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Year : 2017  |  Volume : 33  |  Issue : 3  |  Page : 186-187

Clinical andrology: The missing jigsaw pieces

1 Department of Urology, American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, OH, USA
2 Division of Urology, Department of Surgery, Kwong Wah Hospital, Hong Kong

Date of Web Publication30-Jun-2017

Correspondence Address:
Ashok Agarwal
Department of Urology, American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, OH
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/iju.IJU_172_17

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How to cite this article:
Agarwal A, Cho CL. Clinical andrology: The missing jigsaw pieces. Indian J Urol 2017;33:186-7

How to cite this URL:
Agarwal A, Cho CL. Clinical andrology: The missing jigsaw pieces. Indian J Urol [serial online] 2017 [cited 2022 Aug 10];33:186-7. Available from:

The introduction of intracytoplasmic sperm injection (ICSI) in 1992 has revolutionized the management of infertile couples.[1] The workup of female partner remains important in the era of ICSI since she has to go through the procedure and pregnancy. Attention has been drawn to assisted reproduction technologies (ARTs) in improving embryo quality and pregnancy outcome. In contrast, the evolution of ART has had an adverse impact on the enthusiasm of researchers and clinicians in clinical andrology. Research into the clinical management of infertile men slowed to a grind in the last three decades because ICSI technology promises the couple a baby without exploring the cause of the underlying male infertility. However, the live birth rate utilizing ICSI as the treatment of male factor infertility has stagnated at 30% despite the advancement in ART over the years.[2] The limitation is linked to abnormalities in male gamete, including high sperm DNA fragmentation. The male gamete contributes half of the DNA content, and the importance of paternal DNA on pregnancy outcome is being increasingly recognized.[3] In view of the high prevalence of male factor-associated infertility among infertile couples, it is essential to improve the outcome by a comprehensive evaluation and correction of male infertility.[4] In this issue of the Indian Journal of Urology, four important topics in the field of male infertility are discussed in the reviews. These articles cover several areas of advances in the evaluation and management of infertile men.

The central role of oxidative stress (OS) in the pathogenesis of testicular damage and male subfertility has been recognized. Increase in OS probably acts as the common pathway and has been demonstrated in clinical conditions related to male infertility including varicocele, cryptorchidism, testicular torsion, genitourinary tract infection, and inflammation.[5] Numerous laboratory methods for measuring OS have been developed and are broadly classified as direct and indirect assays.[6] The measurement of redox potential has been recently reported and has the advantage of assessing all known and unknown oxidants and antioxidants in real time with a single test.[7] The development of laboratory tests for OS is of paramount importance in identifying patients who may benefit from treatment in alleviating OS. The test result is also essential in monitoring treatment progress. Further refinement of reference values of these tests with optimum sensitivity and specificity has been reported and forms a foundation for wider clinical application of the tests.[8],[9]

The understanding of OS as the central pathway in various etiologies of male infertility makes medical therapy in the form of oral antioxidant an attractive option. However, the encouraging result with the use of antioxidants as seen in animal models [10] has not been reported consistently in human studies, and the use of oral antioxidant therapy in clinical practice is still controversial. Many of the currently available studies are limited by methodological flaws.[11] In addition to a more stringent study design, the incorporation of OS tests in patient selection may be valuable. A consensus on the efficacy of oral antioxidant therapy in improving fertility can only be reached by inclusion of patients with high OS in the studies.

The expansion of knowledge in male factor subfertility further revealed the complex interplay among different, often coexisting, factors in infertile men. Advances in microbiological techniques allow identification of previously unknown uropathogens that may be related to male infertility. The use of appropriate antibiotic may provide relatively simple and effective treatment in this group of patients. Reproductive endocrinology represents another hot topic. The potential benefit of hormonal therapy in idiopathic male infertility and before sperm retrieval procedures [12] has been reported. Better understanding and identification of pathophysiology of male infertility has significantly broadened the scope of reproductive medicine.

