Guideline Title
The management of obstructive azoospermia: AUA best practice statement.
Bibliographic Source(s)
| American Urological Association Education and Research, Inc. The management of obstructive azoospermia: AUA best practice statement. Linthicum (MD): American Urological Association Education and Research, Inc.; 2010. 22 p. [28 references] |
Guideline Status
This is the current release of the guideline.
This guideline updates a previous version: Report on management of obstructive azoospermia. Baltimore (MD): American Urological Association Education and Research, Inc.; 2001 Apr. 10 p. [22 references]
UMLS Concepts ( what's this?)
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Disease/Condition(s)
- Obstructive azoospermia
- Infertility
Guideline Category
Management
Treatment
Clinical Specialty
Family Practice
Internal Medicine
Obstetrics and Gynecology
Surgery
Urology
Intended Users
Physicians
Guideline Objective(s)
To offer recommendations for management of couples with infertility due to obstructive azoospermia
Target Population
Couples with infertility due to obstructive azoospermia in the male partner
Interventions and Practices Considered
- Microsurgical reconstruction of the reproductive tract (vasovasostomy, vasoepididymostomy)
- Transurethral resection of the ejaculatory ducts
- Timing of sperm retrieval based on local preference
- Sperm retrieval
- In vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI)
Major Outcomes Considered
- Return of sperm to ejaculate
- Pregnancy rate (with and without assisted reproductive techniques)
- Clinical pregnancy and delivery rates
- Risks and complications of treatment
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Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence
The initial Medline search that spanned 1999 through October 2007 was supplemented by review of bibliographies and additional focused searches.
Number of Source Documents
341 articles were deemed by the Panel members to be suitable for scrutiny.
Methods Used to Assess the Quality and Strength of the Evidence
Not stated
Rating Scheme for the Strength of the Evidence
Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence
Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations
The supporting systematic literature review and the drafting of the document were conducted by the Infertility Best Practice Statement Panel (the Panel) created in 2007 by the American Urological Association (AUA). The Practice Guidelines Committee (PGC) of the AUA selected the Panel Chair who in turn appointed the additional Panel members with specific expertise in evaluation of the infertile male. The mission of the Panel was to develop either analysis- or consensus-based recommendations, depending on the type of evidence available and Panel processes, to support optimal clinical practices concerning the infertile male. The Panel was charged with developing a best practice statement, based on the previous report, by employing published data in concert with expert opinion.
Rating Scheme for the Strength of the Recommendations
Cost Analysis
The guideline developers reviewed cost analyses. Microsurgical vasovasostomy and vasoepididymostomy have been shown to be more cost-effective than sperm retrieval with in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI).
Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation
This guideline document was submitted to 58 urologists and other health care professionals for peer review, and comments from 21 physicians and researchers were considered by the Panel in making revisions.
After revision of the guideline document based upon the peer review comments, the best practice statement guideline was submitted to and approved by the Practice Guidelines Committee (PGC) and the Board of Directors of the American Urological Association.
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Major Recommendations
Treatment Methods for Obstructive Azoospermia
Sperm Retrieval Techniques and In Vitro Fertilization/Intracytoplasmic Sperm Injection
- The timing of sperm retrieval in relation to oocyte retrieval should be based upon local preference and expertise because there is no evidence that either fertilization or pregnancy rates are different using either fresh or thawed cryopreserved sperm from patients with either obstructive or nonobstructive azoospermia.
- The choice of sperm retrieval by either percutaneous or open surgery from either the testis or epididymis should be based upon local preferences and expertise since there is no evidence that the site or method of sperm retrieval affects outcome of in vitro fertilization with intracytoplasmic sperm injection for patients with obstructive azoospermia.
- Open surgical testicular sperm retrieval with or without microscopic magnification is recommended for patients with nonobstructive azoospermia.
Microsurgical Reconstruction Versus Sperm Retrieval with In Vitro Fertilization/Intracytoplasmic Sperm Injection (IVF/ICSI)
Microsurgical reconstruction of the reproductive tract is preferable to sperm retrieval with IVF/ICSI in men with prior vasectomy if the obstructive interval is less than 15 years and no female fertility risk factors are present. If epididymal obstruction is present, the decision to use either microsurgical reconstruction or sperm retrieval with IVF/ICSI should be individualized. Vasoepididymostomy should be performed by an expert in reproductive microsurgery.
Sperm retrieval/ICSI is preferred to surgical treatment when (1) advanced female age is present, (2) female factors requiring IVF are present, (3) the chance for success with sperm retrieval/ICSI exceeds the chance for success with surgical treatment or (4) sperm retrieval/ICSI is preferred by the couple for financial reasons.
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Evidence Supporting the Recommendations
Type of Evidence Supporting the Recommendations
The type of supporting evidence is not specifically stated for each recommendation.
This guideline document is based on review of available professional literature as well as clinical experience and expert opinion.
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Benefits/Harms of Implementing the Guideline Recommendations
Potential Benefits
Appropriate management of couples with infertility due to obstructive azoospermia
Potential Harms
Risks Associated with Sperm Retrieval
Sperm retrieval is best performed by a surgeon trained in this procedure, because the possible postoperative complications of sperm retrieval include bleeding and infection that may require surgical intervention.
