Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 23-07: Male Infertility + Key Features Download Section PDF Listen +++ +++ Essentials of Diagnosis ++ Male infertility is common, contributing 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 regular, unprotected sexual intercourse 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 Download Section PDF Listen +++ +++ 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 vasa deferentia and epididymides + Diagnosis Download Section PDF Listen +++ +++ Laboratory Tests ++ Semen analysis after 3 to 5 days of ejaculatory abstinence (see Infertility, Female) Evaluation of the hypothalamic-pituitary-gonadal axis Initial testing should include serum testosterone and FSH Specific abnormalities in these hormones should prompt additional testing, including serum LH, and prolactin 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 hypothalamic 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 Can aid in characterizing the testes May detect a testicular mass or a subclinical varicocele Transrectal ultrasound to evaluate the prostate and seminal vesicles MRI Head: Imaging of the sella turcica should be performed in men with markedly elevated prolactin or hypogonadotrophic hypogonadism to evaluate the anterior pituitary gland Pelvis and scrotum: Consider imaging in men for whom the testes cannot be identified in the scrotum by physical examination or ultrasound Imaging of abdomen: Consider in men with unilateral absence of the vas deferens to exclude absence of the ipsilateral kidney +++ Diagnostic Procedures ++ Patients with low volume ejaculation should have post-ejaculation urine samples centrifuged and analyzed to exclude retrograde ejaculation Men with sperm concentrations less than 10 million/mL should consider testing for Y chromosome microdeletions and a karyotypic abnormalities Gene deletions from the long arm of the Y chromosome may cause azoospermia or oligozoospermia with age-related decline in spermatogenesis that is transmissible to male offspring Karyotyping may reveal Klinefelter syndrome (XXY male) + Treatment Download Section PDF Listen +++ +++ Medications ++ Genitourinary tract infections should be treated with antibiotics +++ ENDOCRINE THERAPY ++ Hypogonadotropic hypogonadism Chorionic gonadotropin, 2000 international units intramuscularly three times weekly, once primary pituitary disease has been excluded or treated If sperm counts fail to rise after 12 months, recombinant FSH therapy may be initiated (150 international units subcutaneously three times weekly) +++ EJACULATORY DYSFUNCTION THERAPY ++ Alpha-adrenergic agonists (eg, pseudoephedrine, 60 mg three times daily orally) or imipramine, 25 mg three times daily orally Collect post-ejaculation urine for intrauterine insemination Electroejaculation or vibratory stimulation in cases of absent emission +++ Surgery ++ Varicocelectomy Surgical ligation is accomplished via a subinguinal incision with the aid of a surgical microscope Doppler ultrasound is the gold standard approach given its high success and low complication rates Percutaneous venographic embolization of varicoceles is feasible but incurs both radiation and intravenous contrast exposure Ductal obstruction may be corrected by transurethral resection of the ducts in the prostatic urethra Obstruction of the vas deferens after vasectomy may be managed by microsurgical vasectomy reversal or by surgical sperm retrieval in combination with in vitro fertilization +++ Therapeutic Procedures ++ Education Healthy lifestyle habits should be reinforced, including diet, exercise, and avoidance of gonadotoxins (such as tobacco smoke, marijuana, excessive alcohol) Proper timing for intercourse Avoidance of spermicidal lubricants Removal of toxins or medications Assisted reproductive techniques: intrauterine insemination, in vitro fertilization, and intracytoplasmic sperm injection (ICSI) + Outcome Download Section PDF Listen +++ +++ When to Refer ++ Couples with infertility or who are concerned about fertility potential Men with known genital insults (cryptorchidism, varicocele) or genetic diagnoses (cystic fibrosis, Klinefelter syndrome) that preclude natural fertility Reproductive-aged men with newly diagnosed cancer or other disease that may require cytotoxic therapies with interest in fertility preservation + References Download Section PDF Listen +++ + +Burnett AL et al. Erectile dysfunction: AUA guideline. J Urol. 2018 Sep;200(3):633–41. [PubMed: 29746858] + +Duca Y et al. Current and emerging medical therapeutic agents for idiopathic male infertility. Expert Opin Pharmacother. 2019 Jan;20(1):55–67. Erratum in: Expert Opin Pharmacother. 2018 Dec 18:1. [PubMed: 30407872] + +Esteves SC et al. Intracytoplasmic sperm injection for male infertility and consequences for offspring. Nat Rev Urol. 2018 Sep;15(9):535–62. [PubMed: 29967387] + +Oehninger S et al. Limits of current male fertility testing. Fertil Steril. 2019 May;111(5):835–41. [PubMed: 30975387] + +Okutman O et al. Genetic evaluation of patients with non-syndromic male infertility. J Assist Reprod Genet. 2018 Nov;35(11):1939–51. [PubMed: 30259277] + +Rajanahally S et al. The relationship between cannabis and male infertility, sexual health, and neoplasm: a systematic review. Andrology. 2019 Mar;7(2):139–47. [PubMed: 30767424]