Male infertility in lupus nephritis: Clinical implications and management strategies

Lupus nephritis, a severe manifestation of systemic lupus erythematosus, is a major contributor to morbidity and has significant implications for male reproductive health. Infertility in men with LN is multifactorial, resulting from disease-related immune dysregulation, renal impairment, gonadotoxic therapies such as cyclophosphamide, and the psychosocial burdens of chronic illness. Collectively, these factors impair spermatogenesis, disrupt the hypothalamic-pituitary-gonadal axis, and contribute to erectile dysfunction, diminished libido, hormonal disturbances, and abnormal semen parameters. This underscores the need to recognize male fertility as a critical yet often overlooked dimension of LN management.Encouragingly, fertility preservation strategies and assisted reproductive technologies (ART) provide viable pathways to parenthood. Sperm cryopreservation remains the most reliable and widely accessible option, while surgical sperm retrieval and experimental approaches, including testicular tissue cryopreservation and spermatogonial stem cell transplantation, are under active investigation. ART techniques such as intrauterine insemination (IUI) and in vitro fertilization with intracytoplasmic sperm injection (IVF-ICSI) have enabled conception even in severe cases, although disease quiescence is recommended prior to initiation to optimize outcomes. Notably, paternal exposure to most immunosuppressive agents rarely increases fetal teratogenic risk; however, agents like cyclophosphamide may impair male fertility, a separate gonadotoxic concern. Emerging biologic therapies, including rituximab and belimumab, show promise in LN management with potentially reduced reproductive toxicity, but further studies are needed to establish their safety in male fertility.This review highlights the clinical implications of male infertility in LN and emphasizes the importance of integrated management strategies that combine reproductive counseling, fertility-preserving interventions, and multidisciplinary care.