The Male Infertility Workup
The initial male fertility evaluation consists of a thorough history
and physical examination. The couple's marital history is important,
particularly with regard to prior marriages and sex partners. All
miscarriages, elective terminations, and pregnancies initiated by the
patient or partner should be elicited. Childhood and developmental
conditions that may have an impact on fertility include a history of
undescended testicles, testicular torsion, trauma, and precocious or
delayed puberty. Systemic illnesses such as diabetes mellitus, multiple
sclerosis, and spinal-cord injury may impair normal ejaculation. Any
previous retroperitoneal, pelvic, inguinal, or scrotal surgery should be
noted. Prior exposure to sexually transmitted diseases may lead to
reproductive-tract scarring. Because intratesticular sperm maturation
requires 74 days, exposure during the past several months to systemic
illness, fevers, excessive heat, or various medications should be
elicited. Prior exposure to gonadotoxins such as chemotherapy,
radiation, exogenous androgenic steroids, as well as excessive alcohol
use, cigarette smoking, and use of marijuana and other recreational
drugs have all been associated with decreased fertility. Finally, it is
important to inquire about the couple's sexual history including the
frequency and timing of intercourse. To achieve conception, sexual
intercourse should be initiated prior to ovulation and continued at a
frequency of every other day during the ovulatory period.
In preparation for the initial consultation consider the following
questions: Is there a pattern of infertility in your family? Have you
ever achieved a pregnancy? Have you had pelvic or scrotal surgery? Have
you had any abdominal surgeries, like a hernia operation, that could
scar or injure delicate internal structures? Were or are you exposed to
toxins. This category includes a wide range of substances from
chemotherapy drugs to pesticides to workplace chemicals. How much
alcohol do you consume? Do you use recreational drugs, like marijuana?
Are you exposed to heat for long periods of time (ex. sauna or steam)?
Do you have a condition or disease that requires medications? Which
medications are you taking? Some prescription drugs interfere with sperm
production. Some diseases, (ex. diabetes) may hinder normal ejaculation.
Have you had any sexually transmitted diseases?
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The semen analysis forms the basis of the initial evaluation for
assessing male-factor infertility. Prior to establishing a reliable
fertility baseline, two to three semen analyses should be performed.
Multiple analyses are necessary because semen findings normally
fluctuate for a given individual. For each analysis, patients are
instructed to abstain from intercourse for 2 to 3 days. Abstinence for a
shorter period can decrease ejaculate volume and sperm count whereas
prolonged abstinence may impair sperm motility. It is critical that the
specimen be collected in a nontoxic container, that there be no
inadvertent loss of the specimen, and that the analysis be performed
within 2 hours of collection. A semen analysis reveals the volume of
ejaculate, the concentration or density of sperm, their motility and the
morphology (shape). There are minimal standards of adequacy for each
parameter and anything below those standards is called "abnormal." An
abnormal finding is an indicator that infertility may be a problem, not
a declaration of sterility.
Standards for a normal semen analysis include: Ejaculate volume of
between 2.0 and 5.0 ml. Sperm concentration of at least 20 million per
ml or a total count of greater than 40 million. Motility, quantitatively
at least 50% of the sperm should demonstrate movement. Morphology, (the
shape of each sperm) which evaluates the proportions of head to body to
tail of an individual sperm.
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The blood assays performed may include an Follicle Stimulating
Hormone (FSH) level, the hormone which the brain sends to the testicle
to produce sperm, and the Luteinizing Hormone (LH) level, a
hormone responsible for motivating the testicles to produce
testosterone. A low testosterone level not only has an impact on sperm
production, but also has significant implications for a man' s health in
general including sexual dysfunction, depression, fatigue, bone density
and muscle integrity. Other blood tests performed will evaluate genetic
causes for infertility. Between 30% and 40% of the patients with low or
no sperm in the ejaculate have a genetic problem. For example, an extra
X chromosome indicates a condition called Kleinfelter' s Syndrome.
Pieces of the Y chromosome may be missing, or there may be mutations
associated with cystic fibrosis.
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