Book reviews

Infertility in the male, 4th edn

Edited by Larry I Lipshult, Stuart S Howards and Craig S Niederberger. Cambridge: Cambridge University Press, 2009. 688pp.

£175.00 hardback. Also available as an ebook.

Discussions of issues around fertility have the opportunity to add both time and discomfort to any unsuspecting outpatient clinic. Infertility is frequently a difficult and stressful condition for both patients and doctors to address, especially when it touches on so many domains of potency, sexual health and human relationships. Rather than skirt around the issue, claim ignorance and shrug one's shoulders, it's important to be aware of the clinical issues surrounding this subject, certainly relating to male infertility, because the common focus tends understandably to be more female dominated.

A male factor is involved in approximately 50% of infertile relationships. There is definitely plenty to learn given the myriad causes of infertility in men, the importance of selecting the right investigations and understanding how we are now in a modern era of treatment with advanced technologies such as ICSI (intracytoplasmic sperm injection), which have been developed only as recently as the 1990s. It would be a real shame for general physicians to leave this all to the office urologist or the reproductive medicine team. So, although it may be difficult to dredge up some details from the dim remembrances of medical school – the embryology of the reproductive tract, the male hypothalamic–pituitary–testicular axis, Leydig and Sertoli cell function (Leydig, the German zoologist was a contemporary of Purkinje and Schwann, whereas Sertoli was an Italian physiologist) and how spermatogenesis works – it is perhaps more germane to learn about new concepts in the genetics of male reproduction and fertility, as well as clinical evaluation of the ‘subfertile’ male.

Fortunately, the fourth edition of this detailed and accessible textbook contains a thorough grounding in almost all that should be required to be known on the subject. It does have a rather surgical slant which belies the editors’ backgrounds (all urologists), and this means that the baseline evaluations that they suggest for all patients appear overtly sperm based.

Clinicians are often unfamiliar with the multitude of diagnostic tests currently available, and the interpretation of those tests required to develop a rational management plan. There is an increasing emphasis on evidence-based guidelines and consensus opinion when adequate scientific studies are lacking. This has helped to overcome much of the voodoo and wallet-lightening exercises previously taking place for desperate couples threatened with childlessness.

The primary goals of the evaluation of the male presenting with infertility are: to identify medically significant conditions affecting fertility; to recognise any primary underlying pathophysiology that may be reversed; to appreciate irreversible conditions that will require assisted reproduction techniques, such as IUI (intrauterine insemination), using the male partner's sperm; to know when the donor insemination route is advisable; and finally to have knowledge of genetic conditions that may have implications for the patient and any future children. Therefore anything from a childhood infection such as mumps to environmental causes, lifestyle issues and drugs can play a part in male infertility, and detective work is as important as a sympathetic understanding of the man's dilemma.

After the evaluation stage and the interesting endocrine section, the second half of the text becomes increasingly urological, covering everything that you may think relevant from semen analysis, sperm banking and psychological issues surrounding infertility, to the esoteric and technical: microsurgical repair techniques, measurement of DNA fragmentation and advances in andrology. The editors have assembled all of the (North American) leaders in the field to contribute on their area of expertise – the text has consistency and exciting new information is combined with a clear evidence base to provide modern insights on this varied subject. Ultimately, this is a very useful and up-to-date textbook for anyone interested in male hypogonadism and infertility.