(by Nicola Simonetti) "In 1951 - said Filippo Boscia, former professor of Human Reproductive Medicine at the University of Bari and UOC director of obstetrics and gynecology - it was the gynecologist H. Siebke of the University of Bonn who proposed, for first in the world, the term Andrology.
Personally, I lived at the dawn of that period in which the andrology, emerging from the field of sectoral and empirical improvisations, was qualifying as a modern science, based on serious research, valid clinical experiences to re-establish itself in a new global entity that, while recognizing as roots l 'urology, endocrinology and in some ways dermatology, I would say dermosifilolopathy (that of Professor Mian of Pisa), opened up to surgery, genetics, sexology, clinical pathology, ultrastructural cytomorphological studies, true "new entries" in the field of andrology. Modern andrology arose with the intense desire to harmonize with the many various disciplines to deal with a single vision of a great new chapter in medicine.
Andrology had to be a science capable of accompanying "being human" from being born to his being a male, to developing in puberty, to manifesting himself psycho-physically in adolescence, at full manifestation in adulthood, with interests also addressed in the phases of subsequent fragility and senescence.
Andrology had an arduous task: to get rid of all the problems that for centuries had been conditioned by prejudice, taboos and other things, but this task was not easy.
It was by no means easy to break down that age-old taboo and the well-founded belief that sexual potency coincided with the greatest demonstration of fertility! It was not easy to overcome the infamous shame of sexual impotence, the ghost of which hovered in this context.
That patient, afflicted with andrological problems, wandered from the general practitioner to the dermatologist, urologist, endocrinologist, psychologist, experiencing his eventual impotence as a shame, a ghost, as an embarrassment, rather than as a disease to be cured .
Those times are not so far away! It actually happened that, while the gynecologist had always been a scientific, cultural and psychosocial reference figure for women, the male figure did not exist and the andrologist who was supposed to be a man, was not yet credited as a specialist, but also because for millennia man's sexuality and fertility had been covered by the taboo and by many multiple socio-cultural prejudices.
Certainly there was a belated breakthrough of andrology into the scenario of modern medicine. But the dream pursued in this founding path was to be able to define andrology as a unitary discipline, sister of gynecology, which for some time had been able to integrate the obstetrical, gynecological, endocrinological, reproductive, psychological components into a whole. ., and who in fact had since then founded that feminine gender medicine that unitarily followed the functions of female organisms, from puberty to fertile age and now also to climacteric, menopause and senescence.
Soon, however, it was realized that these projects might have undergone a significant slowdown. It was possible to obtain a reorganization of the specialization schools. There was the promise of the post-graduate specialization school of Pisa and Turin; had been confirmed the first chairs of Andrology of first band assigned to the degree courses of Medicine and Surgery of Rome, Florence and L'Aquila, etc.
But, in the broad context of the disciplines pertaining to Andrology, each defended his hortus conclusus: endocrinologists, urologists, gynecologists, pediatricians, biologists, psychologists, psychiatrists, clinical pathologists.
I think a lot of corporate corporations have played that actually prevented creating andrologists and above all making them grow and get to know.
The CUN, the national university council, classified andrology as a sub-specialty of endocrinology in 89 and included it as such in the organization and didactic objectives of the medical faculties starting from 2000. From this date there was no more specialization or autonomous discipline but teaching inserted in the training courses of "related" and / or "related" disciplines. Following this, Italy, from being a leader in this sector, saw its pioneering and pre-eminent role stifled.
This has had repercussions also on the welfare level. Never again complex operational units of andrology or unitary institutions, but simple structures or occasional assignments.
Andrology became a sub-specialty of endocrinology, sub-specialty of urology, sub-specialty of gynecology and reproductive medicine, sub-specialty of surgery.
The breakthrough of human reproductive medicine and medically assisted reproductive techniques (from insemination to IVF, to ICSI) then allowed these problems to be addressed in the first instance by gynecologists, even without andrologists.
This exclusion was easy because he had tried to establish andrology as a science, but he had prevented himself from being made andrologists and above all he had prevented making them known, preventing many students who hoped for the development of a unitary discipline from being formed in a unitary vision oriented with exclusive reference to "male" health.
In fact, at the beginning of the 90s, lacking an autonomous and unified academic recognition of the figure of the andrologist, it was realized that for the students, for the pupils, for the specialists, for the assisted, the discipline was now dispersed.
After this blunt decision by the CUN, that intimate desire to establish the andrological sciences in a single autonomous discipline broke down.
Andrology did not develop as we had conceived it, but fragmentation prevailed and consequently the only peculiarity required of the andrology foundational was lacking, namely that of bringing together in a single compartment here a thousand super specialized streams, but very often " anemic ". Thus the unitary relationship with all the problems that had given rise to the unitary complex of andrological sciences was lost and also that unitary sincere passion for a discipline that like gynecology should have kept alive the sense of unity was also lost. of a discipline, aimed at creating unique centers specialized in basic assistance for male problems, in hospital and territorial universities.
Today we certainly cannot ignore that the life expectancy of a man living in the Western world is less than five years than that of a woman of the same age.
I believe it is mandatory to underline the question as to why this gap exists and what measures can be taken to cover it. Covering the gender gap must be a moral obligation, so that the right to physical and reproductive and sexual health is not a diluted right in a health system that sometimes travels at two speeds, north against south.
It is necessary to cover these gaps which, among other things, when it comes to the quality of male welfare, concerns many parameters ranging from erectile dysfunction to failure to prevent and the onset of infertility (sterility, andropause, sexually transmitted diseases, osteoporosis, incidences of tumors of the skin, colorectal, prostate, testicle, etc.).
