男性因素不育

继发性性腺机能减退，例如促性腺激素缺乏或遗传学疾病例如Kallmann综合征，可以通过促性腺激素或GnRH脉冲治疗。[29]Liu PY, Handelsman DJ. The present and future state of hormonal treatment for male infertility. Hum Reprod Update. 2003;9:9-23.http://humupd.oxfordjournals.org/cgi/reprint/9/1/9http://www.ncbi.nlm.nih.gov/pubmed/12638778?tool=bestpractice.com

如果绒毛膜促性腺激素（hCG）用于治疗性腺机能减退，治疗6个月后未诱导精子生成，治疗方案中应加入卵泡刺激素（FSH）。

脉冲GnRH可用于数个月的继发性性腺机能减退的治疗，但较促性腺激素治疗更繁琐且昂贵。

垂体肿瘤引起的高泌乳素血症导致的继发性性腺机能减退的男性使用溴隐亭或卡麦角林治疗。

存在抗精子抗体时可使用糖皮质激素治疗。然而，没有证据证明糖皮质激素是有效的。[33]National Institute for Health and Care Excellence. Fertility: assessment and treatment for people with fertility problems. February 2013. http://www.rcog.org.uk (last accessed 28 October 2016).http://www.nice.org.uk/guidance/cg156

抗精子抗体阳性的男性更适于辅助生殖技术（ART）治疗；人工洗涤精子授精或胞浆内精子注射体外授精是更好的选择。

每个疗程的IVF妊娠率均高于IUI。[53]Pashayan N, Lyratzopoulos G, Mathur R. Cost-effectiveness of primary offer of IVF vs. primary offer of IUI followed by IVF (for IUI failures) in couples with unexplained or mild male factor subfertility. BMC Health Serv Res. 2006;6:80.http://www.biomedcentral.com/1472-6963/6/80http://www.ncbi.nlm.nih.gov/pubmed/16796733?tool=bestpractice.com多胎妊娠是IVF的可能并发症。在年轻患者中使用单个胚胎移植是减少这种并发症的最好方法并且预后良好。[54]Pandian Z, Marjoribanks J, Ozturk O, et al. Number of embryos for transfer following in vitro fertilisation or intra-cytoplasmic sperm injection. Cochrane Database Syst Rev. 2013;(7):CD003416.http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003416.pub4/fullhttp://www.ncbi.nlm.nih.gov/pubmed/23897513?tool=bestpractice.com[55]Grady R, Alavi N, Vale R, et al. Elective single embryo transfer and perinatal outcomes: a systematic review and meta-analysis. Fertil Steril. 2012;97:324-331.http://www.ncbi.nlm.nih.gov/pubmed/22177461?tool=bestpractice.comART也轻微增加不良妊娠结局和出生缺陷的风险；然而，增加不育的风险也不能排除。[51]Allen VM, Wilson RD, Cheung A; Genetics Committee of the Society of Obstetricians and Gynaecologists of Canada (SOGC); Reproductive Endocrinology Infertility Committee of the Society of Obstetricians and Gynaecologists of Canada (SOGC). Pregnancy outcomes after assisted reproductive technology. J Obstet Gynaecol Can. 2006;28:220-250.http://www.ncbi.nlm.nih.gov/pubmed/16650361?tool=bestpractice.com[56]Rimm AA, Katayama AC, Katayama KP. A meta-analysis of the impact of IVF and ICSI on major malformations after adjusting for the effect of subfertility. J Assist Reprod Genet. 2011;28:699-705.http://www.ncbi.nlm.nih.gov/pubmed/21625967?tool=bestpractice.com

睾丸精子提取术的风险和显微外科附睾穿刺精子提取术的风险包括睾丸血肿、疼痛和感染。卵胞浆内精子注射被认为是Beckwith-Wiedemann和Angelman's综合征和其他异常甲基化结果的危险因素。这种联系尚未被证实。

