Modern approaches to male infertility under the APHRODITE criteria lens

Sandro Esteves presents APHRODITE as the male counterpart to POSEIDON — a system for stratifying the male factor that goes beyond the familiar semen analysis.

The opening thesis is blunt and practical: "Don't label your patient as having male infertility based on the semen analysis alone — add hormonal stratification." The semen analysis describes the result but not the cause, and without a hormonal picture a substantial share of treatable patients is missed.

The APHRODITE criteria sort men into groups by hormonal and clinical profile; the most severe — APHRODITE-4 — is azoospermia, the hardest category, where surgical sperm retrieval is at stake.

The key intervention is hormonal priming (hCG ± FSH) before surgical sperm retrieval. The point is to restore the intratesticular androgen milieu and support spermatogenesis, improving the odds of finding viable cells during surgery.

The headline results: success above 60% overall and about 45% in the APHRODITE-4 (azoospermia) group. For a category once considered almost hopeless, this fundamentally changes the prognosis and how the couple is counselled.

Mechanistically the approach rests on the same axis as female stimulation: LH (via hCG) and FSH drive spermatogenesis, and their judicious use can "awaken" production where the baseline picture looked unpromising.

APHRODITE dovetails with POSEIDON: female and male stratification combine into a single plan for the couple. Optimising only the female protocol while ignoring the male factor risks the outcome of the whole programme.

The practical workflow: do not stop at the semen analysis, assess the hormonal profile, prime with hCG ± FSH before retrieval when indicated, and time the surgery to the response to priming.