Male Infertility: Clinical Guidelines

List of Abbreviations

ATC group – Anatomical Therapeutic Chemical classification group

HIV – human immunodeficiency virus

IUI – intrauterine insemination (intrauterine administration of husband's/partner's or donor sperm)

ART – assisted reproductive technologies

WHO – World Health Organization

DNA – deoxyribonucleic acid

ICSI – intracytoplasmic sperm injection

BMI – body mass index

LH – luteinizing hormone

MESA – microsurgical epididymal sperm aspiration (A11.21.002 Biopsy of testis, epididymis and spermatic cord)

Micro-TESE – microsurgical testicular sperm extraction

ICD-10 – International Classification of Diseases 10th Revision

NOA – non-obstructive azoospermia

NMU — nomenclature of medical services

OA – obstructive azoospermia

Onco-TESE – oncotesticular sperm extraction

PESA – percutaneous epididymal sperm aspiration (A11.21.002 Biopsy of testis, epididymis and spermatic cord)

PGT – preimplantation genetic testing (A10.20.001)

PGT-A – PGT for aneuploidy (A10.20.001.001 Preimplantation genetic testing for aneuploidies)

PGT-M – PGT for monogenic disorders (A10.20.001.002 Preimplantation genetic testing for monogenic disorders)

PGT-SR – PGT for chromosomal structural rearrangements (A10.20.001.003 Preimplantation genetic testing for structural chromosomal rearrangements)

FET – transfer of thawed embryo(s) into the uterine cavity (A11.20.030.001 Intrauterine administration of a cryopreserved embryo)

PCR – polymerase chain reaction

RE – retrograde ejaculation

TESA – percutaneous testicular sperm aspiration (testicular puncture)

TESE – testicular sperm extraction (testicular biopsy)

TRUS – transrectal ultrasound

US – ultrasound examination

SDF – sperm DNA fragmentation

FSH – follicle-stimulating hormone

IVF – in vitro fertilization

AZF – azoospermia factor

CFTR – cystic fibrosis transmembrane conductance regulator, a protein involved in chloride ion transport across the cell membrane; mutations in the CFTR gene lead to cystic fibrosis, a systemic hereditary autosomal recessive disease

MAR test – mixed antiglobulin reaction, a test for antisperm antibodies

Terms and Definitions

Aspermia – absence of ejaculate (or retrograde ejaculation).

Percutaneous epididymal sperm aspiration (PESA) or epididymal aspiration biopsy – a surgical procedure involving needle aspiration of the epididymis to obtain spermatozoa.

Testicular sperm aspiration (TESA) or testicular aspiration biopsy – a surgical procedure involving needle aspiration of the testis to obtain spermatozoa.

Asthenozoospermia – the percentage of progressively motile spermatozoa is below reference values.

Azoospermia – absence of spermatozoa in the ejaculate (azoospermia is diagnosed after evaluating the centrifuged pellet of the ejaculate).

Infertility – a disease characterized by the failure to achieve a clinical pregnancy after 12 months of regular unprotected sexual intercourse due to an impairment of a person's capacity to reproduce either as an individual or with their partner. Infertility evaluations and interventions may be initiated sooner than 1 year based on medical, sexual, and reproductive history, age, physical examination findings, and diagnostic test results.

Infertility is a disease characterized by the presence of an obstacle to the realization of reproductive function.

Intrauterine insemination (IUI) or intrauterine administration of husband's (partner's) or donor sperm – a procedure in which laboratory-processed sperm is injected into the uterine cavity to achieve pregnancy

Assisted reproductive technologies (ART) – methods of infertility treatment where some or all stages of conception and early embryo development are carried out outside the maternal organism (including the use of donor and/or cryopreserved gametes, reproductive tissues, and embryos), as well as surrogacy (defined in accordance with Article 55 of Federal Law No. 323-FZ of November 21, 2011 (as amended on December 25, 2011) "On the Fundamentals of Public Health Protection in the Russian Federation").

Secondary infertility – a condition in which the man has previously achieved pregnancies, but conception has not occurred within a year of regular unprotected sexual intercourse

Miscarriage (spontaneous abortion) – spontaneous termination of pregnancy (expulsion or extraction of the embryo/fetus) before 22 weeks of gestation.

Female infertility associated with male factors – infertility associated with impaired reproductive function in the male partner

Cryopreservation – the process of freezing biological material (gametes, zygotes, cleavage-stage embryos, blastocysts, gonadal tissues) at extremely low temperatures for its preservation

Cryptozoospermia – spermatozoa are absent in the native preparation but present in the ejaculate pellet.

Leukocytospermia (leukospermia, pyospermia) – presence of leukocytes in the ejaculate above reference values.

Microsurgical epididymal sperm aspiration (MESA) – a type of epididymal biopsy, a surgical procedure involving the retrieval of epididymal spermatozoa under microscopic control.

Microsurgical testicular sperm extraction (micro-TESE) – a type of testicular biopsy, a surgical procedure involving the visualization of testicular seminiferous tubules and their extraction under microscopic control using 6–25x optical magnification to obtain spermatozoa.

Male infertility – impairment of male reproductive function leading to the inability to conceive

Necrozoospermia – a low percentage of live and a high percentage of immotile spermatozoa in the ejaculate.

Normozoospermia – total sperm count and the percentage of progressively motile and morphologically normal spermatozoa are equal to or above reference values.

Oligozoospermia – total sperm count is below reference values.

Onco-TESE – oncotesticular sperm extraction from the testes, performed before gonadotoxic treatment

Embryo transfer (intrauterine embryo administration) – introduction of embryo(s) into the uterine cavity at any stage of development from day 1 to day 7 post-IVF or ICSI, or using thawed embryo(s)

Primary infertility – a condition in which no pregnancies have been achieved by the man, despite regular sexual intercourse for one year without contraception.

Preimplantation genetic testing (A10.20.001) – DNA analysis of embryos (at the cleavage or blastocyst stage) to detect genetic abnormalities. It includes preimplantation genetic testing for aneuploidies – A10.20.001.001 (PGT-A), preimplantation genetic testing for monogenic disorders – A10.20.001.002 (PGT-M), and preimplantation genetic testing for structural chromosomal rearrangements – A10.20.001.003 (PGT-SR).

Preconceptional (pregravid) preparation in men – a set of diagnostic, therapeutic, and preventive measures aimed at optimizing male reproductive function

Recurrent pregnancy loss (RPL, recurrent miscarriage) – the occurrence of 2 or more clinical pregnancy losses in a woman at gestations under 22 weeks.

Reproductive function (fertility) is the ability of an organism to produce viable offspring. In men, it is determined by the state of the reproductive system organs ensuring sperm formation and delivery, ejaculate parameters, functional characteristics of spermatozoa, and the quality of their genetic material required for egg fertilization and embryo development.

Teratozoospermia – the percentage of morphologically normal spermatozoa is below reference values.

Testicular sperm extraction (TESE) – a type of testicular biopsy, a surgical procedure involving the extraction of testicular tissue to obtain spermatozoa.

In vitro fertilization (IVF) – a sequence of manipulations including extracorporeal fertilization of oocytes (includes traditional in vitro insemination and intracytoplasmic sperm injection (ICSI),

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Infertility is a disease characterized by the failure to achieve a clinical pregnancy after 12 months of regular unprotected sexual intercourse due to an impairment of a person's capacity to reproduce either as an individual or with their partner. Infertility evaluations and interventions may be initiated sooner than 1 year based on medical, sexual, and reproductive history, age, physical examination findings, and diagnostic test results. Infertility is a disease that is characterized by the presence of an obstacle to the realization of reproductive function [1].

Infertility in a couple may be caused by absolute infertility (sterility) of one or both partners; however, it is more commonly due to a relative insufficiency of their reproductive function (relative infertility). In such couples, interpreting the results of the male reproductive system evaluation in isolation from the female partner's examination parameters is impractical [2, 3]. An impairment of male reproductive function leading to the inability to conceive indicates male infertility, while his spouse (partner) may be diagnosed with "female infertility associated with male factors" (ICD-10 code N97.4).

Male reproductive function (fertility) is determined by the state of the reproductive system organs ensuring the formation and delivery of spermatozoa, ejaculate parameters, functional characteristics of spermatozoa, and the quality of their genetic material necessary for egg fertilization and embryo development. Reproductive function indicators are naturally highly variable; they depend on sexual activity, age, genetic and phenotypic characteristics of men, as well as general health status, acute and/or chronic diseases, lifestyle, and environmental conditions, etc. The probability of successful sperm-egg interaction and embryo development under natural conditions and during IUI and ART, the onset and spontaneous termination of pregnancy, as well as the birth of a healthy child may decrease in various diseases and pathological conditions, under the influence of adverse lifestyle factors, environmental pollution, occupational hazards, etc. A sign of male reproductive function insufficiency (reproductive dysfunction) can be not only infertility in a couple, but also recurrent miscarriage in the wife (female partner) or failure of her infertility treatment using IUI and ART (for example, due to the lack of oocyte fertilization or arrest of embryo development), etc. Assessment of reproductive function (Z31.6 "General counseling and advice on procreation") is performed during routine check-ups of men of reproductive age, during preconceptional (pregravid) preparation planning, etc., in order to clarify the probability of conception and childbirth, identify and subsequently eliminate the causes hindering this, and prevent disorders [4, 5, 6, 7]. It is advisable to supplement the conclusion on the state of reproductive function with appropriate formulations, such as "infertility in a couple", "recurrent miscarriage in the wife (female partner)", "failure of treatment using IUI or ART", which allow substantiating plans for subsequent examination and treatment [8].

