A male factor is responsible for infertility in about 20 percent of infertile couples and is a contributing factor in another 30 to 40 percent. Both partners of an infertile couple should be evaluated simultaneously. Screening for causes of infertility is generally initiated after one year of unprotected sexual intercourse, although testing may begin earlier if a risk for infertility exists or if the man suspects that he is infertile. Sharlip and associates, members of the Male Infertility Best Practice Policy Committee of the American Urology Association, developed a guide for evaluating infertile men based on current professional literature, clinical experience, and expert opinion.
Initial screening should include a reproductive history and two semen analyses done at least one month apart, if possible. Infertility is possible even after previous fertility. If the couple's reproductive history is abnormal, the semen analysis is abnormal, or the couple has unexplained infertility, the man should be evaluated by a urologist or another physician specializing in male reproduction. A complete examination includes a more thorough medical history, genital and endocrinologic physical examinations, and more precise testing, when indicated. Tests may include sex hormone quantitations, postejaculatory urinalysis to look for sperm that might represent retrograde ejaculation, transrectal ultrasonography to look for ejaculatory duct obstruction, scrotal ultrasonography, genetic screening, and specialized semen and sperm testing.
Specific findings that are more common in infertile men include azoospermia and varicocele. Azoospermia, the complete absence of sperm from the ejaculate, occurs in 10 to 15 percent of infertile men. Causes (see accompanying table) may be pre-testicular, testicular, or post-testicular; therefore, further evaluation should focus on conditions such as (1) endocrine abnormalities, which are rare, (2) disorders of spermatogenesis specific to the testes, and (3) ejaculatory dysfunction or obstruction of sperm transport to the urethral meatus. Some of the more common anatomic conditions associated with azoospermia include (1) absence of the vas deferens, (2) bilateral testicular atrophy, and (3) ductal obstruction. Varicoceles are present in about 40 percent of infertile men. The resultant increase in testicular temperature and venous reflux may adversely affect sperm production. Most significant varicoceles are palpable on examination. Genetic testing may also be appropriate in some patients.
|Possibly reversible conditions (e.g., varicocele, obstructive azoospermia)|
|Conditions that are not reversible but in which viable sperm are available (e.g., inoperable obstructive azoospermia, ejaculatory dysfunction)|
|Conditions that are not reversible and in which there are inadequate or no viable sperm available (e.g., hypogonadism)|
|Serious, potentially life-threatening conditions (e.g., testicular cancer, pituitary cancer)|
|Genetic abnormalities that affect fertility (e.g., cystic fibrosis gene mutations associated with absence of the vas deferens, chromosome abnormalities resulting in impaired testicular function)|
Treatment of men with infertility varies according to cause and circumstances. Obstructive azoospermia may be resolved by microsurgery, and repair or percutaneous embolization may cure varicocele-related infertility when no other cause is identified. Sperm retrieval techniques allow for good results with in vitro fertilization in men with obstructive azoospermia, when surgical repair is unsuccessful or is not an option, and may improve outcomes if the female partner has advanced age or has infertility problems herself.
editor's note: For many years, we have recognized that a good sexual history reveals much about our patients' health and risk of sexually transmitted diseases. More recently, the impact of sexual health on emotional and relationship issues has been revealed, with these, in turn, affecting physical well-being. Discussions about sexual activity are more common during office visits as we become more comfortable initiating a dialog and our patients learn to ask us for assistance and advice. These discussions can be initiated while we obtain a social history, during a review of systems, immediately before or after the genital physical examination, or any time the physician feels comfortable. We need information and a level of comfort to be able to respond to patients' questions in a useful manner. These policies for male infertility evaluation offer helpful information about discussing fertility issues with patients and educating them about the appropriate evaluation and potential causes of their problem.—r.s.