Infertility affects up to 12% of all men, and sexual dysfunction occurs frequently in men of reproductive age, causing infertility in some instances
Infertile men can experience a heavy psychological burden. Infertility and its associated psychological concerns can underlie sexual dysfunction
General health perturbations can lead to male infertility and/or sexual dysfunction. Erectile dysfunction and male infertility are considered proxies for general health
Medications used for general health problems can cause sperm abnormalities and sexual dysfunction. The treatment of some causes of male infertility might improve semen quality and reverse infertility-related sexual dysfunction
In infertile men, an investigation of sexual, general, and psychological health status is advisable to improve reproductive problems and general health.
Infertility affects up to 12% of all men, and sexual dysfunction occurs frequently in men of reproductive age, causing infertility in some instances. In infertile men, hypoactive sexual desire and lack of sexual satisfaction are the most prevalent types of sexual dysfunction, ranging from 8.9% to 68.7%. Erectile dysfunction and/or premature ejaculation, evaluated with validated tools, have a prevalence of one in six infertile men, and orgasmic dysfunction has a prevalence of one in ten infertile men. In addition, infertile men can experience a heavy psychological burden. Infertility and its associated psychological concerns can underlie sexual dysfunction. Furthermore, general health perturbations can lead to male infertility and/or sexual dysfunction. Erectile dysfunction and male infertility are considered proxies for general health, the former underlying cardiovascular disorders and the latter cancerous and noncancerous conditions. The concept that erectile dysfunction in infertile men might be an early marker of poor general health is emerging. Finally, medications used for general health problems can cause sperm abnormalities and sexual dysfunction. The treatment of some causes of male infertility might improve semen quality and reverse infertility-related sexual dysfunction. In infertile men, an investigation of sexual, general, and psychological health status is advisable to improve reproductive problems and general health.
Subscribe to Journal
Get full journal access for 1 year
only $17.75 per issue
All prices are NET prices.
VAT will be added later in the checkout.
Rent or Buy article
Get time limited or full article access on ReadCube.
All prices are NET prices.
Boivin, J., Bunting, L., Collins, J. A. & Nygren, K. G. International estimates of infertility prevalence and treatment-seeking: potential need and demand for infertility medical care. Hum. Reprod. 22, 1506–1512 (2007).
Mascarenhas, M. N., Cheung, H., Mathers, C. D. & Stevens, G. A. Measuring infertility in populations: constructing a standard definition for use with demographic and reproductive health surveys. Popul. Health Metr. 10, 17 (2012).
Mascarenhas, M. N., Flaxman, S. R., Boerma, T., Vanderpoel, S. & Stevens, G. A. National, regional, and global trends in infertility prevalence since 1990: a systematic analysis of 277 health surveys. PLoS Med. 9, e1001356 (2012).
World Health Organization. Towards more objectivity in diagnosis and management of male fertility. Int. J. Androl 7, 1–53 (1987).
Chandra, A., Copen, C. E. & Stephen, E. H. Infertility and impaired fecundity in the United States, 1982-2010: data from the National Survey of Family Growth. Natl Health Stat. Rep. 67, 1–18 (2013).
Berger, M. H., Messore, M., Pastuszak, A. W. & Ramasamy, R. Association between infertility and sexual dysfunction in men and women. Sex. Med. Rev. 4, 353–365 (2016).
Lewis, R. W. et al. Definitions/epidemiology/risk factors for sexual dysfunction. J. Sex. Med. 7, 1598–1607 (2010).
Laumann, E. O., Paik, A. & Rosen, R. C. Sexual dysfunction in the United States: prevalence and predictors. JAMA 281, 537–544 (1999).
Laumann, E. O., Paik, A. & Rosen, R. C. The epidemiology of erectile dysfunction: results from the National Health and Social Life Survey. Int. J. Impot Res. 11 (Suppl. 1), S60–S64 (1999).
Parazzini, F. et al. Frequency and determinants of erectile dysfunction in Italy. Eur. Urol. 37, 43–49 (2000).
Mirone, V., Ricci, E., Gentile, V., Basile Fasolo, C. & Parazzini, F. Determinants of erectile dysfunction risk in a large series of Italian men attending andrology clinics. Eur. Urol. 45, 87–91 (2004).
Moreira, E. D. Jr, Hartmann, U., Glasser, D. B., Gingell, C. & GSSAB Investigators Group. A population survey of sexual activity, sexual dysfunction and associated help-seeking behavior in middle-aged and older adults in Germany. Eur. J. Med. Res. 10, 434–443 (2005).
Moreira, E. D. Jr, Glasser, D. B., Gingell, C. & GSSAB Investigators Group. Sexual activity, sexual dysfunction and associated help-seeking behaviours in middle-aged and older adults in Spain: a population survey. World J. Urol. 23, 422–429 (2005).
Lotti, F. et al. Clinical correlates of erectile dysfunction and premature ejaculation in men with couple infertility. J. Sex. Med. 9, 2698–2707 (2012).
Lotti, F. et al. Semen quality impairment is associated with sexual dysfunction according to its severity. Hum. Reprod. 31, 2668–2680 (2016).
Gao, J. et al. Relationship between sexual dysfunction and psychological burden in men with infertility: a large observational study in China. J. Sex. Med. 10, 1935–1942 (2013).
Ferraresi, S. R. et al. Current research on how infertility affects the sexuality of men and women. Recent Pat. Endocr. Metab. Immune Drug Discov. 7, 198–202 (2013).
Lara, L. A. et al. Effect of infertility on the sexual function of couples: state of the art. Recent Pat. Endocr. Metab. Immune Drug Discov. 9, 46–53 (2015).
Bechoua, S., Hamamah, S. & Scalici, E. Male infertility: an obstacle to sexuality? Andrology 4, 395–403 (2016).
Song, S. H., Kim, D. S., Yoon, T. K., Hong, J. Y. & Shim, S. H. Sexual function and stress level of male partners of infertile couples during the fertile period. BJU Int. 117, 173–176 (2016).
Shindel, A. W., Nelson, C. J., Naughton, C. K. & Mulhall, J. P. Premature ejaculation in infertile couples: prevalence and correlates. J. Sex. Med. 5, 485–491 (2008).
McCabe, M. P. et al. Risk factors for sexual dysfunction among women and men: a consensus statement from the Fourth International Consultation on Sexual Medicine 2015. J. Sex. Med. 13, 153–167 (2016).