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

Male infertility is a symptom of various diseases and pathological conditions of body organs and systems that lead to the inability to conceive due to impaired reproductive function at the stages of sperm maturation, their delivery into the female genital tract and subsequent transport, capacitation, acrosome reaction, egg fertilization, and embryo development [9].

The following factors may have a negative impact on reproductive function [10, 11].

• congenital developmental anomalies (anorchia, cryptorchidism and testicular hypoplasia, congenital absence of the vas deferens, hermaphroditism, hypospadias, etc.);

• acquired structural changes and dysfunction of the reproductive system organs (obstruction of the seminal ducts, testicular atrophy, etc.).

• genetic disorders (Klinefelter syndrome, Y chromosome microdeletions and translocations of other chromosomes, point mutations and gene polymorphisms, etc.);

• malignant neoplasms

• infectious and inflammatory diseases

• elevated scrotal temperature (hot baths, sauna, etc., varicocele);

• endocrine disorders (hypothalamic and pituitary insufficiency, hyperprolactinemia, thyroid dysfunction, hypogonadism, androgen resistance and decreased sensitivity to gonadotropins, etc.);

• immunological disorders (antisperm antibodies, systemic autoimmune diseases, etc.);

• systemic diseases (diabetes, chronic renal and hepatic failure, etc.);

• sexual disorders (erectile dysfunction, ejaculation disorders, etc.);

• lifestyle factors and intoxications (smoking, anabolic steroids, drugs, stress, overheating, etc.);

• environmental factors (exposure to physical and chemical factors, occupational hazards — electromagnetic radiation, pesticides, heavy metals, etc.)

• iatrogenesis (consequences of diagnostic and therapeutic interventions: medication use, surgical interventions, etc.)

• functional disorders of spermatozoa and their genetic material (sperm aneuploidy, abnormal chromatin packaging, sperm DNA fragmentation, etc.)

The state of reproductive function depends on the age of men: after 30-35 years, a decrease in ejaculate parameters, indicators characterizing sperm function and the quality of their genetic material may be observed; the probability of having a child when the prospective father is older than 35 years is lower compared to younger fathers, including when using ART [12, 13].

Recent studies have shown that adverse chemical and physical environmental factors, lifestyle features, and comorbid conditions can lead to oxidative stress — the excessive generation of reactive oxygen species (ROS) causing damage to cellular structures, specifically sperm DNA fragmentation (SDF), which ultimately leads to impaired sperm function and increases the risks of pregnancy loss and hereditary defects in the fetus [14, 15, 16, 17].

In 30-40% of cases, etiopathogenetic factors of male infertility cannot be identified; these men have no history of diseases affecting fertility, and have normal physical examination findings as well as normal hormonal, genetic, and biochemical laboratory test results. It is believed that their reproductive dysfunction may be associated with yet unknown or previously unidentified pathological factors, which include, but are not limited to, endocrine disorders resulting from environmental pollution, reactive oxygen species (ROS) generation/sperm DNA damage, or genetic and epigenetic abnormalities [18, 19].

1.3 Epidemiology of the Disease or Condition

According to WHO data, 17.5% of people face the problem of infertility during their lifetime, with male infertility detected in 8.2-21.8% of cases [20].

In Russia, during the period 2000-2018, a 2.1-fold increase in the number of men with infertility was noted, alongside a significant spread in the registration frequency of male infertility both across Federal Districts of the Russian Federation and between regions of the same district [21].

In recent years, publications have emerged indicating a gradual decline in sperm count and concentration in men across most countries of the world, including the Russian Federation, as well as the negative impact of adverse environmental and lifestyle factors on ejaculate parameters and sperm functional characteristics [22, 23, 24].

1.4 Features of Coding the Disease or Condition

N46 – Male infertility

Z31.6 – General counseling and advice on procreation

1.5 Classification of the disease or condition

There is no universally accepted classification of male infertility. The classification of the causes of male infertility is built taking into account the localization of the impairment (hypothalamus, pituitary gland, testes, accessory sex glands, seminal ducts) and its nature (genetic, endocrine, inflammatory, traumatic, etc.). Based on the pathogenesis of the disorders, several main forms of male infertility can be distinguished, which may coexist [8, 19, 25].

• Secretory infertility, characterized by insufficient sperm production

• Excretory infertility, characterized by impaired sperm transport through the seminal ducts

• Immunological infertility

• Other forms of infertility, which may be caused by functional inadequacy of spermatozoa and their genetic material (due to 100% sperm morphology abnormalities making fertilization impossible, sperm damage under the influence of oxidative stress caused by sperm DNA structure defects, chromosomal rearrangements, genetic disorders, etc.)

• Idiopathic or unexplained infertility, where the causes of infertility remain unidentified after comprehensive evaluation

Unspecified infertility refers to infertility in a couple where the cause could not be established.

Regarding the primary organ of the reproductive system, the testis, pretesticular, testicular, and posttesticular forms of infertility are also distinguished

Male infertility can be primary and secondary.

1.6 Clinical presentation of the disease or condition

Infertility in a couple manifests as the inability to achieve a clinical pregnancy after 12 months of regular unprotected sexual intercourse. The clinical presentation of male infertility is represented by diseases and pathological conditions in the man that lead to the inability to conceive naturally.

Male reproductive function insufficiency (reproductive dysfunction) manifests as alterations in the state of the reproductive system organs ensuring the formation and delivery of spermatozoa, ejaculate parameters, functional characteristics of spermatozoa, and the quality of their genetic material necessary for egg fertilization and embryo development; it can lead to a decrease in a man's reproductive capacity, treatment failures using IUI and ART, as well as pregnancy loss [2, 26].

2. Diagnostics, medical indications and contraindications for diagnostic methods

Infertility in a couple is diagnosed when there is a complaint of the inability to achieve a clinical pregnancy after 12 months of regular unprotected sexual intercourse. Conception occurs in approximately 80% of couples within the first 6 months of regular unprotected intercourse. Because female fecundity declines each year after the age of 30 (being reduced by approximately half compared to women aged 20), the evaluation of a couple for the absence of pregnancy in a woman older than 35 may be initiated after 6 months of active unprotected sexual intercourse [27, 28].

Diagnostic Criteria

Male infertility is diagnosed when male reproductive disorders leading to the inability to conceive are identified—such as sexual dysfunction or anatomical defects preventing sperm delivery, azoospermia and cryptozoospermia, or functional impairment of spermatozoa and their contained genetic material (e.g., 100% asthenozoospermia, necrozoospermia, and globozoospermia, acephalic sperm syndrome, etc.) [1, 34, 35, 36].

• Diagnostic measures for couple infertility should be initiated in both men and women simultaneously; the male evaluation is performed by a urologist. The recommended duration of evaluation is no more than 6 months, and female fertility must be taken into account when planning male diagnosis and treatment [32, 33].

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comments: the state of male reproductive function directly affects not only the likelihood of natural conception, but also the outcomes of oocyte fertilization, embryo development in ART programs, and the probability of pregnancy achievement and successful gestation.

Evaluation of the male regarding recurrent pregnancy loss in the wife (female partner) and following failed infertility treatment using IUI and ART is carried out taking into account the conclusion of the obstetriciangynaecologist.

Diagnostics have the following objectives:

• To assess the state of the man's reproductive function and diagnose male infertility;

• To identify diseases, pathological conditions, and other factors contributing to reproductive dysfunction and male infertility, such as lifestyle and environmental factors, occupational hazards, and acute and/or chronic diseases; to assess the feasibility of preconception (pregravid) counseling and preparation, treatment, and mitigation of adverse impacts, as well as the planning of preventive and health-promoting measures; to determine the likelihood and timeframe for fertility recovery;

• To assess the feasibility of treatment using IUI and ART (including donor sperm) in agreement with the obstetrician-gynaecologist, and to clarify the causes of previous treatment failures in order to plan preconception preparation to increase the likelihood of success in subsequent treatments;

• To determine the patient routing when organizing interdisciplinary care.

2.1 Complaints and Anamnesis

Comments: taking complaints and medical history should include the following data

- age of the man and his spouse (partner)

- information on the frequency of sexual intercourse and its alignment with the interval of highest probability of female conception.

- duration of infertility, presence of children or pregnancies in partners in the past

- general well-being

- state of sexual function (libido, erection, ejaculation)

- information on developmental anomalies, hereditary diseases, and childhood and adolescent disorders

- past and chronic diseases, including systemic conditions, malignancies, drug therapy, surgical interventions, and results of previous infertility treatments, including assisted reproductive technologies

- sexually transmitted infections and inflammatory diseases of the genital organs (orchitis, epididymitis, prostatitis), and outcomes of previous treatments

- allergic reactions

- adverse environmental and lifestyle factors, including occupational hazards and exposure to toxins and radiation

- alcohol consumption, smoking,

- use of anabolic steroids

- exposure to high temperatures (e.g., visiting baths, saunas).

