Definition — Azoospermia কাকে বলে?

Azoospermia হলো semen analysis-এ ejaculate-এর মধ্যে কোনো sperm না পাওয়া। সঠিকভাবে বললে, semen sample centrifuge করার পর pellet পরীক্ষা করেও sperm না পাওয়া গেলে azoospermia বলা হয়। AUA/ASRM guideline অনুযায়ী azoospermia confirm হলে obstruction না impaired sperm production—এটি semen volume, physical examination এবং FSH দিয়ে আলাদা করতে হয়।

এটি aspermia থেকে আলাদা।
Azoospermia = semen আছে, কিন্তু sperm নেই।
Aspermia = ejaculation-এ semen-ই বের হয় না বা খুব কম/না আসে।

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2. Types / Classification

1. Pre-testicular azoospermia

Hormonal signal কম থাকে। Hypothalamus বা pituitary থেকে GnRH/LH/FSH কম হলে testis sperm তৈরি করতে পারে না।

2. Non-obstructive azoospermia — NOA

Testis-এর ভিতরে sperm production কম বা বন্ধ। এখানে semen passage খোলা থাকতে পারে, কিন্তু sperm তৈরি হয় না বা খুব কম হয়।

3. Obstructive azoospermia — OA

Testis sperm তৈরি করছে, কিন্তু duct blockage-এর কারণে sperm semen-এ আসছে না। Vas deferens, epididymis বা ejaculatory duct blockage থাকতে পারে।

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3. Causes — কারণ

A. Pre-testicular / hormonal cause

• Hypogonadotropic hypogonadism
• Kallmann syndrome
• Pituitary tumour
• Hyperprolactinaemia
• Anabolic steroid / testosterone misuse
• Severe obesity
• Chronic systemic illness
• Thyroid disorder
• Certain drugs: testosterone, anabolic steroid, opioids, chemotherapy

AUA/ASRM guideline অনুযায়ী low testosterone infertile male-এ hCG, SERM বা aromatase inhibitor ব্যবহার করা যেতে পারে, কিন্তু fertility চাইলে testosterone monotherapy দেওয়া উচিত নয়, কারণ exogenous testosterone spermatogenesis কমিয়ে azoospermia করতে পারে।

B. Testicular / non-obstructive cause

• Klinefelter syndrome
• Y-chromosome microdeletion
• Sertoli-cell-only syndrome
• Maturation arrest
• Cryptorchidism / undescended testis
• Mumps orchitis
• Testicular torsion / trauma
• Chemotherapy / radiotherapy
• Varicocele
• Idiopathic testicular failure

AUA/ASRM primary infertility with azoospermia বা severe oligozoospermia-তে karyotype ও Y-chromosome microdeletion test recommend করে, বিশেষ করে FSH high, testis small বা impaired sperm production suspicion থাকলে।

C. Post-testicular / obstructive cause

• Vasectomy
• Congenital bilateral absence of vas deferens — CBAVD
• Epididymal obstruction
• Ejaculatory duct obstruction
• Post-infection obstruction: epididymitis, prostatitis, TB
• Post-surgical obstruction: hernia repair, scrotal surgery, prostate surgery
• Retrograde ejaculation
• Anejaculation

Vasal agenesis বা idiopathic obstructive azoospermia হলে CFTR mutation testing এবং female partner-এর genetic evaluation দরকার হতে পারে।

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4. Symptoms — লক্ষণ

• বেশিরভাগ ক্ষেত্রে কোনো direct symptom থাকে না।
• প্রধান complaint: ১ বছর regular unprotected intercourse-এর পরও pregnancy না হওয়া।
• Low libido, erectile dysfunction, fatigue — hypogonadism suspicion।
• Small testis, কম beard/body hair, gynecomastia — primary testicular failure বা endocrine cause।
• Scrotal heaviness / dragging pain — varicocele।
• Dry orgasm বা ejaculation কম — retrograde ejaculation/aspermia।
• Dysuria, urethral discharge, testicular pain — infection/STI/epididymitis।
• Semen volume খুব কম — ejaculatory duct obstruction, CBAVD বা retrograde ejaculation suspicion।

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5. Clinical Diagnosis — clinically কীভাবে diagnose করবেন?

