Male infertility made clear: Quick insights from the AUA guidelines
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Why does male evaluation matter?1
  • Male factors contribute fully or partially to infertility in up to 50% of all couples.
  • Although many couples can achieve pregnancy through IUI or ART (IVF ± ICSI), evaluating the male partner is essential.
  • The AUA guideline provides a framework for evaluating and managing the male partner by means of:

    History taking

    Physical examination

    Targeted laboratory and imaging tests

    Appropriate use of medical, surgical and ART interventions

Key recommendations at a glance1
Assessment essentials

Assessment essentials

  • Evaluate both partners at the same time and take a reproductive history from the male partner during the initial evaluation.
  • Perform one or more semen analyses.
  • If semen parameters are abnormal, conduct a thorough history and physical examination as well as further tests.
Diagnostic highlights

Diagnostic highlights

  • Obtain hormonal evaluation (FSH and testosterone) for males presenting with impaired libido, erectile dysfunction, oligozoospermia, azoospermia and atrophic testes.
  • For azoospermia, use physical examination, semen volume/pH and FSH levels to differentiate between obstruction and impaired sperm production.

Recommendations1
  1. Karyotype testing for primary infertility with azoospermia or sperm concentration <5 million/mL, especially with elevated FSH, testicular atrophy or impaired sperm production.
  2. Y-chromosome microdeletion testing for sperm concentration ≤1 million/mL with features of impaired sperm production.
  3. CFTR mutation testing for males with vasal agenesis or idiopathic obstructive azoospermia.

For recurrent pregnancy loss: Karyotype with DNA fragmentation testing is recommended.1

Values related to the DNA fragmentation index2
  • Normal/Low risk: ≤15%
  • Intermediate: 15%–30%
  • High/Severe: >30%

Higher DFI value is associated with a negative fertility outcome.

Commonly used DNA fragmentation index tests3
  • SCSA
  • TUNEL
  • Comet assay
  • SCD

Treatment overview1
Varicocele

Varicocele

  • Consider varicocelectomy for palpable varicocele, infertility and abnormal semen, except in males with azoospermia.
Sperm retrieval

Sperm retrieval

  • For non-obstructive azoospermia, perform microdissection testicular sperm extraction.
  • For obstructive azoospermia, sperm may be extracted from the testis or epididymis.
  • Consider testicular sperm use in non-azoospermic males with elevated DNA fragmentation index.
  • For aspermia, consider surgical sperm extraction or methods for induced ejaculation.
  • Treat retrograde ejaculation with sympathomimetics, induced ejaculation or surgical retrieval.
Obstructive azoospermia and post-vasectomy

Obstructive azoospermia and post-vasectomy

  • Microsurgical reconstruction may restore sperm in vasal/epididymal obstruction.
  • Ejaculatory duct obstruction can be treated with transurethral resection of the ejaculatory ducts.
Medical and nutraceuticals

Medical and nutraceuticals

  • Counsel couples with low total motile sperm count that IUI success may be reduced and ART may be considered.
  • Aromatase inhibitors, human chorionic gonadotropin, selective oestrogen receptor modulators or combinations may be used in males with low serum testosterone.
  • Avoid prescribing exogenous testosterone for males interested in fertility.
  • Consider FSH analogues for males with idiopathic infertility.

Abbreviations

ART: Assisted reproductive technologies; AUA: American Urological Association; CFTR: Cystic fibrosis transmembrane conductance regulator; DNA: Deoxyribonucleic acid; FSH: Follicle-stimulating hormone; ICSI: Intracytoplasmic sperm injection; IUI: Intrauterine insemination; IVF: In vitro fertilisation; SCSA: Sperm chromatin structure assay; SCD: Sperm chromatin dispersion; TUNEL: Terminal deoxynucleotidyl transferase dUTP nick end labelling

References

1. Diagnosis and treatment of infertility in men: AUA/ASRM guideline 2020; Amended 2024.
Available from: https://www.auanet.org/guidelines-and-quality/guidelines/male-infertility. Accessed on: 27 November 2025.

2. Okubo T, Onda N, Hayashi T, et al. Performing a sperm DNA fragmentation test in addition to semen examination based on the WHO criteria can be a more accurate diagnosis of IVF outcomes. BMC Urol. 2023;23(1):78.
Available from: https://link.springer.com/content/pdf/10.1186/s12894-023-01257-y.pdf

3. Baskaran S, Agarwal A, Panner Selvam MK, et al. Tracking research trends and hotspots in sperm DNA fragmentation testing for the evaluation of male infertility: a scientometric analysis. Reprod Biol Endocrinol. 2019;17(1):110.
Available from: https://link.springer.com/content/pdf/10.1186/s12958-019-0550-3.pdf