Sartorius, G. A. & Handelsman, D. J. in Andrology. Male Reproductive Health and Dysfunction 3rd edn (eds Nieschlag, E., Behre, H. M. & Nieschlag, S.) 339–364 (Springer-Verlag, Berlin, Germany, 2010).
Salonia, A. et al. Are infertile men less healthy than fertile men? Results of a prospective casecontrol survey. Eur. Urol. 56, 1025–1031 (2009).
Ventimiglia, E. et al. Infertility as a proxy of general male health: results of a cross-sectional survey. Fertil. Steril. 104, 48–55 (2015).
Eisenberg, M. L., Li, S., Cullen, M. R. & Baker, L. C. Increased risk of incident chronic medical conditions in infertile men: analysis of United States claims data. Fertil. Steril. 105, 629–636 (2016).
Eisenberg, M. L. et al. Relationship between paternal somatic health and assisted reproductive technology outcomes. Fertil. Steril. 106, 559–565 (2016).
Krausz, C. Male infertility: pathogenesis and clinical diagnosis. Best Pract. Res. Clin. Endocrinol. Metab. 25, 271–285 (2011).
Wischmann, T. H. Sexual disorders in infertile couples. J. Sex. Med. 7, 1868–1876 (2010).
Pierik, F. H., Van Ginneken, A. M., Dohle, G. R., Vreeburg, J. T. & Weber, R. F. The advantages of standardized evaluation of male infertility. Int. J. Androl 23, 340–346 (2000).
Brandes, M., Hamilton, C. J., de Bruin, J. P., Nelen, W. L. & Kremer, J. A. The relative contribution of IVF to the total ongoing pregnancy rate in a subfertile cohort. Hum. Reprod. 25, 118–126 (2010).
Rantala, M. L. & Koskimies, A. I. Sexual behavior of infertile couples. Int. J. Fertil. 33, 26–30 (1988).
Jungwirth, A. et al. EAU Guidelines on Male Infertility (European Association of Urology, Arnhem, Netherlands, 2016).
Tuttelmann, F. & Nieschlag, E. in Andrology. Male Reproductive Health and Dysfunction 3rd edn (eds Nieschlag, E., Behre, H. M. & Nieschlag, S.) 87–92 (Springer-Verlag, Berlin, Germany, 2010).
Punab, M. et al. Causes of male infertility: a 9-year prospective monocentre study on 1737 patients with reduced total sperm counts. Hum. Reprod. 32, 18–31 (2017).
Lotti, F. et al. in Scrotal Pathology (eds Bertolotto, M. & Trombetta, C.) 223–240 (Springer-Verlag, Berlin, Germany, 2012).
World Health Organization. International statistical classification of diseases and related health problems — 10th revision. WHO http://www.who.int/classifications/icd/en/ (2016)
Yafi, F. A. et al. Erectile dysfunction. Nat. Rev. Dis. Primers 2, 16003 (2016).
Perlis, N., Lo, K. C., Grober, E. D., Spencer, L. & Jarvi, K. Coital frequency and infertility: which male factors predict less frequent coitus among infertile couples? Fertil. Steril. 100, 511–515 (2013).
Melnik, T., Soares, B. G. & Nasselo, A. G. Psychosocial interventions for erectile dysfunction. Cochrane Database Syst. Rev. 3, CD004825 (2007).
Mehta, A. & Sigman, M. Management of the dry ejaculate: a systematic review of aspermia and retrograde ejaculation. Fertil. Steril. 104, 1074–1081 (2015).
Barazani, Y., Stahl, P. J., Nagler, H. M. & Stember, D. S. Management of ejaculatory disorders in infertile men. Asian J. Androl 14, 525–529 (2012).
Di Sante, S. et al. Epidemiology of delayed ejaculation. Transl Androl Urol. 5, 541–548 (2016).
Kinsey, A. C., Pomeroy, W. R. & Martin, C. E. Sexual behavior in the human male. 1948. Am. J. Publ. Health 93, 894–898 (2003).
Ohl, D. A., Quallich, S. A., Sønksen, J., Brackett, N. L. & Lynne, C. M. Anejaculation and retrograde ejaculation. Urol. Clin. North Am. 35, 211–220 (2008).
Fode, M. et al. Male sexual dysfunction and infertility associated with neurological disorders. Asian J. Androl 14, 61–88 (2012).
Revenig, L., Leung, A. & Hsiao, W. Ejaculatory physiology and pathophysiology: assessment and treatment in male infertility. Transl Androl Urol. 3, 41–49 (2014).
Rowland, D. et al. Disorders of orgasm and ejaculation in men. J. Sex. Med. 7, 1668–1686 (2010).
Lotti, F. & Maggi, M. Ultrasound of the male genital tract in relation to male reproductive health. Hum. Reprod. Update 21, 56–83 (2015).
Chen, J. The pathophysiology of delayed ejaculation. Transl Androl Urol. 5, 549–562 (2016).
Pearce, S., Steinberg, Z. & Eggener, S. Critical evaluation of modified templates and current trends in retroperitoneal lymph node dissection. Curr. Urol. Rep. 14, 511–517 (2013).
Fode, M., Ohl, D. A. & Sønksen, J. A step-wise approach to sperm retrieval in men with neurogenic anejaculation. Nat. Rev. Urol. 12, 607–616 (2015).
Parnham, A. & Serefoglu, E. C. Retrograde ejaculation, painful ejaculation and hematospermia. Transl Androl Urol. 5, 592–601 (2016).
Safarinejad, M. R. Midodrine for the treatment of organic anejaculation but not spinal cord injury: a prospective randomized placebo-controlled double-blind clinical study. Int. J. Impot Res. 21, 213–220 (2009).
World Health Organization. WHO Laboratory Manual for the Examination and Processing of Human Semen 5th edn (WHO Press, Geneva, Switzerland, 2010).
Marci, R. et al. Procreative sex in infertile couples: the decay of pleasure? Health Qual. Life Outcomes 10, 140 (2012).
Hurwitz, M. B. Sexual dysfunction associated with infertility. A comparison of sexual function during the fertile and the non-fertile phase of the menstrual cycle. S. Afr. Med. J. 76, 58–61 (1989).
Berger, D. M. Impotence following the discovery of azoospermia. Fertil. Steril. 34, 154–156 (1980).
Berger, D. M. Couples' reactions to male infertility and donor insemination. Am. J. Psychiatry 137, 1047–1049 (1980).
