Male Infertility

1. See Also
   1. Infertility
2. Epidemiology
   1. InfertilityPrevalence: 15% of couples
   2. Male factors contribute to two thirds of Infertility
      1. One third of Infertility cases due to male only
      2. One third of Infertility cases due to both partners
3. Causes
   1. Idiopathic (40-50%)
   2. Primary Hypogonadism (Testicular Failure): 30-40%
      1. Varicocele (40%)
      2. Medication of drug use (See Gonadotoxin)
      3. Exposures
         1. Excessive Heat Exposure (hot tubs, saunas)
         2. Toxic chemicals
         3. Pesticides
      4. Testicular surgeries or injury
      5. Cryptorchidism
      6. Chromosomal abnormality (e.g. Klinefelter Syndrome)
      7. Genital radiation or Chemotherapy
      8. Orchitis
         1. Post-pubertal mumps
         2. Sexually Transmitted Disease
   3. Obstructive azoospermia or altered transport (10-20%)
      1. Erectile Dysfunction
      2. Retrograde ejaculation or other dysfunction
      3. Hypospadias
      4. Vas deferens absence (e.g. Cystic Fibrosis)
      5. Epididymal absence
   4. Secondary Hypogonadism (Hypothalamic-Pituitary Axis):2%
      1. Hypogonadotropic Hypogonadism
      2. Androgen Excess (e.g. Anabolic Steroids)
      3. Estrogen excess (e.g. tumor)
      4. Pituitary adenoma
      5. Infiltrative Disorder
         1. Sarcoidosis
         2. Tuberculosis
4. History
   1. See Infertility for coital factor history
   2. Comorbid condition
      1. Diabetes Mellitus
      2. Prior surgeries
         1. Cryptorchidism
         2. Testicular Torsion
         3. Genitourinary ot retroperitoneal surgery
   3. Social history
      1. Gonadotoxin use
   4. Review of systems
      1. Anosmia (Kallmann's Syndrome)
      2. Chronic Sinusitis and Bronchiectasis
         1. Young's Syndrome
         2. Kartagener's Syndrome (also with Situs inversus)
      3. Visual field defect, Galactorrhea (Pituitary lesion)
5. Examination
   1. Signs of Endocrinopathy (Hypogonadotropic Hypogonadism)
      1. Thyromegaly
      2. Dermatologic changes in hair or fat
   2. Genital exam
      1. Hypospadias
      2. Assess testicular size
         1. Normal >20 cm or >4 cm in diameter
      3. Assess vas deferens and epididymis
      4. Varicocele
   3. Rectal exam
      1. Assess Prostate Gland for Nodules or swelling
6. Evaluation of Male Infertility
   1. Step 1: Semen Analysis (2 samples, 2 weeks apart)
      1. Normal Semen Analysis
         1. Evaluate for Female Infertility
         2. Discontinue Gonadotoxins
         3. Discontinue lubricant use with intercourse
         4. Reevaluate timing of intercourse during Ovulation
      2. Abnormal Semen Analysis
         1. Varicocele present: Refer to Urology for repair
         2. No Varicocele present: Go to Sept 2a Below
      3. Leukospermia (>1 million WBCs per ml)
         1. Diagnosis requires additional staining of WBCs
         2. May be consistent with Prostatitis
         3. Treat with Doxycycline 100 mg PO bid for 2 weeks
         4. Repeat Semen Analysis after treatment
      4. Azoospermia (No sperm present): 10-15% of cases
         1. Refer to Male Infertility clinic
         2. Further evaluation will distinguish causes
            1. Vas deferens abnormality (absence, Vasectomy)
            2. Hypogonadotropic Hypogonadism
            3. Testicular abnormality
   2. Step 2a: Is semen volume <1 ml?
      1. No: Semen volume normal: Go to Step 3
      2. Yes: Semen volume <1 ml: Go to Step 2b
   3. Step 2b: Obtain post-ejaculatory urine analysis
      1. Positive: Retrograde Ejaculation
         1. Pseudophedrine 60 mg PO tid
      2. Negative: Possible ejaculatory duct obstruction
         1. Follicle Stimulating Hormone (FSH)
         2. Refer to Urology (and Transrectal Ultrasound)
   4. Step 3: Evaluate sperm concentration
      1. Sperm >10 million/ml
         1. Refer to Male Infertility clinic
      2. Sperm <10 million/ml
         1. Refer to Male Infertility clinic
         2. Follicle Stimulating Hormone (FSH)
         3. Serum Testosterone
         4. Genetic counseling for sperm <5 million/ml
7. References
   1. (2004) Fertil Steril 82(Suppl 1):S102-6
   2. De Krester (1997) Lancet 349:787-90
   3. Kolettis (2003) Am Fam Physician 67(10):2165-72
   4. Kolettis (2001) J Urol 166:178-80
   5. Sharlip (2002) Fertil Steril 77:873-82
   6. Sigman (1997) Urology 50:659-64