Clinical andrology: from evidence-base to ethics - The 'E' quintet in clinical andrology

The management of the infertile man should be founded on consensus-based me dicine, i,e, the consensual opinion of experts considering evidence-based a s well as empirical or experience-based medicine, the effective cumulative rate of successful deliveries, ethical and economic considerations. The app arent contradictions between conclusions from experience-based medicine and evidence-based medicine regarding the efficacy of varicocele treatment and tamoxifen treatment can be explained by scientific reasons. It is argued t hat the suggestion not to implement these treatments is ill founded because of flawed meta-analyses, The effective cumulative rate of successful deliv eries and time to pregnancy as observed in cohort studies should be conside red the ultimate touchstone of treatment efficacy. Based on the data of eff ective cumulative delivery rate, cost per successful delivery, and the know n prevalence of aetiological diagnoses in infertile men, it is possible to estimate the number of deliveries that can be attained thanks to an investm ent of, e.g. 1 million Euro. This number is similar to 70-80 if IVF (includ ing intracytoplasmic sperm injection) is chosen as first line treatment, an d four times higher if conventional treatment (including intrauterine insem ination) is applied. It is concluded that the well thought out approach rec ommended by the World Health Organization should generally be implemented f or the management of couples in whom infertility is (mainly) due to a male factor.