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White PapersWhite PapersThe Australian Guidelines for Male Infertility offer clinicians a unified evidence-based framework to improve diagnosis, management, and counseling for male fertility issues.
Infertility, defined as the inability to achieve a spontaneous pregnancy after at least 12 months of regular unprotected intercourse, remains a pervasive health concern, with male factors contributing significantly to its occurrence. Recognizing that male infertility is also a biomarker for overall health, the first Australian evidence-based guidelines provide a long-awaited framework to inform and support Australian clinicians.
The initial approach to a concerned man or couple experiencing infertility is clearly outlined. Mandatory steps include offering an initial evaluation comprising a reproductive and general history, a physical examination (including scrotal assessment), and semen analysis. This evaluation should be performed concurrently with an assessment of the female partner to prevent delays in accessing timely fertility care. Importantly, if the first semen analysis is abnormal, a second analysis is required approximately six weeks later. The guidelines explicitly recommend against the routine use of scrotal ultrasound and antisperm antibody testing during this initial phase.
For men requiring further evaluation due to suspected or confirmed abnormal semen parameters, referral to a specialist in male reproduction is recommended. Further evaluation includes mandatory hormonal testing (morning, preferably fasting, total testosterone, SHBG, FSH, and LH) if there are signs of testosterone deficiency or abnormal semen parameters.
Specific recommendations are provided for complex conditions. For men with azoospermia (no sperm in the ejaculate), evaluation is mandatory to differentiate between obstructive (OA) and non-obstructive (NOA) types, guided initially by semen volume, pH, scrotal examination, and serum FSH. If sperm retrieval is necessary in NOA, micro testicular sperm extraction (Micro-TESE) is the preferred method, offering higher retrieval rates. Crucially, the guidelines suggest that diagnostic testicular biopsy is not required prior to Micro-TESE, as it risks compromising future sperm retrieval.
Regarding varicocele management, treatment is only considered for men with a palpable (clinical) varicocele and associated indicators, such as abnormal semen parameters, unexplained infertility, or raised sperm DNA fragmentation. Treatment is not recommended for sub-clinical varicoceles.
A major component of management involves comprehensive counselling. Given the link between male infertility and other non-gonadal health conditions (such as cardiovascular or metabolic disease), clinicians are advised to inform men with abnormal semen parameters of associated health risks that may require regular review. Lifestyle changes, including maintaining a healthy weight, smoking cessation, and reducing alcohol intake, are recommended to potentially improve sperm quality. Finally, a mandatory guideline statement cautions that testosterone therapy must not be prescribed to men with current or imminent reproductive intent, as it suppresses the hormonal axis necessary for fertility.
These guidelines are expected to serve as an essential clinical aid, facilitating evidence-based care across the most common areas of male infertility and helping to raise awareness of this common condition
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