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Male Infertility in the Era of ART: Why Treat; How to Treat
26 February 2009 (online)
Marc Goldstein, M.D. Zev Rosenwaks, M.D.
Recent dramatic advances in the diagnosis and treatment of male infertility have made it possible to achieve pregnancies in men who were previously considered to be untreatable or even sterile. Moreover, the elucidation of the molecular genetic underpinnings of spermatogenesis and the development of new sperm function tests have led to a better understanding of and to improved treatments for male infertility. Specifically, the advent of in vitro fertilization combined with intracytoplasmic sperm injection (IVF/ICSI) has revolutionized the treatment of even the most severely compromised males. Although IVF/ICSI has allowed reproductive endocrinologists to treat couples with severe male factor infertility, it is important to emphasize that a careful urologic and genetic evaluation should be performed before IVF/ICSI as recent studies have demonstrated a higher incidence of testicular cancer and/or genetic abnormalities in these men.
In some instances, appropriate medical or surgical treatment can enhance sperm production whereas others with persistent nonobstructive azoospermia, in spite of vigorous treatment, may require testicular sperm extraction. Microsurgical management of obstructive azoospermia and of varicoceles, as well as microdissection testicular extraction, has made the achievement of pregnancies possible in scenarios that were unimaginable only a decade ago. In addition, many conditions associated with infertility, such as varicocele, have been shown to be associated with more rapid declines in testosterone levels compared with those in age-matched men without varicocele. Thus, treatment of these infertility-associated conditions may not only improve fertility but may also prevent androgen deficiency in the aging male.
In this issue of Seminars in Reproductive Medicine, we have assembled a cadre of leading experts who present the current state of the art and future directions in the diagnosis and treatment of male infertility.