II. Epidemiology

  1. Infertility Prevalence: 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

III. 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
      1. Y Deletions
        1. Small Testes, low Sperm Count
      2. Klinefelter Syndrome (XXY)
        1. Learning Disorders, Tall Stature, Gynecomastia
        2. Small Testes, Low Sperm Count
        3. Low testosterone, increased FSH
      3. Cystic Fibrosis is associated with vas deferens absence
        1. Related genes: CFTR gene, 5T Allele
    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. Hemochromatosis
    6. Kallman Syndrome
    7. Infiltrative Disorder
      1. Sarcoidosis
      2. Tuberculosis

IV. 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 (Medications that Impair Male Fertility)
  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)

V. Exam

  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

VI. Evaluation

  1. Step 1: Semen Analysis
    1. Obtain 2 samples at 2-3 months apart
      1. Three month interval between tests reflects a >2 month sperm generation time
    2. Normal Semen Analysis
      1. Evaluate for Female Infertility
      2. Discontinue Gonadotoxins
      3. Discontinue lubricant use with intercourse
      4. Reevaluate timing of intercourse during Ovulation
    3. Abnormal Semen Analysis
      1. Varicocele present
        1. Consider referral to Urology for repair
        2. Inadequate data to suggest corrective surgery improves conception rates
          1. Baazeem (2011) Eur Urol 60(4): 796-808 [PubMed]
      2. No Varicocele present
        1. Go to Step 2a Below
    4. 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
    5. 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 <1.5 ml?
    1. No: Semen volume normal: Go to Step 3
    2. Yes: Semen volume <1.5 ml: Go to Step 2b
  3. Step 2b: Obtain post-ejaculatory urine analysis
    1. Positive: Retrograde Ejaculation
      1. Consider Pseudophedrine 60 mg orally three times daily
    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 >10-15 million/ml
      1. Refer to Male Infertility clinic
    2. Sperm <10-15 million/ml (Oligospermia)
      1. Suggests Hypogonadism
        1. Primary Hypogonadism presents with increased FSH and decreased Serum Testosterone
        2. Secondary Hypogonadism presents with decreased FSH and decreased Serum Testosterone
      2. Refer to Male Infertility clinic
      3. Follicle Stimulating Hormone (FSH)
      4. Serum Testosterone
      5. Serum Prolactin
      6. Genetic counseling for sperm <5 million/ml

VII. Management: Non-specific options

  1. In Vitro Fertilization (with or without intracytoplasmic sperm injection)
    1. Standard approach to Male Infertility without reversible cause
  2. Hormonal agents
    1. Antiestrogens
    2. Gonadotropins
    3. Attia (2013) Cochrane Database Syst Rev (8): CD005071 [PubMed]
  3. Antioxidants
    1. Zinc supplementation
    2. Vitamin E Supplementation
    3. L-Carnitine supplementation
    4. Showell (2011) Cochrane Database Syst Rev (1): CD007411 [PubMed]

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Ontology: Male infertility (C0021364)

Definition (MEDLINEPLUS)

Infertility is a term doctors use if a man hasn't been able to get a woman pregnant after at least one year of trying. Male infertility can result from physical problems, hormone problems, and lifestyle or environmental factors.

About a third of the time, infertility is because of a problem with the man. One third of the time, it is a problem with the woman. Sometimes no cause can be found.

If you suspect you are infertile, see your doctor. There are tests that may tell if you have fertility problems. When it is possible to find the cause, treatments may include medicines, surgery, or assisted reproductive technologies. Happily, two-thirds of couples treated for infertility are able to have babies.

Dept. of Health and Human Services Office on Women's Health

Definition (MSH) The inability of the male to effect FERTILIZATION of an OVUM after a specified period of unprotected intercourse. Male sterility is permanent infertility.
Concepts Disease or Syndrome (T047)
MSH D007248
ICD9 606.9, 606
ICD10 N46 , N46.9
SnomedCT 155924001, 198018002, 2904007
English Infertility, Male, Male infertility, unspecified, Male infertility, male infertility, male infertility (diagnosis), Infertility male, Male infertility NOS, Infertility, Male [Disease/Finding], Male Infertility, Male infertility NOS (disorder), infertility; male, Male infertility, NOS, Male infertility (disorder), Male infertility (finding), Male infertility NOS (finding), Infertility, male, Infertility;M
Dutch niet-gespecificeerde mannelijke onvruchtbaarheid, infertiliteit; man, Infertiliteit bij man, onvruchbaarheid mannelijk, Infertiliteit van de man
German maennliche Infertilitaet, unspezifisch, Sterilitaet beim Mann, Unfruchtbarkeit des Mannes, Fruchtbarkeitsstörung des Mannes, Infertilität, männliche, Unfruchtbarkeit, männliche
Italian Infertilità maschile, non specificata, Infertilità maschile
Portuguese Infertilidade masculina NE, Infertilidade masculina, Infertilidade Masculina
Spanish Esterilidad masculina no especificada, infertilidad masculina, SAI (hallazgo), infertilidad masculina (hallazgo), infertilidad masculina, SAI, infertilidad masculina, SAI (trastorno), infertilidad masculina, Esterilidad masculina, infertilidad masculina (trastorno), Infertilidad Masculina
Japanese 男性不妊症、詳細不明, 男性不妊症, ダンセイフニンショウショウサイフメイ, ダンセイフニンショウ
Swedish Barnlöshet hos män
French Infertilité chez l'homme, non précisée, Infertilité masculine, Infertilité de l'homme, Infertilité mâle
Czech infertilita mužská, Mužská neplodnost, blíže neurčená, Mužská neplodnost
Finnish Miehen hedelmättömyys
Russian BESPLODIE MUZHSKOE, STERIL'NOST' MUZHSKAIA, БЕСПЛОДИЕ МУЖСКОЕ, СТЕРИЛЬНОСТЬ МУЖСКАЯ
Korean 남성 불임증
Croatian NEPLODNOST MUŠKARCA
Polish Niepłodność męska
Hungarian Férfi infertilitas, Nem meghatározott férfi infertilitas
Norwegian Mannlig infertilitet