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As a result of the technological advance provided by intracytoplasmic sperm injection (ICSI) in 1992, the evaluation and treatment of the infertile male has changed significantly. Many men who were previously thought to be irreversibly infertile have the potential to initiate their own biologic pregnancy. However, not all men having impaired semen parameter are ideal candidates for ICSI for numerous reasons including a lack of addressing the underlying problem causing the male infertility, unknown genetic consequences, and cost－effectiveness issues. In this era of ICSI, the fundamental approach to the male with suspected subfertility is unchanged and is based on a history, physical examination, and focused laboratory testing. The urologist should approach the patient with an intent to identify remediable causes of subfertility given the specific clinical situation. For instance, should a gentleman have his varicocele repaired or vasectomy reversed, or should he proceed directly with ICSI? If no factors can be improved in a timely manner, then ICSI should be considered using the available sperm. Examples of recent advances include the diagnosis and treatment of ejaculatory duct obstruction, indications and techniques for performing test is biopsy, and technique for sperm harvesting. In addition, potential genetic causes of male subfertility should be diagnosed and discussed with the patient. Cystic fibrosis gene mutation, karyotype abnormalities, and Y－chromosome microdeletions all have recently been identified as causative for male infertility in otherwise phenotypically normal men. With recently evolved diagnostic and therapeutic techniques now available for the infertile couple, even the most severe male factor problems in patients previously considered irreversibly infertile are now potentially treatable. The physician should be aware of the availability and limitations of these new and exciting reproductive technologies because they will allow him to provide timely and more effective therapy for the infertile couple. An understanding of these advances by all physicians is important as we progress into the 21st century.
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