The probability of conception is maximal with a frequency of sexual intercourse of 2–4 times per week. Abstinence intervals of more than 2 days can negatively affect sperm quality [37, 38, 39, 40].

2.2 Physical Examination

2.3 Laboratory Diagnostics

Laboratory tests are aimed at assessing the state and regulation of male reproductive function, identifying the causes of infertility, and detecting genetic abnormalities. Performing basic (medical service "Spermogram"), extended, and advanced ejaculate tests in accordance with the methodologies described in the WHO manual [41] (determination of antisperm antibodies in the ejaculate, sperm DNA fragmentation (SDF), sperm aneuploidy, histone-to-protamine ratio, oxidative stress, acrosome reaction, etc.) and other tests provides data on the functional characteristics of spermatozoa and the quality of their genetic material, which can help clarify the cause of infertility, failures of treatment using IUI and ART, and pregnancy loss. At the same time, low counts, motility, and proportions of normal sperm forms are frequently accompanied by higher levels of markers indicating their functional impairment [42, 43].

Evaluation of antisperm antibodies and SDF in the ejaculate has become widespread; however, the clinical interpretation of results from these and other tests is complicated by the variability of the studied parameters, insufficient standardization of execution protocols, and a lack of consensus regarding reference intervals, which each laboratory is currently advised to establish independently [19, 44, 45, 46, 47].

Autoimmune reactions against spermatozoa are accompanied by the production of antisperm antibodies (ASA). The mixed antiglobulin reaction test for spermatozoa (MAR test for the presence of antisperm antibodies in semen) belongs to the category of immunological tests and assesses the presence of IgA and IgG immunoglobulins on the sperm surface, which reduce fertility. ASA levels above 50% in men complaining of infertility are encountered more frequently than in fertile men—in 2.6%–6% and 0.9% of cases, respectively, which can be explained by their negative impact on the components of the reproductive system and the stages of reproductive function: membrane and DNA integrity, sperm concentration and motility, ability to penetrate cervical mucus, capacitation, acrosome reaction, and interaction with the oocyte. The probability of natural conception from men with MAR test results equal to 100% was significantly lower than that of those with values ranging from 50% to 99%, amounting to 4.5% and 30.0%, respectively. The previously proposed MAR test threshold of 50% failed to predict the probability of natural pregnancy; therefore, the authors of the WHO manual reported a lack of data allowing the establishment of reference values for ejaculate MAR tests and classified it among extended research methods. The presence of antisperm antibodies does not affect the pregnancy rate during infertility treatment using IVF or ICSI [48, 49, 50, 51, 52, 53, 54].

Extended ejaculate test methods also include sperm DNA fragmentation (SDF) tests. The pathogenesis of sperm DNA breaks at the cellular level involves mechanisms of apoptosis, impaired sperm chromatin maturation, and oxidative stress. Higher SDF levels correspond to a lower probability of achieving and subsequently carrying a pregnancy, as well as conceiving and giving birth to a child after IUI and ART treatment. Currently, several methods based on different principles are used to determine this indicator; opinions on the advantages and disadvantages of each, as well as on the cutoff thresholds of the obtained reference intervals, are contradictory. Professional communities lack a consensus on the indications for this study (which include various diseases, conditions, and factors capable of negatively affecting reproductive function, as well as recurrent pregnancy loss and previous ART treatment failures in the female partner, etc.). Treatment methods for patients regarding identified diseases and conditions, therapeutic measures described in Section 3, as well as the elimination of risk factors and shortening the period of abstinence, can reduce the SDF level. Selection of spermatozoa with a lower SDF value can be performed at the ART stage, including via testicular sperm extraction and ICSI [15, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64].

Comments: ejaculate parameters are highly variable both between different men and within the same individual, and they also exhibit regional characteristics. The results of a single ejaculate analysis may be sufficient to gain an understanding of spermatogenesis and recommend subsequent evaluation of the male; a more comprehensive understanding of reproductive function may require the analysis of two or three ejaculate samples, and at least two samples must be analyzed to confirm azoospermia. The minimum reference limits for ejaculate parameters (5th percentile) obtained in cohorts of fertile men according to foreign and Russian researchers [36, 41] are presented in Table 1.

Table 1. Minimum reference limits for ejaculate parameters in fertile men (5th percentile)

The minimum reference values for ejaculate parameters in fertile men have no clinical significance and should not be viewed as boundary parameters distinguishing fertile from infertile men. Consequently, the authors of the WHO manual [41] abandoned the use of terms such as "normozoospermia," "oligozoospermia," "asthenozoospermia," and "teratozoospermia" when describing the results of basic ejaculate tests, as these indicate compliance or non-compliance with these values. There is a correlation between the probability of conception and sperm count, viability, motility, and morphology. The most informative predictor of natural conception is the motile sperm count: the pregnancy rate from men with less than 1 million and from 1 to 5 million motile spermatozoa in the ejaculate was lower compared to those in whom this parameter exceeded 5 million (odds ratios were 0.371 (0.215–0.64) and 0.505 (0.307–0.832), respectively), while at values exceeding 50 million, the probability of pregnancy within 5 years was 45% higher. The proportion of normal spermatozoa does not allow for predicting pregnancy and live birth in an individual case (except for 100% globozoospermia, acitotoxic sperm syndrome, etc.) [66, 67, 68, 69, 70, 71].

The man must be given clear instructions regarding ejaculate collection via masturbation. Coitus interruptus is not recommended due to the risk of incomplete collection and contamination with vaginal secretions and other impurities. In exceptional cases, the ejaculate may be obtained during intercourse using a condom that does not contain sperm-immobilizing substances. Lubricants should be avoided during ejaculate collection. The ejaculate must be collected in its entirety, and the man should be warned that if this fails, he needs to report any loss of a portion of the sample. It is advisable to suggest that the man collect the ejaculate for analysis after a period of abstinence typical of his usual rhythm of sexual activity; however, the duration of this period should not be less than 2 days and more than 7 days. If the sample is not collected in the immediate vicinity of the laboratory, it should be transported at a temperature not lower than 20°C and not higher than 37°C, and the analysis should begin within 30–60 minutes after collection [72].

• All men who are found to have a round cell concentration exceeding 1×10⁶/ml upon basic ejaculate analysis are recommended to have the leukocyte concentration in the semen determined in order to rule out infectious and inflammatory diseases of the reproductive system [3, 46, 73, 74].

GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)

Comments: it is not possible to reliably differentiate leukocytes from germ cells among round cells during a basic ejaculate analysis. An elevated leukocyte count in semen may be a sign of an infectious and inflammatory disease that impairs reproductive function and requires further evaluation and treatment of the patient [11, 75].

• If the leukocyte level in the ejaculate is elevated, patients are recommended to undergo microbiological (culture) analysis of the ejaculate for aerobic and facultatively anaerobic opportunistic microorganisms to rule out infectious and inflammatory diseases of the reproductive system [76, 77].

LeRR CLoE 4Level of recommendation confidence C (level of evidence – 4)

• If the leukocyte level in the ejaculate is elevated, patients are recommended to undergo molecular biological testing of semen for Chlamydia trachomatis, molecular biological testing of semen for Mycoplasma hominis, molecular biological testing of semen for Ureaplasma urealyticum (NMU – Molecular biological testing of semen for Ureaplasmas [Ureaplasma urealyticum, Ureaplasma parvum]), molecular biological testing of semen for Neisseria gonorrhoeae, and molecular biological testing of semen for Trichomonas vaginalis to identify pathogens of urogenital diseases capable of negatively affecting male reproductive function [76, 77, 78, 79, 80, 231].

GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)

Comments: Ureaplasma parvum is not associated with male infertility [79].

• To rule out retrograde ejaculation in a patient with azoospermia and an ejaculate volume of less than 1 ml, it is recommended to perform microscopic examination of urine sediment (post-ejaculatory urinalysis) [81, 82, 83].

GCR BLoE 3Level of Evidence B (Level of Confidence of Evidence – 3)

• To diagnose hypogonadism in patients with azoospermia and oligozoospermia, it is recommended to determine hormone levels by measuring follicle-stimulating hormone (FSH) in blood serum and total blood testosterone [3, 84].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)

Comments: blood sampling for sex hormones is performed from 8:00 AM to 11:00 AM. Measurement of serum follicle-stimulating hormone (FSH) and luteinizing hormone (LH), total estradiol, prolactin, and thyroid-stimulating hormone in the blood, and an initial appointment (examination, consultation) with an endocrinologist are indicated to clarify endocrine causes of reproductive failure and assess the feasibility of correcting them [85].

• A cytogenetic study (karyotype) and an initial consultation with a geneticist are recommended to detect chromosomal abnormalities in patients with azoospermia and a sperm concentration of less than 10 million/mL, unexplained infertility, recurrent pregnancy loss, and repeated implantation failure during assisted reproductive technology (ART) treatments of the female partner [86, 87, 88, 89, 90, 91, 92, 93, 94, 95].

