Male Infertility
Evaluation

The routine evaluation for male factor infertility includes:

Semen analysis: The semen analysis has long been the cornerstone in the evaluation of the infertile male. It remains the initial screening test for the clinician. Newer measurements of sperm characteristics are constantly emerging. Due to a lack of standardization in specimen handling, semen analysis results can be highly variable. Even with meticulous internal controls a direct correlation between seminal parameters and fertility potential does not exist. Consequently, the interpretation of semen analysis results remains controversial. To establish accurate interpretation of bulk seminal parameters a complete medical evaluation of the male is needed as well as additional measurements of sperm characteristics. We recommend that men have at least three semen analyses over the course of 2 weeks, following a history and physical exam. Multiple semen analyses are needed because intra-individual variability exists and one analysis my not be representative. At least 2 days of abstinence are needed and the specimen needs to be in the laboratory no later than 1 hour after collection.

Semen parameters measured include:

• Sperm count
  
• Motility including progression
  
• Morphology
  
• Seminal fluid volume
  
• Viscosity
  
• Agglutination
  
• The presence of white and red blood cells

The current accepted World Health Organization (WHO) minimal standards of seminal adequacy are:

• Volume: 1.5-5.0 ml
  
• Sperm density (concentration): greater than 20 million/ml
  
• Motility: greater than 50% with a forward progression greater than 2 on a scale of 0-4
  
• Morphology: greater than 30% normal forms
  
• White blood cells: less than 1 million/ml

The American Society for Reproductive Medicine (ASRM) cites a study at USC to evaluate sperm quality in men whose partners were in treatment for infertility. Semen from 1347 men was tested over a three-year period revealing that 52% had at least one type of abnormality.

History: A thorough history should be obtained from the patient including:

• Age
  
• Fertility history including number of previous partners and pregnancies
  
• Previous fertility work-up
  
• Female partner work-up
  
• Sexual history
  
• Childhood history including:
  - Onset of puberty
  - Childhood diseases
  - Injuries
  - Surgeries
  
• Medical history including: diseases such as diabetes and hypertension
  
• Adult surgical history including: hernia repair, and bladder surgery
  Infections: including prostatitis, epididymitis, venereal diseases
  
• Exposure to toxic substances including: pesticides and chemicals
  
• Social history including: smoking, alcohol and recreational drug use
  
• Family history including: paternal history of infertility, chromosomal abnormality

Physical Exam including:

• Thyroid
  
• Heart position
  
• Abdomen
  
• Penis
  
• Scrotum and Testicles- It is important to examine the patient in the standing position, having him perform the Valsalva maneuver (i.e. take a deep breath and bear down) in order to evaluate the presence of varicoceles. Physical structure such as testicular size, uniformity, and the presence of the vas deferens will be evaluated.

Additional testing may be required to verify physical findings. These may include:

• Ultrasound: Examination of the prostate, testicles, spermatic cord, and kidneys
  
• Hormone blood tests: FSH, LH, Testosterone and Prolactin
  
• Antibody testing of the semen
  
• Sperm function testing
  
• Testicular biopsy: This is a procedure that allows examination of testicular architecture and sperm production. The testicular tissue is examined microscopically by a pathologist for seminiferous tubules (sperm producing tubules), interstitial tissue (cells between the tubules where Leydig cells are found). Patterns likely to be found on the examination of the testis biopsy include:
  

  Normal testis indicates normal sperm production. Consequently, any decrease or absence of sperm in the ejaculate is due to an obstruction.
  

  Maturation arrest indicates an arrest at some level in the series of maturation steps which begin with primitive (immature) germ cells. In general, the earlier arrest occurs in the process of sperm development, the worse the prognosis. However, if there is a block in the late stages of sperm development, appropriate therapy with medications may help to allow the sperm to mature fully.
  

  Hypospermatogenesis indicates a presence of all of the elements of sperm production, but there are fewer of them. This may coexist with a maturation abnormality. Hypospermatogenesis normally results in lower numbers of sperm in the ejaculate.
  

  Germinal cell aplasia indicates a complete absence of germ cells in the testis and, therefore, are an inability to produce sperm. At the present time there is no treatment for these patients, therefore, consideration of donor sperm insemination of their partner or adoption is their only option in order to have a family.
  

  Miscellaneous abnormalities can be detected including: evidence of previous infection of the testicles, abnormalities of the interstitial tissue and Leydig cells, and in rare instances a testicular malignancy (not an expected finding).

  
  
  
• Venography
  
  

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