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For further information, see CMDT Part 23-07: Male Infertility

Key Features

Essentials of Diagnosis

  • 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 for certain health conditions

General Considerations

  • Infertility is defined as the inability of a couple to conceive a child after 12 months of sexual intercourse without contraceptive use

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

  • Approximately half of cases result from male factors

  • Evaluation is indicated at 1 year

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

Male infertility is associated with a higher risk of testicular germ cell cancer; thus, men with infertility 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

  • 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


Laboratory Tests

  • Semen analysis after 2–5 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, and prolactin

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

    • Low FSH and LH and low testosterone (hypogonadotropic hypogonadism) occur in secondary testicular failure 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

    • Aids in characterizing the testes

    • May detect a testicular mass or a varicocele

  • Transrectal ultrasound to evaluate the prostate and seminal vesicles


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