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Diagnosis and Treatment of Infertility in Men: AUA/ASRM Guideline Part I
Abstract
PURPOSE: The summary presented herein represents Part I of the two-part series dedicated to the Diagnosis and Treatment of Infertility in Men: AUA/ASRM Guideline. Part I outlines the appropriate evaluation of the male in an infertile couple. Recommendations proceed from obtaining an appropriate history and physical exam (Appendix I), as well as diagnostic testing, where indicated. MATERIALS/METHODS: The Emergency Care Research Institute Evidence-based Practice Center team searched PubMed®, Embase®, and Medline from January, 2000 through May, 2019. When sufficient evidence existed, the body of evidence was assigned a strength rating of A (high), B (moderate), or C (low) for support of Strong, Moderate, or Conditional Recommendations. In the absence of sufficient evidence, additional information is provided as Clinical Principles and Expert Opinions (table 1[Table: see text]). This summary is being simultaneously published in Fertility and Sterility and The Journal of Urology. RESULTS: This Guideline provides updated, evidence-based recommendations regarding evaluation of male infertility as well as the association of male infertility with other important health conditions. The detection of male infertility increases the risk of subsequent development of health problems for men. In addition, specific medical conditions are associated with some causes for male infertility. Evaluation and treatment recommendations are summarized in the associated algorithm (figure[Figure: see text]). CONCLUSION: The presence of male infertility is crucial to the health of patients and its effects must be considered for the welfare of society. This document will undergo updating as the knowledge regarding current treatments and future treatment options continues to expand.
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“The American Urological Association advises starting the diagnostic process by carefully reviewing the patient’s reproductive history and the outcomes of two meticulously performed semen tests [32].”
BackgroundVariant PNLDC1 , Defective piRNA Processing, and Azoospermia
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“75,91,106”
BackgroundClinical application of aromatase inhibitors to treat male infertility
Yang, C., Li, P., & Li, Z. (2021) · Human Reproduction Update · doi:10.1093/humupd/dmab036 · Cited by 77
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“(2) Guidelines The recent AUA/ASRM guidelines do not comment on post-VR complications, but the 2011 guidelines warn that laparoscopic VR does have some risk of major intraperitoneal complications.”
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“(Conditional Recommendation; Evidence Level: Grade B)” [60].”
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“Utilizing FSH in predicting surgical outcomes has already been incorporated into Urologists’ practice, and based on our model should be added to the initial diagnostic workup of men with varicocele [24].”
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“Major scientific societies, including the European Association of Urology (EAU) [21] and the American Urological Association/American Society for Reproductive Medicine (AUA/ASRM) [22], are not supporting the routine use of AOXs in infertile men, mainly due to the heterogeneity of data.”
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“The relatively low prevalence of ASA has prompted the American Society for the Reproductive Medicine (ASRM), the American Urological Association (AUA) and the European Association of Urology (EAU) to not endorse the ASA test as a first-line test for the evaluation of infertile men [14,17,18].”
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“Infertile men with leukocytospermia and a positive semen culture should be treated with a course of antibiotics [98].”
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“This data collection was driven by the potentially relevant predictors identified from the literature and expert recommendations regarding evaluation of male infertility [6,41,42].”
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“org necessary and practice guidelines recommend that the initial infertility evaluation for the woman and the man be done concurrently [2].”
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“Routine semen analysis is amongst the cardinal points in MFI investigation, being significantly related to conception chance [1,6,7].”
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Medical management of non-obstructive azoospermia: A systematic review
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“In the case of FSH (or a FSH analogue), it is started after normalising testosterone levels with hCG [7].”
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“…10 6 round cells/mL) concentration of round cells is detected in the semen analysis, the guideline indicates that routine semen culture has no prospective benefit for infertile couples [117] as there is no clear association between the incidence of leukocytosper-mia and reproductive success [118].”
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“Despite these alarming findings, the role of paternal ageing when assessing the reproductive potential of a couple is underestimated by the national guidelines, and the assessment is often less comprehensive than that for the female partner [141,142].”
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“sperm with DNA damage in the ejaculate is indicative of lower chances of pregnancy in couples attempting natural conception or insemination [16].”
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“Medicine (ASRM) and AUA 2020 male infertility guidelines highlight that for men with NOA undergoing sperm retrieval, micro-TESE should be performed [3].”
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FIGO statement: Fertility preservation
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“In the case of varicocele repair in men with NOA before ART, the situation is more complex.”
