safety and side effects. Cauterisation and fascial interposition are the most effective techniques.
Patients seeking consultation about vasectomy must be informed about the surgical method, risk A*
of failure, irreversibility, the need for post-procedure contraception until clearance, and the risk of
complications.
Microsurgical vasectomy reversal is a low-risk and (cost-) effective method of restoring fertility. B
MESA/TESE/PESA and ICSI should be reserved for failed vasectomy reversal surgery. A
For couples wanting to achieve pregnancy, sperm aspiration together with ICSI is a second-line option B
for selected cases and in those with failed vasovasostomy.
10.5 References
1. Reproductive Health Strategy. Reproductive Health Research World Health Organisation, Geneva.
Adopted at the 57th World Health Assembly, 2004.
http://www.who.int/reproductive-health/publications/strategy.pdf
2. Handelsman D, Waites G. Tradional methods. In: Schill W, Comhaire F, Hargreave T (eds). Andrology
for the Clinician. Berlin: Springer Verlag, 2006, pp. 122-4.
3. Griffin D, Ringheim K. Male hormonal contraception. What prospects exist and how acceptable are
they? Plan Parent Chall 1996;(2):20-4.
4. Gallo MF, Grimes DA, Lopez LM, et al. Non-latex versus latex male condoms for contraception.
Cochrane Database Syst Rev 2006 Jan;(1):CD003550.
5. Naz RK. Antisperm immunity for contraception. J Androl 2006 Mar-Apr;27(2):153-9.

6. Matthiesson KL, McLachlan RI. Male hormonal contraception: concept proven, product in sight? Hum
Reprod Update 2006 Jul-Aug;12(4):463-82.
7. Handelsman DJ, Waites GMH. Hormonal male contraception. In: Schill W, Comhaire F, Hargreave T
(eds). Andrology for the Clinician. Berlin: Springer Verlag, 2006, pp. 520-4.
8. Schwingl PJ, Guess HA. Safety and effectiveness of vasectomy. Fertil Steril 2000 May;73(5):923-36.
9. Dohle G, Diemer Th, Kopa Z, et al. European Association of Urology Guidelines on Vasectomy.
Eur Urol 2012 Jan;61(1):159-63.
10. Holden CA, McLachlan RI, Cumming R, et al. Sexual activity, fertility and contraceptive use in middle-
aged and older men: Men in Australia, Telephone Survey (MATeS). Hum Reprod 2005 Dec:20(12):3429-
34.
11. Li SQ, Goldstein M, Zhu J, et al. The no-scalpel vasectomy. J Urol 1991 Feb;145(2):341-4.
12. Nirapathpongporn A, Huber D, Krieger N. No-scalpel vasectomy at the King’s birthday vasectomy
festival. Lancet 1990 Apr;335(8694):894-5.
13. Sokal, D, Irsula, B, Hays M, et al; Investigator Study Group. Vasectomy by ligation and excision, with
or without fascial interposition: a randomized controlled trial. BMC Med 2004 Mar;2:6.
14. Barone MA, Irsula B, Chen-Mok M, et al; Investigator Study Group. Effectiveness of vasectomy using
cautery. BMC Urol 2004 Jul;19;4:10.
15. Sokal DC, Irsula B, Chen-Mok M, et al. A comparison of vas occlusion techniques: cautery more
effective than ligation and excision with fascial interposition. BMC Urol 2004 Oct;4(1):12.
16. Bernal-Delgado E, Latour-Perez J, Pradas-Arnal F, et al. The association between vasectomy and
prostate cancer: a systematic review of the literature. Fertil Steril 1998 Aug;70(2):191-200.
17. Schwingl PJ, Guess HA. Safety and effectiveness of vasectomy. Fertil Steril 2000 May;73(5):923-36.
18. Christiansen CG, Sandlow JI. Testicular pain following vasectomy: a review of postvasectomy pain
syndrome. J Androl 2003 May-Jun;24(3):293-8.
19. Verhulst APM, Hoekstra JW. Paternity after bilateral vasectomy. BJU Int 1999 Feb;83(3):280-2.
20. Korthorst RA, Consten D, van Roijen JH. Clearance after vasectomy with a single semen
sample containing < than 100 000 immotile sperm/mL: analysis of 1073 patients. BJU Int 2010
Jun;105(11):1572-5.
21 Schroeder-Printzen I, Diemer T, Weidner W. Vasovasostomy. Urol Int 2003;70(2):101-7.
22. Belker AM, Thomas AJ Jr, Fuchs EF, et al. Results of 1,469 microsurgical vasectomy reversals by the
Vasovasostomy Study Group. J Urol 1991 Mar;145(3):505-11.
23. Chan PT, Brandell RA, Goldstein M. Prospective analysis of outcomes after microsurgical
intussusception vasoepididymostomy. BJU Int 2005 Sep;96(4):598-601.
24. Pavlovich CP, Schlegel PN. Fertility options after vasectomy: a cost-effectiveness analysis. Fertil Steril
1997 Jan;67(1):133-41.
25. Heidenreich A, Altmann P, Engelmann UH. Microsurgical vasovasostomy versus microsurgical
epididymal sperm aspiration/testicular extraction of sperm combined with intracytoplasmic sperm
injection. A cost-benefit analysis. Eur Urol 2000 May;37(5):609-14.
26. Esteves SC, Miyaoka R, Agarwal A. Sperm retrieval techniques for assisted reproduction. Int Braz J
Urol 2011 Sep-Oct;37(5): 570-83

27. Cook LA, Van Vliet HA, Pun A, et al. Vasectomy techniques for male sterilization: systematic
Cochrane review of randomized controlled trials and controlled clinical trials. Hum Reprod 2004
Nov;19(11):2431-8.
11. MALE ACCESSORY GLAND INFECTIONS AND

INFERTILITY
11.1 Introduction
Infections of the male urogenital tract are potentially curable causes of male infertility (1-3). The WHO considers
urethritis, prostatitis, orchitis and epididymitis to be male accessory gland infections (MAGIs) (2). However,
specific data are not available to confirm that these diseases have a negative influence on sperm quality and
male fertility in general.
In order to keep the guidelines as short as possible, the MAGI section is discussed in detail in the
Guidelines for Urological Infections and Chronic Pelvic Pain (4,5).
11.2. Ejaculate analysis

11.2.1 Introduction
Ejaculate analysis (see Chapter 2) clarifies whether the prostate is involved as part of a generalised MAGI
and provides information about sperm quality. In addition, leukocyte analysis allows differentiation between
inflammatory and non-inflammatory chronic pelvic pain syndrome (CPPS) (NIH IIa vs NIH IIIb).
11.2.2 Microbiological findings

After exclusion of urethritis and bladder infection, > 106 peroxidase-positive white blood cells (WBCs) per
millilitre of ejaculate indicate an inflammatory process. In this case, a culture should be performed for common
urinary tract pathogens, particularly Gram-negative bacteria.
A concentration of > 103 cfu/mL urinary tract pathogens in the ejaculate is indicative of significant
bacteriospermia. Various microorganisms are found in the genital tract of men seen in infertility clinics;
usually with more than one strain of bacteria present (1). The sampling time can influence the positive rate of
microorganisms in semen and the frequency of isolation of different strains (6). The ideal diagnostic test for
Chlamydia trachomatis in semen has not yet been established (7). In contrast to serological findings in women,
antibody tests for C. trachomatis in seminal plasma are not indicative if no type-specific methods are used (7).
Ureaplasma urealyticum is pathogenic only in high concentrations (> 103 cfu/mL ejaculate). No more
than about 10% of samples analysed for ureaplasma exceed this concentration (8). Normal colonisation of the
urethra hampers the clarification of mycoplasma-associated urogenital infections, using samples such as the
ejaculate (9).
11.2.3 White blood cells

The clinical significance of an increased concentration of leukocytes in the ejaculate is controversial (10).
Infection is indicated only by an increased level of leukocytes (particularly polymorphonuclear leukocytes)
and their products (e.g., leukocyte elastase) secreted into the seminal fluid. Most leukocytes are neutrophilic
granulocytes, as suggested by the specific staining of the peroxidase reaction (2). Although leukocytospermia
is a sign of inflammation, it is not necessarily associated with bacterial or viral infections (11). Earlier findings
have shown that elevated leukocyte numbers are not a natural cause of male infertility (12). According to WHO
classification, leukocytospermia is defined as > 106 WBCs/mL. Only two studies have analysed alterations of
WBCs in the ejaculate of patients with proven prostatitis (13,14). Both studies found more leukocytes in men
with prostatitis compared to those without inflammation (CPPS, type NIH IIIb).
11.2.4 Sperm quality

