After completing the physical exam, history, endocrine evaluation, and semen analyses, we use an algorithm to stratify treatment options based on the couples’ goals and TMC (figure 4). Further, we always recommend cryopreserving sperm in order to allow multiple attempts at in vitro fertilization/intracytoplasmic sperm injection from one procedure. We typically obtain six vials of sperm from one TESE procedure from a man with obstructive azoospermia and one to four from a man with azoospermic spermatogenic failure. For men with obstructive azoospermia, we offer TESE or microsurgical reconstruction.
Our management of varicocele is based on the potential of treatment to impact the ultimate therapeutic course of the patient. Recent data have indicated that up to 45% of the partners of men who undergo varicoelectomy may become pregnant within 1 year of follow-up. This same study also found that only preoperative sperm concentration was an independent predictor of spontaneous pregnancy, leading the authors to conclude that patients with high initial sperm concentration may benefit from varicocelectomy (Fertil Steril 2015; 103:635-9). Despite these recent data, we base our decision of whether to surgically repair a varicocele on four factors:
- Is the varicocele at least Grade 2?
- Are there female factors that would mandate IVF?
- Would the couple consider IVF?
- Is treatment of the varicocele likely to enable IUI or natural pregnancy?
Part of the difficulty in providing cost-effective care of the infertile male is the inability of bulk semen parameters to predict pregnancy. For this reason, in couples with normozoospermia and unexplained infertility or recurrent pregnancy loss, we obtain a DNA fragmentation assay and a sperm penetration assay. If there is less than 5% sperm penetration or a DNA fragmentation is >35%, we typically recommend IVF/ICSI.