Global Andrology Forum (GAF) Clinical Guidelines on the Management of Non-obstructive Azoospermia: Bridging the Gap between Controversy and Consensus

Abstract

Purpose: Non-obstructive azoospermia (NOA), defined as the absence of sperm in the ejaculate due to testicular failure, is observed in 5% to 15% of infertile men and accounts for two-thirds of azoospermia cases. The management of NOA is marked by significant controversy and global variation in diagnostic and therapeutic approaches, highlighting the crucial need for well-designed and standardized clinical practice guidelines. We present comprehensive graded clinical practice

recommendations and statements for diagnosing and treating NOA, aiming to establish standardized strategies that can glob- ally help guide practitioners in their practice.

Materials and Methods: A comprehensive literature review was conducted to gather evidence on the epidemiological, di- agnostic, and therapeutic aspects of NOA. The Global Andrology Forum (GAF) recommendations were developed through

the collaboration of a global panel of experts using the Delphi method and surveys to achieve consensus. Statements were graded according to the Oxford Centre for Evidence-Based Medicine “GRADE” classification as either “Strong” or “Weak.” Statements receiving at least 80% expert consensus were graded as “Strong,” while others were categorized as “Weak.”

Results: The GAF has formulated a total of 49 recommendations and statements on the diagnosis and treatment of NOA, in- cluding 21 for diagnosis and 28 for treatment. The recommendations and statements were evaluated and graded by a panel

of 48 GAF experts from 25 countries worldwide. The majority of experts (60.5%) had more than 10 years of clinical experi- ence in managing NOA.

Conclusions: The GAF guidelines address discrepancies in NOA management across diverse clinical settings and provide comprehensive graded recommendations to guide clinicians in its diagnosis and treatment. Developed and graded by a large

worldwide panel of experts, the current guidelines present simplified, high-standard strategies that can be seamlessly inte- grated into the daily global practice, offering practitioners a clear framework for managing NOA.