The deleterious effects of chronic prostatitis on sperm density, motility and morphology are under debate
(1). All investigations have given contradictory results, and have not confirmed that chronic prostatitis has a
decisive role in altering conventional semen parameters (15-17).
11.2.5 Seminal plasma alterations

Seminal plasma elastase is a biochemical indicator of polymorphonuclear lymphocyte activity in the ejaculate
(1,18,19), with a suggested cut-off level of approximately 600 ng/mL (1). Various cytokines are involved in

inflammation and can influence sperm function. Several studies have investigated the association between
interleukin (IL) concentration, leukocytes, and sperm function (20-22), but no correlations have been found.
The prostate is the main site of origin of IL-6 and IL-8 in the seminal plasma. Cytokines, especially IL-6, play an
important role in the male accessory gland inflammatory process (23). However, elevated cytokine levels do not
depend on the number of leukocytes in expressed prostatic secretion (EPS) (24).
11.2.6 Glandular secretory dysfunction

Infections of the sex glands can impair their excretory function. Decreased quantities of citric acid,
phosphatase, fructose, zinc, and α-glutamyl-transferase activity are indicators of disturbed prostatic secretory
parameters (1). Reduced fructose concentration indicates impaired vesicular function (8,25).
11.2.7 Sperm antibodies

Serum antibodies to sperm antigens are not useful in the diagnosis of immune infertility. Early studies found an
association between increased levels of sperm antibodies in serum and non- or abacterial prostatitis (26,27).
However, except for suspected chlamydial infections (28), only a history of vasectomy is predictive of sperm
antibody formation (29).
11.2.8 Reactive oxygen species

Reactive oxygen species might be increased in chronic urogenital infections associated with increased
leukocyte numbers (30). However, their biological significance in prostatitis remains unclear (1).
11.2.9 Therapy
Treatment of chronic prostatitis is usually targeted at relieving symptoms (31,32). Andrologically, the aims of
therapy for altered semen composition in male adnexitis (acute and chronic infections of the male urogenital
tract) are:
• reduction or eradication of microorganisms in prostatic secretions and semen;
• normalisation of inflammatory (e.g., leukocytes) and secretory parameters;
• improvement of sperm parameters to counteract fertility impairment (33).
Treatment includes antibiotics, anti-inflammatory drugs, surgical procedures, normalisation of urine flow,
physical therapy, and alterations in general and sexual behaviour.
Only antibiotic therapy of chronic bacterial prostatitis (NIH II) has provided symptomatic relief,
eradication of microorganisms, and a decrease in cellular and humoral inflammatory parameters in urogenital
secretions. The use of α-blockers for symptom relief is controversial. Although antibiotics might improve sperm
quality (33), there is no evidence that treatment of chronic prostatitis increases the probability of conception
(1,34).
11.3 Epididymitis
11.3.1 Introduction
Inflammation of the epididymis causes unilateral pain and swelling, usually with acute onset. Among sexually
active men < 35 years of age, epididymitis is most often caused by C. trachomatis or Neisseria gonorrhoea
(35,36). Sexually transmitted epididymitis is usually accompanied by urethritis. Non-sexually transmitted
epididymitis is associated with urinary tract infection and occurs more often in men aged > 35 years, those who
have recently undergone urinary tract instrumentation or surgery, and those who have anatomical abnormalities
(37).
11.3.2 Ejaculate analysis

Ejaculate analysis according to WHO criteria, including leukocyte analysis, might indicate persistent
inflammatory activity. In many cases, transiently decreased sperm counts and forward motility are observed
(36,38,39). Ipsilateral low-grade orchitis (40,41) might be the cause of this slight impairment in sperm quality
(Table 14) (42).
Development of stenosis in the epididymal duct, reduction of sperm count, and azoospermia are more
important in the follow-up of bilateral epididymitis (see Chapter 5). The extent of azoospermia after epididymitis
is unclear.

Table 14: Acute epididymitis and impact on sperm parameters.
Authors Negative influence

Density Motility Morphology Comment
Ludwig & + + + Pyospermia in 19 of 22 cases
Haselberger (43)
Berger et al. (36) +
Weidner et al. (44) + + + Azoospermia in 3 of 70 men
Haidl (45) + Chronic infections; macrophages
Elevated
Cooper et al. (46) Decrease in epididymal markers:
α-glucosidase, L-carnitine
11.3.3 Treatment
Antibiotic therapy is indicated before culture results are available (Table 13). Treatment of epididymitis results in:
• microbiological cure of infection;
• improvement of clinical signs and symptoms;
• prevention of potential testicular damage;
• prevention of transmission;
• decrease of potential complications (e.g., infertility or chronic pain).
Patients with epididymitis known or suspected to be caused by N. gonorrhoeae or C. trachomatis must be told
to refer their sexual partners for evaluation and treatment (47).
11.4 Conclusions and recommendations for male accessory gland infections
Conclusions LE
Urethritis and prostatitis are not associated clearly with male infertility. 3
Antibiotic treatment often only eradicates microorganisms; it has no positive effect on inflammatory 2a
alterations, and cannot reverse functional deficits and anatomical dysfunction.
Although antibiotic treatment for MAGI might provide improvement in sperm quality, it does not 2a
necessarily enhance the probability of conception.
Recommendations GR
Patients with epididymitis that is known or suspected to be caused by N. gonorrhoeae or B
C. trachomatis must be instructed to refer their sexual partners for evaluation and treatment.
11.5 References
1. Weidner W, Krause W, Ludwig M. Relevance of male accessory gland infection for subsequent fertility
with special focus on prostatitis. Hum Reprod Update 1999 Sep-Oct;5(5):421-32.
3. Purvis K, Christiansen E. Infection in the male reproductive tract. Impact, diagnosis and treatment in
relation to male infertility. Int J Androl 1993 Feb;16(1):1-13.
4. Engeler D, Baranowski AP, Dinis Oliveira P, et al. Members of the EAU Guidelines Office. EAU
Guidelines on Chronic Pelvic Pain. In: EAU Guidelines, edition presented at the 27th EAU Annual
Congress, Paris 2012. ISBN 978-90-79754-83-0.
5. Grabe M, Bjerklund Johansen TE, Botto H, et al. Members of the EAU Guidelines Office. EAU
Guidelines on Urological Infections. In: EAU Guidelines, edition presented at the 27th EAU Annual
Congress, Paris 2012. ISBN 978-90-79754-83-0.
6. Liversedge NH, Jenkins JM, Keay SD, et al. Antibiotic treatment based on seminal cultures from
asymptomatic male partners in in-vitro fertilization is unnecessary and may be detrimental. Hum
Reprod 1996 Jun;11(6):1227-31.