GCR BLoE 3Level of Evidence B (Level of Confidence of Evidence – 3)

Comments: impaired spermatogenesis and male fertility may be caused by chromosomal abnormalities, hereditary diseases, syndromic and non-syndromic genetic disorders, with the highest prevalence observed in patients with non-obstructive azoospermia. A large number of genes are involved in the regulation of spermatogenesis, many of which probably have not yet been identified [96, 97]. Patients with oligozoospermia associated with genetic disorders (including Robertsonian and reciprocal translocations) may undergo sperm cryopreservation (Medical Service Nomenclature: Cryopreservation of gametes (oocytes, spermatozoa) for subsequent ART treatment for the female partner in a deferred motherhood program) [98].

• A molecular genetic study for Y-chromosome AZF microdeletions (Medical Service Nomenclature: Molecular genetic study of Y-chromosome microdeletions in blood) and an initial consultation with a geneticist are recommended for patients with azoospermia and a sperm concentration of less than 5 million/mL in order to identify risk factors for genetic defects in offspring [3, 99].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)

Comments: the recommendation applies to men who have not had a higher sperm concentration in previous analyses. AZF deletions are a cause of spermatogenesis impairment; their prognostic value in TESE in men with azoospermia correlates with the type of deletion: with complete deletions of the AZFa and/or AZFb loci, the probability of surgically retrieving spermatozoa is practically zero. Patients with oligozoospermia may undergo gamete (sperm) cryopreservation for subsequent ART use by the female partner in a deferred motherhood program [99]. The couple must be informed that Y-chromosome microdeletions are always inherited by sons, their presence may lead to decreased reproductive function and infertility, and ART treatment shows low rates of fertilization, pregnancy, and live birth [100, 101, 102, 103], whereas partial deletions of the AZFc region (b2/b3, gr/gr, and others) have been detected in fertile men [104].

Comments: if a CFTR gene mutation is detected in a man, it is also important to recommend that his partner undergo molecular genetic testing for CFTR gene mutations (cystic fibrosis) and consult a geneticist. About 2,000 mutations responsible for the development of cystic fibrosis symptoms have been identified. According to the National Registry in Russia, the most frequent mutations are: F508del (53.14%), CFTRdele2,3 (6.18%), E92K (3.11%), 3849+10kbC>T (2.29%), 2143delT (2.05%), 2184insA (1.88%), 1677delTA (1.76%), N1303K (1.69%), W1282X (1.63%), L138ins (1.46%), G542X (1.43%) [106][[1]] If the female partner is found to be a carrier of the same CFTR gene mutation, the probability of having a child with cystic fibrosis, congenital bilateral aplasia of the vas deferens, or other cystic fibrosis-associated diseases can reach 25–50% [99, 107].

Comments: in accordance with paragraph 4.3 of the sanitary and epidemiological rules SP 3.1.5.2826-10 "Prevention of HIV Infection", the standard laboratory diagnostic method for HIV infection is the simultaneous determination of antibodies to HIV types 1 and 2 and HIV p24/25 antigen using ELISA and CLIA diagnostic tests [119]. If the infection is detected, it is recommended to refer the man for an initial consultation with an infectious disease specialist at the AIDS and Infectious Diseases Prevention and Control Center to confirm/exclude the diagnosis. The examination is not required prior to a cryopreserved/thawed embryo transfer (ET) program.

• In order to prepare for IUI and ART programs in consultation with an obstetrician-gynecologist, prevent adverse events in IUI and ART, and prevent the spread of hepatitis B, it is recommended to refer the patient for hepatitis B screening: determination of antibodies to hepatitis B surface antigen (HBsAg) (Hepatitis B virus) in blood or determination of hepatitis B surface antigen (HBsAg) (Hepatitis B virus) in blood [120, 121, 122, 123, 124].

Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).

Comments: if infection is detected, the patient is referred for an initial consultation with an infectious disease specialist to confirm/exclude the diagnosis. Partner screening is not required prior to the ET program.

• In order to prepare for IUI and ART programs in consultation with an obstetrician-gynecologist, prevent adverse events in IUI and ART, and prevent the spread of hepatitis C, it is recommended to refer the patient for hepatitis C screening: determination of total antibodies of classes M and G (anti-HCV IgG and anti-HCV IgM) to hepatitis C virus (Hepatitis C virus) in blood [120, 122, 123, 124].

Level of Evidence CLevel of Evidence C (confidence level: 5)

Comment: if infection is detected, the patient is referred for an initial consultation with an infectious disease specialist to confirm/exclude the diagnosis. Partner screening is not required prior to the ET program.

• In order to prepare for IUI and ART programs in consultation with an obstetrician-gynecologist and prevent adverse events in IUI and ART, it is recommended to refer the man for syphilis screening (determination of antibodies to Treponema pallidum in blood) in accordance with current clinical guidelines for the disease [125, 126].

GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)

Comment: if infection is detected, the patient is referred for an initial consultation with a dermatovenerologist to confirm/exclude the diagnosis. Partner screening is not required prior to the ET program.

2.4 Instrumental Diagnostics

• All men presenting with complaints of infertility are recommended to undergo a scrotal ultrasound to clarify the diagnosis [108, 109].

GCR BLoE 3Level of Evidence B (Level of Confidence of Evidence – 3)

Comments: in addition to the physical examination, scrotal ultrasound helps detect signs of seminal tract obstruction (e.g., dilation of the rete testis or enlargement of the epididymis with cystic changes), as well as rule out or confirm varicocele, hypoplasia (testicular volume <12 mL), and identify signs of testicular dysgenesis (e.g., inhomogeneous testicular structure, presence of microcalcifications, neoplasms). Men with testicular failure and bilateral microcalcifications, testicular atrophy, and cryptorchidism have an increased risk of developing testicular germ cell tumors [110, 111]. If signs of a testicular neoplasm are detected, the man must be referred for an oncological consultation as soon as possible.

• Patients with azoospermia and low ejaculate volume are recommended to undergo transrectal ultrasonography (TRUS) of the prostate to detect signs of distal seminal tract obstruction [109, 112].

GCR BLoE 3Level of Evidence B (Level of Confidence of Evidence – 3)

Comments: TRUS allows visualization of prostatic cysts and seminal vesicle dilation, which indicates ejaculatory duct obstruction in men with low ejaculate volume (less than 1.5 mL).

2.5 Other Procedures

The scope of other diagnostic examinations is determined according to the clinical situation. In addition to the tests listed below, other diagnostic examinations may be performed in accordance with the specific clinical situation, when indicated, following the evaluation of complaints, medical history taking, physical examination, laboratory diagnostic tests, and instrumental diagnostic tests.

Comment: evaluation of a couple for infertility should begin in both men and women simultaneously. The examination of women is carried out by an obstetrician-gynecologist in accordance with clinical guidelines developed by the Russian Society of Obstetricians and Gynecologists and the Russian Association of Human Reproduction. The conclusion of an obstetrician-gynecologist is required when drawing up a treatment plan for the man and performing preconception (pregravid) preparation for the treatment of an infertile couple using IUI and ART.

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

Men in whom diseases, pathological conditions, and other factors contributing to impaired reproductive function and the development of male infertility have been identified are indicated for treatment, during which restoration of fertility and the ability to conceive naturally may occur, although this does not always happen. When planning such treatment, it is necessary to take into account the woman's fertility, the likelihood of her retaining chances of natural conception within the expected timeframe of her husband's (partner's) recovery, and, in the presence of indications (unexplained infertility, infertility for which other treatment methods are impossible, infertility unresponsive to treatment within 12 months from diagnosis, a higher probability of overcoming infertility using ART compared to other methods, the need for preimplantation genetic testing, HIV infection in discordant patients, the presence of germ cells cryopreserved before reproductive function-reducing treatment—surgery, chemo- and radiation therapy, etc., or under the "delayed motherhood" program), consider treating the couple using IUI or ART in agreement with an obstetrician-gynecologist based on the "Female Infertility" clinical guidelines [33]. In intrauterine insemination, laboratory-processed sperm is injected into the uterine cavity to achieve pregnancy. ART represents methods of infertility treatment in which some or all stages of conception and early embryo development are carried out outside the mother's body (including the use of donor and/or cryopreserved gametes, reproductive tissues and embryos, as well as surrogacy).

To preserve a man's reproductive function, cryopreservation of ejaculate spermatozoa obtained via masturbation, as well as cryopreservation of surgically retrieved spermatozoa, may be performed for subsequent use with IUI or ART in delayed motherhood programs (in agreement with an obstetrician-gynecologist) (NOM gamete cryopreservation (oocytes, spermatozoa)). Surgical sperm retrieval is used when no ejaculate spermatozoa suitable for use are available (in non-obstructive and obstructive azoospermia, aspermia, 100% necrozoospermia, etc.). The choice of the optimal method for sperm retrieval—percutaneous and open testicular biopsies: PESA, TESA, TESE, MESA, microTESE (using 6–25x optical magnification and microsurgical technique)—is made by a urologist depending on the patient's individual characteristics [72, 73, 127, 128, 129128].

Since DNA fragmentation index (DFI) values in testicular spermatozoa may be lower than in ejaculate spermatozoa, the use of surgically retrieved testicular spermatozoa for ICSI may help increase the likelihood of successful ART treatment for couples with prior unsuccessful attempts at such treatment [64, 128].

