The future of male infertility management and assisted reproduction technology

Intracytoplasmic sperm injection (ICSI) is undoubtedly a powerful, and sometimes the only effective, form of infertility treatment. Nonetheless, it is a non-specific treatment that, combined with increasingly heroic techniques to recover male germinal cells, has led to perceptions of men as just providers of gametes in the infertility equation. In response to this nihilist attitude, where women are investigated extensively and scant attention is paid to men, there is a re-emerging awareness of andrology--particularly in countries with limited healthcare resources. Structured management strategies, using diagnostic information to recognize causative factors amenable to simpler, even systemic, therapies with reasonable chances of pregnancy rather than resorting prematurely to assisted reproduction technology, represent rational, cost-effective approaches to infertility management. Furthermore, genetic testing (particularly cystic fibrosis gene defects and Y-chromosome microdeletions) is essential for couples to make fully informed decisions on their options. Recognition that free radical-induced damage to the sperm genome (e.g. from smoking or in-vitro sperm manipulation) underlies deleterious paternal effects on preimplantation development promotes further synergy between andrology and embryology. Although societies strike different balances between considerations of affordability and cost-effectiveness of assisted reproduction technology, ICSI represents a last resort, to be used when less-invasive, lower-cost treatments have been deemed inappropriate or have failed. Consequently, rather than assisted reproduction technology eliminating the need for andrology, the future will see increasingly tighter integration of multidisciplinary infertility care, embracing careful diagnosis and patient education before obtaining truly informed consent and embarking upon cost-effective treatment.