Step 1: Semen analysis confirm করা

• ২–৭ দিন abstinence-এর পর semen sample দিতে হবে।
• Sample complete collection হয়েছে কি না নিশ্চিত করতে হবে।
• WHO-standard laboratory-তে semen analysis করতে হবে। WHO semen manual semen examination-এর standardized protocol দেয়।
• একবার sperm না পাওয়া গেলে repeat semen analysis করতে হবে।
• Centrifuged pellet পরীক্ষা করে rare sperm আছে কি না দেখতে হবে।
• দুইটি properly collected semen analysis-এ sperm না পাওয়া গেলে azoospermia confirm করা যায়।

Step 2: History

• Infertility duration
• Previous pregnancy history
• Puberty history
• Libido, erection, ejaculation
• Semen volume / dry ejaculation
• Mumps orchitis, cryptorchidism, testicular trauma
• Vasectomy বা pelvic/scrotal surgery
• STI, epididymitis, prostatitis, TB history
• Chemotherapy/radiotherapy
• Testosterone/anabolic steroid/opioid use
• Diabetes, spinal cord injury, neurological disease
• Female partner age ও fertility status

AUA/ASRM initial evaluation-এ male reproductive history এবং এক বা একাধিক semen analysis recommend করে; একই সঙ্গে female partner evaluation-ও parallel করতে হয়।

Step 3: Physical examination

• BMI, waist circumference
• Secondary sexual characters
• Testicular volume
• Epididymis palpation
• Vas deferens present/absent
• Varicocele পরীক্ষা — standing + Valsalva
• Gynecomastia
• Prostate/seminal vesicle suspicion থাকলে DRE
• Signs of endocrine disease

Step 4: Clinical differentiation

• Small testis + high FSH + normal semen volume → usually non-obstructive azoospermia।
• Normal testis volume + normal FSH + low semen volume বা absent vas deferens/enlarged epididymis → obstructive azoospermia suspicion।
• Low testosterone + low/normal LH/FSH → hypogonadotropic hypogonadism।
  AUA/ASRM guideline এই clinical approach-ই recommend করে।

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6. Investigations — পরীক্ষা

Basic investigations

• Semen analysis — repeat, centrifuged pellet সহ
• Semen volume, pH, fructose if needed
• Post-ejaculatory urine analysis — retrograde ejaculation suspicion
• CBC, fasting glucose/HbA1c, lipid profile if metabolic risk থাকে

Hormonal profile

• Morning total testosterone
• FSH
• LH
• Prolactin
• TSH
• Estradiol — obesity/gynecomastia/low T:E ratio suspicion

AUA/ASRM azoospermia, impaired libido, ED, atrophic testis বা hormonal abnormality থাকলে FSH ও testosterone testing recommend করে।

Genetic tests

• Karyotype
• Y-chromosome microdeletion
• CFTR mutation testing — absent vas deferens বা idiopathic obstructive azoospermia
• Female partner CFTR carrier testing if male CFTR positive

Imaging

• Scrotal Doppler ultrasound — varicocele, testis volume, mass, epididymal lesion suspicion
• TRUS — semen volume low, acidic semen, normal testosterone, palpable vas deferens, ejaculatory duct obstruction suspicion
• Renal ultrasound — vasal agenesis থাকলে renal abnormality দেখতে
• Pituitary MRI — persistent high prolactin বা hypogonadotropic hypogonadism suspicion

AUA/ASRM routine initial scrotal ultrasound বা routine TRUS recommend করে না; TRUS specific ejaculatory duct obstruction pattern থাকলে করা হয়।

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7. Treatment / Management:-

General management

• Couple-based infertility management করতে হবে।
• Female partner evaluation parallel করতে হবে।
• Smoking, alcohol, cannabis, anabolic steroid বন্ধ।
• Testosterone injection/gel/capsule বন্ধ করতে হবে যদি fertility desired হয়।
• Diabetes, thyroid disease, obesity, infection, varicocele, prolactin disorder treat করতে হবে।
• Chemotherapy/radiotherapy-এর আগে sperm banking ideally করা উচিত।
• Genetic cause থাকলে genetic counselling দরকার।

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Obstructive azoospermia management

• Vasectomy-এর পর conception চাইলে vasovasostomy বা vasoepididymostomy।
• Epididymal/vasal obstruction হলে microsurgical reconstruction।
• Ejaculatory duct obstruction হলে TURED বা sperm retrieval + ICSI।
• Sperm retrieval options: PESA, MESA, TESA, TESE।
• Retrieved sperm দিয়ে IVF/ICSI করা যায়। AUA/ASRM obstructive azoospermia-তে epididymis বা testis থেকে sperm extraction গ্রহণযোগ্য বলে।