Saleh, R. A., Ranga, G. M., Raina, R., Nelson, D. R. & Agarwal, A. Sexual dysfunction in men undergoing infertility evaluation: a cohort observational study. Fertil. Steril. 79, 909–912 (2003).
Rosen, R. C., Cappelleri, J. C., Smith, M. D., Lipsky, J. & Pena, B. M. Development and evaluation of an abridged, 5-item version of the International Index of Erectile Function (IIEF-5) as a diagnostic tool for erectile dysfunction. Int. J. Impot. Res. 11, 319–326 (1999).
O'Brien, J. H., Lazarou, S., Deane, L., Jarvi, K. & Zini, A. Erectile dysfunction and andropause symptoms in infertile men. J. Urol. 174, 1932–1934 (2005).
Satkunasivam, R. et al. Hormone abnormalities are not related to the erectile dysfunction and decreased libido found in many men with infertility. Fertil. Steril. 101, 1594–1598 (2014).
Cappelleri, J. C., Rosen, R. C., Smith, M. D., Mishra, A. & Osterloh, I. H. Diagnostic evaluation of the erectile function domain of the International Index of Erectile Function. Urology 54, 346–351 (1999).
Khademi, A., Alleyassin, A., Amini, M. & Ghaemi, M. Evaluation of sexual dysfunction prevalence in infertile couples. J. Sex. Med. 5, 1402–1410 (2008).
Shindel, A. W., Nelson, C. J., Naughton, C. K., Ohebshalom, M. & Mulhall, J. P. Sexual function and quality of life in the male partner of infertile couples: prevalence and correlates of dysfunction. J. Urol. 179, 1056–1059 (2008).
Sahin, A., Urkmez, A., Verit, A., Yuksel, O. H. & Verit, F. F. Psychologic and sexual dysfunction in primary and secondary infertile male patients. Arch. Ital. Urol. Androl. 89, 120–124 (2017).
Keskin, U. et al. Differences in prevalence of sexual dysfunction between primary and secondary infertile women. Fertil. Steril. 96, 1213–1217 (2011).
Gabr, A. A. et al. Prevalence of sexual dysfunction in infertile versus fertile couples. Eur. J. Obstet. Gynecol. Reprod. Biol. 217, 38–43 (2017).
Davari Tanha, F., Mohseni, M. & Ghajarzadeh, M. Sexual function in women with primary and secondary infertility in comparison with controls. Int. J. Impot Res. 26, 132–134 (2014).
Boddi, V. et al. Lack of sexual privacy affects psychological and marital domains of male sexual dysfunction. J. Sex. Med. 11, 431–438 (2014).
Fisher, A. D. et al. Metabolic and cardiovascular outcomes of fatherhood: results from a cohort of study in subjects with sexual dysfunction. J. Sex. Med. 9, 2785–2794 (2012).
Van Zyl, J. A. Sex and infertility: Part I. Prevalence of psychosexual problems and subjacent factors. S. Afr. Med. J. 72, 482–484 (1987).
Jain, K., Radhakrishnan, G. & Agrawal, P. Infertility and psychosexual disorders: relationship in infertile couples. Indian J. Med. Sci. 54, 1–7 (2000).
Hassanzadeh, K., Yavari-kia P., Ahmadi-Asrbadr, Y., Nematzadeh-Pakdel, A. & Alikhah, H. Features of premature ejaculation in infertile men. Pak. J. Biol. Sci. 13, 911–915 (2010).
Hite, S. in The Hite Report on Male Sexuality 323–856 (Knopf, New York, 1981).
Frank, E., Anderson, C. & Rubinstein, D. Frequency of sexual dysfunction in “normal” couples. N. Engl. J. Med. 299, 111–115 (1978).
Symonds, T. et al. Development and validation of a premature ejaculation diagnostic tool. Eur. Urol. 52, 565–573 (2007).
McMahon, C. G., Lee, G., Park, J. K. & Adaikan, P. G. Premature ejaculation and erectile dysfunction prevalence and attitudes in the Asia-Pacific region. J. Sex. Med. 9, 454–465 (2012).
Serefoglu, E. C., Cimen, H. I., Atmaca, A. F. & Balbay, M. D. The distribution of patients who seek treatment for the complaint of ejaculating prematurely according to the four premature ejaculation syndromes. J. Sex. Med. 7, 810–815 (2010).
Basile Fasolo, C., Mirone, V., Gentile, V., Parazzini, F. & Ricci, E. Premature ejaculation: prevalence and associated conditions in a sample of 12,558 men attending the Andrology Prevention Week 2001 — a study of the Italian Society of Andrology (SIA). J. Sex. Med. 2, 376–382 (2005).
Serefoglu, E. C. et al. Prevalence of the complaint of ejaculating prematurely and the four premature ejaculation syndromes: results from the Turkish Society of Andrology Sexual Health Survey. J. Sex. Med. 8, 540–548 (2011).
Gao, J. et al. Prevalence and factors associated with the complaint of premature ejaculation and the four premature ejaculation syndromes: a large observational study in China. J. Sex. Med. 10, 1874–1881 (2013).
Serefoglu, E. C. et al. An evidence-based unified definition of lifelong and acquired premature ejaculation: report of the second international society for sexual medicine ad hoc committee for the definition of premature ejaculation. Sex. Med. 2, 41–59 (2014).
Maggi, M., Buvat, J., Corona, G., Guay, A. & Torres, L. O. Hormonal causes of male sexual dysfunctions and their management (hyperprolactinemia, thyroid disorders, GH disorders, and DHEA). J. Sex. Med. 10, 661–677 (2013).
Lotti, F. et al. Is thyroid hormones evaluation of clinical value in the work-up of males of infertile couples? Hum. Reprod. 31, 518–529 (2016).
Krassas, G. E., Poppe, K. & Glinoer, D. Thyroid function and human reproductive health. Endocr. Rev. 31, 702–755 (2010).
Ramezanzadeh, F., Aghssa, M. M., Jafarabadi, M. & Zayeri, F. Alterations of sexual desire and satisfaction in male partners of infertile couples. Fertil. Steril. 85, 139–143 (2006).
Laumann, E. O., Glasser, D. B., Neves, R. C., Moreira, E. D. Jr & GSSAB Investigators Group. A population-based survey of sexual activity, sexual problems and associated help-seeking behavior patterns in mature adults in the United States of America. Int. J. Impot. Res. 21, 171–178 (2009).
