Integrating surgical and clinical andrology is essential to improve the quality of care delivered to infertile couples

Drs. Yovich and Keane’s commentary (1) about the recently published clinical practice guidelines for sperm DNA fragmentation (SDF) testing based on clinical scenarios (2) is an excellent piece of writing. The authors commence by acknowledging the importance of male infertility evaluation and integration of clinical and laboratory andrology in the modern workup of infertile couples. However, they pointed out that current practice values the male factor only if semen analysis is severely abnormal in contrast to the usual comprehensive female infertility evaluation. Given the success of ICSI, male infertility is indeed often neglected. This factor is aggravated by the limitations of semen analysis, to which we concurred and discussed elsewhere (3-6). To illustrate their point, Yovich and Keane discussed the often debated issue of varicocele and male infertility. Despite overwhelming evidence confirming the adverse effect of varicocele on several sperm markers and the benefit of varicocelectomy in selected men (7-12), only recently—and after more than 150 years since the first publication about varicocele—the Cochrane review confirmed that there might be a benefit to performing varicocelectomy in subfertile men (13). Regrettably, many subfertile men could have benefitted from treatment; the benefit of performing varicocele repair using microsurgery techniques has been advocated for a long time by eminent urological microsurgeons (14-16). Along these lines, Dr. Yovich himself contributed significantly to the evolution of laboratory and clinical andrology in his distinguished career in reproductive medicine for over 35 years (17). His seminal works on human sperm function in the 90’s had a tremendous impact on clinical practice and set the path for future research (18-22)