Male Infertility

Snapshot

• A 35-year-old man presents to the physicians office with concerns about his fertility. He has a history of cryptorchidism. Though he had been counseled on the possibilities of infertility, he had not given it much thought until he became engaged. He wishes to furtively evaluate his sperm before approaching the topic with his fiancée.

Introduction

• Definition of infertility
  • inability to conceive
    • after 1 year of unprotected sex in the absence of any known causes of infertility
    • after 6 months if the woman is > 35 years old or in couples with known risk factors for infertility
• Terms related to sperm cells
  • oligozoospermia
    • decrease in number of sperm cells in ejaculate
  • azoospermia
    • no sperm cells in ejaculate
  • asthenozoospermia
    • decrease in sperm motility
  • teratozoospermia
    • abnormal morphology
• Epidemiology
  • 10-15% of reproductive-aged couples in the US
  • 12% of men are infertile
    • 80% of men with infertility have oligozoospermia with asthenozoospermia, but with normal morphology of sperm
    • more common in those over 40-years-old
    • often unable to determine etiology

Endocrine and Systemic Disorders	Genetic Disorders of Spermatogenesis	Acquired Disorders of Spermatogensis	Post-testicular Defects and Disorders of Sperm Transport
• Kallmann syndrome • Hemochromatosis • Pituitary disorders • Post-irradiation • Exogenous androgen use  • Obesity	• Klinefelter’s syndrome (XXY) • Androgen insensitivity syndromes • 5-alpha-reductase deficiency • Myotonic dystrophy	• Infection causing orchitis (e.g.,mumps, tuberculosis, and leprosy) • Epididymo-orchitis (often due to • gonorrhea and chlamydia) • Cryptorchidism • Testicular torsion • Varicocele	• Vas deferens abnormalities • Cystic fibrosis • Ejaculatory duct obstruction • Retrograde ejaculation

Presentation

• Symptoms
  • inability to conceive
  • history of undescended testical
  • history of orchitis
  • history of surgical procedure in the area
  • absence of sense of smell
    • Kallmann syndrome
• Physical exam
  • hypogonadism
  • body habitus
    • decreased muscle mass and increased body fat may indicate androgen deficiency
    • obesity
  • abnormal scrotum
    • varicocele
• gynecomastia

Evaluation

• Standard semen analysis
  • measure semen volume and pH
  • assess sperm concentration, motility, and morphology
  • sperm leukocyte count
  • microscopy for debris, agglutination, and immature germ cells
  • tested for hyperviscosity
• Specialized semen analysis
  • sperm autoantibodies
  • semen culture
  • sperm-cervical mucus interaction
• Endocrine tests
  • testosterone, lutenizing hormone, and follicle-stimulating hormone
• Genetic testing if suspicious for cystic fibrosis or other genetic disorder

Differential Diagnosis

• Female infertility 
• Insufficient time to conceive
• Past vasectomy

Treatment

• Limited treatment available
• Lifestyle modification
  • smoking cessation
  • reduce alcohol intake
  • exercise and weight loss
• Treat underlying condition if possible
  • varicocele ligation
  • dopamine agonist for hyperprolactinemia
  • testosterone supplementation if deficient
• Assisted reproductive techniques
  • manual extraction of mature spermatozoa or spermatids in testicular biopsy
  • in vitro fertilization
  • intrauterine insemination
• artificial insemination with donor semen

Prognosis, Prevention, and Complications

• Prognosis
  • depends on etiology of infertility
  • factors associated with better prognosis
    • younger age of female partner
    • shorter duration of infertility
    • higher percent of sperm concentration
    • good sperm motility
    • normal sperm morphology
• Complications
  • psychiatric complications