Wincze, J. P. Psychosocial aspects of ejaculatory dysfunction and male reproduction. Fertil. Steril. 104, 1089–1094 (2015).
Elia, J., Delfino, M., Imbrogno, N. & Mazzilli, F. The impact of a diagnosis of couple subfertility on male sexual function. J. Endocrinol. Invest. 33, 74–76 (2010).
Ohl, J. et al. Impact of infertility and assisted reproductive techniques on sexuality. Gynecol. Obstet. Fertil. 37, 25–32 (2009).
Reder, F., Fernandez, A. & Ohl, J. Does sexuality still have a place for couples treated with assisted reproductive techniques? J. Gynecol. Obstet. Biol. Reprod. 38, 377–388 (2009).
Chevret-Measson, M. Desir d'enfant et sexualite. Prat Psychol. 4, 51–55 (1999).
Drosdzol, A. & Skrzypulec, V. Evaluation of marital and sexual interactions of Polish infertile couples. J. Sex. Med. 6, 3335–3346 (2009).
Andrews, F. M., Abbey, A. & Halman, L. J. Stress from infertility, marriage factors, and subjective well-being of wives and husbands. J. Health Soc. Behav. 32, 238–253 (1991).
Smith, J. F. et al. Sexual, marital, and social impact of a man's perceived infertility diagnosis. J. Sex. Med. 6, 2505–2515 (2009).
Monga, M., Alexandrescu, B., Katz, S. E., Stein, M. & Ganiats, T. Impact of infertility on quality of life, marital adjustment, and sexual function. Urology 63, 126–130 (2004).
Wischmann, T. et al. Sexuality, self-esteem and partnership quality in infertile women and men. Geburtshilfe Frauenheilkd 74, 759–763 (2014).
Daniluk, J. C. Infertility: intrapersonal and interpersonal impact. Fertil. Steril. 49, 982–990 (1988).
Müller, M. J., Schilling, G. & Haidl, G. Sexual satisfaction in male infertility. Arch. Androl 42, 137–143 (1999).
Lee, T. Y., Sun, G. H. & Chao, S. C. The effect of an infertility diagnosis on the distress, marital and sexual satisfaction between husbands and wives in Taiwan. Hum. Reprod. 16, 1762–1767 (2001).
Tao, P., Coates, R. & Maycock, B. Investigating marital relationship in infertility: a systematic review of quantitative studies. J. Reprod. Infertil. 13, 71–80 (2012).
Johansson, M., Hellström, A. L. & Berg, M. Severe male infertility after failed ICSI treatment — a phenomenological study of men's experiences. Reprod. Health 8, 4 (2011).
Akbal, C., Mangir, N., Tavukçu, H. H., Ozgür, O. & Simsek, F. Effect of testicular sperm extraction outcome on sexual function in patients with male factor infertility. Urology 75, 598–601 (2010).
Raboch, J., Mellan, J. & Stárka, L. Klinefelter's syndrome: sexual development and activity. Arch. Sex. Behav. 8, 333–339 (1979).
Yoshida, A. et al. Sexual function and clinical features of patients with Klinefelter's syndrome with the chief complaint of male infertility. Int. J. Androl 20, 80–85 (1997).
Corona, G. et al. Sexual dysfunction in subjects with Klinefelter's syndrome. Int. J. Androl 33, 574–580 (2010).
Vignozzi, L., Corona, G., Forti, G., Jannini, E. A. & Maggi, M. Clinical and therapeutic aspects of Klinefelter's syndrome: sexual function. Mol. Hum. Reprod. 16, 418–424 (2010).
El Bardisi, H. et al. Sexual dysfunction in Klinefelter's syndrome patients. Andrologia 49, e12670 (2017).
Samplaski, M. K. et al. Phenotypic differences in mosaic Klinefelter patients as compared with non-mosaic Klinefelter patients. Fertil. Steril. 101, 950–955 (2014).
Majzoub, A. et al. 46 XX karyotype during male fertility evaluation; case series and literature review. Asian J. Androl 19, 168–172 (2017).
Behre, H. M., Nieschlag, E., Partsch, C. J., Wieacker, P. & Simoni, M. in Andrology. Male Reproductive Health and Dysfunction 3rd edn (eds Nieschlag, E., Behre, H. M. & Nieschlag, S.) 169–192 (Springer-Verlag, Berlin, Germany, 2010).
Tsang, A., Moriarty, C. & Towns, S. Contraception, communication and counseling for sexuality and reproductive health in adolescents and young adults with CF. Paediatr. Respir. Rev. 11, 84–89 (2010).
Chambers, R., Lucht, A., Reihill, A. & Hough, J. Prevalence and impact of pelvic floor dysfunction in an adult cystic fibrosis population: a questionnaire survey. Int. Urogynecol J. 28, 591–604 (2017).
Sawyer, S. M., Farrant, B., Cerritelli, B. & Wilson, J. A survey of sexual and reproductive health in men with cystic fibrosis: new challenges for adolescent and adult services. Thorax 60, 326–330 (2005).
Levine, S. B. & Stern, R. C. Sexual function in cystic fibrosis. Relationship to overall health status and pulmonary disease severity in 30 married patients. Chest 81, 422–428 (1982).
Gameiro, S. et al. ESHRE guideline: routine psychosocial care in infertility and medically assisted reproduction-a guide for fertility staff. Hum. Reprod. 30, 2476–2485 (2015).
Valoriani, V. et al. Differences in psychophysical well-being and signs of depression in couples undergoing their first consultation for assisted reproduction technology (ART): an Italian pilot study. Eur. J. Obstet. Gynecol. Reprod. Biol. 197, 179–185 (2016).
Capogrosso, P. et al. Sexual functioning mirrors overall men's health status, even irrespective of cardiovascular risk factors. Andrology 5, 63–69 (2017).
Salonia, A. et al. Is erectile dysfunction a reliable proxy of general male health status? The case for the International Index of Erectile Function-Erectile Function domain. J. Sex. Med. 9, 2708–2715 (2012).
Salonia, A. et al. Is erectile dysfunction a reliable indicator of general health status in men? Arab J. Urol. 11, 203–211 (2013).
Jannini, E. A. et al. Premature ejaculation: old story, new insights. Fertil. Steril. 104, 1061–1073 (2015).
Jenkins, L. C. & Mulhall, J. P. Delayed orgasm and anorgasmia. Fertil. Steril. 104, 1082–1088 (2015).
