Medical associations want to do more to combat male infertility

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It has been known for years that male fertility is declining. While more precise figures from western industrialized countries initially showed that sperm concentration and total sperm count have almost halved over the past 30 years, corresponding data is now also available for the Global South, Asia and Africa. Here, too, the picture is no different: men are finding it increasingly difficult to become fathers. That alone would be bad enough, were it not for another problem:

The exact reasons are unclear. There are various possible approaches – from the chemical revolution, including the use of pesticides, to microplastic pollution and modern lifestyles –, but it is simply not possible to pinpoint a cause or a cure. Worse still, diagnostics are lagging massively behind, ensuring that those affected are left in the dark when it simply doesn't work out when they want to have children. This alone causes enormous suffering for the families and those affected.

Enormous increase in those affected

The German Society of Andrology (DGA), the German Society of Urology (DGU) and the Professional Association of German Urology (BvDU) therefore issued an appeal and consensus paper in November to improve the care situation for men affected by infertility. The aim is to finally establish uniform medical standards, which have long been in place for the treatment of infertile women but are still lacking for men – for unclear reasons –. Currently, every sixth couple in Germany is considered to be involuntarily childless, meaning that medical help is needed. It is assumed that in at least half of all cases, the male partner is at least involved.

The DGA, DGU and BvDU have now drawn up a catalog that defines "medically relevant examinations of infertile men based on the current legal framework and the known causes". It is to be established across the board in andrological care in future "to ensure the best possible and efficient care for those affected", according to the doctors. A key problem remains that the health insurance companies have not yet adapted to the current situation. Treatable causes of male infertility sometimes have to be paid for privately or are therefore not treated at all. It is therefore not surprising that the three associations are also calling for necessary changes in reimbursement.

A widespread disease on the way to becoming a pandemic

This could ultimately even save costs: "Particularly before the use of medically assisted reproductive procedures, the couples affected should be identified and, if necessary, treated in order to avoid unnecessary invasive reproductive medical measures with risks, especially for women." As absurd as this may sound, it is currently not uncommon for female partners to undergo unnecessary interventions because insufficient solutions have been sought for the man. If the sperm quality improves, for example, a stressful in vitro fertilization (IVF) may no longer be necessary. However, if the man is not treated, the woman receives an overuse that is harmful to her health.

Many – including politicians – are unaware that fertility disorders have long been widespread diseases whose spread could take on pandemic proportions. "Since fertility is negatively influenced by socio-economic factors, but also by environmental influences and congenital disorders, the number of fertility treatments is also increasing," the doctors write. There is therefore a lack of guideline-based examinations of infertile men, which is a prerequisite for a medically justified treatment recommendation for the couple as a whole. According to DGA head Prof. Dr. Sabine Kliesch, an interdisciplinary indication for assisted reproductive procedures is needed. This is currently by no means available across the board for men. "Consensual diagnostics can prevent unnecessary reproductive treatments for women," Kliesch sums up. Such IVF treatments, which are often accompanied by ICSI (intracytoplasmic sperm injection), especially in the case of male fertility problems, are expensive, but are still only half covered by health insurance – and for a maximum of three attempts. Women have to undergo physical interventions and often very unpleasant hormone treatments, and success is not guaranteed.

Genetic diagnostics could help

It is therefore important to clarify the situation in men. There are often genetic causes for certain forms of disorders such as a severely reduced sperm count (oligozoospermia) or the complete absence of sperm cells in the ejaculate (azoospermia). It is estimated that these occur in 20 percent of all cases of male infertility. However, further genetic diagnostics are not always carried out here, which could reveal the causes – or at least give men an indication of the cause. For a group of men who are still far too large and unable to conceive, there is a complete lack of information as to the cause. However, azoospermia may also be treatable if sperm cells are extracted directly from the testicles. However, this requires appropriately trained specialists – and, above all, a direct offer to those affected, who are not always informed about this.

In addition to the recommendation to expand genetic diagnostics, the DGA, DGU and BvDU have defined standards that are easy to comply with, which have been summarized in the consensus paper. There are standard and basic examinations as well as further examinations. The basic examinations include personal, family and couple anamnesis, including sexual anamnesis. Medication and stimulants are recorded and a physical examination is carried out to determine whether there are any physiological causes. This includes a sonographic examination of the testicles to detect tumors or varicoceles (varicose veins in the testicular veins) that restrict fertility. "A central element of diagnostics is the spermiogram according to WHO standards as the basis for ejaculate diagnostics. Endocrine examinations initially require basic diagnostics with hormone analyses of LH, FSH and testosterone in order to identify disorders of testicular function," says the consensus paper.

There is practically no prevention

Affected men should ask their urologist or andrologist whether they are aware of the consensus paper and whether they adhere to it. Until now, it has been the case that the examination of the man during fertility treatment has only been an "appendage" offered by external urologists in practices that focus primarily on the care of women. It is therefore wise to get a second opinion if you suspect this or to go straight to an andrologist who specializes specifically in male fertility problems. Andrology is the equivalent of gynecology, but is usually only consulted by men when problems have already arisen. Unfortunately, there is practically no preventative care in this field of medicine. While women go to the gynecologist at the onset of puberty, men do not routinely visit a gynecologist. However, male fertility problems do exist and could be treated at an early stage if they were recognized in time.

"In view of the social relevance of reproductive medicine and the increasing need for care, the DGA, DGU and BvDU emphasize the urgency of ensuring the medical standard, which has proven to be relevant in guidelines and guidelines and is a prerequisite for the indication of reproductive medical measures, also in population-wide andrological care," the doctors said in a statement. Politicians must now also "pave the way for adequate remuneration of these services".

(vza)