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  • Infertility is common, and male factors are present in 50% of cases.

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

  • Abnormal semen quality is a risk factor for infertility and may indicate poor health or increased risk of certain health conditions.


Infertility is disease that results in the failure of a couple to conceive a child after 12 months of sexual intercourse without contraceptive use. It affects 15–20% of US couples and half of cases result from male factors. The evaluation of both partners is critical for optimizing treatment. Following a detailed history and physical examination, a semen analysis should be performed at least twice, on two separate occasions (Figure 23–2). Because spermatogenesis requires approximately 75 days, it is important to review health events and gonadotoxic exposures from the preceding 3 months. Male infertility is associated with a higher risk of testicular germ cell cancer and with a higher rate of medical comorbidity. These men should be counseled and screened appropriately and taught testicular self-examination.

Figure 23–2.

Couple-based approach to evaluation and treatment of male factor infertility. FNA, fine-needle aspiration.


A. Symptoms and Signs

The history should include prior testicular insults (torsion, cryptorchidism, trauma), infections (mumps orchitis, epididymitis, sexually transmitted infections), environmental factors (excessive heat, radiation, chemotherapy, prolonged pesticide exposure), medications (testosterone, finasteride, cimetidine, SSRIs, and spironolactone may affect spermatogenesis; phenytoin may lower FSH; sulfasalazine and nitrofurantoin affect sperm motility; tamsulosin causes retrograde ejaculation), and other drugs (alcohol, tobacco, marijuana). Sexual function, frequency and timing of intercourse, use of lubricants, and each partner’s previous fertility are important. Past medical and surgical history should be surveyed for chronic disease, including obesity, cardiovascular, thyroid, or liver disease (decreased spermatogenesis); diabetes mellitus (decreased spermatogenesis, retrograde or anejaculation); or radical pelvic or retroperitoneal surgery (absent seminal emission secondary to sympathetic nerve injury).

Physical examination should assess features of hypogonadism: underdeveloped sexual characteristics, diminished male pattern hair distribution (axillary, body, facial, pubic), body habitus, gynecomastia, and obesity. Testicular size should be noted (normal size approximately 4.5 × 2.5 cm, volume 18 mL). Varicoceles are abnormally dilated, refluxing veins of the pampiniform plexus that can be identified in the standing position by gentle palpation of the spermatic cord and, on occasion, may only be appreciated with the Valsalva maneuver. The vasa deferentia and epididymides should be palpated (absence of all or part of one or both of the vasa deferentia may indicate the presence of congenital bilateral or unilateral absence of the vasa deferentia).

B. Laboratory Findings

Semen analysis should be performed after 2–5 days of ejaculatory abstinence. The specimen should ...

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