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Updated: Dec 9 2021

Male Infertility

  • 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
  • Etiology
    • Endocrine and Systemic DisordersGenetic Disorders of SpermatogenesisAcquired Disorders of SpermatogenesisPost-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
  • Complications
    • Psychiatric complications
      • depression
      • anxiety
      • low self-esteem
      • sexual dysfunction
  • Prognosis
    • 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
    • Depends on etiology of infertility
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