Non-obstructive azoospermia management

• Hormonal correctable cause থাকলে আগে treat।
• Otherwise main fertility option: micro-TESE + ICSI।
• AUA/ASRM NOA-তে sperm retrieval করলে microdissection TESE recommend করে।
• Complete AZFa/AZFb microdeletion থাকলে sperm retrieval chance খুব poor; genetic counselling জরুরি।
• No sperm পাওয়া গেলে donor sperm/adoption discussion দরকার।

Hypogonadotropic hypogonadism management

• hCG দিয়ে endogenous testosterone normalize করা হয়।
• Testosterone normalize হওয়ার পর FSH analogue add করে spermatogenesis stimulate করা হয়। AUA/ASRM HH-তে hCG শুরু করে testosterone monitor, পরে FSH/FSH analogue add করার approach উল্লেখ করে।

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8. Pharmacological Treatment — drug point আকারে

এগুলো prescription-only। Azoospermia-এর drug treatment cause-specific। True obstructive azoospermia-তে শুধু medicine দিয়ে blockage খুলে যায় না; surgery/ART লাগে।

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1. Human Chorionic Gonadotropin — hCG

• Drug description: hCG LH-এর মতো কাজ করে Leydig cell stimulate করে endogenous testosterone বাড়ায়।
• Injection IM/SC 1.HCG  5000IU/Vial AS A Human chorionic gonadotropin AS A Female Sex hormones.
• Using purpose: Hypogonadotropic hypogonadism, low LH/FSH with low testosterone, fertility desired male।
• Dose: 500–1,000 IU IM three times weekly for 3 weeks, then same dose twice weekly for 3 weeks; অন্য regimen হিসেবে 4,000 IU IM three times weekly for 6–9 months, তারপর 2,000 IU three times weekly for additional 3 months। Official Pregnyl label-এ selected male hypogonadotropic hypogonadism dosing এভাবে দেওয়া আছে।
• Practical fertility protocol: 1,000–2,250 IU SC/IM 2–3 times/week until serum testosterone normal; response পেতে 3–6 months লাগতে পারে।
• Duration: minimum 3–6 months; sperm appear করতে 6–12 months বা বেশি লাগতে পারে।
• Side effects: headache, irritability, restlessness, depression, fatigue, edema, gynecomastia, injection-site pain, acne।
• Interaction / caution: androgen-dependent tumour/prostate cancer suspected হলে contraindicated; hCG + menotropin/FSH only infertility specialist supervision-এ। Allergy/anaphylaxis rare but possible।
• Monitoring: testosterone, estradiol, semen analysis every 3 months, testis volume, gynecomastia, hematocrit if needed।

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2. Follitropin alfa / Follitropin beta / Urofollitropin — FSH analogue

• Drug description: Recombinant বা urinary FSH; Sertoli cell stimulate করে spermatogenesis শুরু/বাড়াতে সাহায্য করে।
• Injection 1.Gonal-F SC Injection75IU/Pre-filled syringe AS A  Follitropin alfa Drugs for Infertility.
• Using purpose: Hypogonadotropic hypogonadism with azoospermia; hCG দিয়ে testosterone normalize হওয়ার পর sperm production induce করতে।
• Dose: Follitropin alfa 150 IU SC three times/week + hCG 1,000 IU three times/week বা testosterone maintain করার জন্য required hCG dose। Azoospermia persist করলে FSH dose 300 IU three times/week পর্যন্ত বাড়ানো যায়।
• Duration: up to 18 months পর্যন্ত লাগতে পারে।
• Side effects: acne, injection-site pain, fatigue, gynecomastia, seborrhea, decreased libido। FDA label-এ male hypogonadotropic hypogonadism trial-এ এগুলো common adverse reaction হিসেবে উল্লেখ আছে।
• Interaction / caution: major drug interaction কম; hCG-এর সাথে combination protocol-এ ব্যবহার হয়; primary testicular failure হলে response poor।
• Monitoring: semen analysis 3 monthly, testosterone/estradiol, testicular volume, adverse effect।

