Evaluation and Treatment of the Subfertile Male

Creation Date: August 2001
Last Revision Date: August 2001
Peer Review Status: Internally Peer Reviewed

*Currently Associate Professor and Vice Chair, Medical College of Wisconsin, Department of Urology

The most common cause of male infertility is the varicocele. This may be identified in up to 40 percent of men presenting for male factor subfertility evaluation. Other identifiable factors include excurrent ductal obstruction, hypogonadism, ejaculatory dysfunction, and gonadotoxins. Treatment of these conditions often result in increased fertility, manifested by improved sperm counts and/or pregnancy.

The history is an extremely crucial part of the evaluation. Duration of infertility, previous pregnancies, and previous evaluation and/or treatment are key points. Sexual history, particularly with respect to potency and ejaculatory function, should be ascertained. Past medical history, including childhood and development, should be gathered. Specifically, any history of torsion, cryptorchidism, or trauma in childhood may play a role in the etiology. Systemic illnesses, such as diabetes mellitus, neurologic disease, such as multiple sclerosis, and previous cancer treatment, such as chemotherapy or radiation, may be involved in the fertility problem. Past surgeries may lead to the etiology, specifically retroperitoneal and bladder neck surgery. Previous hernia repair may cause vasal and secondary epididymal obstruction.

Infections can affect fertility in several ways. Febrile episodes may transiently decrease spermatogenesis, although this is usually self-limited. Mumps in adolescence may lead to mumps orchitis. Sexually transmitted diseases, specifically Chlamydia and gonorrhea, may cause ductal obstruction, as can any inflammatory condition within the testes or epididymides.

Gonadotoxins in the form of chemicals, medications (both prescription and over the counter), tobacco, alcohol, and elicit drugs, all affect spermatogenesis to some degree. The duration and amount of exposure often dictates the severity and reversibility of the spermatogenic dysfunction.

Finally, both family history and review of systems may suggest an etiology. Other family members with fertility problems, or disorders such as cystic fibrosis or androgen receptor deficiency, all may suggest a genetic etiology. Impaired visual fields, galactorrhea, frequent respiratory infections, or anosmia may also help identify both congenital or acquired causes of infertility.

The physical examination should be thorough, yet focused. Approximately 1 percent of men with subfertility have an underlying medical condition, such as testis cancer, endocrine dysfunction, or genetic disorders. The general exam should evaluate body habitus, secondary sexual characteristics, gynecomastia, and lymphadenopathy. The genital exam should exam penile curvature, location of the meatus, and phimosis/paraphimosis. Testicular exam should focus upon testicular size/volume, symmetry, consistency, and presence of masses. Asymmetry of the testis may signify a focal process, as well as varicocele. The epididymides should be examined for the presence of the entire gland, continuity with the vas deferens, induration, or tenderness. Examination of the spermatic cord, with special attention to the presence or absence of the vas deferens and/or varicoceles, is important. Finally, rectal exam to detect prostatic infection or palpable seminal vesicles may rule out ejaculatory duct/seminal vesicle obstruction.

Laboratory evaluation, used selectively, may be a cost effective adjunct to making the diagnosis. All patients should have at least two semen analyses (SFA). There should be three to five days of ejaculatory abstinence, and the samples should be collected one to two weeks apart. Because there is normal variation of sperm counts within an individual, if the two SFAs are not similar, a third should be obtained. Although there are many variables that may be examined, the most important are the sperm density (million/ml), motility (percent of moving sperm), volume and pH of ejaculate, speed of sperm movement, and the total number of motile sperm in the ejaculate. Other factors include agglutination, viscosity, and morphology. It is important to remember that the spermatogenic cycle is approximately 70 days in the human male, with another 15-20 days of transit through the ductal system. Therefore, it takes approximately 90 days for any therapeutic intervention to be reflected in the SFA.

Other laboratory assessments include a post-ejaculate urine to rule out significant retrograde ejaculation, auto-sperm antibodies, and functional assays, such as sperm penetration assay, cervical mucous migration, post-coital test, and hemi-zona assay. Many of these are lab dependent, and are beyond the scope of this discussion.

Hormonal evaluation should be limited to those men with severe oligospermia (<10 million/ml). Studies have shown that it is extremely rare to detect significant endocrine abnormalities in men with mild to moderate oligospermia and normal physical examination. Endocrine studies should include total testosterone to evaluate Leydig cell function, and follicle stimulating hormone (FSH) to evaluate Sertoli cell/germ cell function. Leutinizing hormone (LH), estradiol, and prolactin may also be obtained, although this is not a routine, and is usually obtained in a pooled sample in the case of abnormal hormonal studies.

The treatment of male factor infertility is directed towards treating reversible causes, halting damaging factors, and assisting in advanced reproductive techniques. Varicoceles, dilated veins around the testicles, are the most common cause of male subfertility. The success rate following treatment results in improvement in seminal parameters in up to 70 percent of men, with a 35-40 percent unassisted pregnancy rate.

Correction of obstruction, whether from vasectomy or other factors, results in return of sperm to the ejaculate in as many as 90 percent or more of men. Pregnancy rates as high as 65 percent have been obtained. We currently obtain sperm for freezing at the time of surgical correction; thus, if the procedure is not technically successful, the couple has frozen sperm that may be used in conjunction with in vitro fertilization.

Treatment of hormonal abnormalities typically results in moderate pregnancy rates, even when sperm counts do not improve dramatically. The secondary benefits of improved libido and energy make evaluation and treatment of hormonal abnormalities worthwhile.

Finally, emperic treatment of male factor infertility is often successful in improving sperm counts, although no randomized studies have shown a significant improvement in pregnancy rates. Most of these medications have little to minimal side effects, but close monitoring of blood levels is important. It is also important to remind the patient that it may take at least four to six months to see any improvement.

In the era of assisted reproductive technology, it is tempting to bypass evaluation of the male partner and proceed to more aggressive treatments, such as in vitro fertilization. However, this is a disservice to many couples, as identification and treatment of the male partner often results in pregnancy without other intervention, as well as correction of any underlying disorders. Therefore, it is reasonable to evaluate the male partner of all infertile couples prior to embarking upon further therapy.

See related Patient Textbooks about Urology.

See related Patient Topics Infertility, Men's Health, Pregnancy and Reproduction, Urology or Women's Health.

See related Provider Textbooks about Urology.

See related Provider Topics Infertility, Men's Health, Pregnancy and Reproduction, Urology or Women's Health.

All contents copyright © 1992-2004 the Author(s) and The University of Iowa. All rights reserved.

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