7. Taylor-Robinson D. Evaluation and comparison of tests to diagnose Chlamydia trachomatis genital
infections. Hum Reprod 1997 Nov;12(11 Suppl):113-20.
8. Weidner W, Krause W, Schiefer HG, et al. Ureaplasmal infections of the male urogenital tract, in
particular prostatitis, and semen quality. Urol Int 1985;40(1):5-9.
9. Taylor-Robinson D. Infections due to species of Mycoplasma and Ureaplasma: an update. Clin Infect
Dis 1996 Oct;23(4):671-684; quiz 683-4.
10. Aitken RJ, Baker HW. Seminal leukocytes: passengers, terrorists or good samaritans? Hum Reprod
1995 Jul;10(7):1736-9.
11. Trum JW, Mol BW, Pannekoek Y, et al. Value of detecting leukocytospermia in the diagnosis f genital
tract infection in subfertile men. Fertil Steril 1998 Aug;70(2):315-9.
12. Tomlinson MJ, Barratt CLR, Cooke ID. Prospective study of leukocytes and leukocyte subpopulations
in semen suggests they are not a cause of male infertility. Fertil Steril 1993 Dec;60(6):1069-75.
13. Krieger JN, Berger RE, Ross SO, et al. Seminal fluid findings in men with nonbacterial prostatitis and
prostatodynia. J Androl 1996 Dec;17(3):310-8.
14. Weidner W, Jantos C, Schiefer HG, et al. Semen parameters in men with and without proven chronic
prostatitis. Arch Androl 1991 May-Jun;26(3):173-83.
15. Giamarellou H, Tympanidis K, Bitos NA, et al. Infertility and chronic prostatitis. Andrologia 1984 Sep-
Oct;16(5):417-22.
16. Christiansen E, Tollefsrud A, Purvis K. Sperm quality in men with chronic abacterial prostatovesiculitis
verified by rectal ultrasonography. Urology 1991 Dec;38(6):545-9.
17. Leib Z, Bartoov B, Eltes F, et al. Reduced semen quality caused by chronic abacterial prostatitis: an
enigma or reality? Fertil Steril 1994 Jun;61(6):1109-16.
18. Wolff H, Bezold G, Zebhauser M, et al. Impact of clinically silent inflammation on male genital tract
organs as reflected by biochemical markers in semen. J Androl 1991 Sep-Oct;12(5):331-4.
19. Wolff H. The biologic significance of white blood cells in semen. Fertil Steril 1995 Jun;63(6):1143-57.
20. Dousset B, Hussenet F, Daudin M, et al. Seminal cytokine concentrations (IL-1beta, IL-2, IL-6, sR
IL-2, sR IL-6), semen parameters and blood hormonal status in male infertility. Hum Reprod 1997
Jul;12(7):1476-9.
21. Huleihel M, Lunenfeld E, Levy A, et al. Distinct expression levels of cytokines and soluble cytokine
receptors in seminal plasma of fertile and infertile men. Fertil Steril 1996 Jul;66(1):135-9.
22. Shimonovitz S, Barak V, Zacut D, et al. High concentration of soluble interleukin-2 receptors in
ejaculate with low sperm motility. Hum Reprod 1994 Apr;9(4):653-5.
23. Zalata A, Hafez T, van Hoecke MJ, et al. Evaluation of beta-endorphin and interleukin-6 in seminal
plasma of patients with certain andrological diseases. Hum Reprod 1995 Dec;10(12):3161-5.
24. Alexander RB, Ponniah S, Hasday J, et al. Elevated levels of proinflammatory cytokines in the semen
of patients with chronic prostatitis/chronic pelvic pain syndrome. Urology 1998 Nov;52(5):744-9.
25. Comhaire F, Verschraegen G, Vermeulen L. Diagnosis of accessory gland infection and its possible
role in male infertility. Int J Androl 1980 Feb;3(1):32-45.
26. Jarow JP, Kirkland JA Jr, Assimos DG. Association of antisperm antibodies with chronic nonbacterial
prostatitis. Urology 1990 Aug;36(2):154-6.

27. Witkin SS, Zelikovsky G. Immunosuppression and sperm antibody formation in men with prostatitis.
J Clin Lab Immunol 1986 Sep;21(1):7-10.
28. Munoz MG, Witkin SS. Autoimmunity to spermatozoa, asymptomatic Chlamydia trachomatis genital
tract infection and gamma delta T lymphocytes in seminal fluid from the male partners of couples with
unexplained infertility. Hum Reprod 1995 May;10(5):1070-4.
29. Jarow JP, Sanzone JJ. Risk factors for male partner antisperm antibodies. J Urol 1992
Dec;148(6):1805-7.
30. Depuydt CE, Bosmans E, Zalata A, et al. The relation between reactive oxygen species and
cytokines in andrological patients with or without male accessory gland infection. J Androl 1996 Nov-
Dec;17(6):699-707.
31 Wagenlehner FM, Diemer T, Naber KG, et al. Chronic bacterial prostatitis (NIH type II): diagnosis,
therapy and influence on the fertility status. Andrologia 2008 Apr;40(2):100-4.
32. Schaeffer AJ. Clinical practice. Chronic prostatitis and chronic pelvic pain syndrome. N Engl J Med
2006 Oct 19;355(16):1690-8.
33. Weidner W, Ludwig M, Miller J. Therapy in male accessory gland infection-what is fact, what is fiction?
Andrologia 1998;30(Suppl 1):87-90.
34. Comhaire FH, Rowe PJ, Farley TM. The effect of doxycycline in infertile couples with male accessory
gland infection: a double blind prospective study. Int J Androl 1986 Apr;9(2):91-8.
35. Berger RE, Alexander RE, Harnisch JP, et al. Etiology, manifestations and therapy of acute
epididymitis: prospective study of 50 cases. J Urol 1979 Jun;121(6):750-4.
36. Berger RE. Epididymitis. In: Holmes KK, Mardh PA, Sparling PF et al. (eds). Sexually Transmitted
Diseases. New York: McGraw-Hill, 1984, pp. 650-62.
37. Weidner W, Schiefer HG, Garbe C. Acute nongonococcal epididymitis. Aetiological and therapeutic
aspects. Drugs 1987;34(Suppl 1):111-17.
38. [No authors listed.] Association of Genitourinary Medicine and the Medical Society for the Study of
Venereal Diseases: National guideline for the management of epididymo-orchitis. Sex Transm Infect
1999 Aug;75(Suppl 1):S51-3. [No abstract available]
39. Weidner W, Krause W. Orchitis. In: Knobil E, Neill JD (eds). Encyclopedia of Reproduction. Vol. 3. San
Diego: Academic Press, 1999, pp. 92-5. [No abstract available]
40. Nilsson S, Obrant KO, Persson PS. Changes in the testis parenchyma caused by acute non-specific
epididymitis. Fertil Steril 1968 Sep-Oct;19(5):748-57.
41. Osegbe DN. Testicular function after unilateral bacterial epididymo-orchitis. Eur Urol 1991;19(3):204-8.
42. Weidner W, Krause W, Ludwig M. Relevance of male accessory gland infection for subsequent fertility
with special focus on prostatitis. Hum Reprod Update 1999 Sep-Oct;5(5):421-32.
43. Ludwig G, Haselberger J. [Epididymitis and fertility. Treatment results in acute unspecific epididymitis.]
Fortschr Med 1977 Feb;95(7):397-9. [Article in German]
44. Weidner W, Garbe C, Weissbach L, et al. [Initial therapy of acute unilateral epididymitis using ofloxacin.
II. Andrological findings.] Urologe A 1990 Sep;29(5):277-280. [Article in German]
45. Haidl G. Macrophages in semen are indicative of chronic epididymal infection. Arch Androl
1990;25(1):5-11.

46. Cooper TG, Weidner W, Nieschlag E. The influence of inflammation of the human genital tract on
secretion of the seminal markers alpha-glucosidase, glycerophosphocholine, carnitine, fructose and
citric acid. Int J Androl 1990 Oct;13(5):329-36.
47. Robinson AJ, Grant JB, Spencer RC, et al. Acute epididymitis: why patient and consort must be
investigated. Br J Urol 1990 Dec;66(6):642-5.
12. GERM CELL MALIGNANCY AND TESTICULAR

MICROCALCIFICATION
12.1 Germ cell malignancy and male infertility
Testicular germ cell tumour (TGCT) is the most common malignancy in Caucasian men aged 15-40 years
and affects approximately 1% of subfertile men. The lifetime risk of TGCT varies between ethnic groups and
countries. The highest annual incidence of TGCT occurs in Caucasians, and varies from 10/100,000 (e.g., in
Denmark and Norway) to 2/100,000 (e.g., in Finland and the Baltic countries). Generally, seminomas and non-
seminomas are preceded by CIS, and untreated ITGCNU will eventually progress to invasive cancer (1,2).
The most convincing evidence for a general decline in male reproductive health is the increase
in testicular cancer seen in western countries (3). In almost all countries with reliable cancer registers, the
incidence of testicular cancer has increased (4). Cryptorchidism and hypospadias are associated with an
increased risk of testicular cancer; men with cryptorchidism and/or hypospadias are over-represented among
patients with testicular cancer.
Men with dysgenic testes have an increased risk of developing testicular cancer in adulthood. These
cancers arise from premalignant gonocytes or CIS cells (5). Testicular microlithiasis (TM), seen on ultrasound,
can be associated with GCT and CIS of the testes.
12.2 Testicular germ cell cancer and reproductive function

