Male Infertility Work Up

Approximately 15% of couples cannot conceive after one year of unprotected intercourse. A malefactor is solely responsible for about 20% of infertile couples and contributes to another 30-40%. If a male infertility factor is present, it is almost always defined by finding an abnormal semen analysis. However, other malefactors may play a role even when the semen analysis is normal.

Components of evaluation for male infertility The complete evaluation for male infertility for every patient should include a full medical history, a urologist’s physical examination, tons, and at least two semen analyses.

• A complete medical and surgical history including chronic diseases and surgeries since childhood trauma.

• Review of medications and allergies

• Lifestyle exposures like smoking, alcohol, recreational drugs

• Family reproductive history

• A survey of past infections such as sexually transmitted diseases and respiratory infections.

• A general physical examination

• Secondary sexual characteristics including body habitus, hair distribution, and breast development

• Examination of the male genital system for testicular size, epididymis, vas, the location of the urethral opening, the presence of infections, or any swellings.

Semen analysis is the cornerstone of the laboratory evaluation of the infertile male and helps define the male factor’s severity. Normal Semen parameters according to recent WHO criteria are listed below:

Semen analysis is performed with abstinence of 3 to 5 days on two occasions. Usually, no further evaluation is required if the above tests are normal. Other advanced trials are warranted for any abnormality of the above tests or in case of unexplained infertility or repeated treatment failures.

1. Endocrine evaluation

Initial endocrine evaluation should include at least a serum testosterone and FSH. It should be performed if there is

• An abnormally low sperm concentration, significantly less than 10 million/ml

• Impaired sexual function

• Clinical findings suggestive of a specific endocrinopathy

Other hormonal assays include LH, Inhibin B, prolactin, TSH, SHBG. All these tests may help determine the cause of abnormal spermatogenesis or infertility.

2. post-ejaculatory urinalysis should be performed in patients with ejaculate volumes of less than 1 ml, except in patients with bilateral vasal agenesis or clinical signs of hypogonadism to rule out retrograde ejaculation of sperms into the urinary bladder. Significant numbers of sperm must be found in the urine of patients with low ejaculate volume oligospermia to diagnose retrograde ejaculation.

3. Ultrasonography – Transrectal ultrasonography/ Scrotal ultrasonography Transrectal ultrasonography is indicated in azoospermic patients with palpable vasa and low ejaculate volumes to determine if ejaculatory duct obstruction exists. Scrotal ultrasonography is indicated in those patients in whom physical examination of the scrotum is complex or inadequate or in whom a testicular mass or small varicocele is suspected.

4. DNA Integrity / DNA Fragmentation Index (DFI) This test is done in repeated treatment failures or unexplained infertility cases. The results correlate reasonably with the potential of sperm from a given male to produce embryos that would be sufficiently “competent” to make a live birth. Based on the level of DNA integrity, successful treatment can be suggested. Test interpretation is as follows:

5. Computer-aided sperm analysis computer-aided sperm analysis (CASA) requires sophisticated instruments for quantitative assessment of sperm from a microscopic image or videotape. CASA is most useful clinically for assessing sperm motility and motion parameters, such as velocity or speed and head movement, which some believe may be essential in determining sperm fertility potential.

6. Antisperm antibody testing pregnancy rates may be reduced by anti-sperm antibodies (ASA) in the semen. ASA's risk factors include ductal obstruction, prior genital infection, testicular trauma and prior genital surgeries, isolated low motility of sperms, and unexplained infertility.

7. Sperm Viable tests these assays determine whether non-motile sperms are viable by identifying which sperm have intact cell membranes.

8. Less commonly used specialized tests:

• Sperm penetration assay: to test the ability of sperm to change and fuse to egg

• Tests of sperm-cervical mucus interaction: to look for the presence of antibodies

• Reactive oxygen species (ROS) levels: Increased ROS can cause infertility by affecting semen parameters

9. Testicular Biopsy This is mainly done in cases of Azoospermia with an average hormone profile to know if there is spermatogenesis in testes

10. Genetic screening /Karyotyping Genetic abnormalities may cause infertility by affecting sperm production or sperm transport. The three most common genetic factors known to be related to male infertility are:

• Cystic fibrosis gene mutations associated with congenital absence of the vas deferens

• Chromosomal abnormalities resulting in impaired testicular function

• Y-chromosome microdeletions associated with isolated spermatogenic impairment.

A precise and detailed medical history, physical examination, semen analyses, and complementary tests, as appropriate, are the key to obtaining a correct diagnosis and to determining the best treatment strategies.