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For further information, see CMDT Part 25-07: 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, COVID-19)

    • 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, tobacco, 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 (decreased 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 2–5 days of ejaculatory abstinence (see Infertility, Female)

    • Sperm concentration

      • Oligozoospermia is the presence of < 15 million sperm/mL in the ejaculate

      • Azoospermia is the complete absence of sperm

    • Semen volume

      • Normal semen volume should be ≥ 1.5 mL

      • Lesser volumes may be due to retrograde ejaculation, ejaculatory duct obstruction, congenital bilateral absence of the vasa deferentia, or hypogonadism

    • Sperm motility and morphology

      • Normal: > 39% motile cells and > 3% normal morphology

      • Abnormal motility (asthenozoospermia) may result from varicocele, antisperm antibodies, infection, abnormalities of the sperm flagella, or ejaculatory duct obstruction

      • Abnormal morphology may result from a varicocele, infection, or exposure to gonadotoxins (eg, tobacco, marijuana)

  • Endocrinologic evaluation

    • Warranted if

      • Sperm concentration is < 10 million sperm/mL or

      • History and physical examination suggest ...

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