Men with TGCT have decreased semen quality, even before cancer is diagnosed (6). Orchidectomy implies a
risk of azoospermia in these men, with sperm found in the ejaculate before the tumour-bearing testis has been
removed. Semen cryopreservation before orchidectomy should therefore be considered (see Chapter 14).
Treatment of TGCT can result in additional impairment of semen quality (7).
In addition to spermatogenic failure, patients with TGCT have Leydig cell dysfunction, even in the
contralateral testis (8). The risk of hypogonadism may therefore be increased in men treated for TGCT. The
measurement of pretreatment levels of testosterone, SHBG, LH and oestradiol might help to anticipate post-
treatment hypogonadism. Men who have had TGCT and have low normal androgen levels should receive long-
term follow-up because they are at risk of developing hypogonadism as a result of an age-related decrease in
testosterone production (9).
The risk of hypogonadism is most pronounced in TGCT patients treated with > 3 cycles of
chemotherapy or irradiation of retroperitoneal lymph nodes. However, this risk is greatest at 6-12 months post-
treatment. This suggests there may be some improvement in Leydig cell function, and why it is reasonable to
expect initiation of androgen replacement, until the patient shows continuous signs of testosterone deficiency,
even at 2 years follow-up (10). The risk of low libido and erectile dysfunction is also increased in TGCT patients
(11).
12.3 Testicular microlithiasis

Microcalcification inside the testicular parenchyma can be found in 0.6-9% of men referred for testicular
ultrasound (12-14). Although the true incidence of microcalcification in the general population is unknown,
it is probably rare. However, ultrasound findings of TM are common in men with TGCT, cryptorchidism,
testicular dysgenesis, infertility, testicular torsion and atrophy, Klinefelter’s syndrome, hypogonadism, male
pseudohermaphroditism, varicocele, epididymal cysts, pulmonary microlithiasis, and non-Hodgkin’s lymphoma.
The incidence reported seems to be higher with high-frequency ultrasound machines (16).
The relationship between TM and infertility is unclear, but probably relates to dysgenesis of the testes,
with degenerate cells being sloughed inside an obstructed seminiferous tubule and failure of the Sertoli cells to
phagocytose the debris. Subsequently, calcification occurs.
Testicular microlithiasis is found in testes at risk of malignant development. The reported incidence
of TM in men with TGCT is 6-46% (17-19), and TM should therefore be considered premalignant. Testicular

biopsies from men with TM have found a higher prevalence of CIS, especially in those with bilateral
microlithiasis (20). However, TM is found most often in men with a benign testicular condition and the
microcalcification itself is not malignant.
Further investigation of the association between TM and CIS will require testicular biopsies in large
series of men without signs of TGCT. However, available data indicate that men in whom TM is found by
ultrasound, and who have an increased risk of TGCT, should be offered testicular biopsy for detection of CIS.
The list of high-risk patients includes men with infertility and bilateral TM, atrophic testes, undescended testes,
a history of TGCT, and contralateral TM (21).
12.4 Recommendations for germ cell malignancy and testicular microcalcification
Recommendations GR
As for all men, patients with TM and without special risk factors (see below) should be encouraged to B
perform self-examination because this might result in early detection of TGCT.
Testicular biopsy should be offered to men with TM, who belong to one of the following high-risk B
groups: infertility and bilateral TM, atrophic testes, undescended testes, a history of TGCT, or
contralateral TM.
If there are suspicious findings on physical examination or ultrasound in patients with TM and B
associated lesions, surgical exploration with testicular biopsy or orchidectomy should be considered.
Testicular biopsy, follow-up scrotal ultrasound, routine use of biochemical tumour markers, or B
abdominal or pelvic CT is not justified in men with isolated TM without associated risk factors (e.g.,
infertility, cryptorchidism, testicular cancer, and atrophic testis).
Men with TGCT are at increased risk of developing hypogonadism and sexual dysfunction and should B
therefore be followed up.
12.5 References
1. Skakkebaek NE. Carcinoma in situ of the testis: frequency and relationship to invasive germ cell
tumours in infertile men. Histopathology 1978 May;2(3):157-70.
2. von der Maase H, Rorth M, Walbom-Jorgensen S, et al. Carcinoma in situ of contralateral testis
in patients with testicular germ cell cancer: study of 27 cases in 500 patients. Br Med J 1986
Nov;293(6559):1398-401.
3. Jacobsen R, Bostofte E, Engholm G, et al. Risk of testicular cancer in men with abnormal semen
characteristics: cohort study. BMJ 2000 Sep;321(7264):789-92.
4. Huyghe E, Matsuda T, Thonneau P. Increasing incidence of testicular cancer worldwide: a review.
J Urol 2003 Jul;170(1):5-11.
5. Giwercman A, Muller J, Skakkebaek NE. Carcinoma in situ of the undescended testis. Semin Urol
1988 May;6(2):110-9. [No abstract available]
6. Petersen PM, Skakkebaek NE, Vistisen K, et al. Semen quality and reproductive hormones before
orchiectomy in men with testicular cancer. J Clin Oncol 1999 Mar;17(3):941-7.
7. Eberhard J, Stahl O, Giwercman Y, et al. Impact of therapy and androgen receptor polymorphism on
sperm concentration in men treated for testicular germ cell cancer: a longitudinal study. Hum Reprod
2004 Jun;19(6):1418-25.
8. Willemse PH, Sleijfer DT, Sluiter WJ, et al. Altered Leydig cell function in patients with testicular
cancer: evidence for bilateral testicular defect. Acta Endocrinol (Copenh) 1983 Apr;102(4):616-24.
9. Nord C, Bjoro T, Ellingsen D, et al. Gonadal hormones in long-term survivors 10 years after treatment
for unilateral testicular cancer. Eur Urol 2003 Sep;44(3):322-8.
10. Eberhard J, Stahl O, Cwikiel M, et al. Risk factors for post-treatment hypogonadism in yesticular
cancer patients. Eur J Endocrinol 2008 Apr;158(4):561-70.

11. Eberhard J, Stahl O, Cohn-Cedermark G, et al. Sexual function in men treated for testicular cancer.
J Sex Med 2009 Jul;6(7):1979-89.
12. Parra BL, Venable DD, Gonzalez E, et al. Testicular microlithiasis as a predictor of intratubular germ
cell neoplasia. Urology 1996 Nov;48(5):797-9.
13. Peterson AC, Bauman JM, Light DE, et al. The prevalence of testicular microlithiasis in an
asymptomatic population of men 18 to 35 years old. J Urol 2001 Dec;166(6):2061-4.
14. von Eckardstein S, Tsakmakidis G, Kamischke A, et al. Sonographic testicular microlithiasis as an
indicator of premalignant conditions in normal and infertile men. J Androl 2001 Sep-Oct;22(5):818-24.
15. Thomas K, Wood SJ, Thompson AJ, et al. The incidence and significance of testicular microlithiasis in
a subfertile population. Br J Radiol 2000 May;73(869):494-7.
16. Pierik FH, Dohle GR, van Muiswinkel JM, et al. Is routine scrotal ultrasound advantageous in infertile
men? J Urol 1999 Nov;162(5):1618-20.
17. Derogee M, Bevers RF, Prins HJ, et al. Testicular microlithiasis, a premalignant condition: prevalence,
histopathologic findings, and relation to testicular tumor. Urology 2001 Jun;57(6):1133-7.
18. Miller FN, Sidhu PS. Does testicular microlithiasis matter? A review. Clin Radiol 2002 Oct;57(10):
883-90.
19. Giwercman A, Muller J, Skakkebaek NE. Prevalence of carcinoma in situ and other histopathological
abnormalities in testes from 399 men who died suddenly and unexpectedly. J Urol 1991 Jan;145(1):
77-80.
20. de Gouveia Brazao CA, Pierik FH, Oosterhuis JW, et al. Bilateral testicular microlithiasis predicts the
presence of the precursor of testicular germ cell tumors in subfertile men. J Urol 2004 Jan;171(1):
158-60.
21. van Casteren NJ, Looijenga LH, Dohle GR. Testicular microlithiasis and carcinoma in situ overview and
proposed clinical guideline. Int J Androl 2009 Aug;32(4):279-87.
13. DISORDERS OF EJACULATION

13.1 Definition
Disorders of ejaculation are uncommon, but important, causes of male infertility. This group includes several
heterogeneous dysfunctions, which can be either organic or functional.
13.2 Classification and aetiology

13.2.1 Anejaculation
Anejaculation involves complete absence of antegrade or retrograde ejaculation. It is caused by failure
of semen emission from the seminal vesicles, prostate and ejaculatory ducts into the urethra (1). True
anejaculation is usually associated with a normal orgasmic sensation. Occasionally (e.g., in incomplete spinal
cord injuries), this sensation is altered or decreased. True anejaculation is always associated with central or
peripheral nervous system dysfunction or with drugs (2) (Table 15).
13.2.2 Anorgasmia
Anorgasmia is the inability to reach orgasm and can give rise to anejaculation. Anorgasmia is often a primary
condition and its cause is usually psychological. Some patients report sporadic events of nocturnal emission or
of ejaculation during great emotional excitement unrelated to sexual activity (3).
13.2.3 Delayed ejaculation

In delayed ejaculation, abnormal stimulation of the erect penis is needed to achieve orgasm with ejaculation (1).

