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For further information, see CMDT Part 23-07: Male Infertility
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Essentials of Diagnosis
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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 for certain health conditions
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General Considerations
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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)
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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
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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
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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
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