Treatment of male fertility disturbances. Current concepts

Medical therapy of male infertility aims to improve or normalise the fertility status of a subfertile patient. However, this can be a frustrating task due to limited knowledge about the pathophysiology of male reproductive functions, and the fact that pharmacological therapy is mainly empirical and less often specific. Nevertheless, the spectrum of treatment approaches has increased within the last decade and comprises hormonal and non-hormonal compounds. Hormonal therapy is performed with antioestrogens (clomiphene, tamoxifen), gonadotrophin-releasing hormone (GnRH), prolactin inhibitors (bromocriptine), gonadotrophins (hMG, hCG), androgens (testosterone, mesterolone), and testosterone aromatase inhibitors (testolactone). Tissue hormone-releasing proteases (kallikrein) can also be applied, liberating kinins as mediator substances with different effects at the cellular level. Non-hormonal therapy includes improvement of testicular microcirculation by oxpentifylline, antimicrobial and anti-inflammatory agents, drugs to improve or allow emission and ejaculation, and psychotropic and antispasmodic drugs to diminish functional disturbances induced by emotional stress. Treatment schedules are either specifically or empirically based. If treatment is based on a pathophysiological concept which implies strong patient selection, success of treatment is excellent. In contrast, despite an increased number of compounds, empirically based therapies remain unpredictable and the results are moderate and often not reproducible. However, when different drugs are compared with a placebo group in selected, well-controlled patients with idiopathic normogonadotrophic oligozoospermia, pregnancy rates will be in the range of 30 to 40% within an observation period of 1 year, as compared with the spontaneous conception rate of between 10 and 20%.