Delayed ejaculation can be considered a mild form of anorgasmia, and both conditions can be found alternately
in the same patient. The causes of delayed ejaculation can be psychological, organic (e.g., incomplete spinal
cord lesion (3) or iatrogenic penile nerve damage (4), or pharmacological [e.g., selective serotonin re-uptake
inhibitors (SSRIs), antihypertensives, or antipsychotics] (5).
13.2.4 Retrograde ejaculation

Retrograde ejaculation is the total, or sometimes partial, absence of antegrade ejaculation as a result of
semen passing backwards through the bladder neck into the bladder. Patients experience a normal or
decreased orgasmic sensation, except in paraplegia. Partial antegrade ejaculation must not be confused with
the secretion of bulbourethral glands. The causes of retrograde ejaculation can be divided into neurogenic,
pharmacological, or urethral, or bladder neck incompetence (Table 15).
Table 15: Aetiology of anejaculation and retrograde ejaculation
Neurogenic Pharmacological
Spinal cord injury Antihypertensives
Cauda equina lesions α1-adrenoceptor antagonists
Multiple sclerosis Antipsychotics and antidepressants
Autonomic neuropathy (diabetes mellitus) Alcohol
Retroperitoneal lymphadenectomy Bladder neck incompetence
Sympathectomy or aortoiliac surgery Congenital defects/dysfunction of hemitrigone
Colorectal and anal surgery Bladder extrophy
Parkinson´s disease Bladder neck resection (transurethral resection of the
prostate)
Urethral Prostatectomy
Ectopic ureterocele
Urethral stricture
Urethral valves or verumontaneum hyperplasia
Congenital dopamine β-hydroxylase deficiency
13.2.5 Asthenic ejaculation

Asthenic ejaculation, also defined as partial ejaculatory incompetence or “ejaculation baveuse” (5), is
characterised by an altered propulsive phase, with a normal emission phase. The orgasmic sensation is
reduced and the typically rhythmical contractions associated with ejaculation are missing, whereas in asthenic
ejaculation caused by urethral obstruction, these contractions are present. Asthenic ejaculation generally is
caused by the neurogenic or urethral pathologies already listed in Table 16. Asthenic ejaculation does not
usually affect semen quality.
13.2.6 Premature ejaculation

The International Society for Sexual Medicine (ISSM) has adopted the first evidence-based definition of lifelong
premature ejaculation (PE): “Premature ejaculation is a male sexual dysfunction characterised by ejaculation
which always or nearly always occurs prior to or within about one minute of vaginal penetration; and inability
to delay ejaculation on all or nearly all vaginal penetrations; and negative personal consequences, such as
distress, bother, frustration and/or the avoidance of sexual intimacy”.
Premature ejaculation may be strictly organic (e.g., prostatitis-related) or psychogenic, partner-
related or non-selective, and can be associated with erectile dysfunction. It does not impair fertility, provided
intravaginal ejaculation occurs.
13.2.7 Painful ejaculation

Painful ejaculation is usually an acquired condition that is often related to lower urinary tract symptoms (6). It
sometimes causes moderate sexual dysfunction. The painful sensation might be felt in the perineum, or urethra
and urethral meatus (7). It can be caused by ejaculatory duct obstruction, all types of chronic prostatitis/CPPS,
urethritis, urethrocele, antidepressant drugs, and psychological problems.
13.3 Diagnosis
Diagnostic management includes the following recommended procedures.
13.3.1 Clinical history

The patient must be carefully checked for diabetes, neuropathy, trauma, urogenital infection, previous surgery,

and medication. Particular attention must be paid to the characteristics of micturition and ejaculation (presence
of nocturnal emission, ejaculatory ability in given circumstances, and primary or acquired disorder), as well as
to psychosexual aspects (education, features of affective relationship, pre-existent psychological trauma, and
previous psychological therapy).
13.3.2 Physical examination

Genital and rectal examinations are conducted, including evaluation of the prostate, bulbocavernosus reflex,
and anal sphincter tone. Minimal neurological tests include:
• sensitivity of scrotum, testes, and perineum;
• cremasteric and abdominal cutaneous reflex;
• leg osteotendinous and plantar reflexes.
13.3.3 Post-ejaculatory urinalysis

Post-ejaculatory urinalysis of centrifuged urine can be used to determine if there is total or partial retrograde
ejaculation.
13.3.4 Microbiological examination

Initial, mid-stream urine, EPS, and/or urine after prostatic massage are cultured for evidence of prostatic
infection. In cases of increased leukocytes in semen, semen culture or biochemical infection marker tests are
also suggested (8).
13.3.5 Optional diagnostic work-up

This diagnostic work-up can include:
• neurophysiological tests (bulbocavernosus evoked response and dorsal nerve somatosensory evoked
potentials);
• tests for autonomic neuropathy;
• psychosexual evaluation;
• videocystometry;
• cystoscopy;
• transrectal ultrasonography;
• uroflowmetry;
• vibratory stimulation of the penis.
13.4 Treatment
Infertility caused by disorders of ejaculation is seldom treated on the basis of aetiology. Treatment usually
involves retrieval of spermatozoa for use in ARTs. The following aspects must be considered when selecting
treatment:
• age of patient and his partner;
• psychological problems of the patient and his partner;
• couple’s willingness and acceptance of different fertility procedures;
• associated pathology;
• psychosexual counselling.
13.5 Aetiological treatment

If possible, any pharmacological treatment that is interfering with ejaculation should be stopped. In painful
ejaculation, tamsulosin can be administered during antidepressant treatment (9). Treatment should be given
for urogenital infections (i.e., in cases of painful ejaculation) (8). Dapoxetin is an SSRI that has been introduced
for the therapy of PE (10), because it appears that PE is related to serotonin levels. If possible, any underlying
urethral pathology or metabolic disorder (e.g., diabetes) should be corrected. Psychotherapy is usually not very
effective.
13.6 Symptomatic treatment

13.6.1 Premature ejaculation
Primature ejaculation can be treated with the SSRI dapoxetine, topical anaesthetic agents to increase
intravaginal ejaculation latency time, behavioural therapy, and/or psychotherapy. Off-label use of SSRIs (e.g.,
paroxetine and fluoxetine) should be applied with caution.
13.6.2 Retrograde ejaculation

In the absence of spinal cord injury, anatomical anomalies of the urethra, or pharmacological agents, drug
treatment must be used to induce antegrade ejaculation (Table 16). Alternatively, the patient can be encouraged

to ejaculate when his bladder is full to increase bladder neck closure (11).
Table 16: Drug therapy for retrograde ejaculation
Drug Dosage regimen Ref.