对生育能力低的男性治疗精索静脉曲张是否获益的随机临床回顾性试验仍存在争议。为治疗不育而进行的精索静脉曲张的治疗应在与不育夫妇充分讨论过治疗是否获益存在争议并排除其他导致男性或女性不孕不育的病因后进行。[14]Evers JL, Collins JA. Assessment of efficacy of varicocele repair for male subfertility: a systematic review. Lancet. 2003;361:1849-1852.http://www.ncbi.nlm.nih.gov/pubmed/12788571?tool=bestpractice.com[34]Cayan S, Shavakhabov S, Kadioglu A. Treatment of palpable varicocele in infertile men: a meta-analysis to define the best technique. J Androl. 2009;30:33-40.http://www.ncbi.nlm.nih.gov/pubmed/18772487?tool=bestpractice.com[35]Ficarra V, Cerruto MA, Liguori G, et al. Treatment of varicocele in subfertile men: The Cochrane Review - a contrary opinion. Eur Urol. 2006;49:258-263.http://www.ncbi.nlm.nih.gov/pubmed/16426727?tool=bestpractice.com[36]Madgar I, Weissenberg R, Lunenfeld B, et al. Controlled trial of high spermatic vein ligation for varicocele in infertile men. Fertil Steril. 1995;63:120-124.http://www.ncbi.nlm.nih.gov/pubmed/7805900?tool=bestpractice.com证据 B治疗益处：有中等质量证据不建议行精索静脉曲张结扎术，除非已与患者充分讨论过手术治疗效果的不确定性。European Association of Urology: guidelines for the investigation and treatment of male infertility受试者＜200名的随机对照临床试验（RCT）、受试者＞200名且方法学存在缺陷的随机对照临床试验（RCT）、方法学存在缺陷的系统评价或者高质量的观察性（队列）研究。 两项 Meta 分析显示没有其他不育因素的男性患者行曲张精索静脉切除术后精液参数改善并且使受孕率增高。[37]Kroese AC, de Lange NM, et al. Surgery or embolization for varicoceles in subfertile men. Cochrane Database Syst Rev. 2012;10:CD000479.http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000479.pub5/fullhttp://www.ncbi.nlm.nih.gov/pubmed/23076888?tool=bestpractice.com[38]Schauer I, Madersbacher S, Jost R, et al. The impact of varicocelectomy on sperm parameters: a meta-analysis. J Urol. 2012;187:1540-1547.http://www.ncbi.nlm.nih.gov/pubmed/22425089?tool=bestpractice.com没有研究专注于提高出生存活率[37]Kroese AC, de Lange NM, et al. Surgery or embolization for varicoceles in subfertile men. Cochrane Database Syst Rev. 2012;10:CD000479.http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000479.pub5/fullhttp://www.ncbi.nlm.nih.gov/pubmed/23076888?tool=bestpractice.com

严重的并发症很少见。外伤感染、睾丸鞘膜积液、持续性或复发性精索静脉曲张、长期疼痛的风险较小，睾丸萎缩更少见。

对原因不明的男性不育症给予促性腺激素和抗雌激素是经验性治疗。

绒毛膜促性腺激素（hCG）和卵泡刺激素（FSH）治疗不明原因不育症的原理是增加精子生成量。然而，随机对照研究显示对不明原因不育症使用促性腺激素的经验性治疗无效。[57]Tournaye H. Evidence-based management of male subfertility. Curr Opin Obstet Gynecol. 2006;18:253-259.http://www.ncbi.nlm.nih.gov/pubmed/16735823?tool=bestpractice.com这不包括他们在男性性腺机能减退治疗中的作用。

