Updated: 10/9/2018

Male Infertility

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Snapshot
  • A 41-year-old man presents with his 25-year-old wife to a fertility specialist. They have been trying to conceive for about one and a half years now. A few months ago, his wife was evaluated thoroughly for causes of female infertility, which all returned normal. Based on her physician’s recommendations, they are now concerned about his fertility.
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
    • more common in developing countries
Endocrine and Systemic Disorders Genetic Disorders of Spermatogenesis Acquired Disorders of Spermatogenesis Post-testicular Defects and Disorders of Sperm Transport
  • Kallmann syndrome 
  • Hemochromatosis
    • increased deposition of iron in pituitary gland
  • 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 testicle
    • history of orchitis
    • history of surgical procedure in the area
      • vasectomy
    • absence of sense of smell
  • 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
    • semen volume and pH
    • 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
  • Over the counter at-home test
    • limited reliability of test
    • does not assess sperm motility or morphology
  • Endocrine tests
    • testosterone, lutenizing hormone, and follicle-stimulating hormone
  • Genetic testing if suspicious for cystic fibrosis or other genetic disorder
Differential
  • Female infertility
  • Insufficient time to conceive
  • Past vasectomy
Treatment
  • Limited treatment available
  • Lifestyle modifications
    • smoking cessation
    • reduce alcohol intake
    • exercise and weight loss
    • avoid lubricants
  • Treat underlying condition if possible
    • varicocele ligation
    • dopamine agonist for hyperprolactinemia
    • gonadotropin therapy or pulsatile GnRH for hypogonadotropic hypogonadism
    • 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
      • depression
      • anxiety
      • low self-esteem
      • sexual dysfunction

 

 

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Questions (1)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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