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Key Features

Essentials of Diagnosis

  • Male partner factors contribute to approximately 50% of infertility cases

  • Causes include decreased or absent sperm production or function, or obstruction of the male genital tract

  • Abnormal semen quality may indicate poor health or increased risk for certain health conditions

General Considerations

  • Infertility is defined as the inability of a couple to conceive a child after 1 year of sexual intercourse without contraceptive use

  • Infertility affects 15–20% of couples who wish to conceive

  • Approximately 50% of cases result from male factors

  • Simultaneous evaluation of the female partner is warranted (see Infertility, Female)

  • Evaluation is indicated at 1 year

  • Male infertility is associated with a higher risk of testicular germ cell cancer; thus, these men should be counseled appropriately and taught testicular self-examination

Clinical Findings

Symptoms and Signs

  • History

    • Prior testicular insults (torsion, cryptorchism, trauma)

    • Infections (mumps orchitis, epididymitis, sexually transmitted infection)

    • Environmental factors (excessive heat, radiation, chemotherapy, prolonged pesticide exposure)

    • Medications

      • Testosterone, finasteride, cimetidine, selective serotonin reuptake inhibitors (SSRIs), and spironolactone may affect spermatogenesis

      • Phenytoin may lower follicle-stimulating hormone (FSH)

      • Sulfasalazine and nitrofurantoin may affect sperm motility

      • Tamsulosin may cause retrograde ejaculation

    • Drugs (eg, alcohol, marijuana)

    • Sexual function, frequency and timing of intercourse, use of lubricants, and each partner's previous fertility are important

    • Loss of libido, headaches, visual disturbances, or galactorrhea may indicate a pituitary tumor

  • Past medical or surgical history

    • Chronic disease, including obesity; cardiovascular, thyroid or liver disease (abnormalities of spermatogenesis)

    • Diabetes mellitus (decreased spermatogenesis, retrograde or anejaculation)

    • Radical pelvic or retroperitoneal surgery (absent seminal emission secondary to sympathetic nerve injury)

  • Physical examination: signs of hypogonadism, such as underdeveloped sexual characteristics, diminished male pattern hair distribution (axillary, body, facial, pubic), body habitus, gynecomastia, and obesity

  • Evaluate testicular size (normal size ~4.5 × 2.5 cm, volume 18 mL)

  • Examine for varicocele in the standing position, with Valsalva maneuver

  • Palpate the vas deferens, epididymis, and prostate

Diagnosis

Laboratory Tests

  • Semen analysis after 3 to 5 days of ejaculatory abstinence (see Infertility, Female)

  • Endocrinologic evaluation

    • Initial testing should include serum testosterone and FSH

    • Specific abnormalities in these hormones should prompt additional testing, including serum LH, prolactin, and estradiol

    • Elevated FSH and LH and low testosterone (hypergonadotropic hypogonadism) in primary testicular failure

    • Low FSH and LH and low testosterone in secondary testicular failure (hypogonadotropic hypogonadism) of hypothalmic or pituitary origin

    • Elevation of serum prolactin may indicate the presence of prolactinoma

    • Elevation of estradiol may impair normal gonadotropin production and impact normal spermatogenesis

Imaging Studies

  • Scrotal ultrasound for varicocele

  • Transrectal ultrasound to evaluate the prostate and seminal vesicles

  • MRI

    • Imaging of the sella turcica should be performed in men with markedly elevated prolactin or hypogonadotrophic hypgonadism to evaluate the anterior pituitary gland

    • Imaging of the pelvis and scrotum should ...

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