Clinical andrology: from evidence-base to ethics. The 'E' quintet in clinical andrology

The management of the infertile man should be founded on consensus-based medicine, i.e. the consensual opinion of experts considering evidence-based as well as empirical or experience-based medicine, the effective cumulative rate of successful deliveries, ethical and economic considerations. The apparent contradictions between conclusions from experience-based medicine and evidence-based medicine regarding the efficacy of varicocele treatment and tamoxifen treatment can be explained by scientific reasons. It is argued that the suggestion not to implement these treatments is ill founded because of flawed meta-analyses. The effective cumulative rate of successful deliveries and time to pregnancy as observed in cohort studies should be considered the ultimate touchstone of treatment efficacy. Based on the data of effective cumulative delivery rate, cost per successful delivery, and the known prevalence of aetiological diagnoses in infertile men, it is possible to estimate the number of deliveries that can be attained thanks to an investment of, e.g. 1 million Euro. This number is approximately 70-80 if IVF (including intracytoplasmic sperm injection) is chosen as first line treatment, and four times higher if conventional treatment (including intrauterine insemination) is applied. It is concluded that the well thought out approach recommended by the World Health Organization should generally be implemented for the management of couples in whom infertility is (mainly) due to a male factor.