Infertility, Male

Key Features

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

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

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 ...