Parish, S. J. & Hahn, S. R. Hypoactive sexual desire disorder: a review of epidemiology, biopsychology, diagnosis, and treatment. Sex. Med. Rev. 4, 103–120 (2016).
Peng, X., Zeng, X., Peng, S., Deng, D. & Zhang, J. The association risk of male subfertility and testicular cancer: a systematic review. PLoS ONE 4, e5591 (2009).
Walsh, T. J. et al. Increased risk of high-grade prostate cancer among infertile men. Cancer 116, 2140–2147 (2010).
Eisenberg, M. L., Betts, P., Herder, D., Lamb, D. J. & Lipshultz, L. I. Increased risk of cancer among azoospermic men. Fertil. Steril. 100, 681–685 (2013).
Eisenberg, M. L., Li, S., Brooks, J. D., Cullen, M. R. & Baker, L. C. Increased risk of cancer in infertile men: analysis of U. S. claims data. J. Urol. 193, 1596–1601 (2015).
Eisenberg, M. L., Li, S., Behr, B., Pera, R. R. & Cullen, M. R. Relationship between semen production and medical comorbidity. Fertil. Steril. 103, 66–71 (2015).
Jensen, T. K., Jacobsen, R., Christensen, K., Nielsen, N. C. & Bostofte, E. Good semen quality and life expectancy: a cohort study of 43,277 men. Am. J. Epidemiol. 170, 559–565 (2009).
Eisenberg, M. L. et al. Semen quality, infertility and mortality in the USA. Hum. Reprod. 29, 1567–1574 (2014).
Eisenberg, M. L. et al. Fatherhood and the risk of cardiovascular mortality in the NIH-AARP Diet and Health Study. Hum. Reprod. 26, 3479–3485 (2011).
Giwercman, A. & Giwercman, Y. L. Epidemiology of male reproductive disorders. in Endotext [Internet] (eds De Groot, L. J. et al.) (MDText.com, South Dartmouth, MA, USA, 2013).
Lotti, F. et al. Seminal, ultrasound and psychobiological parameters correlate with metabolic syndrome in male members of infertile couples. Andrology 1, 229–239 (2013).
Ventimiglia, E. et al. Metabolic syndrome in white European men presenting for primary couple's infertility: investigation of the clinical and reproductive burden. Andrology 4, 944–951 (2016).
Ventimiglia, E. et al. Metabolic syndrome in White-European men presenting for secondary couple's infertility: an investigation of the clinical and reproductive burden. Asian J. Androl 19, 368–373 (2017).
Tarín, J. J., García-Pérez, M. A., Hamatani, T. & Cano, A. Infertility etiologies are genetically and clinically linked with other diseases in single meta-diseases. Reprod. Biol. Endocrinol. 13, 31 (2015).
Dong, J. Y., Zhang, Y. H. & Qin, L. Q. Erectile dysfunction and risk of cardiovascular disease: meta-analysis of prospective cohort studies. J. Am. Coll. Cardiol. 58, 1378–1385 (2011).
Vlachopoulos, C. V., Terentes-Printzios, D. G., Ioakeimidis, N. K., Aznaouridis, K. A. & Stefanadis, C. I. Prediction of cardiovascular events and all-cause mortality with erectile dysfunction: a systematic review and meta-analysis of cohort studies. Circ. Cardiovasc. Qual. Outcomes 6, 99–109 (2013).
Udell, J. A., Lu, H. & Redelmeier, D. A. Failure of fertility therapy and subsequent adverse cardiovascular events. CMAJ 189, E391–E397 (2017).
Isidori, A. M. et al. A critical analysis of the role of testosterone in erectile function: from pathophysiology to treatment-a systematic review. Eur. Urol. 65, 99–112 (2014).
De Sanctis, V., Soliman, A. & Mohamed, Y. Reproductive health in young male adults with chronic diseases in childhood. Pediatr. Endocrinol. Rev. 10, 284–296 (2013).
Baker, H. W. Reproductive effects of nontesticular illness. Endocrinol. Metab. Clin. North Am. 27, 831–850 (1998).
Kim, E. D., Crosnoe, L., Bar-Chama, N., Khera, M. & Lipshultz, L. I. The treatment of hypogonadism in men of reproductive age. Fertil. Steril. 99, 718–724 (2013).
Ramasamy, R., Scovell, J. M., Kovac, J. R. & Lipshultz, L. I. Testosterone supplementation versus clomiphene citrate for hypogonadism: an age matched comparison of satisfaction and efficacy. J. Urol. 192, 875–879 (2014).
Majzoub, A., Sabanegh, E. Jr. Testosterone replacement in the infertile man. Transl Androl. Urol. 5, 859–865 (2016).
Guay, A. T., Jacobson, J., Perez, J. B., Hodge, M. B. & Velasquez, E. Clomiphene increases free testosterone levels in men with both secondary hypogonadism and erectile dysfunction: who does and does not benefit? Int. J. Impot. Res. 15, 156–165 (2003).
Guay, A. T., Bansal, S. & Heatley, G. J. Effect of raising endogenous testosterone levels in impotent men with secondary hypogonadism: double blind placebo-controlled trial with clomiphene citrate. J. Clin. Endocrinol. Metab. 80, 3546–3552 (1995).
Taylor, F. & Levine, L. Clomiphene citrate and testosterone gel replacement therapy for male hypogonadism: efficacy and treatment cost. J. Sex. Med. 7, 269–276 (2010).
Katz, D. J., Nabulsi, O., Tal, R. & Mulhall, J. P. Outcomes of clomiphene citrate treatment in young hypogonadal men. BJU Int. 110, 573–578 (2012).
Moskovic, D. J., Katz, D. J., Akhavan, A., Park, K. & Mulhall, J. P. Clomiphene citrate is safe and effective for long-term management of hypogonadism. BJU Int. 110, 1524–1528 (2012).
Buvat, J., Lemaire, A. & Buvat-Herbaut, M. Human chorionic gonadotropin treatment of nonorganic erectile failure and lack of sexual desire: a double-blind study. Urology 30, 216–219 (1987).
Patel, D. P., Chandrapal, J. C. & Hotaling, J. M. Hormone-based treatments in subfertile males. Curr. Urol. Rep. 17, 56 (2016).
Jensen, C. F. S. et al. Varicocele and male infertility. Nat. Rev. Urol. 14, 523–533 (2017).
Dabaja, A. A. & Goldstein, M. When is a varicocele repair indicated: the dilemma of hypogonadism and erectile dysfunction? Asian J. Androl 18, 213–216 (2016).
