Evaluation

Evaluation of male infertility requires a comprehensive review of the patient’s past medical history, review of attempts at conception, sexual history, surgical history, exposure to toxins, medications and other agents that can affect sperm production.  Detailed information is important as some of the unique adverse effects on male reproduction can be based on subtle history or prior treatment effects.

Physical examination can also provide unique insight into causes of male infertility and/or its effects.  Special attention during exam is paid to general endocrine effects (i.e., testosterone action in the affected man), as well as testicular size, consistency, position and the presence/absence of structures around the testis such as enlarged scrotal veins (varicoceles), the vas deferens, position and consistency of the epididymis.  These findings can be critical, for example, in sorting out whether azoospermia (lack of sperm in the ejaculate) is because of obstruction or impaired sperm production.

A relevant image of the male anatomy important for understanding normal fertility was published in JAMA:

https://cdn.jamanetwork.com/

Reference: Kashanian JA, Brannigan RE. Male Infertility. JAMA. 2015;313(17):1770

If sperm production is significantly impaired, then hormonal testing with FSH and serum testosterone levels should be assessed.  Testosterone levels are best measured with a morning blood test, preferably with the patient fasting.   If testosterone levels are low, then further evaluation of LH levels as well as prolactin hormone levels are indicated.  

For men with congenital azoospermia, additional genetic testing is required.  Men with low sperm production (non-obstructive azoospermia), Y chromosome microdeletion analysis and karyotype testing are indicated.  The results of this testing can affect both the chance of successful treatment as well as to allow counseling of the couple regarding why infertility has occurred.

For men with congenital obstructive azoospermia, there is a measurable risk of CF mutations being present as the cause of the obstruction.  In some cases,  obstruction can be linked to kidney abnormalities, so a renal ultrasound is indicated.

In cases of prior failed IVF, recurrent miscarriages or even unexplained infertility, then sperm testing for DNA fragmentation defects can be helpful to identify the cause of reproductive failure.  Other testing such as scrotal ultrasound, transrectal ultrasound, antisperm antibody testing or other evaluations.  Scrotal ultrasound may be indicated for evaluation of the testis or other scrotal contents.  Transrectal ultrasound may be helpful for evaluation of men with low semen volume or other evidence of obstruction at the ejaculatory duct level.  Antisperm antibody testing can help support a diagnosis of obstruction of the reproductive tract.

Male evaluation is overviewed in the joint American Urological Association/American Society for Reproductive Medicine Guidelines, published in 2021 ( doi: 10.1016/j.fertnstert.2020.11.015 ).