Book Review

Evaluation and Treatment of the Infertile Male

N Engl J Med 1997; 336:1766-1767June 12, 1997

Article

Evaluation and Treatment of the Infertile Male
Edited by Grace M. Centola and Kenneth A. Ginsburg. 322 pp., illustrated. New York, Cambridge University Press, 1996. $74.95. ISBN: 0-521-45059-4

Biblical tradition holds that God's first commandment to mankind was to “be fruitful and multiply.” As with many divine instructions, this one is sometimes easier said than done. In Western countries today, it is estimated that infertility affects as many as one of every five couples.

Many infertile couples must cope with an identifiable male factor, such as the absence of sperm, deficient numbers of sperm in the ejaculate, or the inability of the sperm to reach the egg and complete the fertilization process. The aim of this book is to provide a reference on the basic aspects of evaluating the male partner in an infertile couple and diagnosing the problem. The chapters on diagnosis contain valuable reminders about how to take a directed history and perform a physical exam and how to do a routine semen analysis. The newer techniques, such as computer-assisted semen analysis and sperm-penetration assay, are described in enough detail for readers to appreciate their complexity. Their main value seems to be in giving a prognosis for the potential of success with in vitro fertilization rather than diagnostic information. The diagnosis and treatment algorithms for identifiable endocrine abnormalities and for azoospermia are especially lucid.

Beyond this diagnostic review, fully half the material in the book is an elaboration on the technologies that have become available for bringing sperm and ova together in the laboratory. The tools for the rehabilitation and salvage of minute numbers of sperm, even to the point of intracytoplasmic injection of a single sperm, are prodigious. A modern medical Bismarck might observe that reproduction has become the new “art of the possible” for the coming millennium. However, the results of these in vitro techniques in compensating for adverse male factors are variable.

The focus on glamorous technology and the salvation of a single gamete, in isolation from “the infertile male” himself, can be problematic. Berg and Mikesell's chapter on the psychological aspects of infertility provides a necessary balance. They acknowledge that we clinicians must deal with the patients in our care. Indeed, the infertile couple is itself a “patient,” comprising two persons. “Infertility can be a profound and troubling experience,” they note, and physicians who want to help their patients through this emotionally charged process would do well to make special allowances for the vulnerability and shame that infertile men may feel. Men may be especially reluctant to verbalize or express these feelings, because of personal and cultural conditioning. Additional legal and ethical complexities, frankly discussed in the book, may arise when donor insemination is considered as a solution for infertility.

Even after two decades of expanding the boundaries of technological assistance in reproduction, there are still practical limitations to what may be achieved. As Rebecca Sokol points out in her chapter on endocrine assessment, “The majority of infertile men present with disorders that are either nontreatable or questionably amenable to treatment.” Even couples in treatable circumstances may not have the personal or financial resources to take advantage of all treatment options.

This book is a showcase of what is possible in assisted-reproduction centers of excellence. Armed with this knowledge, the practicing clinician may offer many couples hope. Healthful lifestyle choices and the avoidance of toxic exposures can also be encouraged for all. For many men and women with infertility, there may be no medical “cure.” The experience of infertility is a transforming life event, marked by pain and grieving for lost opportunities. Clinicians in this circumstance should recognize that not all healing comes from their hands (or micropipettes). As always, the physician's most important offerings may be compassion and comfort.

Todd J. Garvin, M.D.
Doctors Clinic, Bremerton, WA 98310