Infertility and treatment failures regarding infertility, including those involving IUI and ART, as well as the need to discuss the use of donor gametes, have a negative psychological impact on men, which in turn can adversely affect sexual function, semen quality, and reduce the likelihood of pregnancy; therefore, they may require psychological counseling [130, 131].

Comments: preparation of a man for conception should be personalized, taking into account existing lifestyle factors, environment, acute and chronic diseases, etc. It may require organizing interdisciplinary cooperation with general practitioners, endocrinologists, geneticists, and coordination with obstetrician-gynecologists in accordance with the woman's treatment plan.

3.1 Treatment of male infertility in hypogonadotropic hypogonadism

Hypogonadotropic (central) hypogonadism is a consequence of gonadotropin-releasing hormone and/or gonadotropin (FSH, LH) deficiency [133]. In adult patients, the most common causes of hypogonadotropic hypogonadism are hypothalamic-pituitary region tumors and/or treatment received for them (surgery, radiation therapy). Among congenital causes (frequently diagnosed in adults), Kallmann syndrome, characterized by anosmia or hyposmia, is the most prevalent.

• All patients with infertility caused by hypogonadotropic hypogonadism require an initial consultation (examination, assessment) by an endocrinologist and an initial consultation (examination, assessment) by a geneticist to clarify the diagnosis and formulate a treatment plan aimed at normalizing reproductive function and identifying risk factors for genetic defects in offspring [134].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)

Comments: the choice of medications and their regimen depend on the etiology of hypogonadotropic hypogonadism. Patients who developed hypogonadism before puberty and have not received therapy may require 1–2 years of treatment to achieve normal spermatogenesis. To stimulate spermatogenesis in patients with hypogonadotropic hypogonadism, chorionic gonadotropin** may be prescribed at a starting dose of 1000–2000 IU 2–3 times a week intramuscularly. Depending on the results of follow-up blood total testosterone levels and spermiogram testing, an increase in the dose of chorionic gonadotropin** to 5000 IU twice a week intramuscularly and/or combination with follitropin alfa** at a dose of 150 IU three times a week for at least 4 months may be required. The duration of treatment to achieve adequate testicular volume and spermatogenesis ranges from 6 to 24 months [138]. Baseline testicular volume is a predictor of response to chorionic gonadotropin** monotherapy: at a volume of less than 5 ml, the likelihood of achieving an effect is low.

Menotropins (G03GA02 Gonadotropins) are prescribed to stimulate spermatogenesis in hypogonadotropic hypogonadism at a dose of 75 IU to 150 IU 3 times a week along with injections of chorionic gonadotropin** at a dose of 2000 IU 3 times a week. Treatment according to this regimen should be continued for at least 4 months until spermatogenesis improves. In the absence of a positive effect during this time, combination therapy may be continued until a positive therapeutic result is achieved. According to studies, improving spermatogenesis may require at least 18 months of treatment [135, 136, 138, 139, 140, 141].

• For the treatment of male infertility, testosterone replacement therapy** is not recommended [142].

LeRR CLoE 4Level of recommendation confidence C (level of evidence – 4)

Comments: exogenous administration of testosterone** inhibits the secretion of LH and FSH, leading to a decrease or complete cessation of spermatogenesis.

3.2 Treatment of infertility in men with varicocele

Comments: varicocele is a common congenital anomaly, observed in approximately 15% of men, and can be asymptomatic or cause pain and discomfort, impaired growth and development of the ipsilateral testis with subsequent clinical manifestations of hypogonadism, as well as negatively affect reproductive function. Varicocele is more common in infertile men—in 35–81% of cases—which is attributed to its negative impact on sperm count and motility in the ejaculate, as well as on the integrity of sperm genetic material due to elevated scrotal temperature, hypoxia, and the reflux of toxic metabolites. It may be more pronounced in higher grades of varicocele and in older men; however, a direct causal link between decreased male fertility and the presence of varicocele has not yet been proven, and improvement in semen quality after varicocele treatment does not always lead to conception [144, 145, 146]. Therefore, studies on its clinical utility for improving male reproductive function are ongoing.

On the one hand, data have been obtained indicating that surgical treatment for clinically manifesting varicocele (medical service technologies: "Ligation and transection of the testicular vein", "Subinguinal ligation and transection of the testicular vein", "Testicular vein clipping using video-endoscopic technologies") in men with oligozoospermia and non-obstructive azoospermia (NOA) resulted in an increased sperm count and a higher probability of natural conception as well as conception using assisted reproductive technologies (ART). However, the quality of available evidence for men with NOA was low (therefore, the risks and benefits of varicocele treatment in such patients must be discussed in detail prior to treatment), with the treatment effect being more pronounced in higher grades of the disease. In clinically insignificant forms of varicocele, surgical treatment proved ineffective; furthermore, data regarding the possibility of improving motility and increasing the proportion of spermatozoa with normal morphology through such surgery have been contradictory [147, 148, 149, 150, 151, 152, 153, 154]. Since data have been reported on postoperative decrease in sperm DNA fragmentation (SDF) in patients with varicocele, assessing SDF in men with varicocele after failed infertility treatment using ART, as well as in cases of recurrent pregnancy loss in female partners, may be useful for deciding on the appropriateness of surgical correction to increase the likelihood of success in subsequent ART treatments and live birth. This is also supported by data indicating a higher live birth rate after ICSI treatment in men who underwent surgery for varicocele [155]. Such a strategy requires coordination with an obstetrician-gynecologist based on the assessment of the partner's reproductive function and the expected timeframe for the clinical effect of surgical treatment, which is typically 3–6 months [156, 157, 158, 159]. According to meta-analysis data, natural conception following surgical treatment for clinically significant varicocele and oligozoospermia occurred in approximately 1 out of 7 men [151]; the improvement of reproductive function parameters and the probability of conception in the postoperative period were also facilitated by the oral administration of agents possessing antioxidant properties (ATC: Amino acids and their derivatives, Vitamins, Zinc preparations) [160, 161, 162].

On the other hand, a Cochrane meta-analysis identified only two studies comparing the effect of surgical or radiological treatment for varicocele versus no treatment on the live birth rate in infertility, and the conclusions of the authors of these studies were contradictory. Consequently, it was suggested that the question regarding the appropriateness of such treatment remains open until the results of new comparative randomized clinical trials evaluating live birth rates, adverse events, and quality of life become available. Russian researchers have also reported on the negative impact of surgical treatment for varicocele on the subsequent live birth probability in infertile couples [162, 163].

Currently, there is evidence supporting the possibility of improving reproductive function by increasing sperm concentration and motility in men with varicocele without surgical treatment, through the oral administration of agents with antioxidant properties (ATC: Amino acids and their derivatives, vitamins, zinc preparations, etc.) [161]. Therefore, the decision regarding the appropriateness of treatment (conservative or surgical) for varicocele in a man should be made on an individual basis, taking into account the clinical significance of the varicocele, all aspects of the reproductive status of both partners, and the physician's personal clinical experience [2].

3.3 Treatment of infertility in men with obstructive azoospermia

Obstructive azoospermia (OA) is caused by bilateral impairment of the patency of the seminal tracts. In OA, testicular volume and FSH levels are typically normal, whereas physical and instrumental examinations may reveal signs of obstruction: dilation of the rete testis, enlargement and induration of the epididymis, absence of the vas deferens, and dilation of the seminal vesicles. It is customary to distinguish between intratesticular obstruction, obstruction at the level of the epididymis, the vas deferens, and the ejaculatory ducts [164, 165, 166, 167].

• For azoospermia caused by acquired obstruction at the level of the epididymis and/or the proximal vas deferens, microsurgical vasovasostomy or tubulovasostomy (medical services: "Creation of a vaso-vaso anastomosis", "Creation of a vaso-epididymo anastomosis") is recommended to restore male fertility [168, 169].

LeRR CLoE 4Level of recommendation confidence C (level of evidence – 4)

Comments: subsequent restoration of seminal tract patency may occur within 3–18 months.

• Prior to performing microsurgical vasovasostomy or tubulovasostomy (medical services: "Creation of a vaso-vaso anastomosis", "Creation of a vaso-epididymo anastomosis"), patients are recommended to undergo surgical sperm retrieval (medical services: "Testicular puncture", "Biopsy of the testis, epididymis, and spermatic cord" using PESA, TESA, TESE, or MESA methods) and sperm cryopreservation (medical service – cryopreservation of gametes [oocytes, spermatozoa] for subsequent use in ART in agreement with an obstetrician-gynecologist) [170].

LeRR CLoE 4Level of recommendation confidence C (level of evidence – 4)

• For the treatment of infertility in patients with azoospermia due to obstruction of the seminal tracts at the level of the testis, distal vas deferens, or ejaculatory duct, it is recommended to perform surgical sperm retrieval (medical services: "Testicular puncture", "Biopsy of the testis, epididymis, and spermatic cord" using PESA, TESA, TESE, or MESA methods) followed by ART in agreement with an obstetrician-gynecologist. This approach may also be recommended if seminal tract reconstruction is impossible or refused by the patient. It is necessary to ensure cryopreservation of the surgically retrieved spermatozoa (medical service – cryopreservation of gametes [oocytes, spermatozoa]) [167, 170, 171].