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3. Clomiphene citrate

• Drug description: Selective estrogen receptor modulator — SERM; hypothalamus-pituitary axis-এ estrogen negative feedback কমিয়ে LH/FSH ও endogenous testosterone বাড়াতে পারে।
• Tablet 1.Ovuclon 50 mg AS A Clomiphene citrate AS A Drugs for Infertility.
• Using purpose: Low testosterone with low/normal LH, fertility desired; selected idiopathic infertility/NOA case-এ off-label।
• Dose: 25 mg orally every other day; response অনুযায়ী 25 mg daily বা 50 mg every other day specialist supervision-এ।
• Duration: 3–6 months; 6–8 weeks পর testosterone/LH/FSH, 3 months পর semen analysis।
• Side effects: headache, mood change, acne, gynecomastia, nausea, visual blurring/spots/flashes; visual symptom হলে drug stop করতে হয়। DailyMed clomiphene-এ visual symptoms warning দেয়।
• Interaction / caution: active liver disease বা previous liver dysfunction থাকলে contraindicated; organic intracranial lesion/pituitary tumour suspicion থাকলে আগে evaluation দরকার।
• Important note: Male infertility-তে clomiphene use often off-label; AUA/ASRM idiopathic infertility-তে SERM benefit limited বলে।

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4. Anastrozole

• Drug description: Aromatase inhibitor; testosterone থেকে estradiol conversion কমায়, ফলে selected men-এ testosterone-to-estradiol ratio improve করতে পারে।
• Tablet 1.Entroza 1mg  AS A Anastrozole AS A Hormonal Chemotherapy.
• Using purpose: Obese male, high estradiol, low testosterone-to-estradiol ratio, fertility desired low testosterone case।
• Dose: 0.5–1 mg orally 2–3 times/week; কিছু specialist protocol-এ 1 mg daily short course ব্যবহার হয়।
• Duration: 3 months trial, তারপর hormone profile ও semen analysis; selected case-এ 6 months।
• Side effects: joint pain, hot flush, low libido if estrogen too low, headache, mood change, increased cholesterol, liver enzyme alteration, bone mineral density কমতে পারে। FDA label anastrozole-এর bone effect, cholesterol rise এবং common adverse reactions উল্লেখ করে।
• Interaction / caution: tamoxifen বা estrogen-containing therapy একসাথে দিলে effect কমতে পারে; long-term use হলে bone health monitor দরকার।
• Monitoring: testosterone, estradiol, LH/FSH, lipid profile, liver function, bone risk।

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5. Cabergoline

• Drug description: Dopamine D2 receptor agonist; pituitary prolactin secretion কমায়।
• Using purpose: Hyperprolactinaemia-induced hypogonadism, low libido, ED, low testosterone, azoospermia/oligospermia associated with high prolactin।
• Tablet 1.Caberol 0.5mg AS A  Cabergoline AS A Antiparkinson drugs.
• Dose: 0.25 mg orally twice weekly; prolactin অনুযায়ী প্রতি ≥4 সপ্তাহে 0.25 mg twice weekly করে titrate; maximum 1 mg twice weekly। FDA label এই starting dose ও titration দেয়।
• Duration: prolactin normalize হওয়া পর্যন্ত; prolactinoma থাকলে months to years endocrinologist follow-up লাগে।
• Side effects: nausea, headache, dizziness, vomiting, constipation, fatigue, postural hypotension; rare valvular heart disease, pulmonary/retroperitoneal fibrosis, impulse-control disorder। FDA label nausea ও headache common adverse reaction হিসেবে উল্লেখ করে।
• Interaction / caution: dopamine antagonist যেমন metoclopramide, antipsychotic phenothiazine/butyrophenone effect কমাতে পারে; antihypertensive drug-এর সাথে hypotension বাড়তে পারে। Valvular heart disease থাকলে avoid।
• Monitoring: serum prolactin, testosterone, pituitary MRI indication অনুযায়ী, BP, echocardiography if long-term/high dose।

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6. Doxycycline

• Drug description: Tetracycline antibiotic; Chlamydia trachomatis, nongonococcal urethritis এবং STI-related epididymitis/prostatitis coverage।
• Capsule 1.Doxibac 100 mg Doxycycline Hydrochloride Tetracycline group of drugs.
• Using purpose: Infection/STI suspected azoospermia, pyospermia, epididymitis, chlamydia suspicion।
• Dose: 100 mg orally twice daily।
• Duration: NGU/chlamydia urethritis usually 7 days; STI epididymitis হলে 10 days। CDC epididymitis guideline ceftriaxone plus doxycycline 100 mg twice daily for 10 days recommend করে when chlamydia/gonorrhoea likely।
• Side effects: nausea, gastritis, esophagitis, photosensitivity, diarrhea।
• Interaction / caution: antacid, calcium, iron, zinc, magnesium-এর সাথে absorption কমে; dose আলাদা করে নিতে হবে। Warfarin use করলে INR monitoring দরকার।
• Clinical note: partner treatment এবং abstinence until treatment completion জরুরি if STI confirmed/suspected।

