Male Infertility Work Up

Approximately 15% of couples are unable to conceive after one year of unprotected intercourse. A male factor is solely responsible for about 20% of infertile couples and contributory in another 30-40%. If a male infertility factor is present, it is almost always defined by the finding of an abnormal semen analysis, although other male factors may play a role even when the semen analysis is normal.

The minimum full evaluation for male infertility for every patient should include a complete medical history, physical examination by a urologist and at least two semen analyses.

> A complete medical and surgical history including chronic diseases, surgeries since childhood, trauma.

> Review of medications (prescription and non-prescription) and allergies

> Lifestyle exposures like smoking, alcohol, recreational drugs

> Family reproductive history

> A survey of past infections such as sexually transmitted diseases and respiratory infections.

> A general physical examination

> Secondary sexual characteristics include body habitus, hair distribution, and breast development

> Examination of the male genital system for testicular size, epididymis, vas, the location of the urethral opening, the presence of infections or any swellings.

Semen analysis is the cornerstone of the laboratory evaluation of the infertile male and helps to define the severity of the male factor. Normal Semen parameters according to recent WHO criteria are listed below: Semen analysis is performed with abstinence of 3 to 5 days on two occasions. Usually, if the above tests are normal, no further evaluation is required. Any abnormality of the above tests, or in case of unexplained infertility or repeated treatment failures, further advanced tests are warranted.

Other procedures and tests for assessing male fertility

An initial endocrine evaluation should include at least serum testosterone and FSH. It should be performed if there is

> An abnormally low sperm concentration, especially if less than 10 million/ml

> Impaired sexual function

> Clinical findings suggestive of a specific endocrinopathy

Other hormonal assays include LH, Inhibin B, prolactin, TSH, SHBG. All these tests may together help to determine the cause of abnormal spermatogenesis or infertility.

A post-ejaculatory urinalysis should be performed in patients with ejaculate volumes of less than 1 ml, except in patients with bilateral vasal agenesis or clinical signs of hypogonadism to rule out retrograde ejaculation of sperms into the urinary bladder. Significant numbers of sperm must be found in the urine of patients with low ejaculate volume oligospermia to suggest the diagnosis of retrograde ejaculation

Transrectal ultrasonography is indicated in azoospermic patients with palpable vasa and low ejaculate volumes to determine if ejaculatory duct obstruction exists. Scrotal ultrasonography is indicated in those patients in whom physical examination of the scrotum is difficult or inadequate or in whom a testicular mass or small varicocele is suspected.

This test is done in cases of repeated treatment failures or unexplained infertility. The results correlate fairly well with the potential of sperm from a given male to produce embryos that would be sufficiently “competent” to produce a live birth. Based on the level of DNA integrity, the line of successful treatment can be suggested. Test interpretation is as follows:

> Less than or equal to 15 per cent DFI: Excellent to Good fertility potential

> 15 per cent to 25 per cent DFI: Good to Fair fertility potential

> Greater than 25 per cent DFI: Fair to Poor fertility potential