Male Infertility 4

Question 1

What are important areas to evaluate in terms of patient history in terms of male infertility?

Answer 1

• History of infertility: Duration, prior pregnancies, previous evaluation, partner evaluation.
• Sexual history: Timing of intercourse, erectile dysfunction, frequency, lubricants
• Childhood and development: Congenital anomalies, testicular torsion, trauma, puberty onset.
• Medical history: Systemic illness, MS, DM, h/o cancer, etc.
• Surgical history: Orchiectomy, herniorrhaphy, pelvic or scrotal procedures, TURP, RPLND
• Infections: Virile, febrile, mumps orchitis, STD, TB.
• Gonadotoxins: Pesticides, Heat, Radiation, Drugs (ie:cimetidine, sulfasalazine, marijuana)
• Family History/Genetic History: Cystic Fibrosis mutations, Y Chromosome microdeletions, karyotype abnormalities.
• Review of Systems: Respiratory infections, anosmia, impaired visual fields.

Question 2

What are the important physical exam findings for male infertility?

Answer 2

• General Appearance: Evidence of systemic illness, chronic disease.
• Body Habitus: Androgen deficiency characteristics.
• Thyroid Gland: Nodules, enlarged gland.
• Chest: Gynecomastia
• Abdomen: Surgical scars (hernia, orchidopexy)
• Penis/Urethra: penile curvature, hypospadias. Urethral discharge,
• Scrotum: Testicular sizeà20 cc volume , 4 cm length x 2 cm width is normal; consistency, varicocele, epididymis and vasal architecture
• Digital Rectal Exam: The prostate is a reproductive organ (Prostatic cyst, prostatic induration, etc.)

Question 3

What are the routine laboratory tests for male infertility?

Answer 3

• Laboratory testing is an essential component of male evaluation. This should consist of:
  
  • FSH, Testosterone
  • LH and prolactin if either Testosterone or FSH is low
  • Estradiol if patient is obese
  • Semen Analysis x 2: 48-72 hours of abstinence should precede each collection.

Question 4

What are additional laboratory tests done for male infertility (not routine).

Answer 4

• Semen WBC: Evaluate for GU tract inflammation. Semen culture if (+).
• Immunobead Assay for Antisperm Antibodies: Used primarily in patients with poor motility (
• Reactive Oxygen Species: Excessively high levels of ROS can impair sperm motility and possibly interfere with the normal function of the sperm membrane.
• Vitality Stains: Used especially to assess if nonmotile sperm are alive, viable.
• Hypo-osmotic swelling test: A functional test that assesses vitality without killing the sperm. Living sperm develop swelling and tail curling in a hypoosmotic environment. Dead ones do not.
• Semen Centrifugation/Pelleting: This technique is used to rule out severely low sperm concentrations. Especially in the era of IVF/ICSI, a few sperm may be adequate for a successful cycle. Remember, only one sperm is required per oocyte with IVF/ICSI.
• 7. Post-ejaculate urinalysis (PEU): This procedure is performed to r/o retrograde ejaculation. Consider performing in men with low ejaculate volume azoospermia, diabetes mellitus, h/o TURP or bladder neck surgery, retroperitoneal surgery affecting sympathetic chain.
• 8. Transrectal Ultrasound (TRUS) with Seminal vesicle aspiration:à Use for men with low ejaculate volume and azoospermia or low motility. Absence of retrograde ejaculation on PEU should first be documented. Seminal vesicle dilation > 15 mm width warrants aspiration to assess for ejaculatory duct blockage. A large number of sperm in the aspirate signals a blockage.