雌激素拮抗物和芳香酶抑制剂被认为间接增加FSH和LH的生成并提高精子生成量。这些治疗根据观察性研究显示出了良好的预后，但需通过设计严谨的随机对照试验验证。[58]Kumar R, Gautam G, Gupta NP. Drug therapy for idiopathic male infertility: rationale versus evidence. J Urol. 2006;176:1307-1312.http://www.ncbi.nlm.nih.gov/pubmed/16952617?tool=bestpractice.com[59]Dankert T, Kremer JA, Cohlen BM, et al. A randomized clinical trial of clomiphene citrate versus low dose recombinant FSH for ovarian hyperstimulation in intrauterine insemination cycles for unexplained and male subfertility. Hum Reprod. 2007;22:792-797.http://humrep.oxfordjournals.org/cgi/content/full/22/3/792http://www.ncbi.nlm.nih.gov/pubmed/17110396?tool=bestpractice.com[60]Bhattacharya S, Harrild K, Mollison J, et al. Clomifene citrate or unstimulated intrauterine insemination compared with expectant management for unexplained infertility: pragmatic randomised controlled trial. BMJ. 2008;337:a716.http://www.bmj.com/cgi/content/full/337/aug07_2/a716http://www.ncbi.nlm.nih.gov/pubmed/18687718?tool=bestpractice.com

针对经选择患者组全部患者的治疗推荐

抗氧化剂例如维生素C和E、左旋肉碱、己酮可可碱和谷胱甘肽被用于治疗男性不育症。这些药物的使用是经验性的。一些体外观察性研究显示精液参数改善。一项系统性回顾研究显示男性患者使用抗氧化剂治疗后出生存活率增高。[61]Showell MG, Mackenzie-Proctor R, Brown J, et al. Antioxidants for male subfertility. Cochrane Database Syst Rev. 2014;(12):CD007411.http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007411.pub3/fullhttp://www.ncbi.nlm.nih.gov/pubmed/25504418?tool=bestpractice.com

己酮可可碱能改善睾丸的微循环、精子活力和精子浓度。[62]Safarinejad MR. Effect of pentoxifylline on semen parameters, reproductive hormones, and seminal plasma antioxidant capacity in men with idiopathic infertility: a randomized double-blind placebo-controlled study. Int Urol Nephrol. 2011;43:315-328.http://www.ncbi.nlm.nih.gov/pubmed/20820916?tool=bestpractice.com

维生素C和E、左旋肉碱、谷胱甘肽能够减少睾丸环境的活性氧类物质。给予外源性酶Q-10同样增加精液中的辅酶水平，并且能够提高特发性弱精子症患者的精子动力学特点。[63]Balercia G, Buldreghini E, Vignini A, et al. Coenzyme Q10 treatment in infertile men with idiopathic asthenozoospermia: a placebo-controlled, double-blind randomized trial. Fertil Steril. 2009;91:1785-1792.http://www.ncbi.nlm.nih.gov/pubmed/18395716?tool=bestpractice.com[64]Safarinejad MR. Efficacy of coenzyme Q10 on semen parameters, sperm function and reproductive hormones in infertile men. J Urol. 2009;182:237-248.http://www.ncbi.nlm.nih.gov/pubmed/19447425?tool=bestpractice.com[65]Safarinejad MR, Safarinejad S, Shafiei N, et al. Effects of the reduced form of coenzyme Q10 (ubiquinol) on semen parameters in men with idiopathic infertility: a double-blind, placebo controlled, randomized study. J Urol. 2012;188:526-531.http://www.ncbi.nlm.nih.gov/pubmed/22704112?tool=bestpractice.com补充硒和N-乙酰半胱氨酸能提高精液质量。[66]Safarinejad MR, Safarinejad S. Efficacy of selenium and/or N-acetyl-cysteine for improving semen parameters in infertile men: a double-blind, placebo controlled, randomized study. J Urol. 2009;181:741-751.http://www.ncbi.nlm.nih.gov/pubmed/19091331?tool=bestpractice.com[67]Ciftci H, Verit A, Savas M, et al. Effects of N-acetylcysteine on semen parameters and oxidative/antioxidant status. Urology. 2009;74:73-76.http://www.ncbi.nlm.nih.gov/pubmed/19428083?tool=bestpractice.com

