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Thanks to a worrying decrease in male fertility, understanding how sperm 'work' is a matter both of interest and great importance. Sperm of all animals detect various environmental cues. The 'behavioural' and physiological responses of sperm must be specific, appropriate and correctly timed. Strangely, in a cell with few organelles and minimal cytoplasmic volume, internal Ca(2+) concentration, [Ca(2+)](i), regulates almost all these activities. How does such a simple cell achieve this - and is it as simple as it seems?

BACKGROUNDHerein, we describe the consensus guideline methodology, summarize the evidence-based recommendations we provided to the World Health Organization (WHO) for their consideration in the development of global guidance and present a narrative review of the diagnosis of male infertility as related to the eight prioritized (problem or population (P), intervention (I), comparison (C) and outcome(s) (O) (PICO)) questions. Additionally, we discuss the challenges and research gaps identified during the synthesis of this evidence.OBJECTIVE AND RATIONALEThe aim of this paper is to present an evidence-based approach for the diagnosis of male infertility as related to the eight prioritized PICO questions.SEARCH METHODSCollating the evidence to support providing recommendations involved a collaborative process as developed by WHO, namely: identification of priority questions and critical outcomes; retrieval of up-to-date evidence and existing guidelines; assessment and synthesis of the evidence; and the formulation of draft recommendations to be used for reaching consensus with a wide range of global stakeholders. For each draft recommendation the quality of the supporting evidence was then graded and assessed for consideration during a WHO consensus.OUTCOMESEvidence was synthesized and recommendations were drafted to address the diagnosis of male infertility specifically encompassing the following: What is the prevalence of male infertility and what proportion of infertility is attributable to the male? Is it necessary for all infertile men to undergo a thorough evaluation? What is the clinical (ART/non ART) value of traditional semen parameters? What key male lifestyle factors impact on fertility (focusing on obesity, heat and tobacco smoking)? Do supplementary oral antioxidants or herbal therapies significantly influence fertility outcomes for infertile men? What are the evidence-based criteria for genetic screening of infertile men? How does a history of neoplasia and related treatments in the male impact on (his and his partner's) reproductive health and fertility options? And lastly, what is the impact of varicocele on male fertility and does correction of varicocele improve semen parameters and/or fertility?WIDER IMPLICATIONSThis evidence synthesis analysis has been conducted in a manner to be considered for global applicability for the diagnosis of male infertility.

Intracellular Ca 2C stores play a central role in the regulation of cellular [Ca 2C ] i and the generation of complex [Ca 2C ] signals such as oscillations and waves. Ca 2C signalling is of particular significance in sperm cells, where it is a central regulator in many key activities (including capacitation, hyperactivation, chemotaxis and acrosome reaction) yet mature sperm lack endoplasmic reticulum and several other organelles that serve as Ca 2C stores in somatic cells. Here, we review i) the evidence for the expression in sperm of the molecular components (pumps and channels) which are functionally significant in the activity of Ca 2C stores of somatic cells and ii) the evidence for the existence of functional Ca 2C stores in sperm. This evidence supports the existence of at least two storage organelles in mammalian sperm, one in the acrosomal region and another in the region of the sperm neck and midpiece. We then go on to discuss the probable identity of these organelles and their discrete functions: regulation by the acrosome of its own secretion and regulation by membranous organelles at the sperm neck (and possibly by the mitochondria) of flagellar activity and hyperactivation. Finally, we consider the ability of the sperm discretely to control mobilisation of these stores and the functional interaction of stored Ca 2C at the sperm neck/midpiece with CatSper channels in the principal piece in regulation of the activities of mammalian sperm.Reproduction (