The Indian perspective on male infertility care: Takeaways from USI guidelines
  • Home
  • Update - The Indian perspective on male infertility care: Takeaways from USI guidelines

Evaluation and semen analysis1,2
  • Conduct a relevant reproductive history and focused clinical examination.
  • Semen analysis must follow the WHO 6th edition standards.

    Standardised collection (2–7 days abstinence)

    Accurate volume measurement

    Sperm concentration, motility, morphology and vitality assessment

    Internal/external quality control

WHO 6th-edition reference values2
Parameter Reference value (5th percentile, 95% CI)
Semen volume (mL) 1.4 (1.3–1.5)
Sperm concentration (million/mL) 16 (15–18)
Total sperm number (million/ejaculate) 39 (35–40)
Total motility (PR + NP, %) 42% (40–43)
Progressive motility (PR, %) 30% (29–31)
Vitality (%) 54% (50–56)
Normal morphology (%) 4% (3.9–4.0)

Indications for further evaluation1
  • Endocrine evaluation is indicated only after two abnormal semen analyses.
  • Scrotal ultrasound is recommended for obese men, those with prior scrotal surgery, or those who have a tight/small scrotum.
  • Transrectal ultrasound is reserved for suspected ejaculatory duct obstruction.

Obstructive azoospermia1
  1. Suspect congenital bilateral absent vas deferens in men with non-palpable vas and test for CFTR mutations.
  2. Testicular biopsy should be performed in centres with sperm retrieval and cryopreservation capability.
  3. Microsurgical reconstruction (vasovasostomy / epididymovasostomy) is preferred in men with partners with good ovarian reserve.
  4. When ovarian reserve is limited, use sperm retrieval (MESA/TESE/PESA/TESA) adjunctively.
  5. For irreparable obstruction, sperm retrieval is preferred for ICSI/IVF.

Non-obstructive azoospermia1
  1. A comprehensive evaluation includes a detailed history, hormonal profile and genetic testing.
  2. AZFa/AZFb microdeletions contraindicate surgical sperm retrieval.
  3. Microdissection TESE is the most efficient sperm retrieval technique in NOA.

Hypogonadotropic hypogonadism1
  1. HH results from pituitary/hypothalamic dysfunction, causing impaired androgen and sperm production.
  2. Diagnosis: Confirm by low FSH, LH and testosterone; brain imaging is advised.
  3. Androgen replacement therapy is recommended when fertility is not desired; gonadotropins are required to induce spermatogenesis.

Infections Infections1
  • A 3–6 week course of antibiotics and anti-inflammatory agents may help with infections and related conditions.
  • Antioxidants may aid ROS reduction following epididymal inflammation.

Genetic considerations Genetic considerations1
  • High LH/FSH levels in azoospermia warrant genetic testing.
  • Sperm concentration <10 million/mL (especially <5 million/mL) requires genetic counselling and karyotyping/microdeletion testing.
  • Men with Klinefelter syndrome have 22%–50% sperm retrieval success rate via micro-TESE.

Varicocele Varicocele1
  • Only a clinically palpable varicocele requires treatment.
  • Microsurgical varicocelectomy is preferred.

Cancer and fertility Cancer and fertility1
  • Fertility counselling and cryopreservation are mandatory.
  • Assess and discuss hypogonadism risk and establish baseline hormones.
  • Onco-TESE is an option for azoospermia with bilateral tumours.

Idiopathic infertility Idiopathic infertility1
  • Empirical therapy includes hormonal agents and antioxidants.
  • Treat for 4–6 months before considering ART.
  • Men with abnormal testosterone-to-oestradiol ratio may benefit from aromatase inhibitors.

Abbreviation

ART: Assisted reproductive technology; CFTR: Cystic fibrosis transmembrane conductance regulator; CI: Confidence interval; FSH: Follicle-stimulating hormone; HH: Hypogonadotropic hypogonadism; ICSI: Intracytoplasmic sperm injection; IVF: In vitro fertilisation; LH: Luteinising hormone; MESA: Microsurgical epididymal sperm aspiration; NOA: Non-obstructive azoospermia; NP: Non-progressive motility; PESA: Percutaneous epididymal sperm aspiration; PR: Progressive motility; ROS: Reactive oxygen species; TESE: Testicular sperm extraction; TESA: Testicular sperm aspiration; USI: Urological Society of India; WHO: World Health Organization

References

1. Priyadarshi S, Tanwar R, Malhotra V, et al. The Urological Society of India guidelines for the management of male infertility (Executive Summary). Indian J Urol. 2023;39(1):7–11.
Available from: https://journals.lww.com/indianjurol/fulltext/2023/39010/the_urological_society_of_india_guidelines_for_the.3.aspx

2. World Health Organization. Laboratory manual for the examination and processing of human semen — 6th Edition (2021).
Available from: https://iris.who.int/server/api/core/bitstreams/4038e736-37b3-4064-a39a-60475e0ccecc/content. Accessed on: 11 December 2025.