Tremendous development has been witnessed in the diagnostics of infertile men over the last two decades. The advancement in the evaluation of male partner drives the development of new treatment strategies. However, many of these new laboratory tests and treatments are not yet widely applied clinically. The rapidly expanding literature in the field of male infertility will probably transmit the advancements from bench to clinic and benefit infertile couples in the near future. Dramatic revolution in clinical andrology can be anticipated in the years to come. Indeed, it is an exciting time for fertility specialists to move forward in improving both natural pregnancy and ART outcomes by putting together the pieces of jigsaw which have been left aside.

   References Top

Palermo G, Joris H, Devroey P, Van Steirteghem AC. Pregnancies after intracytoplasmic injection of single spermatozoon into an oocyte. Lancet 1992;340:17-8.  Back to cited text no. 1
Neri QV, Tanaka N, Wang A, Katagiri Y, Takeuchi T, Rosenwaks Z, et al. Intracytoplasmic sperm injection. Accomplishments and qualms. Minerva Ginecol 2004;56:189-96.  Back to cited text no. 2
Agarwal A, Cho CL, Esteves SC. Should we evaluate and treat sperm DNA fragmentation? Curr Opin Obstet Gynecol 2016;28:164-71.  Back to cited text no. 3
Agarwal A, Mulgund A, Hamada A, Chyatte MR. A unique view on male infertility around the globe. Reprod Biol Endocrinol 2015;13:37.  Back to cited text no. 4
Cho CL, Esteves SC, Agarwal A. Novel insights into the pathophysiology of varicocele and its association with reactive oxygen species and sperm DNA fragmentation. Asian J Androl 2016;18:186-93.  Back to cited text no. 5
[PUBMED]  [Full text]  
Majzoub A, Esteves SC, Gosálvez J, Agarwal A. Specialized sperm function tests in varicocele and the future of andrology laboratory. Asian J Androl 2016;18:205-12.  Back to cited text no. 6
[PUBMED]  [Full text]  
Agarwal A, Roychoudhury S, Bjugstad KB, Cho CL. Oxidation-reduction potential of semen: What is its role in the treatment of male infertility? Ther Adv Urol 2016;8:302-18.  Back to cited text no. 7
Agarwal A, Ahmad G, Sharma R. Reference values of reactive oxygen species in seminal ejaculates using chemiluminescence assay. J Assist Reprod Genet 2015;32:1721-9.  Back to cited text no. 8
Agarwal A, Roychoudhury S, Sharma R, Gupta S, Majzoub A, Sabanegh E. Diagnostic application of oxidation-reduction potential assay for measurement of oxidative stress: Clinical utility in male factor infertility. Reprod Biomed Online 2017;34:48-57.  Back to cited text no. 9
Cam K, Simsek F, Yuksel M, Turkeri L, Haklar G, Yalcin S, et al. The role of reactive oxygen species and apoptosis in the pathogenesis of varicocele in a rat model and efficiency of Vitamin E treatment. Int J Androl 2004;27:228-33.  Back to cited text no. 10
Agarwal A, Sekhon LH. The role of antioxidant therapy in the treatment of male infertility. Hum Fertil (Camb) 2010;13:217-25.  Back to cited text no. 11
Ramasamy R, Ricci JA, Palermo GD, Gosden LV, Rosenwaks Z, Schlegel PN. Successful fertility treatment for Klinefelter's syndrome. J Urol 2009;182:1108-13.  Back to cited text no. 12

This article has been cited by
1 A scientometric analysis of research publications on male infertility and assisted reproductive technology
Ashok Agarwal, Manesh Kumar Panner Selvam, Saradha Baskaran, Renata Finelli, Kristian Leisegang, Catalina Barbaro?ie, Peter Natesan Pushparaj, Kathy Amy Robert, Rafael Ambar, Concetta Iovine, Damayanthi Durairajanayagam, Ralf Henkel
Andrologia. 2021; 53(1)
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