Hayden, R. P. & Tanrikut, C. Testosterone and varicocele. Urol. Clin. North Am. 43, 223–232 (2016).
Lotti, F. et al. The association between varicocele, premature ejaculation and prostatitis symptoms: possible mechanisms. J. Sex. Med. 6, 2878–2887 (2009).
Asadpour, A. A., Aslezare, M., Nazari Adkani, L., Armin, M. & Vojdani, M. The effects of varicocelectomy on the patients with premature ejaculation. Nephrourol. Mon. 6, e15991 (2014).
Ahmed, A. F. et al. Impact of varicocelectomy on premature ejaculation in varicocele patients. Andrologia 47, 276–281 (2015).
Kose, O. & Ozbek, E. Re: Ahmed et al.: Impact of varicocelectomy on premature ejaculation (PE) in varicocele patients (Andrologia. 2014, March 10). Andrologia 47, 603 (2015).
Keller, J. J., Chen, Y. K. & Lin, H. C. Varicocele is associated with erectile dysfunction: a population-based case-control study. J. Sex. Med. 9, 1745–1752 (2012).
Zohdy, W., Ghazi, S. & Arafa, M. Impact of varicocelectomy on gonadal and erectile functions in men with hypogonadism and infertility. J. Sex. Med. 8, 885–893 (2011).
Ko, E. Y., Siddiqi, K., Brannigan, R. E. & Sabanegh, E. S. Jr. Empirical medical therapy for idiopathic male infertility: a survey of the American Urological Association. J. Urol. 187, 973–978 (2012).
Piva, I., Lo Monte, G., Graziano, A. & Marci, R. A literature review on the relationship between infertility and sexual dysfunction: does fun end with baby making? Eur. J. Contracept. Reprod. Health Care 19, 231–237 (2014).
Kushnir, V. A., Barad, D. H., Albertini, D. F., Darmon, S. K. & Gleicher, N. Systematic review of worldwide trends in assisted reproductive technology 2004–2013. Reprod. Biol. Endocrinol. 15, 6 (2017).
Ciocca, G. et al. SIAMS survey on sexological screening during the assisted reproductive technologies in Italy. J. Endocrinol. Invest. 38, 999–1005 (2015).
Lenzi, A., Lombardo, F., Salacone, P., Gandini, L. & Jannini, E. A. Stress, sexual dysfunctions, and male infertility. J. Endocrinol. Invest. 26, 72–76 (2003).
Bayar, U. et al. Sexual dysfunction in infertile couples: evaluation and treatment of infertility. J. Pak. Med. Assoc. 64, 138–145 (2014).
Samplaski, M. K. & Nangia, A. K. Adverse effects of common medications on male fertility. Nat. Rev. Urol. 12, 401–413 (2015).
Fusco, F., Franco, M., Longo, N., Palmieri, A. & Mirone, V. The impact of non-urologic drugs on sexual function in men. Arch. Ital. Urol. Androl 86, 50–55 (2014).
Hatzimouratidis, K. et al. Pharmacotherapy for erectile dysfunction: recommendations from the Fourth International Consultation for Sexual Medicine (ICSM 2015). J. Sex. Med. 13, 465–488 (2016).
Hatzimouratidis, K. et al. EAU Guidelines on Male Infertility (European Association of Urology, Arnhem, Netherlands, 2017).
McMahon, C. G., Jannini, E., Waldinger, M. & Rowland, D. Standard operating procedures in the disorders of orgasm and ejaculation. J. Sex. Med. 10, 204–229 (2013).
Rubio-Aurioles, E. & Bivalacqua, T. J. Standard operational procedures for low sexual desire in men. J. Sex. Med. 10, 94–107 (2013).
Althof, S. E. & McMahon, C. G. Contemporary management of disorders of male orgasm and ejaculation. Urology 93, 9–21 (2016).
Lessan-Pezeshki, M. & Ghazizadeh, S. Sexual and reproductive function in end-stage renal disease and effect of kidney transplantation. Asian J. Androl. 10, 441–446 (2008).
Navaneethan, S. D. et al. Prevalence and correlates of self-reported sexual dysfunction in CKD: a meta-analysis of observational studies. Am. J. Kidney Dis. 56, 670–685 (2010).
Burra, P. Liver abnormalities and endocrine diseases. Best Pract. Res. Clin. Gastroenterol. 27, 553–563 (2013).
Van Thiel, D. H., Gavaler, J. S., Smith, W. I. & Rabin, B. S. Testicular and spermatozoal autoantibody in chronic alcoholic males with gonadal failure. Clin. Immunol. Immunopathol. 8, 311–317 (1977).
Chien, Y. C., Chiang, H. C., Lin, P. Y. & Chen, Y. L. Erectile function in men with end-stage liver disease improves after living donor liver transplantation. BMC Urol. 15, 83 (2015).
Park, E. S., Villanueva, C. A., Viers, B. R., Siref, A. B. & Feloney, M. P. Assessment of sexual dysfunction and sexually related personal distress in patients who have undergone orthotopic liver transplantation for end-stage liver disease. J. Sex. Med. 8, 2292–2298 (2011).
Van deursen C., Delaere, K. & Tenkate, J. Hemochromatosis and sexual dysfunction. Int. J. Impot. Res. 15, 430–432 (2003).
Pigott, T. A. & Kellner, C. H. Depression and sexual dysfunction complicating neurosarcoidosis. J. S. C Med. Assoc. 83, 16–18 (1987).
Kamischke, A. et al. Testosterone levels in men with chronic obstructive pulmonary disease with or without glucocorticoid therapy. Eur. Respir. J. 11, 41–45 (1998).
Mastrogiacomo, I. et al. Clinical and hormonal aspects of male hypogonadism in myotonic dystrophy. Ital. J. Neurol. Sci. 17, 59–65 (1996).
Kim, W. B. et al. Myotonic dystrophy type 1 presenting as male infertility. Kor. J. Urol. 53, 134–136 (2012).
Atsuta, N. et al. Natural history of spinal and bulbar muscular atrophy (SBMA): a study of 223 Japanese patients. Brain 129, 1446–1455 (2006).
Jokela, M. E. & Udd, B. Diagnostic clinical, electrodiagnostic and muscle pathology features of spinal and bulbar muscular atrophy. J. Mol. Neurosci. 58, 330–334 (2016).
