2023+APSSM／ASMHA共识建议：男性不育症并发性功能障碍的管理.pdf（英文版）

Received:Jun 24,2023 Revised:Jul 1,2023 Accepted:Jul 9,2023 Published online Oct 16,2023Correspondence to:Eric Chung https:/orcid.org/0000-0003-3373-3668AndroUrology Centre,Suite 3,530 Boundary St,Brisbane,QLD 4000,Australia.Tel:[phone],Fax:[phone],E-mail:Copyright 2023 Korean Society for Sexual Medicine and AndrologyManagement of Male Infertility with Coexisting Sexual Dysfunction:A Consensus Statement and Clinical Recommendations from the Asia-Pacific Society of Sexual Medicine(APSSM)and the Asian Society of Mens Health and Aging(ASMHA)Eric Chung1,25,Jiang Hui2,Zhong Cheng Xin3,Sae Woong Kim4,Du Geon Moon5,Yiming Yuan6,Koichi Nagao7,Lukman Hakim8,Hong-Chiang Chang9,Siu King Mak10,Gede Wirya Kusuma Duarsa11,Yutian Dai12,Bing Yao13,Hwancheol Son14,William Huang15,Haocheng Lin2,Quang Nguyen16,Dung Ba Tien Mai17,Kwangsung Park18,Joe Lee19,Kavirach Tantiwongse20,Yoshikazu Sato21,Bang-Ping Jiann22,Christopher Ho23,Hyun Jun Park24 1Department of Urology,Princess Alexandra Hospital,University of Queensland,Brisbane,QLD,Australia,2Department of Urology,Peking University Third Hospital,Beijing,3Male Reproductive and Sexual Medicine,Department of Urology,The Second Hospital of Tianjin Medical University,Tianjin,China,4Department of Urology,The Catholic University of Korea,Seoul St.Marys Hospital,5Department of Urology,Korea University Guro Hospital,Seoul,Korea,6Andrology Centre,Peking University First Hospital,Peking University,Beijing,China,7Department of Urology,Toho University,Tokyo,Japan,8Department of Urology,Universitas Airlangga Teaching Hospital,Faculty of Medicine,Universitas Airlangga,Surabaya,Indonesia,9Department of Urology,National Taiwan University Hospital,Taipei,Taiwan,10Department of Surgery,Union Hospital,Hong Kong,China,11Faculty of Medicine Udayana University,Bali,Indonesia,12The Department of Andrology,Drum Tower Hospital,Medical School of Nanjing University,13Department of Urology,Affiliated Jinling Hospital,School of Medicine,Nanjing University,Nanjing,China,14Department of Urology,Seoul National University College of Medicine,Seoul,Korea,15Department of Urology,Taipei Veterans General Hospital,Taipei,Taiwan,16Centre of Andrology and Sexual Medicine,Viet Duc University Hospital,Hanoi,17Department of Urology,Binh Dan Hospital,Ho Chi Minh City,Vietnam,18Department of Urology,Chonnam National University Medical School,Gwangju,Korea,19Department of Urology,National University Hospital,Singapore,20Department of Urology,Chulalongkorn University Hospital,Bangkok,Thailand,21Department of Urology,Sanjukai Hospital,Sapporo,Japan,22Department of Urology,Kaohsiung Veterans General Hospital,Kaohsiung,Taiwan,23School of Medicine,Taylors University,Subang,Selangor,Malaysia,24Pusan National University Hospital,Pusan National University School of Medicine,Busan,Korea,25AndroUrology Centre,Brisbane,QLD,AustraliaMale infertility(MI)and male sexual dysfunction(MSD)can often coexist together due to various interplay factors such as psychosexual,sociocultural and relationship dynamics.The presence of each form of MSD can adversely impact male repro-duction and treatment strategies will need to be individualized based on patients factors,local expertise,and geographical socioeconomic status.The Asia Pacific Society of Sexual Medicine(APSSM)and the Asian Society of Mens Health and Aging(ASMHA)aim to provide a consensus statement and practical set of clinical recommendations based on current evidence to guide clinicians in the management of MI and MSD within the Asia-Pacific(AP)region.A comprehensive,narrative review of the literature was performed to identify the various forms of MSD and their association with MI.MEDLINE and EMBASE da-tabases were searched for the following English language articles under the following terms:“low libido”,“erectile dysfunc-tion”,“ejaculatory dysfunction”,“premature ejaculation”,“retrograde ejaculation”,“delayed ejaculation”,“anejaculation”,Review ArticlepISSN:2287-4208/eISSN:2287-4690World J Mens Health Published online Oct 16,2023https:/doi.org/10.5534/wjmh.230180Male sexual health and dysfunctionhttps:/doi.org/10.5534/wjmh.2301802www.wjmh.orgINTRODUCTIONMale infertility(MI)is a global population health concern affecting between 2.5%and 15%of the popula-tion 1,2 while male-specific factors contribute to up to 25%of MI 2.It is thought that the rate of MI is likely higher in the Asia-Pacific(AP)region compared to Western countries secondary to locoregional factors such as uneven distribution of healthcare systems and sociocultural beliefs,especially among patriarchal soci-eties 3.Similarly,male sexual dysfunction(MSD)re-mains a highly prevalent condition and it is estimated around a third of the male population will experience at least one form of MSD in their lifetimes 4-6.MSD is largely divided into low sexual desire,erectile dys-function(ED),ejaculatory disorders(EjD)and orgasmic dysfunction.The presence of MSD can affect males