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7. Ceftriaxone

• Drug description: Third-generation cephalosporin antibiotic; gonorrhoea coverage।
• Injection 1.Axon IM 500MG/VIAL AS A Ceftriaxone Sodium AS A Third generation Cephalosporins.
• Using purpose: Gonococcal urethritis/epididymitis suspected; usually doxycycline-এর সাথে যদি chlamydia excluded না হয়।
• Dose: 500 mg IM single dose; body weight ≥150 kg হলে 1 g IM single dose। CDC guideline এই dosing দেয়।
• Duration: single dose; chlamydia not excluded হলে doxycycline add।
• Side effects: injection-site pain, diarrhea, rash, allergy/anaphylaxis rare, biliary sludge rare।
• Interaction / caution: severe beta-lactam allergy history থাকলে caution; IV calcium-containing solution-এর সাথে mixing avoid।
• Clinical note: partner notification/treatment দরকার।

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8. Levofloxacin

• Drug description: Fluoroquinolone antibiotic; enteric gram-negative organism coverage।
• Tablet 1.Levomax 500 mg AS A Levofloxacin Hemihydrate AS A 4-Quinolone preparations.
• Using purpose: Enteric organism epididymitis/prostatitis suspected, gonorrhoea ruled out হলে।
• Dose: 500 mg orally once daily।
• Duration: 10 days। CDC enteric organism epididymitis-এ levofloxacin 500 mg daily for 10 days recommend করে।
• Side effects: tendinitis/tendon rupture, QT prolongation, dysglycaemia, dizziness, insomnia, peripheral neuropathy, GI upset।
• Interaction / caution: antacid, iron, zinc, magnesium, sucralfate absorption কমায়; warfarin-এর সাথে INR/bleeding risk monitor; QT-prolonging drugs-এর সাথে caution।
• Avoid/caution: elderly, steroid user, tendon disease, arrhythmia, severe renal impairment।

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9. Pseudoephedrine

• Drug description: Sympathomimetic alpha-adrenergic drug; bladder neck closure improve করে semen forward ejaculation-এ সাহায্য করতে পারে।

  Syrup 1.Tusca (30mg+100mg+1.25mg) 100ML Bottle AS A (Pseudoephedrine   +Guaiphenasine+Triprolidine) AS A Combined cough expectorants.

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• Using purpose: Retrograde ejaculation বা partial dry ejaculation causing azoospermia/aspermia।
• Dose: 60 mg orally every 6 hours on the day before semen collection, plus two 60 mg doses on collection day; অন্য practical regimen 60–120 mg 2–3 hours before ejaculation। AUA/ASRM retrograde ejaculation-এ sympathomimetic treatment option হিসেবে উল্লেখ করে।
• Duration: semen collection/fertile-window based short course; chronic daily use না করা ভালো।
• Side effects: palpitation, insomnia, nervousness, dizziness, BP rise, urinary retention।
• Interaction / caution: MAOI চললে বা MAOI বন্ধের ২ সপ্তাহের মধ্যে ব্যবহার করা যাবে না; diabetes, heart disease, hypertension, thyroid disease, BPH থাকলে doctor review দরকার। DailyMed pseudoephedrine label এই warnings দেয়।

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10. Imipramine

• Drug description: Tricyclic antidepressant; alpha-adrenergic effect bladder neck closure বাড়াতে পারে।

Tablet 1.Depram 25 mg Imipramine Hydrochloride AS A Tricyclic & related anti-depressant drugs, Tricyclic Anti-depressant

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• Using purpose: Retrograde ejaculation; pseudoephedrine ineffective/contraindicated হলে selected case।
• Dose: 25 mg orally at night; response অনুযায়ী 25–50 mg/day বা 25 mg twice daily specialist supervision-এ।
• Duration: 1–2 weeks before planned semen collection বা short fertility protocol; long-term হলে cardiometabolic monitoring দরকার।
• Side effects: dry mouth, constipation, urinary retention, sedation, dizziness, blurred vision, tachycardia, QT prolongation, sexual dysfunction, seizure risk।
• Interaction / caution: MAOI-এর সাথে contraindicated; MAOI থেকে switch করতে minimum 14 days gap দরকার। DailyMed imipramine label MAOI combination-এ severe/fatal reaction warning দেয়।
• Avoid/caution: recent MI, arrhythmia, glaucoma, BPH/urinary retention, seizure disorder, elderly patient।