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Sciorio, R., Paola, L. D., Notari, T., Ganduscio, S., Amato, P., Crifasi, L., Marotto, D., Billone, V., Cucinella, G., Perino, A., et al. (2025) · Diagnostics · doi:10.3390/diagnostics15050547 · Cited by 25
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“Additionally, single deviations in the test results should not be equated with a diagnosis of male infertility, and results with numerous deviations are of the greatest diagnostic importance [2].”
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Self-citationThe paternal role in pregnancy loss
Muncey, W. W., Scott, M. L., Lathi, R. B., et al. (2024) · Andrology · doi:10.1111/andr.13603 · Cited by 22
“16 Fortunately, the overall prevalence of this condition is only 2.9% in couples who have experienced two or more pregnancy losses.”
InfluentialSelf-citationAnabolic steroid misuse and male infertility: management and strategies to improve patient awareness
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“Therefore, mTESE should be preferred in men with NOA according to AUA/ASRM guidelines [9,10].”
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Andone, B.-A., Handrea-Dragan, I. M., Botiz, I., & Boca, S. (2023) · Nanomedicine Nanotechnology Biology and Medicine · doi:10.1016/j.nano.2023.102709 · Cited by 17
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“The recent guidelines by the American Urological Association do not specifically address repairing varicoceles for the purposes of improving serum testosterone [85], whereas the European Association of Urology guidelines suggest that it can be considered [86].”
Catford, S. R., Halliday, J. L., Lewis, S., O’Bryan, M. K., Handelsman, D. J., Hart, R. J., McBain, J., Rombauts, L. J. F., Amor, D. J., Saffery, R., et al. (2022) · Fertility and Sterility · doi:10.1016/j.fertnstert.2021.12.026 · Cited by 18
Pharmacological therapies for male infertility
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“It is also important to note that the male partner is also subjected to evaluation simultaneously, as the male factor contributes to approximately 20-30% of cases individually and about 50% of overall infertility cases [25,26].”
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Self-citationThe past, present, and future of the semen analysis
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“A semen analysis should be performed as a part of the initial evaluation of male infertility, followed by hormonal testing in instances of oligozoospermia or azoospermia 159 .”
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“53,54 Case 4: Young Woman With B-ALL S.D.isa24-year-oldwomanreferredtoadultsurvivorshipcare after a 5-year gap in follow-up, having completed therapy for ALL diagnosed in 1995 at age 3 years on CCG-1882.”
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“Sperm DNA fragmentation may adversely affect the outcome of ART treatments and natural fertility, and can increase the rate of miscarriage [21].”
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“Although numerous studies have identified semen analysis parameters as important benchmarks for evaluating reproductive health, its power to predict fertility outcomes remains limited (8–10).”
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Self-citationDiagnosis and Treatment of Infertility in Men
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“For example, the American Urological Association/American Society for Reproductive Medicine guidelines recommend against routine evaluation of SDF in infertility evaluation [24].”
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“AUA/ASRM and EAU guidelines on the association between varicocele and male infertility have been recently updated [23-25].”
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“Despite this, up to 25% of couples are never tested, highlighting the need for a more comprehensive testing [6–8].”
Chromosome defects and male factor infertility
Lamb, D. J. (2025) · Fertility and Sterility · doi:10.1016/j.fertnstert.2025.04.034 · Cited by 10
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Self-citationThe first Australian evidence‐based guidelines on male infertility
Katz, D. J., O’Donnell, L., McLachlan, R. I., et al. (2025) · The Medical Journal of Australia · doi:10.5694/mja2.70080 · Cited by 10
“7,31 As such, it is advisable that clinicians perform a cardiometabolic assessment to identify comorbidities such as obesity, obstructive sleep apnoea, hypertension, and undiagnosed or poorly controlled diabetes.”
Wu, J., Zhu, X., He, J., Ye, C., Pang, B., Zhao, T., & Bao, T. (2022) · Computational and Mathematical Methods in Medicine · doi:10.1155/2022/8438131 · Cited by 10
“Three-dimensional power Doppler ultrasound combined with virtual organ computer-aided analysis (VOCAL) software is more accurate in measuring OV [6].”
MethodRetractedBachelot, G., Lamazière, A., Czernichow, S., Faure, C., Racine, C., Lévy, R., Dupont, C., & Nutrition and Fertility (ALIFERT) Group (2024) · Asian Journal of Andrology · doi:10.4103/aja20247 · Cited by 9
The Evolutionary Route of in vitro Human Spermatogenesis: What is the Next Destination?
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“Infertility occurs in nearly 12–15% of couples and approximately 50% of these cases are due to male factors [20, 21].”