with adverse impacts beyond psychosexual function alone,across various quality of life domains including interpersonal and relationship dynamics 7-9.Infertility affects different areas of the couples life and sexual dysfunctions can be a reason for infertility or can be triggered by infertility.Both MI and MSD often coexist together since various forms of MSD can adversely impact the success of natural conception while the inability to conceive naturally could be a consequence of SD such as ED and anejaculation(AE)10.There is a strong correlation between unfulfilled fertility desires and MSD in the male partner of in-fertile couples and the failure to conceive can result in a significant psychological burden 11.Male partners of infertile couples often experienced psychological distress and are at higher risk of developing MSD 12,13.It is thought the link between these conditions is bidirectional in nature given that patients suffering from fertility issues commonly struggle with feelings of depression,anxiety or inadequacy which could affect the couple resulting in adverse impacts across various sexual functions domains 14.Similarly,the presence or subsequent development of MSD can adversely impact male reproductive function 15.Infertility can have a negative impact on the relationship between couples resulting in sexual dissatisfaction and dys-function 16.While the prevalence of various forms of MSD can vary according to different age groups,litera-ture shows that ED and premature ejaculation are the common types of MSD in males of an infertile couple,compared to the general male population of a similar age 17.This highlights that the sexual function of the male can be significantly affected deprived in the fertile period of their partners cycle,which can be at-tributed to sexual anxiety and distress 12.Given the mutual association between MI and MSD,coupled with the unique locoregional factors,the Asia Pacific Society of Sexual Medicine(APSSM)and the Asian Society of Mens Health and Aging(ASMHA)have decided to evaluate contemporary evidence on the clinical management of pertinent MI and MSD with an aim to provide a set of consensus statements and evidence-based clinical recommendations to guide clini-cians in the AP region.and“orgasmic dysfunction”between January 2001 to June 2022 with emphasis on published guidelines endorsed by various organizations.This APSSM consensus committee panel evaluated and provided evidence-based recommendations on MI and clinically relevant MSD areas using a modified Delphi method by the panel and specific emphasis on locoregional socio-economic-cultural issues relevant to the AP region.While variations exist in treatment strategies for managing MI and MSD due to geographical expertise,locoregional resources,and sociocultural factors,the panel agreed that comprehensive fertility evaluation with a multidisciplinary management approach to each MSD domain is recommended.It is important to address individual MI issues with an emphasis on improving spermatogenesis and facilitating reproductive avenues while at the same time,managing various MSD conditions with evidence-based treatments.All therapeutic options should be discussed and implemented based on the patients individual needs,beliefs and preferences while incorporating locoregional expertise and available resources.Keywords:Keywords:Ejaculation;Erectile dysfunction;Hypogonadism;Infertility,male;Male urogenital diseases;OrgasmThis is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License(http:/creativecommons.org/licenses/by-nc/4.0)which permits unrestricted non-commercial use,distribution,and reproduction in any medium,provided the original work is properly cited.Eric Chung,et al:Guidelines on Male Infertility and Sexual Dysfunction 3www.wjmh.orgMATERIALS AND METHODSThis combined APSSM and ASMHA consensus com-mittee panel was initiated by the lead author(EC)and key opinion leaders from Australia,China,Japan,Indonesia,Malaysia,Singapore,South Korea,Taiwan,Thailand,and Vietnam were invited to participate in this working committee.The panel is tasked to review contemporary literature concerning various forms of MSD in the context of MI,and contents from published clinical guidelines by major urological and sexual medicine organizations were incorporated into this con-sensus statement.No ethical committee approval was needed due to the specific design of this research.MEDLINE and EMBASE databases were searched for the following English language articles under the following terms:“low libido”,“erectile dysfunction”,“ejaculatory dysfunction”,“premature ejaculation”,“retrograde ejaculation”,“delayed ejaculation”,“anejac-ulation”,and“orgasmic dysfunction”between January 2001 to June 2022.The panel evaluated specific clini-cally relevant subheadings for MI and MSD namely 1)Sexual libido,2)Erectile Dysfunction,3)Ejaculatory dysfunction,and 4)Orgasmic dysfunction.For this consensus statement,a narrative approach was per-formed