Ephedrine sulphate 10-15 mg four times daily 12
Midodrine 5 mg three times daily 13
Brompheniramine maleate 8 mg twice daily 14
Imipramine 25-75 mg three times daily 15
Desipramine 50 mg every second day 16
Sperm collection from post-orgasmic urine for use in ART is recommended if:
• drug treatment is ineffective or intolerable as a result of side effects;
• the patient has a spinal cord injury;
• drug therapy inducing retrograde ejaculation cannot be interrupted.
Sperm retrieval is timed to coincide with the partner’s ovulation. Urine must be alkalinised (pH 7.2-7.8)
and osmolarity must be 200-300 mOsmol/kg. Alternatively, a catheter can be inserted into the bladder to
allow instillation of 10-50 mL Tyrode’s or Ham’s F-10 medium. The patient must ejaculate, and a second
catheterisation is carried out immediately to retrieve spermatozoa. The latter treatment minimises contact
between spermatozoa and urine (17,18).
If the biological sperm preparation is not of sufficient quality for intrauterine insemination, the couple
must undergo in vitro reproductive procedures (e.g., ICSI) with fresh or cryopreserved spermatozoa. In the case
of insufficient drug therapy, testicular (TESE or PESA) or epididymal (MESA) sperm retrieval techniques can be
used for assisted reproduction.
13.6.3 Anejaculation
Drug treatment for anejaculation caused by lymphadenectomy and neuropathy, or psychosexual therapy for
anorgasmia is not very effective. In all these cases, and in men who have a spinal cord injury, vibrostimulation
(i.e., application of a vibrator to the penis) is first-line therapy.
In anejaculation, vibrostimulation evokes the ejaculation reflex (19), which requires an intact
lumbosacral spinal cord segment. Complete spinal injuries and injuries above T10 show a better response to
vibrostimulation. Once the safety and efficacy of this procedure has been assessed, patients can manage the
process in their own home. Intravaginal insemination using a 10-mL syringe during ovulation can be carried
out. If the quality of semen is poor, or ejaculation is retrograde, the couple may enter an IVF programme.
If vibrostimulation has failed, electroejaculation is the therapy of choice (20). Electroejaculation
involves electrical stimulation of the periprostatic nerves via a probe inserted into the rectum, which seems
unaffected by reflex arc integrity. Anaesthesia is required except in cases of complete spinal cord injury. In 90%
of patients, electrostimulation induces ejaculation, which is retrograde in one-third of cases. Semen quality is
often poor and most couples will need to enter an IVF programme (21).
When electroejaculation fails or cannot be carried out, sperm can be retrieved from the seminal ducts
by aspiration from the vas deferens (22) (see Chapter 5) or seminal tract washout (23).
When sperm cannot be retrieved, epididymal obstruction or testicular failure must be suspected). If
only immotile sperm can be retrieved, DNA damage is very likely and will yield poor IVF results. TESE can then
be used (8,24). Anejaculation following either surgery for testicular cancer or total mesorectal excision can be
prevented using monolateral lymphadenectomy or autonomic nerve preservation (24), respectively.
13.7 Conclusion and recommendations for disorders of ejaculation
Conclusion LE
Ejaculation disorders can be treated using a wide range of drugs and physical stimulation, with a high 3
level of efficacy.
Recommendations GR
Aetiological treatments for ejaculatory disorders should be offered before sperm collection and ART is B
performed.
Premature ejaculation can be treated successfully with either topical anaesthetic creams or SSRIs. A
In men with spinal cord injury, vibrostimulation and electroejaculation are effective methods of sperm B
retrieval.

13.8 References
1. Buvat J. Glossaire. [Disruptions in ejaculation] In: Buvat J, Jouannet P (eds). [Ejaculation and its
Disruptions.] Lyon-Villeurbanne: SIMEP, 1984, p. 9. [Book in French]
2. Wang R, Monga M, Hellstrom WJG. Ejaculatory dysfunction. In: Comhaire FH (ed). Male
Infertility:Clinical Investigation. Cause, Evaluation and Treatment. London: Chapman Hall, 1996, pp.
205-221.
3. Pryor JP. Erectile and ejaculatory problems in infertility. In: Hargreave TB (ed). Male Infertility.
Berlin:Springer-Verlag, 1997, pp. 319-36.
4. Yachia D. Our experience with penile deformations: incidence, operative techniques, and results.
J Androl 1994 Nov-Dec;15(Suppl):63S-68S.
5. Rudkin L, Taylor MJ, Hawton K. Strategies for managing sexual dysfunction induced by antidepressant
medication. Cochrane Database Syst Rev 2004 Oct18;(4):CD003382.
6. Vallancien G, Emberton M, Harving N, et al; Alf-One Study Group. Sexual dysfunction in 1,274
European men suffering from lower urinary tract symptoms. J Urol 2003 Jun;169(6):2257-61.
7. Hermabessiere J, Bouquet de la Joliniere J, Buvat J. [Painful ejaculation. Researching organic causes.]
In: Buvat J, Jouannet P (eds). [Ejaculation and its Disruptions.] Lyon-Villeurbanne: SIMEP, 1984, pp.
129-134. [Book in French]
8. Abdel-Hamid IA, El Naggar EA, El Gilany AH. Assessment of as needed use of pharmacotherapy and
the pause-squeeze technique in premature ejaculation. Int J Impot Res 2001 Feb;13(1):41-5.
9. Demyttenaere K, Huygens R. Painful ejaculation and urinary hesitancy in association with
antidepressant therapy: relief with tamsulosin. Eur Neuropsychopharmacol 2002 Aug;12(4):337-41.
10. McMahon CG, Porst H. Oral agents for the treatment of premature ejaculation: review of efficacy
and safety in the context of the recent international society for sexual medicine criteria for lifelong
premature ejaculation. Sex Med 2011 Oct;8(10):2707-25.
11. Crich JP, Jequier AM. Infertility in men with retrograde ejaculation: the action of urine on sperm
motility, and a simple method for achieving antegrade ejaculation. Fertil Steril 1978 Nov;30(5):572-6.
12. Gilja I, Parazajder J, Radej M, et al. Retrograde ejaculation and loss of emission: possibilities of
conservative treatment. Eur Urol 1994;25(3):226-8.
13. Jonas D, Linzbach P, Weber W. The use of midodrin in the treatment of ejaculation disorders following
retroperitoneal lymphadenectomy. Eur Urol 1979;5(3):184-7.
14. Schill WB. Pregnancy after brompheniramine treatment of a diabetic with incomplete emission failure.
Arch Androl 1990;25(1):101-4.
15. Brooks ME, Berezin M, Braf Z. Treatment of retrograde ejaculation with imipramine. Urology 1980
Apr;15(4):353-5.
16. Hendry WF. Disorders of ejaculation: congenital, acquired and functional. Br J Urol 1998
Sep;82(3):331-41.
17. Mahadevan.M., Leeton,J.F. and Trounson.A.O. Noninvasive method of semen collection for successful
artificial insemination. Fertil Steril 1981; 36, 243-7. [No abstract available]
18. Yavetz H, Yogev L, Hauser R. Retrograde Ejaculation. Human Reprod. 1994; 9:381-6.
19. Brindley GS. Reflex ejaculation under vibratory stimulation in paraplegic men. Paraplegia
1981;19(5):299-302.
20. Elliott S, Rainsbury PA. Treatment of anejaculation. In: Colpi GM, Balerna M (eds). Treating Male
Infertility: New Possibilities. Basel: Karger AG, 1994, pp. 240-54.
21. Denil J, Kuczyk MA, Schultheiss D, et al. Use of assisted reproductive techniques for treatment of
ejaculatory disorders. Andrologia 1996;28(Suppl 1):43-51.

22. Waldinger MD. The neurobiological approach to premature ejaculation. J Urol 2002 Dec;168(6):
2359-67.
23. Jankowicz E, Drozdowski W, Pogumirski J. [Idiopathic autonomic neuropathy (pandysautonomia)].
Neurol Neurochir Pol 2001 Mar-Apr;35(3):439-52. [Article in Polish]
24. Maurer CA, Z’Graggen K, Renzulli P, et al. Total mesorectal excision preserves male genital function
compared with conventional rectal cancer surgery. Br J Surg 2001 Nov;88(11):1501-5.
14. SEMEN CRYOPRESERVATION

14.1 Definition
Cryopreservation is the storage of biological material at subzero temperatures [e.g., -80 or -196°C (the boiling
point of liquid nitrogen)], at which biochemical processes of cell metabolism are slowed or interrupted. At
-196°C, the biochemical reactions that lead to cell death are stopped.
14.2 Introduction
Cryopreservation was first developed in the 1940s by veterinarians and adapted for human sperm in the 1950s.
The first pregnancy that used cryopreservation took place in 1954 (1). In fertility practice, clinical indications for
cryopreservation include storage of sperm and testicular tissue.
14.3 Indications for storage

