Pocket ObGyn – Male Factor Infertility
See Abbreviations
Definition and Epidemiology (Fertil Steril 2006;86:S202)
- Inability of a male to achieve a Preg w/ a fertile female
- 20% due to purely male Additional 30–40% combined male & female factors.
- Risk factors: Occupational or environmental exposure to chemicals, radiation, or heat; Hx of varicocele, mumps, hernia repair, pituitary tumor, anabolic steroid use, testicular injury, impotence
Etiology
- Hypogonadotropic (secondary) hypogonadism – hypothalamic/pituitary dz. Congen eg, Kallmann syn (abn neuronal migration resulting in anosmia & hypothalamic hypogonadism). Tumors – macroadenoma, Infiltrative dz – sarcoidosis,TB, hemochromatosis. Vascular – infarction, aneurysm. Drugs. Obesity.
- Hypergonadotropic (primary) hypogonadism – testicular failure. Congen eg, Klinefelter syn (XXY), cryptorchidism (failure of descent of testes during fetal dev). Varicocele – dilation of the pampiniform plexus of spermatic veins in scrotum (left more common than right). Acq – cancer, infxn (viral orchitis, mumps), drugs (alkylating chemotherapeutic agents, antiandrogen agents), torsion, radiation, smoking, hyperthermia, antisperm
- Other: Posttesticular defects – Dz of epididymis or vas deferens (infxn, vasectomy, CF). Retrograde Idiopathic (40–50%).
Clinical Manifestations and Workup
- Assess Hx: Prior pregnancies fathered, coital frequency & timing, childhood illness (mumps orchitis), developmental/pubertal Hx, systemic medical illnesses, prior surgeries (hernia repair), environmental exposures (heat), meds, Hx of STIs, trauma to genitals, sexual dysfxn
- Physical exam: Assess secondary sexual characteristics: Body habitus, hair distribution, Examine penis including location of urethral meatus. Palpate testes & estimate testicular volume w/ Prader orchidometer. Assess presence/consistency of vas deferens & epididymidis, presence of varicocele. Digital rectal exam to assess masses.
- Semen analysis: Collect after 2–3 d of abstinence; 2 samples 1 mo apart; see Table
8.3 for assessment & nml values, & also eval leukocyte count, microscopic debris/ agglutination, immature germ cells
| Semen analysis reference values | |||||
| On | at | least | 2 | occasions: | |
| Ejaculate volume | >1.5–5 mL | ||||
| pH | >7.2 | ||||
| Sperm conc | >20 million/mL | ||||
| Total sperm count | >40 million/ejaculate | ||||
| Motility | >50% | ||||
| Forward progression | >2 (scale of 0–4) | ||||
| Nml morphology (depends on source) | >50% nmla
>30% nmlb >14% nmlc |
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| And: | |||||
| Sperm agglutination | <2 (scale of 0–3) | ||||
| Viscosity | <3 (scale of 0–4) | ||||
| Fertil Steril 2006;86:S202.
aWHO, 1987. bWHO, 1992. cKruger (Tygerberg) Strict Criteria WHO, 1999. |
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- After initial w/u: Uro consult if indicated. Additional semen studies (sperm autoantibodies, biochemistry, culture, sperm-cervical mucus interaction, sperm fxn tests [sperm analysis, acrosome rxn, zona-free hamster oocyte penetration test, human zona pellucida binding test, sperm chromatin & DNA assays]). Endocrine eval: Testosterone, LH, FSH, Postejaculatory urinalysis in pt w/ low volume semen to rule out retrograde ejaculation.Transrectal & scrotal US to identify obst & nonpalpable varicocele. Genetic testing – CFTR gene (a/w congen absence of vas deferens), karyotype to detect chromosomal abnormalities (a/w impaired testicular fxn), PCR to detect Y chromo microdeletions (a/w isolated spermatogenic impairment).
Treatment and Medications
- Treat underlying etiology if Improve coital practice – intercourse q2d during most fertile interval (3 d prior to & including day of ovulation).
- Sperm aspiration for obstructive azoospermia – TESE or MESA followed by IVF w/ ICSI (see below)
- Use ARTs as described below, ICSI useful for male factor infertility (see below). May need to consider donor