For years, a couple’s reproductive failures were routinely blamed on the woman: If the longed-for child did not arrive, it was her “fault.” Today, evidence shows infertility factors are attributable to both partners in nearly equal measure, and specialty societies have outlined diagnostic pathways for each to identify obstacles and remove them when possible. In practice, however, the female partner often undergoes more extensive testing than the male partner before the couple is referred for assisted reproduction.

According to the latest report from Italy’s Ministry of Health on the implementation of the country’s assisted reproduction law, with 2022 data, the main infertility factor among couples who turn to assisted reproduction is female in 43.8% of cases, male in 19.9%, both male and female in 19.2%, and idiopathic (unexplained) in 16.2%.

In Italy, the umbrella term is medically assisted procreation (MAP), which covers all fertility interventions; assisted reproductive technology refers specifically to lab-based procedures like in vitro fertilization and intracytoplasmic sperm injection.

“Infertility is defined as idiopathic when the couple has undergone the recommended diagnostic tests and no abnormality emerges that would explain the inability to conceive spontaneously,” said Luca Boeri, urologist and andrologist at Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico in Milan, Italy. “Whereas any abnormalities found in tests performed on the male partner lead to a diagnosis of male infertility. However, in that 39.1% of cases in which a male infertility factor emerges — alone or combined with female infertility — the underlying causes are not always known.”

The ministry report details the proportions of female infertility due to endometriosis, tubal factor, diminished ovarian reserve, and other causes but provides no breakdown of male infertility causes. This imbalance partly reflects couples delaying their first pregnancy and, when conception takes longer, delaying medical help. As a result, today the workup often centers on the female partner’s ovarian reserve, and when time is tight because of age, the pathway to MAP is accelerated to preserve the chances of success.

“The fact is that, in many infertile couples who access MAP, the male partner has undergone only a semen analysis,” Boeri said, “and is not always referred to an andrologist for a thorough assessment and to suggest therapies that could improve the chances of conception, both naturally and with MAP.”

Correct Diagnostic Pathway Is Defined…

The Italian Society of Andrology and Sexual Medicine outlined the recommended pathway for diagnosing male infertility in a 2022 consensus document. “It must be personalized case by case,” said Alberto Ferlin, MD, PhD, professor of endocrinology at the University of Padua, Padua, Italy, director of the Unit of Andrology and Reproductive Medicine at the University Hospital of Padua, and lead author of the document. “First-line testing recommended for everyone includes a medical history, physical exam, semen analysis, semen culture to diagnose possible infections, testicular ultrasound, and hormone assays. Based on the results of these initial tests, further evaluations can follow. In most cases, in-depth diagnostics make it possible to identify the origin of infertility and often to resolve it, allowing natural conception.” According to Ferlin, this should be the primary goal of reproductive medicine, as also provided by Italy’s Law 40 (2004), which regulates assisted reproduction.

An in-depth diagnosis matters beyond reproduction. “Sometimes infertility is a warning sign of a general health problem,” said andrologist and endocrinologist Francesco Lombardo, MD, PhD, professor at Sapienza University of Rome, Rome, Italy. “We have seen infertile men sent to MAP without determining the causes of the problem, and later it emerged they had a tumor. Unlike women, who are used to periodic gynecologic checkups, few men see an andrologist during their lives. It would be advisable for all young men, around legal adulthood, to have a semen analysis, a testicular ultrasound, and an exam to diagnose any abnormalities early and preserve health and fertility.”

…But Often Ignored

“The man with infertility who turns to an andrology specialist undergoes all the necessary tests to determine the origin of his problem,” Ferlin said. “Today, however, most couples who struggle to conceive go directly to an assisted reproduction center, and specialists at these facilities often do not pursue deeper investigations because they are focused on bypassing the cause with MAP.”

Law 40 requires an andrological evaluation of the male partner before entering a MAP pathway. It does not, however, specify in detail which tests must be performed.

“Often, even in large public hospitals, the andrologist works in another department and consults for the assisted reproduction center. He or she does not evaluate all patients who access the center, but only selected cases,” Boeri said. “What is needed instead is parallel care of both partners by the gynecologist and the andrologist for all infertile couples, even before they are referred to MAP.”

Recognition of the need for an equal approach to both partners led Careggi University Hospital in Florence, Italy — a major public academic medical center — to establish, in 2022, the Center for Prevention, Diagnosis and Treatment of Infertility, with unique characteristics in Italy’s public system.

“At our center, active for a couple of years, we manage the female and male partners in parallel to determine the causes of the couple’s infertility,” said Linda Vignozzi, professor of endocrinology at the University of Florence, Florence, Italy, and head of the Andrology, Women’s Endocrinology, and Gender Incongruence Unit at the center. “Once the causes are identified, we try to resolve them, and we resort to MAP only when it is not possible to remove the obstacles to natural conception, or when the woman’s age makes rapid intervention necessary. Before the center was implemented, 90% of male partners reached MAP without an adequate andrological evaluation. Its launch now allows us to identify, in most cases, the underlying pathology of male infertility — often diabetes, hypertension, endocrine diseases, or hormonal alterations that can be effectively corrected.”

This story was translated from Univadis Italy, part of the Medscape Professional network.