Risks Associated with In Vitro Fertilization/Intracytoplasmic Sperm Injection (IVF/ICSI)
- Any couple considering IVF/ICSI should be apprised of the risks associated with this treatment. These risks include the possibility of ovarian hyperstimulation and the potential complications of oocyte retrieval and multiple gestations. The risk of congenital malformations in children conceived after ICSI, compared to results after IVF, have yielded conflicting results. Meta-analysis of studies after assisted reproductive treatments (IVF or ICSI) suggest less than 30% increase in the risk of congenital malformations relative to the rate of malformations in children conceived naturally (1-4% rate of malformations). This information should be shared with couples considering IVF with or without ICSI. The prevalence of sex chromosome abnormalities in children conceived by ICSI is higher than that observed after routine IVF (0.8-1.0% vs. 0.2%). It is unclear whether this apparent increased risk results from the ICSI procedure or from a paternal effect related to abnormal sperm production in the male requiring ICSI.
- IVF carries a risk of mild ovarian hyperstimulation syndrome in up to 20% of patients. Moderate ovarian hyperstimulation occurs in up to 5% of women undergoing IVF. Severe ovarian hyperstimulation, which may require hospitalization and can be life threatening, occurs in 1% of women undergoing IVF.
- The risk of multiple gestations after ICSI in the United States is approximately 30% for twin gestations and less than 5% for triplets. Multiple-gestation births are associated with increased infant morbidity and mortality rates due primarily to prematurity. The neonatal and maternal morbidity induced by multiple gestations accounts for the increased perinatal expense associated with multiple gestations. Whereas the in-hospital costs for delivery of a singleton child are typically less than $10,000, perinatal care for triplets averages more than $100,000.
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Qualifying Statements
- This best practice statement is intended to provide medical practitioners with a consensus of principles and strategies for the care of couples with male infertility problems. This guideline document is based on current professional literature, clinical experience and expert opinion. It does not establish a fixed set of rules or define the legal standard of care and it does not preempt physician judgment in individual cases. Physician judgment must take into account variations in resources and in patient needs and preferences. Conformance with this best practice statement cannot ensure a successful result.
- As medical knowledge expands and technology advances, this best practice statement will change. Today they represent not absolute mandates but provisional proposals or recommendations for treatment under the specific conditions described. For all these reasons, this best practice statement does not preempt physician judgment in individual cases. Also, treating physicians must take into account variations in resources, and in patient tolerances, needs and preferences.
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Implementation of the Guideline
Description of Implementation Strategy
An implementation strategy was not provided.
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Institute of Medicine (IOM) National Healthcare Quality Report Categories
IOM Care Need
Getting Better
IOM Domain
Effectiveness
Patient-centeredness
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Identifying Information and Availability
Bibliographic Source(s)
| American Urological Association Education and Research, Inc. The management of obstructive azoospermia: AUA best practice statement. Linthicum (MD): American Urological Association Education and Research, Inc.; 2010. 22 p. [28 references] |
Adaptation
Not applicable: The guideline was not adapted from another source.
Date Released
2001 Apr (revised 2010)
Guideline Developer(s)
American Urological Association Education and Research, Inc. - Medical Specialty Society
Source(s) of Funding
American Urological Association, Inc. (AUA)
Guideline Committee
Male Infertility Best Practice Statement Panel
Composition of Group That Authored the Guideline
Panel Members: Jonathan Jarow, MD (Chair); Mark Sigman, MD (Facilitator); Peter N. Kolettis, MD; Larry I. Lipshultz, MD; R. Dale McClure, MD; Ajay K. Nangia, MD; Cathy Kim Naughton, MD; Gail S. Prins, PhD; Jay I. Sandlow, MD; Peter N. Schlegel, MD
Consultant: Joan Hurley, JD, MHS
Financial Disclosures/Conflicts of Interest
All panel members completed Conflict of Interest disclosure. Those marked with (C) indicate that compensation was received; relationships designated by (U) indicate no compensation was received; (A) indicates affiliation.
Consultant or Advisor: Larry I. Lipshultz, Humagen (C), Pfizer (C), Lilly ICOS (C), Allergan (AU), Auxilium (AC); Scientific Study or Trial: Larry I. Lipshultz, Auxilium Prostate/T Study (AU), Auxilium Registry Study (AU); Meeting Participant or Lecturer: Larry I. Lipshultz, Solvay (C); Pfizer (C); Auxilium (AC); Investigator: Mark Sigman, GlaxoSmithKline (AC), Other: Peter Niles Schlegel, Theralogix (C), American Board of Urology (AU)
Guideline Status
This is the current release of the guideline.
This guideline updates a previous version: Report on management of obstructive azoospermia. Baltimore (MD): American Urological Association Education and Research, Inc.; 2001 Apr. 10 p. [22 references]
Availability of Companion Documents
NGC Status
This NGC summary was completed by ECRI on November 7, 2001. The information was verified by the guideline developer as of December 24, 2001. This NGC summary was updated by ECRI Institute on November 5, 2010. The updated information was verified by the guideline developer on November 23, 2010.
Copyright Statement
This NGC summary is based on the original guideline, which is copyrighted by the American Urological Association, Inc. (AUA).
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