Gomes, C. M. et al. Erectile function predicts sexual satisfaction in men with spinal cord injury. Sex. Med. 5, e148–e155 (2017).
Taneja, N., Kucheria, K., Jain, S. & Maheshwari, M. C. Effect of phenytoin on semen. Epilepsia 35, 136–140 (1994).
Molitch, M. E. Diagnosis and treatment of pituitary adenomas: a review. JAMA 317, 516–524 (2017).
Ozgör, B. & Selimoglu, M. A. Coeliac disease and reproductive disorders. Scand. J. Gastroenterol. 45, 395–402 (2010).
Bona, G., Marinello, D. & Oderda, G. Mechanisms of abnormal puberty in coeliac disease. Horm. Res. 57 (Suppl. 2), 63–65 (2002).
Ghazi, L. J., Patil, S. A. & Cross, R. K. Sexual dysfunction in inflammatory bowel disease. Inflamm. Bowel Dis. 21, 939–947 (2015).
Farthing, M. J. & Dawson, A. M. Impaired semen quality in Crohn's disease — drugs, ill health, or undernutrition? Scand. J. Gastroenterol. 18, 57–60 (1983).
Dimitrova, D., Kalaydjiev, S., Mendizova, A., Piryova, E. & Nakov, L. Circulating antibodies to human spermatozoa in patients with ulcerative colitis. Fertil. Steril. 84, 1533–1535 (2005).
Safarinejad, M. R. Evaluation of semen quality, endocrine profile and hypothalamus-pituitary-testis axis in male patients with homozygous beta-thalassemia major. Urology 179, 2327–2332 (2008).
Katz, M. et al. Sexual performance and fertility potential in patients with beta thalassemia major. Prog. Clin. Biol. Res. 309, 57–66 (1989).
Smith-Whitley, K. Reproductive issues in sickle cell disease. Hematol. Am. Soc. Hematol. Educ. Program 1, 418–424 (2014).
Lotti, F. et al. Clinical implications of measuring prolactin levels in males of infertile couples. Andrology 1, 764–771 (2013).
Eckstein, N., Haas, B., Hass, M. D. & Pfeifer, V. Systemic therapy of Cushing's syndrome. Orphanet J. Rare Dis. 9, 122 (2014).
Colao, A. et al. Short-term suppression of GH and IGF-I levels improves gonadal function and sperm parameters in men with acromegaly. J. Clin. Endocrinol. Metab. 87, 4193–4197 (2002).
Lotti, F. et al. Erectile dysfunction common among men with acromegaly associated with morbidities related to the disease. J. Sex. Med. 12, 1184–1193 (2015).
King, T. F., Lee, M. C., Williamson, E. E. & Conway, G. S. Experience in optimizing fertility outcomes in men with congenital adrenal hyperplasia due to 21 hydroxylase deficiency. Clin. Endocrinol. 84, 830–836 (2016).
Jääskeläinen, J., Tiitinen, A. & Voutilainen, R. Sexual function and fertility in adult females and males with congenital adrenal hyperplasia. Horm. Res. 56, 73–80 (2001).
Corona, G. et al. Type 2 diabetes mellitus and testosterone: a meta-analysis study. Int. J. Androl 34, 528–540 (2011).
Corona, G., Vignozzi, L., Sforza, A., Mannucci, E. & Maggi, M. Obesity and late-onset hypogonadism. Mol. Cell. Endocrinol. 418, 120–133 (2015).
Campbell, J. M., Lane, M., Owens, J. A. & Bakos, H. W. Paternal obesity negatively affects male fertility and assisted reproduction outcomes: a systematic review and meta-analysis. Reprod. Biomed. Online 31, 593–604 (2015).
MacDonald, A. A., Herbison, G. P., Showell, M. & Farquhar, C. M. The impact of body mass index on semen parameters and reproductive hormones in human males: a systematic review with meta-analysis. Hum. Reprod. Update 16, 293–311 (2010).
Sermondade, N. et al. BMI in relation to sperm count: an updated systematic review and collaborative meta-analysis. Hum. Reprod. Update 19, 221–231 (2013).
Corona, G. et al. Testosterone and metabolic syndrome: a meta-analysis study. J. Sex. Med. 8, 272–283 (2011).
Østensen, M. New insights into sexual functioning and fertility in rheumatic diseases. Best Pract. Res. Clin. Rheumatol. 18, 219–232 (2004).
Wong, N., Levy, M. & Stephenson, I. Hypogonadism in the HIV-infected man. Curr. Treat. Opt. Infect. Dis. 9, 104–116 (2017).
Rusz, A. et al. Influence of urogenital infections and inflammation on semen quality and male fertility. World J. Urol. 30, 23–30 (2012).
Santi, D., Brigante, G., Zona, S., Guaraldi, G. & Rochira, V. Male sexual dysfunction and HIV — a clinical perspective. Nat. Rev. Urol. 11, 99–109 (2014).
Schultheiss, D. Urogenital infections and male sexuality: effects on ejaculation and erection. Andrologia 40, 125–129 (2008).
Souho, T., Benlemlih, M. & Bennani, B. Human papillomavirus infection and fertility alteration: a systematic review. PLoS ONE 10, e0126936 (2015).
Adelman, W. P. & Joffe, A. Genitourinary issues in the male college student: a case-based approach. Pediatr. Clin. North Am. 52, 199–216 (2005).
Moscicki, A. B., Winkler, B., Irwin, C. E. Jr, & Schachter, J. Differences in biologic maturation, sexual behavior, and sexually transmitted disease between adolescents with and without cervical intraepithelial neoplasia. J. Pediatr. 115, 487–493 (1989).
Nagele, E. et al. Sexual activity, psychosexual distress, and fear of progression in women with human papillomavirus-related premalignant genital lesions. J. Sex. Med. 13, 253–259 (2016).
Kucukunal, A., Altunay, I. K. & Mercan, S. Sexual dysfunction in men suffering from genital warts. J. Sex. Med. 10, 1585–1591 (2013).
La Vignera, S., Vicari, E., Condorelli, R. A., D'Agata, R. & Calogero, A. E. Male accessory gland infection and sperm parameters (review). Int. J. Androl. 34, e330–347 (2011).
La Vignera, S., Condorelli, R., Vicari, E., D'Agata, R. & Calogero, A. E. High frequency of sexual dysfunction in patients with male accessory gland infections. Andrologia 44, 438–446 (2012).