LeRR CLoE 4Level of recommendation confidence C (level of evidence – 4)

Comments: in azoospermia caused by post-inflammatory obstructions of the ejaculatory ducts or their communication with prostatic cysts, transurethral resection of the ejaculatory duct orifices in the area of the verumontanum may be performed (medical service: "Internal [transurethral] urethrotomy" [167]); however, it is necessary to discuss with the patient the low efficacy of such treatment regarding subsequent spontaneous pregnancy compared to sperm aspiration and ICSI, as well as the risk of postoperative complications: retrograde ejaculation and urine reflux into the ejaculatory ducts, seminal vesicles, and vas deferens.

3.4 Treatment of infertility in men with retrograde ejaculation and anejaculation

Retrograde ejaculation (RE) and anejaculation (aspermia) account for less than 3% of cases among patients seeking medical care for infertility in marriage [172]. In the absence of an effect from aetiotropic therapy of ejaculatory disorders aimed at restoring fertility, couples are indicated for ART to treat infertility.

• To treat infertility in patients with RE, it is recommended to use spermatozoa recovered from post-ejaculatory urine in ART programs [173, 174].

LeRR CLoE 4Level of recommendation confidence C (level of evidence – 4)

Comments: previously (12 hours and 2 hours before obtaining the ejaculate), in order to alkalinize the urine and minimize its toxic effect on spermatozoa, the patient may be advised to drink a glass of water containing 1 tablespoon of dissolved baking soda [175].

• In infertile men with anejaculation, RE, and absence of viable spermatozoa in post-coital urine, it is recommended to use spermatozoa obtained surgically via PESA, TESA, TESE, or MESA methods in ART programs in agreement with an obstetrician-gynecologist. PESA, TESA, TESE, or MESA methods should be performed only when gamete (spermatozoa) cryopreservation is feasible [174, 176].

LeRR CLoE 4Level of recommendation confidence C (level of evidence – 4)

Comments: in infertile men with anejaculation due to spinal cord injury, spermatozoa obtained by electroejaculation and/or penile vibratory stimulation can be used in ART programs to overcome infertility. These methods are primarily intended for patients with a preserved reflex arc, as well as spinal cord segments S2–S4 and T10–T12. The optimal candidates are men with spinal cord lesions above the T10 segment: in 88% of them, penile vibratory stimulation can yield spermatozoa, whereas in other cases its success rate does not exceed 15%. Electroejaculation is used for similar indications and successfully yields spermatozoa in 97–100% of men with anejaculation due to spinal cord injury. When using vibratory stimulation and electroejaculation, one must keep in mind the risk of developing life-threatening autonomic dysreflexia [177, 178, 179, 180].

3.5 Treatment of infertility in men with non-obstructive azoospermia

Non-obstructive azoospermia (NOA) is a consequence of testicular failure or dysfunction of the hypothalamic-pituitary-gonadal axis. In NOA caused by hypogonadotropic hypogonadism, conservative treatment is possible (see section 3.1).

• For patients with hyper- and normogonadotropic hypogonadism and NOA, it is recommended to use spermatozoa obtained surgically via TESE or micro-TESE, in agreement with an obstetriciangynaecologist, in ART programs for ICSI to treat infertility [181].

GCR BLEL 2Grade of Recommendations B (Level of Evidence – 2)

Comments: the probability of obtaining spermatozoa surgically in men with NOA via open testicular biopsy (CMU – Testicular biopsy) during TESE or micro-TESE (using 6–25x optical magnification) is approximately 50%; samples should be taken from multiple areas of the testis. The results comparing the efficacy of micro-TESE and standard TESE in NOA, including in patients with Klinefelter syndrome, have been contradictory [181, 182, 183, 184]; the choice of the method for sperm retrieval is determined by the urologist based on the patient's individual characteristics. In patients with genetically determined forms of infertility, when deciding on TESE and micro-TESE, the results of genetic testing and the geneticist's conclusion regarding the possibility of obtaining spermatozoa suitable for ART treatment should be taken into account. A negative prognosis for sperm retrieval is observed in men with 46,XX testicular disorder of sex development ("46,XX male" syndrome), deletion of the entire AZF locus (AZFa+b+c), complete deletions of the AZra region and deletions entirely encompassing the DBY gene, complete deletions of the AZfb region and complete deletions of AZfb+, as well as certain chromosomal abnormalities, for example, in patients with sex chromosome polysomy, homologous Robertsonian translocations, X-autosome translocations, etc. [86].

The couple should be informed about the possibilities of preimplantation genetic testing of embryos resulting from ART to assess the risk of having a child with genetic defects [185].

Testicular biopsy (surgical) material must be sent for pathomorphological examination. A biopsy specimen size of approximately 3×3×3 mm or 5–10 mm in length ensures a sufficient number of seminiferous tubules for an adequate assessment of spermatogenesis. The tissue should not be squeezed with forceps, as this may compromise its integrity and hinder the correct morphological evaluation of the seminiferous tubules. For fixation of testicular biopsies, it is recommended to use Bouin's fixative; the use of 10% formalin is not recommended due to tissue distortion, which complicates the evaluation of the germinal epithelium. Based on the results of microscopic examination of hematoxylin and eosin-stained preparations, a conclusion is formed (normal spermatogenesis, tubular hyalinization, Sertoli cell-only syndrome, maturation arrest, hypospermatogenesis, mixed atrophy); if differential diagnosis with carcinoma in situ is required, immunohistochemical studies can be performed [186, 187, 188, 189].

3.6 Empirical treatment aimed at improving male reproductive function

Men in whom fertility-reducing conditions were identified during the examination are indicated for treatment aimed at restoring conception capacity. Antibiotic therapy for infectious and inflammatory processes in the gonads of infertile men can improve sperm quality characteristics, but data on the restoration of fertility are unconvincing [216, 217, 218].

For empirical treatment (i.e., treatment initiated on the basis of a clinical "rational assumption" in the absence of a complete understanding of etiopathogenesis) aimed at improving male reproductive function, researchers have proposed the use of various drugs: gonadotropins, selective estrogen receptor modulators, aromatase inhibitors, cattle testicular polypeptides, prostate extract in combination with zinc arginyl glycinate (ATX group: G04BX "Other urologicals"), including agents with antioxidant properties (ATX amino acids and their derivatives, metabolic agents, Vitamins A, E, zinc and selenium preparations, etc.).

Despite the fact that many researchers have managed to obtain results confirming significant improvements in reproductive function parameters, pregnancy rates, and live birth rates in patients receiving treatment compared with similar parameters in control groups, authors of other similar studies failed to reproduce these results. These contradictions, lack of data and/or differences in opinion regarding pharmacokinetics, the choice of optimal dosages and administration regimens, as well as high numbers needed to treat to achieve a single live birth, currently limit the possibilities of formulating clinical guidelines and defining standard patient models for their prescription.

An analysis by the Cochrane Collaboration review group, based on studies of antioxidant use as well as diets rich in polyunsaturated fatty acids in men with reproductive dysfunction, revealed evidence of a positive effect of therapy on the likelihood of clinical pregnancy (OR 1.89, 95% CI 1.45–2.47, P <0.00001, 20 randomized clinical trials, 1,706 men) and live birth (OR 1.43, 95% confidence interval (CI) 1.07–1.91, P = 0.02, 12 randomized clinical trials, 1,283 men); however, these findings were not confirmed by other authors, and therefore currently no strong recommendations can be made for their prescription as empirical therapy, and the decision on their use should be made on a case-by-case basis taking into account the patient's clinical status, all aspects of the reproductive status of both partners, and the physician's personal experience.

As predictors of treatment efficacy, published authors have suggested assessing serum follicle-stimulating hormone and total testosterone levels, as well as reactive oxygen species and DFI [190, 191, 192, 193, 194, 195, 196, 197, 198, 199, 200, 201, 202, 203, 204, 205, 206, 207, 208, 213, 214, 215].

• To improve reproductive function, it is recommended to inform men about the need to adopt a healthy lifestyle aimed at maintaining physical activity and reducing exposure to environmental hazards—stress, high temperatures, radiation sources, pollutants in ambient air, water, and food (heavy metals such as arsenic, lead, etc., organic compounds such as bisphenol A, etc.)—as well as maintaining a balanced diet rich in omega-3 polyunsaturated fatty acids and vitamins, consuming fish, poultry, vegetables, and fruits, normalizing body weight, quitting smoking, limiting alcohol consumption, and avoiding bathhouses (saunas) [24, 219, 220, 221, 222, 223, 224, 225, 226].

GRC BLEL 2Grade of Recommendation B (Level of Evidence – 2)

• In cases of reproductive dysfunction, to increase sperm count and motility and improve the likelihood of natural conception as empirical therapy, it is recommended to consider therapy with follitropin alfa** at a dose of 75–150 IU three times a week or menotropins at a dose of 75–150 IU 3 times a week, including in combination with human chorionic gonadotropin** at a dose of 100–2000 IU twice a week for 3–6 months. The decision on administration is recommended to be made on an individual basis [234, 235, 236, 237, 238].