based on a modified Delphi method and each panelist provided an opinion on each of the subhead-ings.Published literature in this field was examined,summarized,and internally discussed in an interac-tive peer-review process.Emphasis is placed on societal guidelines,systematic reviews,and meta-analyses.A consensus agreement based on the modified Delphi method 18 was achieved following multiple rounds of discussion.All authors agreed on the list of clinical rec-ommendations in this consensus statement(Appendix 1).The quality of evidence was graded and provided as grades of recommendation as based on the Oxford Centre for Evidence-based Medicine recommendations 19 with specific emphasis on locoregional and socio-economic-cultural issues relevant to the management of MI and MSD within the AP region.DIAGNOSTIC WORKUP FOR MALE INFERTILITY WITH COEXISTING SEXUAL DYSFUNCTION1.Clinical evidence linking MI,MSD,and hormonal dysregulationsThe infertile male often experiences significant psychosocial stressors and stigma,more negative emo-tions,a decline in personal confidence and self-esteem with a sense of inferior masculinity complex when the diagnosis is male factor infertility as opposed to unex-plained or female factor infertility 20.Furthermore,the development and/or progression of psychosexual distress can negatively affect a mans fertility through a direct impact on male gonadal functions in terms of spermatogenesis and testosterone production,the lat-ter responsible for various male sexual functions 21.Studies have shown that both perceived stress and ac-tual stressful life events can be associated with lower semen quality within the general male population 22.Acute psychosocial stress period can induce changes in the sex and hormonal status with testosterone produc-tion may become suppressed 23.Both semen quality and testosterone levels have been found to be reduced in infertile men reporting higher psychological stress compared to infertile men reporting lower stress 24.Spermatogenesis is a highly regulated biological event dependent on the hypothalamic-pituitary-gonad-al(HPG)axis that coordinates essential functions of key hormones responsible for fertility and sexual func-tion through the action of follicle-stimulating hormone(FSH)and luteinizing hormone(LH)and the mainte-nance of high intratesticular testosterone concentra-tion 25,26.In essence,LH stimulates the production of testosterone which is responsible for spermatogenesis,secondary male sexual characteristics,and functions,as well as psychological and anabolic actions 27.On the other hand,FSH enhances testosterone action by maintaining the supporting function of Sertoli cells for germ cells to undergo progressive development into mature sperm within the seminiferous tubules.The crosstalk between these hormones is crucial for the dual functions of fertility and virility of the adult male testis 28,29.The interplay between the differ-ent components and the subsequent direct negative feedback effects of T and inhibin B,produced by the Sertoli cells,are essential for the feedback regulation of gonadotropin-releasing hormones and gonadotropins https:/doi.org/10.5534/wjmh.2301804www.wjmh.orgsecretion in the maintenance of the homeostasis of the HPG axis 30.2.Summary recommendationsPatients with MSD and MI often experience psycho-social stress,and this can worsen sexual function and induce changes in the sex and hormonal status affect-ing spermatogenesis(Grade B).Hormones involved in male sexual function and fer-tility are closely linked with regard to the homeostasis of the HPG axis(Grade B).3.Clinical evaluation relevant to MI and MSDPublish clinical guidelines on the management of various forms of MSD 31-41 and MI 42-48 advocate comprehensive clinical history and tailored physical examination to ascertain the type and extent of MSD and identify any treatable or serious medical condi-tions that could contribute to MI.Careful sexual his-tory taking to discern various male sexual complaints such as libido issues,ED,EjD,disorders of orgasm,and penile conditions(such as Peyronies disease)as well as causes for MI such as undescended testis,genitouri-nary infection(such as mumps orchitis),injury(such as surgery,radiation or trauma),familial history,anatom-ic variances,chromosomal abnormalities and systemic diseases.The presence of other concomitant medical conditions and/or psychosocial factors,relationship dy-namics,medications(including use of anabolic steroid use or illicit drug)and alcohol consumption history,should be obtained in a confidential manner and sensi-tive to the patients sociocultural and personal back-ground.Similarly,environmental factors such as type of work and exposure to chemicals/pesticides should be undertaken too.While the use of validated questionnaires such as the Sexual Health Inventory for Men(SHIM),Inter-national Index of Erectile Function(IIEF)and Male Sexual Health Questionnaire(MSHQ)have been used extensively as both dia