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9. Important warning — Testosterone ব্যবহার করবেন না

Azoospermia বা infertility patient fertility চাইলে testosterone enanthate/cypionate/undecanoate injection, testosterone gel/capsule monotherapy দেওয়া যাবে না। Exogenous testosterone LH/FSH suppress করে sperm production কমিয়ে severe oligospermia বা azoospermia করতে পারে। AUA/ASRM current বা future fertility চাইলে testosterone monotherapy না দিতে বলে।

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Overview / Summary

Azoospermia হলো semen-এ sperm না থাকা, যা confirm করতে repeat semen analysis এবং centrifuged pellet examination দরকার। প্রধান তিন ধরন হলো pre-testicular hormonal, non-obstructive testicular failure, এবং obstructive/ejaculatory cause। Treatment সম্পূর্ণ cause-specific: hypogonadotropic hypogonadism হলে hCG ± FSH, hyperprolactinaemia হলে cabergoline, infection হলে antibiotic, retrograde ejaculation হলে pseudoephedrine/imipramine, obstructive azoospermia হলে reconstruction বা sperm retrieval + ICSI, আর NOA হলে micro-TESE + ICSI প্রধান option।

Actionable Plan / Steps

1. Two semen analysis করুন — ২–৭ দিন abstinence, centrifuged pellet সহ।
2. History ও physical exam দিয়ে semen volume, testis size, vas deferens, epididymis, varicocele assess করুন।
3. Hormone test করুন — morning testosterone, FSH, LH, prolactin, TSH ± estradiol।
4. NOA suspicion হলে karyotype + Y-chromosome microdeletion করুন।
5. Absent vas deferens/OA suspicion হলে CFTR testing ± partner testing করুন।
6. Low semen volume/acidic semen হলে post-ejaculatory urine ও TRUS consider করুন।
7. Fertility চাইলে testosterone/anabolic steroid বন্ধ করুন।
8. Cause-specific treatment দিন: hCG/FSH, cabergoline, antibiotics, sympathomimetic, surgery বা ART/ICSI।

Reference List

Textbook

• Harrison’s Principles of Internal Medicine, 21st ed. Male Infertility; Hypogonadism; Reproductive Endocrinology sections.
• Davidson’s Principles and Practice of Medicine, 24th ed. Endocrinology and Reproductive Medicine sections.
• Robbins & Cotran Pathologic Basis of Disease, 10th ed. Male Genital System chapter.
• Guyton and Hall Textbook of Medical Physiology, 14th ed. Male reproductive physiology chapter.

Guidelines

• WHO Laboratory Manual for the Examination and Processing of Human Semen, 6th ed., 2021.
• AUA/ASRM. Diagnosis and Treatment of Infertility in Men: Guideline Part I, 2020/2021. DOI: 10.1016/j.fertnstert.2020.11.015; DOI: 10.1097/JU.0000000000001521.
• AUA/ASRM. Diagnosis and Treatment of Infertility in Men: Guideline Part II, 2020/2021. DOI: 10.1016/j.fertnstert.2020.11.016; DOI: 10.1097/JU.0000000000001520.
• CDC Sexually Transmitted Infections Treatment Guidelines, 2021.
• EAU Guidelines on Sexual and Reproductive Health: Male Infertility, 2025.

Peer-reviewed DOI

• Schlegel PN, et al. Diagnosis and Treatment of Infertility in Men: AUA/ASRM Guideline Part I. Fertil Steril. DOI: 10.1016/j.fertnstert.2020.11.015.
• Eisenberg ML, et al. Diagnosis and Treatment of Infertility in Men: AUA/ASRM Guideline Part II. Fertil Steril. DOI: 10.1016/j.fertnstert.2020.11.016.
• Björndahl L, Kirkman-Brown J. The sixth edition of the WHO laboratory manual for the examination and processing of human semen. Fertil Steril. DOI: 10.1016/j.fertnstert.2021.12.012.
• McMahon CG, et al. Disorders of Ejaculation: An AUA/SMSNA Guideline. J Urol. DOI: 10.1097/JU.0000000000002392.

Md.Rafiqul Islam Lipu Date:-12-05-2026 Monday Time:11-49-29 Pm