Storage of sperm is available in many clinics for the following indications:
• Before potentially sterilising chemotherapy or radiotherapy for cancer (2) or for non-malignant
diseases.
• Before surgery that might interfere with fertility (e.g. bladder neck surgery in a younger man or removal
of a testicle in a man with testicular malignancy, or before vasectomy or transgender surgery).
• For men with progressive decrease in semen quality as a result of diseases that have an associated
risk of subsequent azoospermia (i.e., pituitary macroadenoma, craniopharyngioma, empty sella
syndrome, chronic nephropathy, uncontrolled diabetes mellitus, and multiple sclerosis).
• For men with paraplegia when sperm have been obtained by electroejaculation or obtained by penile
vibratory stimulation.
• For men with psychogenic anejaculation, after sperm have been obtained either by electroejaculation
or a sperm retrieval procedure.
• After gonadotropin treatment has induced spermatogenesis in men with hypogonadotrophic
hypogonadism.
• For men with NOA, the chance of finding sperm using micro-TESE is ~50%.
Cryopreservation can be used for sperm collected through TESE, avoiding repeated sperm retrieval procedures
and unnecessary hyperstimulation of the female partner.
• In any situation in which sperm have been obtained by a sperm retrieval procedure (e.g., after failed
vasectomy reversal, or in some cases of epididymal obstruction not amenable to surgery).
• For storage of donor sperm, because cryopreservation reduces the risk of transmission of infection
from sperm donors. According to the European directives 2004/23 EC and 2006/17 EC fresh sperm
are no longer to be used for non-partner donations.
14.4 Precautions and techniques

14.4.1 Freezing and thawing process
The cryopreservation techniques currently used are not yet optimal because damage occurs to cells during
cryopreservation and prolonged storage. Most damage occurs during freezing and thawing. Major causes
of damage during freezing are ice crystal formation and cell dehydration, which disrupt the cell wall and
intracellular organelles. Sperm morphology, motility and vitality decrease significantly after thawing, and
cryopreservation increases the damage done to sperm DNA (3-6). Further damage can be caused by
contamination of samples with microorganisms and high levels of superoxide radicals (7,8). To reduce ice
crystal formation, a cryopreservation solution is added before freezing. Various cryopreservation solutions are
available commercially, most of which contain varying proportions of glycerol and albumin. After freezing, the

samples are immersed in liquid nitrogen.
Several techniques have been developed to try to reduce damage caused by freezing and thawing, including:
• One-step freezing method (9,10): sample is held in the vapour phase for 10 min before being plunged
into liquid nitrogen.
• Slow or multi-step method (11): sample is gradually cooled in the vapour phase for approximately 40
min. A programmable automatic freezing machine, which is preset to cool at a rate of 1-10°C/min is
used.
The method available depends on the resources of the laboratory. Whichever freezing technique is used, it
should be tested using donor sperm and post-thaw examination, and should regularly undergo a quality-control
programme.
The likelihood of sperm survival decreases with repeated freezing and thawing. The maximum viable
storage time for human sperm is not known. Many laboratory or regulatory authorities apply a storage limit of
up to 10 years (12). However, longer storage is sometimes needed (e.g., for a 17-year-old man who has had
sperm stored before undergoing chemotherapy for testicular cancer).
14.4.2 Cryopreservation of small numbers of sperm

Standard cryopreservation in straws is an efficient way of storing large numbers of sperm (e.g., for a donor
insemination programme). However, in micro-TESE, few sperm might be obtained, and the choice is either to
freeze testicular tissue and find sperm after thawing the tissue, or to freeze small numbers of sperm. If sperm
are frozen in straws, it can be difficult to find any sperm after thawing. Instead, the sperm should be frozen in a
pellet (13) or in a container (14).
14.4.3 Testing for infections and preventing cross-contamination

Sperm storage in straws is used extensively. Large numbers of straws are stored in canisters, with the straws
being bathed in a pool of liquid nitrogen. Microbial contamination of the pool of liquid nitrogen results in
contamination of the outside of all the straws. The most widely used safeguard is to use so-called high security
closed straws. According to the European directives 2004/23 and 2006/17, samples should be tested for
hepatitis B and C and human immunodeficiency virus (HIV). In case of non-partner donation, samples are also
tested for C. Trachomatis (by NAT) and syphilis, as well as genetics, that is, karyotype and most prevalent
genetic disorders in the population to which the non-partner donor belongs.
Until the test results are known, samples must be stored in an individual quarantine vessel (separate
storage). If open straws are used (e.g., for vitrification purposes) some laboratories use the additional
safeguard of double-wrapping the straws before freezing, although this is more costly. Some centres carry out
cytomegalovirus testing and store negative and positive samples separately.
Considerable ethical issues surround the storage of samples before cancer chemotherapy in men
who are hepatitis-virus- or HIV-positive. Few clinics have separate storage facilities for HIV-positive samples.
However, the success of antiretroviral treatment is increasing the number of HIV-positive men who may wish
to store sperm. There is also concern about HIV transmission to children conceived using HIV-positive sperm,
because sperm-washing techniques fail in ~5% of cases.
14.4.4 Fail-safe precautions to prevent loss of stored materials

Any laboratory that undertakes long-term storage of human biological materials should have procedures that
guard against accidental loss of material caused by storage vessel failure. This is particularly important for
sperm stored before potentially sterilising cancer chemotherapy because these patients may not be able to
obtain further sperm.
14.4.5 Orphan samples

In malignancy and some other situations, several years might pass before stored samples are required.
Inevitably, during this time, the owners of some samples might disappear or die, leaving behind orphan
samples for which the owner is no longer contactable. The duty of the laboratory and the legal ownership of
these samples can create considerable problems.
14.5 Biological aspects

Cryopreservation induces deterioration of semen quality. After the sample has been thawed, motility (16) and
morphology (17,18) are worsened, including mitochondrial acrosomal and sperm tail damage (19). Sperm
freezing decreases motility by 31% and mitochondrial activity by 36%, and causes morphological disruption
in 37% of sperm (9). Motility is correlated best with IVF capacity of the thawed sample. Further improvement
can be achieved by selecting the subpopulation of sperm with the best motility and DNA integrity and freezing
these sperm in seminal plasma (13).

14.6 Cryopreservation of testicular stem cells
Spermatogonial stem cell (SSC) preservation and transplantation have been proposed as a promising strategy
for fertility preservation in young boys facing SSC loss (20). Since the first publication of SSC transplantation
in mice in 1994, remarkable progress has been made towards a clinical application. Cryopreservation
protocols for testicular tissue have been developed in animal models, translated to humans, and are already
used clinically. Transplantation methods are being used in human testes, and the efficiency and safety of the
technique has been evaluated in a mouse model. The application of this technique in humans looks possible,
therefore, banking testicular biopsies from prepubertal boys for future stem cell transplantation is being
introduced in many centres.
14.7 Conclusions and recommendations for semen cryopreservation
Conclusions LE
The purpose of sperm cryopreservation is to enable future assisted reproduction techniques 1b
procedures.
Cryopreservation techniques are not optimal, and future efforts are needed to improve the outcome of 3
sperm banking.
Recommendations GR
Cryopreservation of semen should be offered to all men who are candidates for chemotherapy, A
radiation or surgical interventions that might interfere with spermatogenesis or cause ejaculatory
disorders.
If testicular biopsies are indicated, sperm cryopreservation is strongly advised. A
If cryopreservation is not available locally, patients should be advised about the possibility of visiting, C
or transferring to, the nearest cryopreservation unit before therapy starts.
Consent for cryopreservation should include a record of the man’s wishes for his samples if he dies or C
is otherwise untraceable.
Precautions should be taken to prevent transmission of viral, sexually transmitted or any other C
infection by cryostored materials from donor to recipient, and to prevent contamination of stored
samples. These precautions include testing of the patient and the use of rapid testing and quarantine
of samples until test results are known. Samples from men who are positive for hepatitis virus or HIV
should not be stored in the same container as samples from men who have been tested and are free
from infection.
14.8 References
1. Bunge RG, Keettel WC, Sherman JK. Clinical use of frozen semen; report of four cases. Fertil Steril
1954 Nov-Dec;5(6):520-9. [No abstract available]
2. Saito K, Suzuki K, Iwasaki A, et al. Sperm cryopreservation before cancer chemotherapy helps in the
emotional battle against cancer. Cancer 2005 Aug;104(3):521-4.
3. Desrosiers P, Legare C, Leclerc P, et al. Membranous and structural damage that occur during
cryopreservation of human sperm may be time-related events. Fertil Steril 2006 Jun;85(6):1744-52.
4. Donnelly ET, McClure N, Lewis SE. Cryopreservation of human semen and prepared sperm: effects on
motility parameters and DNA integrity. Fertil Steril 2001 Nov;76(5):892-900.
5. Chohan KR, Griffin JT, Carrell DT. Evaluation of chromatin integrity in human sperm using acridine
orange staining with different fixatives and after cryopreservation. Andrologia 2004 Oct;36(5):321-6.
6. Askari HA, Check JH, Peymer N, et al. Effect of natural antioxidants tocopherol and ascorbic acids in
maintenance of sperm activity during freeze-thaw process. Arch Androl 1994 Jul-Aug;33(1):11-5.
7. Smith KD, Steinberger E. Survival of spermatozoa in a human sperm bank. Effects of long-term
storage in liquid nitrogen. J Am Med Assoc 1973 Feb;223(7):774-7.
8. Agarwal A, Said TM. Oxidative stress, DNA damage and apoptosis in male infertility: a clinical
approach. BJU Int 2005 Mar;95(4):503-7.

