A significant proportion of infertile men may be treated with medication, surgery or a change in lifestyle to avoid assisted conception treatment.

Dr Steven Fleming writes in Bionews on 11 November about “An inconvenient truth: ICSI is not necessary for the majority of IVF patients1. In this article, he supports criticism of the overuse of ICSI, a treatment designed to overcome male factor infertility. He argues that fertility clinics consistently offer ICSI treatment to 53 and 68 % couples in the UK and Australasia respectively, with some UK clinics treating up to 80 % of couples, when only 30 – 40 % of infertility is due to male factor.

We would like to take this one step further and suggest that assisted conception treatment as a whole is overused, since a fair proportion of those men with infertility may well be treated effectively for underlying pathology or lifestyle issues in the first place, rendering IVF treatment unnecessary.

Approximately 15% of infertile men have a varicocoele and there is now evidence to show that varicocoele repair may restore fertility to those affected2,3. Silent infections are present in around 20% of infertile couples, which results in impaired sperm parameters4 and may be associated with unexplained infertility, or recurrent miscarriage5. Antibiotics are an obvious effective form of treatment for most male accessory gland infections and for bacterial prostatitis2. Hypogonadism accounts for almost 6% of male infertility resulting in impaired spermatogenensis and hormone therapy should be administered2,6. In some cases, obstructions of the male reproductive tract may be surgically corrected2. Up to 6% of individuals may suffer from disturbances of semen deposition, including anatomical abnormalities such as Peyronie’s disease or hypospadias which may be corrected surgically2,7, while erectile dysfunction is also a significant contributing factor to male infertility, correlated with reduced coital frequency8. This may be managed pharmacologically or with psychosexual counseling, while pharmacological treatment may be offered for other ejaculation disorders. Sperm quality is also known to be affected by lifestyle factors such as excessive heat exposure, binge alcohol drinking, caffeine, smoking and recreational or prescribed drugs9. These have been implicated in unexplained infertility and studies have shown that semen parameters can improve if these factors are addressed.

The investigation of the majority of men attending assisted conception units starts and ends with a semen analysis, with inevitably only one form of treatment offered for male infertility i.e. IVF/ICSI. It is about time men were properly diagnosed and given an appropriate treatment pathway in the first place before they are shunted down the IVF/ICSI path. This can only happen when men are provided with comprehensive investigation and are seen by qualified specialist Uro-Andrologists to deal with any clinical issues. Assisted conception treatment should be a last resort only.

References:

1. http://www.bionews.org.uk/page_363168.asp?dinfo=WL6tBpHj5WCyiLAGHz6M38dd&PPID=363174

2. Jungwirth, T. Diemer, G.R. Dohle, A. Giwercman, Z. Kopa, C. Krausz, H. Tournaye (2102) Guidelines on Male Infertility. European Association of Urology

3. Mehta A and Goldstein M(2013) Microsurgical varicocelectomy: a review. Asian J Androl 15(1): 56-60

4. Rusz A, Pilatz A, Wagenlehner F, Linn T, Diemer T, Schuppe HC, Lohmeyer J, Hossain H, Weidner W. (2012) Influence of urogenital infections and inflammation on semen quality and male fertility. World J Urol 30: 23-30

5. Nigro G, Mazzocco M, Mattia E, Di Renzo GC, Carta G, Anceschi MM (2011) Role of the infections in recurrent spontaneous abortion. J Matern Fetal Neonatal Med 24(8):983-9. Review.

6. Hwang K, Walters RC, Lipshultz LI (2011) Contemporary concepts in the evaluation and management of male infertility Nat Rev Urol 8(2):86-94

7. Serefoglu EC and Hellstrom WJ (2012) Treatment of Peyronie’s disease: 2012 update. Curr Urol Rep 12 (6): 444-52

8. Perlis N, Lo KC, Grober ED, Spencer L, Jarvi K (2013) Coital frequency and infertility: which male factors predict less frequent coitus among infertile couples? Fertil Steril 100(2):511-5.

9. Sharma R, Biedenharn KR, Fedor JM, Agarwal A (2013) Lifestyle factors and reproductive health: taking control of your fertility. Reprod Biol Endocrinol 11:66. –