Hviid, A., Rubin, S. & Mühlemann, K. Mumps. Lancet 371, 932–944 (2008).
Lambert, B. The frequency of mumps and of mumps orchitis and the consequences for sexuality and fertility. Acta Genet. Stat. Med. 2, 1–166 (1951).
Nigam, P. et al. Male gonads in leprosy — a clinico-pathological study. Indian J. Lepr 60, 77–83 (1988).
Richens, J. Genital manifestations of tropical diseases. Sex. Transm. Infect. 80, 12–17 (2004).
Corona, G. et al. Hypogonadism as a risk factor for cardiovascular mortality in men: a meta-analytic study. Eur. J. Endocrinol. 165, 687–701 (2011).
Annam, K., Voznesensky, M. & Kreder, K. J. Understanding and managing erectile dysfunction in patients treated for cancer. J. Oncol. Pract. 12, 297–304 (2016).
Grunnert, E., Nyfors, A. & Hansen, K. B. Studies on human semen in topical corticosteroid-treated and in methotrexate treated psoriatics. Dermatologica 154, 78–84 (1977).
Molina-Leyva, A., Jiménez-Moleón, J. J., Naranjo-Sintes, R. & Ruiz-Carrascosa, J. C. Sexual dysfunction in psoriasis: a systematic review. J. Eur. Acad. Dermatol. Venereol. 29, 649–655 (2015).
Ozdemir, B. H., Ozdemir, O. G., Ozdemir, F. N. & Ozdemir, A. I. Value of testis biopsy in the diagnosis of systemic amyloidosis. Urology 59, 201–205 (2002).
Podnar, S. & Vodušek, D. B. Sexual dysfunction in patients with peripheral nervous system lesions. Handb. Clin. Neurol. 130, 179–202 (2015).
Sakane, T., Takeno, M., Suzuki, N. & Inaba, G. Behçet's disease. N. Engl. J. Med. 341, 1284–1291 (1999).
Hiz, O., Ediz, L., Gülcü, E. & Tekeoglu, I. Effects of Behçet's disease on sexual function and psychological status of male patients. J. Sex. Med. 8, 1426–1433 (2011).
Hellstrom, W. J. & Sikka, S. C. Effects of alfuzosin and tamsulosin on sperm parameters in healthy men: results of a short-term, randomized, double-blind, placebo-controlled, crossover study. J. Androl 30, 469–474 (2009).
Roehrborn, C. G. et al. The effects of dutasteride, tamsulosin and combination therapy on lower urinary tract symptoms in men with benign prostatic hyperplasia and prostatic enlargement: 2-year results from the CombAT study. J. Urol. 179, 616–621 (2008).
Amory, J. K. et al. The effect of 5α reductase inhibition with dutasteride and finasteride on semen parameters and serum hormones in healthy men. J. Clin. Endocrinol. Metab. 92, 1659–1665 (2007).
Wessells, H. et al. Incidence and severity of sexual adverse experiences in finasteride and placebo-treated men with benign prostatic hyperplasia. Urology 61, 579–584 (2003).
Safarinejad, M. R. Sperm DNA damage and semen quality impairment after treatment with selective serotonin reuptake inhibitors detected using semen analysis and sperm chromatin structure assay. J. Urol. 180, 2124–2128 (2008).
Montejo, A. L., Llorca, G., Izquierdo, J. A. & Rico-Villademoros, F. Incidence of sexual dysfunction associated with antidepressant agents: a prospective multicenter study of 1022 outpatients. J. Clin. Psychiatry 62, 10–21 (2001).
Levin, R. M., Amsterdam, J. D., Winokur, A. & Wein, A. J. Effects of psychotropic drugs on human sperm motility. Fertil. Steril. 36, 503–506 (1981).
Serretti, A. & Chiesa, A. Sexual side effects of pharmacological treatment of psychiatric diseases. Clin. Pharmacol. Ther. 89, 142–147 (2011).
White, D. R., Clarkson, J. S., Ratnasooriya, W. D. & Aitken, R. J. Complementary effects of propranolol and nonoxynol 9 upon human sperm motility. Contraception 52, 241–247 (1995).
[No authors listed.] Adverse reactions to bendrofluazide and propanololo for the treatment of mild hypertension: report on the Medical Research Council Working Party on Mild to Moderate Hypertension. Lancet 2, 539–543 (1981).
Caminos-Torres, R., Ma, L. & Snyder, P. J. Gynecomastia and semen abnormalities induced by spironolactone in normal men. J. Clin. Endocrinol. Metab. 45, 255–260 (1977).
Grimm, R. H. Jr et al. Long term effects on sexual function of five anti-hypertensive drugs and nutritional hygienic treatment in hypertensive men and women. Treatment of mild hypertension study (TOMHS). Hypertension 29, 8–14 (1997).
Pomara, G. et al. Alterations in sperm motility after acute oral administration of sildenafil or tadalafil in young, infertile men. Fertil. Steril. 88, 860–865 (2007).
Sands, K., Jansen, R., Zaslau, S. & Greenwald, D. Review article: the safety of therapeutic drugs in male inflammatory bowel disease patients wishing to conceive. Aliment. Pharmacol. Ther. 41, 821–834 (2015).
Feagins, L. A. & Kane, S. V. Sexual and reproductive issues for men with inflammatory bowel disease. Am. J. Gastroenterol. 104, 768–773 (2009).
Reis, R. M., de Angelo, A. G., Sakamoto, A. C., Ferriani, R. A. & Lara, L. A. Altered sexual and reproductive functions in epileptic men taking carbamazepine. J. Sex. Med. 10, 493–499 (2013).
This work is funded by the Ministry of University and Scientific Research (SIR project to F.L. protocol number: RBSI14LFMQ).
The authors declare no competing financial interests.
About this article
Cite this article
Lotti, F., Maggi, M. Sexual dysfunction and male infertility. Nat Rev Urol 15, 287–307 (2018). https://doi.org/10.1038/nrurol.2018.20
Male Infertility is a Women’s Health Issue—Research and Clinical Evaluation of Male Infertility Is Needed
Evaluation of carvacrol on pituitary and sexual hormones and their receptors in the testicle of male diabetic rats
Human & Experimental Toxicology (2020)
Journal of Reproductive Immunology (2020)
Association Between Deviated Nasal Septum With Inferior Turbinate Hypertrophy and the Risk of Male Infertility
American Journal of Rhinology & Allergy (2020)
The Nurse Practitioner (2020)