REFLECTIONS
pave the way for future work to understand why providers
The reproductive urologic
evaluation: How can we
do better?
As highlighted by the 2020 American Urological Association/
American Society for Reproductive Medicine Guideline on the
Diagnosis and Treatment of Infertility in Men, the male
fertility evaluation is integral to the overall evaluation and
treatment of an infertile couple. The Guideline unequivocally
recommends that male and female partners undergo concur-
rent assessment and that men with one or more abnormal
semen parameters, or presumed male factor infertility, be
evaluated by a male reproductive expert (1).
Several barriers in access to care for male factor infertility
have been described, including the limited availability of
fellowship-trained reproductive urologists across the United
States (2). As such, the male fertility evaluation is often initi-
ated by nonurologists. In fact, a recent study examining data
from the 2006–2016 National Ambulatory Medical Care Sur-
vey found that nonurologists performed a greater proportion
of the total encounters for male factor infertility than urolo-
gists (58% vs. 42%) (3).
The study by Pham et al. (4) is a two-part investigation of
men with abnormal semen testing who initiate fertility
screening through nonurologists. The investigators found
that overall, the rate of referral to a reproductive urologist
was low, with significant variability between providers. Un-
fortunately, but not surprisingly, men who did not receive a
referral for reproductive urologic consultation had an inaccu-
rate understanding of their semen analysis result. This work
has important implications. First, the manuscript provides
an objective estimate of how infrequently men are referred
for a reproductive evaluation. These findings will hopefully
VOL. 117 NO. 3 / MARCH 2022
do or do not initiate a referral for reproductive urologic
evaluation. Second, the manuscript is a reminder of the sub-
stantial downstream effects that forgoing a reproductive eval-
uation may have, including a critical delay in accessing
fertility care for an infertile couple, the possibility of missing
an underlying somatic health condition in the male partner,
failure to treat a potentially reversible cause of male factor
infertility, as well as suboptimal reproductive outcomes.
A multifaceted effort is needed to address the many bar-
riers that exist in access to male reproductive care. Better ed-
ucation of health care providers and our patients about the
importance of the male fertility evaluation will be central to
the success of any such effort.
Akanksha Mehta, M.D., M.S.
Department of Urology, Emory University School of
Medicine, Atlanta, Georgia
https://doi.org/10.1016/j.fertnstert.2022.01.007
DIALOG: You can discuss this article with its authors and other
readers at https://www.fertstertdialog.com/posts/34507
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2. Mehta A, Nangia AK, Dupree JM, Smith JF. Limitations and barriers in access
to care for male factor infertility. Fertil Steril 2016;105:1128–37.
3. Fantus RJ, Alter K, Chang C, Ambulkar SS, Bennett NE, Helfand BT, et al.
Characterizing the epidemiology and provider landscape of male infertility
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4. Pham, et al. Reproductive urologic consultation in subfertile men: predictors
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