9. Grischenko VI, Dunaevskaya AV, Babenko VI. Cryopreservation of human sperm using rapid cooling
rates. Cryo Letters 2003 Mar-Apr;24(2):67-76.
10. Sherman JK, Bunge RG. Observations on preservation of human spermatozoa at low temperatures.
Proc Soc Exp Biol Med 1953 Apr;82(4):686-8. [No abstract available]
11. Sawada Y, Ackerman D, Behrman SJ. Motility and respiration of human spermatozoa after cooling to
various low temperatures. Fertil Steril 1967 Nov-Dec;18(6):775-81. [No abstract available]
12. Henry MA, Noiles EE, Gao D, et al. Cryopreservation of human spermatozoa. IV. The effects of cooling
rate and warming rate on the maintenance of motility, plasma membrane integrity, and mitochondrial
function. Fertil Steril 1993 Nov;60(5):911-8.
13. Bahadur G, Ling KL, Hart R, et al. Semen quality and cryopreservation in adolescent cancer patients.
Hum Reprod 2002 Dec;17(12):3157-61.
14. Hallak J, Hendin BN, Thomas AJ Jr, et al. Investigation of fertilizing capacity of cryopreserved
spermatozoa from patients with cancer. J Urol 1998 Apr;159(4):1217-20.
15. Clarke GN. Sperm cryopreservation: is there a significant risk of cross-contamination? Hum Reprod
1999 Dec;14(12):2941-3. [No abstract available]
16. O’Connell M, McClure N, Lewis SE. The effects of cryopreservation on sperm morphology, motility and
mitochondrial function. Hum Reprod 2002 Mar;17(3):704-9.
17. Woolley DM, Richardson DW. Ultrastructural injury to human spermatozoa after freezing and thawing.
J Reprod Fertil 1978 Jul;53(2):389-94.
18. Watson PF. Recent developments and concepts in the cryopreservation of spermatozoa and the
assessment of their post-thawing function. Reprod Fertil Dev 1995;7(4):871-91.
19. Donnelly ET, McClure N, Lewis SE. Cryopreservation of human semen and prepared sperm: effects on
motility parameters and DNA integrity. Fertil Steril 2001 Nov;76(5):892-900.
20. Geens M, Goossens E, De Block G, et al. Autologous spermatogonial stem cell transplantation in man:
current obstacles for a future clinical application. Hum Reprod Update 2008 Mar-Apr;14(2):121-30.

15. ABBREVIATIONS USED IN THE TEXT
This list is not comprehensive for the most common abbreviations
ABP acute bacterial prostatitis

ART assisted reproduction technique
CBAVD congenital bilateral absence of the vas deferens
CF cystic fibrosis
CFTR cystic fibrosis transmembrane conductance regulator
CIS carcinoma in situ
CPPS chronic pelvic pain syndrome
EAA European Academy of Andrology
EPS expressed prostatic excretion
FISH fluorescent in situ hybridisation
FSH follicle-stimulating hormone
GCT germ cell tumour
GnRH gonadotrophin-releasing hormone
GR grade of recommendation
GREAT G-protein-coupled receptor affecting testis descent
hCG human chorionic gonadotrophin
HIV human immunodeficiency virus
HMG human menopausal gonadotropin
ICSI intracytoplasmic sperm injection
IHH Idiopathic hypogonadotrophic hypogonadism
IL-6 interleukin-6
ITGCNU intratubular germ cell neoplasia of unclassified type
IVF in vitro fertilisation
LE level of evidence
LH luteinising hormone
MAGI male accessory gland infection
MAR mixed antiglobulin reaction
MESA microsurgical epididymal sperm aspiration
NIDDK National Institute of Diabetes and Digestive and Kidney Diseases
NIH National Institutes of Health
NOA non-obstructive azoospermia
OA obstructive azoospermia
OAT oligo-astheno-teratozoospermia [syndrome]
PE premature ejaculation
PGD preimplantation genetic diagnosis
SHBG sex hormone binding globulin
SSRIs selective serotonin reuptake inhibitors
TDS testicular dysgenesis syndrome
TEFNA testicular fine-needle aspiration
TESE testicular sperm extraction
TGCT testicular germ cell tumour
TM testicular microlithiasis
TRUS transurethral ultrasound
TURED transurethral resection of the ejaculatory ducts
WBC white blood cell
VB1 first-voided urine
WHO World Health Organization
Conflict of interest
All members of the Male Infertility Guidelines working group have provided disclosure statements of all
relationships that they have that might be perceived as a potential source of a conflict of interest. This
information is publicly accessible through the European Association of Urology website. This guidelines
document was developed with the financial support of the European Association of Urology. No external
sources of funding and support have been involved. The EAU is a non-profit organisation and funding is limited
to administrative assistance and travel and meeting expenses. No honoraria or other reimbursements have
been provided.

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3. TESTICULAR DEFICIENCY (PRIMARY SPERMATOGENIC FAILURE) 11

4. GENETIC DISORDERS IN INFERTILITY 14

2 MALE INFERTILITY - UPDATE MARCH 2013

9. IDIOPATHIC MALE INFERTILITY 40

MALE INFERTILITY - UPDATE MARCH 2013 3

10. MALE CONTRACEPTION 40

11. MALE ACCESSORY GLAND INFECTIONS AND INFERTILITY 44

12. GERM CELL MALIGNANCY AND TESTICULAR MICROCALCIFICATION 49

13. DISORDERS OF EJACULATION 51

4 MALE INFERTILITY - UPDATE MARCH 2013

14. SEMEN CRYOPRESERVATION 56

15. ABBREVIATIONS USED IN THE TEXT 60

MALE INFERTILITY - UPDATE MARCH 2013 5

1.2 Data identification

1.3 Level of evidence and grade of recommendation

Table 1: Level of evidence*

Level Type of evidence

*Modified from (1).

6 MALE INFERTILITY - UPDATE MARCH 2013

Grade Nature of recommendations

1.4 Publication history

1.5 Potential conflict of interest statement

1.7 Epidemiology and aetiology

MALE INFERTILITY - UPDATE MARCH 2013 7

Diagnosis Unselected patients Azoospermic patients

1.8 Prognostic factors

1.9 Recommendations on epidemiology and aetiology

8 MALE INFERTILITY - UPDATE MARCH 2013

MALE INFERTILITY - UPDATE MARCH 2013 9

Parameter Lower reference limit (range)

2.1.1 Frequency of semen analysis

2.2 Recommendations for investigations in male infertility

10 MALE INFERTILITY - UPDATE MARCH 2013

Table 5: Causes of testicular deficiency

3.3 Medical history and physical examination

3.4.1 Semen analysis

3.4.2 Hormonal determinations

MALE INFERTILITY - UPDATE MARCH 2013 11

3.4.3 Testicular biopsy

3.5 Conclusions and recommendations for testicular deficiency

12 MALE INFERTILITY - UPDATE MARCH 2013

MALE INFERTILITY - UPDATE MARCH 2013 13

4. GENETIC DISORDERS IN INFERTILITY

4.2 Chromosomal abnormalities

14 MALE INFERTILITY - UPDATE MARCH 2013

4.2.2 Autosomal abnormalities

4.2.3 Sperm chromosomal abnormalities

4.3 Genetic defects

MALE INFERTILITY - UPDATE MARCH 2013 15

4.3.3 Mild androgen insensitivity syndrome

4.3.4 Other X-disorders

4.4 Y-chromosome and male infertility

4.4.2 Clinical implications of Y microdeletions

16 MALE INFERTILITY - UPDATE MARCH 2013

4.4.2.1 Testing for Y microdeletions

4.4.2.2 Genetic counselling for AZF deletions

4.4.2.3 Y-chromosome: ‘gr/gr’ deletion

7.2 Hypogonadotrophic hypogonadism: aetiology, diagnosis and therapeutic management

7.3 Hypergonadotrophic hypogonadism: aetiology, diagnosis and therapeutic