Table 1. Practice recommendations for safe delivery of care to male infertility patients during the SARS-CoV-2 pandemic* in Brazil.

Recommendation	Additional remarks
1. Before any service is provided, active SARS-CoV-2 infections and suspected cases should be excluded.	Patient testing should include RT-PCR and/or blood antibody, preferably using ELISA. Ideally, only samples from patients with negative PCR results or who have acquired IgG antibodies through past infection or herd immunity should be treated or have sperm cryopreserved.
2. Andrological services (e.g., diagnostic semen analysis, sperm functional tests and sperm cryopreservation) should not only be available for oncological patients, but also for the group of ‘time-sensitive’ patients.	i. Severe male infertility under medical or surgical treatment aiming at improving sperm quantity or quality (e.g., patients with non-obstructive azoospermia (NOA) or cryptozoospermic/severe oligozoospermia, including post-varicocele repair, and those with evidence of loss of patency after successful surgical reconstruction of the reproductive tract). ii. Men at reproductive age affected by inflammatory diseases or systemic inflammatory diseases (SADs), i.e., before initiation of gonadotoxic therapy or if under the ‘fertility window’ achieved after temporary (at least three months) discontinuation of therapy. iii. Infertile men older than 50 years, in particular those with comorbidities who are candidates for intrauterine insemination (IUI) or assisted reproductive technology (ART), and who are concerned about the risk of acquiring SARS-CoV-2 and/or the possibility of using anti-viral therapy with possible gonadotoxic effects.
3. Surgical sperm retrieval and cryopreservation of testicular sperm or testicular tissue should be considered in specific situations involving men with NOA undergoing medical therapy to improve spermatogenesis.	In this setting, procedures should be performed only for PCR negative or IgG positive patients. The use of electrocautery should be used with caution or used with an air-aspiration negative pressure device; the surgical smoke might carry the virus in case a patient is infected but asymptomatic, despite a negative testing. Only essential staff should stay in the operating theater, and personal protection measures should be strictly followed as determined by the local healthcare authorities. In closed-controlled air systems, the airflow might produce an increase in the viral spread from potential asymptomatic patients. Thus, special attention should be given to air quality control, including the use of air filtration systems, particularly in surgical and laboratory areas.
4. Encourage telemedicine and phone counseling for providing instructions about testing and sperm banking.	None.
5. Adherence to infection prevention recommendations is of utmost importance for patients and health practitioners alike.	This advice includes the use of appropriate personal protective equipment (PPE) by healthcare staff, adherence to social distancing measures for healthcare staff and patients, and space out appointments so that no patients are waiting together in the clinic waiting area. The importance of training staff (receptionists, nurses, technicians, doctors) on PPE needs and usage is highlighted (https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinic-preparedness.html).
6. The precautionary principle and good laboratory practices should be strictly applied when handling the seminal fluid by in the andrology and embryology laboratories.	This advice includes (i) use of class II safety cabinets, which gives protection to the specimen handled as well as the operator performing the work, (ii) use of high-security vials for sperm cryopreservation, as routinely recommended by certified andrology labs and sperm banks, and (iii) additional measures to protect the specimens from laboratory staff (e.g., use of googles, N95 mask, gown/coverall, and gloves) –who might be infected but asymptomatic for SARS-CoV-2.
7. Technicians/biologists should, ideally, be tested by RT-PCR and/or ELISA blood antibody testing before resuming activities, and only staff with negative results or who became IgG positive or have acquired herd immunity should perform laboratory duties.	Although the risk is minimal, if the staff that manipulated specimens get infected during the pandemic and is actively working in the lab, an aliquot of cryopreserved semen samples should be tested (e.g., by RT-PCR) because semen samples, cryopreservation media, cryovials, and pipette tips could be contaminated by asymptomatic PCR-positive biologists and technicians.
8. A thorough discussion between patients and healthcare providers should be made for responsible shared decisions.	This advice includes the development and use of dedicated informed consent, detailing the risks of attending the facility and being treated or banking of sperm during the SARS-CoV-2 pandemic. Furthermore, explanatory material should be made available for patients. Psychological support and financial aid might be offered to those in need. The latter might be particularly relevant to patients under economic pressure due to the pandemic who need to afford the costs of semen analysis, sperm functional tests and sperm banking.
9. Advanced planning should guide the continuation of andrological services.	Working groups and quality managers should determine which patients to prioritize and how working lists should be filled, including staff scheduling. A multi-professional group including reproductive urologists, andrologists, technicians and other relevant health care professionals should work together to provide the optimal care in a safe environment.

* Esteves SC, Lombardo F, Garrido N, et al. SARS-CoV-2 pandemic and repercussions for male infertility patients: A proposal for the individualized provision of andrological services [published online ahead of print, 2020 May 1]. Andrology. 2020;10.1111/andr.12809. doi:10.1111/andr.12809

RT-PCR: Reverse-Transcriptase Polymerase Chain Reaction; ELISA: Enzyme Linked Immuno Sorbent Assay; IgG: Immunoglobulin class G