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 TransportKallmann syndromeHemochromatosisincreased deposition of iron in pituitary glandPituitary disordersPost-irradiationExogenous androgen useObesityKlinefelter's syndrome (XXY)Androgen insensitivity syndromes5-alpha-reductase deficiencyMyotonic dystrophyInfection causing orchitis (e.g., mumps, tuberculosis, and leprosy)Epididymo-orchitis (often due to gonorrhea and chlamydia)CryptorchidismTesticular torsionVaricoceleVas deferens abnormalitiesCystic fibrosisEjaculatory duct obstructionRetrograde 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