BackgroundA Grounded Theory Approach to Understanding Men Confronting Infertility
Abdullahzadeh, M., Vanaki, Z., Mohammadi, E., & Mohtashami, J. (2024) · Journal of Holistic Nursing · doi:10.1177/08980101241275201 · Cited by 9
“Confronting male infertility can be a complex and challenging process that requires more than just treating a medical condition (Schlegel et al., 2021).”
Çayan, S., Farkouh, A., Agarwal, A. K., et al. (2025) · The World Journal of Men s Health · doi:10.5534/wjmh.250005 · Cited by 9
“SDF testing is currently not endorsed as a routine assessment of sperm by any of the medical organizations, likely because controversies continue to exist regarding its actual clinical utility [17,18].”
Self-citationProtein disulfide isomerase is essential for spermatogenesis in mice
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Review of potential spermatogenic and aphrodisiac effects of the Ferula genus
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“Infertility treatments vary for several reasons and range from simple drug therapies to laboratory procedures and advanced surgery [4].”
BackgroundExpanding the role of chromosomal microarray analysis in the evaluation of recurrent pregnancy loss
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Anti-sperm Antibody Positivity in Men with Varicocele: A Systematic Review and Meta-Analysis
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Global Andrology Forum Clinical Guidelines on Antioxidant Use in the Treatment of Male Infertility.
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“8 15 The effectiveness and accuracy of AI-powered responses can significantly influence patient decisions and their subsequent interaction with healthcare professionals.”
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Is It Time for Andrology and Endocrinology Professionals in Assisted Reproduction Centers?
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“Due to these data, the ASRM recommended against the massive use of ICSI in couples undergoing to ART without confirmed male factor infertility [35].”
Thomas, J., Arbeláez, M. C. S., Narasimman, M., Weber, A. R., Blachman-Braun, R., White, J. T., Ledesma, B. R., Ghomeshi, A., Jara-Palacios, M. Á., & Ramasamy, R. (2023) · Cureus · doi:10.7759/cureus.41476 · Cited by 7
“Hypogonadism was defined as serum TT <300 ng/dL with clinical symptoms of hypogonadism, including erectile dysfunction, poor libido, and fatigue [14].”
BackgroundChallenges in completing a successful vasectomy reversal
Andino, J. J., Gonzalez, D. C., Dupree, J. M., Marks, S. F., & Ramasamy, R. (2021) · Andrologia · doi:10.1111/and.14066 · Cited by 7
“…Urological Association (AUA) 2020 male infertility guidelines highlight that couples desiring conception after vasectomy have the option of surgical reconstruction, surgical sperm retrieval, or both reconstruction and simultaneous sperm retrieval for cryopreservation (Schlegel et al., 2020).”
BackgroundInfluential
Metadata
- Authors
- Schlegel, P. N., Sigman, M., Collura, B., De Jonge, C. J., Eisenberg, M. L., Lamb, D. J., Mulhall, J. P., Niederberger, C., Sandlow, J. I., Sokol, R. Z., Spandorfer, S. D., Tanrikut, C., Treadwell, J. R., Oristaglio, J. T., & Zini, A.
- Affiliations
- NewYork–Presbyterian Hospital (US)
- Brown University (US)
- ReSoLVE Center of Excellence (FI)
- University of Minnesota School of Medicine
- Stanford Medicine (US)
- Weill Cornell Medicine (US)
- Memorial Sloan Kettering Cancer Center (US)
- University of Illinois Chicago (US)
- University of Southern California (US)
- Georgetown University (US)
- ECRI Institute (US)
- McGill University (CA)
- ORCID
- Venue
- Journal of Urology
- Published
- 2021-01
- Volume
- 205
- Issue
- 1
- Pages
- 36-43
- ISSN
- 0022-5347 (ISSN-L)
- 1527-3792
- OpenAlex
- W4254230981
- Cited by
- 274
- References
- 0
- Citations by year
- 2026: 53 · 2025: 51 · 2024: 67 · 2023: 43 · 2022: 39 · 2021: 21
- FWCI
- 18.64
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- The Journal of Urology (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Reproductive Medicine › Sperm and Testicular Function
- Health Sciences › Medicine › Urology › Male Reproductive Health Studies
- Health Sciences › Medicine › Reproductive Medicine › Reproductive Health and Technologies
- Keywords
- male infertility, infertility evaluation, infertility diagnosis, infertility treatment, clinical guidelines, diagnostic testing, history and physical examination
- MeSH terms
- Counseling, Humans, Infertility, Male, Life Style, Male, Scrotum, Societies, Medical, Ultrasonography, United States, Urology, Reproductive Medicine, Evidence-Based Medicine, Semen Analysis
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