“It is necessary - says prof. Milone (university, Naples) rebalance the attention of doctors and the population to balance research efforts with an adequate approach to regional health policies, equal for all (and not differentiated by region). It is necessary to provide for the most homogeneous and widespread provision of medical services, in order to identify, produce or strengthen the right strategies to prevent and reduce discrepancies between the two sexes.
There is no doubt that the concept of prevention is able to penetrate the culture of the Italian male with much greater difficulty than the woman, but this observation must lead us even more to the creation of specialized centers for male problems that today are lacking in the Italian welfare panorama, for example, not only at university and / or hospital levels but also at the consultancy level or in territorial policies or in health homes. Motivating greater attention to men's health is important because the health education of the person must not be something that can be skimped on one sex over the other, nor can the allocation of resources be guided by fashions or indices of greater use of advanced techniques in reproductive medicine.
Paradoxically, however, in this dispersion, which to some seemed a strong signal of agony of Andrology, Andrology itself has had the opportunity to make up for lost time: in reality the entry of andrology into the field of reproductive medicine and techniques of medically assisted procreation has taken place and, within these realities, andrology has recovered all the previous missed opportunities and relaunched this discipline that has set itself as a reference reality in III level techniques (ICSI and micro injection) .
In PMA the function of the andrologist focuses on the new knowledge of pathophysiology of infertility and reproduction, which are indispensable for assessing the real quality of the seed and searching for those phenomena of DNA fragmentation in human spermatozoa.
Having tests available today that can test the genomic integrity of male gametes now appears essential. A patiently accurate job is needed to assess not only the real quality of the seed, but also to be able to highlight within the overall sperm population present in the seed those characterized by the presence of fragmented DNA.
This last annotation allows me to mention the newest aspect that inserts andrology in the field of reproductive medicine, especially in reference to microinjection techniques, which by their nature are based, as we know, on the use of a single spermatozoon: this is an aspect of fundamental importance, since medicine, from purely "curative" has become, albeit improperly, "procreative"
The future of genetics, and of pharmacogenetics, will perhaps leave us with possibilities that cannot be imagined.
Surgical techniques in the andrology field - in the forms susceptible of improvement with such interventions - have also been considerably refined. Just think of the standardization and optimization of gamete aspiration techniques directly from the epididymis or the testicle or the optimization of techniques for the correction of varicocele, now possible also with retrograde or percutaneous scleroembolization methods, or laparoscopic video techniques up to to microsurgery techniques for recanalization or vascular anastomosis.
Even more astonishing, the "violence" of the breakthrough and the rapidity of evolution of andrology in the field of clinical medicine, recent, indeed very recent, of Andrology with regard to erectile dysfunction (a semantic term that by convention has replaced that of "impotence" in whose essence contained an implicit judgment of contempt and condemnation of patients).
The “wall of silence” around this problem actually fell in the late 80s.
In this scenario Andrology recovers its lost meaning and from a “dispersed discipline” it becomes both an interdisciplinary and an intradisciplinary science, improving knowledge and prognosis in the endocrinological, metabolic, morphological, ultra-structural endothelial and ultimately genetic fields.
The use of medically assisted procreation must not become the failure of andrology.
The improvised emphasis, heralded left and right, that a single sperm is enough to solve a reproductive problem of the infertile male, has been rightly seen by some as the trivialization of andrology. Many infertile males have been abandoned to a sad fate.
Lacking the ease of access to andrology services and labeling andrological consultations as useless or futile, we certainly did not do good service to the community. Someone then talking about "controlled reproductive chain" spoke of PMA techniques as first choice techniques, which if controlled in each phase guarantee higher percentages of births of healthy children.
Certainly at a distance from the advent of ICSI we must certainly reflect on the indications but also on the excessive, sometimes groundless, use of these techniques.
ICSI is a very useful technique in the most serious cases of male infertility, but its abuse must be complained of, also because this technique raises important ethical problems relating to the indications and limits to be placed on these techniques which have become first option.
Substantial innovations have involved the various sectors of andrology: just think of the role of the andrologist in gender identity, the search for fertility of the couple in an increasingly advanced age, the problem of the aging population and declining birth rates and still moral question on assisted reproduction techniques, on the use of post mortem gametes or on the multitude of frozen embryos waiting for implantation or even more on the increasingly acute anticipation of an early multipartner sexuality in the very young which in this period oblige us even more than in the past to the early prevention of genital virosis even in school age etc.
The percentages of male infertility are on the rise and the developments recorded in molecular and cellular biology techniques have opened new chapters in many fields, but above all in the era of genetic testing the great chapter of identification in genetic diseases before birth was opened. allowing the study of pathological hereditary traits directly on the embryo at the stage of a few cells.
Precisely in this moment in which technologies applied to human reproduction can offer interesting possibilities for new therapeutic treatments, andrology as a branch in its own right must resume a decisive role in the selection of gametes, in the diagnosis and therapy of the sterile or sub-fertile male and further enhance research which, if of good quality, could indicate alternatives capable of reducing the number of failures, reducing the number of implantation failures and biochemical pregnancies. The transfer of the male genome, already organized as such, is practically possible through combined methods of in vitro fertilization and micromanipulation of the gametes, thus being able to heal even those cases of inability of the sperm to fertilize the oocytes.
These possibilities and many other advanced technologies are up to andrologists - concluded Boscia - who must claim that role of unavoidable guide in modern reproductive medicine paths.