LoR CGoE 1Level of Recommendation C (Level of Evidence – 1)

Comment: treatment with gonadotropic preparations may help increase sperm concentration and motility, reduce the degree of sperm DNA fragmentation (SDF), and increase the pregnancy rate, which occurred in an average of 1 in 10–18 partners of the treated men [234, 235, 236, 237, 238]. In patients with normal gonadotropin levels and non-obstructive azoospermia, empirical therapy increases the likelihood of sperm retrieval during testicular biopsy [239].

• In reproductive dysfunction, to increase sperm count and motility and improve the likelihood of natural conception as empirical therapy, it is recommended to consider clomifene** therapy at 25–50 mg every other day / daily for 3–6 months. The decision to use clomifene** as empirical therapy aimed at improving reproductive function should be made on an individual basis in each case [192, 209, 210].

GGR BLOE 1Grade of Recommendation B (Level of Evidence – 1)

Comments: clomifene** is a synthetic stimulator of gonadotropin production that selectively modulates estrogen receptors. A meta-analysis of data from eleven RCTs demonstrated that selective estrogen receptor modulators can help increase FSH and testosterone levels, improve sperm count and motility, and increase the pregnancy rate, which occurred in an average of 1 in 10 partners of men receiving clomifene** [209]. Similar results were confirmed in the latest updated meta-analysis of sixteen studies [197]; however, a previous meta-analysis failed to find any association between clomifene use and the likelihood of conception [210], which possibly indicates the need for treatment in selected patients. Research findings have shown that prognostically favorable signs for clomifene** therapy include low LH levels (<6 mIU/mL) and a testicular volume of more than 14 cm³ [232], whereas unfavorable signs include elevated FSH levels, a testicular volume of less than 10 cm³, a BMI of more than 35 kg/m², and a sperm concentration of less than 5x10⁶/mL [233].

• In reproductive dysfunction in patients with a serum total testosterone (in ng/dL) to estradiol (E2, in pg/mL) ratio of <10, as empirical therapy, it is recommended to consider therapy with #letrozole 2.5 mg daily or #anastrozole** 1 mg daily for 3 months to increase sperm count and motility and improve the likelihood of natural conception. [240, 241]

Level of Evidence BLevel of Confidence 2Level of recommendation B (level of evidence – 2).

Comments: the positive effect on male reproductive function was more pronounced in patients with overweight and obesity, as well as those with a testosterone (ng/dL) / estradiol (pg/mL) ratio of ˂10. Considering the important role of estrogens in spermatogenesis, when using #letrozole and #anastrozole**, it is advisable to monitor the hormonal profile during treatment to prevent a drop in estradiol levels, reducing the dosage if necessary. The pregnancy rate was studied in two studies and amounted to 1 in 5 and 1 in 14 partners of the treated men, respectively [242, 243, 244].

• In reproductive dysfunction, to increase sperm count and motility and improve the likelihood of natural conception as empirical therapy, it is recommended to consider a course of intramuscular injections of bovine testicular polypeptides at a dosage of 5 mg once a week for 10 weeks [206, 207, 211, 212].

Level of Evidence BLevel of Confidence 2Level of recommendation B (level of evidence – 2).

Comments: data on the pharmacokinetics of bovine testicular polypeptides are lacking. Data from a clinical study confirming the positive effects of testicular polypeptides on ejaculate parameters have been published; a retrospective analysis conducted from 1 to 9 months after therapy completion showed that, compared to the placebo group, conception was more frequently achieved by couples in which the men received the drug (13 of 42 (30.95%) and 17 of 34 (50%) couples, respectively). Before prescribing testicular polypeptides, a thorough patient evaluation should be performed, including the assessment of serum follicle-stimulating hormone, luteinizing hormone, total testosterone, and total and free prostate-specific antigen in the blood. The decision to use bovine testicular polypeptides as empirical therapy to improve reproductive function should be made on an individual basis in each case [206, 207, 211, 212].

4. Medical Rehabilitation and Sanatorium-Resort Treatment

Specific rehabilitation is not provided.

5. Prevention and Dispensary Observation

A key aspect of preserving male reproductive health is the timely detection of diseases and a comprehensive assessment of male health. Male infertility is often detected in men who have presented with no complaints regarding the reproductive system. Therefore, active and multi-stage preventive work by the healthcare system is of great importance.

Comments: measures aimed at improving the health of the adult population of reproductive age include the assessment of reproductive health.

The corresponding list of examinations and other medical interventions was established in the Program of State Guarantees of Free Medical Care for Citizens for 2024 and for the Planning Period of 2025 and 2026, approved by Decree of the Government of the Russian Federation No. 2353 dated December 28, 2023 (hereinafter referred to as the Program) [72].

For men aged 18-49 years, a medical examination aimed at assessing their reproductive health is organized in stages and simultaneously with the preventive medical examination or periodic health screening, with the purpose of identifying signs and risk factors for diseases or conditions that may adversely affect reproductive function.

The health check-up is carried out in two stages.

The first stage of the health check-up for men to assess reproductive health includes a dispensary appointment (examination, consultation) with a urologist (in the absence of a urologist, a dispensary appointment (examination, consultation) with a surgeon trained in male reproductive health issues).

The second stage is carried out based on the results of the first stage for additional examination and clarification of the diagnosis of the disease (condition). If indicated, the second stage includes:

1) spermiogram;

2) if leukocyte levels exceed the spermiogram results, a microbiological (culture) examination of the ejaculate for aerobic and facultatively anaerobic opportunistic microorganisms is recommended to exclude infections of the reproductive organs; and

3) laboratory tests to detect pathogens of pelvic inflammatory diseases by PCR, as specified in Section 2.3 "Laboratory Diagnostic Tests";

4) ultrasound of the prostate gland and ultrasound of the scrotum;

5) repeat appointment (examination, consultation) with a urologist or repeat appointment (examination, consultation) with a surgeon.

Depending on the examination results, 3 reproductive health groups are established [72]:

• Group I of reproductive health: reproductively healthy men.

The first group includes men in whom no reproductive system diseases have been identified and who have no risk factors for their development.

• Group II of reproductive health: risk of developing reproductive disorders.

The second health group includes men in whom no reproductive system diseases have been identified, but who have risk factors for their development:

1) overweight (BMI ⩾25.0 kg/m²) with a waist circumference of ⩾94 cm or obesity (BMI ⩾30 kg/m²);

2) history of sexually transmitted infections (chlamydia, trichomoniasis, gonorrhea, ureaplasma/mycoplasma infection, human papillomavirus);

3) history of inflammatory diseases of the male genital glands (prostatitis, epididymitis, epididymo-orchitis);

4) history of mumps in childhood;

5) history of or current varicocele, including post-surgical status;

6) endocrine system diseases (diabetes mellitus, hypo- and hyperthyroidism).

• Group III of reproductive health: presence of reproductive disorders.

The third health group includes men who have reproductive system diseases or proven fertility impairment:

1) male infertility;

2) signs of reproductive dysfunction based on spermiogram results;

3) current and historical primary and secondary hypogonadism (decreased testosterone levels);

4) delayed puberty.

5) current or history of congenital anomalies (malformations) of male genital organs (including cryptorchidism, testicular torsion, hypospadias), including after surgical treatment;

6) impaired reproductive function following previous treatment for oncological or autoimmune diseases (use of glucocorticoids and/or antineoplastic agents (cytostatics), chemotherapy for tumors of any localization, surgical treatment or radiation therapy for tumors of the testes, prostate, penis, rectum).

Men in reproductive health group I undergo health check-ups (dispensary evaluation) in the established manner.

Within 6 months, men in reproductive health group II are referred for a dispensary check-up (examination, consultation) by a urologist at the medical organization (outpatient clinic) at their place of residence for a more detailed evaluation and risk factor mitigation. Further medical care is provided in accordance with the clinical guidelines and the Procedure for the Provision of Medical Care to the Adult Population in the Profile «Urology», approved by Order of the Russian Ministry of Health No. 907n dated November 12, 2012.

Men with obesity (BMI 30–40 kg/m²) and overweight (BMI 25–29.9 kg/m²) (with a waist circumference greater than 102 cm) are referred to the Health Center for advanced preventive counseling and further dispensary follow-up.

Men with a history of sexually transmitted infections (chlamydia, trichomoniasis, gonorrhea, ureaplasma/mycoplasma infection, human papillomavirus) are referred to the Health Center for advanced preventive counseling.

Within 1 month, patients in health group III are referred to a urologist at the regional Family and Reproductive Health Center or (if absent) to a urologist at the Reproductive Health Department of the Perinatal Center, or (if absent) to a urologist at the assisted reproductive technologies center, or a urologist at the regional hospital who has received additional training (has practical experience) in the field of andrology/diagnosis and treatment of male reproductive system disorders.

• Men undergoing treatments that impair reproductive function—surgery, chemo- and radiation therapy, etc.—are recommended sperm cryopreservation (medical service technology: cryopreservation of gametes (oocytes, spermatozoa)) to preserve fertility, ensure the subsequent realization of reproductive function, and overcome infertility in the couple using IUI or ART, in agreement with the obstetrician-gynecologist [228].

GPP BLOE 3Grade of Recommendation B (Level of Evidence – 3).