疗程：3个月。

研究显示宫腔内人工授精（IUI）的治疗对于男性因素不育的夫妇实现妊娠优于指导同房治疗。[57]Tournaye H. Evidence-based management of male subfertility. Curr Opin Obstet Gynecol. 2006;18:253-259.http://www.ncbi.nlm.nih.gov/pubmed/16735823?tool=bestpractice.com控制性卵巢刺激宫腔内人工授精能进一步提高妊娠率。

当人工授精总活动精子数<1×10^7/mL时IUI治疗无明显获益。[68]Van Voorhis BJ, Barnett M, Sparks AE, et al. Effect of the total motile sperm count on the efficacy and cost-effectiveness of intrauterine insemination and in vitro fertilization. Fertil Steril. 2001;75:661-668.http://www.ncbi.nlm.nih.gov/pubmed/11287015?tool=bestpractice.com诱导排卵24到36小时后二次人工授精与单次人工授精相比并未显示能提高妊娠率。[46]Tonguc E, Var T, Onalan G, et al. Comparison of the effectiveness of single versus double intrauterine insemination with three different timing regimens. Fertil Steril. 2010;94:1267-1270.http://www.ncbi.nlm.nih.gov/pubmed/19782353?tool=bestpractice.com

每个疗程的IVF妊娠率均高于IUI。[53]Pashayan N, Lyratzopoulos G, Mathur R. Cost-effectiveness of primary offer of IVF vs. primary offer of IUI followed by IVF (for IUI failures) in couples with unexplained or mild male factor subfertility. BMC Health Serv Res. 2006;6:80.http://www.biomedcentral.com/1472-6963/6/80http://www.ncbi.nlm.nih.gov/pubmed/16796733?tool=bestpractice.com多胎妊娠是IVF的可能并发症。在年轻患者中使用单个胚胎移植是减少这种并发症的最好方法并且预后良好。[54]Pandian Z, Marjoribanks J, Ozturk O, et al. Number of embryos for transfer following in vitro fertilisation or intra-cytoplasmic sperm injection. Cochrane Database Syst Rev. 2013;(7):CD003416.http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003416.pub4/fullhttp://www.ncbi.nlm.nih.gov/pubmed/23897513?tool=bestpractice.com[55]Grady R, Alavi N, Vale R, et al. Elective single embryo transfer and perinatal outcomes: a systematic review and meta-analysis. Fertil Steril. 2012;97:324-331.http://www.ncbi.nlm.nih.gov/pubmed/22177461?tool=bestpractice.comART也轻微增加不良妊娠结局和出生缺陷的风险；然而，增加不育的风险也不能排除。[51]Allen VM, Wilson RD, Cheung A; Genetics Committee of the Society of Obstetricians and Gynaecologists of Canada (SOGC); Reproductive Endocrinology Infertility Committee of the Society of Obstetricians and Gynaecologists of Canada (SOGC). Pregnancy outcomes after assisted reproductive technology. J Obstet Gynaecol Can. 2006;28:220-250.http://www.ncbi.nlm.nih.gov/pubmed/16650361?tool=bestpractice.com[56]Rimm AA, Katayama AC, Katayama KP. A meta-analysis of the impact of IVF and ICSI on major malformations after adjusting for the effect of subfertility. J Assist Reprod Genet. 2011;28:699-705.http://www.ncbi.nlm.nih.gov/pubmed/21625967?tool=bestpractice.com

睾丸精子提取术的风险和显微外科附睾穿刺精子提取术的风险包括睾丸血肿、疼痛和感染。卵胞浆内精子注射被认为是Beckwith-Wiedemann和Angelman's综合征和其他异常甲基化结果的危险因素。这种联系尚未被证实。

供者人工授精对拒绝ART或无精子生成的严重少精子症/无精子症患者是一种可选择的治疗方式。