Editing Infertility: Diagnosis and Evaluation (section)

== General principles ==
* '''<span style="color:#ff0000">For initial infertility evaluation, both male and female partners should undergo concurrent assessment.</span>'''
** '''<span style="color:#ff0000">Maternal age is the strongest predictor of fertility outcome in couples undergoing therapy.</span>'''
**Many couples have more than one fertility issue present.
*** For the female partner, tests are indicated to evaluate ovarian reserve, ovulatory function, tubal structures as well as assessment of the uterine cavity.
*** For the male partner, good clinical practice is to 
****Obtain a reproductive history
****Perform a physical examination
****Basic diagnostic tests of reproductive function
*'''Males with abnormal SAs''' and/or abnormal reproductive history, including physical examination and selected laboratory and radiologic assessment '''should be evaluated by specialists in male reproduction'''
*'''Goals of evaluation are to identify (5):[https://pubmed.ncbi.nlm.nih.gov/33295257/ ★]'''
*# '''Potentially correctable conditions for treatment to allow for conception through intercourse or through techniques, such as IUI or IVF, when those approaches would otherwise not be possible'''
*# '''Irreversible conditions that are amenable to ART using the sperm of the male partner'''
*# '''irreversible conditions that are not amenable to the above, and for which donor insemination or adoption are possible options'''
*# '''Life- or health-threatening conditions (e.g.''' '''testicular cancer or pituitary tumours) that may underlie the infertility or associated medical comorbidities that require medical attention'''
*# '''Genetic abnormalities or lifestyle and age factors that may affect the health of the male patient or of offspring particularly if ART are to be employed'''
* '''In couples with failed assisted reproductive technology cycles or recurrent pregnancy losses (RPL) (two or more losses), evaluation of the male should be considered.'''
**In this clinical setting, the male partner should be evaluated by a male reproductive expert and consideration given to evaluation of sperm DNA fragmentation and karyotype testing of the male. 
***Even with a "normal" SA, a sperm that appears morphologically and functionally normal may not be chromosomally normal or may have a high level of DNA fragmentation.
**Some experts would also consider sperm aneuploidy testing
***This test is not universally available for all centers.
*'''Timing'''
** '''Infertility should be evaluated after 6 months of attempted conception when the female partner is over 35 years of age[https://pubmed.ncbi.nlm.nih.gov/33295257/ ★]'''
*Patient Counselling
**Counsel infertile men or men with abnormal semen parameters of the health risks associated with abnormal sperm production.
*** 1-6% of men have undiagnosed medical diseases at the time of an infertility evaluation
***Abnormal semen parameters associated with increased risk of 
****Testicular cancer
****Mortality
*'''Advise couples with advanced paternal age (≥40) that there is an increased risk of adverse health outcomes for their offspring.'''
**'''Effects of male age on reproductive function'''
***Reproductive function
***Sexual function
***Testicular morphology
***Semen parameters (except sperm concentration, semen parameters decrease as age increases)
***Infections of the accessory glands
***Vascular disease
*** Genetics (sperm aneuploidies, aneuploidies in off-spring, sperm DNA integrity, telomeres, epigenetics)
***Fertility
***Miscarriage
***C-section
***Pre-eclampsia
***Trophobalst disease
***Preterm birth
***Adverse outcome in offspring
**Genetic counseling may be appropriate for couples with advanced paternal age to discuss the magnitude of these risks