Comments: ejaculate for cryopreservation is obtained by masturbation; in cases of azoospermia and the absence of viable or motile spermatozoa in the ejaculate, spermatozoa for cryopreservation can be obtained surgically via onco-TESE prior to gonadotoxic therapy [229, 230].

6. Organization of Medical Care

Indications for scheduled hospitalization (admission to a day hospital):

Performance of surgical intervention (PESA, TESA, TESE, micro-TESE, MESA) to obtain spermatozoa surgically for subsequent use in ART programs and sperm cryopreservation.

Indications for emergency hospitalization: none.

Indications for discharging the patient from the hospital:

Completion of surgical intervention (PESA, TESA, TESE, micro-TESE, MESA) to obtain spermatozoa surgically for subsequent use in ART programs and gamete (spermatozoa) cryopreservation.

7. Additional Information

No additional information available.

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

1. Oleg I. Apolikhin, MD, PhD, Professor, Corresponding Member of the Russian Academy of Sciences, Director of the Lopatkin Research Institute of Urology and Interventional Radiology – Branch of the National Medical Research Radiological Center of the Russian Ministry of Health. No conflict of interest.

2. Alina Yu. Babenko, MD, PhD, Chief Researcher, Head of the Research Laboratory of Diabetology at the Institute of Endocrinology, Professor at the Department of Internal Diseases, Institute of Medical Education, Almazov National Medical Research Centre. No conflict of interest.

3. Sergey V. Bogoliubov, PhD, Associate Professor, Leading Researcher at the Department of ART, National Medical Research Center for Endocrinology of the Ministry of Health of the Russian Federation, Director of the Andrology Group at the NGC Clinic, Moscow. No conflict of interest.

4. Vladimir A. Bozhedomov, MD, PhD, Professor at the Department of Urology and Andrology, Faculty of Fundamental Medicine, Lomonosov Moscow State University; Leading Researcher at the National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Ministry of Health of the Russian Federation; Scientific Advisor for Andrology and Reproduction at Polyclinic No. 3 of the Presidential Administration of the Russian Federation. No conflict of interest.

5. Igor V. Vinogradov, MD, PhD, Professor, Chairman of the Interregional Public Organization «League of Male Reproduction Specialists», Scientific Director of the Scientific and Practical Center for «Reproductive and Regenerative Medicine». No conflict of interest.

6. Magomed-S.Alkhazurovich Gazimiev, MD, PhD, Professor, Director of the Scientific and Technological Park of Biomedicine, Deputy Director of the Institute of Urology and Human Reproductive Health, Sechenov First Moscow State Medical University of the Ministry of Health of Russia (Sechenov University). No conflict of interest.

7. Safar I. Gamidov, MD, PhD, Professor at the Department of Obstetrics, Gynecology, Perinatology and Reproductology, Faculty of Postgraduate Professional Education, Sechenov First Moscow State Medical University, Head of the Department of Andrology and Urology at the National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Ministry of Health of the Russian Federation. No conflict of interest.

8. Badri R. Gvasaliya, MD, PhD, Professor at the Department of Urology, Russian University of Medicine, Ministry of Health of the Russian Federation, Moscow. No conflict of interest.

9. Evgeny V. Grebenkin, PhD, Pathologist, Botkin Moscow City multidisciplinary Clinical Hospital of the Moscow Healthcare Department; Senior Lecturer at the Department of Fundamental Medicine, National Research Nuclear University MEPhI, Moscow. No conflict of interest.

10. Elena A. Epanchintseva, PhD, Senior Researcher at the Laboratory of Endocrinology, Federal Research Center of Fundamental and Translational Medicine; Associate Professor at the Department of Urology, Novosibirsk State Medical University of the Ministry of Health of Russia; Endocrinologist at the «Novosibirsk Center for Reproductive Medicine», Mother and Child Group of Companies. No conflict of interest.

11. Evgeny A. Efremov, MD, PhD, Professor at the Department of Urology, Andrology and Oncourology, Faculty of Additional Professional Education, Pirogov Russian National Research Medical University of the Ministry of Health of Russia. No conflict of interest.

12. Oleg B. Zhukov, Head of the Urology Department at the European Medical Center, Associate Professor at the Department of Endourology, Faculty of Advanced Medical Training, Peoples' Friendship University of Russia (RUDN University). No conflict of interest.

13. Armais A. Kamalov, MD, PhD, Professor, Academician of the Russian Academy of Sciences, Head of the Department of Urology and Andrology, Faculty of Fundamental Medicine, Lomonosov Moscow State University. No conflict of interest.

14. Mikhail I. Kogan – Honored Scientist of the Russian Federation, MD, PhD, Professor, Head of the Department of Urology and Human Reproductive Health with a Course of Pediatric Urology-Andrology, Rostov State Medical University. No conflict of interest.

15. Igor A. Korneev, MD, DSc, Professor, Department of Urology, Pavlov First Saint Petersburg State Medical University, Medical Director of the International Centre for Reproductive Medicine. No conflict of interest

16. Stepan S. Krasnyak, Leading Research Scientist, Department of Andrology and Human Reproduction, Lopatkin Research Institute of Urology and Interventional Radiology, Executive Secretary of the Profile Commission on Reproductive Health of the Russian Ministry of Health, PhD. No conflict of interest

17. Irina V. Moiseeva, Head of the ART Department, "Dynasty" Medical Center, Chief Freelance Specialist in Women's Reproductive Health for the Ministry of Health of the Russian Federation in the Volga Federal District and Samara Region, PhD. No conflict of interest

18. Ruslan I. Ovchinnikov, Director of the Andrology Development Department, Head of the Department of Andrology and Urology, SkyFert Reproductive Medicine Center, Moscow, PhD, Board Member of the "Aspect" Association of the Russian Society of Urology. No conflict of interest

19. Vladlen S. Petrishchev, NovaClinic Medical-Genetic Center, Moscow, Uro-Andrologist, Scientific Advisor in Andrology. No conflict of interest

20. Dmitry Yu. Pushkar, Academician of the Russian Academy of Sciences, Professor, MD, Head of the Department of Urology, Russian University of Medicine. No conflict of interest

21. Dmitry S. Rogozin, Associate Professor, Department of General Surgery, South Ural State Medical University, PhD, Chief Medical Officer of the "DNA" Reproductive Clinic, Chelyabinsk. No conflict of interest

22. Ruslan T. Savzikhanov, Associate Professor, Department of Urology, Dagestan State Medical University, Chief Medical Officer of the Family Medical Center. No conflict of interest

23. Revaz R. Kharchilava, PhD, Director of the "Praxi Medica" Medical Practice Training Center, Sechenov First Moscow State Medical University. No conflict of interest.

24. Vyacheslav B. Chernykh, Head of the Laboratory of Reproductive Genetics, Bochkov Research Centre for Medical Genetics, Professor, Department of General and Medical Genetics, Faculty of Biomedical Sciences, Pirogov Russian National Research University of the Russian Ministry of Health. No conflict of interest

25. Oksana V. Shurygina, Head of the ART Laboratory, Infertility Treatment Center, IDK Medical Company, MD, Professor, Department of Human Histology and Embryology, Samara State Medical University, Associate Professor, Department of Histology and Embryology, Samara State Medical University. No conflict of interest

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience for these clinical guidelines:

- Urologist

- Obstetrician-Gynecologist

- Endocrinologist

- Geneticist

- Clinical and Laboratory Diagnostics Physician

- Embryologist

- Medical students, residents, postgraduate students

Table 1. Levels of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)

Table 2. Scale for grading levels of evidence certainty (LEC) for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)

Table 3. Scale for grading grades of recommendation (GR) for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)

Procedure for updating clinical guidelines.

The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

1. Order of the Russian Ministry of Health No. 803n dated July 31, 2020, "On the Procedure for Using Assisted Reproductive Technologies, Contraindications and Restrictions on Their Use" (Registered with the Ministry of Justice of Russia on October 19, 2020, No. 60457)

2. Female Infertility. Clinical Guidelines (2024)

3. Recurrent Pregnancy Loss. Clinical Guidelines (2022)

4. Letter of the Ministry of Health of the Russian Federation No. 17-6/I/2-6434 dated April 8, 2024, On the Distribution of Methodological Guidelines for Preventive Medical Examinations of Men and Women of Reproductive Age to Assess Reproductive Health

Appendix B. Physician Action Algorithms

Appendix C. Patient Information

What is male infertility?

Infertility in a couple is defined as the failure to achieve a desired pregnancy within one year in a sexually active couple not using contraception. If the reason conception does not occur lies with the man, it is referred to as impaired male reproductive function, or male infertility; however, infertility in a couple is most commonly the result of combined male and female reproductive impairments relative to each other. Therefore, the goal of evaluating a man with infertility is to identify diseases, pathological conditions, as well as environmental and lifestyle factors that negatively impact reproductive function, in order to eliminate them. The evaluation of both the man and the woman should be performed simultaneously; upon its completion, a treatment plan is developed to normalize reproductive function. This treatment may be medical or surgical, and in cases where the cause of infertility remains unclear or treatment to overcome the fertility issue is not feasible, assisted reproductive technologies may be utilized.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Rating scales, questionnaires, and other assessment tools are not required.